RESUMEN
We describe the anaesthetic and intensive care management of a 38-year-old mother with presumed amniotic fluid embolism who suffered cardiorespiratory collapse following delivery of a normal baby by caesarean section. After initial resuscitation, her recovery was complicated by development of disseminated intravascular coagulation and a large sub-capsular hepatic haematoma. We describe the initial resuscitative efforts and subsequent intensive therapy to full neurological recovery and discharge from hospital.
Asunto(s)
Embolia de Líquido Amniótico/terapia , Paro Cardíaco/terapia , Hematoma/etiología , Hepatopatías/etiología , Adulto , Coagulación Intravascular Diseminada/etiología , Embolia de Líquido Amniótico/complicaciones , Femenino , Humanos , EmbarazoRESUMEN
A 61-yr-old woman presented with severe tetanus. Her intensive care management was complicated by severe generalized tetanic spasms despite the use of propofol, midazolam, alfentanil, magnesium sulphate, and atracurium. We describe the management of this problem with a variable dose remifentanil infusion.
Asunto(s)
Analgésicos Opioides/uso terapéutico , Piperidinas/uso terapéutico , Tétanos/tratamiento farmacológico , Esquema de Medicación , Resultado Fatal , Femenino , Humanos , Hipoxia Encefálica/etiología , Infusiones Intravenosas , Persona de Mediana Edad , Remifentanilo , Tétanos/complicacionesRESUMEN
A postal questionnaire survey was sent to Royal College of Anaesthetists' tutors in Great Britain and Northern Ireland to gain insight into current practice with regard to information and consent for anaesthesia. Details of consent practice in three specific areas were requested: anaesthesia in general, teaching medical students during anaesthesia and obstetric anaesthesia. Replies were received from 218 tutors (77%). Of these, 72% of departments had a policy on consent for anaesthesia that was in accordance with The Association of Anaesthetists of Great Britain and Ireland guidelines on 'Information and Consent for Anaesthesia'. We identified three areas of concern. Firstly, almost a third of departments (27%) had no policy on consent for anaesthesia. Second, only 18% of relevant departments obtain specific consent for the teaching of medical students on anaesthetised patients. Third, 1 year after publication of the guidelines, 17% of obstetric anaesthetic units, despite stating an intention to alter their departmental policy based on the Association's recommendations, had not yet implemented any changes.
Asunto(s)
Anestesia , Consentimiento Informado , Pautas de la Práctica en Medicina/estadística & datos numéricos , Anestesia Obstétrica , Anestesiología/educación , Educación de Postgrado en Medicina , Adhesión a Directriz , Encuestas de Atención de la Salud , Humanos , Guías de Práctica Clínica como Asunto , Encuestas y Cuestionarios , Reino UnidoRESUMEN
1. Acidosis alters the transient outward current, ito, in the heart. We have studied the mechanism underlying the effect of acidosis on one of the K+ channels, Kv1.4 (heterologously expressed in Xenopus laevis oocytes), known to underlie ito. 2. At pH 6.5, wild-type Kv1.4 current was inhibited during repetitive pulsing, in part as a result of a slowing of recovery from N-type inactivation. 3. Acidosis still caused slowing of recovery after deletion of just one (either the first or second) of the N-terminal inactivation ball domains. However, deletion of both the N-terminal inactivation ball domains greatly reduced the inhibition. 4. As well as the N-terminus, other parts of the channel are also required for the effect of acidosis, because, whereas the transfer of the N-terminus of Kv1.4 to Kv1.2 conferred N-type inactivation, it did not confer acidosis sensitivity. 5. Replacement of an extracellular histidine with a glutamine residue (H508Q) abolished the slowing of recovery by acidosis. Reduction of C-type inactivation by raising the bathing K+ concentration or by the mutation K532Y also abolished the slowing. 6. It is concluded that binding of protons to H508 enhances C-type inactivation and this causes a slowing of recovery from N-type inactivation and, thus, an inhibition of current during repetitive pulsing.
Asunto(s)
Histidina , Concentración de Iones de Hidrógeno , Canales de Potasio con Entrada de Voltaje , Canales de Potasio/fisiología , Sustitución de Aminoácidos , Animales , Femenino , Hurones , Canal de Potasio Kv1.4 , Modelos Moleculares , Mutagénesis Sitio-Dirigida , Oocitos/fisiología , Técnicas de Placa-Clamp , Bloqueadores de los Canales de Potasio , Canales de Potasio/química , Estructura Secundaria de Proteína , Ratas , Proteínas Recombinantes de Fusión/química , Proteínas Recombinantes de Fusión/metabolismo , Proteínas Recombinantes/antagonistas & inhibidores , Proteínas Recombinantes/química , Proteínas Recombinantes/metabolismo , Eliminación de Secuencia , Xenopus laevisRESUMEN
The peri-operative management of the only surviving case, to date, of living-related small bowel transplantation is described. The anaesthetic technique was chosen to optimize hepato-splanchnic blood flow. Peri-operative splanchnic blood flow was measured and alterations in flow with changes in inotropic agents and volume loading monitored. There appears to be a role for the use of dopexamine and aggressive volume loading.
Asunto(s)
Anestesia por Inhalación , Intestino Delgado/trasplante , Adulto , Volumen Sanguíneo , Femenino , Humanos , Intestino Delgado/diagnóstico por imagen , Cuidados Intraoperatorios , Persona de Mediana Edad , Circulación Esplácnica/fisiología , Donantes de Tejidos , UltrasonografíaAsunto(s)
Dopamina/análogos & derivados , Mucosa Intestinal/irrigación sanguínea , Mucosa Intestinal/trasplante , Intestino Delgado/irrigación sanguínea , Intestino Delgado/trasplante , Microcirculación/fisiología , Trasplante Homólogo/fisiología , Vasodilatadores/farmacología , Adulto , Dopamina/administración & dosificación , Dopamina/farmacología , Inglaterra , Femenino , Supervivencia de Injerto , Hemodinámica/efectos de los fármacos , Humanos , Infusiones Intravenosas , Microcirculación/efectos de los fármacos , Persona de Mediana Edad , Flujo Sanguíneo Regional/efectos de los fármacos , Estudios Retrospectivos , Vasodilatadores/administración & dosificación , Vísceras/trasplanteRESUMEN
Isoflurane has been considered the agent of choice where preservation of splanchnic blood flow is required. Liver blood flow and the hepatic artery buffer response are maintained better in the presence of isoflurane than with other volatile anaesthetic agents. The effects of desflurane have not been assessed in humans. Therefore, we have compared the effects of isoflurane and desflurane anaesthesia on small bowel and hepatic microcirculatory flow during major surgery using laser Doppler flowmetry in a prospective, randomized, single-blind, crossover study. Patients were allocated randomly to receive desflurane or isoflurane (1 MAC) in oxygen-enriched air. Steady-state jejunal and liver blood flow in segment III were assessed by laser Doppler flowmetry. Volatile anaesthetics were then interchanged, and measurements repeated at steady state. Desflurane anaesthesia at 1 MAC was associated with significantly greater gut blood flow than 1 MAC of isoflurane. These differences could not be explained by systemic haemodynamic differences. The similarity in total hepatic flow between groups implies an intact hepatic artery buffer response with desflurane and isoflurane.
Asunto(s)
Anestésicos por Inhalación/farmacología , Isoflurano/análogos & derivados , Isoflurano/farmacología , Circulación Esplácnica/efectos de los fármacos , Abdomen/cirugía , Adulto , Estudios Cruzados , Desflurano , Humanos , Yeyuno/irrigación sanguínea , Flujometría por Láser-Doppler , Circulación Hepática/efectos de los fármacos , Microcirculación/efectos de los fármacos , Estudios Prospectivos , Método Simple CiegoRESUMEN
A 46-yr-old woman with rapidly progressing primary biliary cirrhosis presented for liver transplantation. The use of preoperative recombinant human erythropoietin enabled this to be achieved without prohibited blood products. Perioperative management of this patient and general principles of management of Jehovah's Witnesses undergoing major surgery are discussed.