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BACKGROUND: Peri-operative respiratory adverse events (PRAEs) in paediatric patients with upper respiratory tract infections (URTIs) remain inadequately explored in patients allowed to proceed to anaesthesia and surgery. OBJECTIVE: To determine the incidence and risk factors of PRAE in children with URTI allowed to proceed to anaesthesia. DESIGN: Multicentre cohort study performed over 6 months in France. SETTING: Sixteen centres with dedicated paediatric anaesthetists. PATIENTS: Eligible patients were aged from 0 to 18 years with URTI symptoms on admission or a history of such over the preceding 4 weeks. MAIN OUTCOMES: The primary outcome of the study was to determine predictors of PRAE. Secondary outcomes were: predictors of peri-operative arterial desaturation and of the decision to proceed with anaesthesia and surgery in children with URTI. RESULTS: Overall, 621 children were included and 489 (78.7%) anaesthetised. Of those anaesthetised, 165 (33.5%) and 97 (19.8%) experienced PRAE and arterial desaturation, respectively. Factors predictive of PRAE included patient age, tracheal intubation and the absence of midazolam premedication. Factors predictive of peri-operative arterial desaturation included patient age, anaesthetist experience, endoscopic procedures and the presence of other PRAE. Factors predicting proceeding to anaesthesia in the context of URTI included anaesthetist experience, emergency procedures and the absence of severe URTI symptoms. CONCLUSION: The risk of PRAE in patients anaesthetised in the presence of URTI was similar to previous publications - close to 30%. In the light of our findings, first, current rescheduling indications should be questioned, and second, further medical and organisational strategies should be investigated to reduce PRAE in children with URTI. TRIAL REGISTRATION: The study was registered in the European Networks of Centers for Pharmacoepidemiology and Pharmacovigilance (EUPAS16436).
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Anestesia General/efectos adversos , Atención Perioperativa/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/epidemiología , Anestesia General/tendencias , Niño , Preescolar , Estudios de Cohortes , Femenino , Francia/epidemiología , Humanos , Lactante , Recién Nacido , Masculino , Atención Perioperativa/tendencias , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Infecciones del Sistema Respiratorio/prevención & control , Factores de RiesgoRESUMEN
Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.
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Butirilcolinesterasa/genética , Terapia Electroconvulsiva/métodos , Esquizofrenia/enzimología , Esquizofrenia/genética , Alelos , Humanos , Masculino , Mutación , Psicología del Esquizofrénico , Trastornos Relacionados con Sustancias/genética , Trastornos Relacionados con Sustancias/psicología , Succinilcolina , Adulto JovenRESUMEN
OBJECTIVE: The Formation de référents aux techniques d'intubation difficile (FRTID) is a French continuing medical education program on difficult airway management. Its objectives are to train experts in the task of training other physicians in their hospitals for better guideline compliance. Our aim was to describe the curriculum of the experts and to evaluate the program's efficacy via a prospective survey. METHODS: Each participant was asked to complete a questionnaire before (T0), immediately (T1), 6 (T6) and 12 (T12) months after the course. The main criterion was the proportion of the participants who declared that they had implemented at least one action to improve difficult airway management in their institution at 6 months. Other criteria included the proportion of participants who declared that they had modified their own clinical practice and the frequency of use of specific devices assessed on modified Likert numerical rating scales. RESULTS: Two hundred and forty-four participants were included in the survey. One hundred and three, 91 and 62 participants responded to the T1 (immediately after the course), T6 (6 months later) and T12 (12 months later) questionnaires, respectively; 73 physicians (i.e. 30% of all participants and 80% of the survey responders) declared that they had implemented at least one action likely to optimize the management of difficult airways. On the T6 and T12 questionnaires, 91% and 97% of the responders respectively declared that they had changed their clinical practice. The course has resulted in increased use of transtracheal oxygenation with manual devices (Manujet(®), Enk(®)) and Seldinger cricothyroidotomy as well as paediatric difficult airway techniques such as paediatric sized elastic gum and Airtraq™ or fibrescopic intubation under general anaesthesia with spontaneous ventilation (through a laryngeal mask). CONCLUSION: These data encourage the training of experts in difficult airways. This curriculum is contributing to the dissemination of the recommendations among a large number of practitioners.
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Manejo de la Vía Aérea , Anestesiología/educación , Competencia Clínica , Adulto , Manejo de la Vía Aérea/instrumentación , Anestesia General , Anestesiólogos , Niño , Cartílago Cricoides/cirugía , Evaluación Educacional , Humanos , Intubación Intratraqueal/instrumentación , Intubación Intratraqueal/métodos , Máscaras Laríngeas , Estudios Prospectivos , Mejoramiento de la Calidad , Encuestas y CuestionariosRESUMEN
OBJECTIVES: Cerebral non-invasive monitoring of oxygen saturation by near-infrared spectroscopy (rSO2) during paediatric cardiac surgery is supposed to decrease the risk of neurological complications. Since haemoglobin level is one of the factors changing rSO2, we aimed to explore if rSO2 monitoring influences intra-operative RBC (red blood cell) transfusion threshold and volumes, as well as the duration of ICU stay. METHODS: The design was a retrospective analysis involving 91 children less than 2 years of age (including 16 neonates) with a congenital heart disease requiring surgical treatment with or without cardiopulmonary bypass from January 2006 to August 2009. Systematic rSO2 monitoring was introduced after September 2007 (n=56). The independent factors associated with the intra-operative transfusion threshold haemoglobin (Hb) level>9.5g/dL, total volume of intra-operative RBC transfusion<30mL/kg and ICU stay<6 days were identified by multivariate analysis logistic regression. Data were expressed as medians (25-75%). RESULTS: Cardiac malformations and demographic characteristics were similar in both periods. Two independent factors, weight and rSO2 monitoring, were identified as independent factors associated with the three end-points. The transfusion threshold, total transfusion volume and ICU stay with and without rSO2 were 9.8 (8.9 to 10.3) versus 8.7 (8.2 to 9.6) g/dL (P<0.0001), 20 (14-49) versus 36 (22.5-51.5) mL/kg (P=0.0165) and 5 (3-8) versus 7 (5-10.7) days (P=0.0084), respectively. CONCLUSION: rSO2 monitoring changed our transfusion strategy with an earlier transfusion but a reduced total RBC volume and decreased the length of ICU stay.
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Transfusión Sanguínea/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Cuidados Intraoperatorios/métodos , Monitoreo Intraoperatorio/métodos , Volumen Sanguíneo , Puente Cardiopulmonar , Estudios de Cohortes , Cuidados Críticos , Determinación de Punto Final , Transfusión de Eritrocitos , Femenino , Cardiopatías Congénitas/cirugía , Hemoglobinas/análisis , Humanos , Lactante , Recién Nacido , Tiempo de Internación , Masculino , Oxígeno/sangre , Estudios Retrospectivos , Espectroscopía Infrarroja CortaRESUMEN
OBJECTIVE: To evaluate whether the Script Concordance Test (SCT) can discriminate between levels of experience among anesthesiology residents and attending physicians. STUDY TYPE: Multicenter (Toulouse, Nantes, Bordeaux and Limoges), prospective, observational study. PATIENTS AND METHODS: A SCT made of 60 items was used to evaluate "junior residents" (n=60), "senior residents" (n=47) and expert anesthesiologists (n=10). RESULTS: There were no missing data in our study. Mean scores (±SD) were 69.9 (±6.1), 73.1 (±6.5) and 82.0 (±3.5) out of a potential score of 100 for "junior residents", "senior residents" and expert anesthesiologists, respectively. Results were statistically different between the 3 groups (P=0.001) using the Kruskall-Wallis test. The Cronbach's α score was 0.63. CONCLUSIONS: The SCT is a valid and useful tool for discriminating between anesthesia providers with varying levels of experience in anesthesiology. It may be a useful tool for documenting the progression of reasoning during anesthesia residency.
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Anestesiología/normas , Competencia Clínica/normas , Médicos/normas , Adulto , Educación de Postgrado en Medicina , Evaluación Educacional , Servicios Médicos de Urgencia , Femenino , Fracturas Cerradas/terapia , Humanos , Internado y Residencia , Masculino , Estudios ProspectivosRESUMEN
CONTEXT AND AIMS: Little is known about onset and duration of sciatic block after 0.5% levobupivacaine (Levo) versus 0.5% ropivacaine (Ropi) for ultrasound-guided technique. We assessed these parameters in the ultrasound-guided block, to know for the practice. SETTING AND DESIGN: A comparative randomized double-blind study was conducted in the University Hospital. MATERIALS AND METHODS: Were included 35 adults of ASA I-II, scheduled for foot surgery, presenting clear imaging of their sciatic nerve at mid-thigh. A volume of 20 mL of either 0.5% Levo or 0.5% Ropi were injected around the sciatic nerve at mid-thigh using ultrasound guidance (out of the plane) followed by placement of a catheter to use, if necessary, for perioperative analgesia. A femoral single shot block was systematically performed to block the saphenous nerve. The onset times until complete foot block (primary outcome) and the sensory and motor block duration (secondary outcome) were assessed using Wilcoxon test. Values were expressed as medians (1(st)-3(rd) quartile). RESULTS: Except for two delayed sciatic blocks in each group, the onset time otherwise was 35 min (20-60) in Ropi versus 40 min (30-60) in Levo, P = 0.5. Sensory block lasted longer in Levo, 17 h (14-27) compared with 15 h (10-17) in Ropi, P = 0.04. No significant between-group difference was found with motor block durations, 15 h (12-18) in Levo and 15 h (12-16) in Ropi, P = 0.3. CONCLUSION: No difference of onset times was found in ultrasound-guided sciatic block whether using Levo or Ropi. Levo induced a longer-lasting sensory block.
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BACKGROUND: Few data are available in the literature on risk factors for postoperative vomiting (POV) in children. OBJECTIVE: The aim of the study was to establish independent risk factors for POV and to construct a pediatric specific risk score to predict POV in children. METHODS: Characteristics of 2392 children operated under general anesthesia were recorded. The dataset was randomly split into an evaluation set (n = 1761), analyzed with a multivariate analysis including logistic regression and backward stepwise procedure, and a validation set (n = 450), used to confirm the accuracy of prediction using the area under the receiver operating characteristic curve (ROCAUC ), to optimize sensitivity and specificity. RESULTS: The overall incidence of POV was 24.1%. Five independent risk factors were identified: stratified age (>3 and <6 or >13 years: adjusted OR 2.46 [95% CI 1.75-3.45]; ≥6 and ≤13 years: aOR 3.09 [95% CI 2.23-4.29]), duration of anesthesia (aOR 1.44 [95% IC 1.06-1.96]), surgery at risk (aOR 2.13 [95% IC 1.49-3.06]), predisposition to POV (aOR 1.81 [95% CI 1.43-2.31]), and multiple opioids doses (aOR 2.76 [95% CI 2.06-3.70], P < 0.001). A simplified score was created, ranging from 0 to 6 points. Respective incidences of POV were 5%, 6%, 13%, 21%, 36%, 48%, and 52% when the risk score ranged from 0 to 6. The model yielded a ROCAUC of 0.73 [95% CI 0.67-0.78] when applied to the validation dataset. CONCLUSIONS: Independent risk factors for POV were identified and used to create a new score to predict which children are at high risk of POV.
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Náusea y Vómito Posoperatorios/diagnóstico , Náusea y Vómito Posoperatorios/epidemiología , Adolescente , Factores de Edad , Analgésicos Opioides , Anestesia General , Niño , Preescolar , Femenino , Francia/epidemiología , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Probabilidad , Estudios Prospectivos , Curva ROC , Reproducibilidad de los Resultados , Riesgo , Factores de Riesgo , Sensibilidad y Especificidad , Factores Sexuales , Factores de TiempoRESUMEN
PURPOSE: Preload responsiveness parameters could be useful in the hemodynamic management of septic shock. METHODS: A multicentric prospective echocardiographic observational study was conducted from March 2009 to August 2011. Clinically brain-dead subjects were included. Pulse pressure variations (ΔPPs) were recorded. Cardiac index, variation of the maximum flow velocity of aortic systolic blood flow, and right ventricular function parameters were evaluated via transthoracic echocardiography. Fluid responsiveness was defined by at least 15% cardiac index increase, 30 minutes after a 500-mL colloid solution infusion. The number of organs harvested was recorded. RESULTS: Twenty-five subjects were included. Pulse pressure variation could not discriminate responders (n=15) from nonresponders (n=10). The best ΔPP threshold (20%) could discriminate responders with a sensitivity of 100% and a specificity of 40%. Variation of the maximum flow velocity of aortic systolic blood flow, tricuspid annular plane systolic excursion, and right ventricle dilation could not discriminate responders from nonresponders. Eighteen subjects underwent organ harvesting. The number of organs harvested was higher in responders (3.5 [3-5]) than in nonresponders (2.5 [2-3]; P=.03). CONCLUSIONS: A ΔPP threshold of 13% is insufficient to guide volume expansion in donors. The best threshold is 20%. Fluid responsiveness monitoring could enhance organ harvesting.
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Presión Sanguínea/fisiología , Muerte Encefálica/fisiopatología , Fluidoterapia/métodos , Choque Séptico/terapia , Adulto , Velocidad del Flujo Sanguíneo/fisiología , Ecocardiografía , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Respiración Artificial , Sensibilidad y Especificidad , Choque Séptico/fisiopatología , Sístole , Recolección de Tejidos y Órganos/estadística & datos numéricos , Función Ventricular Derecha/fisiologíaRESUMEN
BACKGROUND: Neonates are considered as immunologically immature. There are no specific guidelines for surgical antibiotic prophylaxis in this population since data concerning the risk factors for surgical site infection (SSI) are lacking. METHODS: A 40-month retrospective single-center study that included all consecutive neonates undergoing surgery was performed. The variables that could influence the rate of SSI were analyzed by multivariate analysis in order to determine the independent risk factors for SSI. RESULTS: The survey included 286 neonates (91 F/195 M). Median age, term, and weight were 10 (0-19) days, 38 (37-39) weeks, 3 (2.7-3.5) kg, respectively. Sixteen percent of the neonates were premature. Surgery was mostly abdominal (71%). Prophylactic antibiotic was given in 66.4% of the cases and was highly variable (amoxicillin-clavulanate 20.3%, first generation cephalosporin 26.2%, second generation cephalosporin 11.9%, imidazole derivatives 13.6%, aminoglycosides 12.6%, vancomycin 0.7%, and ticarcillin-clavulanate 3.1%). The rate of SSI was 3.8%. Only two variables were identified as independent risk factors for SSI: gestational age OR: 0.821 (0.690-0.977) and preoperative hospitalization in an intensive care unit OR: 8.433 (1.031-69.005). CONCLUSION: Preoperative stay in an intensive care unit and, to a lesser degree, low gestational age are associated with an increased SSI rate.
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Unidades de Cuidados Intensivos , Cuidados Preoperatorios/efectos adversos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Estudios de Cohortes , Femenino , Humanos , Recién Nacido , Masculino , Estudios Retrospectivos , Medición de Riesgo , Factores de RiesgoRESUMEN
INTRODUCTION: This study aimed to evaluate the pupillary dilatation reflex (PDR) during a tetanic stimulation to predict insufficient analgesia before nociceptive stimulation in the intensive care unit (ICU). METHODS: In this prospective non-interventional study in a surgical ICU of a university hospital, PDR was assessed during tetanic stimulation (of 10, 20 or 40 mA) immediately before 40 endotracheal suctionings in 34 deeply sedated patients. An insufficient analgesia during endotracheal suction was defined by an increase of ≥1 point on the Behavioral Pain Scale (BPS). RESULTS: A total of 27 (68%) patients had insufficient analgesia. PDR with 10 mA, 20 mA and 40 mA stimulation was higher in patients with insufficient analgesia (P <0.01). The threshold values of the pupil diameter variation during a 10, 20 and 40 mA tetanic stimulation to predict insufficient analgesia during an endotracheal suctioning were 1, 5 and 13% respectively. The areas (95% confidence interval) under the receiver operating curve were 0.70 (0.54 to 0.85), 0.78 (0.61 to 0.91) and 0.85 (0.721 to 0.954) with 10, 20 and 40 mA tetanic stimulations respectively. A sensitivity analysis using the Richmond Agitation Sedation Scale (RASS) confirmed the results. The 40 mA stimulation was poorly tolerated. CONCLUSIONS: In deeply sedated mechanically ventilated patients, a pupil diameter variation ≥5% during a 20 mA tetanic stimulation was highly predictable of insufficient analgesia during endotracheal suction. A 40 mA tetanic stimulation is painful and should not be used.
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Analgesia/métodos , Enfermedad Crítica , Intubación Intratraqueal/métodos , Dimensión del Dolor/métodos , Reflejo Pupilar/fisiología , Adulto , Anciano , Enfermedad Crítica/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estimulación Física/métodos , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reflejo Pupilar/efectos de los fármacos , Respiración Artificial/métodos , SucciónRESUMEN
BACKGROUND: A widely used physiological simulator is generally accepted to give valid predictions of oxygenation status during disturbances in breathing associated with anesthesia. We compared predicted measures with physiological measurements available in the literature, or derived from other models. METHODS: Five studies were selected from the literature which explored arterial oxygenation, with or without preoxygenation, in clinical situations or through mathematical modeling as well as the evolution of the fraction of expired oxygen (Feo2) during preoxygenation maneuvers. Scenarios from these studies were simulated on the METI-Human Patient Simulator™ simulator, and the data were compared with the results in the literature. RESULTS: Crash-induction anesthesia without preoxygenation induces an O2 pulse saturation (Spo2) decrease that is not observed on the METI simulator. In humans, after 8 minutes of apnea, Spo2 decreased below 90% while the worst value was 95% during the simulation. The apnea time to reach 85% was less with obese patients than with healthy simulated patients and was shortened in the absence of preoxygenation. However, the data in the literature include METI simulator confidence interval 95% values only for healthy humans receiving preoxygenation. The decrease in Pao2 during 35-second apnea started at end-expiration was slower on the METI simulator than the values reported in the literature. Feo2 evolution during preoxygenation maneuvers on the METI simulator with various inspired oxygen fractions (100%, 92%, 84%, and 68%) was very close to those reported in humans when perfect mask seal is provided. In practice, this seal is impossible to obtain on the METI simulator. CONCLUSIONS: Spo2 decreased much later during apnea on the METI simulator than in a clinical situation, whether preoxygenation was performed or not. The debriefing after simulation of critical situations or the use of the METI simulator to test a new equipment must consider these results.
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Anestesia General , Apnea/fisiopatología , Simulación por Computador , Pulmón/fisiopatología , Maniquíes , Terapia por Inhalación de Oxígeno , Intercambio Gaseoso Pulmonar , Apnea/diagnóstico , Humanos , Obesidad/fisiopatología , Reproducibilidad de los Resultados , Volumen de Ventilación Pulmonar , Factores de TiempoRESUMEN
INTRODUCTION: We sought to investigate whether the use of balanced solutions reduces the incidence of hyperchloraemic acidosis without increasing the risk for intracranial hypertension in patients with severe brain injury. METHODS: We conducted a single-centre, two-arm, randomised, double-blind, pilot controlled trial in Nantes, France. Patients with severe traumatic brain injury (Glasgow Coma Scale score ≤8) or subarachnoid haemorrhage (World Federation of Neurosurgical Society grade III or higher) who were mechanically ventilated were randomised within the first 12 hours after brain injury to receive either isotonic balanced solutions (crystalloid and hydroxyethyl starch; balanced group) or isotonic sodium chloride solutions (crystalloid and hydroxyethyl starch; saline group) for 48 hours. The primary endpoint was the occurrence of hyperchloraemic metabolic acidosis within 48 hours. RESULTS: Forty-two patients were included, of whom one patient in each group was excluded (one consent withdrawn and one use of forbidden therapy). Nineteen patients (95%) in the saline group and thirteen (65%) in the balanced group presented with hyperchloraemic acidosis within the first 48 hours (hazard ratio = 0.28, 95% confidence interval [CI] = 0.11 to 0.70; P = 0.006). In the saline group, pH (P = .004) and strong ion deficit (P = 0.047) were lower and chloraemia was higher (P = 0.002) than in the balanced group. Intracranial pressure was not different between the study groups (mean difference 4 mmHg [-1;8]; P = 0.088). Seven patients (35%) in the saline group and eight (40%) in the balanced group developed intracranial hypertension (P = 0.744). Three patients (14%) in the saline group and five (25%) in the balanced group died (P = 0.387). CONCLUSIONS: This study provides evidence that balanced solutions reduce the incidence of hyperchloraemic acidosis in brain-injured patients compared to saline solutions. Even if the study was not powered sufficiently for this endpoint, intracranial pressure did not appear different between groups. TRIAL REGISTRATION: EudraCT 2008-004153-15 and NCT00847977.
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Lesiones Encefálicas/terapia , Fluidoterapia/métodos , Derivados de Hidroxietil Almidón/administración & dosificación , Soluciones Isotónicas/administración & dosificación , Cloruro de Sodio/administración & dosificación , Acidosis/diagnóstico , Acidosis/epidemiología , Acidosis/prevención & control , Adulto , Anciano , Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/epidemiología , Soluciones Cristaloides , Método Doble Ciego , Femenino , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Proyectos PilotoRESUMEN
PURPOSE: To investigate the impact of etomidate on the rate of hospital-acquired pneumonia (HAP) in trauma patients and the effects of hydrocortisone in etomidate-treated patients. METHODS: This was a sub-study of the HYPOLYTE multi-centre, randomized, double-blind, placebo-controlled trial of hydrocortisone in trauma patients (NCT00563303). Inclusion criterion was trauma patient with mechanical ventilation (MV) of ≥48 h. The use of etomidate was prospectively collected. Endpoints were the results of the cosyntropin test and rate of HAP on day 28 of follow-up. RESULTS: Of the 149 patients enrolled in the study, 95 (64 %) received etomidate within 36 h prior to inclusion. 79 (83 %) of 95 patients receiving etomidate and 34 of the 54 (63 %) not receiving etomidate had corticosteroid insufficiency (p = 0.006). The administration of etomidate did not alter basal cortisolemia (p = 0.73), but it did decrease the delta of cortisolemia at 60 min (p = 0.007). There was a correlation between time from etomidate injection to inclusion in the study and sensitivity to corticotropin (R (2) = 0.19; p = 0.001). Forty-nine (51.6 %) patients with etomidate and 16 (29.6 %) patients without etomidate developed HAP by day 28 (p = 0.009). Etomidate was associated with HAP on day 28 in the multivariate analysis (hazard ratio 2.48; 95 % confidence interval 1.19-5.18; p = 0.016). Duration of MV with or without etomidate was not significantly different (p = 0.278). Among etomidate-exposed patients, 18 (40 %) treated with hydrocortisone developed HAP compared with 31 (62 %) treated with placebo (p = 0.032). Etomidate-exposed patients treated with hydrocortisone had fewer ventilator days (p < 0.001). CONCLUSIONS: Among the patients enrolled in the study, etomidate did not alter basal cortisolemia, but it did decrease reactivity to corticotropin. We suggest that in trauma patients, etomidate is an independent risk factor for HAP and that the administration of hydrocortisone should be considered after etomidate use.
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Insuficiencia Suprarrenal/inducido químicamente , Anestésicos Intravenosos/efectos adversos , Infección Hospitalaria/inducido químicamente , Etomidato/efectos adversos , Hidrocortisona/efectos adversos , Neumonía Bacteriana/inducido químicamente , Heridas y Lesiones/tratamiento farmacológico , Adolescente , Insuficiencia Suprarrenal/tratamiento farmacológico , Insuficiencia Suprarrenal/etiología , Adulto , Anciano , Anestésicos Intravenosos/administración & dosificación , Niño , Preescolar , Cosintropina , Infección Hospitalaria/tratamiento farmacológico , Método Doble Ciego , Etomidato/administración & dosificación , Femenino , Humanos , Hidrocortisona/uso terapéutico , Masculino , Persona de Mediana Edad , Neumonía Bacteriana/tratamiento farmacológico , Respiración Artificial , Factores de Riesgo , Heridas y Lesiones/complicaciones , Adulto JovenRESUMEN
STUDY OBJECTIVE: To define the risk factors of allogeneic erythrocyte transfusion in patients older than 65 years of age who underwent hip fracture surgery. DESIGN: Retrospective, single-center study. SETTING: Orthopedic unit of a university hospital. MEASUREMENTS: The records of 413 consecutive patients undergoing hip fracture surgery over a 12-month period and receiving low-molecular-weight heparin (LMWH) for thromboprophylaxis were retrospectively reviewed. Preoperative independent predictors of transfusion were determined by multivariate analysis, from which a model of individual probability of transfusion was derived using creatinine clearance calculated by Cockroft-Gault (CG) and the Modification of Diet in Renal Disease (MDRD) formulas. MAIN RESULTS: Using the CG and MDRD formulas, 56.9% and 50.1% of patients had moderate renal impairment that was an independent factor associated with transfusion, with adjusted odds ratios of 2.44 (1.49 - 4.02) and 2.35 (1.32 - 4.18), respectively. Other factors were fracture with trochanteric extension, preoperative hemoglobin (Hb) < 12 g/dL, and weight. The observed transfusion rate and probability of transfusion calculated with the regression logistic model were well correlated: y = 0.9534x + 0.0287, P < 0.0001, Pearson coefficient 0.988, goodness of fit, χ(2), P = 1 with CG; y = 0.9197x + 0.0504, P < 0.0001, Pearson coefficient 0.956, goodness of fit, χ(2), P = 1 with MDRD). CONCLUSION: This predictive model may be useful to identify those elderly patients undergoing hip fracture repair who are at risk of blood transfusion.
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Anticoagulantes/efectos adversos , Transfusión de Eritrocitos/estadística & datos numéricos , Heparina de Bajo-Peso-Molecular/efectos adversos , Fracturas de Cadera/cirugía , Insuficiencia Renal/complicaciones , Tromboembolia/prevención & control , Anciano , Biomarcadores/sangre , Pérdida de Sangre Quirúrgica , Creatinina/sangre , Femenino , Hemoglobinas/metabolismo , Humanos , Masculino , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/prevención & control , Periodo Preoperatorio , Insuficiencia Renal/diagnóstico , Estudios Retrospectivos , Factores de Riesgo , Tromboembolia/etiologíaRESUMEN
INTRODUCTION: Description of a continuous hypertonic saline solution (HSS) infusion using a dose-adaptation of natremia in traumatic brain injured (TBI) patients with refractory intracranial hypertension (ICH). METHODS: We performed a single-center retrospective study in a surgical intensive care unit of a tertiary hospital. Fifty consecutive TBI patients with refractory ICH treated with continuous HSS infusion adapted to a target of natremia. In brief, a physician set a target of natremia adapted to the evolution of intracranial pressure (ICP). Flow of NaCl 20% was a priori calculated according to natriuresis, and the current and target natremia that were assessed every 4 hours. RESULTS: The HSS infusion was initiated for a duration of 7 (5 to 10) (8 ± 4) days. ICP decreased from 29 (26 to 34) (31 ± 9) mm Hg at H0 to 20 (15 to 26) (21 ± 8) mm Hg at H1 (P < 0.05). Cerebral perfusion pressure increased from 61 (50 to 70) (61 ± 13) mm Hg at H0 up to 67 (60 to 79) (69 ± 12) mm Hg at H1 (P < 0.05). No rebound of ICH was reported after stopping continuous HSS infusion. Natremia increased from 140 (138 to 143) (140 ± 4) at H0 up to 144 (141 to 148) (144 ± 4) mmol/L at H4 (P < 0.05). Plasma osmolarity increased from 275 (268 to 281) (279 ± 17) mmol/L at H0 up to 290 (284 to 307) (297 ± 17) mmol/L at H24 (P < 0.05). The main side effect observed was an increase in chloremia from 111 (107 to 119) (113 ± 8) mmol/L at H0 up to 121 (117 to 124) (121 ± 6) mmol/L at H24 (P < 0.05). Neither acute kidney injury nor pontine myelinolysis was recorded. CONCLUSIONS: Continuous HSS infusion adapted to close biologic monitoring enables long-lasting control of natremia in TBI patients along with a decreased ICP without any rebound on infusion discontinuation.
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Lesiones Encefálicas/terapia , Fluidoterapia/métodos , Hipertensión Intracraneal/complicaciones , Solución Salina Hipertónica/administración & dosificación , Sodio/sangre , Adulto , Lesiones Encefálicas/sangre , Lesiones Encefálicas/fisiopatología , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Infusiones Intravenosas/métodos , Hipertensión Intracraneal/sangre , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
CONTEXT: The role of stress-dose hydrocortisone in the management of trauma patients is currently unknown. OBJECTIVE: To test the efficacy of hydrocortisone therapy in trauma patients. DESIGN, SETTING, AND PATIENTS: Multicenter, randomized, double-blind, placebo-controlled HYPOLYTE (Hydrocortisone Polytraumatise) study. From November 2006 to August 2009, 150 patients with severe trauma were included in 7 intensive care units in France. INTERVENTION: Patients were randomly assigned to a continuous intravenous infusion of either hydrocortisone (200 mg/d for 5 days, followed by 100 mg on day 6 and 50 mg on day 7) or placebo. The treatment was stopped if patients had an appropriate adrenal response. MAIN OUTCOME MEASURE: Hospital-acquired pneumonia within 28 days. Secondary outcomes included the duration of mechanical ventilation, hyponatremia, and death. RESULTS: One patient withdrew consent. An intention-to-treat (ITT) analysis included the 149 patients, a modified ITT analysis included 113 patients with corticosteroid insufficiency. In the ITT analysis, 26 of 73 patients (35.6%) treated with hydrocortisone and 39 of 76 patients (51.3%) receiving placebo developed hospital-acquired pneumonia by day 28 (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.30-0.83; P = .007). In the modified ITT analysis, 20 of 56 patients (35.7%) in the hydrocortisone group and 31 of 57 patients (54.4%) in the placebo group developed hospital-acquired pneumonia by day 28 (HR, 0.47; 95% CI, 0.25-0.86; P = .01). Mechanical ventilation-free days increased with hydrocortisone by 4 days (95% CI, 2-7; P = .001) in the ITT analysis and 6 days (95% CI, 2-11; P < .001) in the modified ITT analysis. Hyponatremia was observed in 7 of 76 (9.2%) in the placebo group vs none in the hydrocortisone group (absolute difference, -9%; 95% CI, -16% to -3%; P = .01). Four of 76 patients (5.3%) in the placebo group and 6 of 73 (8.2%) in the hydrocortisone group died (absolute difference, 3%; 95% CI, -5% to 11%; P = .44). CONCLUSION: In intubated trauma patients, the use of an intravenous stress-dose of hydrocortisone, compared with placebo, resulted in a decreased risk of hospital-acquired pneumonia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00563303.
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Antiinflamatorios/uso terapéutico , Infección Hospitalaria/prevención & control , Hidrocortisona/uso terapéutico , Traumatismo Múltiple/complicaciones , Neumonía/prevención & control , Adolescente , Insuficiencia Suprarrenal/diagnóstico , Insuficiencia Suprarrenal/tratamiento farmacológico , Insuficiencia Suprarrenal/etiología , Adulto , Infección Hospitalaria/etiología , Método Doble Ciego , Femenino , Humanos , Infusiones Intravenosas , Unidades de Cuidados Intensivos , Intubación Intratraqueal , Masculino , Persona de Mediana Edad , Neumonía/etiología , Respiración Artificial , Adulto JovenRESUMEN
BACKGROUND: microbiologic data are lacking regarding pediatric community-acquired peritonitis (CAP). METHODS: we conducted a 2-year retrospective single center study. Consecutive children undergoing CAP surgery were included. Microbiology and antimicrobial susceptibility of peritoneal isolates were analyzed. RESULTS: a total of 70 children from 3 months to 14 years of age were included. A total of 123 bacterial isolates were analyzed. Escherichia coli was the predominant aerobic organism (51% of isolates); 54.8% were susceptible to amoxicillin whereas 90.3% were susceptible to amoxicillin-clavulanate. Anaerobes accounted for 29% of isolates, and 94.3% of strains were susceptible to amoxicillin-clavulanate and 68.5% were susceptible to clindamycin. Pseudomonas aeruginosa was present in 6% of isolates and in 10% of children. The presence of E. coli resistant to amoxicillin or to amoxicillin-clavulanate was the only independent risk factor associated with postoperative peritonitis. CONCLUSION: microbiology of pediatric CAP is similar to adult CAP with a predominancy of E. coli and anaerobes. P. aeruginosa in peritoneal samples had no apparent influence on the outcome.
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Bacterias/aislamiento & purificación , Infecciones Comunitarias Adquiridas/epidemiología , Infecciones Comunitarias Adquiridas/microbiología , Peritonitis/epidemiología , Peritonitis/microbiología , Adolescente , Antibacterianos/farmacología , Bacterias/clasificación , Bacterias/efectos de los fármacos , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Pruebas de Sensibilidad Microbiana , Prevalencia , Estudios RetrospectivosRESUMEN
Infections are the most frequent cause of complications in trauma patients. Post-traumatic immune suppression (IS) exposes patients to pneumonia (PN). The main pathogen involved in PN is Methicillin Susceptible Staphylococcus aureus (MSSA). Dendritic cells () may be centrally involved in the IS. We assessed the consequences of hemorrhage on pneumonia outcomes and investigated its consequences on DCs functions. A murine model of hemorrhagic shock with a subsequent MSSA pneumonia was used. Hemorrhage decreased the survival rate of infected mice, increased systemic dissemination of sepsis and worsened inflammatory lung lesions. The mRNA expression of Tumor Necrosis Factor-alpha (TNF-α), Interferon-beta (IFN-ß) and Interleukin (IL)-12p40 were mitigated for hemorrhaged-mice. The effects of hemorrhage on subsequent PN were apparent on the pDCs phenotype (reduced MHC class II, CD80, and CD86 molecule membrane expression). In addition, hemorrhage dramatically decreased CD8(+) cDCs- and CD8(-) cDCs-induced allogeneic T-cell proliferation during PN compared with mice that did not undergo hemorrhage. In conclusion, hemorrhage increased morbidity and mortality associated with PN; induced severe phenotypic disturbances of the pDCs subset and functional alterations of the cDCs subset. After hemorrhage, a preventive treatment with CpG-ODN or Monophosphoryl Lipid A increased transcriptional activity in DCs (TNF-α, IFN-ß and IL-12p40) and decreased mortality of post-hemorrhage MSSA pneumonia.
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Modelos Animales de Enfermedad , Lípido A/análogos & derivados , Oligodesoxirribonucleótidos/uso terapéutico , Neumonía Bacteriana/prevención & control , Choque Hemorrágico/complicaciones , Staphylococcus aureus/aislamiento & purificación , Animales , Proliferación Celular , Citocinas/genética , Lípido A/uso terapéutico , Ratones , Proyectos Piloto , Neumonía Bacteriana/complicaciones , Neumonía Bacteriana/microbiología , Neumonía Bacteriana/mortalidad , ARN Mensajero/genética , Linfocitos T/patologíaRESUMEN
BACKGROUND: The Manujet™ and the ENK Oxygen Flow Modulator™ (ENK) deliver oxygen during transtracheal oxygenation. We sought to describe the ventilation characteristics of these 2 devices. METHODS: The study was conducted in an artificial lung model consisting of a 15-cm ringed tube, simulating the trachea, connected via a flow analyzer and an artificial lung. A 15-gauge transtracheal wire reinforced catheter was used for transtracheal oxygenation. The ENK and Manujet were studied for 3 minutes at respiratory rates of 0, 4, and 12 breaths/min, with and without the artificial lung, in a totally and a partially occluded airway. Statistical analysis was performed using analysis of variance followed by a Fisher exact test; P < 0.05 was considered significant. RESULTS: Gas flow and tidal volume were 3 times greater with the Manujet than the ENK (approximately 37 vs 14 L · min(-1) and 700 vs 250 mL, respectively) and were not dependent on the respiratory rate. In the absence of ventilation, the ENK delivered a 0.6 ± 0.1 L · min(-1) constant gas flow. In the totally occluded airway, lung pressures increased to 136 cm H(2)O after 3 insufflations with the Manujet, whereas the ENK, which has a pressure release vent, generated acceptable pressures at a low respiratory rate (4 breaths/min) (peak pressure at 27.7 ± 0.7 and end-expiratory pressure at 18.8 ± 3.8 cm H(2)O). When used at a respiratory rate of 12 breaths/min, the ENK generated higher pressures (peak pressure at 95.9 ± 21.2 and end-expiratory pressure at 51.4 ± 21.4 cm H(2)O). In the partially occluded airway, lung pressures were significantly greater with the Manujet compared with the ENK, and pressures increased with the respiratory rate with both devices. Finally, the gas flow and tidal volume generated by the Manujet varied proportionally with the driving pressure. DISCUSSION: This study confirms the absolute necessity of allowing gas exhalation between 2 insufflations and maintaining low respiratory rates during transtracheal oxygenation. In the case of total airway obstruction, the ENK may be less deleterious because it has a pressure release vent. Using a Manujet at lower driving pressures may decrease the risk of barotrauma and allow the safe use of higher respiratory rates.