Anestezjologia intensywna terapia最新文献

Haemodialysis central venous catheters are commonly being introduced in patients requiring emergency or chronic renal replacement therapy. There are two main categories of haemodialysis catheters: 1. Non-tunnelled, uncuffed, designed for short-term venous access of up to three weeks. They are, made of stiff materials such as polyurethane or polyvinyl. 2. Tunnelled, cuffed catheters. They are usually made of silicone, silastic elastomeric, or carbothane, are much softer and can be used for both temporary and permanent access. The latter catheters are usually inserted via peel-away sheaths, introduced using the Seldinger technique. Unlike surgically implanted devices, they can be used immediately after correct placement under fluoroscopy. The paper reviews catheters currently available, including discussion of materials, design, vascular access sites, and possible complications.

Background: Spontaneous respiration with 100% oxygen prior to induction of anaesthesia (preoxygenation) may enable safe management of an apnoeic phase. In the majority of patients, three minutes of inhalation of 100% of oxygen should result in almost complete (>90%) saturation of FRC. However, this may not be true in morbidly obese, because of their limited FRC and oxygen reserve.

Methods: This was a prospective, non-randomised study in morbidly obese patients (BMI >40 kg m2). All patients were positioned in a 25 degrees head-up position, and were asked to breathe 100% O2 (flow rate 8 L min(-1)) via a tight face mask. We measured the time from the beginning of inhalation of 100% O2, to achievement of E(T)O2 >90%.

Results: Forty-three patients with a mean BMI of 47 kg m(-2) were enrolled to the study. The mean time to E(T)O2 >90% was 295 sec, but in only 25% of patients was the time shorter than 3 min. Based on the results obtained, we estimated that the safe time for pre-oxygenation in 95% of morbidly obese patients should be 450 sec.There was no correlation between BMI, weight, age, and the time taken to achieve E(T)O2 > 90%.

Conclusion: We recommend pre-oxygenating morbidly obese patients for longer than those with standard body weight. Eight minutes of 100% oxygen inhalation should be effective in the majority of these patients.

Background: Central venous cannulation is necessary for long-term parenteral nutrition in premature infants. Peripherally inserted long catheters are commonly used in these patients but even this relatively simple technique can end in serious complications. We present a case in which perforation of the vena cava and migration of the catheter to the intrapleural space resulted in multiple organ failure and death.

Case report: A 700 g bw. infant, born at 28 weeks of gestation, was referred to our centre because of suspected bowel perforation. In the referring hospital, the infant had a central venous catheter inserted peripherally. The catheter migrated to the right intrapleural space, and parenteral formula was delivered over several hours to the right pleura, resulting in hydrothorax with serious compression of the lung and atelectasis. Emergency laparotomy did not reveal any pathology and a chest tube was inserted into the right pleura; the effusion fluid contained a large number fat particles. The child's condition worsened and he died 16 days after surgery because of multiple organ failure and sepsis.

Conclusion: Accidental migrations of central venous catheters to the pleural space have been described by many authors. It can result in severe pneumonia, cardiac tamponade or sepsis and is often fatal. We conclude that central venous catheters in premature infants should be inserted under ultrasonography or fluoroscopy. Catheters should never be forced along vessels; their size ought to be adjusted to age, and a free outflow of blood should be obtained before they are used.

Sugammadex is a modified gamma cyclodextrin, specifically designed for the reversal of neuromuscular blockade (NMB) induced by the steroidal neuromuscular blocking agents, rocuronium and vecuronium. Sugammadex acts by encapsulating the unbound drug molecules and reducing their concentration at the neuromuscular junction, allowing rapid reversal of NMB at every stage. Unlike acetylcholinesterase inhibitors, sugammadex is also effective in the reversal of profound NMB and is well tolerated. The recommended doses are in the range of 2-16 mg kg(-1), depending on the intensity of the block. Perioperative neuromuscular transmission monitoring is mandatory in enabling the choice of the right doses of sugammadex. This review presents various aspects of the use of sugammadex in adult and paediatric patients, and provides guidelines for practical administration.

Background: In-hospital cardiac arrest is still associated with a high mortality rate, due to late recognition of life-threatening processes such as progressive hypotension, or cerebral ischemia.The aim of the study was to analyse some selected parameters influencing early results of in-hospital cardiopulmonary resuscitation.

Methods: We analysed cardiopulmonary resuscitation reports, prepared following in-hospital cardiac arrests, according to the Utstein templates. In each case, resuscitation was performed according to the recent ERC guidelines.

Results: Thirty-eight reports were analysed. 16% of cardiac arrests were caused by defibrillation-susceptible cardiac rhythms, and 84% were non-defibrillation-susceptible. Return of spontaneous circulation was achieved in 45% of cases: in 67% of defibrillation-susceptible cardiac rhythm arrests, and 40% of non-defibrillation-susceptible cardiac rhythm situations.

Conclusion: The mechanism of cardiac arrest determines the early chance of survival in in-hospital cardiac arrest.

Multidrug-resistant Gram-negative bacteria pose a serious and rapidly emerging threat to patients in healthcare settings, and are especially prevalent and problematic in intensive therapy units. Recently, the emergence of pandrug-resistance in Gram-negative bacteria poses additional concerns. This review examines the clinical impact and epidemiology of multidrug-resistant Gram-negative bacteria as a cause of increased morbidity and mortality among ITU patients. Beta-lactamases, cephalosporinases and carbapenemases play the most important role in resistance to antibiotics. Despite the tendency to increased resistance, carbapenems administered by continuous infusion remain the most effective drugs in severe sepsis. Drug concentration monitoring, albeit rarely used in practice, is necessary to ensure an effective therapeutic effect.

The authors discuss the usefulness of therapeutic hypothermia for neuroprotection in patients with hypoxic cerebral damage. Although first reports on this method were published more than 50 years ago, it gained wider popularity at the end of 20th century. This popularity was related to the fact that deep hypothermia (below 30 degrees C) was displaced by mild hypothermia using higher temperatures (32-35 degrees C). The therapeutic benefit of mild hypothermia is based on the decrease of cerebral metabolism (5-7% per one degree Celsius). The ATP consumption by neurons is decreased despite the lack of glucose and oxygen associated with cardiac arrest, and membrane function is longer preserved. Hypothermia also prevents cerebral oedema, both of vascular and cytotoxic origin, and other reactions associated with reperfusion injury. Recently, the American Heart Association and European Resuscitation Council recommended the use of mild hypothermia (32-34 degrees C) in adult patients after ventricular fibrillation. Some clinical data also indicates that induced hypothermia reduces cerebral hypoxic ischemic injury. Randomized clinical trials in newborns with hypoxic ischemic encephalopathy confirm improved neurological outcomes and survival at 18 months of age with therapeutic hypothermia. The use of hypothermia after craniocerebral and spinal trauma, or ischemic brain damage is controversial, and not widely recommended. The authors describe various methods of inducing hypothermia in clinical settings; perhaps the most effective is intravenous infusion of cold fluids together with superficial cooling. Side effects and complications are discussed. They conclude that mild hypothermia can be regarded as a useful therapy in adult patients after VF cardiac arrest, and in neonates with hypoxic cerebral brain damage.

Background: Modern medicine is becoming increasingly aware of economic-organizational aspects. In the field of anaesthesiology, the number of agents used markedly increases due to continuous pharmacological progress. A high proportion of them are expensive. The aim of the study was to compare hospital costs of general vs. subarachnoid anaesthesia for Caesarean section.

Methods: Costs were assessed from the perspective of a service provider. Direct costs were measured using the micro-cost method based on detailed data of the resources used during anaesthetic procedures. Non-medical costs were calculated by the direct allocation method (costs of auxiliary units). Unit costs of hospitalization were determined using the "top-to-bottom" assessment. Costs related to anaesthetic staff work were calculated by the micro-cost method based on duration of anaesthesia. Sensitivity analysis was performed.

Results: Mean direct cost of general anaesthesia for Caesarean section was lower than of subarachnoid anaesthesia. Mean personnel cost of subarachnoid anaesthesia was found to be higher compared to general anaesthesia. Costs of pharmaceuticals for general anaesthesia were lower than for subarachnoid one. Costs of medical materials related to the method used were significantly higher in subarachnoid anaesthesia.

Conclusions: Subarachnoid anaesthesia takes more time than general one, which results in higher costs of medical staff work. Avoiding inhalation anaesthetics (sevoflurane) makes indirect costs of general anaesthesia lower compared to subarachnoid anaesthesia.