Thoracic epidural anaesthesia (TEA) reduces cardiac and splanchnic sympathetic activity and thereby influences perioperative function of vital organ systems. A recent meta-analysis suggested that TEA ...decreased postoperative cardiac morbidity and mortality. TEA appears to ameliorate gut injury in major surgery as long as the systemic haemodynamic effects of TEA are adequately controlled. The functional benefit in fast-track and laparoscopic surgery needs to be clarified. Better pain control with TEA is established in a wide range of surgical procedures. In a setting of advanced surgical techniques, fast-track regimens and a low overall event rate, the number needed to treat to prevent one death by TEA is high. The risk of harm by TEA is even lower, and other methods used to control perioperative pain and stress response also carry specific risks. To optimize the risk–benefit balance of TEA, safe time intervals regarding the use of concomitant anticoagulants and consideration of reduced renal function impairing their elimination must be observed. Infection is a rare complication and is associated with better prognosis. Close monitoring and a predefined algorithm for the diagnosis and treatment of spinal compression or infection are crucial to ensure patient safety with TEA. The risk–benefit balance of analgesia by TEA is favourable and should foster clinical use.
Background Approximately 30–80% of postoperative patients complain about moderate to severe post-surgical pain, indicating that postoperative pain treatment is still a problem. Methods We analysed ...prospectively collected data on patients in a university hospital receiving systemic and epidural patient-controlled analgesia and continuous peripheral nerve block (CPNB) documented by the acute pain service team in a computer-based system. Results Of 18 925 patients visited in the postoperative period between 1998 and 2006, 14 223 patients received patient-controlled epidural analgesia (PCEA), 1591 i.v. patient-controlled analgesia (IV-PCA), 1737 continuous brachial plexus block, and 1374 continuous femoral/sciatic nerve block. Mean dynamic and resting pain scores (VAS 0–100) were significantly lower for peripheral or neuroaxial regional analgesia compared with patient-controlled systemic opioid analgesia (P<0.05). The risk of a symptomatic spinal mass lesion including epidural haematoma (0.02%; 1:4741) or epidural abscess (0.014%; 1:7142) after PCEA was 1:2857 (0.04%). Neurological complications after CPNB occurred in two patients who received interscalene brachial plexus block. Conclusions We demonstrated that PCEA, IV-PCA, and CPNB are safe and efficient. Although all of these treatment strategies provide effective analgesia, PCEA and CPNB provided superior pain relief compared with IV-PCA. We demonstrated that serious complications of analgesic techniques are rare but possibly disastrous necessitating a close supervision by an acute pain service. We found a low rate of adverse effects including hypotension and motor impairment and a low incidence of epidural haematoma for thoracic PCEA compared with lumbar PCEA.
Direct observations from an array of current meter moorings across the Mozambique Channel in the south‐west Indian Ocean are presented covering a period of more than 4 years. This allows an analysis ...of the volume transport through the channel, including the variability on interannual and seasonal time scales. The mean volume transport over the entire observational period is 16.7 Sv poleward. Seasonal variations have a magnitude of 4.1 Sv and can be explained from the variability in the wind field over the western part of the Indian Ocean. Interannual variability has a magnitude of 8.9 Sv and is large compared to the mean. This time scale of variability could be related to variability in the Indian Ocean Dipole (IOD), showing that it forms part of the variability in the ocean‐climate system of the entire Indian Ocean. By modulating the strength of the South Equatorial Current, the weakening (strengthening) tropical gyre circulation during a period of positive (negative) IOD index leads to a weakened (strengthened) southward transport through the channel, with a time lag of about a year. The relatively strong interannual variability stresses the importance of long‐term direct observations.
Abstract Aims Evaluation of school pupils’ resuscitation performance after different types of training relative to the effects of training frequency (annually vs. biannually), starting age (10 vs. 13 ...years) and facilitator (emergency physician vs. teacher). Methods Prospective longitudinal study investigating 433 pupils in training and control groups. Outcome criteria were chest compression depth, compression frequency, ventilation volume, ventilation frequency, self-image and theoretical knowledge. In the training groups, 251 pupils received training annually or biannually either from emergency physicians or CPR-trained teachers. The control group without any training consisted of 182 pupils. Results Improvements in training vs. control groups were observed in chest compression depth (38 vs. 24 mm), compression frequency (74 vs. 42 min−1 ), ventilation volume (734 ml vs. 21 ml) and ventilation frequency (9/min vs. 0/min). Numbers of correct answers in a written test improved by 20%, vs. 5% in the control group. Pupils starting at age 10 showed practical skills equivalent to those starting at age 13. Theoretical knowledge was better in older pupils. Self-confidence grew in the training groups. Neither more frequent training nor training by emergency physicians led to better performance among the pupils. Conclusions Pupils starting at age 10 are able to learn cardiopulmonary resuscitation with one annual training course only. After a 60-min CPR-training update, teachers are able to provide courses successfully. Early training reduces anxieties about making mistakes and markedly increases participants’ willingness to help. Courses almost doubled the confidence of pupils that what they had learned would enable them to save lives.
Patient blood management in Europe Shander, A.; Van Aken, H.; Colomina, M.J. ...
British journal of anaesthesia : BJA,
07/2012, Letnik:
109, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Preoperative anaemia is common in patients undergoing orthopaedic and other major surgery. Anaemia is associated with increased risks of postoperative mortality and morbidity, infectious ...complications, prolonged hospitalization, and a greater likelihood of allogeneic red blood cell (RBC) transfusion. Evidence of the clinical and economic disadvantages of RBC transfusion in treating perioperative anaemia has prompted recommendations for its restriction and a growing interest in approaches that rely on patients' own (rather than donor) blood. These approaches are collectively termed ‘patient blood management' (PBM). PBM involves the use of multidisciplinary, multimodal, individualized strategies to minimize RBC transfusion with the ultimate goal of improving patient outcomes. PBM relies on approaches (pillars) that detect and treat perioperative anaemia and reduce surgical blood loss and perioperative coagulopathy to harness and optimize physiological tolerance of anaemia. After the recent resolution 63.12 of the World Health Assembly, the implementation of PBM is encouraged in all WHO member states. This new standard of care is now established in some centres in the USA and Austria, in Western Australia, and nationally in the Netherlands. However, there is a pressing need for European healthcare providers to integrate PBM strategies into routine care for patients undergoing orthopaedic and other types of surgery in order to reduce the use of unnecessary transfusions and improve the quality of care. After reviewing current PBM practices in Europe, this article offers recommendations supporting its wider implementation, focusing on anaemia management, the first of the three pillars of PBM.
Temperature, salinity and velocity data are presented, along with the estimated volume transport, from seven full-length deep sea moorings placed across the narrowest part of the Mozambique Channel, ...southwest Indian Ocean, during the period November 2003 to December 2009. The dominant water mass in the upper layer is Sub-Tropical Surface Water (STSW) which overlies South Indian Central Water (SICW), and is normally capped by fresher Tropical Surface Water (TSW). Upper ocean salinity increased through 2005 as a result of saline STSW taking up a relatively larger part of the upper layer, at the expense of TSW. Upper waters are on average warmer and lighter in the central Channel than on the sides. Throughout the upper 1.5km of the water column there is large hydrographic variability, short-term as well as interannual, and in particular at frequencies (four to seven cycles per year) associated with the southward passage of anticyclonic Mozambique Channel eddies. The eddies have a strong T–S signal, in the upper and central waters as well as on the intermediate level, as the eddies usually carry saline Red Sea Water (RSW) in their core. While the interannual frequency band displays an east–west gradient with higher temperature variance on the western side, the eddy frequency band shows highest variance in the centre of the Channel, where the eddy band contains about 40% of the total isopycnal hydrographic variability. Throughout the >6 years of measurements, the frequency and characteristics of eddies vary between periods, both in terms of strength and vertical structure of eddy T–S signals. These changes contribute to the interannual variability of water mass properties: an increase in central water salinity to a maximum in late 2007 coincided with a period of unusually frequent eddies with strong salinity signals. The warmest and most saline deep water is found within the northward flowing Mozambique Undercurrent, on the western side of the Channel. The Undercurrent has two cores: an intermediate one mainly containing diluted Antarctic Intermediate Water (AAIW), and a deep one consisting of North Atlantic Deep Water (NADW). In the intermediate core, T–S properties are strongly correlated with current velocity, probably because of the strong salinity gradient at the interface between Red Sea Water (RSW) and AAIW. In the deep core, velocity and hydrographic time series do not correlate on a daily basis, but they do at longer time scales.
► Long hydrographic time series from moorings in the Mozambique Channel are analysed. ► A large part of the T–S variability relates to the passage of anticyclonic eddies. ► The significant interannual variability is also in part linked to warm-core eddies. ► The Mozambique Undercurrent carries fresh intermediate and saline deep water. ► Separate volume transport estimates are made for the two cores of the Undercurrent.
Optimized anaesthetic management might improve the outcome after cancer surgery. A retrospective analysis was performed to assess the association between spinal anaesthesia (SpA) or general ...anaesthesia (GA) and survival in patients undergoing surgery for malignant melanoma (MM).
Records for 275 patients who required SpA or GA for inguinal lymph-node dissection after primary MM in the lower extremity between 1998 and 2005 were reviewed. The follow-up ended in 2009. Survival was calculated as days from surgery to the date of death or last patient contact. The primary endpoint was mortality during a 10 yr observation period.
Of 273 patients included, 52 received SpA and 221 GA, either as balanced anaesthesia (sevoflurane/sufentanil, n=118) or as total i.v. anaesthesia (propofol/remifentanil, n=103). The mean follow-up period was 52.2 (sd 35.69) months after operation. Significant effects on cumulative survival were observed for gender, ASA status, tumour size, and type of surgery (P=0.000). After matched-pairs adjustment, no differences in these variables were found between patients with SpA and GA. A trend towards a better cumulative survival rate for patients with SpA was demonstrated mean survival (months), SpA: 95.9, 95% confidence interval (CI), 81.2–110.5; GA: 70.4, 95% CI, 53.6–87.1; P=0.087. Further analysis comparing SpA with the subgroup of balanced volatile GA confirmed this trend mean survival (months), SpA: 95.9, 95% CI, 81.2–110.5; volatile balanced anaesthesia: 68.5, 95% CI, 49.6–87.5, P=0.081.
These data suggest an association between anaesthetic technique and cancer outcome in MM patients after lymph-node dissection. Prospective controlled trials on this topic are warranted.
During systemic inflammation, leucocytes are activated and extravasate into damaged tissue. Activation and recruitment are influenced by different mechanisms, including the interaction of leucocytes ...with platelets and neutrophil extracellular traps (NET) formation. Here, we investigated the molecular mechanism by which hydroxyethyl starch (HES 130/0.4) dampens systemic inflammation in vivo.
Systemic inflammation was induced in C57Bl/6 wild-type mice by caecal ligation and puncture and cytokine concentrations in the blood, neutrophil recruitment, platelet–neutrophil aggregates, and NET formation were investigated in vivo. Intravascular adherent and transmigrated neutrophils were analysed by intravital microscopy (IVM) of the cremaster muscle and the kidneys. Flow chamber assays were used to investigate the different steps of the leucocyte recruitment cascade.
By using flow cytometry, we demonstrated that HES 130/0.4 reduces neutrophil recruitment into the lung, liver, and kidneys during systemic inflammation (n=8 mice per group). IVM revealed a reduced number of adherent and transmigrated neutrophils in the cremaster and kidney after HES 130/0.4 administration (n=8 mice per group). Flow chamber experiments showed that HES 130/0.4 significantly reduced chemokine-induced neutrophil arrest (n=4 mice per group). Furthermore, HES 130/0.4 significantly reduced the formation of platelet–neutrophil aggregates, and NET formation during systemic inflammation (n=8 mice per group).
Our findings suggest that HES 130/0.4 significantly reduces neutrophil–platelet aggregates, NET formation, chemokine-induced arrest, and transmigration of neutrophils under inflammatory conditions.
Improved anaesthesia safety has made severe anaesthesia-related incidents, complications, and deaths rare events, but concern about morbidity and mortality in anaesthesia continues. This study ...examines possible severe adverse outcomes or death recorded in a large national surveillance system based on a core data set (CDS).
Cases from 1999 to 2010 were filtered from the CDS database. Cases were defined as elective patients classified as ASA physical status grades I and II (without relevant risk factors) resulting in death or serious complication. Four experts reviewed the cases to determine anaesthetic involvement.
Of 1 374 678 otherwise healthy, ASA I and II patients in the CDS database, 36 met the study inclusion criteria resulting in a death or serious complication rate of 26.2 per million 95% confidence interval (CI), 19.4–34.6 procedures, and for those with possible direct anaesthetic involvement, 7.3 per million cases (95% CI, 3.9–12.3).
This is the first study assessing severe incidents and complications from a national outcome-tracking database. Annual identification and review of cases, perhaps with standardized database queries in the respective departments, might provide more detailed information about the cascades that lead to unfortunate outcomes.
Background: Protein disulfide isomerase (PDI) controls platelet integrin function, tissue‐factor (TF) activation, and concentrates at fibrin and thrombus formation sites of vascular injury. ...Objective: To investigate the involvement of surface thiol isomerases and especially PDI, in thrombin‐mediated thrombin amplification on human platelets. Methods/results: Using a newly developed thrombin‐dependent platelet thrombin generation assay, we observed that the feedback activation of thrombin generation on the platelet surface does not depend on TF, as anti‐TF antibodies inhibiting TF‐induced thrombin formation in platelet‐depleted plasma had no effect compared with vehicle‐treated controls. Feedback activation of thrombin generation in the presence of platelets was significantly diminished by membrane impermeant thiol blockers or by the thiol isomerase‐inhibitors bacitracin and anti‐PDI antibody RL90, respectively. Platelet thrombin formation depends on binding of coagulation factors to the platelet surface. Therefore, involvement of thiol isomerases in this binding was investigated. As shown by confocal microscopy and flow cytometry, thrombin‐stimulated platelets exhibited increased surface‐associated PDI as well as extracellular disulfide reductase activity compared with unstimulated platelets. Flow cytometric analysis revealed that membrane impermeant thiol blockers or PDI inhibitors, which had been added after platelet stimulation and after phosphatidylserine exposure to exclude their influence on primary platelet activation, significantly inhibited binding of all coagulation factors to thrombin‐stimulated platelets. Conclusions: Thus, surface‐associated PDI is an important regulator of coagulation factor ligation to thrombin‐stimulated platelets and of subsequent feedback activation of platelet thrombin generation. Cell surface thiol isomerases might be therefore powerful targets to control hemostasis and thrombosis.
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