Anestezjologia intensywna terapia最新文献

Background: Congenital pseudocholinesterase (pChe) deficiency is a rare genetic abnormality which may lead to prolonged duration of action of muscle relaxants that are hydrolysed by pChe. We describe two cases in which mivacurium resulted in neuromuscular block lasting several hours.

Case reports: Two non-related male patients, aged 26 and 7 years, scheduled for elective ENT surgery, received propofol, desflurane, remifentanil and mivacurium. At the end of the surgery it was not possible to reverse the neuromuscular blockade, and there were no responses to TOF or post-tetanic stimulation. Neuromuscular transmission returned spontaneously after 7, and 4 h, respectively. Postoperative assay revealed severe pChe deficiency in both patients, with values of 3393 UL(-1)and 2558 UL(-1), respectively (normal range 5100-11700 UL(-1). Family screening confirmed the presence of pChe deficiency in both cases.

Conclusion: In any case of unexpected prolonged muscle relaxation after mivacurium, pChe deficiency should be considered and its activity measured.When confirmed, careful family screening is mandatory.

Functional endoscopic sinus surgery (FESS) is a surgical procedure, during which all necessary manipulations are performed while using a fibreoptic camera. The endoscope is inserted together with the surgical instruments, through the nasal cavity. During the surgery, bleeding has to be minimized, since even a small amount of blood may completely obstruct vision via the endoscope. Various approaches have been used to secure a dry operating field; among them are: topical vasoconstrictors, Fowler's position, alpha-and beta-adrenergic blockade, and preoperative steroids. All these methods are far from being effective and are associated with significant side effects. The recently approved approach to this problem is to combine total intravenous anaesthesia using propofol and remifentanil, together with esmolol. With the heart rate reduced to 60 bpm, excellent operative conditions can be achieved with moderate hypotension (MAP 65 mm Hg-8.7 kPa). Altered microcirculation and a low cardiac output are the principal underlying mechanisms in these cases.

Background: Early recognition of cardiac arrest (CA) and immediate commencement of resuscitation, may increase the survival rate among CA victims. We therefore conducted a survey among medical students to assess their knowledge of BLS and AED.

Methods: The audit was performed among students, most of whom had completed at least one first aid course and those who had not done a first-aid course at all. The ERC-recommended questionnaire 2005 was used for the survey.

Results: One hundred and sixty five students completed the survey. Most of them recognized the usefulness of basic resuscitation algorithms and the use of AEDs. 88% of students recognized the importance offirst aid courses, and 91.6% would undertake them again. Despite obvious enthusiasm and self-declared adequate knowledge, 45.7% of the audited students were not familiar with the guidelines and answered wrongly to more than 6 of 12 questions in the questionnaire. The vast majority of the first year medical students were not familiar with the algorithms.

Conclusion: We conclude that general knowledge of resuscitation algorithms among medical students is inadequate, and regular refresher courses are essential.

Background: Acute pancreatitis may be accompanied by a number of complications. They include diffuse peritonitis, intra-abdominal and retroperitoneal abscesses, and severe haemorrhage. These complications are the cause of approximately 50% of all deaths in acute pancreatitis.

Case report: A 33-year-old man was admitted to ITU with septic shock, due to acute pancreatitis and necrosis after multiple surgeries. On the fifth day after admission, his condition deteriorated due to respiratory distress and massive bleeding from the splenic region requiring surgical packing. On the next day, the bleeding became critical. More than 2000 mL of blood was evacuated from the peritoneal cavity, the bleeding site was re-packed, and the patient was transfused with RBCs, FFP and 0.04 mg kg(-1) of recombinant factor VIIa concentrate. This resulted in haemostasis, however the subsequent clinical course was complicated by septic shock, perforation of the transverse colon and peritonitis. The patient eventually recovered and was discharged home after 105 days in hospital.

Conclusion: Multifactorial management of acute pancreatitis is essential; in cases of severe haemorrhage, surgical packing and administration of recombinant factor VIIa concentrate are key components of successful treatment.

Background: Effective multimodal postoperative analgesia is one of determinants of patient satisfaction after successful surgery. Following the recommendations of non-steroidal antiinflammatory agents (NSAIDs) for pre-emptive analgesia, we assessed the efficacy of ketoprofen administered before urological surgery.

Methods: Fifty-two ASA I and II adult patients, scheduled for elective urologic procedures under general anaesthesia, were enrolled in this prospective, double blind study. They were randomized to receive intravenously either 100 mg ketoprofen or placebo (0.9% saline), one hour before the procedure, and at 8, 24, 36 and 48 h after. Pethidine was given for rescue analgesia. VAS was used for pain scoring.

Results: Pain scores were similar in both groups and identified as severe (VAS >4) during the first 48 h after surgery. There was no difference in the number of patients requiring rescue pethidine analgesia, mostly required during the first 12 postoperative hours.

Conclusion: Pre-emptive analgesia with intravenous ketoprofen was ineffective in patients undergoing urological surgery.

Background: The aim of the study was to compare the intubating conditions, onset time, and duration of action of atracurium, cisatracurium, and vecuronium, when used for muscle relaxation in laparoscopic surgery with carbon dioxide inflation. In trying to find an "ideal" relaxant we compared the relative potency of these drugs, and also measured pH, PaCO2 and skin temperature.

Methods: Ninety-five ASA I and II patients were randomly allocated to three groups, to receive atracurium (I), cisatracurium (II), or vecuronium (III), during propofol/fentanyl anaesthesia. Neuromuscular transmission was monitored using accelerography (TOF GUARD). Patients were intubated after the injection of 0.5 mg kg-1 atracurium (I), 0.1 mg kg(-1) cisatracurium (II), or 0.1 mg kg(-1) vecuronium (III). Muscle relaxation was maintained with incremental doses of 0.1 0.2 mg kg(-1) and 0.03 mg kg(-1) of the relaxants respectively, given after a second response to TOF stimulation was noted. Recovery time was defined as the time from a maximal block (TOF=0) to spontaneous recovery of TOF 75%.

Results: Conditions for performing tracheal intubation were noted to be excellent in groups I and III, and good in group II. The mean recovery time was significantly shorter in groups II and III, than in group I. No significant correlations were found between the duration of neuromuscular blockade and pH, PaCO2 or palm skin temperature.

Conclusions: Vecuronium, besides providing excellent conditions for tracheal intubation, had the fastest onset time and optimal duration of action. We found the drug to be the most suitable for laparoscopic surgery.

Background: Treatment of severe sepsis (SS) is a major challenge for an ITU, because of the high mortality. The severity of 55 is scored according to the number of organ systems that have failed. We analysed the results of treatment of SS in the ITU of the Upper Silesian Medical Centre, and compared them to previously reported data obtained from other centres.

Methods: Between 2008 and 2009, 45 SS cases were treated. Demographic data, laboratory tests and therapeutic routines were analysed.

Results: The overall mortality rate was 58%. There was a positive correlation between mortality, male gender and advanced age. The most common initial sources of infection were the respiratory system and abdominal cavities. Serious metabolic disturbance and central nervous system failure markedly affected prognosis. In 56% of cases, five or more organ systems were affected,

Discussion: Survival in SS is related to the number of affected organ systems. All patients were admitted in critical condition requiring respiratory and inotropic support. Despite strict application of the Surviving Sepsis Campaign (SSC) recommendations and a relatively short time from diagnosis to commencement of adequate treatment, the mortality rate was found to be higher than the European average, but comparable to that from the Polish registry.

Conclusions: Advanced age, male gender and intraperitoneal pathology worsened the prognosis in SS. Mortality was directly related to the number of organ systems involved, and the number of coexistent diseases. An interdisciplinary approach during diagnosis and a reduced time to the start of intensive treatment are essential for survival. Ready access to updated databases on SS enables regular reviews of the results of treatment and improvement of algorithms.

Background: Pregabalin, an antiepileptic and chronic pain medication, has been used by various authors for preoperative analgesia. We have assessed the effect of pre-emptive administration of the drug to patients scheduled for elective abdominal hysterectomy.

Methods: Seventy-four ASA I and II patients were included in this prospective, double blind study. They were randomised to receive 75, 150, or 300 mg of pregabalin, or 7.5 mg of midazolam as a placebo, one hour before anaesthesia and surgery. Anaesthesia was induced with propofol and maintained with sevoflurane or desflurane. Fentanyl was used for analgesia and rocuronium for muscle relaxation. Immediately after surgery, patients received morphine intravenously in 2 mg increments until the NRS score was below 3. This was then followed by PCA.

Results: Morphine consumption and pain scores were only significantly lower in the 300 mg pregabalin group, when compared to the placebo and other treatment groups; there were no differences between placebos and lower doses of pregabalin.

Conclusion: We conclude that pre-emptive administration of 300 mg pregabalin reduces postoperative pain and morphine consumption. Further studies on higher doses would appear to be justified.

Central blocks, continuous subarachnoid-epidural anaesthesia, including combined spinal-epidural anaesthesia (CSE) are used for long and painful procedures of lower limbs. They provide quick and good-quality anaesthesia as well as satisfactory postoperative analgesia. After their administration, ambulation is quick and rehabilitation instituted early, which is essential for the postoperative course of orthopaedic procedures. Peripheral blocks are an excellent alternative, especially in patients at high perioperative risk, who require anticoagulants. The novel techniques of location of peripheral nerves and plexuses, i.e., nerve stimulation- and ultrasound-guidance, improve the efficacy of blocks and shorten the duration of anaesthesia. Moreover, they improve safety and comfort of patients.

Myocardial infarction represents one of the most serious perioperative complications. Reducing the risk of perioperative myocardial infarction is one of the most important priorities of anesthetic treatment. Discovery of cardioprotective effects of volatile anesthetics exerted strong impact on everyday anesthetic practice, particularly in cardiac-surgical setting. Anesthetic preconditioning is a complex process which is divided into two separate phenomena initiated by the same event. The first, referred to as early preconditioning, involves activation of protective enzymes within cardiomyocytes and the second, referred to as late preconditioning, is dependent on de novo synthesis of these protective proteins. Although pre-, as well as post-conditioning's effects on cardiomyocytes are crucial for cardioprotective effects of volatile anesthetics, their influence on coronary endothelium may be even more important for the improvement of the long-term prognosis, demonstrated in coronary surgery patients. Improved outcome after anesthesia with volatile anesthetics in non-cardiac surgical patients at risk of perioperative myocardial infarction has not been univocally demonstrated yet. Some data indicate that volatile anesthetics, especially sevoflurane, reduces inflammatory response to ischaemia-reperfusion and other pro-inflammatory stimuli. The issue of inflammatory modulation exerted by volatile anesthetics and its influence on patients' clinical condition remains to be addressed in future studies.