RESUMO
BACKGROUND: Hereditary transthyretin amyloidosis (ATTR) is usually characterised by a progressive peripheral and autonomic neuropathy often with associated cardiac failure and is due to dominantly inherited transthyretin mutations causing accelerated amyloid deposition. The UK population is unique in that the majority of patients have the T60A missense mutation in ATTR where tyrosine is replaced by adenine at position 60. This has been traced to a single founder mutation from north-west Ireland. The neuropathy phenotype is less well described than the cardiac manifestations in this group. METHODS: We present the findings from an observational cohort study of patients with ATTR attending the National Hospital Inherited Neuropathy Clinic between 2009 and 2013. Detailed clinical neurological and electrophysiological data were collected on all patients alongside correlating autonomic and cardiac assessments. Follow-up data were available on a subset. RESULTS: Forty-four patients with genetically confirmed ATTR were assessed; 37 were symptomatic; mean age at onset=62 years, range=38-75 years; 75.7% male. T60A was the most common mutation (17/37), followed by V30M (5/37). A severe, rapidly progressive, predominantly length dependent axonal sensorimotor neuropathy was the predominant phenotype. T60A patients were distinguished by earlier and more frequent association with carpal tunnel syndrome; a predominance of negative sensory symptoms at onset; significant vibration deficits; and a non-length dependent progression of motor deficit. Progression of the neuropathy was observed over a relatively short follow-up period (2 years) in 20 patients with evidence of clinically measurable annual change in Medical Research Council (MRC) sum score (-1.5 points per year) and Charcot Marie Tooth Neuropathy Score (CMTNS:2.7 points per year), and a congruent trend in the electrophysiological measures used. CONCLUSION: The description of the ATTR neuropathy phenotype, especially in the T60A patients, should aid early diagnosis as well as contribute to the understanding of its natural history.
Assuntos
Neuropatias Amiloides Familiares/diagnóstico , Doenças do Sistema Nervoso Periférico/diagnóstico , Adenina , Adulto , Idoso , Neuropatias Amiloides Familiares/genética , Neuropatias Amiloides Familiares/fisiopatologia , Estudos de Coortes , Análise Mutacional de DNA , Progressão da Doença , Feminino , Genes Dominantes , Humanos , Masculino , Pessoa de Meia-Idade , Mutação de Sentido Incorreto , Condução Nervosa/fisiologia , Exame Neurológico , Doenças do Sistema Nervoso Periférico/genética , Doenças do Sistema Nervoso Periférico/fisiopatologia , Fenótipo , Pré-Albumina/genética , Estudos Retrospectivos , Tirosina/genéticaRESUMO
BACKGROUND: Acute neuromuscular respiratory failure (NMRF) is a life-threatening feature of a variety of neurological conditions that can present in extremis prior to the establishment of a definitive diagnosis, so early clinical decision making is difficult. Population-based data on the frequency, outcome and aetiological spectrum are lacking. OBJECTIVE: To establish accurate epidemiological descriptive statistics in this patient group. METHODS: The regional Intensive Care National Audit and Research Centre (ICNARC) database was searched for patients admitted with acute NMRF from 1/1/2000 to 31/12/2010. Demographics, diagnosis, length of intensive care unit (ICU) stay, follow-up and outcome (modified Rankin score (mRS)) were recorded. A comparison dataset of all non-NMRF neurology patients admitted to ICU was obtained. RESULTS: 55 patients were identified; age 17-88 (median 66 years), M:F ratio 1:1.5, incidence rate (IR) 2.81 (2.12 to 3.66) cases per million person-years and mortality rate (MR) 0.26 (0.08 to 0.60) deaths per million person-years. Causes included inflammatory neuropathy (65%), myasthenia gravis (18%), rhabdomyolysis (2%) and amyotrophic lateral sclerosis (9%), and 5% were undiagnosed. Follow-up ranged from 0 to 7 years (median 500.5 days); long-term mRS 1 (range 0-6). NMRF patients were older (p<0.0001), had longer ICU stay (p<0.0001), but significantly better outcome (p<0.0001) than 93 non-NMRF neurology patients requiring ICU admission. CONCLUSION: Inflammatory and degenerative neuromuscular conditions can present in acute NMRF. Long-term outcome is good and MR is low, and significantly better than in other neurology patients requiring ICU admission despite longer ICU stay.
Assuntos
Esclerose Lateral Amiotrófica/epidemiologia , Miastenia Gravis/epidemiologia , Oxigenoterapia , Insuficiência Respiratória/epidemiologia , Rabdomiólise/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Esclerose Lateral Amiotrófica/complicações , Esclerose Lateral Amiotrófica/mortalidade , Esclerose Lateral Amiotrófica/terapia , Cuidados Críticos/métodos , Bases de Dados Factuais , Tomada de Decisões , Avaliação da Deficiência , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Miastenia Gravis/complicações , Miastenia Gravis/mortalidade , Miastenia Gravis/terapia , Irlanda do Norte/epidemiologia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/terapia , Rabdomiólise/complicações , Rabdomiólise/mortalidade , Rabdomiólise/terapiaRESUMO
BACKGROUND: Healthcare development in the UK has resulted in an increase in neurologists working in district general hospitals. METHODS: The aim of the study was to determine the use of a neurologist for inpatient diagnosis and management, and to measure a neurologist's diagnostic reliability in a district general hospital over a 27-month period. Patient data were prospectively recorded. Follow-up was performed independently by two clinicians reviewing the medical notes. Reasons for diagnostic change were determined. RESULTS: 306 inpatients were referred to the neurologist between 1 January 2007 and 31 March 2009 (2% of medical admissions). Mean (SD) age was 49.3 (18.8) years, and the female/male ratio was 1.2:1. Epilepsy and stroke were the most common diagnoses. Diagnostic concordance between referring physician and neurologist ranged from κ score 0.13 (spinal pathology) to 0.83 (central nervous system infection). Neurological opinion resulted in diagnostic change in 38.2% and management change in 88.8%. Only 1.6% of patients remained without a diagnosis, a fourfold improvement from physician referral. After medical records had been reviewed, 3.3% of inpatient diagnoses (10 of 306 patients) changed from the original diagnosis by the neurologist. Specialist investigation helped in revising diagnoses in four of the 10 diagnostic changes. CONCLUSION: This study shows that in a district general hospital a neurologist can contribute to inpatient diagnosis and management with minimal diagnostic change over time, suggesting reliability of this service.
Assuntos
Técnicas de Diagnóstico Neurológico , Departamentos Hospitalares , Hospitais de Distrito , Hospitais Gerais , Doenças do Sistema Nervoso/diagnóstico , Neurologia , Adulto , Idoso , Feminino , Seguimentos , Necessidades e Demandas de Serviços de Saúde , Departamentos Hospitalares/organização & administração , Hospitais de Distrito/organização & administração , Hospitais Gerais/organização & administração , Humanos , Pacientes Internados , Masculino , Serviços de Saúde Mental/organização & administração , Pessoa de Meia-Idade , Neurologia/organização & administração , Estudos Prospectivos , Encaminhamento e Consulta , Reino Unido , Recursos HumanosRESUMO
BACKGROUND: Assessment centres are an accepted method of recruitment in industry and are gaining popularity within medicine. We describe the development and validation of a selection centre for recruitment to speciality training in anaesthesia based on an assessment centre model incorporating the rating of candidate's non-technical skills. METHODS: Expert consensus identified non-technical skills suitable for assessment at the point of selection. Four stations-structured interview, portfolio review, presentation, and simulation-were developed, the latter two being realistic scenarios of work-related tasks. Evaluation of the selection centre focused on applicant and assessor feedback ratings, inter-rater agreement, and internal consistency reliability coefficients. Predictive validity was sought via correlations of selection centre scores with subsequent workplace-based ratings of appointed trainees. RESULTS: Two hundred and twenty-four candidates were assessed over two consecutive annual recruitment rounds; 68 were appointed and followed up during training. Candidates and assessors demonstrated strong approval of the selection centre with more than 70% of ratings 'good' or 'excellent'. Mean inter-rater agreement coefficients ranged from 0.62 to 0.77 and internal consistency reliability of the selection centre score was high (Cronbach's α=0.88-0.91). The overall selection centre score was a good predictor of workplace performance during the first year of appointment. CONCLUSIONS: An assessment centre model based on the rating of non-technical skills can produce a reliable and valid selection tool for recruitment to speciality training in anaesthesia. Early results on predictive validity are encouraging and justify further development and evaluation.
Assuntos
Anestesiologia/educação , Competência Clínica , Educação de Pós-Graduação em Medicina/métodos , Seleção de Pessoal/métodos , Avaliação Educacional/métodos , Inglaterra , Humanos , Simulação de Paciente , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Pre-treatment screening for IgA deficiency and close monitoring of full blood count(FBC) and renal function is recommended with intravenous immunoglobulin(IVIg) therapy in neurological diseases. AIMS: To examine the frequency of biochemically defined and clinically significant episodes of treatment associated haemolysis, neutropenia, thrombocytopenia and acute kidney injury(AKI) in a cohort of patients on maintenance Immunoglobulin(Ig) therapy for inflammatory neuropathy. METHODS: A retrospective review of routine blood monitoring in patients from two UK specialist peripheral nerve centres. Accepted definitions for clinically and biochemically significant haemolysis, neutropenia, thrombocytopenia and AKI were used. RESULTS: 1919 infusion episodes in 90 patients were analysed. Age(mean(S.D))â¯=â¯58.09(14.4)years, 63% male, 72% CIDP(28% MMN), 97% IVIg(3% SCIg). Doseâ¯=â¯1.57(0.79)g/kg/month or 97.1(37.3)g/infusion, frequency:3.9(1.4) weeks. Relative IgA deficiency was noted in 2 individuals (prevalence:2.2%, 95%C.I.:0-5.2) who received a combined total of 38 infusions(3800â¯g IVIg) without adverse event. No clinically significant episodes of haemolysis, neutropenia, thrombocytopenia or AKI occurred in relation to treatment. An asymptomatic drop>10â¯g/L haemoglobin(Hb) occurred in 3.5%(95%CI:2.7-4.3) of treatment episodes in 38 individuals, mean reduction:17.7(7.4)g/L; lowest Hb:86â¯g/L. Lower pre-treatment haemoglobin correlated with risk of recurrent Ig-related drop(p:0.007). Two patients with chronic renal failure(stage 1 and 3) received 28(IV) and 104(SC) infusions respectively(6416â¯g) without impact on estimated glomerular filtration rate(eGFR). CONCLUSIONS: No clinically significant Ig-related episodes of haemolysis or AKI were identified in this representative cohort. This suggests that routine monitoring is not essential in long-term Ig use but should be considered when clinically indicated.
Assuntos
Monitoramento de Medicamentos/métodos , Imunoglobulinas Intravenosas/sangue , Imunoglobulinas Intravenosas/uso terapêutico , Polirradiculoneuropatia Desmielinizante Inflamatória Crônica/sangue , Polirradiculoneuropatia Desmielinizante Inflamatória Crônica/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Monitoramento de Medicamentos/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polirradiculoneuropatia/sangue , Polirradiculoneuropatia/diagnóstico , Polirradiculoneuropatia/tratamento farmacológico , Polirradiculoneuropatia Desmielinizante Inflamatória Crônica/diagnóstico , Estudos Retrospectivos , Adulto JovemRESUMO
Here we describe a patient with genetically confirmed ATTR, a family history of the disease and histological confirmation following carpal tunnel release surgery but no other manifestations. The first major neurological or systemic manifestation was cauda equina syndrome with ATTR deposits contributing to lumbar spinal stenosis. Recent gene therapy trials showed improvement in the neuropathy in TTR amyloidosis. This case highlights the need for awareness of the heterogeneous neurological phenotype seen in ATTR to aid earlier diagnosis especially now that disease modifying therapies are available.
Assuntos
Neuropatias Amiloides Familiares/complicações , Estenose Espinal/etiologia , Adulto , Síndrome do Túnel Carpal/etiologia , Feminino , Humanos , Região Lombossacral , Pessoa de Meia-IdadeRESUMO
In 2020, the ESA ExoMars and NASA Mars 2020 missions will be launched to Mars to search for evidence of past and present life. In preparation for these missions, terrestrial analog samples of rock formations on Mars are studied in detail in order to optimize the scientific information that the analytical instrumentation will return. Desert varnishes are thin mineral coatings found on rocks in arid and semi-arid environments on Earth that are recognized as analog samples. During the formation of desert varnishes (which takes many hundreds of years), organic matter is incorporated, and microorganisms may also play an active role in the formation process. During this study, four complementary analytical techniques proposed for Mars missions (X-ray diffraction [XRD], Raman spectroscopy, elemental analysis, and pyrolysis-gas chromatography-mass spectrometry [Py-GC-MS]) were used to interrogate samples of desert varnish and describe their capacity to sustain life under extreme scenarios. For the first time, both the geochemistry and the organic compounds associated with desert varnish are described with the use of identical sets of samples. XRD and Raman spectroscopy measurements were used to nondestructively interrogate the mineralogy of the samples. In addition, the use of Raman spectroscopy instruments enabled the detection of ß-carotene, a highly Raman-active biomarker. The content and the nature of the organic material in the samples were further investigated with elemental analysis and methylated Py-GC-MS, and a bacterial origin was determined to be likely. In the context of planetary exploration, we describe the habitable nature of desert varnish based on the biogeochemical composition of the samples. Possible interference of the geological substrate on the detectability of pyrolysis products is also suggested. Key Words: Desert varnish-Habitability-Raman spectroscopy-Py-GC-MS-XRD-ExoMars-Planetary science. Astrobiology 17, 1123-1137.
Assuntos
Clima Desértico , Exobiologia/métodos , Marte , Minerais/análise , Pintura/análise , Planeta Terra , Exobiologia/instrumentação , Cromatografia Gasosa-Espectrometria de Massas/instrumentação , Cromatografia Gasosa-Espectrometria de Massas/métodos , Minerais/química , Voo Espacial , Análise Espectral Raman/instrumentação , Análise Espectral Raman/métodos , Difração de Raios X/instrumentação , Difração de Raios X/métodosRESUMO
Hereditary transthyretin amyloidosis (ATTR) is a genetically and clinically heterogeneous disease manifesting with predominant peripheral and autonomic neuropathy; cardiomyopathy, or both. ATTR V122I is the most common variant associated with non-neuropathic familial amyloid cardiomyopathy. We present an unusual case of V122I amyloidosis with features of amyloid neuropathy and myopathy, supported by histological confirmation in both sites and diffuse tracer uptake on (99m)Tc-3,3-Diphosphono-1,2-Propanodicarboxylic acid (DPD) scintigraphy throughout skeletal and cardiac muscle. A 64 year old Jamaican man presented with cardiac failure. Cardiac MR revealed infiltrative cardiomyopathy; abdominal fat aspirate confirmed the presence of amyloid, and he was homozygous for the V122I variant of transthyretin. He also described general weakness and EMG demonstrated myopathic features. Sural nerve and vastus lateralis biopsy showed TTR amyloid. The patient is being treated with diflunisal, an oral TTR stabilising agent. Symptomatic myopathy and neuropathy with confirmation of tissue amyloid deposition has not previously been described. Extracardiac amyloidosis has implications for diagnosis and treatment.
Assuntos
Neuropatias Amiloides Familiares/patologia , Neuropatias Amiloides Familiares/fisiopatologia , Cardiopatias/complicações , Neuropatias Amiloides Familiares/complicações , Cardiopatias/patologia , Cardiopatias/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/patologia , Miocárdio/patologia , Doenças do Sistema Nervoso Periférico/complicações , Doenças do Sistema Nervoso Periférico/diagnósticoRESUMO
OBJECTIVE: This study sought to determine the efficacy of post-operative wound infiltration with local anaesthetic following paediatric appendicectomy. METHOD: In a randomised, controlled, prospective, clinical trial children aged between five and sixteen years were assigned to one of three treatment arms; infiltration of the surgical wound with bupivicaine, saline, or no infiltration. Anaesthetic and analgesic protocols were employed. Patients and observers were blinded to the treatment group. The primary end-points were post-operative pain, scored at intervals during the first twenty post-operative hours, and additional post-operative analgesic requirements beyond that which was provided by a standard protocol. In addition, adverse wound outcomes were recorded. RESULTS: Eighty-eight children were recruited. There were no differences in age, sex or other confounding variables between groups. There was no significant difference in mean pain scores or analgesic requirements between groups through-out the post-operative period. CONCLUSION: Wound infiltration with local anaesthetic following appendicectomy in children provides no additional benefit over regular simple analgesia. Its routine use represents dogmatic practise which ought to be challenged for this patient group.
Assuntos
Anestesia Local , Anestésicos Locais , Apendicectomia , Bupivacaína , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Medição da Dor , Dor Pós-Operatória , Cuidados Pós-Operatórios , Estudos ProspectivosAssuntos
Antibacterianos , Ácido Fusídico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Rabdomiólise/induzido quimicamente , Idoso , Contraindicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infecção da Ferida Cirúrgica/tratamento farmacológico , Resultado do Tratamento , Infecções Urinárias/tratamento farmacológicoRESUMO
The presence of reserve nitrous oxide cylinders on anaesthetic machines is not necessary and potentially hazardous, wasteful and polluting. Although reserve nitrous oxide cylinders are routinely present on the anaesthetic machines in many hospitals in the UK, it is our concern that they are not checked or maintained properly. We examined a sample of cylinders and surveyed the practice amongst the anaesthetic staff in our Department with an anonymous questionnaire. This confirmed that: (1) the equipment is not properly maintained, 68% of cylinders sampled having passed a 3-year expiry date; (2) checks are of little practical use, are not routinely performed by anaesthetists, and only 46% of respondents routinely check the nitrous oxide cylinders. In conclusion, the nitrous oxide cylinders are not properly checked or maintained and may represent a safety hazard.
Assuntos
Anestesia por Inalação/instrumentação , Anestésicos Inalatórios , Óxido Nitroso , Atitude do Pessoal de Saúde , Embalagem de Medicamentos , Armazenamento de Medicamentos/normas , Humanos , Gestão da Segurança/normas , Inquéritos e QuestionáriosRESUMO
Improvements in anaesthesia have led to the introduction of rapid-acting agents which quicken recovery and decrease sleepiness. Whether parents believe a rapid postanaesthetic recovery is an advantage is unknown. Therefore, we evaluated the parental perceptions, expectations and preferences for the postanaesthetic recovery of children. One hundred and three parents of children having ambulatory surgery completed a structured questionnaire and the results of 101 are presented. Results indicate that 93% of parents expect their child to be sleepy after surgery. Seventy-four per cent of parents indicated they would prefer their child to be sleepy or tired in the first 24 h postoperatively. Eight-five percent of parents would not be upset if their child's discharge was delayed up to three hours because their child was too sleepy. Finally 45.5% of parents are extremely concerned about their child experiencing postoperative pain and 68% believe that their child would be in more pain if they recovered rapidly from the anaesthetic. These results indicate that rapid recovery from anaesthesia and quick discharge from hospital are not key expectations of parents of children admitted for day surgery. Parents associate a rapid recovery with more pain. Parents need to be more fully informed of the advantages of a rapid recovery and reassured that children can recover quickly and completely but at the same time be comfortable postanaesthetic.
Assuntos
Período de Recuperação da Anestesia , Atitude , Pais/psicologia , Procedimentos Cirúrgicos Ambulatórios , Criança , Humanos , Dor Pós-Operatória , Alta do Paciente , Fases do Sono , Inquéritos e Questionários , Fatores de TempoRESUMO
To determine whether the incidence of masseter muscle rigidity is affected by the anaesthetic induction sequence, we prospectively studied for ten months the anaesthetic course in 5,641 infants and children who received muscle relaxation to facilitate tracheal intubation. The anaesthetic induction sequence consisted of intravenous sodium thiopentone (STP) 5 mg.kg-1 alone, halothane induction alone 1-4%, or halothane followed by STP. Inhalational inductions with halothane included nitrous oxide and oxygen. Tracheal intubation was facilitated by either intravenous succinylcholine (Sch) at least 1.5 mg.kg-1 or by a non-depolarizing muscle relaxant. The induction sequence and all episodes of MMR were recorded. Ninety percent of the patients received Sch and 10% received a non-depolarising agent. Of those who received Sch, 88% (5,064 patients) were anaesthetised with STP and 12% (607 patients) were anaesthetised with halothane alone or halothane followed by STP. Masseter muscle rigidity was defined clinically by the transient inability to distract the mandible from the maxilla such that the mouth could not be opened or could only be opened with force. No children anaesthetised with STP followed by Sch developed MMR. One child (0.9%) developed MMR after halothane and Sch and two developed MMR after halothane, STP and Sch (0.4%). The incidence of MMR after Sch was less with STP than with halothane alone or with halothane and STP (P < 0.025). The peak CPK values in the three children who developed MMR were 17,580 IU.L-1 after halothane and Sch, and 7,280 IU.-1 and 3,273 IU.-1 after halothane, STP and Sch. There was no evidence of MH reactions in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Músculo Masseter/efeitos dos fármacos , Rigidez Muscular/induzido quimicamente , Succinilcolina/efeitos adversos , Anestesia por Inalação , Anestesia Intravenosa , Criança , Pré-Escolar , Interações Medicamentosas , Halotano/administração & dosagem , Halotano/farmacologia , Humanos , Incidência , Lactente , Intubação Intratraqueal , Hipertermia Maligna/etiologia , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Óxido Nitroso/administração & dosagem , Estudos Prospectivos , Tiopental/administração & dosagem , Tiopental/farmacologiaRESUMO
This study compared the effectiveness and side-effects of intra-operative fentanyl with fentanyl and morphine for elective adenotonsillectomy in a double-blind study, in 60 children randomly allocated to receive either intravenous fentanyl 1 microg x kg(-1) intra-operatively or intramuscular morphine 100 microg x kg(-1) at induction. All children received a standard anaesthetic induction with intravenous fentanyl 1 microg x kg(-1) and propofol 4-5 mg x kg(-1) and maintenance with oxygen, nitrous oxide and isoflurane. Pain scores, emetic episodes and supplemental morphine requirements were recorded for 24 h postoperatively. The overall incidence of postoperative vomiting was high in both groups: 70% in the fentanyl group and 78% in the morphine group. The incidence of postoperative vomiting was lower in the fentanyl group (p < 0.03) in the first 4 h, but similar by 24 h. Children who received morphine at any time in the first 24 h had more median (range) episodes of vomiting [2 (0-7)] than children receiving fentanyl only [l (0-3); p < 0.03]. Administration of rescue anti-emetics, pain scores in recovery and pain scores over the next 24 h were similar between the two groups.
Assuntos
Adenoidectomia , Analgésicos Opioides/uso terapêutico , Fentanila/uso terapêutico , Morfina/uso terapêutico , Dor Pós-Operatória/prevenção & controle , Tonsilectomia , Adolescente , Analgésicos Opioides/efeitos adversos , Antieméticos/uso terapêutico , Criança , Pré-Escolar , Método Duplo-Cego , Feminino , Fentanila/efeitos adversos , Humanos , Masculino , Morfina/efeitos adversos , Medição da Dor/métodos , Náusea e Vômito Pós-Operatórios/induzido quimicamenteRESUMO
It is common practice at the Hospital for Sick Children, Toronto, to administer atropine 20 micrograms.kg-1 prior to succinylcholine in infants and children. It is unclear whether "prophylactic" administration of this dose of atropine to older children (6-16 yr) is necessary. This study was designed to compare the changes in heart rate, rhythm and mean arterial pressure after administration of either atropine 10 or 20 micrograms.kg-1 with succinylcholine or vecuronium (control group) to older children anaesthetized with thiopentone. Thirty-six ASA I or II patients (6-16 yr) were studied. Anaesthesia was induced with thiopentone 5 mg.kg-1. Patients were randomly assigned to receive: (a) atropine 10 micrograms.kg-1 and succinylcholine 1.5 mg.kg-1 (n = 12), (b) atropine 20 micrograms.kg-1 and succinylcholine 1.5 mg.kg-1 (n = 13) or (c) vecuronium 0.1 mg.kg-1 (n = 11) to facilitate tracheal intubation. Heart rate and rhythm were recorded continuously using a computerised analogue interface whereas blood pressure was monitored non-invasively before induction of anaesthesia, immediately before and at one and three minutes after laryngoscopy. No difference was observed between patients who received atropine 10 or 20 micrograms.kg-1 prior to succinylcholine. No episode of sinus bradycardia occurred. Premature atrial contractions were observed in two patients (one succinylcholine/atropine 20 micrograms.kg-1, one vecuronium). Administration of atropine 20 micrograms.kg-1 prior to succinylcholine provides no advantage over atropine 10 micrograms.kg-1 in older children in terms of cardiovascular stability.
Assuntos
Anestesia Intravenosa , Atropina/administração & dosagem , Succinilcolina/administração & dosagem , Adolescente , Arritmia Sinusal/induzido quimicamente , Função Atrial/efeitos dos fármacos , Atropina/farmacologia , Pressão Sanguínea/efeitos dos fármacos , Bradicardia/induzido quimicamente , Complexos Cardíacos Prematuros/induzido quimicamente , Criança , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Lactente , Intubação Intratraqueal , Laringoscopia , Masculino , Succinilcolina/farmacologia , Tiopental/administração & dosagem , Brometo de Vecurônio/administração & dosagem , Brometo de Vecurônio/farmacologiaRESUMO
Dimenhydrinate, an H1-receptor antagonist, has been used to both prevent and treat postoperative vomiting (POV) in children for several decades. However, its effectiveness for POV after strabismus surgery remains anecdotal. This study was designed to determine the effectiveness and side effects of dimenhydrinate for the prevention of POV in children after strabismus surgery. Eighty ASA physical status I or II children, ages 1-12 yr inclusive, who were undergoing strabismus surgery, were prospectively and randomly allocated to receive either dimenhydrinate 0.5 mg/kg intravenously (n = 40) or placebo (n = 40) at induction of anesthesia. The incidence of POV and the times to arousal (and discharge from the recovery room and hospital) were recorded postoperatively in a double blinded manner. For 24 h after discharge from the hospital, all emetic episodes and medications given were recorded by the parents. Demographic data did not differ between the groups. Children who received dimenhydrinate had significantly less POV both inhospital (10%) and overall (30%) than those who received placebo (in-hospital 38%, P < 0.008; overall 65%, P < 0.003). The times to arousal and discharge from the hospital did not differ between the two groups. Dimenhydrinate (0.5 mg/kg) is an effective, safe, and inexpensive antiemetic in children undergoing strabismus surgery. It significantly reduces the incidence of vomiting for 24 h postoperatively and is not associated with prolonged sedation or other adverse effects.
Assuntos
Antieméticos/uso terapêutico , Dimenidrinato/uso terapêutico , Estrabismo/cirurgia , Vômito/prevenção & controle , Criança , Pré-Escolar , Humanos , Lactente , Fatores de TempoRESUMO
To determine the incidence of malignant hyperthermia (MH) reactions after trigger-free anaesthesia in a large population of MH-susceptible (MHS) patients, the charts of 2,214 patients who underwent elective muscle biopsy for malignant hyperthermia were reviewed. Either general or regional anaesthesia with non-triggering drugs was used. For general anaesthesia, the trachea was intubated in the absence of muscle relaxants. The halothane/caffeine contracture test was performed on the biopsied muscle. Suspected MH reactions were identified according to their site of occurrence (in the operating room, recovery room or ward). Ninety-seven percent of patients received a general anaesthetic; 3% received a regional anaesthetic or field block. Of the 2214 patients whose muscles were biopsied, 1082 patients were biopsy-positive for MH. Five patients in whom MH reactions were diagnosed in the recovery room were all subsequently proved to be biopsy-positive for MH. Four of the five received intravenous dantrolene as part of their therapy; the fifth received only symptomatic therapy as parenteral dantrolene was not commercially available. All patients recovered completely from their reactions. We conclude that the incidence of MH reactions in biopsy-positive patients who receive a trigger-free anaesthetic for minor surgery is small (0.46%, (0.15-1.07%, 95% CI)). These reactions occur in the immediate postoperative period.
Assuntos
Biópsia , Hipertermia Maligna/epidemiologia , Músculo Esquelético/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Período de Recuperação da Anestesia , Anestesia por Condução , Anestesia Geral , Cafeína , Criança , Pré-Escolar , Contratura/diagnóstico , Dantroleno/uso terapêutico , Suscetibilidade a Doenças , Halotano , Humanos , Incidência , Lactente , Complicações Intraoperatórias , Hipertermia Maligna/diagnóstico , Hipertermia Maligna/tratamento farmacológico , Pessoa de Meia-Idade , Bloqueio Nervoso , Estudos RetrospectivosRESUMO
PURPOSE: Epidural infusions of fentanyl (2 micrograms.ml-1) alone or combined with bupivacaine 0.125% were compared for perioperative analgesia, motor block and other side-effects in children who underwent urological surgery. METHODS: In a prospective, double-blind study, 42 children, ASA I-II, 1-16 yr, were randomly allocated to receive either epidural F (fentanyl bolus 2 micrograms.kg-1 in 0.5 ml.kg-1 saline followed by 2 micrograms.ml-1 fentanyl infusion) or epidural F-B (fentanyl bolus 2 micrograms.kg-1 in 0.5 ml.kg-1 bupivacaine 0.25% followed by 2 micrograms.ml-1 fentanyl infusion in bupivacaine 0.125%) after induction of general anaesthesia. Adequacy of analgesia, lower limb motor block and side-effects were assessed four hourly postoperatively. RESULTS: Both infusion regimens provided excellent analgesia (median objective pain scores = 0). Epidural infusion rates were similar in the F (0.29 +/- 0.07 ml.kg-1.hr-1) and F-B (0.26 +/- 0.05 ml.kg-1.hr-1) groups. Three children in the F group and all children in the F-B group developed lower limb weakness. (P < 0.05) Bromage scores were different in the F group (median 0, range 0-0.66) compared with the F-B group (median 0.33, range 0-1) (P < 0.001). Other side-effects did not differ. CONCLUSION: Postoperative epidural fentanyl infusion provides equipotent analgesia to administration of a solution including both fentanyl and bupivacaine 0.125% and causes less lower limb weakness. No reduction in the fentanyl requirement resulted from the addition of bupivacaine 0.125%.
Assuntos
Analgesia Epidural , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Fentanila/administração & dosagem , Neurônios Motores/efeitos dos fármacos , Debilidade Muscular/induzido quimicamente , Bloqueio Nervoso , Adolescente , Criança , Pré-Escolar , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Lactente , Injeções Epidurais , Perna (Membro)/inervação , Masculino , Medição da Dor , Estudos Prospectivos , Procedimentos Cirúrgicos UrogenitaisRESUMO
PURPOSE: To investigate the efficacy of a subhypnotic dose of propofol to treat vomiting in children after adenotonsillectomy. METHODS: Two hundred and fifty-two children, aged 2-12 yr, underwent a standardized anaesthetic opioid administration, and postoperative care after adenotonsillectomy, adenoidectomy or tonsillectomy. A prospective, double-blinded, placebo-controlled study was performed in 70 of the patients who retched or vomited after surgery and who had intravenous access. Patients were assigned randomly to receive either 0.2 mg.kg-1) propofol (n = 35), or placebo (intralipid 10%, n = 35). RESULTS: The overall incidence of vomiting during the first 18-24 hr was 50%. Of those who had received propofol after the first episode of vomiting, 63% relapsed requiring a rescue antiemetic compared with 57% of those who had received intralipid (P = NS). Of the children who received propofol, 54% experienced pain on injection and 46% were mildly sedated compared with 3% and 11%, respectively, in the placebo group (P < 0.003). CONCLUSION: We conclude that an intravenous bolus of 0.2 mg.kg-1 propofolis not effective in the treatment of postoperative vomiting in children after adenotonsillectomy when a standardized anaesthetic with thiopentone, halothane, nitrous oxide, and 1.5 mg.kg-1 codeine phosphate is used, but it does cause sedation and pain on injection.