Tobacco use as a screener for Clostridium difficile infection outcomes.

A retrospective cohort study was conducted to evaluate the utility of self-reported tobacco use for developing a clinical prediction rule for poor outcomes of Clostridium difficile infection. Patients with any history of smoking were significantly less likely than never smokers to be cured of their infection within two weeks. Disease recurrence, readmission within 30 days, death before treatment completion, and the severity of Clostridium difficile infection were not associated with smoking status.

Intra-abdominal pressure and intra-abdominal hypertension in critically ill obstetric patients: a prospective cohort study.

BACKGROUND: Critically ill obstetric patients may have risk factors for intra-abdominal hypertension. This study evaluated the intra-abdominal pressure and its effect on organ function and the epidemiology of intra-abdominal hypertension. METHODS: Obstetric patients admitted to an Intensive Care Unit, with an anticipated stay greater than 24hours, were included. Intra-abdominal pressure was measured daily via a Foley catheter, based on intravesical pressure. RESULTS: One-hundred-and-one patients were enrolled. The intra-abdominal pressure was 5-7mmHg in 34%; 7-12mmHg in 60%; and ≥12mmHg (intra-abdominal hypertension) in 6%. All six patients with intra-abdominal hypertension were pregnant at the time of admission. The intra-abdominal pressure in four patients normalized to <12mmHg following delivery, but in the remaining two it persisted ≥12mmHg and both these patients died. Correlation between intra-abdominal pressure and organ dysfunction was weak (r=0.211). Statistical comparison between patients with and without intra-abdominal hypertension for risk factors, daily intra-abdominal pressures, and Sequential Organ Failure Assessment score could not be done due to the disproportionately small number of patients with intra-abdominal hypertension as opposed to those without (6 versus 95). Intra-abdominal pressure did not significantly differ between survivors and non-survivors (8.5±1.1 vs 7.9±1.7mmHg, P=0.079). CONCLUSIONS: The incidence of intra-abdominal hypertension in critically ill obstetric patients was lower than previously defined for mixed Intensive Care Unit populations, with an association with the pregnant state. Normalization of intra-abdominal pressure after delivery was associated with better survival. There was no correlation between intra-abdominal pressure and organ function or mortality.

Antimicrobial resistance patterns of bovine Salmonella enterica isolates submitted to the Wisconsin Veterinary Diagnostic Laboratory: 2006-2015.

Salmonellosis on the dairy continues to have a significant effect on animal health and productivity and in the United States. Additionally, Salmonella enterica ssp. enterica causes an estimated 1.2 million cases of human illness annually. Contributing to the morbidity and mortality in both human and domestic animal species is emergence of antimicrobial resistance by Salmonella species and increased incidence of multidrug-resistant isolates. This study describes serotype distribution and the antimicrobial resistance patterns for various Salmonella serotypes isolated from bovine samples submitted to the Wisconsin Veterinary Diagnostic Laboratory (WVDL) over the past 10 yr. Salmonella serotyping and antimicrobial susceptibility testing data were obtained from the laboratory information management system at WVDL. Data from accessions were limited to bovine samples submitted to the WVDL between January 2006 and June 2015 and those that had both a definitive serotype and complete results for antimicrobial susceptibility testing. A total of 4,976 isolates were identified. Salmonella enterica ser. Dublin was the most prevalent serotype identified among bovine samples submitted to the WVDL, accounting for a total of 1,153 isolates (23% of total isolates) over the study period. Along with Dublin, Salmonella enterica ser. Cerro (795, 16%), Newport (720, 14%), Montevideo (421, 8%), Kentucky (419, 8%), and Typhimurium (202, 4%) comprised the top 6 most commonly isolated serotypes during that time. Overall, resistance of bovine Salmonella isolates in the study population remained stable, although decreases in resistance were noted for gentamicin, neomycin, and trimethoprim sulfamethoxazole during the study period. All isolates remained susceptible to enrofloxacin. These data show that antimicrobial susceptibility for bovine Salmonella has changed in the population served by WVDL in the past 10 yr. This information is important for understanding Salmonella disease ecology in Wisconsin. Our findings are also relevant for animal and public health by improving informed antimicrobial use, new drug development, and regulation of their use in food animals.

Comparision of clonidine and dexmedetomidine for attenuation of laryngoscopy and intubation response - A randomized controlled trial.

BACKGROUND: Clonidine and dexmedetomidine are alpha-2 agonists with beneficial effect on the hemodynamic response to laryngoscopy and intubation. The present study was designed to evaluate and compare the efficacy of intravenous clonidine 1 µg/kg, and dexmedetomidine in doses of 0.5 µg/kg and 1 µg/kg, for blunting the hemodynamic changes during laryngoscopy and intubation. METHOD: Adult patients of ASA physical grade I/II scheduled for surgery under general anaesthesia with endotracheal tube were randomly divided into three groups using a computer generated random number table, each group receiving one of the following drugs prior to induction of anaesthesia, by a blinded anaesthesiologist in a volume of 100 mL infused intravenously over 20 minutes: clonidine 1 µg/kg, or dexmedetomidine 0.5 µg/kg, or dexmedetomidine 1 µg/kg. General anaesthesia was induced using standard technique and intubations performed by same anaesthesiologist. Heart rate and mean blood pressure were recorded in pre-operative room (baseline) and again at 1 minute, 3 minutes, 5 minutes and 10 minutes after intubation. An increase in heart rate and/or mean blood pressure by >20% above baseline values during observation period was taken to indicate a positive intubation response. RESULTS: The incidence of intubation response was similar in all three groups (P>.05). The number of patients developing hypotension was significantly higher in group receiving dexmedetomidine1µg/kg group (P<.005) as compared to other two groups. Both the groups receiving dexmedetomidine had higher number of patients developing bradycardia as compared to patients receiving clonidine. DISCUSSION & CONCLUSION: Dexmedetomidine 0.5 µg/kg, 1 µg/kg and clonidine 1 µg/kg attenuate the laryngoscopy and intubation response but Clonidine 1 µg/kg was associated with lesser side effects.

Randomized double-blind comparison of ephedrine and phenylephrine for management of post-spinal hypotension in potential fetal compromise.

BACKGROUND: Most studies comparing phenylephrine and ephedrine have been conducted during elective caesarean sections in healthy mothers with no fetal compromise. The effect of vasopressors on fetal outcome may differ between healthy and compromised fetuses. There has been little research into the effect of phenylephrine and ephedrine, when used for management of post-spinal hypotension in the presence of potential fetal compromise. METHODS: Healthy women with a singleton pregnancy undergoing emergency caesarean section for fetal compromise under spinal anaesthesia were studied. One-hundred-and-six consecutive subjects, who developed hypotension after spinal anaesthesia, were randomly allocated to two groups of 53 each, to receive either phenylephrine (Group P) or ephedrine (Group E). For every systolic blood pressure reading <100mmHg patients received phenylephrine 100µg or ephedrine 8mg depending on group allocation. Umbilical blood gas parameters and Apgar scores were recorded. RESULTS: There was no statistically significant difference in umbilical arterial pH (P=0.79), umbilical venous pH (P=0.98), other blood gas parameters, incidence of fetal acidosis (P=1.00) and Apgar scores. The number of hypotensive episodes, vasopressor doses for treatment of the first hypotensive episode and the total number of doses used during the study period were comparable. The median [IQR] total number of doses of phenylephrine and ephedrine used before delivery were 2 [1-2] and 2 [1-2], respectively (P=0.67). More patients receiving ephedrine (24.5%) developed tachycardia than those receiving phenylephrine (3.8%) (P=0.004). Bradycardia was more common with phenylephrine, with 39.6% of patients in Group P as compared to only 1.9% of patients in Group E developing a heart rate <60beats/min after vasopressor administration (P=0.001). CONCLUSIONS: Both phenylephrine 100µg and ephedrine 8mg boluses are equally efficacious when treating post-spinal hypotension in the presence of potential fetal compromise. However, phenylephrine may be a better choice in the presence of maternal tachycardia.

Effect of different phenylephrine bolus doses for treatment of hypotension during spinal anaesthesia in patients undergoing elective caesarean section.

The efficacy of phenylephrine might be improved by giving doses higher than that traditionally used (100 µg). This study compared the effects of three initial bolus doses of intravenous phenylephrine; 100 µg (group P100), 125 µg (group P125) and 150 µg (group P150), for the treatment of post-spinal hypotension in patients undergoing elective caesarean delivery. If hypotension was not corrected by this dose, additional boluses of 25 µg were given every minute. Further hypotensive episodes were treated with half the initial bolus dose, followed by 25 µg boluses, as required. Umbilical arterial and venous blood samples were obtained for blood gas analysis and Apgar scores recorded. One hundred and twenty subjects (40 per group) who developed post-spinal hypotension (75%) were included in this randomised, double blind trial. Although systolic blood pressure was higher at certain time-points after 150 µg phenylephrine, there were no statistically significant differences in the effectiveness of the first bolus of phenylephrine to treat hypotension (85%, 95% and 95% in groups P100, P125 and P150, respectively, P=0.215); the additional dose of phenylephrine after the first bolus (P=0.810); the number of additional boluses (P=0.318) or of hypotensive episodes (P=0.118). There were no significant differences in the number of patients developing reactive hypertension or bradycardia, in maternal side-effects or in neonatal outcomes. Although the study may have been underpowered, initial phenylephrine bolus doses of 100 µg, 125 µg and 150 µg did not significantly differ in efficacy to treat post-spinal hypotension in these patients.

Asymptomatic carriage of toxigenic Clostridium difficile by hospitalized patients.

Asymptomatic carriage of Clostridium difficile is common in hospitals, but the risk for transmission by carriers is unclear. In this point prevalence culture survey of asymptomatic hospitalized patients, 18 of 149 (12%) were carriers of toxigenic C. difficile. By comparison with C. difficile infection (CDI) patients, the prevalence of skin and/or environmental contamination was significantly lower in asymptomatic carriers (3/18, 17% versus 5/6, 83%; P = 0.007), but carriers outnumbered CDI patients in the hospital by a factor of 3 to 1. These data suggest that asymptomatic carriers have the potential to contribute to C. difficile transmission in hospitals.

Effect of intravenous magnesium sulphate on postoperative pain following spinal anesthesia. A randomized double blind controlled study.

BACKGROUND: Magnesium sulphate (MgSO4), NMDA receptor antagonist, is known to reduce perioperative requirement of anesthetics and analgesics. However, no studies assessed the effect of MgSO4 on onset and recovery from spinal anesthesia. A prospective, randomised, double blind study was designed to assess the effect of intravenous (IV) MgSO4 on onset and recovery from spinal anesthesia and post operative analgesic requirement following below umbilical surgery. METHODS: Sixty patients (ASA class I & II) were selected randomly and divided into two groups. Patients were given either MgSO4 50 mg kg(-1) in 10 mL within 10 min, followed by an infusion of MgSO4 10 mg kg(-1) hr(-1) IV in 4mL (MG group) for 12 hrs or normal saline in same volume and rate for 12 hrs as used in MG group (NS group). After initiating the infusion, spinal anesthesia was given with 0.5% bupivacaine (Hyperbaric) 2.5 mL at L3/4 or L4/5 space. Time taken for sensory block at the level of T-10 and motor block (modified Bromage Score-1) was noted. Postoperatively, time taken for recovery from spinal anesthesia, pain score and requirement of postoperative analgesic in 24 hours were observed and compared between the two groups. RESULTS: The first rescue analgesia was required after 334 +/- 202 min in MG group and after 233 +/- 141 min in NS group with significant difference (p < 0.05). The morphine required over 24 hours for analgesia was significantly less in MG group (3.99 +/- 1.25 mg) as compared to NS group (7.13 +/- 2.68 mg) (p < 0.000). CONCLUSION: Intravenous MgSO4 improves postoperative analgesia without affecting the onset and recovery from spinal anesthesia.

Epidural volume extension: a review.

Epidural volume extension is a technical modification of the combined spinal epidural block. It involves the epidural injection of normal saline or a small volume of local anaesthetic after an intrathecal injection, aiming to augment the post-spinal sensory level. Although the consequent sensory block augmentation has been adequately documented, the probable factors influencing epidural volume extension and its implications for clinical practice are not well defined. This article reviews published literature relating to the probable factors affecting epidural volume extension, its clinical implications, case reports of its successful clinical application and summarises its unexplored effects.

Intrathecal sufentanil versus fentanyl for lower limb surgeries - a randomized controlled trial.

BACKGROUND: To compare the efficacy and safety of intrathecal sufentanil or fentanyl as adjuvants to hyperbaric bupivacaine in patients undergoing major orthopaedic lower limb surgeries in terms of onset and duration of sensory block, motor block and post-operative pain relief. PATIENTS #ENTITYSTARTX00026; METHODS: Ninety patients were recruited in this Prospective, randomized double blind study to receive either intrathecal sufentanil 5 µg (Group S), fentanyl 25 µg (Group F) or normal saline 0.5 ml (Group C) as adjuvants to 15 mg of 0.5% hyperbaric bupivacaine. The onset and duration of sensory and motor block were assessed intraoperatively. The pain scores were assessed postoperatively. Duration of complete and effective analgesia was recorded. The incidence of side effects such as nausea, vomiting, pruritus, shivering and PDPH was recorded. RESULTS: The Demographic data, hemodynamic and respiratory parameters were comparable in the three groups. There was a significantly earlier onset and prolonged duration of sensory block in the sufentanil and fentanyl groups. The duration of complete and effective analgesia were also significantly prolonged in the fentanyl and sufentanil groups. Pruritus was noticed in the study groups (Groups S&F). CONCLUSIONS: Intrathecal sufentanil (5 µg) and fentanyl (25 µg), as adjuvants lead to an earlier onset and prolonged duration of sensory block. The duration of effective analgesia with intrathecal sufentanil and fentanyl as adjuvants to hyperbaric bupivacaine is longer than that of bupivacaine alone.

A comparison of pressure-controlled and volume-controlled ventilation for laparoscopic cholecystectomy.

The potential advantages of pressure-controlled over volume-controlled ventilation during laparoscopic surgery have yet to be proven. We randomly assigned 42 patients with BMI <30 kg.m(-2) scheduled for laparoscopic cholecystectomy to receive either pressure- or volume-controlled ventilation. Compared with volume-controlled ventilation, pressure-controlled ventilation resulted in a significant decrease in mean (SD) peak airway pressure at 10 min (20.4 (2.7) vs 24.0 (4.7)cmH2O, p=0.004) and 30 min (20.7 (3.0) vs 23.9 (4.9)cmH2O, p=0.015) and an increase in mean airway pressure at 10 min (10.5 (0.9) vs 9.6 (1.1)cmH2O, p=0.007) and 30 min (10.5 (1.1) vs 9.6 (1.2)cmH2O, p=0.016) after the start of surgery. Gas exchange and haemodynamic stability were similar. We conclude that pressure-controlled ventilation is a safe alternative and offers some advantages to volume-controlled ventilation during laparoscopic cholecystectomy in non-obese patients.

Comparison of phenylephrine hydrochloride and mephentermine sulphate for prevention of post spinal hypotension.

This study compared the effects of intravenous infusions of phenylephrine and mephentermine on the prevention of maternal hypotension and neonatal outcome in patients receiving spinal anaesthesia for caesarean section. Sixty ASA 1-2 patients with term, uncomplicated singleton pregnancy undergoing caesarean section under spinal anaesthesia were randomly divided into two groups of 30 each, to receive a prophylactic intravenous infusion of either phenylephrine or mephentermine. The incidence of hypotension was statistically similar in the two groups. However, in patients receiving phenylephrine, 7 (23%) developed bradycardia and 6 (20%), reactive hypertension. Neonatal outcome, in terms of Apgar scores and umbilical artery pH, was similar in both the groups. To conclude, phenylephrine and mephentermine infusions are equally effective in preventing post spinal hypotension in patients undergoing caesarean section and are associated with a similar neonatal outcome.

Subdural block and the anaesthetist.

There are a number of case reports describing accidental subdural block during the performance of subarachnoid or epidural anaesthesia. However it appears that subdural drug deposition remains a poorly understood complication of neuraxial anaesthesia. The clinical presentation may often be attributed to other causes. Subdural injection of local anaesthetic can present as high sensory block, sometimes even involving the cranial nerves due to extension of the subdural space into the cranium. The block is disproportionate to the amount of drug injected, often with sparing of sympathetic and motor fibres. On the other hand, the subdural deposition can also lead to failure of the intended block. The variable presentation can be explained by the anatomy of this space. High suspicion in the presence of predisposing factors and early detection could prevent further complications. This review aims at increasing awareness amongst anaesthetists about inadvertent subdural block. It reviews the relevant anatomy, incidence, predisposing factors, presentation, diagnosis and management of unintentional subdural block during the performance of neuraxial anaesthesia.

Intrathecal sufentanil versus fentanyl for lower limb surgeries - a randomized controlled trial.

BACKGROUND: To compare the efficacy and safety of intrathecal sufentanil or fentanyl as adjuvants to hyperbaric bupivacaine in patients undergoing major orthopaedic lower limb surgeries in terms of onset and duration of sensory block, motor block and post-operative pain relief. PATIENTS #ENTITYSTARTX00026; METHODS: Ninety patients were recruited in this Prospective, randomized double blind study to receive either intrathecal sufentanil 5 µg (Group S), fentanyl 25 µg (Group F) or normal saline 0.5 ml (Group C) as adjuvants to 15 mg of 0.5% hyperbaric bupivacaine. The onset and duration of sensory and motor block were assessed intraoperatively. The pain scores were assessed postoperatively. Duration of complete and effective analgesia was recorded. The incidence of side effects such as nausea, vomiting, pruritus, shivering and PDPH was recorded. RESULTS: The Demographic data, hemodynamic and respiratory parameters were comparable in the three groups. There was a significantly earlier onset and prolonged duration of sensory block in the sufentanil and fentanyl groups. The duration of complete and effective analgesia were also significantly prolonged in the fentanyl and sufentanil groups. Pruritus was noticed in the study groups (Groups S&F). CONCLUSIONS: Intrathecal sufentanil (5 µg) and fentanyl (25 µg), as adjuvants lead to an earlier onset and prolonged duration of sensory block. The duration of effective analgesia with intrathecal sufentanil and fentanyl as adjuvants to hyperbaric bupivacaine is longer than that of bupivacaine alone.

Potency of mephentermine for prevention of post-spinal hypotension.

This study was designed to determine the minimum effective dose (ED50) of mephentermine for prevention of post-spinal hypotension in women undergoing elective caesarean section. Dixon's up-down method of sequential allocation was used to determine the patient's dose of vasopressor drug. In our previous study, mephentermine appeared to be much more potent than ephedrine, so the present study was conducted using a lower initial dose and smaller dose interval for this vasopressor. Following administration of spinal anaesthesia, a prophylactic infusion of mephentermine was started with 5 mg infused over a period of 30 minutes as the initial dose and a dose interval of 1 mg. The ED50 of mephentermine of 3.7 mg (95% confidence interval 2.4 to 5.7 mg) was much less than that of ephedrine, as calculated in our previous study using the same methodology. Using these values gives a potency ratio of ephedrine to mephentermine of 1:6.8 (95% confidence interval 6.0 to 7.5).

Tramadol for prevention of postanaesthetic shivering: a randomised double-blind comparison with pethidine.

The present study was conducted with the aims of comparing intravenous tramadol 1, 2 and 3 mg.kg(-1) with pethidine 0.5 mg.kg(-1) for prophylaxis of postanaesthetic shivering and to find a dose of tramadol that could provide the dual advantage of antishivering and analgesic effect in the postoperative period. The study included 165 patients, randomly allocated to five groups of 33 each. Tramadol in doses of 1, 2 and 3 mg.kg(-1), pethidine 0.5 mg.kg(-1) or normal saline were administered at the time of wound closure. All three doses of tramadol were effective and comparable to pethidine in preventing postanaesthetic shivering. Tramadol 2 mg.kg(-1) had the best combination of antishivering and analgesic efficacy without excessive sedation and thus appeared to be a good choice to be administered at the time of wound closure to provide antishivering effect and analgesia without significant side effects in the postoperative period.

Pre-operative intravenous fluid therapy with crystalloids or colloids on post-operative nausea & vomiting.

BACKGROUND & OBJECTIVE: Post-operative nausea and vomiting (PONV) is a frequent complication and may be a reason for increased morbidity and cost of treatment. Following elective surgery, it is believed to result from gut ischaemia consequent to hypovolemia from overnight fasting. This study was carried out to study the effects of pre-operative intravenous fluid supplementation, either crystalloids or colloids, on PONV. METHODS: In this prospective randomized clinical trial, 60 female patients undergoing elective open cholecystectomy were randomly allocated to three equal groups A, B and C. All patients received preoperative fluid supplementation. Group A patients received 2 ml/kg Ringer lactate iv (intravenously) and served as control, Group B patients received 12 ml/kg Ringer lactate iv whereas Group C patients received 12 ml/kg of 4.5 per cent hydroxyethylstarch (Hetastarch) iv. All patients underwent cholecystectomy under standard anaesthesia technique with intraoperative fluid replacement by Ringer's lactate (6 ml/kg/h). An independent blinded observer assessed PONV during first 24 h following surgery using visual analogue scale (VAS) score (0 = no nausea, 10 = worst imaginable nausea or vomiting). Rescue antiemetic was given whenever VAS was > 5. RESULTS: The three groups were comparable in terms of age, body weight and duration of surgery. VAS scores in Groups B and C patients were less than that of Group A patients at all time intervals post-operatively and became significantly different at 4 h post-operatively. The VAS scores of Groups B and C patients were comparable throughout. A significantly large number (90%) of Group A patients required rescue antiemetic as compared to 50 and 55 per cent patients in Group B and Group C, respectively. INTERPRETATION & CONCLUSION: Pre-operative intravenous fluid supplementation using crystalloids and colloids results in significantly decreased incidence of PONV. Both, crystalloids as well as colloids were found to be equally effective in preventing PONV.