Anestezjologia intensywna terapia最新文献

Background: Pulmonary haemorrhage due to negative airway pressure is a very rare but potentially fatal complication of general anaesthesia. Only a few such cases have been reported in the literature.

Case report: A previously healthy, 25-year-old man underwent general anaesthesia for internal stabilisation of a fractured clavicle. Shortly after extubation, he developed laryngospasm followed by pulmonary bleeding and acute respiratory failure. A CT-scan revealed acute pulmonary oedema. The patient was treated with mechanical ventilation and recovered completely after 72 hours.

Conclusion: This rare complication may occur unexpectedly during routine anaesthesia. The rapid recognition and management of laryngospasm is essential.

Background: The long-term survival rate after sudden cardiac arrest remains low despite progress in resuscitation, possibly due to acute ischemia of vital organs and subsequent general inflammatory reaction. We investigated a possible relationship between inflammatory cytokine concentrations and cardiac arrest (CA) survival.

Methods: Fifty one adult acute coronary syndrome patients, 35 males and 16 females, aged 62 +/- 12 years, who survived out-of-hospital CA (45%) and in-hospital CA (55%) were enrolled in the study. Twenty four of the patients died (D-CA); the other 27 survived and were discharged from the hospital (S-CA). Clinical conditions were rated by the Simplified Acute Physiology Score II (SAPS II) and Multiple Organ Dysfunction Score (MODS). Blood samples were obtained immediately after cardiac arrest. Serum concentrations of IL-6, IL-10 and TNF-alpha were analysed and rated against survival rates.

Results: Higher mean concentrations of all cytokines were found in the D-CA group, when compared to the S-CA group. The mean concentration of IL-6 was 225 +/- 178 IU mL(-1) in the D-CA patients and 88 +/- 120 IU mL(-1) in the S-CA group (p = 0.006), and correlated inversely with survival (p = 0.018). The higher concentrations of IL-10 and TNF-alpha in non-survivors were not significant and bore no relation to survival rates. We also found significantly higher SAPS II and MODS scores, which correlated with both IL-6 levels and survival rates.

Conclusions: The relationship between the concentration of inflammatory cytokines and survival has been reported by others and should be regarded as a marker of generalized inflammatory response. A concentration of IL-6 is of high prognostic value.

Regional cerebral oximetry (RCO), introduced to clinical practice 15 years ago, is a non-invasive method of measuring regional cerebral venous oxygen saturation using optical spectroscopy. Monitoring during anaesthesia is mainly directed at providing optimal oxygenation and avoiding desaturation incidents. RCO offers new and broader possibilities for measurement of cerebral and regional tissue oxygenation.This method has proven useful both in anaesthesia and in intensive care; The article shows the indications for which this method of monitoring may be useful during anaesthesia and in intensive care units, allowing the avoidance of more invasive methods, e.g., mixed venous saturation and venous bulbar saturation. It is also extremely useful in small children in whom cannulation of large vessels may be difficult or impossible. In the review, possible applications of the method are presented and discussed.

Background: Obstetric anaesthesia and analgesia have come to be regarded as a subspecialty.Various countries and societies have published evidence-based guidelines. In this paper are presented the results of a survey of anaesthesia for Caesarean section (CS), conducted in Poland in 2009.

Methods: 432 questionnaires were sent. The questions asked related to: characteristics of the hospital, premedication, preoperative laboratory screening, methods of anaesthesia, local analgesic agents (LA), postoperative enteral feeding, positioning, and analgesia.

Result: The questionnaire return rate was 24%. Only 10 hospitals (out of 98) employed anaesthesiologists exclusively for obstetric anaesthesia and analgesia. Alkalinisation of gastric contents, gastric emptying drugs and H blockers were used in 38% of hospitals in elective CS, and in 32% of hospitals in emergency CS. Preoperative laboratory screening was conducted in 93% of hospitals before elective CS, and 77% before emergency CS (usually haematocrit, haemoglobin concentration, red blood count and platelets). In 50% of hospitals, the lowest acceptable concentration of platelets before central blocks was 100,000; while in 30% of hospitals, a level of 50,000 was considered acceptable. Spinal anaesthesia was used in more than 90% of elective CS cases in 75% of hospitals, in emergency CS--in 50% of patients only and in the presence of a foetal stress in 65% of hospitals general anaesthesia was preferred. Bupivacaine remains the most commonly used LA (97%). Lidocaine is still used in 3% of hospitals, and adjuvants are used in 42% of hospitals. The flat supine position was recommended in 75% of hospitals; and 13% of parturients were requested to stay in this position for 24 hours. In 74% of hospitals, enteral feeding was delayed, and in 27% was delayed for 24 hours after CS (27%). Postoperative analgesia was based on parenteral analgesics (usually paracetamol and ketoprofen). Pethidine was used in 35% of hospitals.

Conclusion: There is an urgent need for national guidelines on obstetric anaesthesia and analgesia in Poland.

In recent years, significant interest has been observed in intra-abdominal hypertension and abdominal compartment syndromes. Intra-abdominal pressure (IAP) has been defined as a static pressure between organs in the abdominal cavity. Continuous or recurrent increase in the IAP above 12 mm Hg (1.6 kPa) is regarded as abdominal hypertension (IAH). Among the most common causes of IAH are massive fluid resuscitation after major injuries or burns, and ischemia of intestines after major vascular surgery. Abdominal compartment syndrome has been defined as a continuous intra-abdominal pressure above 20 mm Hg (2.67 kPa) with coexisting organ dysfunction or failure. The mortality of patients with recognized abdominal compartment syndrome may be as high as 42%. Diagnosis of intra-abdominal hypertension is based on the measurement of IAP only. The World Society of the Abdominal Compartment Syndrome (WSACS) has been advising screenings of IAP in all patients admitted to intensive care units with certain risk factors. As a standard measurement of IAP, the pressure in the bladder filled maximally with 25 mL of sterile normal saline is accepted. IAP should be measured at the end-expiratory phase, in the flat supine position, after relaxation of abdominal muscles and referred to the median axillary line as a zero-level. In confirmed cases of IAH and/or ACS, immediate action should be taken. It consists of evacuation of gastric and bowel contents, maintenance of adequate blood pressure, diuretics and/or ultrafiltration, and ultimately deeper sedation and/or muscle relaxation. Surgical percutaneous evacuation of the fluid or a decompression laparotomy may be considered.

Pain in children, especially in infancy, is frequently underestimated. Surprisingly, in ancient times, writers were more aware of the existence of pain in infancy and the need for its relief than in 20th century. They rated pain perception as being higher in infancy than in childhood. The study by McGraw (1941), although badly designed, convinced the vast majority of clinicians that infants do not feel pain and do not require analgesia. This theory, reinforced by the fear of using opioids in young children, dominated medical thinking for more than 30 years. Later studies on pain perception in foetuses, and careful analysis of infants' reactions to blood sampling, helped doctors to understand the necessity of adequate analgesia in young children. In this review, we present the approach to pain in children over centuries, from ancient times to the latest developments in this field.

The role, and even the necessity of hospital ethics committees, is not universally agreed upon. In the 2005, the UNESCO advised the establishment of four types of bioethics committees at different levels: policy-making and/or advisory bioethics committees/commissions/councils at national levels (PMAs), health-professional association (HPAs) bioethics committees, health care/hospital ethics committees (HECs), and research ethics committees (RECs). Until recently in Poland, only RECs existed. The article discusses the necessity of establishing HECs nationwide. So far, only two bodies of this kind exist in two large, academic paediatric hospitals. In some other academic centers, institutional RECs try to act as HECs, but it is only a temporary solution. A nationwide discussion, and formal establishment of HECs will be necessary.

Background: Metallo-beta-lactamases (MBL) are the enzymes that are able to hydrolyse almost the full range of beta-lactame antibiotics--penicillins, cephalosporins and carbapenems. The latter are the drugs of choice for treatment of serious infections caused by Enterobacteriaceae strains, which produce extended-spectrum-beta-lactamases. The presence of MBL-producing strains markedly decreases the therapeutic possibilities in severe, life-threatening infections.

Case report: We present the case of a 61-yr-old man who underwent surgery for acute leg ischemia, and in whom a bifurcation prosthesis was implanted. The postoperative course was complicated with serious nosocomial infection, caused by MBL-positive Klebsiella pneumoniae strains. Despite multi drug treatment and intensive care, the patient died 30 days after surgery due to multi organ failure. All isolates cultured from the patient were resistant to carbapenems with their MICs exceeding 32 microg mL(-1). The presence of MBLs was detected with the double-disk synergy test. The presence of genes encoding MBLs was determined with a commercial kit, hyplex MBL ID (Bag Health Care, USA). The isolate from blood was found to carry the blaVIM-like family gene, located in a conjugative plasmid.

Conclusion: The MBL-producing isolates were the first K. pneumoniae isolates of the kind identified in Poland. They present a serious danger, limiting the usefulness of carbapenems in ITU patients. We recommend that detection of MBLs in Enterobacteriaceae should be regarded as a standard in Polish hospitals.

In some countries, the influenza A/H1N1v pandemic, recently announced by WHO, was severe. Up to 10-30% of patients required ITU therapy due to rapidly increasing respiratory failure. In Poland, recommendations concerning the management of A/H1N1v infections, including those during ITU hospitalization, are vague and scattered. The WHO guidelines stress that the spread of infections should be limited by observance of personal hygiene rules, use of appropriate preventive measures and suitable administrative and technical actions. Only 30-60% of medical staff cleans their hands. Hand washing practices are inaccurate and too rare. Likewise, protective clothes and face masks are worn too rarely. FFP3 is believed to be the best mask in such cases, if properly used. Such masks should be individually adjusted, placed tightly over the face, without leaks around the edges. After use, masks and protective clothes should be considered as medical waste. Moreover, the guidelines for management of ITU patients diagnosed with A/H1N1v infections are extremely relevant in cases of other infections.

The incidence of allergic reactions during anaesthesia has been estimated to be from 1:3500 to 1:20000, with muscle relaxants being the most common allergens. Symptoms may involve all organs and systems with various intensities--from mild skin reactions to bronchospasm and cardiovascular collapse in the most severe cases. In a case of suspected perioperative allergic reaction, the management should not be limited to resuscitation and restoration of basic life functions, but must include careful investigation of potential allergens. An appropriate diagnostic strategy is essential for confirmation of an allergic reaction, identification of the allergen, and recommendations for future prevention. In this review, the various aspects of anaphylaxis and anaphylactoid reactions to muscle relaxants are discussed, including the role of tryptase and its assay in the diagnostic regimen.