Anestezjologia intensywna terapia最新文献

Suxamethonium is the only depolarising neuromuscular blocking agent, which is still being widely used during general anaesthesia. Some of its unique properties rank suxamethonium as an ideal neuromuscular blocking agent i.e. the fast onset of muscle paralysis and spontaneous neuromuscular block reversal. However, the agent may trigger malignant hyperthermia, hyperkaliaemia, severe bradycardia and other complications, which have to be considered. Due to differences in postsynaptic nicotine receptor structure and functional insufficiency of the neuromuscular junction, paediatric patients when compared to adults, are more sensitive to potential side effects when suxamethonium is administered. Malignant hyperthermia is an important risk factor. Ryanidine receptors located in the sarcoplasmic/endoplasmic reticulum membrane are responsible for the release of Ca2+ from intracellular stores and trigger this complication.The risk of hyprethermia increases in children when some neurologic and muscle diseases coexist. Nowadays, in rapid sequence induction of anaesthesia, suxamethonium may be replaced with rocuronium - a non-depolarising muscle relaxant which provides the intubating conditions similar to suxamethonium. The rocuronium-induced neuromuscular blockade, which lasts longer than blockade following suxamethonium, is reversed with sugammadex - a new selective relaxant binding agent. Despite new agents and methods, suxamethonium still remains the drug of choice for muscle relaxation for intubation in children.

Background: The recent outbreak of AH1N1 influenza was associated with an increased number of respiratory complications. There were some extremely severe cases of ARDS, in which conventional therapy could not secure adequate gas exchange. These patients fulfilled ECMO criteria, however, due to late referral, were not suitable for transportation. To solve this problem, a portable ECMO system, providing for safe management of these patients, has been introduced in our institution.

Case report: We reviewed five adult ARDS patients, who were transported by an ambulance for a distance ranging from 2 to 95 km, over 35 to 120 min. In four cases, a veno-venous ECMO system was used, and one patient had an arterio-venous circuit. All circuits were implanted before transportation by a dedicated team from the reference hospital, comprising an anaesthesiologist, a cardiac surgeon and a perfusionist. All transportations were successful and no complications and/or technical problems were observed. During the subsequent ITU treatment, three patients survived and two died (one because of uncontrollable bleeding from the ECMO cannula, and one because of sepsis and multiple organ failure).

Conclusion: We conclude that safe use of ECMO during transportation is possible, and does not require very sophisticated and expensive equipment. A standard ambulance is sufficient for the purpose.

Resuscitation should always be attempted in a patient who has at least a theoretical chance of survival. This assumes that there are patent cerebral, coronary and pulmonary vessels, a reasonable time from cardiac arrest has not been exceeded, and cardiac arrest did not occur as a result of a terminal condition caused by an untreatable disease. During resuscitation, medical personnel may face two dilemmas: when to start CPR, and when (and how) to stop it. Apart from various medical conditions, possible outcome and will of a victim has to be taken into consideration. CPR is frequently started without an adequate knowledge of the patient's medical status. As soon as the latter is obtained, a decision about continuing CPR should be reconsidered. CPR and/or life-prolonging treatment can be stopped in several situations, i.e. lack of cardiovascular response or recognition of a life-limiting condition. The decision should be made by a team leader, acting in accordance with national or house guidelines. In terminal patients, a DNR order should be issued well in advance, usually by an attending physician. After that, the patient should be provided with palliative care, consisting of pain therapy, and treatment of dyspnoea, congestive cardiac failure, etc. In their review, the authors discuss various medical and ethical aspects of resuscitation, concluding that hospital ethics committees could be of great value in solving complicated questions relating to limitation of resuscitation and life-prolonging treatment.

Background: The type of anaesthetic used affects the cardiovascular function in morbidly obese patients during pneumoperitoneum. In this prospective randomized study, we evaluated the influence of inhalation anaesthesia with sevoflurane or intravenous anaesthesia with propofol on haemodynamic performance in obese patients during laparoscopy.

Methods: Patients scheduled for laparoscopic bariatric procedures were randomly divided into two groups: sevoflurane (group S) or propofol (group P). Haemodynamic function was measured using the transoesophageal Doppler method after induction of anaesthesia (T₁), insuflation of CO₂ (T₂) and in the anti-Trendelenburg position with pneumoperitoneum (T₃).

Results: One hundred patients were enrolled in the study. The demographic data did not differ between the groups. At T₂, the blood flow parameters and ventricle ejection parameters decreased in both groups whereas the systemic vascular resistance and mean arterial pressure increased. The heart rate was stable. At T₃, afterload parameters and heart rate increased in both groups yet blood flow parameters decreased in group P. The changes observed were not accompanied by any serious clinical signs of cardiovascular deterioration.

Conclusions: Pneumoperitoneum has an important negative impact on haemodynamic function in morbidly obese patients but those changes are not accompanied by severe cardiovascular disturbances. Volatile anaesthesia provides better haemodynamic stability during laparoscopic bariatric surgery in such patients.

Sex hormones exert a substantial effect on brain function; their action is determined by the predominance of one hormone group over the remaining ones. Estrogens have indirect and direct neuroprotective effects. The indirect effects involve improved function of the vascular endothelium and increased blood flow through the brain. The direct effects (nervous cells and glia) consist in strong antioxidative properties, maintenance of Ca+2 homeostasis, blockage of activating amino acids, modification of tissue and humoral immune responses and inhibition of activity of immediate early genes. Gestagens, on the other hand, prevent neuronal death, inhibit lipid membrane peroxidation, and promote growth of nervous cells and formation of new synapses. The role of sex hormones within the brain is equally important. However, in cases of brain pathology, protective effects of gestagens seem to be much strongly expressed.

Background: Transportation to the recovery room after surgery can be associated with significant hypoxaemia, if a portable oxygen source and a pulse oximeter are not used. We analysed the condition of patients on admission to recovery after being transported from the operating room without additional oxygen and monitoring.

Methods: One hundred and thirty-one ASA II and III patients, aged 58.2 ± 15.96 years, were enrolled to the study. SaO2 readings immediately before transportation, and on arrival in recovery, were compared. Additionally, blood-gas analysis was performed 10 min after admission to the recovery room. The duration times of transport (T1), lack of monitoring (T2) and breathing with room air (T3) were measured.

Results: The mean SaO2 before transportation was 96.9 ± 10.55%, and on arrival in the recovery room was 93.0% ± 6.35. The mean T values were: T1 - 90.0 ± 94.2 s, T2 - 152.6 ± 86.6 s, and T3 - 122.9 ± 86.8 s. Although the length of transport time was relatively short, mild hypoxaemia was observed in all patients, with the SaO2 returning to normal after 10 min on 40% oxygen. Blood gas analysis revealed mild respiratory acidosis in 73% of cases.

Conclusion: Additional oxygen via face mask and appropriate monitoring should be provided to all patients during transportation from the operating room to the recovery area.

Patients with cardiac diseases undergoing non-cardiac surgery experience more perioperative problems than the others. The prevention of these problems includes proper preoperative evaluation of patients, careful intraoperative management and postoperative surveillance. Preoperative examination of such patients, including echocardiography if necessary, is crucial. The need for preoperative medication (e.g. beta-blockers, statins) ought to be carefully considered. Intraoperative management requires goal-directed haemodynamic monitoring and therapy as well as proper fluid infusion. There are no data confirming the superiority of general over regional anaesthesia in such patients. However, lower incidence of pulmonary complications and lower mortality rates were observed after regional blocks.

Background: The satisfaction of family members with the care provided in Polish intensive therapy units has arisen as an important factor in assessing of the overall outcome of treatment. The opinions received from various ITUs were different, but showed a generally low level of satisfaction regarding the availability of physicians for regular discussion. The purpose of this study was to evaluate the levels of satisfaction arising from contact between ITU staff and patients' families.

Methods: Fifty-nine relatives of ITU patients, treated at the Gdańsk Medical University, were asked to complete questionnaires based on the following: general conditions and privacy during information sessions, the accessibility and quality of information, and the readiness for participation in the care of their relatives.

Results: Families rated the accessibility of information highly (76.3%). The information provided was deemed to be understandable 84.7% of the time, becoming more comprehensive over time (91.5%). In 84.7% of cases, respondents considered that there was consistency in the information given to other members of family. 66% of those questioned were informed by the chief physician, but only 30.5% were able to talk with physicians together with other family members, in a specially designated room. 87% of those questioned were ready to participate actively in the ITU care of their relative.

Conclusions: The study showed that the present system of informing patients' relatives in the ITU was satisfactory, but only in terms of the accessibility and quality of information. The conditions provided for meetings with ITU physicians were far from being satisfactory, and families received information from too many physicians.