Romanian journal of anaesthesia and intensive care最新文献

We present the case of a 67-year-old male patient, who was admitted to the intensive care unit for hypoxemic respiratory failure due to severe COVID-19 pneumonitis, requiring mechanical ventilation. Despite close monitoring using transpulmonary pressure measurements and interventions to pursue lung-protective ventilation, the patient developed extensive barotrauma including a right-sided pneumothorax, subcutaneous emphysema and pneumomediastinum while on pressure support ventilation. We hypothesize that the high respiratory drive that COVID-19 patients seem to exhibit, combined with diffuse alveolar injury and increased alveolar pressure, resulted in gross barotrauma.

Conclusion: The respiratory characteristics that COVID-19 patients seem to exhibit might expose those on mechanical ventilation to an increased risk of developing ventilation-induced lung injury. This case emphasizes that caution should be taken in the respiratory treatment of patients with COVID-19 pneumonitis.

Objective: The choice of anesthesia for emergency cesarean delivery (CD) is one of the most important choices to make in obstetric anesthesia. In this study, we examine which type of anesthesia was used for emergency CD in our hospital, and how the choice affected the time from entry to the operation room until incision (TTI), time until delivery (TTD), and maternal/neonatal outcomes.

Methods: Retrospectively, we examined all emergency CD's performed in Shaare Zedek Medical Center between January-December 2018. Results: 1059 patients met the inclusion criteria, of which 7.7% underwent general anesthesia (GA), 36.2% - conversion from labor epidural analgesia to surgical anesthesia, 52% - spinal anesthesia and 4.1% - combined spinal epidural. We did not find a significant difference between the GA and conversion epidural groups in terms of TTI or TTD. Nevertheless, GA was found to be correlated to a high rate of blood-products requirement and ICU admission. The rate of newborns with an APGAR score of less than 7, in both first and fifth second after birth, was significantly higher in the GA group, as well as the need for NICU admission.

Conclusion: This study clearly emphasizes that the TTI are shortest when using GA or conversion of labor epidural analgesia to surgical anesthesia. Meanwhile, GA is also linked to higher rates of admissions to ICU as well as poorer neonatal outcomes compared to the other groups. Additionally, our study uncovered a low rate of GA, and relatively low rate of regional anesthesia failure, which meets the accepted standards.

Background: Septic events complicated by hemodynamic instability can lead to decreased organ perfusion, multiple organ failure, and even death. Acute renal failure is a common complication of sepsis, affecting up to 50-70 % of cases, and it is routinely diagnosed by close monitoring of urine output. We postulated that analysis of the minute-to-minute changes in the urine flow rate (UFR) and also of the changes in its minute-to-minute variability might lead to earlier diagnosis of renal failure. We accordingly analyzed the clinical significance of these two parameters in a group of critically ill patients suffering from new septic events.

Methods: The study was retrospective and observational. Demographic and clinical data were extracted from the hospital records of 50 critically ill patients who were admitted to a general intensive care unit (ICU) and developed a new septic event characterized by fever with leukocytosis or leukopenia. On admission to the ICU, a Foley catheter was inserted into the urinary bladder of each patient. The catheter was then connected to an electronic urinometer - a collecting and measurement system that employs an optical drop detector to measure urine flow. Urine flow rate variability (UFRV) was defined as the change in UFR from minute to minute.

Results: Both the minute-to-minute UFR and the minute-to-minute UFRV decreased significantly immediately after each new septic episode, and they remained low until fluid resuscitation was begun (p < 0.001 for both parameters). Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFR and the decrease in the systemic mean arterial pressure (MAP) (R = 0.03, p = 0.003) and between the decrease in UFRV and the decrease in the MAP (R = 0.03, p = 0.004). Additionally, both the UFR and the UFRV demonstrated good responses to fluid administration prior to improvement in the MAP.

Conclusion: We consider that minute-to-minute changes in UFR and UFRV could potentially serve as early and sensitive signals of clinical deterioration during new septic events in critically ill patients. We also suggest that these parameters might be able to identify the optimal endpoint for the administration of fluid resuscitative measures in such patients.

Clinical background: Volatile anaesthetics (VAs) have been shown to protect cardiomyocytes against ischaemia and reperfusion injury in cardiac surgery.

Clinical problems: VAs have been shown in multiple trials and meta-analyses to be associated with better outcomes when compared to intravenous anaesthesia in cardiac surgery. However, recent data from a large randomised controlled trial do not confirm the superiority of VA as compared to total intravenous anaesthesia in this population.

Review objectives: This mini review presents the VA cardioprotective effects, their clinical use in cardiac surgery and the most recent evidence that compares VA to intravenous anaesthesia for reducing perioperative morbidity. At present, there is no clear superiority of VA over intravenous anaesthesia in improving the outcome after cardiac surgery.

Cardiogenic shock is a constant challenge for the intensivist when complicating a myocardial infarction, due to the high rate of associated morbidity and mortality, especially in the setting of mechanical complications such as papillary muscle rupture. We present the case of a 49-year-old woman with cardiogenic shock due to acute myocardial infarction (AMI) complicated by severe mitral valve insufficiency due to papillary muscle rupture. She was treated initially by medical optimization, followed by mitral valve replacement and complete surgical revascularization, requiring rescue mechanical circulatory support by extracorporeal membrane oxygenation (ECMO). ECMO proved to be a rescue therapy in a patient with refractory cardiogenic shock after urgent cardiac surgery.

The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists ('alpha-2 agonists') led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids ("conventional" sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for 'cooperative' sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects ('personalized' indications, as opposed to a 'one size fits all' approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.

Introduction: Trochanteric fractures are a major trauma in the elderly population and represent a significant part of public health spending. Various fixation devices are used as treatment for these fractures. This study aimed to evaluate three surgical methods in the treatment of pertrochanteric femoral fractures.

Materials and methods: From January 1, 2013, to December 31, 2014, 86 patients were divided into 3 groups. Fifteen patients were treated with osteosynthesis by reamed intramedullary nailing (RIMN), 15 patients were treated with unreamed intramedullary nailing (UIMN), and 13 patients were treated with dynamic hip screw (DHS) plate osteosynthesis. All patients were >75 years of age. They were evaluated with a clinical radiological follow-up and laboratory examination (LDH, CPK, IL-1-B, IL-8, TNF-α, alpha-1-acid glycoprotein, D-dimer, fibrinogen, ESR, CRP, and procalcitonin).

Results: IL-8, TNF-α, fibrinogen, D-dimer and alpha-1-acid glycoprotein levels were higher in the DHS group compared with the other two groups at 1 month after surgery (P<0.05). LDH, IL-1β, and IL-6 levels were higher in the DHS group compared with the other two groups at 3 months after surgery (P<0.05). From 3 to 6 months after surgery, the TNF-α level was high in the DHS and RIMN groups (P<0.05). Infection markers did not demonstrate a difference among the 3 groups. Twelve patients died during the 12-month follow-up. Regardless of the method used, morbidity and mortality are linked to enticement and comorbidities rather than surgery within 48 hours after the trauma.

Conclusions: From our study, we can affirm that the values of cytokines and interleukins observed remain high during the 12-month follow up, regardless of whatever fixation devices or surgery type was performed within 48 hours of injury. Inflammatory markers are higher in patients in the DHS group. This can probably be explained by the fact that DHS technique is performed by open surgery, and this can create a higher inflammation of soft tissue. Mortality is reduced in the first 30 days after surgery if patients are mobilized early. Therefore, mortality in our study population of patients aged >75 years is linked more to the chronic inflammatory state and comorbidities, rather than fixation device or surgical type used.However, future studies are needed to answer further questions that go beyond the scope of our study.

Objective: Through this study, we want to see to what extent the stress is present among the patients admitted in the intensive care units of the Fundeni Clinical Institute of Bucharest, outlining intervention strategies both individually and collectively and validating the psychological evaluation tool (IPAT) specific to the anesthesia and intensive care units in our population.

Method: Intensive Psychological Assessment Tool (IPAT) with 10 items was used for stress assessment in the intensive care unit and Hospital Anxiety Depression Scale (HADS) with 14 items and two subscales, one for anxiety (7 items) and one for depression (7 items).

Conclusion: The study demonstrates the validity of IPAT scale for the patients participating in the study; the results of the study provide the specialists in anesthesia and intensive care units directions to identify elements of stress, anxiety and depression - directions that can improve their daily work, communication with patients and possibly a better quality of life for all involved in the care of a patient.

Results: The results of the study provide the specialists in anesthesia and intensive care units the directions to improve their daily work and possibly a better quality of life for all involved in the care of a patient.

Cystic fibrosis is a polymorphic disease, marked by multiple and difficult-to-treat respiratory exacerbations with severe evolution. The lung disease dictates the disease's evolution and it must be diagnosed early and treated accordingly, but the diagnosis is sometimes challenging because of the lack of a sensible tool. In the era of the biomarkers, the need for a sensitive and reliable one would be extremely important, considering that inflammation secondary to infections produce irreversible structural changes in the cystic fibrosis lungs. The present paper reviews the studied biomarkers in inflammation and infection with potential role in cystic fibrosis lung disease.

Introduction: Sedative premedication is the mainstay of pharmacological therapy in children undergoing surgeries. This study compares preoperative melatonin, clonidine, and dexmedetomidine on sedation, ease of anesthesia induction, emergence delirium, and analgesia.

Materials and methods: One hundred and five children, 3-8 years, either sex, ASA I/II, posted for infraumbilical surgery, randomized to receive clonidine 5 mcg/kg (Group C), dexmedetomidine 3 mcg/kg (Group D), and melatonin 0.2 mg/kg (Group M) 45 minutes before surgery. Preoperative Sedation/Anxiety and Child-Parent Separation Score (CPSS) were assessed. Identical anesthesia technique was utilized. Emergence delirium (Watcha score) and postoperative pain (Objective Pain Scale score) were monitored postoperatively.

Results: Patients were demographically comparable. Sedation score >Grade 3 was absent. Grades 1/2/3 were present in 10/19/6 (Group C), 2/26/7 (Group D), and 7/26/2 (Group M). Grade 1 CPSS was present in 42.6% (Group C), 37.1% (Group D), and 28.6% (Group M). Pediatric Anesthesia Behavior Score (PABS) was comparable between Groups C and D (p = 0.224; 95% CI -0.090 to 0.604) and Groups C and M (p = 0.144; 95% CI -0.633 to 0.061) while PABS was better in Group D compared to Group M (p = 0.0007; 95% CI -0.890 to -0.195). Watcha scores were 33/2/0/0 (Group C), 34/1/0/0 (Group D), and 32/2/1/0 (Group M) immediately after extubation. Scores were 31/4/0/0 (Group C), 33/2/0/0 (Group D), and 31/4/0/0 (Group M) at 30 minutes and 28/7/0/0 (Group C), 29/6/0/0 (Group D), and 24/11/0/0 (Group M) at 1 hour. The scores were comparable (p > 0.05). Objective Pain Scale scores were comparable between Groups C and D and Groups C and M (p > 0.05). Lower scores were present in Group D compared to M (p = 0.023).

Conclusion: Melatonin, clonidine, and dexmedetomidine are efficacious for producing preoperative sedation, reducing anxiety, postoperative pain, and emergence delirium.