As golf becomes increasingly popular, the number of injuries while playing golf also increases. We experienced two cases of traumatic tibia shaft fractures caused by the impact of a golf ball.
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Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Παρασκευή 24 Αυγούστου 2018
Traumatic tibia shaft fractures caused by the impact of a golf ball: two case reports
Oxygen Reserve Index: Validation of a New Variable
BACKGROUND: Pulse oximetry–derived oxygen saturation is typically >97% in normoxia and hyperoxia, limiting its clinical use. The new Oxygen Reserve Index (ORi), a relative indicator of the partial pressure of oxygen dissolved in arterial blood (PaO2) in the range of 100–200 mm Hg, may allow additional monitoring of oxygen status. METHODS: In this prospective validation intervention study, 20 healthy volunteers were breathing standardized oxygen concentrations ranging from mild hypoxia (fraction of inspired oxygen = 0.14) to hyperoxia (fraction of inspired oxygen = 1.0) via a tight-fitting face mask. ORi was measured noninvasively by multiwavelength pulse co-oximetry using 2 finger sensors. These ORi values (unitless scale, 0.00–1.00) were compared with measured PaO2 values. Repeated-measurements correlation analysis was performed to assess the ORi/PaO2 relationship. ORi trending ability was assessed using a 4-quadrant plot. The area under the receiver operating characteristics curve was calculated to assess the prediction of hypoxia (low-ranged PaO2,
https://ift.tt/2PDH0qe
https://ift.tt/2PDH0qe
Dexmedetomidine Pharmacokinetics and a New Dosing Paradigm in Infants Supported With Cardiopulmonary Bypass
BACKGROUND: Dexmedetomidine is increasingly used off-label in infants and children with cardiac disease during cardiopulmonary bypass (CPB) and in the postoperative period. Despite its frequent use, optimal dosing of dexmedetomidine in the setting of CPB has not been identified but is expected to differ from dosing in those not supported with CPB. This study had the following aims: (1) characterize the effect of CPB on dexmedetomidine clearance (CL) and volume of distribution (V) in infants and young children; (2) characterize tolerance and sedation in patients receiving dexmedetomidine; and (3) identify preliminary dosing recommendations for infants and children undergoing CPB. We hypothesized that CL would decrease, and V would increase during CPB compared to pre- or post-CPB states. METHODS: Open-label, single-center, opportunistic pharmacokinetics (PK) and safety study of dexmedetomidine in patients ≤36 months of age administered dexmedetomidine per standard of care via continuous infusion. We analyzed dexmedetomidine PK data using standard nonlinear mixed effects modeling with NONMEM software. We compared model-estimated PK parameters to those from historical patients receiving dexmedetomidine before anesthesia for urologic, lower abdominal, or plastic surgery; after low-risk cardiac or craniofacial surgery; or during bronchoscopy or nuclear magnetic resonance imaging. We investigated the influence of CPB-related factors on PK estimates and used the final model to simulate dosing recommendations, targeting a plasma concentration previously associated with safety and efficacy (0.6 ng/mL). We used the Wilcoxon rank sum test to evaluate differences in dexmedetomidine exposure between infants with hypotension or bradycardia and those who did not develop these adverse events. RESULTS: We collected 213 dexmedetomidine plasma samples from 18 patients. Patients had a median (range) age of 3.3 months (0.1–34.0 months) and underwent CPB for 161 minutes (63–394 minutes). We estimated a CL of 13.4 L/h/70 kg (95% confidence interval, 2.6–24.2 L/h/70 kg) during CPB, compared to 42.1 L/h/70 kg (95% confidence interval, 38.7–45.8 L/h/70 kg) in the historical patients. No specific CPB-related factor had a statistically significant effect on PK. A loading dose of 0.7 µg/kg over 10 minutes before CPB, followed by maintenance infusions through CPB of 0.2 or 0.25 µg/kg/h in infants with postmenstrual ages of 42 or 92 weeks, respectively, maintained targeted concentrations. We identified no association between dexmedetomidine exposure and selected adverse events (P = .13). CONCLUSIONS: CPB is associated with lower CL during CPB in infants and young children compared to those not undergoing CPB. Further study should more closely investigate CPB-related factors that may influence CL. Accepted for publication June 27, 2018. Funding: K.O.Z. is funded by grant KL2TR001115-03 from the Duke Clinical and Translational Science Awards and K23 grant HD091398 from the National Institutes of Health (NIH). H.W. received salary support from grant K23HD0785891 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) for completion of this project. M.L. receives support from the US government for work in neonatal clinical pharmacology, clinical trials, and cohort studies including Food and Drug Administration (FDA) R01 FD005101, Prinicipal Investigator (PI) M.L.; National Heart, Lung and Blood Institute (NHLBI) R34 HL124038, PI M.L.; the NIH Office of the Director, Environmental Influences on Child Health Outcomes (ECHO) Coordinating Center U2C OD023375, PI P.B.S., Duke University School of Medicine; the NICHD Pediatric Trials Network Government Contract HHSN267200700051C, PI Daniel Benjamin Jr, Duke University School of Medicine; and as the satellite site PI for the NICHD Neonatal Research Network NICHD U10 HD040492, PI C. Michael Cotten, Duke University School of Medicine. R.G.G. receives salary support for research from the NIH training grants (5T32HD043029-13), NIH awards (HHSN 275201000003I, HHSN 272201300017I), and from the FDA (HHSF223201610082C). P.B.S. receives salary support for research from the NIH (NIH-1R21HD080606-01ª1) and the National Center for Advancing Translational Sciences of the NIH (UL1TR001117), the NICHD (HHSN275201000003I), and the FDA (1R18-FD005292-01). C.P.H. receives salary support for research from the National Center for Advancing Translational Sciences of the NIH (UL1TR001117) and the US government for his work in pediatric and neonatal clinical pharmacology (Government Contract HHSN267200700051C, PI: Daniel Benjamin Jr under the Best Pharmaceuticals for Children Act). M.C.-W. receives support for research from the NIH (1R01-HD076676-01A1), the National Institute of Allergy and Infectious Disease (HHSN272201500006I and HHSN272201300017I), the NICHD (HHSN275201000003I), the Biomedical Advanced Research and Development Authority (HHSO100201300009C), and industry for drug development in adults and children (https://ift.tt/2PAHZY8). K.M.W. receives support from the Pediatric Critical Care and Trauma Scientist Development Program (5K12HD047349) and the NICHD (1K23HD075891) for his work in pediatric clinical pharmacology. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Kanecia O. Zimmerman, MD, MPH, Department of Pediatrics, Duke University School of Medicine, Box 3850, Durham, NC 27710. Address e-mail to Kanecia.obie@dm.duke.edu. © 2018 International Anesthesia Research Society
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https://ift.tt/2wo5w5B
Process Optimization and Digital Quality Improvement to Enhance Timely Initiation of Epidural Infusions and Postoperative Pain Control
BACKGROUND: Although intraoperative epidural analgesia improves postoperative pain control, a recent quality improvement project demonstrated that only 59% of epidural infusions are started in the operating room before patient arrival in the postanesthesia care unit. We evaluated the combined effect of process and digital quality improvement efforts on provider compliance with starting continuous epidural infusions during surgery. METHODS: In October 2014, we instituted 2 process improvement initiatives: (1) an electronic order queue to assist the operating room pharmacy with infusate preparation; and (2) a designated workspace for the storage of equipment related to epidural catheter placement and drug infusion delivery. In addition, we implemented a digital quality improvement initiative, an Anesthesia Information Management System–mediated clinical decision support, to prompt anesthesia providers to start and document epidural infusions in pertinent patients. We assessed anesthesia provider compliance with epidural infusion initiation in the operating room and postoperative pain-related outcomes before (PRE: October 1, 2012 to September 31, 2014) and after (POST: January 1, 2015 to December 31, 2016) implementation of the quality improvement initiatives. RESULTS: Compliance with starting intraoperative epidural infusions was 59% in the PRE group and 85% in the POST group. After adjustment for confounders and preintervention time trends, segmented regression analysis demonstrated a statistically significant increase in compliance with the intervention in the POST phase (odds ratio, 2.78; 95% confidence interval, 1.73–4.49; P
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https://ift.tt/2PxLPBj
Update on Perioperative Acute Kidney Injury
Acute kidney injury (AKI) in the perioperative period is a common complication and is associated with increased morbidity and mortality. A standard definition and staging system for AKI has been developed, incorporating a reduction of the urine output and/or an increase of serum creatinine. Novel biomarkers may detect kidney damage in the absence of a change in function and can also predict the development of AKI. Several specific considerations for AKI risk are important in surgical patients. The surgery, especially major and emergency procedures in critically ill patients, may cause AKI. In addition, certain comorbidities, such as chronic kidney disease and chronic heart failure, are important risk factors for AKI. Diuretics, contrast agents, and nephrotoxic drugs are commonly used in the perioperative period and may result in a significant amount of in-hospital AKI. Before and during surgery, anesthetists are supposed to optimize the patient, including preventing and treating a hypovolemia and correcting an anemia. Intraoperative episodes of hypotension have to be avoided because even short periods of hypotension are associated with an increased risk of AKI. During the intraoperative period, urine output might be reduced in the absence of kidney injury or the presence of kidney injury with or without fluid responsiveness. Therefore, fluids should be used carefully to avoid hypovolemia and hypervolemia. The Kidney Disease: Improving Global Outcomes guidelines suggest implementing preventive strategies in high-risk patients, which include optimization of hemodynamics, restoration of the circulating volume, institution of functional hemodynamic monitoring, and avoidance of nephrotoxic agents and hyperglycemia. Two recently published studies found that implementing this bundle in high-risk patients reduced the occurrence of AKI in the perioperative period. In addition, the application of remote ischemic preconditioning has been studied to potentially reduce the incidence of perioperative AKI. This review discusses the epidemiology and pathophysiology of surgery-associated AKI, highlights the importance of intraoperative oliguria, and emphasizes potential preventive strategies. Accepted for publication July 17, 2018. Funding: A.Z. received lecture fees from Baxter, Astute Medical, Fresenius, Braun, and Ratiopharm and unrestricted research grants from Fresenius, German Research Foundation, Astellas, and Astute Medical. J.L.K. reports receiving consulting fees from Astute Medical, Sphingotec, and Pfizer and research funds from Astute Medical, Bioporto, Nxstage, Satellite Healthcare, and the National Institutes of Health. J.A.K. reports consulting fees and grant support from Astute Medical. E.A.J.H. received a travel grant from AM Pharma, a speaker's fee from Astute Medical, and a research grant from Bellco. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Alexander Zarbock, MD, Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Bldg A1, 48149 Münster, Germany. Address email to zarbock@uni-muenster.de. © 2018 International Anesthesia Research Society
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https://ift.tt/2wnRnpd
Randomized, Double-Blind, Placebo-Controlled Study of Intravenous Amisulpride as Treatment of Established Postoperative Nausea and Vomiting in Patients Who Have Had No Prior Prophylaxis
BACKGROUND: Postoperative nausea and vomiting (PONV) occurs commonly in surgical patients despite widespread prophylactic antiemetic use. Rescue options are currently limited. 5HT3 antagonists are most frequently used for prophylaxis, but if they fail, additional doses are not effective as rescue medication. Intravenous (IV) amisulpride, a well-studied D2/D3 antagonist, has been shown in trials to prevent PONV. This study was designed to determine if amisulpride could be used to treat established PONV in patients at low-to-moderate risk of PONV who had not received any prior prophylaxis. METHODS: Men and women aged over 18 years were permitted to enroll if they were to undergo general inhalational anesthesia, expected to last at least 1 hour, for an outpatient or inpatient surgical procedure. Patients who then suffered PONV were randomized equally to 1 of 3 single-dose IV regimens: placebo or 5 or 10 mg amisulpride. The primary end point was complete response, defined as no emesis in the period 30 minutes to 24 hours after study drug treatment and no use of rescue medication in the entire 24-hour period. RESULTS: One thousand nine hundred eighty-eight patients were enrolled preoperatively, of whom 560 were randomized to a treatment arm. Complete response occurred in 39 of 181 patients (21.5%) in the placebo group compared to 60 of 191 patients (31.4%; P = .016) and 59 of 188 patients (31.4%; P = .016) in the amisulpride 5 and 10 mg groups, respectively. The adverse event profile of amisulpride at either dose was similar to placebo. CONCLUSIONS: IV amisulpride at 5 and 10 mg was safe and efficacious in the treatment of established PONV in surgical patients undergoing general anesthesia with no prior PONV prophylaxis. Accepted for publication July 3, 2018. Funding: This work was supported by Acacia Pharma Ltd, Cambridge, United Kingdom. Conflicts of Interest: See Disclosures at the end of the article. Clinical trial registry number: ClinicalTrials.gov NCT2449291. Reprints will not be available from the authors. Address correspondence to Keith A. Candiotti, MD, Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Jackson Memorial Hospital, (C-302), 1611 NW 12th Ave, Miami, FL 33136. Address e-mail to kcandiotti@miami.edu. © 2018 International Anesthesia Research Society
https://ift.tt/2wlNCR1
https://ift.tt/2wlNCR1
Anesthesiologists’ Overconfidence in Their Perceived Knowledge of Neuromuscular Monitoring and Its Relevance to All Aspects of Medical Practice: An International Survey
BACKGROUND: In patients who receive a nondepolarizing neuromuscular blocking drug (NMBD) during anesthesia, undetected postoperative residual neuromuscular block is a common occurrence that carries a risk of potentially serious adverse events, particularly postoperative pulmonary complications. There is abundant evidence that residual block can be prevented when real-time (quantitative) neuromuscular monitoring with measurement of the train-of-four ratio is used to guide NMBD administration and reversal. Nevertheless, a significant percentage of anesthesiologists fail to use quantitative devices or even conventional peripheral nerve stimulators routinely. Our hypothesis was that a contributing factor to the nonutilization of neuromuscular monitoring was anesthesiologists' overconfidence in their knowledge and ability to manage the use of NMBDs without such guidance. METHODS: We conducted an Internet-based multilingual survey among anesthesiologists worldwide. We asked respondents to answer 9 true/false questions related to the use of neuromuscular blocking drugs. Participants were also asked to rate their confidence in the accuracy of each of their answers on a scale of 50% (pure guess) to 100% (certain of answer). RESULTS: Two thousand five hundred sixty persons accessed the website; of these, 1629 anesthesiologists from 80 countries completed the 9-question survey. The respondents correctly answered only 57% of the questions. In contrast, the mean confidence exhibited by the respondents was 84%, which was significantly greater than their accuracy. Of the 1629 respondents, 1496 (92%) were overconfident. CONCLUSIONS: The anesthesiologists surveyed expressed overconfidence in their knowledge and ability to manage the use of NMBDs. This overconfidence may be partially responsible for the failure to adopt routine perioperative neuromuscular monitoring. When clinicians are highly confident in their knowledge about a procedure, they are less likely to modify their clinical practice or seek further guidance on its use. Accepted for publication July 3, 2018. A. F. Kopman is now retired. Funding: S.J.B. has received research funding from Merck & Co, Inc (Kenilworth, NJ) (funds to Mayo Clinic). Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). M. Naguib and S. J. Brull contributed equally to this work and share first authorship. Reprints will not be available from the authors. Address correspondence to Mohamed Naguib, MD, MSc, FCARCSI, Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, NE6-306, Cleveland, OH 44195. Address e-mail to naguibm@ccf.org. © 2018 International Anesthesia Research Society
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https://ift.tt/2PAGiKi
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