Anestezjologia intensywna terapia最新文献

Background: Peripheral perfusion may be compromised during anaesthesia and surgery, however its direct assessment is difficult, and sometimes may lead to false conclusions. Recently, a new generation of pulse oximeters has been introduced, which allows for the differentiation between pulsatile and non-pulsatile flow. The difference is expressed as the perfusion index (PI).

Methods: ASA I and II class women, scheduled for elective gynaecologic surgery, received fentanyl/ desflurane anaesthesia were studied. PI was noted before anaesthesia, after fentanyl injection, after endotracheal intubation, at the beginning of surgery, during the procedure at 10 minute intervals, at the end of procedure, after eye opening, after extubation, and before discharge to the ward. The depth of anaesthesia was assessed by spectral entropy and expressed as the A-line Autoregressive Index (AAI); the latter was compared to PI.

Results: Forty-five patients aged 37 +/- 13.8 years were enrolled in the study. PI increased after induction of anaesthesia and remained increased during surgery. There was a significant negative correlation between PI and AAI (r = -0.908; p = 0.00000), and between AAI and end-tidal desflurane concentration ((r = -0.788; p = 0.0008). PI correlated positively with end-tidal desflurane concentration (r = +0.757; p = 0.002).

Conclusion: The new generation of pulse oximeters allows not only the more accurate assessment of haemoglobin saturation, but also the detection of pathologic forms of haemoglobin and the assessment of peripheral blood flow. Peripheral perfusion is increased during desflurane anaesthesia, and is also closely related to the depth of anaesthesia.

Background: Unitaleral lung pathology presents a serious challenge for the anaesthesiologist. Conventional ventilation usually leads to over distension of the non-affected lung and hypoventilation of the affected lung. The optimal ventilatory strategy in such situations, is intubation with a double lumen tube and independent lung ventilation with two respirators. This is expensive and difficult, especially in an operating room. A novel approach to this problem is based on the use of a single ventilator with a volume splitter, which enables the independent ventilation of each lung, with the same frequency but different volumes, I:E ratios and PEEPs.

Methods: We used the splitter in thirty-four patients, of both sexes, aged 19-78 years, and scheduled for elective thoracic surgery. All patients were intubated with a double lumen tube and ventilated in the supine and lateral positions with and without the splitter. When the lateral position was used, the volume delivered by the ventilator was split equally to each lung.

Results: In the lateral position, without the splitter, the distribution of gas delivered by the ventilator was unequal: the dependent lung receiving 47.4 +/- 6.8% of the total volume, and the non-dependent lung receiving 52.6 +/- 6.8%. When the splitter was used, both lungs were ventilated with equal volumes. All patients were cardiovasculary stable.

Conclusion: A novel method of ventilation during anaesthesia is described, opening up new possibilities for thoracic anaesthesia that allows easy and atraumatic independent lung ventilation.

Background: Transesophageal echocardiography (TEE) has been regarded as a standard diagnostic method for assessment of cardiac output in aortic dissection, pulmonary embolism, atrial and ventricular septal defects, and acquired valvular defects. It is also a standard method of assessment of the adequacy of their surgical repair. It allows for on-line estimation of ejection fractions and stroke volumes, and calculation of cardiac output. In this prospective study, we compared the cardiac outputs estimated by aortic continuous-wave Doppler, and pulse wave Doppler via transgastric long-axis imaging plane TEE, with results obtained by thermodilution.

Methods: Cardiac output was determined in thirty adult patients, of both sexes, with good left ventricular function, scheduled for off pump coronary artery bypass grafting. Aortic valve area was plotted from the transverse short-axis view of the valve assuming a triangular shape for the valve orifice.

Results: Mean cardiac output measured by thermodilution [CO(S-G)] was 4.59 +/- 2.5 L min(-1), compared to 4.49 +/- 1.14 L min(-1) obtained from contour wave [CO(CW)] and 4.57 +/- 1.29 L min(-1) from continuous-wave [CO(PW)] analysis. The correlation coefficient (r) between CO(S-G) and CO(CW) was 0.939, (p < 0.001).The correlation coefficient (r) between CO(S-G) and CO(PW) was 0.912 (p < 0.001).

Conclusions: Results of cardiac output measurements, obtained from all three methods, were comparable.

Background: Accidental laceration of major abdominal vessels during lumbar disc surgery is a relatively rare complication that requires rapid diagnosis and management.

Case report: A 25-yr-old woman, operated on for an L4-L5 disc hernia, developed cardiovascular collapse after disc removal. This was treated with volume replacement and ephedrine, and a postoperative CT scan revealed a large retroperitoneal haematoma. During an immediate laparotomy, a 10 cm laceration of the left iliac artery was repaired and massive blood loss replaced (to lowest haemoglobin concentration during the surgery was 2.1 mmol L(-1)).The patient made a full recovery.

Conclusion: In any case of unexpected hypotension during lumbar disc herniation surgery, accidental vascular damage should be suspected and a CT scan performed immediately.

Unlabelled: BACKGROUND; DNAR is the procedure when CPR is not undertaken as it appears to conflict with the patient's will or may not be in his or her best interests due to medical futility. DNAR decisions should be carefully discussed in advance by the medical team and patients and finally formally documented. DNAR orders are still extremely rare in Polish hospitals and decisions to forgo CPR are usually made at the very last moment. Therefore, we compare actual practice and opinions of physicians related to DNAR decisions.

Methods: The study, carried out during three consecutive months in a big university hospital, was based on two questionnaires. The first questionnaire explored actual practice regarding the decision to forgo CPR, whereas the second one--opinions about DNAR guidelines. The former was filled in by physicians involved in the "do not to attempt resuscitation" decision, the latter by the group of other physicians employed in the hospital.

Results: The survey was performed among 286 physicians filling in the first questionnaire and 200 physicians completing the second one. On-call doctors were prime decision makers (49%) with no input from the patient when the "do not attempt resuscitation" decision was made. Decisions to forgo resuscitation were usually informal and communicated to medical team orally (98%). However, 20% of physicians declare that patients should be involved in the decision-making process concerning CPR, and more then 30% respondents stress the need for collegial discussion. Nearly 80% of physicians believe that such formal decisions should be recorded in the patient's medical history.

Conclusions: Current opinions of physicians regarding DNAR differ strikingly from clinical practice. Respondents highlighted the need for collegial discussions, the growing role of a patient in the decision-making process and importance of suitable documentation.

Background: Continuous renal replacement therapy (CRRT) is commonly used for the treatment of acute renal failure in haemodynamically unstable patients after cardiac surgery. The main problem associated with CRRT is the need for systemic anticoagulation that may lead to bleeding complications. As an alternative to heparins, and to avoid systemic anticoagulation, the use of regional citrate infusion has been proposed for patients with a high risk of bleeding.

Case reports: We present the clinical course of three patients with a high risk of bleeding after cardiac surgery in which CRRT, based on regional citrate anticoagulation, was conducted safely. Circuit survival times were over 80 hours and filters were changed on schedule, without any signs of dysfunction. Metabolic alkalosis was observed in one patient, who was treated by reducing the circuit blood flow and increasing the dialisate flow. One patient required chronic dialysis, the other two recovering after short-term CRRT.

Conclusion: Regional citrate anticoagulation during CRRT should be used as a method of choice in patients with a high risk of haemorrhage in the postoperative period.

Background: Excessive tracheal tube cuff pressure can cause ischemia of the tracheal mucosa, and possible serious complications, such as tracheal stenosis, formation of tracheo-oesophageal fistula or even life-threatening haemorrhage. Inadequate cuff pressure increases the risk of aspiration of gastric contents.

Methods: The cuff pressures were analysed on the basis of the anaesthesiologists' experience. The results were compared to those obtained during the previous study which had been conducted seven years earlier (2002). The physicians were divided into three groups, according to their experience: group I - less than 2 years of practice; group II--2 to 10 years of practice; and group III--over 10 years of practice. High-volume, low-pressure tubes were used for intubation. The anaesthesiologists were not informed of the planned audit.

Results: Statistical analysis demonstrated significant differences between cuff pressure readings in the respective study groups. Cuff pressures in group II (p < 0.05) and group III (p < 0.0005) were greater than those in group I. In 2002, no statistically significant differences had been observed between the three groups (p = 0.1156). When comparing results from 2002 and present one differences were observed inside individual groups, concerning group II (p < 0.05) and group III (p < 0.0005).

Conclusion: There is a tendency to overinflation of endotracheal tube cuffs in all groups. This problem is more common in the group of highly experienced anaesthesiologists, and is more more prevalent at present than in 2002.

Identification and preparation of a potential organ donor requires careful and meticulous intensive care, so that the organs may be harvested in the best possible condition for transplantation. The protocol consists of three key elements: (1) monitoring and haemodynamicstabilisation, (2) hormonal therapy, and (3) adequate mechanical ventilation and nosocomial pneumonia prophylaxis. Standard haemodynamic monitoring should consist of a 12 lead EGG, and direct monitoring of arterial and central venous pressures. Pulmonary artery catheterisation is indicated in donors with a left ventricular ejection fraction (LVEF) below 45%. PCWP should be kept at around 12 mm Hg, Cl at greater than 2.4 L m(-2), and SVR between 800 and 1200 dyn s(-1) cm(-5). When a vasopressor is necessary, vasopressin should be used as the drug of choice. If vasopressin is not available, noradrenaline or adrenaline may be used. Haemoglobin concentration should be maintained between 5.5-6.2 mmol L(-1). In a potential heart donor, troponin concentration should be checked daily. Neutral thermal conditions should be maintained using a warm air blower. A brain dead patient cannot maintain adequate pituitary function, therefore hormone replacement therapy with methylprednisolone, thyroxin and desmopressin is indicated. Glucose concentrations should be kept within the normal range, using insulin if necessary. The lung harvesting protocol should be similarto ARDS treatment guidelines (optimal PEEP, low tidal volumes). Lung recruitment manoeuvres, and aggressive prevention and treatment of nosocomial infection are essential.

Background: Ventilator-associated pneumonia (VAP) is a common complication in intensive care patients. Patients are most likely to be affected after abdominal and thoracic surgery.

Methods: The aim of the study was to analyze the epidemiology and aetiology of ventilator-associated pneumonia (VAP) following coronary artery surgery. Suspected cases were detected by the hospital Infection Control Team, in cooperation with ward personnel, and in accordance with CDC definitions.

Results: Fifty-three VAP cases were detected among 2,170 cardiac surgery patients. The ventilator utilization rate was 52%.The total cumulative VAP incidence was 2.2%, and the ventilator-associated pneumonia rate was 18.3/1,000 ventilator days, with a mortality of 1.9%.The most common isolates were Gram negative bacteria (P aeruginosa--10.4%, E. coli--12.5%, Klebsiella pneumoniae--16.7%) and Candida albicans.

Conclusions: The incidence of VAP was similar to those reported in NHSN and KISS programs, however the data on the epidemiology of VAP were different. There were also differences in both the epidemiology and microbiology of VAP in this hospital, compared with results reported from other cardiac centres. This indicates the necessity of introducing an effective detection system for hospital acquired pneumonia after cardiac surgery.