RESUMEN
BACKGROUND: Rheumatic heart disease (RHD) remains an important health issue for indigenous women of child-bearing age in northern Australia. However, the influence of RHD on maternal outcomes with current clinical practice is unclear. AIMS: To determine maternal cardiac complications and obstetric outcomes in patients with RHD. METHODS: Retrospective case note analysis of women with RHD who received obstetric care between July 1999 and May 2010 at Cairns Base Hospital in north Queensland. Outcome measures were obstetric interventions and outcomes, cardiac interventions and complications, stratified according to a cardiac risk score (CRS). RESULTS: Ninety-five confinements occurred in 54 patients, of whom 52 were Indigenous Australians. There were no maternal or neonatal deaths. With a CRS of 0, cardiac complications occurred in 0 of 70 confinements; with a CRS of 1, complications occurred in 5 of 17 confinements (29%); with a CRS of >1, complications occurred in 2 of 4 confinements (50%). Another four patients were first diagnosed with RHD after developing acute pulmonary oedema during the peripartum period. CONCLUSIONS: RHD has a major impact on maternal cardiac outcomes. However, with current management practices, maternal and fetal mortality are low, and the incidence of complications is predictable based on known risk factors.
Asunto(s)
Complicaciones Cardiovasculares del Embarazo/epidemiología , Cardiopatía Reumática/epidemiología , Adulto , Fármacos Cardiovasculares/uso terapéutico , Parto Obstétrico , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/tratamiento farmacológico , Enfermedades de las Válvulas Cardíacas/epidemiología , Humanos , Recién Nacido , Nativos de Hawái y Otras Islas del Pacífico , Paridad , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Complicaciones Cardiovasculares del Embarazo/tratamiento farmacológico , Resultado del Embarazo , Trastornos Puerperales/epidemiología , Edema Pulmonar/epidemiología , Queensland/epidemiología , Estudios Retrospectivos , Cardiopatía Reumática/diagnóstico por imagen , Cardiopatía Reumática/tratamiento farmacológico , Ultrasonografía , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/tratamiento farmacológico , Disfunción Ventricular Izquierda/epidemiología , Adulto JovenRESUMEN
BACKGROUND: The optimal dose of oxytocin at Caesarean section is unclear. Oxytocin may cause adverse cardiovascular effects, including tachycardia and hypotension, whereas an inadequate dose can result in increased uterine bleeding. We compared the effects of two doses of oxytocin in a randomized double-blind trial. METHODS: Eighty patients undergoing elective Caesarean section received an i.v. bolus of either 2 or 5 units (u) of oxytocin after delivery, followed by an oxytocin infusion of 10 u h(-1). All received combined spinal-epidural anaesthesia with arterial pressure maintained by a phenylephrine infusion. We compared changes in heart rate (HR), mean arterial pressure (MAP), blood loss, uterine tone, the need for additional uterotonic drugs, and emetic symptoms. RESULTS: There was a greater increase in mean (sd) HR in patients who received 5 u of oxytocin [32 (17) beats min(-1)] than in those who received 2 u [24 (13) beats min(-1)] (P=0.015). There was a larger decrease in MAP in patients who received 5 u [13 (15) mm Hg] than in those who received 2 u [6 (10) mm Hg] (P=0.030). The frequency of nausea and antiemetic use was higher after 5 u (32.5%) than 2 u (5%) (P=0.003). There were no differences in blood loss, uterine tone, or requests for additional uterotonic drugs (17.5% in both groups). CONCLUSIONS: In elective Caesarean section, a 2 u bolus of oxytocin results in less haemodynamic change than 5 u, with less nausea and no difference in the need for additional uterotonics.
Asunto(s)
Cesárea , Oxitócicos/administración & dosificación , Oxitocina/administración & dosificación , Adulto , Anestesia Epidural , Anestesia Obstétrica/métodos , Anestesia Raquidea , Presión Sanguínea/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Infusiones Intravenosas , Tono Muscular/efectos de los fármacos , Oxitócicos/efectos adversos , Oxitocina/efectos adversos , Cuidados Posoperatorios/métodos , Náusea y Vómito Posoperatorios/inducido químicamente , Embarazo , Útero/efectos de los fármacos , Útero/fisiología , Adulto JovenRESUMEN
Field experiments evaluated the effects of nematicide and fertility on performance of 'Tifway 419' bermudagrass parasitized by the sting nematode (Belonolaimus longicaudatus). Plot treatments were nontreated or nematicide (1,3-dichloropropene) treated combined with different nitrogen (N) fertilizer levels. Effects of treatments on numbers of B. longicaudatus and turf performance were compared. Nematicide consistently reduced numbers of B. longicaudatus, but fertilizer level had no effect on B. longicaudatus. Turf performance of nematicide-treated plots was improved compared with nontreated plots during both experiments. Increasing N fertilizer level improved turf performance in nematicide-treated plots in some cases, but had no effect on turf performance in nontreated plots in either experiment. Results suggest that increasing N fertilizer levels may not improve turf performance at sites infested with B. longicaudatus unless nematode management tactics are effective in reducing nematode densities.
RESUMEN
Experiments were conducted to quantify the effects of the sting nematode (Belonolaimus longicaudatus) on root reductions and quantity of nitrate (NO(3) (-)) leached from 'Tifdwarf' bermudagrass in lysimeters. Forty lysimeters were planted with 'Tifdwarf' bermudagrass, of which 20 were inoculated with B. longicaudatus and 20 were noninoculated. Root length was compared between treatments at six, 12, and 18 weeks after initiation of the experiments. Turf was fertilized every three weeks, and leaching events were simulated at 21 and 42-day intervals in trial one and trial two, respectively. Leachate was collected, and the quantity of NO(3) (-) leached was compared between treatments. Root reductions were observed in lysimeters inoculated with B. longicaudatus at all evaluation dates. Quantity of NO(3) (-) leached was greater in inoculated lysimeters at the 18-week evaluation during both trials. This study indicates that nematode damage to turf roots limits root vigor and N uptake, thereby increasing nitrate leaching, adding to water quality concerns.
RESUMEN
We describe an opioid-tolerant patient with severe acute pain which was unrelieved by morphine and ketamine via intravenous patient-controlled analgesia, but almost totally relieved by methadone. In the previous 24 hours, 509 mg of intravenous morphine and 769 mg of ketamine had been used and this was replaced by 200 mg of oral methadone. This implies that the success of methadone in morphine tolerant patients chiefly involves factors other than its role as an N-methyl-D-aspartate receptor antagonist, and that methadone should be considered as a replacement for morphine when the N-methyl-D-aspartate antagonist ketamine has proved ineffective.
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Analgésicos Opioides/administración & dosificación , Analgésicos/administración & dosificación , Ketamina/administración & dosificación , Metadona/administración & dosificación , Morfina/administración & dosificación , Trastornos Relacionados con Opioides , Dolor/tratamiento farmacológico , Enfermedad Aguda , Administración Oral , Adulto , Analgesia Controlada por el Paciente , Tolerancia a Medicamentos , Humanos , Masculino , Abuso de Sustancias por Vía IntravenosaAsunto(s)
Anestesiología , Médicos Hospitalarios , Atención Perioperativa , Anestesiología/educación , HumanosRESUMEN
BACKGROUND: There is controversy over (1) the relative incidence of sore throat between the face mask (FM) and laryngeal mask airway (LMA), (2) the efficacy of LMA intracuff pressure reduction as a mechanism for minimizing sore throat, and (3) the relative incidence of sore throat with the LMA between males and females. In a randomized double-blind study, the authors compared laryngopharyngeal, neck, and jaw discomfort with the FM and LMA at high and low cuff volumes in males and females. METHODS: Three hundred adult patients were randomly assigned to three equal-sized groups for airway management: (1) the FM, (2) the LMA with a fully inflated cuff (LMA-High), or (3) the LMA with a semi-inflated cuff (LMA-Low). Anesthesia was administered with propofol, nitrous oxide, oxygen, and isoflurane. In the FM group, a Guedel-type oropharyngeal airway and jaw thrust were used only if necessary. In the LMA groups, cuff inflation was achieved with either 15 or 30 ml for the size 4 (females) and 20 or 40 ml for the size 5 (males). The LMA was removed when the patient was awake. Patients were questioned 18-24 h postoperatively about surgical pain, sore throat, sore neck, sore jaw, dysphonia, and dysphagia, and about whether they were satisfied with their anesthetic. RESULTS: The incidence of sore throat was lower in the FM (8%) than the LMA-High (42%) and LMA-Low (20%) groups (both: P < or = 0.02). The incidence of sore neck was higher for the FM (14%) than the LMA-High group (6%; P = 0.05) but similar to the LMA-Low group (8%). The incidence of sore jaw was higher in the FM (11%) than the LMA-High (3%) and LMA-Low (3%) groups (both: P = 0. 02). There were no differences among groups for surgical pain or dysphonia. The incidence of dysphagia was lower in the FM (1%) than the LMA-High group (11%; P = 0.003), but similar to the LMA-Low group (1%). The incidence of sore throat and dysphagia was lower in the LMA-Low group than the LMA-High group for both males and females (all: P < or = 0.04). There were no differences in discomfort levels between males and females in any group. Two patients from the FM group and one from the LMA-High group were not satisfied with their anesthetic. These complaints were unrelated to postoperative morbidity. CONCLUSION: The LMA causes more sore throat and dysphagia but less jaw pain than the FM. Sore throat and dysphagia are more common with the LMA if the initial cuff volume is high. There are no differences in discomfort levels between males and females. However, these discomforts do not influence patient satisfaction after LMA or FM anesthesia.
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Trastornos de Deglución/etiología , Máscaras Laríngeas/efectos adversos , Faringitis/etiología , Adulto , Método Doble Ciego , Femenino , Humanos , Incidencia , Maxilares/lesiones , Masculino , Máscaras , Dolor Postoperatorio/etiología , Complicaciones Posoperatorias/etiología , Distribución por SexoAsunto(s)
Máscaras Laríngeas , Diseño de Equipo , Femenino , Humanos , Masculino , Orofaringe/lesiones , TonsilectomíaRESUMEN
An audit of postoperative pain management was conducted before and after the introduction of an Acute Pain Service (APS) run entirely by medical staff. The ability of patients to complete two pain-scoring systems, a verbal rating score (VRS) and a numerical rating score (NRS, where 0 = no pain, 10 = worst pain) was compared. We surveyed 605 adults 24 hours postoperatively. For major operations, the incidence of "severe" or "unbearable" pain at rest (VRS) over the first 24 hours decreased from 18.1% before to 3.5% after the APS (P = 0.0002) and severe/unbearable pain with movement decreased from 50% to 31% (P = 0.0037). The average NRS pain scores fell from 4.65 to 3.37 at rest (P < 0.0001) and from 6.77 to 6.19 with movement (P = 0.046). The incidence of severe/unbearable pain at rest with patient-controlled analgesia (PCA) decreased from 19.7% to 3.2% after the APS (P = 0.0012) and with movement from 51.3% to 35.1% (P = 0.049). For epidural analgesia, severe/unbearable pain at rest was 18.8% prior to the APS and 4.4% after (P = 0.14), and with movement was 43.8% before and 19.1% after (P = 0.079). The NRS pain-scoring system was unsuitable for Aboriginal or Torres Strait Islander patients. Patient satisfaction was high both before and after the introduction of the APS, and was an unreliable indicator of effective pain relief. We conclude that an APS can improve postoperative pain control with PCA and epidural analgesia.
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Dolor Postoperatorio/terapia , Enfermedad Aguda , Adulto , Analgesia Epidural , Analgesia Controlada por el Paciente , Analgésicos/administración & dosificación , Femenino , Humanos , Inyecciones Intramusculares , Masculino , Auditoría Médica , Dimensión del Dolor , Satisfacción del Paciente , Encuestas y CuestionariosRESUMEN
OBJECTIVES: This study compared the hemodynamic effects of a propofol infusion with fentanyl analgesia in patients undergoing cardiac surgery with normal and low cardiac output states. Low cardiac output was defined as a cardiac index less than 2.5 L/min/m2 with a minimum pulmonary capillary wedge pressure of 7 mmHg. DESIGN: A prospective and open study. SETTING: A single center cardiothoracic unit within a teaching hospital. PARTICIPANTS: Patients were assigned to group P, poor cardiac output or group N, normal cardiac output, after thermodilution pulmonary artery catheter assessments. INTERVENTIONS: Both groups received a propofol infusion, 8 mg/kg/hr, until induction of anesthesia, followed by 4 mg/kg/hr until the intensive care unit. Fentanyl, 15 micrograms/kg, and pancuronium, 0.15 mg/kg, were administered after induction. The lungs were ventilated with oxygen. MEASUREMENTS AND MAIN RESULTS: Hemodynamic assessments were repeated at intervals until cardiopulmonary bypass. Changes within and between groups were compared using t tests on percentage change from baseline. Group N had significantly greater decreases in cardiac index, stroke volume, and left ventricular stroke work index than group P. There were comparable decreases in mean arterial pressure on induction of anesthesia, 14% and 8% in group N and group P, respectively. In both groups, right ventricular ejection fraction was unchanged. CONCLUSIONS: The use of a propofol infusion for induction and maintenance of anesthesia in patients with low cardiac output states undergoing cardiac surgery is not contraindicated.
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Anestésicos Intravenosos/administración & dosificación , Gasto Cardíaco Bajo/fisiopatología , Gasto Cardíaco/efectos de los fármacos , Procedimientos Quirúrgicos Cardíacos , Propofol/administración & dosificación , Analgésicos Opioides/administración & dosificación , Presión Sanguínea/efectos de los fármacos , Puente Cardiopulmonar , Femenino , Fentanilo/administración & dosificación , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Pancuronio/administración & dosificación , Estudios Prospectivos , Presión Esfenoidal Pulmonar/efectos de los fármacos , Volumen Sistólico/efectos de los fármacos , Función Ventricular Izquierda/efectos de los fármacos , Función Ventricular Derecha/efectos de los fármacosRESUMEN
Total intravenous anaesthesia with propofol and fentanyl was used in 23 patients undergoing coronary artery and 16 patients undergoing valve surgery and the haemodynamic effects in the two groups were compared. Baseline values showed that the valve surgery group had a higher mean heart rate, pulmonary artery wedge pressure and pulmonary artery pressure and smaller mean stroke volume than the coronary artery surgery group. In both groups, heart rate, arterial pressure, pulmonary artery wedge pressure, pulmonary artery pressure and cardiac index decreased during surgery. In the valve surgery group there were greater percentage decreases in heart rate, mean arterial pressure and diastolic arterial pressure. Overall, propofol and moderate-dose fentanyl anaesthesia was no more detrimental to the haemodynamics in patients undergoing valve surgery when compared to those undergoing coronary artery surgery.
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Anestesia Intravenosa , Vasos Coronarios/cirugía , Fentanilo , Válvulas Cardíacas/cirugía , Propofol , Anciano , Presión Sanguínea/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Hemodinámica/efectos de los fármacos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
We have compared the haemodynamic effects of an infusion of propofol 8 mg kg-1 h-1 followed by 4 mg kg-1 h-1 and fentanyl 15 micrograms kg-1 (group 1) with midazolam 3-6 mg and fentanyl 60 micrograms kg-1 (group 2) in patients with a low cardiac output state undergoing cardiac surgery. Heart rate was lower in group 1 throughout the period before cardiopulmonary bypass. There were no significant differences between the groups in other measured variables. Arterial pressure decreased in both groups after induction, by 21% in group 1 and 18% in group 2. Thermodilution assessment of right ventricular ejection fraction was unchanged. Myocardial contractility was not affected adversely. Patients in group 1 who received an infusion of propofol and a smaller dose of fentanyl awakened sooner and the trachea was extubated earlier.
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Anestesia Intravenosa/métodos , Gasto Cardíaco Bajo/fisiopatología , Procedimientos Quirúrgicos Cardíacos , Fentanilo/administración & dosificación , Propofol/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Periodo de Recuperación de la Anestesia , Puente Cardiopulmonar , Esquema de Medicación , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Hemodinámica/efectos de los fármacos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
We studied angiographically the access route 1-27 months after the insertion temporary dialysis catheters in 52 patients: 32 subclavian and 20 internal jugular. The two groups were statistically similar with respect to age, sex and race. The subclavian catheters were left in for a mean of 11.5 days (2-22) while the internal jugular ones were inserted for 15.8 days (5-25; p = 0.0015). One hundred percent of the internal jugular patients were free of any venogram abnormalities in their venous access return. In marked contrast, 50% of the subclavian sites had mild to severe stricutures with 90% having 70-100% occlusion of the subclavian vein. Six patients had bilateral severe strictures. The long-term stricture rate of subclavian catheters in the subclavian vein was unacceptably high compared to the internal jugular route.
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Cateterismo Venoso Central/efectos adversos , Diálisis Renal/instrumentación , Catéteres de Permanencia/efectos adversos , Femenino , Humanos , Venas Yugulares , Masculino , Persona de Mediana Edad , Diálisis Renal/métodos , Estudios Retrospectivos , Vena Subclavia , Tromboflebitis/etiologíaRESUMEN
The axillary artery-iliac vein graft using externally supported PTFE is a viable option for this difficult patient group. It is capable of functioning well for up to 12 months. Most importantly, despite numerous prior access procedures, the axillary artery and iliac vein in each case were amenable to the procedure. Critical technical points include the use of externally splinted PTFE grafts, avoidance of crossing joints, and angling of the graft in the direction of the iliac vein at that anastomosis. The lack of thrombosis or infection to date, coupled with successful dialysis in every patient, suggests that this is one more option that can be used in the difficult secondary access patient.