RESUMO
BACKGROUND: Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), associated with morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite. OBJECTIVES: To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within ten minutes after birth in the delivery suite compared with routine thermal care. SEARCH STRATEGY: The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to July Week 4 2007 ), CINAHL (1982 to July Week 4 2007), EMBASE (1974 to 01/08/2007), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2007), conference/symposia proceedings using ZETOC (1993 to 17/08/2007), ISI proceedings (1990 to 17/08/2007) and OCLC WorldCat (July 2007). Identified articles were cross-referenced. No language restrictions were imposed. SELECTION CRITERIA: All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight =2500 g. DATA COLLECTION AND ANALYSIS: Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent review authors. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes. MAIN RESULTS: Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories:1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03), but not in infants between 28 to 31 week's gestation. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress kept infants =1500 g significantly warmer and reduced the incidence of hypothermia on admission to NICU(one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4). AUTHORS' CONCLUSIONS: Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.
Assuntos
Hipotermia/prevenção & controle , Recém-Nascido de Baixo Peso , Doenças do Prematuro/prevenção & controle , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Assistência Perinatal/métodos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
A 31-year-old primiparous, healthy woman presented for emergency caesarean section. Following the siting of a spinal anaesthetic, seconds after starting a phenylephrine infusion, she developed ventricular bigeminy. She reverted to sinus rhythm spontaneously when the phenylephrine infusion was stopped at delivery. The possible proarrhythmic and antiarrhythmic effects of phenylephrine are discussed. We suggest that this was most probably a stretch-induced ventricular arrhythmia due to increased ventricular afterload.
Assuntos
Anestesia Obstétrica , Raquianestesia , Arritmias Cardíacas/induzido quimicamente , Cesárea , Hipotensão/prevenção & controle , Complicações Intraoperatórias/induzido quimicamente , Fenilefrina/efeitos adversos , Vasoconstritores/efeitos adversos , Adulto , Feminino , Humanos , Fenilefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Disfunção Ventricular/induzido quimicamente , Disfunção Ventricular/fisiopatologiaRESUMO
BACKGROUND: Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), with associated morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite. OBJECTIVES: To assess efficacy and safety of interventions, designed for prevention of hypothermia in preterm and/or low birthweight infants, applied within 10 minutes after birth in the delivery suite compared with routine thermal care. SEARCH STRATEGY: The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to May Week 4 2004 ), CINAHL (1982 to May Week 4 2004), EMBASE (1974 to 09/07/04), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2004), conference/symposia proceedings using ZETOC (1993 to July 2004), ISI proceedings (1990 to 09/07/2004) and OCLC WorldCat (July 2004). Identified articles were cross-referenced. No language restrictions were imposed. SELECTION CRITERIA: All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight =2500 g. DATA COLLECTION AND ANALYSIS: Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent reviewers. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes. MAIN RESULTS: Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories: 1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and 2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03) but not in the 28 to 31 week group. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress significantly kept infants =1500 g warmer and reduced the incidence of hypothermia on admission to NICU (one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4). AUTHORS' CONCLUSIONS: Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.
Assuntos
Hipotermia/prevenção & controle , Recém-Nascido de Baixo Peso , Doenças do Prematuro/prevenção & controle , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Assistência Perinatal/métodos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Inadvertent intravascular, intrathecal or subdural injection in obstetric regional analgesia are potentially life-threatening, so following a catastrophic complication it was decided to collect data regionally. METHOD: Obstetric anaesthetists from 14, later 12 maternity units in the South West Thames Region collected and pooled data on obstetric anaesthetic interventions and complications from 1987 to 2003. RESULTS: During the 17-year period, 145,550 epidurals (26.3%) were administered to 553,905 mothers. The incidence of intravascular injection was 1 in 5,000 epidurals (0.02% [95%CI 0.014-0.029%]), of intrathecal injection 1 in 2,900 epidurals (0.035% [95%CI 0.027-0.046%]), of subdural injection 1 in 4,200 epidurals (0.024% [95%CI 0.017-0.033%]) and of high or total spinal block 1 in 16,200 epidurals (0.006% [95%CI 0.003-0.012%]). The incidence of serious complications did not change during the course of the study, nor was there any difference in the incidence of serious complications in obstetric units of different sizes or in obstetric units with different rates of epidural analgesia. CONCLUSION: The incidence of intravascular, intrathecal and subdural injection and of high or total spinal block was similar to that found in previous prospective studies in obstetric and non-obstetric patients. The incidence of these complications has not changed and is not related to the number of deliveries or the epidural rate in obstetric units.
Assuntos
Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Anestesia Epidural/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Feminino , Humanos , Incidência , Gravidez , Estudos ProspectivosRESUMO
A retrospective analysis has been performed of children who have undergone cardiac operations during the past 6 years to determine the clinical presentation and management of acute hepatic failure (AHF) in the postoperative period. Eleven patients had a clinical picture of AHF with jaundice, elevation of the levels of serum glutamic oxaloacetic transaminase (SGOT) and serum ammonia, and marked prolongation of the prothrombin time associated with failure of hemostasis. Hypoglycemia developed in seven. All patients had evidence of low cardiac output and acute renal failure. Patients with AHF had evidence of reduced hepatic perfusion during the previous 24 hours with reduced mean arterial pressure and elevated central venous pressure. Six children died of myocardial failure. A modified Fontan procedure was performed in six children, of whom four died. All had a right atrial pressure of 21 torr or greater. Five children survived the acute episode of hepatic failure. The importance of early diagnosis and effective management of complications such as hypoglycemia and the bleeding tendency are emphasized.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hepatopatias/etiologia , Doença Aguda , Adolescente , Adulto , Pressão Sanguínea , Baixo Débito Cardíaco/etiologia , Pressão Venosa Central , Criança , Pré-Escolar , Feminino , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Hipoglicemia/etiologia , Hipoglicemia/terapia , Lactente , Hepatopatias/diagnóstico , Hepatopatias/terapia , Testes de Função Hepática , Masculino , Cuidados Pós-Operatórios , Tempo de Protrombina , Estudos RetrospectivosRESUMO
A retrospective audit of obstetric epidurals was performed at Royal Surrey County Hospital. The aim was to determine the efficacy of epidural blood patch in the management of post-dural puncture headache following inadvertent dural puncture in the obstetric population, over a 5-year period between March 1993 and February 1998. During that time, there were 55 recognized dural punctures (overall incidence 0.96%). A total of 62 epidural blood patches were performed in 48 patients. Following treatment with one epidural blood patch, 33% of patients obtained complete and permanent relief, 50% partial relief and 12% no relief. Twenty-nine percent of patients required a second epidural blood patch of which 50% were completely successful, 36% were partially successful and 14% gave no relief.
RESUMO
Preoperative anxiety was assessed using the hospital anxiety and depression (HAD) scale, multiple affect adjective check list (MAACL) and linear analogue anxiety scale (LAAS) in 100 consecutive day case patients undergoing termination of pregnancy. The HAD scale, a recently introduced self assessment scale comprising 7 multiple choice questions, was readily accepted and easily understood by patients. There was a high degree of correlation between the HAD scale and both the MAACL (correlation coefficient 0.74) and the LAAS (correlation coefficient 0.67). There was only a moderate degree of correlation between the HAD scale and the anaesthetist's assessment of anxiety (correlation coefficient 0.46). The HAD scale is a useful method of subjective measurement of preoperative anxiety.
Assuntos
Ansiedade/diagnóstico , Testes Psicológicos , Procedimentos Cirúrgicos Operatórios/psicologia , Aborto Induzido/psicologia , Feminino , Humanos , Gravidez , Escalas de Graduação Psiquiátrica , Psicometria , Autoavaliação (Psicologia)RESUMO
We describe a one year old boy with meningococcaemia complicated by the adult respiratory distress syndrome. Maintenance of oxygenation required a positive end-expiratory pressure of 20 cm H2O. Resultant barotrauma produced pneumothorax and pneumomediastinum. Prompt recognition and treatment of this complication can reduce its high mortality rate.
Assuntos
Infecções Meningocócicas/complicações , Neisseria meningitidis , Síndrome do Desconforto Respiratório/etiologia , Sepse/complicações , Humanos , Lactente , Masculino , Enfisema Mediastínico/etiologia , Pneumotórax/etiologia , Respiração com Pressão Positiva/efeitos adversos , Síndrome do Desconforto Respiratório/terapiaRESUMO
Experience with childhood urinary tract infection is reviewed in conjunction with recent information on the management of the problem by family practitioners in the same health board. The need for bacteriological confirmation of the diagnosis in every case is confirmed and the importance of radiological investigation of the urinary tract after a first infection irrespective of age or sex is emphasised, as 17% of intravenous pyelograms and 31% of micturating cystogram examinations showed significant abnormality.
Assuntos
Infecções Urinárias/diagnóstico por imagem , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , UrografiaAssuntos
Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Fentanila/administração & dosagem , Dor/etiologia , Refrigeração , Método Duplo-Cego , Armazenamento de Medicamentos/métodos , Feminino , Humanos , Injeções Epidurais , Medição da Dor , Gravidez , Estudos ProspectivosRESUMO
BACKGROUND: Benchmarking is that process through which best practice is identified and continuous quality improvement pursued through comparison and sharing. The Vermont Oxford Neonatal Network (VON) is the largest international external reference centre for very low birth weight (VLBW) infants. This report from 2004-7 compares survival and morbidity throughout Ireland and benchmarks these results against VON. METHODS: A standardised VON database for VLBW infants was created in 14 participating centres across Ireland and Northern Ireland. RESULTS: Data on 716 babies were submitted in 2004, increasing to 796 babies in 2007, with centres caring for from 10 to 120 VLBW infants per year. In 2007, mortality rates in VLBW infants varied from 4% to 19%. Standardised mortality ratios indicate that the number of deaths observed was not significantly different from the number expected, based on the characteristics of infants treated. There was no difference in the incidence of severe intraventricular haemorrhage between all-Ireland and VON groups (5% vs 6%, respectively). All-Ireland rates for chronic lung disease (CLD; 15-21%) remained lower than rates seen in the VON group (24-28%). The rates of late onset nosocomial infection in the all-Ireland group (25-26%) remained double those in the VON group (12-13%). DISCUSSION: This is the first all-Ireland international benchmarking report in any medical specialty. Survival, severe intraventricular haemorrhage and CLD compare favourably with international standards, but rates of nosocomial infection in neonatal units are concerning. Benchmarking clinical outcomes is critical for quality improvement and informing decisions concerning neonatal intensive care service provision.