Anestezjologia intensywna terapia最新文献

Background: Awake fibreoptic intubation has been recommended for adult patients with a difficult airway in whom anaesthesia and/or relaxation could lead to the "can not ventilate, can not intubate" situation. The paper describes three cases of elective awake intubations, as examples of our strategy in cases with a predicted difficult airway.

Case reports: Three male patients with Mallampati scores 2, 3 and 3, scheduled for elective surgery, were premedicated with 7.5 mg oral midazolam and 0.5 mg iv atropine. With the patient on the operating table in the anti-Trendelenburg position, the upper airways were anaesthetized with 4 mL of topical 2% lidocaine, administered from a nebulizer via face mask. Additionally, the base of the tongue, nasal cavity and lower throat were sprayed with 10% lidocaine solution. Immediately before insertion of the bronchoscope, the patients received intravenously, 2 mg of midazolam and 0.05-0.1 µg kg-1 of fentanyl. A 5.2 mm/65 cm fibreoptic bronchoscope was inserted into the trachea and a reinforced endotracheal tube was slid down over it. Oxygen and additional doses of lidocaine were administered through the working channel of the scope.

Conclusion: The described method is safe and effective, and can be recommended for cases where there is serious doubt about the possibility of maintaining an open airway during induction of anaesthesia, or in cases where intubation has failed during previous anaesthesia. Awake intubation is rarely associated with serious episodes of desaturation and it is usually well tolerated by motivated patients.

Background: There are several kinds of adverse reactions to the administration of local anaesthetics (LAs): hypersensitivity, which causes reproducible symptoms or signs, initiated by exposure to a defined stimulus at a dose tolerated by normal subjects; toxic reactions - caused by overdose or inappropriate administration; and allergy - when an immunologic mechanism can be shown to be important.The most serious adverse reaction is anaphylaxis, which can be of allergic or non-allergic (anaphylactoid) origin. We analysed clinical adverse reactions to local anaesthetic agents that occurred in the Silesian region.

Methods: Thirty-two patients, aged 22-56 years, in whom significant reactions had occurred after administration of an LA, were investigated in our institution. The investigation was based on skin prick, intradermal injections and patch testing. In every patient, the concentration of latex IgE antibodies was measured.

Results: True allergic reactions were confirmed in three patients. The allergens were: lidocaine in all three cases, additionally: nickel - in one person and preservative (paraben) - in one patient. No latex allergy was diagnosed.

Discussion: The results showed that real allergic reactions to LA agents are rare and that most of the reported reactions were caused by hypersensitivity. Nevertheless, in each case of adverse reaction, careful review of the history, and testing of immediate and late allergic reactions not only to LA but also to latex and preservatives, should be mandatory.

Awake fiberoptic intubation has been recommended for adult patients with a difficult airway in whom anaesthesia and/or relaxation could lead to the "cannnot ventilate, cannot intubate" situation. We describe the strategy and protocols of such management in cases with a predicted difficult airway. The described method is safe and effective, and can be recommended for cases where there is serious doubt about the possibility of maintaining an open airway during induction of anaesthesia, or in cases where intubation has failed during previous anaesthesia. Awake intubation is rarely associated with serious episodes of desaturation and it is usually well tolerated by motivated patients.

Background: Postoperative pain still poses a serious problem for 80% of patients undergoing surgery. We assessed the effects of the implementation of standards of postoperative analgesia, according to the guidelines of the "Pain-free hospital" project, and PROSPECT group recommendations, in the daily practice of a general surgical hospital ward.

Methods: One hundred adult patients, scheduled for elective inguinal or umbilical hernia surgery, were included in the study and allocated to two groups, to receive analgesics on demand (control), or postoperative analgesia according to the introduced programs. The number of additional interventions and patients' satisfaction were chosen as primary end points to assess the clinical value of the introduced standards. Additionally, the type and dose of analgesics, and duration of hospital stay were noted.

Results: One additional intervention (2%) was required in the treated group, and 9 (18%) - in the control group (p=0.023). In the treated group, the patient satisfaction (0 to 10) score was rated 9 by 39 patients (78%) and 10 by 11 patients (22%). The duration of hospitalisation was similar in both groups.

Conclusion: We confirmed the success of introducing the standards of pain treatment into the daily practice of a surgical ward.

Background: Morbid obesity BMI 40 kg mL-2 is associated with several changes in anatomy and physiology of the respiratory system. Respiratory work is increased whereas compliance of the chest wall and lungs is decreased. Increased intra-abdominal pressure compresses the diaphragm and reduces its movability. Abdominal opening should influence respiratory mechanics.

Methods: Forty-seven morbidly obese patients (BMI 49.54 ± 7.21 kg m-2) scheduled for elective bariatric surgery (open Roux-en-Y-Gastric Bypass - RYGB) were included in the study and divided into 3 groups: 40< BMI <50, 50< BMI <60 and BMI >60. Measurements were performed during general anaesthesia at two time points: before (T1) and after abdominal opening (T2). All patients were ventilated using the volume control mode.

Results: Preoperative spirometry revealed significantly decreased FEV 1% in the BMI >60 group. The conditions of mechanical ventilation during general anaesthesia deteriorated with an increasing BMI. After abdominal opening,the mechanical ventilation conditions improved: increased lung compliance and decreased airway pressures. The difference was statistically significant in the entire population studied. After dividing the population into groups, however, the difference was no longer significant in patients with BMI >60. The most significant difference in peak and plateau pressures after abdominal opening was observed in patients with BMI <50.

Conclusion: Abdominal opening improves the conditions of mechanical ventilation in morbidly obese patients; when BMI is over 60 kg m-2, this improvement may not be relevant.

Background: The number of surgical interventions performed in obese patients has recently been increasing. Anaesthesia in a morbidly obese patient may be difficult, due to many pathophysiologic changes and co-morbidities, together with altered pharmacokinetics and pharmacodynamics of anaesthestic agents. We present a case of multimodal preventive analgesia in a bariatric patient with chronic renal failure.

Case report: A 36-year-old, morbidly obese man (BMI 47.8 kg m-2) was scheduled for a laparoscopic adjustable gastric banding (LAGB). The anaesthetic risk was increased because of hypertension, chronic renal failure, steatohepatitis and obstructive sleep apnoea syndrome. 30 minutes before anaesthesia, the patient received 2 g iv paracetamol. After induction, he was given 8 mg dexamethasone and 100 mg tramadol. All port-sites were infiltrated with 0.5% bupivacaine and adrenaline, both before skin incision, and before wound closure. Since NSAIDs and opioids were contraindicated because of the patient's co-morbidities, postoperative analgesia consisted of tramadol and paracetamol, given alternately, every 3 hours. The patient was discharged home 28 hours after surgery.

Discussion and conclusion: According to the Polish Postoperative Pain Management Recommendations 2008, the pain after LAGB is multifactorial and rated as category 2. The pre-emptive analgesia and postoperative regimen presented in this case can be recommended in similar cases.

Background: Several surveys have been published, documenting the lack of knowledge of cardiopulmonary resuscitation (CPR) among anaesthesiology residents. As a result, we decided to assess the competency of local trainees in basic and advanced CPR.

Methods: The survey was conducted among 26 residents in anaesthesiology who were asked twice (at the beginning, and at the end of refresher courses) to complete an open test on adult and paediatric CPR guidelines.

Results: The results in the first, introductory surveys were poor. Most of the wrong answers concerned the age borderline between an adult and a child; the correct CPR sequences and their modification in children; and paediatric medication. The respondents were not able to define all reversible causes of cardiac arrest. The second survey were somewhat better, but the respondents could still not name the correct lidocaine dosage in all age groups.

Conclusions: Residents in anaesthesiology show the tendency their knowledge of resuscitation guidelines to decay. Refresher life support courses should be mandatory for this group of physicians.

Background: The aim of the study was to review our three year experience with translumbar insertion of dialysis catheters.

Methods: In five adult patients (4 males and one female, mean age 45 yr), requiring dialysis due to end-stage chronic renal failure, the inferior vena cava was cannulated because of the impossibility of using any other approach. All procedures were performed under fluoroscopy. After visualisation of the inferior vena cava by injection of contrast medium into a peripheral vein, the vena cava was punctured with a 20 cm long needle, at the L3 level. The position of the needle was confirmed by injection of contrast medium, and the vein was then cannulated with a peel-away cannula, using a standard Seldinger technique. Subsequently, a pre-tunneled silastic catheter was introduced and secured.

Results: The catheters were used for from 3 to 10 months. No case of permanent catheter dysfunction was noted. Three episodes of temporary thrombosis, in two patients, were successfully treated with heparin and urokinase. Three catheters became contaminated, but they were treated without the necessity for catheter removal.

Conclusion: The described method is a safe and effective way of securing haemodialysis access in patients where a standard approach is not possible.

Background: Identification of pathogens in severe fungal infections, by positive cultures, is usually difficult, delays appropriate therapy, and impairs treatment. Despite progress in biologic sciences, the diagnosis of candidiasis still poses a challenge. Early symptoms are not specific, and cultures are usually negative. Molecular methods are rarely used in clinical practice. Common empiric therapy of suspected fungal infection is based on examination, history, and analysis of risk factors. The aim of the study was to analyse fungal infections in ITU and to find factors which may help in their recognition.

Methods: In this retrospective study, the medical histories of ITU patients were analysed. Patients were divided into two groups: I - suspected and II - confirmed, fungal infections. The factors considered were: age, gender, suspected source of fungal infection, co-existing bacterial infection, Candida Score, laboratory tests taken on the day of fungal infection diagnosis (leukocyte count, platelets, and CRP), duration of hospitalisation, declarations of infection from departments, and results of treatment.

Results: Statistically significant differences between the groups were found in Candida Scores, duration of hospitalisation and departments of infection. The Candida Scores were higher among those patients in whom infections were already suspected. In this group, the duration of hospitalization was shorter, and infections frequently developed during hospitalisation in the ITU.

Conclusion: The analysis of infections and Candida Scores helped to initiate prompt antifungal therapy and to reduce the duration of hospitalisation. Infection markers that were routinely used in the ITU were not specific, did not allow identification of patients with fungal infection.

Background: The protective lung strategy for severe ARDS, has markedly decreased the associated morbidity and mortality. Sometimes, even the best instrumentation and therapeutic strategy may be insufficient, and extracorporeal gas exchange support is necessary. We describe a desperate case of ARDS, in which various modes of ventilation, combined with vigorous extracorporeal support, resulted in a successful outcome.

Case report: A 35-year-old man, a heavy smoker, was admitted to the hospital because of lobar pneumonia. Despite wide spectrum antimicrobial therapy, he developed ARDS and was placed on a ventilator. Standard ventilation was ineffective and veno-venous ECMO was instituted. The extravascular lung water index (EVLWI) was extremely high (over 30 mL kg-1) and signs of a hyperdynamic circulation (CI 6.1 L m-2 min-1) were observed. Modification of the inotropic support and continuous infusion of furosemide resulted in normalisation of the hydration status, and over a week of ECMO therapy, the patient's general condition improved to the stage that he was scheduled to be weaned from extracorporeal treatment. On the 7th day however, he suddenly deteriorated. A lung CT-scan revealed bilateral pneumothoraces and diffuse pulmonary embolism. Three thoracic drains were inserted, but unfortunately, the drainage was complicated by massive bleeding and a subsequent thoracotomy. Two days later, a gastrointestinal haemorrhage occurred. Heparin dosage was reduced, and ECMO was discontinued and replaced with HFOV. This resulted in adequate oxygenation, however because of ineffective CO2 elimination, pumpless arteriovenous extracorporeal lung assist (PECLA) was instituted, allowing conventional ventilation to be resumed after 8 days. The further clinical course was complicated by persistent bilateral pneumothoraces, pleural effusion and Pseudomonas nosocomial infection. The man eventually recovered after 54 days in the ICU, and was transferred to a rehabilitation department.

Discussion and conclusion: ECMO has been recommended for severe ARDS since it avoids overdistension of the lungs and the use of high oxygen concentrations. Early institution of ECMO decreases mortality and morbidity in rapidly progressing ARDS. In the described case, ECMO was probably started too late, after volutrauma has already occurred. A combination of HFOV and PECLA may be recommended in selected cases, in which CO2 retention poses a serious problem.