RESUMEN
BACKGROUND: Mechanical ventilation with high tidal volumes aggravates lung injury in patients with acute lung injury or acute respiratory distress syndrome. The authors sought to determine the effects of short-term mechanical ventilation on local inflammatory responses in patients without preexisting lung injury. METHODS: Patients scheduled to undergo an elective surgical procedure (lasting > or = 5 h) were randomly assigned to mechanical ventilation with either higher tidal volumes of 12 ml/kg ideal body weight and no positive end-expiratory pressure (PEEP) or lower tidal volumes of 6 ml/kg and 10 cm H2O PEEP. After induction of anesthesia and 5 h thereafter, bronchoalveolar lavage fluid and/or blood was investigated for polymorphonuclear cell influx, changes in levels of inflammatory markers, and nucleosomes. RESULTS: Mechanical ventilation with lower tidal volumes and PEEP (n = 21) attenuated the increase of pulmonary levels of interleukin (IL)-8, myeloperoxidase, and elastase as seen with higher tidal volumes and no PEEP (n = 19). Only for myeloperoxidase, a difference was found between the two ventilation strategies after 5 h of mechanical ventilation (P < 0.01). Levels of tumor necrosis factor alpha, IL-1alpha, IL-1beta, IL-6, macrophage inflammatory protein 1alpha, and macrophage inflammatory protein 1beta in the bronchoalveolar lavage fluid were not affected by mechanical ventilation. Plasma levels of IL-6 and IL-8 increased with mechanical ventilation, but there were no differences between the two ventilation groups. CONCLUSION: The use of lower tidal volumes and PEEP may limit pulmonary inflammation in mechanically ventilated patients without preexisting lung injury. The specific contribution of both lower tidal volumes and PEEP on the protective effects of the lung should be further investigated.
Asunto(s)
Neumonía/prevención & control , Respiración con Presión Positiva/métodos , Respiración Artificial/métodos , Volumen de Ventilación Pulmonar/fisiología , Anciano , Femenino , Humanos , Mediadores de Inflamación/sangre , Enfermedades Pulmonares/sangre , Enfermedades Pulmonares/fisiopatología , Enfermedades Pulmonares/prevención & control , Masculino , Persona de Mediana Edad , Neumonía/sangre , Neumonía/fisiopatologíaRESUMEN
BACKGROUND: Alveolar fibrin deposition is a hallmark of acute lung injury, resulting from activation of coagulation and inhibition of fibrinolysis. Previous studies have shown that mechanical ventilation with high tidal volumes may aggravate lung injury in patients with sepsis and acute lung injury. The authors sought to determine the effects of mechanical ventilation on the alveolar hemostatic balance in patients without preexistent lung injury. METHODS: Patients scheduled for an elective surgical procedure (lasting > or = 5 h) were randomly assigned to mechanical ventilation with either higher tidal volumes of 12 ml/kg ideal body weight and no positive end-expiratory pressure (PEEP) or lower tidal volumes of 6 ml/kg and 10 cm H2O PEEP. After induction of anesthesia and 5 h later bronchoalveolar lavage fluid and blood samples were obtained, and markers of coagulation and fibrinolysis were measured. RESULTS: In contrast to mechanical ventilation with lower tidal volumes and PEEP (n = 21), the use of higher tidal volumes without PEEP (n = 19) caused activation of bronchoalveolar coagulation, as reflected by a marked increase in thrombin-antithrombin complexes, soluble tissue factor, and factor VIIa after 5 h of mechanical ventilation. Mechanical ventilation with higher tidal volumes without PEEP caused an increase in soluble thrombomodulin in lavage fluids and lower levels of bronchoalveolar activated protein C in comparison with lower tidal volumes and PEEP. Bronchoalveolar fibrinolytic activity did not change by either ventilation strategy. CONCLUSIONS: Mechanical ventilation with higher tidal volumes and no PEEP promotes procoagulant changes, which are largely prevented by the use of lower tidal volumes and PEEP.
Asunto(s)
Trastornos de la Coagulación Sanguínea/complicaciones , Respiración con Presión Positiva , Alveolos Pulmonares/fisiología , Respiración Artificial , Volumen de Ventilación Pulmonar/fisiología , Anciano , Anestesia General , Antitrombinas/metabolismo , Líquido del Lavado Bronquioalveolar , Protocolos Clínicos , Femenino , Fibrinólisis/fisiología , Hemodinámica/fisiología , Hemostasis/fisiología , Humanos , Masculino , Persona de Mediana Edad , Activadores Plasminogénicos/metabolismo , Alveolos Pulmonares/irrigación sanguínea , Circulación Pulmonar/fisiología , Procedimientos Quirúrgicos Operativos , Trombina/metabolismoRESUMEN
We used Orthogonal Polarization Spectral Imaging to examine the microcirculation of the vaginal mucosa in nine anesthetized patients during two consecutive anesthetic interventions: hypervolemic hemodilution using hydroxyethyl starch followed by thoracic epidural lidocaine. Images taken before and after each intervention were compared. During hypervolemic hemodilution, systolic blood pressures increased significantly, but functional capillary density remained unchanged. Epidural anesthesia decreased systolic and diastolic blood pressures, but there was no change in capillary density, venular diameter, or flow velocity. We concluded that when using Orthogonal Polarization Spectral imaging, no consistent effects on the microcirculation of the vaginal wall can be detected.
Asunto(s)
Analgesia Epidural , Hemodilución , Lidocaína/administración & dosificación , Microcirculación , Adulto , Presión Sanguínea/efectos de los fármacos , Femenino , Humanos , Inyecciones Epidurales , Microcirculación/efectos de los fármacos , Microscopía Fluorescente , Microscopía de Polarización , Persona de Mediana EdadRESUMEN
BACKGROUND: Spinal cord ischemia and visceral ischemia may occur simultaneously during thoracoabdominal aortic aneurysm repair. The present rabbit study investigated the effect of a temporary interruption of the visceral perfusion on the development of ischemia-reperfusion injury of the spinal cord. METHODS: Spinal cord ischemia was induced by occlusion of the infrarenal aorta for variable durations (6 to 20 minutes) in 32 rabbits. In the visceral ischemia group, 20-minute concurrent clamping of the celiac trunk and mesenteric arteries was performed. At 24, 48, and 72 hours after ischemia, neurologic outcome was assessed in the control and visceral ischemia group. The PD50 (the duration of ischemia that produces lower limb neurologic deficits in 50% of the animals) was determined by quantal bioassay analysis. At 72 hours, histologic evaluation of spinal cord infarct size was performed. RESULTS: Compared with control animals, PD50 was significantly longer in the visceral ischemia group at 48 hours and 72 hours after ischemia. Neurologic and histologic outcomes correlated well (r = -0.90). CONCLUSIONS: The results of the present rabbit study suggest that concurrent temporary visceral ischemia does not aggravate spinal cord ischemic injury in the rabbit. Moreover, the results suggest that concurrent visceral ischemia may increase the tolerance of the spinal cord to ischemic damage.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Isquemia/etiología , Isquemia de la Médula Espinal/etiología , Vísceras/irrigación sanguínea , Animales , Velocidad del Flujo Sanguíneo , Modelos Animales de Enfermedad , Isquemia/patología , Isquemia/prevención & control , Nitroprusiato/uso terapéutico , Conejos , Isquemia de la Médula Espinal/patología , Isquemia de la Médula Espinal/prevención & controlRESUMEN
OBJECTIVE: Use of lung-protective mechanical ventilation (MV) by applying lower tidal volumes is recommended in patients suffering from acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Recent data suggest that lung-protective MV may benefit non-ALI/ARDS patients as well. This study analyzed tidal volume settings in three ICUs in The Netherlands to determine the effect of feedback and education concerning use of lung-protective MV. DESIGN AND SETTING: Observational study in one academic and two nonacademic "closed format" ICUs. PATIENTS: Intubated mechanically ventilated subjects. INTERVENTIONS: Feedback and education concerning lung-protective MV with special attention to the importance of closely adjusting tidal volumes to predicted body weight (PBW). RESULTS: Tidal volumes declined significantly within 6 months after intervention (from 9.8+/-2.0 at baseline to 8.1+/-1.7 ml/kg PBW) as the percentage of undesirable ventilation data points, defined as tidal volumes greater than 8 ml/kg PBW (84% vs. 48%). There were no differences between patients meeting the international definition criteria for ALI/ARDS and those not. Only four patients received tidal volumes less than 6 ml/kg PBW. Lower tidal volumes were still used after 12 months. Tidal volumes in patients on mandatory MV and patients breathing on spontaneous modes were similar. CONCLUSIONS: Feedback and education improve physician compliance in use of lung-protective MV.
Asunto(s)
Educación Continua , Retroalimentación , Adhesión a Directriz , Pautas de la Práctica en Medicina , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/prevención & control , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Síndrome de Dificultad Respiratoria/terapia , Volumen de Ventilación PulmonarRESUMEN
UNLABELLED: Working time reduction is an issue in many sectors of the economy of several countries. In the health care sector, this reduction is mostly felt in regions with a shortage of personnel. In The Netherlands, this is the operating theater suite. We designed this study to evaluate the effects of a policy reduction in working time from 38 to 36 h/wk on the performance of the operating theater suite. The study describes the policy process and its context. For retrospective before-and-after analyses of various performance variables, multivariate linear regression techniques were used. A 4% decrease to a 36-h work week was implemented in our hospital during a period of shortage of personnel in the labor market. This resulted in a 2% decrease in the number of surgical operations performed. The expected increased demand for nursing personnel is reflected in larger wages and the introduction of additional benefits. Additionally, the introduction of a 36-h work week and the 4-day working schedule was accompanied by an increase in absenteeism. Taken together, this resulted in an increase in nursing costs per average operation of 20%. This means that a small reduction in working time during a period of labor shortage can cause an important decrease in surgical productivity. In our hospital, this was accompanied by an increase in sick leave, resulting in a substantial increase of nursing costs per operation. IMPLICATIONS: Our retrospective study describes an increase of 20% in nursing costs after a 4% decrease in nurse working time. During the period of implementation of the new working schedule, an increase in sick leave was observed. The interaction between shortage of nursing personnel, working time, and wages is discussed.
Asunto(s)
Eficiencia Organizacional/economía , Enfermeras y Enfermeros/economía , Quirófanos/organización & administración , Admisión y Programación de Personal/economía , Servicio de Cirugía en Hospital/economía , Carga de Trabajo/economía , Citas y Horarios , Renta , Quirófanos/economía , Análisis de Regresión , Estudios Retrospectivos , Servicio de Cirugía en Hospital/organización & administración , Factores de TiempoRESUMEN
IMPLICATIONS: This case report describes the successful perioperative management of a patient with a rare and disabling neurologic disorder, the stiff person syndrome. The patient had a delayed emergence despite apparent full reversal of neuromuscular blockade. We suggest an interaction between the GABAergic effects of baclofen and volatile anesthetics as a possible cause.
Asunto(s)
Anestesia/métodos , Síndrome de la Persona Rígida , Anestesia/efectos adversos , Femenino , Humanos , Persona de Mediana Edad , Hipotonía Muscular/etiologíaRESUMEN
IMPLICATIONS: Neuropathic cancer pain caused by tumor infiltration in the sacral plexus is primarily treated by nonsteroidal antiinflammatory drugs, antidepressants, anticonvulsants, and opioids. In one patient with severe pain despite pharmacotherapy, a catheter for the continuous administration of local anesthetics was inserted along the first sacral root, resulting in markedly improved analgesia.
Asunto(s)
Bloqueo Nervioso/métodos , Neoplasias Ováricas/fisiopatología , Dolor Intratable/terapia , Raíces Nerviosas Espinales , Adulto , Femenino , Humanos , Región SacrococcígeaRESUMEN
IMPLICATIONS: In this case report we describe a technique used to provide local analgesia for surgical procedures. Although this technique has a reduced risk of complications, we present a patient who experienced a life-threatening paralysis without loss of consciousness during an attempted brachial plexus block with a posterior approach.