Current Issue : October - December Volume : 2015 Issue Number : 4 Articles : 11 Articles
Background: Learning from adverse events and near misses may reduce the incidence of preventable errors.\nCurrent literature on adverse events and near misses in the ICU focuses on errors reported by nurses and\nintensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and\nsystem weaknesses not identified by other providers, and may differ in character and causality from near misses in\nother anesthesia locations.\nMethods: We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We\ncompared causative mechanisms of ICU near misses with near misses in other anesthesia locations.\nResults: A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal\nmechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses\nfrom the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be\nassociated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated\nwith equipment issues (23 % vs. 48 %, p = 0.02).\nConclusions: A limited number of causal mechanisms explained the majority of ICU near misses, providing targets\nfor quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist\nconsultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the\nICU patient safety movement....
Background: We herein provide an analysis of lumbar epidural catheterization, which outlines a detailed\nanatomical description of the epidural anatomy, and may improve the success rate of neuraxial cannulation.\nMethods: Lumbar epidural catheters were placed in 50 adult embalmed cadavers. After catheterization, the lumbar\ndura and connecting structures between the epidural space and the vertebral body were separated. The positional\nrelationship between the catheter and the posterior epidural space were observed and photographed.\nResults: Amongst the 50 specimens, the epidural catheter curled into a circle in three cases, entered the\nintervertebral foramen in two cases, and caused epidural venous damage in five cases.\nConclusions: Meningo-vertebral ligaments exist in the posterior epidural space and connect to the venous plexus,\nwhich may contribute to epidural catheter failure, uneven distribution of anaesthesia and epidural hemorrhage. Our\nstudy provides anaesthesiologists with a better understanding of the anatomy and may mitigate complications of\nlumbar epidural catheter placement....
Background: The application of pulsed radiofrequency (PRF) close to the dorsal root ganglia, or peripheral nerves,\nhas been demonstrated to be effective for the treatment of chronic neuropathic pain conditions. The goal of this\nstudy was to investigate the analgesic effect of immediate PRF treatment after nerve injury and its possible cellular\nalterations in the dorsal horn of the spinal cord in rats with spared nerve injury (SNI).\nMethods: Neuropathic pain was achieved in a SNI neuropathic pain model by ligating and cutting the\ncommon peroneal and tibial branches of the left sciatic nerve, leaving the sural nerve intact. Wistar rats were\ndivided into four groups that received different treatments, i.e., SNI and PRF for 6 min at 45 V (SNI + PRF-45 V),\nat 60 V (SNI + PRF-60 V), SNI alone, and sham groups. After the SNI surgery, each rat was immediately given the\nPRF treatment (500 kHz, rate of 2 Hz, 20 ms duration, temperature below 42 Ã?°C) on the left sciatic nerve 0.3ââ?¬â??0.4 cm\nproximal to the injured site. The behavioral measurements included mechanical allodynia and cold allodynia of\nthe ipsilateral hind paw and were performed during the 28 days that followed the SNI surgery and PRF treatment.\nTotal extracellular signal-regulated kinase 1 and 2 (ERK1/2) and phospho-ERK1/2 were measured using Western\nblot in the ipsilateral spinal cord from animals in the different groups.\nResults: The three groups of rats with nerve injuries manifested a lower paw withdrawal threshold (PWT) in the\nbehavioral measurement of mechanical allodynia and a shorter painful-behavior duration in the cold allodynia test over\n28 days. Mechanical allodynia measurement showed that both the PRF-45 V and PRF-60 V treatment groups exhibited\na more prominent antiallodynic effect than did the SNI group from days 1 to 28 after surgery. Similarly, in comparison\nwith the SNI group, both the SNI + PRF-45 V and SNI + PRF-60 V groups had significant inhibition on the cold allodynia\nmeasurement from days 1 to 28 after surgery. Furthermore, the activation of the extracellular signal-regulated kinase 1\nand 2 (ERK1/2) in the ipsilateral spinal dorsal horn of SNI rats was effectively inhibited in the SNI + PRF-45 V and SNI +\nPRF-60 V groups for 28 days after surgery.\nConclusions: Immediate PRF application on the proximal nerve injury site provided a significant inhibition of\nneuropathic pain formation, accompanied by the inhibition of ERK activation....
Introduction. The prognostic value of age, physical status, and duration of surgery on perioperative course has been extensively\nstudied. However, the impact of deep hypnotic time (time when Bispectral Index values are less than 40) has not been well\nevaluated. Methods.We designed an observational study to clarify the relative influence of deep hypnotic time (DHT) on outcome.\nEligible participants were mentally stable patients over 18 years old scheduled for elective major abdominal surgery. In total,\n248 patients enrolled. Data were analyzed using Fisherââ?¬â?¢s exact test and multiple logistic regression. Results. Five variables (DHT,\nhypotension, age, comorbidity, and duration of surgery) showed statistically significant association with complications, when\nexamined independently. However, when all variables were examined together in a multiple logistic regression model, age and\ncomorbidity were no longer associated with outcome. DHT, hypotension, and duration of surgery were significant predictors of\nââ?¬Å?complications,ââ?¬Â and ââ?¬Å?hypotensionââ?¬Â was a significant predictor of prolonged hospital stay (P < 0.001). Conclusion. Deep hypnotic\ntime emerged as a new factor associated with outcome, and its impact compared to other factors such as age, surgery duration,\nhypotension, and comorbidity is redefined.Monitoring and managing depth of anesthesia during surgery are important and should\nbe part of careful operation planning...
Background. Sugammadex is a new reversal agent that has entered use recently. It is known that with sugammadex some changes in\ncoagulation parameters occur without documented clinical results.Aimof theWork.The objective of this study was to identify effects\nof sugammadex on liver functions, coagulation, and fibrinolytic systems. Methods. Thirty-six rats were randomized into six groups:\nGroup I, control; Group II, rocuronium group; Group III, sugammadex administered in 16mg kg?1 dose; Group IV, sugammadex\nadministered in 96mg kg?1 dose; Group V, rocuronium and sugammadex administered in 16mg kg?1 dose; and Group VI,\nrocuronium and sugammadex administered in 96mg kg?1 dose. After 120 minutes, blood samples were obtained for prothrombin\ntime, activated partial thromboplastin time, D-dimer, fibrinogen, aspartate aminotransferase, alanine aminotransferase, albumin,\nplatelet, and mean platelet volume analyses. Results. Compared to the control group, in all groups measured parameters did not\nshow any effect froma statistical viewpoint either due to the administered drugs alone or due to interaction effects. Conclusion.The\nconclusion was reached that administration of sugammadex in rats did not have any significant effect on the fibrinolytic system,\ncoagulation parameters, and liver function....
Background: Administration of vancomycin in critically ill patients needs close regulation. While subtherapeutical\nvancomycin serum concentration (VSC) is associated with increased mortality, accumulation is responsible for\nnephrotoxicity. Our study aimed to estimate the efficacy of a vancomycin-dosing protocol in reaching appropriate\nserum concentration in patients with and without kidney dysfunction.\nMethods: This was a retrospective study in critically ill patients treated with continuous infusion of vancomycin.\nPatients with creatinine clearance >50 ml/min (Group A) were compared to those with creatinine clearance\n?50 ml/min (Group B).\nResults: 348 patients were enrolled (210 in Group A, 138 in Group B). At first determination, patients with kidney\ndysfunction (Group B) had a statistically higher percentage of vancomycin in target range, while the percentage of\npatients with a VSC under the range was almost equal. These percentages differed at the subsequent\nmeasurements. The number of patients with low vancomycin concentration progressively decreased, except in\nthose with augmented renal clearance; the percentage of patients with VSC over 30 mg/L was about 28 %,\nirrespective of the presence or absence of kidney dysfunction. Patients who reached a subtherapeutic level at the\nfirst VSC measurement had a significant correlation with in-hospital mortality.\nConclusions: Our protocol seems to allow a rapid achievement of a target VSC particularly in patients with kidney\ndysfunction. In order to avoid subtherapeutical VSC, our algorithm should be implemented by the estimation of the\npresence of an augmented renal clearance....
Central airway collapse plays a significant, underrecognized role in respiratory failure after extubation of critically ill patients.\nHistorically, airway collapse has been attributed to tracheomalacia (TM), softening of the cartilage in the trachea and other large\nairways. More recently, excessive dynamic airway collapse (EDAC) has been described as a distinct process unrelated to a loss of\ncartilaginous airway support. EDAC is caused by the posterior wall of the trachea bulging forward and causing airway obstruction\nduring exhalation. This process is exaggerated when intrathoracic pressure is increased and results in a clinical picture of coughing,\ndifficulty clearing secretions, dyspnea, and stridor. The increased use of computerized tomography and fiberoptic bronchoscopy\nhas identified varying degrees of EDAC and TM in both symptomatic and asymptomatic individuals. This has led to renewed\nconsideration of airway collapse and the different processes that contribute to it. Here we describe a 43-year-old morbidly obese\npatient who failed repeated attempts at extubation after elective hysterectomy. We will discuss the processes of EDAC and TM,\ndescribe how this condition contributed to this patient�s respiratory failure, and review diagnosis and management options....
We present the first documented case of Candida parapsilosis infective endocarditis in a pregnant patient. While the incidence of\ninfective endocarditis during pregnancy is rare, the incidence of C. parapsilosis endocarditis is even rarer. The numerous specific\nrisks and decision making processes regarding this case are presented....
Clonidine when added to intrathecal bupivacaine, prolongs the duration of analgesia.Our aim was to assess the effect of different dose of clonidine on duration of sensorymotor blockade and hemodynamic parameters. 120 patients of ASA grade I and II, aged 20-60 years scheduled for elective gynaecological surgeries were divided into four groups. Group ‘B’ being the control and received only 0.5% hyperbaric bupivacaine 15 mg. Group BC1, BC2, BC3 received injection clonidine 30; 45; 60 microgram respectively with 15 mg hyperbaric bupivacaine intrathecally. Patients were observed for duration of two segments regression of sensory block, recovery of motor block and duration of analgesia. Mean blood pressure, heart rate, oxygen saturation and sedation scores were monitored. The mean duration of sensory block was significantly longer in the group BC3 (232±13.49 min) as compared to BC2 (185±30.93 min) and BC1 (149±25.91 min) (p<0.001) respectively. While in B group it was (104±11.01 min). The mean duration of motor blockade was also found to be longer in group BC3 (334.0±22.06 min) as compared to BC2 (266±33.79 min) and BC1 (238±20.24 min) (p<0.0001) and in B group it was (165±22.39 min). Incidence of side effects was non-significant. Addition of clonidine to hyperbaric bupivacaine through intrathecal route increases the duration of sensorymotor blockade with postoperative analgesia in a dose dependent manner without increasing the side effects....
Peripheral nerve blockade (PNB) is superior to neuraxial anesthesia and/or opioid therapy for perioperative analgesia in total knee\nreplacement (TKR). Evidence on the safety of PNB in patients with coagulopathy is lacking. We describe the first documented\naccount of continuous femoral PNB for perioperative analgesia in a patient with VonWillebrand Disease (vWD). Given her history\nof opioid tolerance and after an informative discussion, a continuous femoral PNB was planned for in this 34-year-old female\nundergoing TKR. A Humate-P intravenous infusion was started and the patient was positioned supinely. Using sterile technique\nwith ultrasound guidance, a Contiplex 18 Gauge Tuohy needle was advanced in plane through the fascia iliaca towards the femoral\nnerve. A nerve catheter was threaded through the needle and secured without complications. Postoperatively, a levobupivacaine\nfemoral catheter infusion was maintained, and twice daily Humate-P intravenous infusions were administered for 48 hours;\nenoxaparin thromboprophylaxis was initiated thereafter. The patient was discharged uneventfully on postoperative day 4. Given\ndocumentation of delayed, unheralded bleeding from PNB in coagulopathic patients, we recommend individualized PNB in vWD\npatients. Multidisciplinary team involvement is required to guide factor supplementation and thromboprophylaxis, as is close\nfollow-up to elicit signs of bleeding throughout the delayed postoperative period....
Background: Pain following hip arthroscopy is highly variable and can be severe. Little published data exists\ndemonstrating reliable predictors of significant pain after hip arthroscopy. The aim of this study was to identify\ninfluence of intraoperative factors (arthroscopic fluid infusion pressure, operative type) on the severity of\npostoperative pain.\nMethods: A retrospective review of 131 patients who had received a variety of arthroscopic hip interventions was\nperformed. A standardized anaesthetic technique was used on all patients and postoperative pain was analysed\nusing recovery pain severity outcomes and analgesic use. A multivariate logistic regression analysis was performed\non intraoperative factors including patient age, sex and BMI, arthroscopic infusion pressures (40 vs 80 mm Hg),\namount of fluid used, length of surgery and types of arthroscopic interventions performed. Thirty six patients were\nalso prospectively examined to determine arthroscopic fluid infusion rates for 40 and 80 mm Hg infusion pressures.\nResults: Use of a higher infusion pressure of 80 mm Hg was strongly associated with all pain severity endpoints (OR\n2.8 ââ?¬â?? 8.2). Other significant factors included hip arthroscopy that involved femoral chondro-ostectomy (OR 5.8) and\nlabral repair (OR 7.5). Length of surgery and total amount of infusion fluid used were not associated with increased pain.\nConclusions: 80 mm Hg arthroscopic infusion pressures, femoral chondro-osteoectomy and labral repair are\nstrongly associated with significant postoperative pain, whereas intraoperative infusion volumes or surgical duration\nare not. Identification of these predictors in individual patients may guide clinical practice regarding the choice of\nmore invasive regional analgesia options. The use of 40 mm Hg arthroscopic infusion pressures will assist in\nreducing postoperative pain....
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