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Новости Анестезиологии И Интенсивной Терапии


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Отправлено 20 октября 2008 - 20:29

Effects of age and gender on intravenous midazolam premedication: a randomized double-blind study

G.-C. Sun1,2, , M.-C. Hsu3, , Y.-Y. Chia4, P.-Y. Chen1 and F.-Z. Shaw2,5,*
1 Department of Anaesthesiology, Yuli Veterans Hospital, No. 91, Xinxing Street, Yuli Town, Hualian County 981, Taiwan, Republic of China
2 Institute of Neuroscience, Tzu Chi University, Hualien, Taiwan, Republic of China
3 Department of Nursing, I-Shou University, No. 8, Yida Road, Yanchao Township, Kaohsiung County 82445, Taiwan, Republic of China
4 Department of Anaesthesia, Kaohsiung Veterans Hospital, No. 386 Ta-Chung 1st Road, Kaohsiung 813, Taiwan, Republic of China
5 Institute of Cognitive Science, National Cheng Kung University, 1 University Road, Tainan 701, Taiwan, Republic of China

* Corresponding author. E-mail: fzshaw@yahoo.com.tw

Background: Given the potentially important effects that age and gender may have on midazolam premedication, this study aimed at determining if these factors alter anxiety, sedation, and cardiorespiratory outcomes when administering two different doses of i.v. midazolam.

Methods: After randomization, patients were premedicated 1 h before surgery with either i.v. midazolam 0.02 or 0.06 mg kg–1 depending on their age and gender group. Levels of anxiety and sedation, heart rate, respiratory rate (RR), mean blood pressure (MBP), and oxygen saturation (SpO2) were measured before and 15 min after midazolam administration.

Results: A higher level of preoperative anxiety was more often observed in women than in men, and in young than in older patients. The female or younger patients showed significant anxiolytic benefits from midazolam. A deeper sedation level was found in men compared with women. Forty-two of 45 patients (93.3%) with excessive sedation received midazolam 0.06 mg kg–1. The elderly patients receiving midazolam 0.06 mg kg–1 showed significant reductions in MBP, RR, and SpO2. Of the patients with an SpO2<90%, 72.7% had received midazolam 0.06 mg kg–1.

Conclusions: Age and gender differences in neuropsychological and physiological responses after midazolam premedication were evident. Midazolam is effective for producing sedation and anxiolysis at a dose of 0.02 mg kg–1, with minimal effects on cardiorespiration and oxygen saturation to patients. Dosage adjustments based on these covariates are, therefore, necessary.

British Journal of Anaesthesia 2008 101(5):632-639; doi:10.1093/bja/aen251
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Отправлено 20 октября 2008 - 20:37

Pre-incisional epidural magnesium provides pre-emptive and preventive analgesia in patients undergoing abdominal hysterectomy

S. Farouk*
Department of Anesthesiology, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

* Corresponding author: 12 Abdullah Abu El-Soad Road, Triumph, Heliopolis, Cairo, Egypt. E-mail: sherifibrahim210@yahoo.com

Background: This prospective, randomized, double-blind study was designed to evaluate the pre-emptive and preventive analgesic efficacy of adding magnesium to a multimodal regimen of patient-controlled epidural analgesia (PCEA) in patients undergoing abdominal hysterectomy.

Methods: Ninety patients were randomly assigned to one of the three groups. Pre-magnesium patients received bolus of magnesium 50 mg epidurally before induction of anaesthesia followed by infusion of 10 mg h–1 until end of surgery. Post-magnesium patients received epidural saline during the same time periods plus bolus epidural magnesium 50 mg at the end of surgery. Patients in the control group received epidural saline during all three periods. Patients in the magnesium groups received PCEA with fentanyl 1 µg ml–1, bupivacaine 0.08%, and magnesium 1 mg ml–1 after operation. Patients in the control group received PCEA with fentanyl 1 µg ml–1 and bupivacaine 0.08%. Data were recorded for three postoperative days.

Results: There were significantly lower pain scores on rest or movement in the pre-magnesium group compared with the post-magnesium and control groups (P<0.05). The daily analgesic consumption in the pre-magnesium group was significantly less than the other two groups (P<0.05) and the dose consumed in the post-magnesium group was significantly smaller than the control group (P<0.05). The groups were similar with respect to haemodynamic and respiratory variables, sedation, pruritus, nausea, and vomiting.

Conclusions: Continuous epidural magnesium started before anaesthesia provided pre-emptive, preventive analgesia, and an analgesic-sparing effect that improved postoperative analgesia without increasing the incidence of side-effects.

British Journal of Anaesthesia 2008 101(5):694-699; doi:10.1093/bja/aen274
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Отправлено 20 октября 2008 - 20:55

Prophylactic mirtazapine reduces intrathecal morphine-induced pruritus

M. J. Sheen1,*, S.-T. Ho1, C.-H. Lee2, Y.-C. Tsung1, F.-L. Chang1 and S.-T. Huang1
1 Department of Anaesthesiology
2 Department of Orthopaedic Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Cheng-gong Road Section 2, Neihu, Taipei 11490, Taiwan

* Corresponding author. E-mail: mkjsheen@ndmctsgh.edu.tw

Background: Activation of the serotonergic system is an important factor in the pathogenesis of intrathecal morphine-induced pruritus. Mirtazapine is a new antidepressant that selectively blocks 5-HT2 and 5-HT3 receptors. We therefore tested the hypothesis that preoperative mirtazapine would reduce the incidence of intrathecal morphine-induced pruritus.

Methods: One hundred and ten ASA I patients undergoing lower limb surgery under spinal anaesthesia were randomly allocated into two equal groups and received either mirtazapine 30 mg or an orally disintegrating placebo tablet 1 h before operation in a prospective, double-blinded trial. All patients received an intrathecal injection of 15 mg of 0.5% isobaric bupivacaine and 0.2 mg preservative-free morphine. The occurrence and the severity of pruritus were assessed at 3, 6, 9, 12, and 24 h after intrathecal morphine.

Results: Pruritus was significantly more frequent in the placebo group compared with the mirtazapine group (75% vs 52%, respectively; P=0.0245). The time to onset of pruritus in the two groups was also significantly different. The patients who experienced pruritus in the placebo group had a faster onset time than that in the mirtazapine group [mean (SD): 3.2 (0.8) vs 7.2 (4.1) h, P<0.0001].

Conclusions: Mirtazapine premedication prevents pruritus induced by intrathecal morphine in patients undergoing lower limb surgery with spinal anaesthesia.

British Journal of Anaesthesia 2008 101(5):711-715; doi:10.1093/bja/aen241
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Отправлено 20 октября 2008 - 21:01

Comparison of Macintosh, Truview EVO2®, Glidescope®, and Airwayscope® laryngoscope use in patients with cervical spine immobilization

M. A. Malik1,2, C. H. Maharaj3, B. H. Harte1 and J. G. Laffey1,2,*
1 Department of Anaesthesia, Clinical Sciences Institute, Galway University Hospitals, Galway, Ireland
2 Clinical Research Facility, National University of Ireland, Galway, Ireland
3 Department of Anaesthesia, Sligo General Hospital, Sligo, Ireland

* Corresponding author. E-mail: john.laffey@nuigalway.ie

Background: The purpose of this study was to evaluate the effectiveness of the Pentax AWS®, Glidescope®, and the Truview EVO2®, in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization.

Methods: One hundred and twenty consenting patients presenting for surgery requiring tracheal intubation were randomly assigned to undergo intubation using a Macintosh (n=30), Glidescope® (n=30), Truview EVO2® (n=30), or AWS® (n=30) laryngoscope. All patients were intubated by one of the three anaesthetists experienced in the use of each laryngoscope.

Results: The Glidescope®, AWS®, and Truview EVO2® each reduced the intubation difficulty score (IDS), improved the Cormack and Lehane glottic view, and reduced the need for optimization manoeuvres, compared with the Macintosh. The mean IDS was significantly lower with the Glidescope® and AWS® compared with the Truview EVO2® device, and the IDS was lowest with the AWS®. The duration of tracheal intubation attempts was significantly shorter with the Macintosh compared with the other devices. There were no differences in success rates between the devices tested. The AWS® produced the least haemodynamic stimulation.

Conclusions: The Glidescope® and AWS® laryngoscopes required more time but reduced intubation difficulty and improved glottic view over the Macintosh laryngoscope more than the Truview EVO2® laryngoscope when used in patients undergoing cervical spine immobilization.

British Journal of Anaesthesia 2008 101(5):723-730; doi:10.1093/bja/aen231
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Отправлено 21 октября 2008 - 17:11

Emergency cricothyroidotomy: a randomised crossover study of four methods

J. C. Dimitriadis 1 and R. Paoloni 2
1 Emergency medicine registrar, Royal Prince Alfred Hospital, Sydney, Australia
2 Emergency physician, Concord Hospital, Sydney, Australia
Correspondence to Dr Richard Paoloni E-mail: rpao@bigpond.net.au

ABSTRACT
Emergency physicians and registrars performed emergency cricothyroidotomy on an artificial airway model using a standard surgical approach and three common commercial products, participants had received no refresher training. The order in which the methods were used was randomised to minimise any learning effect. Three methods (standard surgical, Minitrach II, and Quicktrach) were universally successful in obtaining ventilation within 150 s, whilst the Melker kit had a 26% failure rate and significantly longer median time to ventilation (126 s vs≤48 s for other methods, p < 0.001). Despite success in using the surgical method, the Quicktrach and Minitrach II were rated as first or second preference by the majority of operators (78% and 70% respectively). Without refresher training emergency physicians and registrars successfully performed emergency cricothyroidotomy using the standard surgical method, Quicktrach and Minitrach II kits however the use of the Melker kit under these conditions resulted in significant delays or failure to establish an airway.

Anaesthesia. Volume 63 Issue 11, Pages 1204 - 1208 DOI 10.1111/j.1365-2044.2008.05631.x
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Отправлено 21 октября 2008 - 17:28

A Rational Approach to Perioperative Fluid Management
[Review Articles]


Chappell, Daniel M.D.*; Jacob, Matthias M.D.*; Hofmann-Kiefer, Klaus M.D.*; Conzen, Peter M.D.†; Rehm, Markus M.D.‡

* Staff Anesthesiologist, † Professor of Anesthesiology, ‡ Associate Professor of Anesthesiology.

Anesthesiology:Volume 109(4)October 2008pp 723-740

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Отправлено 21 октября 2008 - 17:38

Biologic Effects of Nitrous Oxide: A Mechanistic and Toxicologic Review
[Review Articles]


Sanders, Robert D. B.Sc., M.B., B.S., F.R.C.A.*; Weimann, Jörg M.D., D.E.A.A.†; Maze, Mervyn M.B., Ch.B., F.R.C.P., F.R.C.A., F.Med.Sci.‡

Section Editor(s): Warner, David S. M.D.; Warner, Mark A. M.D., Editors

* Academic Clinical Fellow and Specialist Registrar, ‡ Professor, Department of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom. † Professor, Department of Anaesthesia and Intensive Care Medicine, Sankt Gertrauden-Krankenhaus, Berlin, Germany.

Anesthesiology:Volume 109(4)October 2008pp 707-722

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Отправлено 21 октября 2008 - 17:55

Endotracheal tube malposition within the pediatric population: a common event despite clinical evidence of correct placement

Eric A. Harris, MD MBA*, Kristopher L. Arheart, EdD and Donald H. Penning, MD*
* From the Departments of Anesthesiology, Perioperative Medicine, and
Pain Management, and Epidemiology and Public Health, University of Miami / Miller School of Medicine, Miami, Florida, USA.

Address correspondence to: Dr. Eric A. Harris, 2574 Mayfair Ln., Weston, FL 33327-1506, USA. Phone: 305-585-5094; Fax: 305-585-8127; E-mail: eharris2@med.miami.edu

Purpose: To ensure that the endotracheal tube (ETT) is ideally placed for proper ventilation, radiographic confirmation of ETT placement is frequently used to supplement clinical examination in the intensive care unit setting. However, fluoroscopy rarely serves the same role during surgery, despite the fact that portable units are often present in the operating room. The purpose of this study was to ascertain the value of fluoroscopy in determining ETT malposition among the pediatric surgical population.

Methods: Chest radiographs from 257 children (age 12 days–12 yr), who presented for a total of 446 individual procedures in the fluoroscopy suite, were studied to determine the incidence of ETTs placed too shallow (above the inferior clavicular border) or too deep (at or below the carina). A logistic regression with outcomes of correct and incorrect was used to analyze the data points.

Results: Eighteen percent of all the radiographs showed initial improper ETT placement, despite clinical evidence suggesting the contrary. The peak incidence of malposition, which occurred in patients under one year old, reached 35%. Incidence decreased with advancing age, but remained over 10% until the age of ten. A second attempt at positioning the tube, based on information from the chest radiograph, was successful in 95% of the cases. The remaining 5% required placement of the ETT under continuous fluoroscopic guidance.

Conclusion: Fluoroscopy, when readily available in the operating room, is a safe and useful technique to ensure proper ETT placement among the pediatric population.

Canadian Journal of Anesthesia 55:685-690 (2008)
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Отправлено 21 октября 2008 - 18:03

Defining rules for the identification of critical ventilatory events

J. Mark Ansermino, FRCPC, Maryam Dosani, BSc, Erica Amari, BA, Peter T. Choi, MD FRCPC MSC and Stephan K. W. Schwarz, MD PhD FRCPC
From the Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada.

Address correspondence to: Dr. J. Mark Ansermino, British Columbia Children’s Hospital, Department of Pediatric Anesthesia, Room 1L7, 4480 Oak Street, Vancouver V6H 3V4, Canada. E-mail: anserminos@yahoo.ca

Purpose: The automated recognition of critical clinical events by physiological monitors is a challenging task exacerbated by a lack of standardized and clinically relevant threshold criteria. The objective of this investigation was to develop consensus for such criteria regarding the identification of three ventilatory events: disconnection or significant leak in the anesthesia circuit, decreased lung compliance or increased resistance, and anesthetic overdose from inhaled anesthetics.

Methods: We individually administered a structured interview to five expert anesthesiologists to gain insight into the cognitive processes used by clinicians to diagnose ventilatory events and to determine the common heuristics (rules of thumb) used in clinical practice. We then used common themes, identified from analysis of the structured interviews, to generate questions for a series of web-based questionnaires. Using a modified Delphi technique, iterative questionnaire administration facilitated rapid consensus development on the thresholds for the specific rules used to identify ventilatory events.

Results: A threshold for 75% agreement was described for each scenario in a healthy ventilated adult. A disconnection or significant leak in the anesthesia circuit is diagnosed with peak airway pressure (< 5 cm H2O or change of 15 cm H2O), ETCO2 (0 mmHg, 40% drop, or value below 10 mmHg for a duration of 20 sec), and inspired-expired volume difference (300 mL). Increased resistance or decreased lung compliance is diagnosed with high peak airway pressure (40 cm H2O or a 20 cm H2O change), asymmetry of capnogram, and changes in measured compliance or resistance. Anesthetic overdose from inhaled anesthetics is diagnosed with high end-tidal anesthetic agent concentration (2 MAC in a patient less than 60 yr of age or 1.75 MAC in a patient over 60 yr of age), low systolic blood pressure (below 60 mmHg), and low modified electroencephalogram (bispectral index or entropy).

Conclusion: This investigation has provided a set of consensus-based criteria for developing rules for the identification of three critical ventilatory events and has presented insight into the decision heuristics used by clinicians.

Canadian Journal of Anesthesia 55:702-714 (2008)
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Отправлено 21 октября 2008 - 18:15

The effect of anaesthetic agents on induction, recovery and patient preferences in adult day case surgery: a 7-day follow-up randomized controlled trial

J. K. Moorea1 c1, R. A. Elliotta2, K. Paynea21, E. W. Moorea1, A. S. St Legera32, N. J. N. Harpera4, B. J. Pollarda4 and J. Kerra13

a1 Wirral Hospital Trust, Cheshire, Manchester, UK
a2 University of Manchester, School of Pharmacy and Pharmaceutical Sciences, Manchester, UK
a3 University of Manchester, School of Epidemiology and Health Sciences, Biostatistics Group, Manchester, UK
a4 Central Manchester & Manchester Children’s University Hospitals NHS Trust, Department of Anaesthesia, Manchester, UK

Summary
Background and objective To compare induction, pre- and post-discharge recovery characteristics and patient preferences between four anaesthetic regimens in adult day-surgery.

Methods Randomized controlled trial. In all, 1158 adults assigned to: propofol induction and maintenance, propofol induction with isoflurane/N2O, or sevoflurane/N2O maintenance, or sevoflurane/N2O alone. We prospectively recorded induction and pre-discharge recovery characteristics, collected 7-day post-discharge recovery characteristics using patient diaries and patient preferences by telephone follow-up.

Results Recruitment rate was 73% – of the 425 refusals, 226 were not willing to risk a volatile induction. During induction, excitatory movements and breath holding were more common with sevoflurane only (P < 0.01). Injection pain and hiccup were more common with propofol induction (P < 0.01). In the recovery room and the postoperative ward, both nausea and vomiting were more common with sevoflurane only (P < 0.01). This difference disappeared within 48 h. There was no difference between groups in the mental state on awakening, recovery time, time to discharge or overnight admissions; then was also no difference in pain between the four groups for each of the seven postoperative days (P < 0.01), nor any differences in concentration or forgetfulness. Patients took 6.5 days (95% CI: 6.0–7.0, n = 693) to resume normal activities. Patients who received sevoflurane only were more likely to recall an unpleasant induction and least likely to want the same induction method again (P < 0.01).

Conclusion Differences in outcome between the four regimens are transient; sevoflurane is not an ideal sole agent for adult day case anaesthesia and, in this setting, patients base their preferences for future anaesthetics on the method of induction.

European Journal of Anaesthesiology (2008), 25:876-883 Cambridge University Press
doi:10.1017/S0265021507003493

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Отправлено 21 октября 2008 - 18:23

Percutanous dilatational tracheotomy in the ICU: a Norwegian survey focusing on perceived risk and safety attitudes

S. J. M. Sollida1 c1, K. Stranda1 and E. Søreidea1

a1 Stavanger University Hospital, Division of Acute Care Medicine, Department of Anaesthesia and Intensive Care, Stavanger, Norway

Summary
Background and objectives Despite its popularity, serious complications do occur with percutaneous dilatational tracheotomy in the ICU. The associated risks in daily practice are probably underestimated and may reflect system flaws in training and team function. This study was performed to obtain an impression of risk perception and safety culture in connection with percutaneous dilatational tracheotomy in Norwegian ICUs.

Methods The Medical Director or intensivist on-call in the 30 ICUs participating in the Norwegian Intensive Care Registry was telephone interviewed using a semi-structured questionnaire. Data on the practice of tracheotomy and a qualitative assessment of complications experienced during the last 2 years were collected. In the second part, percutaneous dilatational tracheotomy operators in two ICUs were questioned about their perception of risk with percutaneous dilatational tracheotomy and asked to assess their own abilities as percutaneous dilatational tracheotomy operators and the training they had undergone.

Results Of the 30 ICUs, 23 used percutaneous dilatational tracheotomy. The majority reported knowledge of severe complications like bleeding, hypoxia and tube dislodgment. Percutaneous dilatational tracheotomy-related deaths were also reported. Operators rated themselves relatively low and indicated the absence of any organized training. They acknowledged the known hazards related to percutaneous dilatational tracheotomy and suggested measures like fibreoptic guidance during the percutaneous dilatational tracheotomy and fewer operators with more experience as well as better team training, to improve patient safety.

Conclusion Based on the frequent reporting of serious complications and the suggested safety precautions, we conclude that the percutaneous dilatational tracheotomy is considered a high-risk procedure and that there is still room for improving the safety of this much used ICU procedure.

European Journal of Anaesthesiology (2008), 25:925-932 Cambridge University Press
doi:10.1017/S0265021508004791

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Отправлено 30 октября 2008 - 09:29

Practice

Guidelines
Prevention and treatment of surgical site infection: summary of NICE guidance

David Leaper, visiting professor1, Shona Burman-Roy, systematic reviewer 2, Ana Palanca, research assistant 2, Katherine Cullen, health economist2, Danielle Worster, information scientist 2, Eva Gautam-Aitken, project manager2, Martin Whittle, clinical codirector2, On behalf of the Guideline Development Group

1 Department of Wound Healing, Cardiff University, Cardiff, 2 National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA

Correspondence to: D Leaper, National Collaborating Centre for Women’s and Children’s Health, King’s Court, 2-16 Goodge Street, London W1T 2QA profdavidleaper@doctors.org.uk

Why read this summary?
The consequences of infection at the site of surgery can be devastating to the patient and costly to manage, often requiring readmission to hospital. Surgical site infections account for 14% of all healthcare acquired infections.1
This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) for the prevention and management of surgical site infection.2

Recommendations
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Information for patients and carers
Provide patients and carers with clear and consistent, easily understood information and advice throughout all stages of their care. Information should include:
  • The risks of surgical site infections, how to prevent them, and how they are managed using an integrated care pathway
  • How to recognise a surgical site infection and who to contact if they are concerned
  • How to care for their wound after discharge from hospital.
  • Whether they have been given antibiotics before or after an operation.
[All these recommendations are based on a high quality randomised controlled trial and on the opinion of the Guideline Development Group]

Preoperative phase
Showering
  • Advise patients to shower or have a bath using soap (or help them with this) either the day before, or on the day of, surgery.
Hair removal
  • Do not use hair removal routinely to reduce the risk of surgical site infection. [Based on a high quality systematic review of randomised controlled trials]
  • If hair removal is necessary, use electric clippers with a single-use head on the day of surgery rather than razors, which increase risk of surgical site infection. [Based on a high quality systematic review of randomised controlled trials and a cost-effectiveness analysis]
Theatre wear
  • Give patients specific theatre wear that is practicable for the operation, with consideration for their comfort and dignity.
  • Staff should wear specific non-sterile theatre wear in all operating areas and keep their movements in and out of these areas to a minimum.
  • The operating team must remove artificial nails and nail polish, and where possible, hand jewellery, before operations.
Nasal decontamination
  • Do not routinely use nasal decontamination with topical antimicrobial agents aimed at eliminating Staphylococcus aureus to reduce the risk of surgical site infection.
Mechanical bowel preparation
  • Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection. [Based on a high quality meta-analysis of small to medium sized randomised controlled trials]
Antibiotic prophylaxis and treatment
  • Give antibiotic prophylaxis to patients before:
    [indent]
  • Clean surgery involving the placement of a prosthesis or implant
  • Clean-contaminated surgery
  • Contaminated surgery. [/indent]
  • Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound.
  • Consider giving a single intravenous dose of antibiotic prophylaxis on starting anaesthesia, or earlier for operations in which a tourniquet is used. Repeat the dose if the operation is longer than the half life of the antibiotic given.
  • Do not use antibiotic prophylaxis routinely for clean, non-prosthetic uncomplicated surgery.
[All four recommendations based on randomised controlled trials and meta-analysis of randomised controlled trials3 and on the opinion of the Guideline Development Group]

Intraoperative phase
Hand decontamination
  • Before the first operation the members of the operating team should wash their hands with antiseptic surgical solution, using a single-use brush or pick for the nails, and should ensure that hands and nails are visibly clean.
  • Before subsequent operations, wash hands with either an alcoholic hand rub or an antiseptic surgical solution. If hands are soiled then wash them again with an antiseptic surgical solution.
Sterile gowns and gloves
  • The operating team should wear sterile gowns in the operating theatre during the operation.
  • Consider wearing two pairs of sterile gloves when there is a high risk of glove perforation and the consequences of contamination are serious.
Incise drapes
  • If an incise drape is required, use one that is impregnated with iodophore unless the patient has an iodine allergy.
Antiseptic skin preparation
  • Prepare the skin at the surgical site immediately before incision using an aqueous or alcohol based antiseptic preparation (povidone iodine or chlorhexidine are most suitable). [Based on a meta-analysis of several small and medium sized randomised controlled trials]
Diathermy
  • Do not use diathermy for surgical incision to reduce the risk of surgical site infection.
Maintaining patient homoeostasis
  • Maintain adequate perfusion, oxygenation, and temperature control during surgery.
  • Do not give insulin routinely to patients who do not have diabetes to reduce risk of surgical site infection by optimising postoperative blood glucose levels.
Wound irrigation and intracavity lavage
  • Do not use wound irrigation or intracavity lavage to reduce the risk of surgical site infection.
Antiseptic and antimicrobial agents before wound closure
  • Do not repeat skin disinfection during an operation or use topical cefotaxime in abdominal surgery to reduce the risk of surgical site infection.
Wound dressings
  • Cover surgical incisions with an appropriate interactive dressing at the end of the operation. [Based on several low quality randomised controlled trials and on the opinion of the Guideline Development Group]
Postoperative phase
Postoperative cleansing and dressing changes
  • Advise patients that they may shower safely 48 hours after surgery.
  • Use an "aseptic" non-touch technique for changing or removing surgical wound dressings.
  • For wound cleansing, use sterile saline up to 48 hours after surgery. Use tap water after 48 hours if the surgical wound has separated or has been surgically opened to drain pus.
Wound healing by primary intention
  • Do not use topical antimicrobial agents to reduce the risk of surgical site infection.
Wound healing by secondary intention
  • Refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate interactive dressings. [Based on several low quality, small randomised controlled trials]
  • Do not use chlorinated solutions (such as Eusol) and gauze; moist cotton gauze; or mercuric antiseptic solutions.
Management of surgical site infection
  • When surgical site infection is suspected, either de novo or because of treatment failure, use an antibiotic that covers the likely causative organisms, taking into consideration local resistance patterns and the results of microbiological tests.
  • If debridement is required, do not use chlorinated solutions, gauze, dextranomer, or enzymatic treatments.
Specialist wound care services
Although no direct evidence exists to support the provision of specialist wound care services for managing surgical wounds that are difficult to heal, a structured approach to care (including preoperative assessments to identify individuals with potential wound healing problems) is necessary for improving overall management of surgical wounds. To support this structured approach, better education of healthcare workers, patients, and carers, and sharing of clinical expertise will be needed.

Overcoming barriers
Although the seriousness of surgical site infection is recognised, reduction of its incidence requires an understanding of several complex issues. For example, surgical operations involve different anatomical sites, are done for different clinical reasons, and may be performed in various locations.

Understanding the significance of surgical site infection requires surveillance using clear definitions and methods, and standardisation of these is currently lacking. The reduction in the rates of surgical site infection has relied on strict surgical discipline, and the evidence base for many measures is generally weak and contains data from a range of heterogeneous procedures and circumstances. There is plainly a need for research projects to improve the evidence base, preferably from multicentre randomised controlled trials.

The use of antibiotic prophylaxis is evidently effective in reducing the incidence of surgical site infection, but the potential cost in terms of antibiotic resistance may be high and needs to be defined. The importance of tissue viability experts in the management of complicated surgical site infections is clear, but implementation of the wound healing recommendations will require adequate resources to train appropriate healthcare professionals.

Further information on the guidance
In the absence of adequate research, many of the procedures during surgery are based on accepted, often ritualistic practice to minimise risks to both patients and staff. Nevertheless, variations in practice exist throughout the surgical care pathway. Most of these inconsistencies relate to use of antiseptic, antibiotic, and other anti-infective agents during routine perioperative activities. Individual patient characteristics as well as the type and duration of procedure also bring independent risks to surgery, and hence other practice variations reflect the balance of clinical and patient outcomes requiring consideration.
As surgical site infection can be a life threatening result of surgery, it is important to distinguish those practices that reduce the risk of surgical site infection from those that are done according to the individual preferences of the patient or surgical team (for example, to improve surgical technique, patient comfort, cosmetic result).

Considerable variation in practice in the preoperative, intraoperative, and postoperative phases of surgery is likely to continue unless standardisation of practice across the NHS is introduced using an evidence based model.

Methods
The guidance was developed by the National Collaborating Centre for Women’s and Children’s Health in accordance with NICE guideline development methods (www.nice.org.uk).

The collaborating centre established a Guideline Development Group consisting of healthcare professionals, representatives for patients and carers, and experts in guideline methodology from the collaborating centre. Membership of the Guideline Development Group included two surgeons, a tissue viability nurse, two microbiologists, a theatre nurse, a surveillance coordinator, an infection control specialist, and two patient representatives.

Evidence was identified from the consultation draft previously prepared by the National Collaborating Centre for Nursing and Supportive Care, from searches performed by the information scientist at the National Collaborating Centre for Women’s and Children’s Health Collaborating Centre, and from the Guideline Development Group. The development group appraised clinical evidence and evaluated cost effectiveness of interventions where possible. A draft of the guideline was provided for stakeholder organisations to submit comments on. The draft was later revised to take account of comments received. Future updates of the guidance will be prepared as part of the NICE guideline development programme.

Areas for future research
Definitions, surveillance, and risk factors
  • Would a risk assessment tool developed by consensus methodology help predict the risk of surgical site infection?
Preoperative phase
  • Is it cost effective to use mupirocin for nasal decontamination? In which patients is it most effective?
Intraoperative phase
  • What is the cost effectiveness of new materials used in reusable and disposable operative drapes and gowns in reducing the incidence of surgical site infection?
  • What is the value of supplemented oxygenation in the recovery room in the prevention of surgical site infection? What are the likely mechanisms of action?
  • What are the possible benefits of improved postoperative blood glucose control to the incidence of surgical site infection?
  • Does irrigation with modern antiseptics and saline under pressure, with or without added antiseptics, in a broader range of surgery allow the development of a strategy less dependent on antibiotic prophylaxis to reduce the incidence of surgical site infection?
  • Does the use of antiseptic products applied to the wound before closure in elective, clean non-prosthetic surgery reduce the reliance on antibiotic prophylaxis for reducing the incidence of surgical site infection?
  • What is the cost effectiveness of collagen implants with antibiotics or antiseptics in reducing the incidence of surgical site infection?
  • What types of closure methods will reduce the risk of surgical site infection?
  • What are the benefits and cost effectiveness of different types of post-surgical interactive dressings for the reduction of surgical site infection?
Postoperative phase
  • What are the most appropriate methods of chronic wound care (including alginates, foams, hydrocolloids, and dressings containing antiseptics such as antimicrobial honey, cadexomer, iodine, or silver) in managing surgical site infection as well as patient outcomes?
  • What is the effectiveness of modern methods of debridement in surgical wounds healing by secondary intention?
Cite this as: BMJ 2008;337:a1924

This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group are Mark Collier, tissue viability lead nurse consultant; David Evans, patient representative; Mark Farrington, consultant medical microbiologist; Elizabeth Gibbs, patient representative; Kate Gould, consultant microbiologist (clinical adviser to the group); Helen Jenkinson, hygiene code implementation manager; Kathryn Kitson, team leader for orthopaedic and trauma theatres (until December 2007); David Leaper, chair of the group, consultant surgeon and professor, wound healing; Matt Thompson, consultant surgeon and professor, vascular surgery; Jennie Wilson, infection control nurse and programme leader, surgical site infection surveillance service; and the following staff members of the National Collaborating Centre for Women’s and Children’s Health: Shona Burman-Roy, systematic reviewer; Katherine Cullen, health economist; Eva Gautam-Aitken, project manager; Paul Jacklin, senior health economist; Ana Palanca, research assistant; Edmund Peston, document supply coordinator; Roxana Rehman, work programme coordinator; Andrew Welsh, editor; Martin Whittle, clinical co-director; Danielle Worster, information scientist.

Contributors: DL, SB-R, and MW wrote the initial draft of the article using material produced collectively by the entire guideline development group. AP, KC, DW, and EG-A contributed to the revision and the final draft of this article. The guarantor is MW.

Funding: The National Collaborating Centre for Women’s and Children’s Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

Competing interests: DL is a part time medical adviser to Renovo on trials of antiscarring agents, and he has a small number of shares in the company. Previously, DL has advised Arizant and Inditherm, which make warming products. He also advises Hutchinson on the development and evaluation of a new device to measure tissue oxygen. The department of wound healing at Cardiff University, where DL is a visiting professor, has received financial support from a large number of companies who have developed products in this area. DL has had many charitable and industry grants for research work in antibiotic prophylaxis and treatment, dressings, and tissue perfusion. He has received financial support from several companies to attend and give papers to meetings of international societies and for educational activities; most of this funding related to the Surgical Infection Society and the European Wound Management Association (previously president) and the European Tissue Repair Society (current board member).

Provenance and peer review: Commissioned; not externally peer reviewed.

References

Smyth ET, McIlvenny G, Enstone JE, Emmerson AM, Humphreys H, Fitzpatrick F, et al. Four country healthcare associated infection prevalence survey 2006: overview of the results. J Hosp Infect 2008;69:230-48.[CrossRef][ISI][Medline]
National Institute for Health and Clinical Excellence. Surgical site infection. 2008. (Clinical guideline 74.) www.nice.org.uk/CG74.
Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery. (Guideline No 104.) 2008. www.sign.ac.uk/guidelines/fulltext/104/index.html
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Отправлено 07 ноября 2008 - 00:09

Использование ингаляционных анестетиков не снижает повреждение миокарда во время интервенционных кардиологических процедур.

У пациентов, которым проводится эндоваскулярная и хирургическая реваскуляризация коронарных сосудов, повышение в крови уровней тропонина миокарда (cTn) после процедуры свидетельствует о развитии нового необратимого повреждении миокарда. Распространенность этого повреждения прямо коррелирует со степенью повышения cTn и является прогностическим маркером для краткосрочных и долговременных исходов стентирования коронарных сосудов. В настоящее время интенсивно изучаются стратегии, с помощью которых можно снизить повреждение миокарда во время реваскуляризации коронарных сосудов, в том числе фармакологические вмешательства. Ранее в экспериментальных исследованиях на изолированном миокарде и на животных было показано, что современные ингаляционные анестетики улучшают восстановление миокарда после ишемии. Использование севофлюрана (sevoflurane) и десфлюрана (desflurane) для поддержания анестезии во время кардиохирургических операций было связано с меньшим повышением cTnI и с меньшей периоперационной частотой развития инфаркта миокарда и меньшим уровнем смертности. В недавно опубликованном рандомизированном контролируемом исследовании, Giovanni Landoni с соавторами изучили, влияют ли субминимальные альвеолярные концентрации севофлюрана во время процедуры стентирования коронарных сосудов на периоперационное повреждение миокарда, которое определялось по степени повышения сывороточных уровней cTnI.
Методы и ход исследования.
В исследование были включены пациенты старше 18 лет, которым выполнялось стентирование коронарных сосудов. Исключались пациенты, которые имели измеримые концентрации cTnI до операции, если они перенесли инфаркт миокарда в предшествующие 6 недель, имели выраженную застойную сердечную недостаточность, им выполнялись какие-либо хирургические операции в течение текущей госпитализации, имели ранее необычные реакции на анестетики или им назначались какие-либо экспериментальные препараты в течение 28 дней до процедуры.
Пациенты в течение процедуры дышали спонтанно через лицевую маску, которую удерживал анестезиолог. В течение операции использовались стандартные методы анестезиологического мониторинга, включая ЭКГ, пульсоксиметрию, капнографию и измерение выдыхаемой концентрации анестетика.
Пациенты были рандомизированны в две группы. В основной группе пациентам с помощью наркозного аппарата в контур подавалась смесь кислорода с воздухом (50/50) и севофлюран, титрованный до достижения концентрации 0,5 МАК (1%) в конце выдоха в течение 20 минут. Пациенты в группе плацебо получали только кислородно-воздушную смесь. Авторы выбрали такую концентрацию и продолжительность введения анестетика, поскольку ранее уже сообщалось о кардиопротективных свойствах этого режима. Первичным оцениваемым показателем исхода был уровень cTnI в сыворотке крови непосредственно после процедуры. У каждого пациента также оценивался уровень cTnI до выполнения стентирования.
Показания и техника проведения стентирования определялись в соответствии со стандартными рекомендациями. Во время процедуры пациенты получали также стандартный болюс нефракционированного гепарина.
На основании ранее опубликованных данных, авторы предполагали частоту повышения уровней cTnI у 60% пациентов и снижение частоты на 50% в группе, получавшей лечение севофлюраном. Качественные переменные между группами сравнивались при помощи теста Фишера с поправкой Йетса, количественные переменные сравнивались с использованием теста Манна-Уитни.
Результаты.
В исследование были включены 30 пациентов, которые случайным образом были разделены на две группы. Пациенты группы вмешательства получали во время процедуры стентирования севофлюран (16 человек), а пациентов группы контроля - плацебо (14 человек). Пациенты статистически не различались по исходным клиническим и демографическим характеристикам. В группе севофлюрана было незначительно больше пациентов, получавших терапию антитромбоцитарными препаратами и ингибиторы АПФ, а в группе контроля больше пациентов, получавших инсулинотерапию. Количество стентированных сосудов было приблизительно одинаковым в обеих группах (1,5 ± 0,73 против 1,4 ± 0,76, p = 0,9).
Систолическое АД исходно не различалось между группами, но к 20 минутам после начала подачи ингаляционного анестетика, в группе севофлюрана систолическое АД было ниже (129 ± 16 против 140 ± 16 мм рт ст, p = 0,06). Ни у одного пациента не было зафиксировано выраженной гипотензии, определяемой как снижение систолического АД более, чем на 30 мм рт ст. Все пациенты в группе севофлюрана спали во время выполнения стентирования, в контрольной группе пациенты бодрствовали. Показатели содержания углекислого газа в конце выдоха у пациентов не отклонялись от нормы.
У 16 пациентов имели определимые уровни cTnI после процедуры стентирования: 10 (62%) в группе севофлюрана, против 6 (43%) в группе плацебо, p = 0,3. Медиана количественных значений cTnI в сыворотке крови также не различалась между основной, 0,15 (0 – 4,73) нг/мл и контрольной группами 0,14 (0 – 0,87) нг/мл, p = 0,4.
У всех пациентов периоперационный период протекал без особенностей и все были выписаны в течение 48 часов после проведения стентирования.
Выводы.
Авторы делают вывод о том, что использование низких доз ингаляционных анестетиков во время процедуры стентирования коронарных сосудов не предотвращает повреждение миокарда. Данные этого небольшого исследования не поддерживают рутинное использование ингаляционных анестетиков при проведении этой процедуры в качестве метода профилактики ишемии миокарда.

Источник.
Landoni G, Zangrillo A, Fochi O, et al: Cardiac Protection With Volatile Anesthetics in Stenting Procedures. Journal of Cardiothoracic and Vascular Anesthesia 22:543-547, 2008.

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Отправлено 07 ноября 2008 - 00:14

Заменное переливание крови через периферические сосуды у новорождённых с гипербилирубинемией безопасно и эффективно.

Частота проведения заменных переливаний крови (ЗПК) у новорождённых в США за последние 20 лет существенно снизилась. Однако ЗПК по-прежнему выполняется во многих странах при неонатальной гипербилирубинемии (ГБЕ) для предотвращения ядерной желтухи.
Цель настоящего исследования состояла в том, чтобы сравнить эффективность и безопасность ЗПК через периферические сосуды по сравнению с ЗПК через вену пуповины при лечении неонатальной ГБЕ.
Методы и ход исследования.
С января 1995 г. по декабрь 2006 г. в перинатальном центре Тайваня было проведено ретроспективное всех новорождённых, кому проводилось ЗПК из-за ГБЕ.
Учитывались причины ГБЕ, эффективность метода ЗПК в снижении концентрации сывороточного билирубина, осложнения и исходы. Данные были сравнены между новорождёнными, которые подверглись ЗПК через периферические артерии и вены (группа ПА/ПВ) и теми, кто подвергся ЗПК через вену пуповины (группа ВП). Данные были также сравнены между стабильными (вес при рождении [ВР] > 1500 г и отсутствие медицинских проблем кроме ГБЕ) и нестабильными новорождёнными.
Результаты.
Информация была доступна для 102 пациентов, которые подверглись общему количеству 123 процедуры ЗПК за период в 12 лет. 16 детей получили > 1 ЗПК: 1 ребёнок - 4 ЗПК, 3 - 3 ЗПК и 12 - 2 ЗПК. В группе ВП (n = 19) было проведено 24 процедуры, в группе ПА/ПВ (n = 83) - 99 процедур. Не было различий в гестационном возрасте, ВР и поле между группами ВП и ПА/ПВ (P > 0,05). В группе ВП было достоверно больше детей с уровнем билирубина < 15 mg/dL до ЗПК (P = 0,037). Новорождённые в группе ПА/ПВ при проведении ЗПК были старше (средний возраст: 6,1 дней), чем в группе ВП (средний возраст: 4,2 дня; P = 0,039). 20 пациентов из группы ПА/ПВ во время ЗПК были в возрасте от 7 до 30 дней с отпавшей пуповиной и эпителизированной пупочной ранкой. ЗПК процедура была проведена не в полном объёме у 3 новорождённых из группы ПА/ПВ: у 2-х из-за несостоятельности катетера в лучевой артерии в конце процедуры; у 1-го (с подозрением на инфекцию, т.к. мать была с лихорадкой в родах) из-за гипотензии и десатурации в конце процедуры. Этим пациентам повторное ЗПК не потребовалось.
Причинами ГБЕ, требовавшей ЗПК, были: 1) идиопатическая ГБЕ у 52 новорождённых (42,2%), 2) инфекция, подтвержденная бактериологической культурой (n = 7) или клинические признаками, и инфекция без подтверждения культурой (n = 18) у 25 (20,3%), 3) несовместимость по АВО у 18 (14,6%), 4) дефицит глюкозо-6-фосфат дегидрогеназы у 21 (17,1%) и 5) гемолитическая болезнь с положительной пробой Кумбса у 7 (5,7%) пациентов.
Средняя продолжительность ЗПК через ВП была 80,9 ± 41,0 минуты, через ПА/ПВ – 79,8 ± 28,6 минуты. Не было различия в длительности ЗПК между этими 2 методами (P = 0,46).
Всего умерло 8 новорождённых (группа ВП: n = 4; группа ПА/ПВ: n = 4), но не было случаев смерти, связанных с ЗПК.
У 2 детей в группе ПА/ПВ развились клинические признаки ядерной желтухи. Один из них был доношенным новорождённым с сепсисом и ДВС. У него была спастическая поза, свидетельствовавшая о развитии ядерной желтухи до ЗПК; он умер из-за сепсиса после 3-х ЗПК. У другого доношенного мальчика спастическая поза появилась на 5-й день, а уровень сывороточного билирубина перед ЗПК достиг 44,6 mg/dL. В возрасте 6 лет 10 месяцев у него были диагностированы глубокая умственная задержка и нарушение слуха.
Не было случаев сепсиса и остановки сердца, связанных с ЗПК. Не было также различий в частоте осложнений в течение или после ЗПК между группами ВП и ПА/ПВ: 9 (37,5%) осложнений и 34 (34,3%) соответственно.
Из 123 процедур ЗПК 87 (70,7%) (ВП: n = 14; ПА/ПВ: n = 73) были выполнены у 75 стабильных пациентов, и 36 (29,3%) (ВП: n = 10; ПА/ПВ: n = 26) - у 27 нестабильных. Серьёзные осложнения у стабильных новорождённых были достоверно (P = 0,024) чаще в группе ВП, чем в группе ПА/ПВ. Среди стабильных пациентов в группе ВП у 2 детей были тяжёлые осложнения, связанные к ЗПК (омфалит, требовавший системного антибиотика [n = 1], и некротический энтероколит [n = 1]) и у 4 детей - нетяжёлые осложнения (бессимптомная гипокальциемия [n = 3], скорректированная глюконатом кальция, и тромбоцитопения [n = 1]). Среди стабильных новорождённых в группе ПА/ПВ было 24 нетяжёлых осложнения: бессимптомная гипокальциемия, скорректированная глюконатом кальция (n = 7); транзиторная ишемия руки, связанная с артериальным катетером (n = 5), у всех пациентов признаки ишемии быстро купировались после ЗПК; тромбоцитопения, не требовавшая переливания тромбоцитов (n = 3); эпизод снижения сатурации кислорода < 90 мм рт. ст. в течение ЗПК (n = 2), который не требовал лечения; транзиторная гипотензия (n = 1) и сывороточный уровень гидрокарбоната после ЗПК 6,1 mEq/L (n = 1).
Среди нестабильных пациентов в группе ВП у 3-х развилась тромбоцитопения, которая не требовала переливания тромбоцитов. У нестабильных новорождённых в группе ПА/ПВ было 10 осложнений. У 2 детей были выявлены тяжелые осложнения: у 1-го ребёнка с сепсисом потребовалась эндотрахеальная интубация и искусственная вентиляция лёгких из-за десатурации в течение ЗПК, у другого - отмечалась ишемия руки с подозрением на эмболию лучевой артерии из-за введённого катетера в течение 3-го ЗПК, что потребовало лечения урокиназой. Признаки ишемии руки полностью купировались за 1 день. 8 из 10 осложнений были нетяжёлыми: у 3-х новорождённых имелась транзиторная десатурация с сепсисом и ДВС; у 2-х - бессимптомная гипокальциемия (с введением глюконата кальция), у 2-х - тромбоцитопения (без переливания тромбоцитов), у 1-го - нарушение функционирования катетера. Все осложнения купировались полностью до выписки из стационара.
Выводы.
Авторы исследования пришли к выводу, что ЗПК через периферические сосуды – эффективная и безопасная альтернатива ЗПК через вену пуповины у новорождённых с ГБЕ.
По мнению авторов, данная техника ЗПК минимизирует ятрогенные риски и особенно показана недоношенным и больным новорождённым.
Ограничения настоящего исследования стали единственный центр изучения, ретроспективный характер и относительно маленький типовой размер.
Авторы считают, что необходимы дополнительные мультицентровые исследования для подтверждения эффективности и безопасности ЗПК через периферические сосуды, особенно у нестабильных и недоношенных новорождённых.

Источник.
Hsiao-Neng Chen et al. Exchange transfusion using peripheral vessels is safe and effective in newborn infants. Pediatrics. October 2008; 122(4): e905-e910.

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Отправлено 16 ноября 2008 - 21:20

Антибактериальная терапия до проведения диагностической люмбальной пункции меняет химический состав спинно-мозговой жидкости у детей с бактериальными менингитами.

Алгоритмы диагностики бактериального менингита (БМ) базируются на клинических и лабораторных показателях, в том числе данных исследования спинно-мозговой жидкости (СМЖ), Известно, что использование антибиотиков (АБ) у детей до выполнения диагностической люмбальной пункции (ЛП) увеличивает количество ложно-негативных результатов исследования СМЖ на бактериальную культуру. Данные о влиянии предшествующего лечения АБ (ПЛАБ) на клеточный и химический состав СМЖ у детей с БМ противоречивы. Повсеместное использование конъюгированных вакцин против инфекций, вызванных Haemophilus influenzae тип b и Streptococcus pneumoniae, повлияло на эпидемиологию БМ у детей. Как изменение этиологической структуры БМ отразилось на составе СМЖ и изменении ее характеристик под влиянием АБ не изучено. В связи с этим американские ученые провели многоцентроввое ретроспективное исследование с целью оценить влияние ПЛАБ до проведения ЛП на состав СМЖ у детей с БМ.
Методы и ход исследования.
Проанализировали медицинские документы всех детей в возрасте от 1 мес до 18 лет с БМ, которые находились в отделениях неотложной помощи 20 педиатрических центров США (2001-2004). БМ определяли как достоверный в случае: 1) положительного анализа СМЖ на бактериальную культуру или 2) плеоцитоза СМЖ (≥10 лейкоцитов в 1 мл СМЖ) в сочетании с положительной культурой крови и/или положительной реакции латекс-агглютинации СМЖ. БМ считали вероятным при положительных результатах окраски по Граму СМЖ в сочетании с отрицательным результатом крови или СМЖ на бактериальную культуру. Исключали больных с СМЖ-шунтами, нейрохирургическими операциями в течение предшествующего 1 мес, иммуносупрессией. ПЛАБ считали, если пациент с БМ получал АБ в течение 72 ч до выполнения ЛП.
Результаты.
За 4 года идентифицировано 245 больных с БМ, в том числе 231 (94,3%) с достоверным БМ и 14 (5,7%) с вероятным БМ. 85 (35%) пациентов с БМ получали ПЛАБ, включая 9 больных с вероятным БМ. Дети ПЛАБ-группы были немного старше (медиана возраста 0,8 лет) больных, не получавших ПЛАБ (медиана возраста 0,4 лет; р=0,09). Из 85 больных ПЛАБ-группы 20 (24%) получали пероральные АБ, 59 (69%) - парентеральные АБ и 6 (7%) - и те и другие АБ. Длительность ПЛАБ различалась в зависимости от пути введения АБ. Для пероральных АБ медиана длительности ПЛАБ составила 24 (24-54) ч, для парентеральных - 4 (1-24) ч, для сочетанного применения АБ - 24(10,5-60) ч. Среди детей с достоверным БМ положительная бактериальная культура крови (66% против 48%; р=0,05) и СМЖ (88% против 70%; р=0,001) была достоверно чаще в группе больных без ПЛАБ.
Анализ влияния ПЛАБ на состав СМЖ в зависимости от возраста больных, длительности лихорадки, артериальной гипотензии и дыхательной недостаточности показал, что длительность введения АБ не имела взаимосвязи ни с числом лейкоцитов СМЖ (β=-0,15; р=0,2), ни с абсолютным числом нейтрофилов СМЖ (β=-0,16; р=0,21). Однако выявлена ассоциация между длительностью ПЛАБ и уровнем глюкозы СМЖ (β=0,19; р=0,04) и концентрацией белка СМЖ (β=-0,31; р=0,01).
Далее исследователи проанализировали влияние ПЛАБ на состав СМЖ в зависимости от длительности назначения АБ в четырех подгруппах: <4 ч (n=25); ≥4 ч (n=47); ≥12 ч (n=33) и ≥24 ч (n=29). Установлено, что эффект введения АБ отмечался уже через 4 ч. Однако достоверные различия выявлены у больных, получавших ПЛАБ ≥12 ч, что выражалось в более высоком уровне глюкозы (р=0,005) и более низкой концентрации белка (р=0,008) в СМЖ. Медиана уровня глюкозы у этих больных была 48 мг/дл (против 29 мг/дл в группе детей, не получавших ПЛАБ), медиана уровня белка в СМЖ - 121 мг/дл (против 178 мг/дл соответственно). Длительность ПЛАБ не имела влияния на клеточный состав СМЖ, включая число лейкоцитов и абсолютное число нейтрофилов. Влияние ПЛАБ ≥24 ч имело сходные результаты на уровень глюкозы, белка, число лейкоцитов и нейтрофилов СМЖ.
Выводы.
Раннее назначение АБ детям с БМ до выполнения ЛП существенно меняло химический состав СМЖ, что проявлялось в виде достоверно более высокого уровня глюкозы и более низкой концентрации белка. Модификация уровня глюкозы и белка в СМЖ наступала уже через 4 ч после введения АБ, однако достоверное изменение химического состава СМЖ отмечалось через ≥12 ч после использования АБ. Следует отметить, что ПЛАБ существенно не влияло на клеточный состав СМЖ, включая число лейкоцитов и абсолютное число нейтрофилов.
Полученные результаты имеют важное практическое значение и должны учитываться при интерпретации результатов анализа СМЖ. Значения глюкозы и белка в СМЖ, используемые для дифференциальной диагностики бактериальных и асептических менингитов, должны рассматриваться с поправкой на возможные их отклонения под влиянием раннего введения АБ.

Источник.
Lise E. Nigrovic et al. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics 2008;122;726-730.

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Отправлено 17 ноября 2008 - 18:24

Randomised double-blinded comparison of phenylephrine vs ephedrine for maintaining blood pressure during spinal anaesthesia for non-elective Caesarean section*

W. D. Ngan Kee 1 , K. S. Khaw 2 , T. K. Lau 3 , F. F. Ng 4 , K. Chui 5 and K. L. Ng 6
1 Professor , 2 Associate Professor, Department of Anaesthesia and Intensive Care , 3 Professor, Department of Obstetrics and Gynaecology , 4 Research Nurse, Department of Anaesthesia and Intensive Care , 5 Clinical Tutor (Honorary), Department of Paediatrics , 6 Clinical Assistant Professor (Honorary), Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
Correspondence to Warwick D. Ngan Kee
E-mail: warwick@cuhk.edu.hk
*Presented in part as a free paper at Euroanaesthesia 2007, Munich, Germany, 11 June 2007.
Copyright © 2008 The Association of Anaesthetists of Great Britain and Ireland

ABSTRACT
In a randomised, double-blinded study, we compared boluses of phenylephrine 100 μg with ephedrine 10 mg for treating hypotension (systolic blood pressure < 100 mmHg) in 204 patients having non-elective Caesarean section under spinal anaesthesia. Umbilical arterial (UA) and venous (UV) pH and base excess were similar between groups. In the ephedrine group, UA lactate concentration was higher (median 2.6 [interquartile range 2.3–3.3] vs 2.4 [1.9–3.0] mmol.l−1, p = 0.002) and UV lactate concentration was higher (2.5 [2.2–3.2] vs 2.3 [1.9–2.8] mmol.l−1, p = 0.016) and more patients had nausea or vomiting (12.7% vs 3.9%, p = 0.02). Clinical neonatal outcome was similar. Of the protocol-compliant patients (n = 148), UA Po2 and UV Po2 were lower in the phenylephrine group although oxygen content was similar. We conclude that phenylephrine and ephedrine are both suitable vasopressors for use in non-elective Caesarean sections.

Anaesthesia
Volume 63 Issue 12, Pages 1319 - 1326
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2044.2008.05635.x

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Отправлено 17 ноября 2008 - 18:46

Comparison of blood pressure measured at the arm, ankle and calf

C. Moore 1 , A. Dobson 2 , M. Kinagi 2 and B. Dillon 3
1 SpR Anaesthetics , 2 Consultant Anaesthetist , 3 Medical Statistician, Department of Medical Statistics, South Manchester University Hospitals NHS Trust, Wythenshawe, Manchester M23 9LT, UK
Correspondence to Dr A. Dobson
E-mail: adam.dobson@smuht.nwest.nhs.uk
Copyright © 2008 The Association of Anaesthetists of Great Britain and Ireland

ABSTRACT
The suitability of alternative sites for non-invasive blood pressure (NIBP) measurement was investigated in 100 awake healthy volunteers. The calf and the ankle were chosen for comparison with the arm, and the results analysed subjected to Bland–Altman analysis. Discomfort was graded using a Visual Analogue Scale. There was a poor agreement between the different sites with respect to systolic blood pressure: the agreement was closer for diastolic and mean measurements. The mean blood pressure calf measurement was on average 4 mmHg (95% limits of agreement −12 to 20), higher than the arm. The ankle was 8 mmHg higher (−8 to 24) than the arm. ANOVA demonstrated a statistically significant difference in the discomfort scores between the sites (p < 0.001). The calf demonstrated the highest discomfort score and the ankle the lowest. We suggest that the ankle should be considered in preference to the calf as an alternative site for NIBP measurement if use of an arm is undesirable or impossible.

Anaesthesia
Volume 63 Issue 12, Pages 1327 - 1331
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2044.2008.05633.x

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Отправлено 17 ноября 2008 - 20:26

Comparison of the Glidescope®, the McGrath®, the Airtraq® and the Macintosh laryngoscopes in simulated difficult airways*

G. L. Savoldelli 1,2 , E. Schiffer 1 , C. Abegg 1 , V. Baeriswyl 1 , F. Clergue 3 and J. L. Waeber 1
1 Staff Anaesthetist, 3 Professor of Anaesthesia, Department of Anaesthesia, Pharmacology and Intensive Care, Geneva University Hospitals and University of Geneva, Switzerland
2 Staff Physician, Unit for Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Switzerland
Correspondence to Dr Georges L. Savoldelli
E-mail: georges.savoldelli@hcuge.ch
*Presented in part at the European Society of Anaesthesiology Meeting, Euroanaesthesia 2008, Copenhagen, Denmark, June 2008.
Copyright © 2008 The Association of Anaesthetists of Great Britain and Ireland

ABSTRACT
Several indirect laryngoscopes have recently been developed, but relatively few have been formally compared. In this study we evaluated the efficacy and the usability of the Macintosh, the Glidescope®, the McGrath® and the Airtraq® laryngoscopes. Sixty anaesthesia providers (20 staff, 20 residents, and 20 nurses) were enrolled into this study. The volunteers intubated the trachea of a Laerdal SimMan® manikin in three simulated difficult airway scenarios. In all scenarios, indirect laryngoscopes provided better laryngeal exposure than the Macintosh blade and appeared to produce less dental trauma. In the most difficult scenario (tongue oedema), the Macintosh blade was associated with a high rate of failure and prolonged intubation times whereas indirect laryngoscopes improved intubation time and rarely failed. Indirect laryngoscopes were judged easier to use than the Macintosh. Differences existed between indirect devices. The Airtraq® consistently provided the most rapid intubation. Laryngeal grade views were superior with the Airtraq® and McGrath® than with the Glidescope®.

Anaesthesia
Volume 63 Issue 12, Pages 1358 - 1364
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2044.2008.05653.x

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Отправлено 17 ноября 2008 - 22:00

Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing
major abdominal surgery†


O. Ahlers1*, I. Nachtigall1, J. Lenze1, A. Goldmann1, E. Schulte1, C. Ho.hne2,
G. Fritz3 and D. Keh1
1Department of Anaesthesiology and Intensive Care Medicine, Charite.—Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany. 2Department of Anaesthesiology and Intensive Care Medicine, Universitaetsklinikum Leipzig, Liebigstr. 20, 04103 Leipzig, Germany. 3Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Evangelisch-Freikirchliches Krankenhaus und Herzzentrum Brandenburg in Bernau, Ladeburger Str. 17, 16321 Bernau, Germany
*Corresponding author. E-mail: olaf.ahlers@charite.de

Background. Intraoperative stress may suppress the adaptive immune system. Abolished proinflammatory lymphocyte function is associated with higher risk of infection and postoperative complications. We hypothesized that thoracic epidural anaesthesia (TEA) reduces intraoperative stress and thus attenuates lymphocyte decrease and impairment of proinflammatory lymphocyte function.
Methods. Fifty-four patients undergoing major abdominal surgery who had a thoracic epidural catheter inserted were studied. In the TEA-I group, this catheter was used for intraoperative analgesia, whereas the TEA-P group received systemic opioids during surgery. In both groups, patient-controlled epidural analgesia was used for postoperative pain management. Blood samples for immune analyses were obtained before induction of anaesthesia, 2 h after skin
incision, and at days 1 and 4 after surgery. Lymphocyte subpopulations, expression of human leucocyte antigen (HLA)-DR on monocytes, plasma concentrations of interleukin (IL)-10, interferon-g (IFN-g), and IL-12, and concanavalin-A-stimulated concentrations of IFN-g and IL-10 were measured. Intraoperative data including bispectral index and plasma concentrations of epinephrine/cortisol were analysed; APACHE-II, SAPS II, and additional postoperative data
were documented.
Results. Plasma concentrations of epinephrine and cortisol were significantly lower in the TEA-I patients during surgery. IFN-g/IL-10 ratio was significantly higher in the TEA-I group from 2 h after skin incision until day 1. Lymphocyte numbers and T-helper cells were significantly higher in the TEA-I group at day 1, whereas no significant differences were detected among IL-12, HLA-DR, and postoperative clinical course.
Conclusions. Intraoperative use of thoracic epidural catheter reduced stress response and prevented stress-induced perioperative impairment of proinflammatory lymphocyte function.

British Journal of Anaesthesia 2008 101(6):781-787; doi:10.1093/bja/aen287
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Отправлено 17 ноября 2008 - 22:05

Dose-dependency of pharmacokinetic/pharmacodynamic parameters after intravenous bolus doses of cisatracurium

C. Chen, N. Yamaguchi and F. Varin*
Facultй de pharmacie, Universitй de Montrйal, C.P. 6128, Succursale Centre-ville, Montrйal, QC, Canada H3C 3J7

* Corresponding author. E-mail: france.varin@umontreal.ca

Background: Pharmacokinetic/pharmacodynamic (PK/PD) parameters of neuromuscular blocking agents (NMBAs) are generally assumed to be dose-independent. To our knowledge, there are very few clinical reports where the PK/PD parameters of a NMBA were derived separately for each dose group during a formal dose-ranging study. The primary objective of this study was to challenge a potential dose-dependency of cisatracurium PK/PD parameters by conducting a well-controlled experimental study.

Methods: Eight dogs were anaesthetized with pentobarbital and mechanically ventilated. Two doses of cisatracurium (1.5xED95 and 6xED95) were administered in a randomized cross-over design after an appropriate washout period. Neuromuscular function was monitored using train-of-four (TOF) stimulation. Arterial blood was sampled continuously for the first minute after cisatracurium injection and at frequent intervals thereafter. Cisatracurium plasma concentrations were determined by high performance liquid chromatography analysis. PK/PD modelling of individual data sets was performed with NONMEM using a non-parametric approach and a descriptive sigmoid Emax model.

Results: Cisatracurium PKs were linear over the dose range studied. Using non-parametric PK/PD analysis, mean values for plasma–effect compartment equilibration delay (ke0) were 0.0600 vs 0.1278 min–1 (P<0.05) and sensitivity (EC50) were 323 vs 235 ng ml–1 (P<0.05) for the high and low doses, respectively.

Conclusions: A dose-dependent effect on the PK/PD parameters of cisatracurium has important clinical implications as an accurate estimate of the EC50 is desirable. PK/PD parameters derived after intubating bolus doses of cisatracurium would be more reliable.

British Journal of Anaesthesia 2008 101(6):788-797; doi:10.1093/bja/aen308

прим. cisatracurium=nimbex
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