RESUMO
Airway management in intensive care or emergency medicine is particularly challenging and is often associated with life-threatening complications. An innovation in the field of airway management is the use of indirect laryngoscopy by means of video laryngoscopes. A digital camera or an optical system at the tip of a laryngoscope blade enables an indirect "look around the corner" to the glottis. Studies have shown that the advantages of video laryngoscopes for endotracheal intubation are particularly beneficial in difficult airway situations. However, the successful use in challenging intubations requires experience and regular use in daily practice. This review gives an overview of indirect laryngoscopes commonly used in Germany and also presents new study results for these novel devices.
Assuntos
Laringoscopia/instrumentação , Gravação em Vídeo/instrumentação , Competência Clínica , Cuidados Críticos , Serviços Médicos de Emergência , Desenho de Equipamento , Humanos , Laringoscopia/efeitos adversos , Laringoscopia/métodos , Fatores de Risco , Gravação em Vídeo/métodosRESUMO
A 52-year-old woman, with a metastatic breast cancer, presented with a nasal septum perforation while receiving a treatment combining paclitaxel and bevacizumab. This is the fifth reported case of nasal septum perforation probably related to an anti-angiogenic therapy. A literature review and a discussion concerning the different causes of nasal septum perforation were performed.
Assuntos
Anticorpos Monoclonais/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Septo Nasal/efeitos dos fármacos , Septo Nasal/patologia , Doenças Nasais/induzido quimicamente , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais Humanizados , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Bevacizumab , Neoplasias da Mama/complicações , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/secundário , Feminino , Humanos , Pessoa de Meia-Idade , Doenças Nasais/patologia , Paclitaxel/administração & dosagem , Paclitaxel/efeitos adversosRESUMO
BACKGROUND: The introduction of the diagnosis-related groups reimbursement system has increased cost pressures. Due to the interaction of many different professional groups, analysis and optimization of internal coordination and scheduling in the operating room (OR) is mandatory. The aim of this study was to analyze the processes at a university hospital in order to optimize strategies by identifying potential weak points. METHODS: Over a period 6 weeks before and 4 weeks after intervention processes time intervals in the OR of a tertiary care hospital (university hospital) were documented in a structured data collection sheet. RESULTS: The main reason for lack of efficiency of labor was underused OR utilization. Multifactorial reasons, particularly in the management of perioperative interfaces, led to vacant ORs. A significant deficit was in the use of OR capacity at the end of the daily OR schedule. After harmonization of working hours of different staff groups and implementation of several other changes an increase in efficiency could be verified. CONCLUSIONS: These results indicate that optimization of perioperative processes considerably contribute to the success of OR organization. Additionally, the implementation of standard operating procedures and a generally accepted OR statute are mandatory. In this way an efficient OR management can contribute to the economic success of a hospital.
Assuntos
Hospitais Universitários/organização & administração , Salas Cirúrgicas/organização & administração , Fluxo de Trabalho , Agendamento de Consultas , Grupos Diagnósticos Relacionados , Eficiência Organizacional , Alemanha , Hospitais Universitários/economia , Salas Cirúrgicas/economia , Assistência Perioperatória , Admissão e Escalonamento de PessoalRESUMO
The implementation of diagnosis-related groups (DRGs) sharply increased economic pressure on hospitals. Hence, process optimization was focussed on cost-intensive areas, namely the operation room (OR) departments. Work-flow in the OR is characterized by a mandatory interlocking of the job functions of many different occupational groups and the availability of a variety of different materials. Alternatives for staff assignment optimization have been published in numerous publications dealing with the importance of OR management. In this connection the issue of material logistics in the context of OR management has not been frequently addressed. In order to perform a surgical procedure according to plan, one depends on personnel and on timely availability of the materials needed. Supply of sterilized materials is of utmost importance, because in most hospitals sterilized surgical devices constitute a critical resource. In order to coordinate the OR process with the production flow of sterilized materials, an organizational connection to the OR management makes sense. Hence, in a German university hospital the Department of Hospital Sterile Supplies was integrated into the OR management of the Department of Anesthesiology. This led to a close coordination of work-flow processes, and concomitantly a significant reduction of production costs of sterile supplies could be achieved by direct interaction with the OR. Thus, hospital sterile supplies can reasonably be integrated into an OR management representing a new interesting business area for OR organization.
Assuntos
Materiais Biomédicos e Odontológicos/provisão & distribuição , Salas Cirúrgicas/economia , Salas Cirúrgicas/organização & administração , Esterilização , Serviço Hospitalar de Anestesia/organização & administração , Alemanha , Humanos , Auxiliares de Cirurgia , Organização e Administração , Admissão e Escalonamento de Pessoal , Procedimentos Cirúrgicos Operatórios , Recursos HumanosRESUMO
BACKGROUND: Current practice at high-frequency oscillatory ventilation (HFOV) initiation is a stepwise increase of the constant applied airway pressure to achieve lung recruitment. We hypothesized that HFOV would lead to more adverse cerebral haemodynamics than does pressure controlled ventilation (PCV) in the presence of experimental intracranial hypertension (IH) and acute lung injury (ALI) in pigs with similar mean airway pressure settings. METHODS: In 12 anesthetized pigs (24-27 kg) with IH and ALI, mean airway pressure (P(mean)) was increased (to 20, 25, 30 cm H(2)O every 30 min), either with HFOV or with PCV. The order of the two ventilatory modes (cross-over) was randomized. Mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral blood flow (CBF) (fluorescent microspheres), cerebral metabolism, transpulmonary pressures (P(T)), and blood gases were determined at each P(mean) setting. Our end-points of interest related to the cerebral circulation were ICP, CPP and CBF. RESULTS: CBF and cerebral metabolism were unaffected but there were no differences between the values for HFOV and PCV. ICP increased slightly (HFOV median +1 mm Hg, P<0.05; PCV median +2 mm Hg, P<0.05). At P(mean) setting of 30 cm H(2)O, CPP decreased during HFOV (median -13 mm Hg, P<0.05) and PCV (median -17 mm Hg, P<0.05) paralleled by a decrease of MAP (HFOV median -11 mm Hg, P<0.05; PCV median -13 mm Hg, P<0.05). P(T) increased (HFOV median +8 cm H(2)O, P<0.05; PCV median +8 cm H(2)O, P<0.05). Oxygenation improved and normocapnia maintained by HFOV and PCV. There were no differences between both ventilatory modes. CONCLUSIONS: In animals with elevated ICP and ALI, both ventilatory modes had effects upon cerebral haemodynamics. The effects upon cerebral haemodynamics were dependent of the P(T) level without differences between both ventilatory modes at similar P(mean) settings. HFOV seems to be a possible alternative ventilatory strategy when MAP deterioration can be avoided.
Assuntos
Circulação Cerebrovascular , Ventilação de Alta Frequência , Síndrome do Desconforto Respiratório/terapia , Pressão do Ar , Animais , Encéfalo/metabolismo , Dióxido de Carbono/sangue , Modelos Animais de Doenças , Hemodinâmica , Hipertensão Intracraniana/complicações , Hipertensão Intracraniana/fisiopatologia , Pressão Intracraniana , Oxigênio/sangue , Pressão Parcial , Troca Gasosa Pulmonar , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/complicações , Síndrome do Desconforto Respiratório/fisiopatologia , SuínosRESUMO
The new CPR guidelines are based on a scientific consensus which was reached by 281 international experts. Chest compressions (100/min, 4-5 cm deep) should be performed in a ratio of 30:2 with ventilation (tidal volume 500 ml, Ti 1 s, FIO2 if possible 1.0). After a single defibrillation attempt (initially biphasic 150-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min. Endotracheal intubation is the gold standard; other airway devices may be employed as well depending on individual skills. Drug administration routes for adults and children: first choice IV, second choice intraosseous, third choice endobronchial [epinephrine dose 2-3x (adults) or 10x (pediatric patients) higher than IV]. Vasopressors: 1 mg epinephrine every 3-5 min IV. After the third unsuccessful defibrillation attempt amiodarone IV (300 mg); repetition (150 mg) possible. Sodium bicarbonate (1 ml/kg 8.4%) only in excessive hyperkalemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider atropine (3 mg) and aminophylline (5 mg/kg). Thrombolysis during spontaneous circulation only in myocardial infarction or massive pulmonary embolism; during CPR only during massive pulmonary embolism. Cardiopulmonary bypass only after cardiac surgery, hypothermia or intoxication. Pediatrics: best improvement in outcome by preventing cardiocirculatory collapse. Alternate chest thumps and chest compression (infants), or abdominal compressions (>1-year-old) in foreign body airway obstruction. Initially five breaths, followed by chest compressions (100/min; approximately 1/3 of chest diameter): ventilation ratio 15:2. Treatment of potentially reversible causes (4 "Hs", "HITS": hypoxia, hypovolemia, hypo- and hyperkaliemia, hypothermia, cardiac tamponade, intoxication, thrombo-embolism, tension pneumothorax). Epinephrine 10 microg/kg IV or intraosseously, or 100 microg (endobronchially) every 3-5 min. Defibrillation (4 J/kg; monophasic oder biphasic) followed by 2 min CPR, then ECG and pulse check. Newborns: inflate the lungs with bag-valve mask ventilation. If heart rate<60/min chest compressions:ventilation ratio 3:1 (120 chest compressions/min). Postresuscitation phase: initiate mild hypothermia [32-34 degrees C for 12-24 h; slow rewarming (<0.5 degrees C/h)]. Prediction of CPR outcome is not possible at the scene; determining neurological outcome within 72 h after cardiac arrest with evoked potentials, biochemical tests and physical examination. Even during low suspicion for an acute coronary syndrome, record a prehospital 12-lead ECG. In parallel to pain therapy, aspirin (160-325 mg PO or IV) and in addition clopidogrel (300 mg PO). As antithrombin, heparin (60 IU/kg, max. 4000 IU) or enoxaparine. In ST-segment elevation myocardial infarction, define reperfusion strategy depending on duration of symptoms until PCI (prevent delay>90 min until PCI). Stroke is an emergency and needs to be treated in a stroke unit. A CT scan is the most important evaluation, MRT may replace a CT scan. After hemorrhage exclusion, thrombolysis within 3 h of symptom onset (0.9 mg/kg rt-PA IV; max 90 mg within 60 min, 10% of the entire dosage as initial bolus, no aspirin, no heparin within the first 24 h). In severe hemorrhagic shock, definite control of bleeding is the most important goal. For successful CPR of trauma patients, a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation, and excessive ventilation pressure may impair outcome in severe hemorrhagic shock. Despite bad prognosis, CPR in trauma patients may be successful in select cases. Any CPR training is better than nothing; simplification of contents and processes remains important.
Assuntos
Reanimação Cardiopulmonar/normas , Adulto , Antiarrítmicos/uso terapêutico , Broncodilatadores/uso terapêutico , Reanimação Cardiopulmonar/instrumentação , Criança , Doença das Coronárias/terapia , Cardioversão Elétrica , Serviços Médicos de Emergência , Europa (Continente) , Humanos , Hipotermia Induzida , Recém-Nascido , Prognóstico , Respiração Artificial , Choque/prevenção & controle , Terapia Trombolítica , Vasoconstritores/uso terapêutico , Equilíbrio Hidroeletrolítico/efeitos dos fármacos , Ferimentos e Lesões/terapiaRESUMO
The underlying neurobiology of autism, a severe pervasive developmental disorder, remains unknown. Few neocortical brain MRI abnormalities have been reported. Using rest functional brain imaging, two independent studies have described localized bilateral temporal hypoperfusion in children with primary autism. In order to search for convergent evidence of anatomical abnormalities in autistic children, we performed an anatomical MRI study using optimized whole-brain voxel-based morphometry (VBM). High-resolution 3-D T1-weighted MRI data sets were acquired in 21 children with primary autism (mean age 9.3 +/- 2.2 years) and 12 healthy control children (mean age 10.8 +/- 2.7 years). By comparing autistic children to normal children, we found bilaterally significant decreases of grey matter concentration located in superior temporal sulcus (STS) (P < 0.05 corrected, after small volume correction; SVC). Children with autism were also found to have a decrease of white matter concentration located in the right temporal pole and in cerebellum (P < 0.05, corrected) compared to normal children. These results suggest that autism is associated with bilateral anatomical abnormalities localized in the STS and are remarkably consistent with functional hypoperfusion previously reported in children with autism. The multimodal STS areas are involved in highest level of cortical integration of both sensory and limbic information. Moreover, the STS is now recognized as a key cortical area of the "social brain" and is implicated in social perceptual skills that are characteristically impaired in autism. Therefore, the convergent anatomical and functional temporal abnormalities observed in autism may be important in the understanding of brain behavior relationships in this severe developmental disorder.
Assuntos
Transtorno Autístico/patologia , Processamento de Imagem Assistida por Computador , Imageamento Tridimensional , Imageamento por Ressonância Magnética , Computação Matemática , Lobo Temporal/anormalidades , Adolescente , Atrofia , Transtorno Autístico/diagnóstico , Criança , Dominância Cerebral/fisiologia , Feminino , Humanos , Masculino , Valores de Referência , Percepção Social , Software , Lobo Temporal/patologiaRESUMO
BACKGROUND: Because of the diffuse nature of gliomatosis cerebri (GC), surgery is not suitable, and large field radiotherapy carries the risk of severe toxicity. In this setting, initial chemotherapy warrants further investigation. METHODS: The authors treated 63 consecutive patients with GC with initial chemotherapy consisting of either PCV (procarbazine, 60 mg/m2 on days 8 to 21; CCNU, 110 mg/m2 on day 1; and vincristine, 1.4 mg/m2 on days 8 and 29) or temozolomide (TMZ; 150 to 200 mg/m2 for 5 days every 4 weeks). There were 40 men and 23 women, with a median age of 48 years (range, 17 to 74 years) and a median Karnofsky performance status of 90 (range, 50 to 100). GC was initially present at diagnosis in 49 patients (primary GC), whereas 14 patients with a circumscribed glioma at onset developed secondary GC after a median follow-up period of 5.11 years. GC was classified based on the predominant tumor cells as astrocytic, oligodendroglial, or mixed GC. RESULTS: Seventeen patients received 1 to 6 cycles (median, 5) of PCV, and 46 received 2 to 24 courses (median, 13) of TMZ. Grade 3 to 4 hematologic toxicity was seen in 4 of 17 (23.5%) patients treated with PCV and in 4 of 46 (8.6%) of those treated with TMZ. Clinical objective responses were observed in 21 of 63 (33%) patients, and radiologic responses were seen in 16 of 62 (26%), with no significant difference between the two regimens. For all patients combined, the median progression-free survival (PFS) and overall survival (OS) were 16 months and 29 months, respectively. Regardless of the chemotherapeutic regimen, oligodendroglial GC had a better prognosis than astrocytic and oligoastrocytic GC in terms of PFS (p < 0.02) and OS (p < 0.0001). CONCLUSION: Initial chemotherapy is useful for some patients with gliomatosis cerebri. Temozolomide is well tolerated and appears to be a valuable alternative to procarbazine-CCNU-vincristine, especially for those with slow-growing, low-grade GC.
Assuntos
Antineoplásicos Alquilantes/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Encefálicas/tratamento farmacológico , Dacarbazina/análogos & derivados , Dacarbazina/uso terapêutico , Neoplasias Neuroepiteliomatosas/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos Alquilantes/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Astrocitoma/tratamento farmacológico , Astrocitoma/radioterapia , Neoplasias Encefálicas/patologia , Neoplasias Encefálicas/radioterapia , Terapia Combinada , Irradiação Craniana , Dacarbazina/efeitos adversos , Progressão da Doença , Intervalo Livre de Doença , Esquema de Medicação , Feminino , Doenças Hematológicas/induzido quimicamente , Humanos , Avaliação de Estado de Karnofsky , Lomustina/administração & dosagem , Lomustina/efeitos adversos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neoplasias Neuroepiteliomatosas/patologia , Neoplasias Neuroepiteliomatosas/radioterapia , Oligodendroglioma/tratamento farmacológico , Oligodendroglioma/radioterapia , Procarbazina/administração & dosagem , Procarbazina/efeitos adversos , Análise de Sobrevida , Temozolomida , Resultado do Tratamento , Vincristina/administração & dosagem , Vincristina/efeitos adversosRESUMO
BACKGROUND AND OBJECTIVE: To investigate the effects of moderate hyponatraemia, induced by intravenous application of an electrolyte-free irrigation fluid, as a model of the human transurethral prostate resection syndrome and of its rapid correction by hypertonic saline infusion in rats. METHODS: Experimental animals received irrigation fluid (Purisole SM) 20 mL kg(-1) body weight, intravenously. In one group, hyponatraemia was subsequently rapidly corrected by infusion of hypertonic saline (NaCl 5.85%), while rats of group two were 'sham-corrected' by infusion of a balanced salt crystalloid solution. Plasma sodium concentrations were analysed during and at the end of the experiments. After 10 days, experimental and untreated control animals were killed humanely, fixed by perfusion and the brains were prepared for electron microscopic investigation of myelin sheets and glial cell numbers in the striatum and pons. RESULTS: The myelin appearance was unaltered in experimental groups compared to controls, but glial cell numbers were distinctly altered in the pons but not in the striatum. In the pons, oligodendrocytes were significantly reduced in number upon rapid correction of hyponatraemia, while astrocyte numbers were increased in rats with uncorrected hyponatraemia. CONCLUSIONS: Our electron microscopic data demonstrate that the effects of hyponatraemia and of its rapid correction are multifarious in animals. This may also apply for human patients during transurethral prostate resection.
Assuntos
Corpo Estriado/ultraestrutura , Hiponatremia/patologia , Ponte/ultraestrutura , Solução Salina Hipertônica/uso terapêutico , Ressecção Transuretral da Próstata/efeitos adversos , Animais , Astrócitos/ultraestrutura , Contagem de Células , Soluções Cristaloides , Modelos Animais de Doenças , Hiponatremia/terapia , Injeções Intravenosas , Soluções Isotônicas , Masculino , Manitol/administração & dosagem , Microscopia Eletrônica , Bainha de Mielina/ultraestrutura , Neuroglia/ultraestrutura , Oligodendroglia/ultraestrutura , Substitutos do Plasma/uso terapêutico , Ratos , Ratos Sprague-Dawley , Soluções para Reidratação/uso terapêutico , Sódio/sangue , Sorbitol/administração & dosagem , SíndromeRESUMO
The "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. An International Consensus an Science" are the first true international CPR guidelines in the history of resuscitation medicine. Experts from major international resuscitation organizations (International Liaison Committee on Resuscitation, ILCOR) achieved a consensus of recommendations which had to pass a rigorous review procedure applying the tools of evidence-based medicine: all proposed guidelines or guideline changes had to be based on critically appraised pieces of evidence which had to be integrated into a final class of recommendations. The most important changes compared to previous recommendations from either the European Resuscitation Council or the American Heart Association are presented and commented upon.
Assuntos
Reanimação Cardiopulmonar/métodos , Suporte Vital Cardíaco Avançado , Reanimação Cardiopulmonar/normas , HumanosAssuntos
Assistência ao Convalescente/métodos , Assistência ao Convalescente/normas , Parada Cardíaca/terapia , Ressuscitação/métodos , Ressuscitação/normas , Anti-Inflamatórios/uso terapêutico , Cardiotônicos/uso terapêutico , Dopamina/uso terapêutico , Medicina Baseada em Evidências , Parada Cardíaca/complicações , Humanos , Hipotermia Induzida/métodos , Hipotermia Induzida/normas , Respiração Artificial/métodos , Respiração Artificial/normas , Esteroides , Fatores de Tempo , Vasoconstritores/uso terapêutico , Vasopressinas/uso terapêuticoRESUMO
Non ketotic hyperglycemia is a metabolic disorder which can induce various hyperkinetic disorders. We report the case of a 74-year old woman admitted to hospital because of choreo-ballic movements of her left hemibody. Laboratory tests revealed non-ketotic hyperglycemia. CT scan showed an increased density in the right putamen and head of caudate. Magnetic resonance imaging disclosed a hyperintense signal involving the right putamen on T1-weighted images. On T2-weighted images, there was a slight hyperintensity in the right putamen and head of caudate. Correction of the underlying hyperglycemia led to complete resolution of abnormal movements. Pathophysiology of this clinicoradiologic syndrome is briefly discussed.
Assuntos
Coreia/etiologia , Discinesias/etiologia , Hiperglicemia/diagnóstico , Idoso , Núcleo Caudado/diagnóstico por imagem , Coreia/diagnóstico , Diagnóstico Diferencial , Discinesias/diagnóstico , Feminino , Humanos , Hiperglicemia/diagnóstico por imagem , Imageamento por Ressonância Magnética , Putamen/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To compare the prognostic ability of sensory evoked potentials in cardiac arrest survivors with the outcome predicted by a panel of experienced emergency physicians based on detailed prehospital, clinical, and laboratory data. DESIGN: Inception cohort study. SETTING: Medical intensive care unit and department of emergency medicine at a university hospital. PATIENTS: A total of 162 unconscious, mechanically ventilated patients who survived > or =24 hrs after resuscitation from cardiac arrest. INTERVENTIONS: Recording of sensory evoked potentials and outcome prediction after review of detailed clinical and laboratory data by emergency physicians within 24 hrs after cardiac arrest. MEASUREMENTS AND MAIN RESULTS: At 6 months, the outcome of 36 patients was classified as favorable and 126 patients were rated as poor. After review of prehospital data, emergency physicians predicted favorable vs. poor outcome with a sensitivity of 70% and a specificity of 65%. After additional assessment of data 1 hr after cardiac arrest, the sensitivity of emergency physician predictions increased to 80%, whereas the specificity decreased to 48%. Outcome prediction by emergency physicians was most accurate after obtaining detailed patient data 24 hrs after cardiac arrest (sensitivity, 81%; specificity, 58%). In 35 of 36 patients with favorable outcomes, the cortical evoked potential N70 peak was detected between 72 and 128 msec. Of 113 patients with an N70 peak latency >130 msec or an absent N70 peak, all except one had a poor outcome. By using a cutoff of 130 msec, the N70 peak latency alone had a sensitivity of 94% and a specificity of 97%. The predictive accuracy of the N70 peak latency was significantly higher than the clinical assessment 24 hrs after cardiac arrest (91% vs. 76%, p = .0003). CONCLUSION: In unconscious cardiac arrest survivors, a recording of long-latency sensory evoked potentials is more accurate in predicting individual outcome than an emergency physician review of clinical data.
Assuntos
Coma/diagnóstico , Potenciais Somatossensoriais Evocados , Parada Cardíaca/diagnóstico , Análise de Variância , Áustria/epidemiologia , Reanimação Cardiopulmonar , Estudos de Casos e Controles , Estudos de Coortes , Coma/etiologia , Coma/mortalidade , Medicina de Emergência/métodos , Feminino , Parada Cardíaca/complicações , Parada Cardíaca/mortalidade , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Respiração Artificial , Sensibilidade e Especificidade , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
Intraosseous (i.o.) infusion is considered a useful technique for the administration of medications and fluids in emergency situations when peripheral intravascular access is not possible. This study investigated the effectiveness of i.o. versus intravenous (i.v.) infusion of hydroxyethyl starch (HES 200/0.5) in hypovolemic pigs. Twenty-three pigs (8- to 9-week-old) were anaesthesized, instrumented and blood was withdrawn (25-30 ml/kg) to < 50 mmHg mean arterial pressure (MAP). The animals were left untreated in haemorrhage for 30 min. Relevant haemodynamic parameters were monitored and blood samples were collected for blood gas and HES concentration analysis. Infusion of HES via i.v. or i.o. line (20 ml/kg per h) carried out over a period of 30 min for volume resuscitation and measurements were taken every 5 min. Infusion was discontinued after 30 min and the animals were monitored for 1 h. Analysis of HES-pharmacokinetics and pharmacodynamics revealed no significant differences between i.o. and the i.v. administration. The results demonstrate i.o. infusion of HES to be a rapid and effective method for fluid resuscitation in hypovolemic shock.
Assuntos
Derivados de Hidroxietil Amido/farmacologia , Substitutos do Plasma/farmacologia , Substitutos do Plasma/farmacocinética , Ressuscitação/métodos , Choque/terapia , Animais , Derivados de Hidroxietil Amido/administração & dosagem , Infusões Intraósseas , Infusões Intravenosas , Substitutos do Plasma/administração & dosagem , SuínosRESUMO
In a prospective, randomized, placebo-controlled, double-blind trial we tested the hypothesis that naloxone given during cardiopulmonary resuscitation (CPR) enhances cerebral and myocardial blood flow. Twenty-one anesthetized, normoventilated pigs were instrumented for measurements of right atrial and aortic pressures, and regional organ blood flow (radiolabeled microspheres). After 5 min of untreated fibrillatory arrest, CPR was commenced using a pneumatic chest compressor/ventilator. With onset of CPR, an i.v. bolus of 40 micrograms/kg b.w. of epinephrine was given, followed by an infusion of 0.4 micrograms/kg per min. After 5 min of CPR, either naloxone, 10 mg/kg b.w. (group N, n = 11) or normal saline (group S, n = 10) was given i.v. Prior to, and after 1, 15, and 30 min of CPR, hemodynamic and blood flow measurements were obtained. After 30 min of CPR, mean arterial pressure was significantly higher in group N (26 +/- 5 vs. 13 +/- 3 mmHg, P < 0.05). Groups did not differ with respect to myocardial perfusion pressure or arterial blood gases at any time during the observation period. Regional brain and heart blood flows were not different between N and S at any point of measurement. We conclude that high-dose naloxone does not augment cerebral or myocardial blood flow during prolonged closed-chest CPR.
Assuntos
Reanimação Cardiopulmonar , Circulação Cerebrovascular/efeitos dos fármacos , Circulação Coronária/efeitos dos fármacos , Naloxona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Equilíbrio Ácido-Base/efeitos dos fármacos , Animais , Relação Dose-Resposta a Droga , Hemodinâmica/efeitos dos fármacos , Naloxona/farmacologia , Antagonistas de Entorpecentes/farmacologia , SuínosRESUMO
In a paediatric population, we compared i.m. v oral atropine premedication to a control group without atropine and determined atropine plasma concentrations (APC). Forty-five children were randomly assigned to one of three groups. Group I received atropine, 20 micrograms.kg-1 i.m., 15 min prior to induction. Group II received atropine, 30 micrograms.kg-1 orally, group III received no atropine. APC (expressed as percent of muscarine-2 receptor subtype occupancy), heart rate, rectal temperature, and salivation were determined before atropine, and 15, 25, 45, 60, 90, 120 (no APC), and 150 min following atropine. Only 10-20% of the M2-cholinoceptors were occupied after oral atropine with a peak at 90 min compared to 60-70% occupancy with a peak 25 min after i.m. atropine. The peak in M2-cholinoceptor occupation in group I was paralleled by a peak percentage change in heart rate of 15% from baseline. The peak in receptor occupation in group II did not correspond to the peak increase in heart rate. The percentage change of heart rate over time was not significantly different from baseline values in any of the groups. Bradycardia or temperature changes did not occur in any of the groups. Antisialogogue effects were observed only in group I. We conclude that atropine; 30 micrograms.kg-1 orally is not an equipotent dosage to atropine, 20 micrograms.kg-1 i.m.
Assuntos
Atropina/administração & dosagem , Antagonistas Muscarínicos/administração & dosagem , Medicação Pré-Anestésica , Administração Oral , Atropina/sangue , Atropina/farmacocinética , Temperatura Corporal/efeitos dos fármacos , Criança , Pré-Escolar , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Injeções Intramusculares , Masculino , Antagonistas Muscarínicos/sangue , Antagonistas Muscarínicos/farmacocinética , Receptor Muscarínico M2 , Receptores Muscarínicos/metabolismo , Salivação/efeitos dos fármacosRESUMO
OBJECTIVE: Rocuronium is a new non-depolarising steroidal muscle relaxant with a short onset time. The present study was undertaken to compare intubating conditions as well as onset and clinical duration of a single dose of 0.6 mg/kg (2 x ED95) with a single dose of 1 mg/kg suxamethonium (3 x ED95). METHODS: After obtaining informed consent and approval of the Ethics Committee, 40 adult patients (ASA I-III) participated in this study. After premedication with oxazepam, anaesthesia was induced with fentanyl and propofol and maintained with propofol, N2O and supplements of fentanyl as needed. Muscular relaxation was assessed by EMG recording of adductor pollicis muscle after supramaximal single twitch stimulation of the ulnar nerve every 10 s. Patients were allocated randomly to receive either rocuronium 0.6 mg/kg or suxamethonium 1 mg/kg. The following parameters were measured: intubating conditions 60 s after injection, onset time and clinical duration of neuromuscular block, % block at intubation, heart rate, blood pressure and arterial oxygen saturation. RESULTS: (mean +/- SD). Intubating conditions after rocuronium and suxamethonium were found to be clinically acceptable (excellent or good) in 90% of patients, though there was only a partial blockade of the adductor pollicis muscle with rocuronium (71 +/- 23%) compared to suxamethonium (95 +/- 14%) (p < 0.05). The onset time and clinical duration of relaxation was shorter after suxamethonium (p < 0.05) and occurred at 0.8 +/- 0.2, 7 +/- 2.1 and 3.2 +/- 1.3, 29 +/- 11 min after suxamethonium and rocuronium respectively. CONCLUSION: At a dosage of 0.6 mg/kg, rocuronium has an onset time of about 3 min and a clinical duration of relaxation of nearly half an hour. These data are supported by various studies, while others show shorter times, probably due to different monitoring techniques. In spite of the pharmacodynamic differences between suxamethonium and rocuronium, the intubating conditions after administration of both compounds are comparable and develop at the same rate.