Hump-nosed pit vipers (Genus: Hypnale) are medically important snakes in Sri Lanka and South India. Merrem's Hump-nosed pit viper (Hypnale hypnale) frequently leads to potentially fatal envenomings in Sri Lanka a...
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Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Πέμπτη 2 Αυγούστου 2018
Hyponatraemia and seizures in Merrem’s hump-nosed pit viper (Hypnale hypnale) envenoming: a case report
Impact of intra-operative fluid and noradrenaline administration on early postoperative renal function after cystectomy and urinary diversion: A retrospective observational cohort study
BACKGROUND The use of noradrenaline to enable a restrictive approach to intra-operative fluid therapy to avoid salt and water overload has gained increasing acceptance. However, concerns have been raised about the impact of this approach on renal function. OBJECTIVES To identify risk factors for acute kidney injury (AKI) in patients undergoing cystectomy with urinary diversion and determine whether administration of noradrenaline and intra-operative hydration regimens affect early postoperative renal function. DESIGN Retrospective observational cohort study. SETTING University hospital, from 2007 to 2016. PATIENTS A total of 769 consecutive patients scheduled for cystectomy and urinary diversion. Those with incomplete data and having pre-operative haemodialysis were excluded. MAIN OUTCOME MEASURES AKI was defined as a serum creatinine increase of more than 50% over 72 postoperative hours. Multiple logistic regression analysis was performed to model the association between risk factors and AKI. RESULTS Postoperative AKI was diagnosed in 86/769 patients (11.1%). Independent predictors for AKI were the amount of crystalloid administered (odds ratio (OR) 0.79 [95% confidence interval (CI), 0.68 to 0.91], P = 0.002), antihypertensive medication (OR 2.07 [95% CI, 1.25 to 3.43], P = 0.005), pre-operative haemoglobin value (OR 1.02 [95% CI, 1.01 to 1.03], P = 0.010), duration of surgery (OR 1.01 [95% CI, 1.00 to 1.01], P = 0.002), age (OR 1.32 [95% CI, 1.44 to 1.79], P = 0.002) but not the administration of noradrenaline (OR 1.09 [95% CI, 0.94 to 1.21], P = 0.097). Postoperative AKI was associated with longer hospital stay (18 [15 to 22] vs. 16 [15 to 19] days; P = 0.035) and a higher 90-day major postoperative complication rate (41.9 vs. 27.5%; P = 0.002). CONCLUSION Noradrenaline administration did not increase the risk for AKI. A too restrictive approach to administration of crystalloids was associated with an increased risk for AKI, particularly in older patients, those receiving antihypertensive medication, and those whose surgery was prolonged. As AKI was associated with longer hospital stay and increased postoperative morbidity, these observations should be taken into account to improve outcome when addressing peri-operative fluid management. TRIAL REGISTRATION Not applicable.https://ift.tt/2Mcrpf1
Cardiac arrest during spinal anaesthesia in a patient with undiagnosed Brugada syndrome
No abstract availablehttps://ift.tt/2LMfo3N
Association between pre-operative biological phenotypes and postoperative pulmonary complications: An unbiased cluster analysis
BACKGROUND Biological phenotypes have been identified within several heterogeneous pulmonary diseases, with potential therapeutic consequences. OBJECTIVE To assess whether distinct biological phenotypes exist within surgical patients, and whether development of postoperative pulmonary complications (PPCs) and subsequent dependence of intra-operative positive end-expiratory pressure (PEEP) differ between such phenotypes. SETTING Operating rooms of six hospitals in Europe and USA. DESIGN Secondary analysis of the 'PROtective Ventilation with HIgh or LOw PEEP' trial. PATIENTS Adult patients scheduled for abdominal surgery who are at risk of PPCs. INTERVENTIONS Measurement of pre-operative concentrations of seven plasma biomarkers associated with inflammation and lung injury. MAIN OUTCOME MEASURES We applied unbiased cluster analysis to identify biological phenotypes. We then compared the proportion of patients developing PPCs within each phenotype, and associations between intra-operative PEEP levels and development of PPCs among phenotypes. RESULTS In total, 242 patients were included. Unbiased cluster analysis clustered the patients within two biological phenotypes. Patients with phenotype 1 had lower plasma concentrations of TNF-α (3.8 [2.4 to 5.9] vs. 10.2 [8.0 to 12.1] pg ml−1; P https://ift.tt/2LNhrEH
Implementation of closed-loop-assisted intra-operative goal-directed fluid therapy during major abdominal surgery: A case–control study with propensity matching
BACKGROUND Goal-directed fluid therapy (GDFT) has been associated with improved patient outcomes. However, implementation of GDFT protocols remains low despite growing published evidence and the recommendations of multiple regulatory bodies in Europe. We developed a closed-loop-assisted GDFT management system linked to a pulse contour monitor to assist anaesthesiologists in applying GDFT. OBJECTIVE To assess the impact of our closed-loop system in patients undergoing major abdominal surgery in an academic hospital without a GDFT programme. DESIGN A case–control study with propensity matching. SETTING Operating rooms, Erasme Hospital, Brussels. PATIENTS All patients who underwent elective open major abdominal surgery between January 2013 and December 2016. INTERVENTION Implementation of our closed-loop-assisted GDFT in April 2015. METHODS A total of 104 patients managed with closed-loop-assisted GDFT were paired with a historical cohort of 104 consecutive non-GDFT patients. The historical control group consisted of patients treated before the implementation of the closed-loop-system, and who did not receive GDFT. In the closed-loop group, the system delivered a baseline crystalloid infusion of 3 ml kg−1 h−1 and additional 100 ml fluid boluses of either a crystalloid or colloid for haemodynamic optimisation. MAIN OUTCOME MEASURES The primary outcome was intra-operative net fluid balance. Secondary outcomes were composite major postoperative complications, composite minor postoperative complications and hospital length of stay (LOS). RESULTS Baseline characteristics were similar in both groups. Patients in the closed-loop group had a lower net intra-operative fluid balance compared with the historical group (median interquartile range [IQR] 2.9 [1.6 to 4.4] vs. 6.2 [4.0 to 8.3] ml kg−1 h−1; P https://ift.tt/2vuGwtf
Epidrum is an unreliable device for identifying the thoracic epidural space
No abstract availablehttps://ift.tt/2LLj461
Safety of moderate-to-deep sedation performed by sedation practitioners: A national prospective observational study
BACKGROUND In the Netherlands, a significant proportion of moderate-to-deep sedation is performed by sedation practitioners under the indirect supervision of an anaesthesiologist but there are limited safety data available. OBJECTIVE To estimate the rate of sedation-related adverse events and patient relevant outcomes (PRO). DESIGN This was a prospective national observational study. Data were collected with a modified adverse event reporting tool from the International Sedation Task Force of the World Society of Intravenous Anaesthesia. SETTING A total of 24 hospitals in the Netherlands where moderate-to-deep sedation was performed by sedation practitioners from the 1 February 2015 to 1 March 2016. PATIENTS Consecutive adults undergoing moderate-to-deep sedation for gastrointestinal, pulmonary and cardiac procedures. INTERVENTION Observation: Analysis included descriptive statistics and a multivariate logistic regression model for an association between adverse events and PRO. MAIN OUTCOME MEASURES The primary outcome was the rate of unfavourable PRO (admission to ICU, permanent neurological deficit, pulmonary aspiration or death). Secondary outcome was the rate of moderate-to-good PRO (unplanned hospital admission or escalation of care). Composite outcome was the sum of all primary and secondary outcomes. RESULTS A total of 11 869 patients with a median age of 64 years [interquartile range 51 to 72] were included. ASA physical score distribution was: first, 19.1%; second, 57.6%; third, 21.6%; fourth, 1.2%. Minimal adverse events occurred in 1517 (12.8%), minor adverse events in 113 (1.0%) and major adverse events in 80 instances (0.7%). Primary outcome: Five (0.04%) unfavourable PRO were observed; four patients needing admission to the intensive care unit; and one died. Secondary outcome: 12 (0.1%) moderate-to-good PRO were observed. Moderate and major adverse events were associated with the composite outcome [3.7 (95% confidence interval 1.1 to 11.9) and 40.6 (95% confidence interval 11.0 to 150.4)], but not minimal or minor adverse events. CONCLUSION Moderate-to-deep sedation performed by trained sedation practitioners has a very low rate of unfavourable outcome.https://ift.tt/2Mcr4ZN
The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study
BACKGROUND Currently used pre-operative prediction scores for postoperative pulmonary complications (PPCs) use patient data and expected surgery characteristics exclusively. However, intra-operative events are also associated with the development of PPCs. OBJECTIVE We aimed to develop a new prediction score for PPCs that uses both pre-operative and intra-operative data. DESIGN This is a secondary analysis of the LAS VEGAS study, a large international, multicentre, prospective study. SETTINGS A total of 146 hospitals across 29 countries. PATIENTS Adult patients requiring intra-operative ventilation during general anaesthesia for surgery. INTERVENTIONS The cohort was randomly divided into a development subsample to construct a predictive model, and a subsample for validation. MAIN OUTCOME MEASURES Prediction performance of developed models for PPCs. RESULTS Of the 6063 patients analysed, 10.9% developed at least one PPC. Regression modelling identified 13 independent risk factors for PPCs: six patient characteristics [higher age, higher American Society of Anesthesiology (ASA) physical score, pre-operative anaemia, pre-operative lower SpO2 and a history of active cancer or obstructive sleep apnoea], two procedure-related features (urgent or emergency surgery and surgery lasting ≥ 1 h), and five intra-operative events [use of an airway other than a supraglottic device, the use of intravenous anaesthetic agents along with volatile agents (balanced anaesthesia), intra-operative desaturation, higher levels of positive end-expiratory pressures > 3 cmH2O and use of vasopressors]. The area under the receiver operating characteristic curve of the LAS VEGAS risk score for prediction of PPCs was 0.78 [95% confidence interval (95% CI), 0.76 to 0.80] for the development subsample and 0.72 (95% CI, 0.69 to 0.76) for the validation subsample. CONCLUSION The LAS VEGAS risk score including 13 peri-operative characteristics has a moderate discriminative ability for prediction of PPCs. External validation is needed before use in clinical practice. TRIAL REGISTRATION The study was registered at Clinicaltrials.gov, number NCT01601223.https://ift.tt/2LNt1zA
Placebo versus low-dose ketamine infusion in addition to remifentanil target-controlled infusion for conscious sedation during oocyte retrieval: A double-blinded, randomised controlled trial
BACKGROUND Currently, there is no gold standard for monitored anaesthesia care during oocyte retrieval. OBJECTIVE In our institution, the standard is a conscious sedation technique using a target-controlled infusion (TCI) of remifentanil, titrated to maintain a visual analogue pain score less than 30 mm. This protocol is well accepted by patients but is associated with frequent episodes of respiratory depression. The main objective of this study was to evaluate whether the addition of a continuous intravenous infusion of ketamine could reduce these episodes. DESIGN Controlled, randomised, prospective, double-blinded study. SETTING The current study was conducted in a tertiary-level hospital in Brussels (Belgium) from December 2013 to June 2014. PATIENTS Of the 132 women undergoing oocyte retrieval included, 121 completed the study. INTERVENTION After randomisation, patients received either a ketamine infusion (40 μg kg−1 min−1 over 5 min followed by 2.5 μg kg−1 min−1) or a 0.9% saline infusion in addition to the variable remifentanil TCI. MAIN OUTCOME MEASURES The primary outcome was the number of respiratory depression episodes. Effect site target remifentanil concentrations, side effects, pain score, patient satisfaction and incidence of pregnancy were also recorded. RESULTS No significant difference in the incidence of respiratory events was noted (pulse oximetry oxygen saturation https://ift.tt/2MehUfg
Does a hypnosis session reduce the required propofol dose during closed-loop anaesthesia induction?: A randomised controlled trial
BACKGROUND Hypnosis has a positive effect on peri-operative anxiety and pain. OBJECTIVE The objective of this study was to assess the impact of a formal deep hypnosis session on the consumption of propofol for anaesthetic induction using automated administration of propofol guided by the bispectral index (BIS) in a closed loop. DESIGN A 1 : 1 randomised, usual-care-controlled, single-centre trial. SETTING Tertiary care centre in France from April 2014 to December 2015. PATIENTS Female adult patients scheduled for outpatient gynaecological surgery under general anaesthesia. INTERVENTION Before surgery, patients were randomised to receive either a deep hypnosis session or routine care. Anaesthetic induction was performed automatically by propofol without opioids and was assisted by the BIS in a closed loop. MAIN OUTCOME MEASURES The primary endpoint was the propofol dose required for anaesthesia induction, defined as a BIS less than 60 for at least 30 s. RESULTS Data for 31 patients in the hypnosis group and 35 in the control group were analysed. There was no evidence of a difference in the mean required propofol dose for anaesthetic induction between the hypnosis and the control groups (2.06 mg kg−1 (95% confidence interval [1.68 to 2.43]) versus 1.79 mg kg−1 (95% CI [1.54 to 2.03]), P = 0.25, respectively). CONCLUSION The current study, which was designed to determine the effect of a deep hypnosis session on anaesthesia induction using an automated tool for propofol administration, failed to detect a difference in the required dose of propofol. TRIAL REGISTRATION ClinicalTrials.gov, NCT02249364.https://ift.tt/2McqUBF
Comparative study of concordance between bispectral index recordings obtained from the standard frontal and infra-orbital sensor position
No abstract availablehttps://ift.tt/2LNsKwy
Peri-operative copeptin concentrations and their association with myocardial injury after vascular surgery: A prospective observational cohort study
BACKGROUND Copeptin levels in conjunction with cardiac troponin may be used to rule out early myocardial infarction in patients presenting with chest pain. Raised pre-operative copeptin has been shown to be associated with postoperative cardiac events. However, very little is known about the peri-operative time course of copeptin or the feasibility of very early postoperative copeptin measurement to diagnose or rule-out myocardial injury. OBJECTIVES In this preparatory analysis for a larger trial, we sought to examine the time course of peri-operative copeptin and identify the time at which concentrations returned to pre-operative levels. Second, in an explorative analysis, we sought to examine the association of copeptin in general and at various time points with myocardial injury occurring within the first 48 h. DESIGN Preparatory analysis of a prospective, observational cohort study. SETTING Single university centre from February to July 2016. PATIENTS A total of 30 consecutive adults undergoing vascular surgery. INTERVENTION Serial peri-operative copeptin measurements. MAIN OUTCOME MEASURE We measured copeptin concentrations before and immediately after surgery (0 h), then at 2, 4, 6 and 8 h after surgery and on the first and second postoperative day. Postoperative concentrations were compared with pre-operative levels with a Wilcoxon signed-rank test. Second, we explored an association between postoperative copeptin concentrations and myocardial injury by the second postoperative day. Myocardial injury was defined as a 5 ng l−1 increase between pre-operative and postoperative high-sensitivity cardiac troponin T with an absolute peak of at least 20 ng l−1. RESULTS Immediate postoperative copeptin concentrations (median [interquartile range]) increased nearly eight-fold from pre-operative values (8.5 [3.6 to 13.8] to 64.75 pmol l−1 [29.6 to 258.7]; P https://ift.tt/2MfDsbH
European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium: erratum
No abstract availablehttps://ift.tt/2LNsDB8
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