Current Issue : January - March Volume : 2014 Issue Number : 1 Articles : 8 Articles
Background: In trauma patients intubated in a physician-led pre-hospital trauma service we prospectively\r\nexamined the rate of misplaced tracheal tubes, the presence and nature of gross airway contamination, and the\r\nvalue of ââ?¬Ë?quick lookââ?¬â?¢ airway assessment to identify patients with subsequent difficult laryngoscopy.\r\nMethods: Patients requiring pre-hospital intubation in a 16 month period were included. Intubation success rate,\r\nmisplaced tracheal tube rate, Cormack and Lehane grade, and the presence and nature of gross airway\r\ncontamination were recorded at laryngoscopy. Tube placement was verified with carbon dioxide detection and\r\nchest x-ray. After visual assessment physicians stated whether laryngoscopy was expected to be a straightforward\r\nor ââ?¬Ë?difficultââ?¬â?¢. The assessment was compared to subsequent laryngoscopy grade.\r\nResults: 400 patients had attempted intubation and 399 were successfully intubated. 42 were in cardiac arrest and\r\nintubated without drugs. There were no oesophageal or misplaced tracheal tubes. Gross airway contamination was\r\nreported in 177 of 400 patients (44%), of which Ã?¾ was from the upper airway. Unconscious patients had higher\r\ncontamination rates (57%) than conscious patients (34%) (p = 0.0001). As a test of difficult intubation, the ââ?¬Ë?quick\r\nlookââ?¬â?¢ generated sensitivity 0.597 and specificity 0.763 (PPV and NPV were 0.336 and 0.904 respectively).\r\nConclusion: This study suggests that when physicians perform pre-hospital anaesthesia they have high intubation\r\nsuccess rates and the use of ETCO2 monitoring reduces or eliminates undetected misplaced tracheal tubes. We\r\nfound high rates of airway contamination; mostly blood from the upper airway. The ââ?¬Ë?quick lookââ?¬â?¢ airway assessment\r\nhad some utility but is unreliable in isolation....
Background: The aim of this study was to examine the effect of breastfeeding on pain relief in full-term neonates\r\nduring injection of hepatitis B vaccine.\r\nMethods: This was a randomized clinical trial. A sample of full-term neonates was randomly allocated into two\r\ngroups: the experimental group and the control group. Neonates in the experimental group were breastfed two\r\nminutes before, during, and after the hepatitis B immunization and the control group were held in mothersâ�� arms\r\nbut not fed. Pain was assessed using the Douleur Aigu�« du Nouveau-n�© (DAN) scale measuring facial expressions,\r\nlimb movements and vocal expressions. The assessments were carried out after hepatitis B immunization.\r\nResults: One hundred thirty healthy full-term neonates were studied (65 in the experimental group and 65 in the\r\ncontrol group). Gestational age, birth weight, Apgar score and gender did not differ between the two groups. The\r\nmean total pain score as measured by the DAN scale was 3.52 (SD = 1.37) for the experimental group and it was\r\n6.78 (SD = 1.69) for the controls indicating a significant lower pain score for the experimental group (P<0.001). Also,\r\nthere were significant differences for the three measures of DAN scale that are facial expressions, limb movements\r\nand vocal expression, between the two study groups (P<0.001).\r\nConclusion: The findings confirm that breastfeeding reduces pain and is effective way for pain relief during\r\nhepatitis B vaccine injection....
Background: Microcirculatory driving pressure is defined as the difference between post-arteriolar and venular\r\npressure. In previous research, an absence of correlation between mean arterial blood pressure (MAP) and\r\nmicrocirculatory perfusion has been observed. However, the microcirculation may be considered as a low pressure\r\ncompartment with capillary pressure closer to venous than to arterial pressure. From this perspective, it is\r\nconceivable that central venous pressure (CVP) plays a more important role in determination of capillary perfusion.\r\nWe aimed to explore associations between CVP and microcirculatory perfusion.\r\nMethods: We performed a post-hoc analysis of a prospective study in septic patients who were resuscitated\r\naccording a strict non-CVP guided treatment protocol. Simultaneous measurements of hemodynamics and\r\nsublingual Sidestream Dark Field imaging were obtained 0 and 30 minutes after fulfillment of resuscitation goals.\r\nData were examined for differences in microcirculatory variables for CVP = or > 12 mmHg and its evolution over\r\ntime, as well as for predictors of a microvascular flow index (MFI) < 2.6.\r\nResults: In 70 patients with a mean APACHE II score of 21, 140 simultaneous measurements of CVP and sublingual\r\nmicrocirculation (vessels < 20 Ã?µmeter) were obtained. (MFI) and the percentage of perfused small vessels (PPV)\r\nwere significantly lower in the ââ?¬Ë?highââ?¬â?¢ CVP (> 12 mmHg) group as compared to patients in the ââ?¬Ë?lowââ?¬â?¢ CVP\r\n(=12 mmHg) group (1.4 Ã?± 0.9 vs. 1.9 Ã?± 0.9, P = 0.006; and 88 Ã?± 21% vs. 95 Ã?± 8%, P = 0.006 respectively). Perfusion\r\npressure (MAPââ?¬â??CVP) and cardiac output did not differ significantly between both CVP groups. From time point 0 to\r\n30 minutes, a significant increase in MFI (from 1.6 Ã?± 0.6 to 1.8 Ã?± 0.9, P = 0.027) but not in PPV, was observed, while\r\nCVP and perfusion pressure significantly decreased in the same period. In a multivariate model CVP > 12 mmHg\r\nwas the only significant predictor for a capillary MFI < 2.6 (Odds ratio 2.5 (95% confidence interval 1.1-5.8),\r\nP = 0.026).\r\nConclusion: We observed a significant association between a higher CVP and impairment of microcirculatory blood\r\nflow. Further research is needed to elaborate on our hypothesis generating findings that an elevated CVP may act\r\nas an outflow obstruction of organ perfusion...
Background: Malignant hyperthermia (MH), a metabolic myopathy triggered by volatile anesthetics and\r\ndepolarizing muscle relaxants, is a potentially lethal complication of general anesthesia in susceptible patients. The\r\nimplementation of modern inhalation anesthetics that research indicates as less potent trigger substances and the\r\nrecommended limitations of succinylcholine use, suggests there may be considerable decline of fulminant MH\r\ncases. In the presented study, the authors analyzed suspected MH episodes during general anesthesia of patients\r\nthat were referred to the Wuerzburg MH unit between 2007 and 2011, assuming that MH is still a relevant\r\nanesthetic problem in our days.\r\nMethods: With approval of the local ethics committee data of patients that underwent muscle biopsy and in vitro\r\ncontracture test (IVCT) between 2007 and 2011 were analyzed. Only patients with a history of suspected MH crisis\r\nwere included in the study. The incidents were evaluated retrospectively using anesthetic documentation and\r\nmedical records.\r\nResults: Between 2007 and 2011 a total of 124 patients were tested. 19 of them were referred because of\r\nsuspected MH events; 7 patients were diagnosed MH-susceptible, 4 MH-equivocal and 8 MH-non-susceptible by\r\nIVCT. In a majority of cases masseter spasm after succinylcholine had been the primary symptom. Cardiac\r\narrhythmias and hypercapnia frequently occurred early in the course of events. Interestingly, dantrolene treatment\r\nwas initiated in a few cases only.\r\nConclusions: MH is still an important anesthetic complication. Every anesthetist must be aware of this lifethreatening\r\nsyndrome at any time. The rapid onset of adequate therapy is crucial to avoid major harm and possibly\r\nlethal outcome. Dantrolene must be readily available wherever MH triggering agents are used for anesthesia....
Background: In a smaller experience, the authors previously demonstrated that end-tidal carbon dioxide (PetCO2)\r\nand cardiac output (CO) had a positive association in emergently intubated trauma patients during Emergency\r\nDepartment resuscitation. The aim of this larger study was to reassess the relationship of PetCO2 with CO and\r\nidentify patient risk-conditions influencing PetCO2 and CO values.\r\nMethods: The investigation consists of acutely injured trauma patients requiring emergency tracheal intubation.\r\nThe study focuses on the prospective collection of PetCO2 and noninvasive CO monitor (NICOM�®) values in the\r\nEmergency Department.\r\nResults: From the end of March through August 2011, 73 patients had 318 pairs of PetCO2 (mm Hg) and CO\r\n(L/min.) values. Mean data included Injury Severity Score (ISS) =15 in 65.2%, Glasgow Coma Score of 6.4 �± 4.6,\r\nhypotension in 19.0%, and death in 34.3%. With PetCO2 = 25 (15.9 �± 8.0), systolic blood pressure was 77.0 �± 69, CO\r\nwas 3.2 �± 3.0, cardiac arrest was 60.4%, and mortality was 84.9%. During hypotension, CO was lower with major\r\nblood loss (1.9), than without major loss (5.0; P = 0.0008). Low PetCO2 was associated with low CO (P < 0.0001). Low\r\nPetCO2 was associated (P = 0.0012) with ISS > 20, hypotension, bradycardia, major blood loss, abnormal pupils,\r\ncardiac arrest, and death. Low CO was associated (P = 0.0059) with ISS > 20, hypotension, bradycardia, major blood\r\nloss, abnormal pupils, cardiac arrest, and death.\r\nConclusions: During emergency department resuscitation, a decline in PetCO2 correlates with decreases in\r\nnoninvasive CO in emergently intubated trauma patients. Decreasing PetCO2 and declining NICOM CO are\r\nassociated with hemodynamic instability, hemorrhage, abnormal pupils, and death. The study indicates that NICOM\r\nCO values are clinically discriminate and have physiologic validity....
Background. Perioperative management of cocaine-abusing patients scheduled for elective surgery varies widely based on individual\r\nanecdotes and personal experience. Methods. Chiefs of the anesthesia departments in the Veterans Affairs (VA) health system were\r\nsurveyed to estimate how often they encounter surgical patients with cocaine use. Respondents were asked about their screening\r\ncriteria, timing of screening, action resulting from positive screening, and if they have a formal policy for management of these\r\npatients. Interest in the development of VA guidelines for the perioperative management of patients with a history of cocaine\r\nuse was also queried. Results. 172 VA anesthesia departments� chiefs were surveyed. Response rate was 62%. Over half of the\r\nfacilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a\r\npositive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%)\r\nthought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent.\r\nResults. 172 VA anesthesia departments� chiefs were surveyed. Response rate was 62%.Over half of the facilities see cocaine-abusing\r\npatients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of\r\nclinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal\r\nguidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Conclusions. There is a\r\ngeneral consensus that formal guidelines would be helpful. Further studies are needed to help formulate evidence-based guidelines\r\nfor managing patients screening positive for cocaine prior to elective surgery....
Multiple protein kinases affect the responses of dorsal horn neurons through phosphorylation of synaptic receptors\r\nand proteins involved in intracellular signal transduction pathways, and the consequences of this modulation may\r\nbe spinal central sensitization. In contrast, the phosphatases catalyze an opposing reaction of de-phosphorylation,\r\nwhich may also modulate the functions of crucial proteins in signaling nociception. This is an important\r\nmechanism in the regulation of intracellular signal transduction pathways in nociceptive neurons. Accumulated\r\nevidence has shown that phosphatase 2A (PP2A), a serine/threonine specific phosphatase, is implicated in synaptic\r\nplasticity of the central nervous system and central sensitization of nociception. Therefore, targeting protein\r\nphosphotase 2A may provide an effective and novel strategy for the treatment of clinical pain. This review will\r\ncharacterize the structure and functional regulation of neuronal PP2A and bring together recent advances on the\r\nmodulation of PP2A in targeted downstream substrates and relevant multiple nociceptive signaling molecules...
Opioids are widely used as the pain reliever and also notorious for being addictive drugs. Sex differences in the\r\nopioid analgesia and addiction have been reported and investigated in human subjects and animal models. Yet,\r\nthe molecular mechanism underlying the differences between males and females is still unclear. Here, we reviewed\r\nthe literature describing the sex differences in analgesic responses and addiction liabilities to clinically relevant\r\nopioids. The reported interactions among opioids, estrogens, opioid receptors, and estrogen receptors are also\r\nevaluated. We postulate that the sex differences partly originated from the crosstalk among the estrogen and\r\nopioid receptors when stimulated by the exogenous opioids, possibly through common secondary messengers and\r\nthe downstream gene transcriptional regulators....
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