RESUMO
BACKGROUND: Laparoscopic surgery causes specific post-operative discomfort and intraoperative cardiovascular, pulmonary, and splanchnic changes. The CO2 pneumoperitoneum-related intra-abdominal pressure (IAP) remains one of the main drivers of these changes. We investigated the influence of deep neuromuscular blockade (NMB) on IAP and surgical conditions. METHODS: This is an open prospective single-subject design study in 20 patients (14 female/6 male) undergoing laparoscopic cholecystectomy. Inclusion criteria were 18 years or older, and American Society of Anesthesiologists classification 1 to 3. Under a standardised anaesthesia, lowest IAP providing adequate surgical conditions was assessed without NMB and with deep NMB [post-tetanic count (PTC)<2] with rocuronium. The differences between IAP allowing for an adequate surgical field before and after administration of rocuronium were determined, as were effects of patient gender, age, and body mass index. RESULTS: Mean IAP without NMB was 12.75 (standard deviation 4.49) mmHg. Immediately after achieving a deep NMB, this was 7.20 (2.51). This pressure difference of 5.55 mmHg (5.08, P<0.001) dropped to 3.00 mmHg (4.30, P<0.01) after 15 min. Higher IAP differences were found in women compared with men. A modest inverse relationship was found between pressure difference and age. CONCLUSIONS: We found an almost 25% lower IAP after a deep NMB compared with no block in laparoscopic cholecystectomy. Younger and female patients appear to benefit more from deep neuromuscular blockade to reduce IAP.
Assuntos
Colecistectomia Laparoscópica/métodos , Bloqueio Neuromuscular/métodos , Abdome , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Androstanóis , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fármacos Neuromusculares não Despolarizantes , Pressão , Estudos Prospectivos , Rocurônio , Adulto JovemRESUMO
Intraoperative hypothermia in open elective abdominal aortic aneurysm repair may be associated with increased hospital morbidity. This retrospective, single centre study investigated whether there was an association between intraoperative hypothermia in open elective abdominal aortic aneurysm repair and postoperative in-hospital morbidity. The data of 119 patients who underwent open infrarenal abdominal aortic aneurysm repair between January 2006 and January 2011 were collected. The electronic databases from the hospital, intensive care unit, transfusion medicine and operating theatres were linked by the patient's unique identifiers including date of birth and unit record number. Intraoperative nasopharyngeal temperature measurements were collected manually from paper-based anaesthetic records. The study group included 102 out of the 119 patients. Sixty-six patients (64.6%) had intraoperative hypothermia as defined by temperature <36°C. Intraoperative temperature was not predictive of hospital length-of-stay or any of the other perioperative complications such as acute renal failure, acute respiratory complications, acute myocardial infarction, transfusion requirements or postoperative infection. In the normothermic group, the number of hours in the intensive care unit was 35% lower (ratio of means=0.65; 95% confidence interval 0.51 to 0.84; P=0.0008), even after adjusting for possible confounders such as age, duration of anaesthesia, size of aneurysm, comorbidities and transfusion. Intraoperative hypothermia is a persisting problem and more aggressive warming strategies may need to be identified and employed to achieve normothermia.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Cirúrgicos Eletivos/métodos , Hipotermia/epidemiologia , Complicações Intraoperatórias/epidemiologia , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Idoso , Causalidade , Estudos de Coortes , Estado Terminal/epidemiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Estudos Retrospectivos , Austrália do Sul/epidemiologiaRESUMO
This retrospective casenote audit involving 374 patients requiring intubation for an anaesthetic found that when the availability of sugammadex became unrestricted, its use increased from 7.1 to 65.3% (P <0.0001) of all muscle relaxant reversals, while neostigmine use decreased from 59.6 to 12.5%. Rocuronium use decreased slightly (90.8 to 79.2%, P=0.006) but vecuronium use increased (2.1 to 8.3%, P=0.02). Cisatracurium and suxamethonium use were unchanged. Total rocuronium dose (55.9 ± 24.1 vs 60.4 ± 22.3 mg) and the number of doses (1.9 ± 1.48 to 1.96 ± 1.27) were unchanged, but the time between the last dose and reversal decreased (91.7 ± 68.1 to 62 ± 52.4 minutes, P=0.0002). There appeared to be no change in postoperative nausea and vomiting, or post-anaesthesia care unit time or oxygen saturation levels. Anaesthetic theatre time fell from 143.5 ± 85.8 to 120 ± 71.2 minutes (P=0.01) and remained significant when adjusted for confounding variables (ratio of means 1.17, 95% confidence interval 1.03 to 1.34, P=0.02), although inferences in relation to causality are limited by the retrospective and observational design of the study. Hospital stay also appeared to fall (4.2 ± 3.5 to 3.4 ± 3.0 days, P=0.035), but was not statistically significant when adjusted for confounding variables (ratio of means 1.04, 95% confidence interval 0.89 to 1.2, P=0.59). These observations suggest that the unrestricted availability of sugammadex will change how steroid-based neuromuscular blocking drugs are used and reversed, but further research is needed to determine if patient outcomes will improve.
Assuntos
Anestesia , Hospitais de Ensino , Relaxantes Musculares Centrais/antagonistas & inibidores , Bloqueio Neuromuscular/métodos , gama-Ciclodextrinas/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Androstanóis , Inibidores da Colinesterase/uso terapêutico , Uso de Medicamentos , Feminino , Auditoria Financeira , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Neostigmina/uso terapêutico , Fármacos Neuromusculares Despolarizantes , Fármacos Neuromusculares não Despolarizantes , Salas Cirúrgicas/organização & administração , Estudos Retrospectivos , Rocurônio , Software , Succinilcolina , Sugammadex , Resultado do Tratamento , gama-Ciclodextrinas/economiaAssuntos
Alcaptonúria/história , Alcaptonúria/complicações , Genética Médica/história , História do Século XIX , História do Século XX , Humanos , Hiperpigmentação/etiologia , Hiperpigmentação/história , Londres , Vértebras Lombares/diagnóstico por imagem , Radiografia , Osteofitose Vertebral/diagnóstico por imagem , Osteofitose Vertebral/etiologia , Osteofitose Vertebral/históriaAssuntos
Cálculos Urinários/genética , Cálcio/metabolismo , Oxalato de Cálcio/antagonistas & inibidores , Oxalato de Cálcio/metabolismo , Feminino , Doenças Genéticas Ligadas ao Cromossomo X/genética , Doenças Genéticas Ligadas ao Cromossomo X/metabolismo , Glicoproteínas/metabolismo , Glicosaminoglicanos/metabolismo , Humanos , Masculino , Glicoproteínas de Membrana/metabolismo , Mucoproteínas/metabolismo , Osteopontina , Fragmentos de Peptídeos/metabolismo , Precursores de Proteínas/metabolismo , Protrombina/metabolismo , Receptores de Detecção de Cálcio/metabolismo , Inibidores de Serina Proteinase/metabolismo , Sialoglicoproteínas/metabolismo , Inibidor da Tripsina de Soja de Kunitz/metabolismo , Cálculos Urinários/metabolismo , Uromodulina , Vitamina D/biossínteseAssuntos
Raquianestesia/efeitos adversos , Cesárea , Embolia Amniótica/etiologia , Adulto , Feminino , Humanos , GravidezRESUMO
OBJECTIVES: To assess and compare the effects of candesartan or lisinopril, or both, on blood pressure and urinary albumin excretion in patients with microalbuminuria, hypertension, and type 2 diabetes. DESIGN: Prospective, randomised, parallel group, double blind study with four week placebo run in period and 12 weeks' monotherapy with candesartan or lisinopril followed by 12 weeks' monotherapy or combination treatment. SETTING: Tertiary hospitals and primary care centres in four countries (37 centres). PARTICIPANTS: 199 patients aged 30-75 years. INTERVENTIONS: Candesartan 16 mg once daily, lisinopril 20 mg once daily. MAIN OUTCOME MEASURES: Blood pressure and urinary albumin:creatinine ratio. RESULTS: At 12 weeks mean (95% confidence interval) reductions in diastolic blood pressure were 9.5 mm Hg (7.7 mm Hg to 11.2 mm Hg, P<0.001) and 9.7 mm Hg (7.9 mm Hg to 11.5 mm Hg, P<0.001), respectively, and in urinary albumin:creatinine ratio were 30% (15% to 42%, P<0.001) and 46% (35% to 56%, P<0.001) for candesartan and lisinopril, respectively. At 24 weeks the mean reduction in diastolic blood pressure with combination treatment (16.3 mm Hg, 13.6 mm Hg to 18.9 mm Hg, P<0. 001) was significantly greater than that with candesartan (10.4 mm Hg, 7.7 mm Hg to 13.1 mm Hg, P<0.001) or lisinopril (mean 10.7 mm Hg, 8.0 mm Hg to 13.5 mm Hg, P<0.001). Furthermore, the reduction in urinary albumin:creatinine ratio with combination treatment (50%, 36% to 61%, P<0.001) was greater than with candesartan (24%, 0% to 43%, P=0.05) and lisinopril (39%, 20% to 54%, P<0.001). All treatments were generally well tolerated. CONCLUSION: Candesartan 16 mg once daily is as effective as lisinopril 20 mg once daily in reducing blood pressure and microalbuminuria in hypertensive patients with type 2 diabetes. Combination treatment is well tolerated and more effective in reducing blood pressure.
Assuntos
Albuminúria/tratamento farmacológico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Benzimidazóis/uso terapêutico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipertensão/tratamento farmacológico , Lisinopril/uso terapêutico , Sistema Renina-Angiotensina/efeitos dos fármacos , Tetrazóis/uso terapêutico , Adulto , Idoso , Compostos de Bifenilo , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do TratamentoRESUMO
This article explores the question of whether rural location influences the diagnosis, management and outcome for patients with asthma. Three cases of asthma respiratory arrest are presented to highlight some of the difficulties of asthma management in rural communities, followed by a review of the current literature relevant to rural asthma.
Assuntos
Asma/diagnóstico , Asma/terapia , Medicina de Família e Comunidade/métodos , Medicina de Família e Comunidade/normas , Padrões de Prática Médica/normas , Serviços de Saúde Rural/normas , Adolescente , Adulto , Asma/complicações , Asma/epidemiologia , Austrália/epidemiologia , Feminino , Humanos , Masculino , Morbidade , Avaliação de Resultados em Cuidados de Saúde , Prevalência , Qualidade da Assistência à Saúde , Insuficiência Respiratória/etiologiaRESUMO
Sexual harassment claims have increased substantially since 1990 and continue to be prominent in the Equal Employment Opportunity Commission's discrimination caseload. The authors surveyed high-level training and human resource practitioners in small, medium, and large health care organizations for suggestions to counter this trend. Three fourths of these professionals suggested that behavior modeling of strong policies combined with effective training helped. The survey results suggest seven preventive medicine strategies for reducing work-related sexual harassment incidents in health care organizations.
Assuntos
Política Organizacional , Gestão de Recursos Humanos/métodos , Assédio Sexual/prevenção & controle , Adulto , Coleta de Dados , Feminino , Pessoal de Saúde/educação , Humanos , Masculino , Desenvolvimento de Pessoal , Estados UnidosRESUMO
Undergraduate teaching of anaesthesia occurs in about two-thirds of Australian departments of anaesthesia: however, student contact hours are limited compared with those of other disciplines. Seventy-five directors of anaesthesia were surveyed by written questionnaire concerning the time devoted in their department to undergraduate study and teaching of practice/skills to undergraduate students (40 responded). One hundred and sixty final year students were surveyed regarding career choice, anaesthesia skills taught them and role models identified during their training (101 responded). Most final year students had been taught and had learnt the basic skills of life support such as bag and mask ventilation, cardiopulmonary resuscitation and intravenous cannulation. However, fewer were taught more specialized skills such as induction of anaesthesia and spinal anaesthesia. Positive role models in teaching anaesthetists were identified by 66% of students, more commonly if they were taught advanced skills, and were significantly associated with satisfaction with theoretical and practical training. For those students intending a career in anaesthesia (18%), 94% identified a positive role model compared to 65% who did not (P = 0.03).
Assuntos
Anestesiologia/educação , Escolha da Profissão , Educação de Graduação em Medicina , Papel do Médico , Humanos , Austrália do Sul , Inquéritos e QuestionáriosRESUMO
Thirty patients (17 females, median age 55 years) with mild/moderate hypertension (sitting diastolic blood pressure 95-110 mmHg over 2 consecutive weeks) participated in a study of the efficacy and tolerability of once-daily diltiazem "controlled delivery" 180 mg-360 mg and amlodipine 5-10 mg compared with placebo (using clinic and 24-h ambulatory blood pressure measurement (Accutraker II). The study was conducted in a general practice setting using a randomized double-blind crossover design with Latin square allocation of treatment order within subjects. During each phase, doses were titrated to achieve a predose clinic sitting diastolic blood pressure of 90 mmHg. Three patients withdrew while taking amlodipine and 3 while taking placebo. The numbers of patients receiving the higher dose in each phase were as follows: placebo 22, diltiazem 12 and amlodipine 19. End-of-phase mean clinic sitting blood pressures were as follows: placebo 152/100, diltiazem 146/95 and amlodipine 140/93. End-of-phase mean 24-h ambulatory blood pressures were as follows: placebo 151/93, diltiazem 143/86 and amlodipine 137/84. Both clinic and ambulatory blood pressures were therefore significantly reduced (p < 0.01) in both active phases compared with placebo, and systolic blood pressure was also significantly lower with amlodipine compared with diltiazem. Heart rate was increased with amlodipine. Both drugs were well tolerated, and adverse events were predictable for each agent, with amlodipine causing more vasodilator side effects. Thus both amlodipine and diltiazem once-daily are effective in reducing blood pressure. While amlodipine is more potent than diltiazem in reducing systolic blood pressure, it causes more vasodilator side effects.
Assuntos
Anlodipino/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Diltiazem/uso terapêutico , Eletrocardiografia Ambulatorial , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Adolescente , Adulto , Idoso , Anlodipino/efeitos adversos , Anti-Hipertensivos/efeitos adversos , Pressão Sanguínea/fisiologia , Bloqueadores dos Canais de Cálcio/efeitos adversos , Diltiazem/efeitos adversos , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Tamanho do Órgão/fisiologiaRESUMO
OBJECTIVE: To examine primary noncompliance in patients suffering with asthma. METHOD: A prospective matching of prescriptions written and then dispensed for patients with asthma. The subjects were patients who were given a general practitioner's prescription for asthma during a 3 month period (1993) in an isolated rural setting. RESULTS: During the period of the study, participating GPs documented 359 prescriptions and of these only 251 (70%) were dispensed by the pharmacies. Primary noncompliance was therefore 30%. The relative risk (RR) of mild asthmatics not filling their prescriptions is 0.81 (95% CI; 0.771 < RR < 0.92) when compared to severe asthma. Compared to patients of high socioeconomic status; patients of low and medium socioeconomic status have decreased relative odds of filling their prescriptions, that is, RR = 0.84 (95% CI; 0.71 < RR < 1.00). Gender and age had no bearing on primary compliance. CONCLUSIONS: Primary noncompliance is high in patients with asthma and is another factor contributing to morbidity. GPs should spend more time counselling patients on the need for treatment and not only its correct use. Patients with mild to moderate asthma and those in lower socioeconomic groups may need more intensive counselling.
Assuntos
Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Cooperação do Paciente , Feminino , Humanos , Masculino , Classe Social , Austrália do SulAssuntos
Hiperoxalúria Primária , Oxalato de Cálcio/metabolismo , Glioxilatos/metabolismo , Humanos , Hiperoxalúria Primária/diagnóstico , Hiperoxalúria Primária/genética , Hiperoxalúria Primária/metabolismo , Hiperoxalúria Primária/terapia , Fígado/enzimologia , Microcorpos/enzimologia , Mutação/genética , Oxalatos/metabolismo , Ácido Oxálico , Transaminases/genética , Transaminases/metabolismoRESUMO
One hundred and sixty seven (82%) of the 204 practising South Australian rural GP obstetricians responded to a questionnaire on training, skills and approach to high-risk obstetrics. The mean length of training was 8.5 months; 78% of GP obstetricians held a diploma. There was a mean of 13 years experience and 22 deliveries per year. However, 26.3% of practitioners had stopped obstetrics in the previous 12 months and cited indemnity insurance and lifestyle factors as the main reason for stopping. The GPs practised a wide range of skills; forceps (96%), Caesarean section (42%) and had good access to epidural services (83.6%), blood transfusions (91%) and specialist advice. High-risk obstetrics such as twin pregnancy, fetal growth retardation, insulin-dependent diabetes and preterm labour, are avoided by most rural GP obstetricians. The mean visual analogue comfort score for providing obstetric care was 7.46 (2.16) and correlated with length of training (p = 0.008) and number of deliveries per year (p = 0.02). Health authorities must continue to support and encourage country GP obstetricians to provide this essential service to rural women.
Assuntos
Serviços de Saúde Materna/estatística & dados numéricos , Obstetrícia , Médicos de Família/estatística & dados numéricos , Gravidez de Alto Risco , Atitude do Pessoal de Saúde , Competência Clínica/estatística & dados numéricos , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Seguro de Responsabilidade Civil , Imperícia , Obstetrícia/normas , Médicos de Família/normas , Gravidez , População Rural , Austrália do Sul , Recursos HumanosRESUMO
Primary hyperoxaluria type I (PHI) is a cause of end-stage renal disease in young people. It is caused by deficient activity of hepatic peroxisomal alanine:glyoxylate aminotransferase (AGT), which results in hyperoxalemia and hyperoxaluria. The consequent urolithiasis and nephrocalcinosis result in renal impairment, with further reduction in oxalate excretion and eventual systemic oxalosis. Historically, renal transplantation has yielded very poor results in these patients because of recurrent oxalosis of the graft. Within the last 10 years, combined hepatorenal transplantation has been successfully applied, simultaneously correcting the metabolic lesion in the liver and replacing the damaged kidneys. It has, however, become apparent that medical therapy with vigorous hydration, inhibitors of stone formation and pyridoxine (AGT co-factor), may be successful at delaying, and occasionally in preventing, urolithiasis in some hyperoxaluric patients, particularly those whose hyperoxaluria is reduced by pyridoxine. This, together with intensive perioperative management and modern surgical methods of stone management such as lithotripsy, laser or ultrasound stone fragmentation, and percutaneous nephrolithotomy, means that renal transplantation alone may be feasible in selected patients. We describe a patient with PHI with clinical and biochemical evidence of significant residual AGT activity who underwent a successful live-related renal transplantation with excellent renal function and no stone recurrence 1 year posttransplantation. The appropriate transplantation strategies for these complex patients are discussed and include isolated renal transplantation for those patients who are without significant systemic oxalosis and have evidence of residual AGT activity.
Assuntos
Hiperoxalúria Primária/cirurgia , Transplante de Rim , Adulto , Oxalato de Cálcio/metabolismo , Feminino , Humanos , Hiperoxalúria Primária/metabolismo , Hiperoxalúria Primária/patologia , Rim/metabolismo , Rim/patologiaRESUMO
The efficacy of epidural corticosteroids in the treatment of sciatica was investigated by meta-analysis of all randomized controlled trials. Eleven suitable trials of good quality were identified involving a total of 907 patients. The use of epidural (caudal or lumbar) steroid in the short-term (up to 60 days) increased the odds ratio (OR) of pain relief ( > 75% improvement) to 2.61 (95% CI 1.90-3.77) when compared with placebo. Despite some variations in trial characteristics there was little evidence of significant heterogeneity (P = 0.07). When the trials were analysed for near or total relief of pain in the short-term the OR is 2.79 (95% CI 1.92-4.06), for heterogeneity (P = 0.07). For longterm relief of pain (up to 12 months) the OR is 1.87 (95% CI 1.31-2.68). Efficacy is independent of the route of injection; for caudal epidural steroid the OR is 3.80 (95% CI 1.36-10.6) and for the lumbar epidural steroid 2.43 (95% CI 1.77-3.74). Adverse events included dural tap (2.5%), transient headache (2.3%) and a transient increase in pain (1.9%). There were no reported longterm adverse events. In conclusion we present quantitative evidence from meta-analysis of pooled data from randomized trials that epidural administration of corticosteroids is effective in the management of lumbosacral radicular pain.