Assuntos
Maternidades , Segurança do Paciente , Centros de Atenção Terciária , Humanos , Feminino , Gravidez , Cultura Organizacional , IrlandaRESUMO
The aim of our study was to determine if using the Epidrum to site epidurals improves success and reduces morbidity. Three hundred parturients requesting epidural analgesia for labour were enrolled. 150 subjects had their epidural sited using Epidrum and 150 using standard technique. We recorded subject demographics, operator experience, number of attempts, Accidental Dural Puncture rate, rate of failure to site epidural catheter, rate of failure of analgesia, Post Dural Puncture Headache and Epidural Blood Patch rates. Failure rate in Epidrum group was 9/150 (6%) vs 0 (0%) in the Control group (P = 0.003). There were four (2.66%) accidental dural punctures in the Epidrum group and none in the Control group (P = 0.060), and 2 epidurals out of 150 (1.33%) in Epidrum group were re-sited, versus 3/150 (2%) in the control group (P = 1.000). The results of our study do not suggest that using Epidrum improves success or reduces morbidity.
Assuntos
Analgesia Epidural , Analgésicos/administração & dosagem , Catéteres/efeitos adversos , Injeções Epidurais/instrumentação , Trabalho de Parto , Seringas/efeitos adversos , Adulto , Analgesia Epidural/efeitos adversos , Analgesia Epidural/métodos , Placa de Sangue Epidural/métodos , Espaço Epidural , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Humanos , Injeções Epidurais/métodos , Cefaleia Pós-Punção Dural/etiologia , Cefaleia Pós-Punção Dural/prevenção & controle , Gravidez , Resultado do TratamentoRESUMO
We present a randomised, controlled, crossover trial of the Caudwell Xtreme Everest (CXE) closed circuit breathing system vs an open circuit and ambient air control in six healthy, hypoxic volunteers at rest and exercise at Everest Base Camp, at 5300 m. Compared with control, arterial oxygen saturations were improved at rest with both circuits. There was no difference in the magnitude of this improvement as both circuits restored median (IQR [range]) saturation from 75%, (69.5-78.9 [68-80]%) to > 99.8% (p = 0.028). During exercise, the CXE closed circuit improved median (IQR [range]) saturation from a baseline of 70.8% (63.8-74.5 [57-76]%) to 98.8% (96.5-100 [95-100]%) vs the open circuit improvement to 87.5%, (84.1-88.6 [82-89]%; p = 0.028). These data demonstrate the inverse relationship between supply and demand with open circuits and suggest that ambulatory closed circuits may offer twin advantages of supplying higher inspired oxygen concentrations and/or economy of gas use for exercising hypoxic adults.
Assuntos
Exercício Físico , Montanhismo/fisiologia , Respiração , Adulto , Altitude , Estudos Cross-Over , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangueRESUMO
BACKGROUND: Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial. METHODS: Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 µg (S(M)) or saline (S(S)) and a postoperative bilateral TAP block with either bupivacaine (T(LA)) 2 mg kg(-1) or saline (T(S)). RESULTS: Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: S(M)T(LA) (20 mm)
Assuntos
Analgesia Obstétrica/métodos
, Analgésicos Opioides/administração & dosagem
, Cesárea
, Morfina/administração & dosagem
, Bloqueio Nervoso/métodos
, Dor Pós-Operatória/prevenção & controle
, Músculos Abdominais
, Adulto
, Analgesia Obstétrica/efeitos adversos
, Analgésicos Opioides/efeitos adversos
, Anestesia Obstétrica/métodos
, Raquianestesia
, Antieméticos/administração & dosagem
, Método Duplo-Cego
, Esquema de Medicação
, Feminino
, Humanos
, Morfina/efeitos adversos
, Bloqueio Nervoso/efeitos adversos
, Medição da Dor/métodos
, Satisfação do Paciente
, Gravidez
, Estudos Prospectivos
, Prurido/induzido quimicamente
RESUMO
We describe a unique ambulatory closed circuit for delivering high fractions of inspired oxygen to an exercising user who does not require isolation from their environment. We describe the major components and their function and suggest potential applications for such a circuit. This circuit may benefit patients who are chronically dependant on oxygen, are unable to exercise due to hypoxia, or require oxygen supplementation at high altitude.
Assuntos
Assistência Ambulatorial/métodos , Exercício Físico/fisiologia , Hipóxia/terapia , Oxigenoterapia/instrumentação , Desenho de Equipamento , Humanos , Hipóxia/fisiopatologia , Máscaras , Oxigenoterapia/métodosRESUMO
Inadvertent dural puncture is a recognised complication of epidural insertion. Parturients are at increased risk of developing a post-dural puncture headache, which can be debilitating for a mother caring for a newborn infant. Epidural blood patch is an effective treatment in patients presenting acutely with post-dural puncture headaches but its efficacy in those with delayed presentation or with late recurrent post-dural puncture headache is less clear. We present the case of a woman with a recurrent post-dural puncture headache who was successfully treated with an epidural blood patch 18â¯months after the initial dural puncture. Patients who develop post-dural puncture headaches may remain symptomatic for some time and an epidural blood patch may be beneficial, following appropriate investigation.
Assuntos
Placa de Sangue Epidural/métodos , Cefaleia Pós-Punção Dural/terapia , Adulto , Feminino , Humanos , Recidiva , Tempo , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVE: Massive post-partum haemorrhage continues to be one of the world's leading causes of maternal morbidity and mortality. Any new treatment that potentially helps at risk parturients should be thoroughly investigated. Recombinant factor VIIa (rVIIa) is increasingly being used in the treatment of massive haemorrhage. We performed a case-matched analysis of its use since 2003 in the treatment of massive post-partum haemorrhage at our hospital. METHODS: Twenty-eight cases of massive post-partum haemorrhage were identified over a 3-yr period since 2003. In six of these cases, rVIIa was used as part of their management. Six case-matched controls were sought. The six women with the greatest requirement for packed red cell transfusion who also had a deranged prothrombin time were included. The groups were then compared for differences. The worst prothrombin time in each group was noted as was the best prothrombin time within 6 h, this was used as our measure of response to treatment. RESULTS: There was no statistical difference in age, gestation, parity, transfusion requirements, mode of delivery or the severity of the coagulopathy between the two groups. In both groups the prothrombin time improved with management. There was no significant difference in either the magnitude of the improvement in the value of the prothrombin time or the absolute value of the best prothrombin time (P = 0.09). Five out of the six women in the rFVIIa group had normal or low prothrombin times within 6 h yet only one woman who did not receive rFVIIa had a normal prothrombin time within 6 h though this was not significant (P = 0.08). CONCLUSIONS: This case-matched analysis supports the management of massive post-partum haemorrhage with appropriate resuscitation, surgical intervention and use of blood and blood products. This study does not support the routine use of rFVIIa in the management of massive obstetric haemorrhage. rFVIIa may have a role to play in this management but further studies and analyses will be required.
Assuntos
Transfusão de Eritrócitos , Fator VIIa/uso terapêutico , Hemorragia Pós-Parto/tratamento farmacológico , Tempo de Protrombina , Adulto , Transfusão de Sangue , Estudos de Casos e Controles , Feminino , Humanos , Gravidez , Proteínas Recombinantes/uso terapêutico , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
We report the first known case of renal vein thrombosis (RVT) in a patient with IgA nephropathy. We discuss the possible significance of this finding in support of the concept that RVT is a complication of glomerular disease.
Assuntos
Glomerulonefrite/imunologia , Imunoglobulina A , Veias Renais , Trombose , Adulto , Glomerulonefrite/patologia , Humanos , MasculinoRESUMO
Reflux nephropathy was diagnosed in 23 patients (14 per cent of all the patients who received transplants) between 1973 and 1977, and nephrectomy was performed in all. Histology and immunofluorescence revealed a glomerular sclerosis associated with the idiopathic nephrotic syndrome. No focal and segmental glomerular sclerosis was seen in kidneys removed from patients with nonglomerular renal disease. Twenty-four hour urinary protein excretion in grams was 3.1 +/- 0.3 (mean +/- SEM) and was greater than that in our patients with end-stage nonglomerular renal disease. Thirty-one renal transplants were performed in these 23 patients; thereafter, maximum protein excretion was 1.4 g. Focal and segmental glomerular sclerosis was seen in only one (chronic rejection, protein excretion less than 0.5) of the 20 kidneys available for histologic study. Thus, focal and segmental glomerular sclerosis is extremely common in reflux nephropathy, accounts for "glomerular" proteinuria and may contribute importantly to progressive renal failure but, unlike that associated with the idiopathic nephrotic syndrome, rarely recurs after renal transplantation.
Assuntos
Glomerulonefrite/patologia , Glomerulosclerose Segmentar e Focal/patologia , Falência Renal Crônica/patologia , Glomérulos Renais/patologia , Refluxo Vesicoureteral/complicações , Adolescente , Adulto , Criança , Pré-Escolar , Glomerulosclerose Segmentar e Focal/complicações , Humanos , Falência Renal Crônica/cirurgia , Transplante de Rim , Pessoa de Meia-Idade , Síndrome Nefrótica/complicações , Síndrome Nefrótica/patologia , Proteinúria , Transplante HomólogoRESUMO
Immunohistologic studies in IgA nephropathy which have suggested activation of the alternative complement pathway prompted us to study serum complement components and control proteins in 28 patients with IgA nephropathy. Thirteen patients, 12 of whom were men, had or developed chronic renal failure (CRF) during 34 +/- 5 months of follow-up. These patients were more hypertensive and had heavier proteinuria than those with stable renal function. Their serum IgA concentrations were not different from patients with normal renal function. The prevalence of HLA antigens was similar to that for the reference population and BW35 was not associated with CRF. Serum C3, B, H and I concentrations in patients with stable normal renal function were higher than they were in patients with CRF. Four patients studied--two with normal renal function and two with CRF--had partial familial deficiencies of single complement proteins. Our data suggest that high serum levels of C3, B, H and I may be associated with stable normal glomerular filtration rate and that complement deficiencies are not infrequent in IgA nephropathy. How these findings relate to the pathogenesis and progression of IgA nephropathy requires further study. We also conclude that higher serum IgA concentrations and the presence of BW35 are not necessarily associated with progressive renal insufficiency in IgA nephropathy.
Assuntos
Proteínas do Sistema Complemento/análise , Glomerulonefrite/imunologia , Imunoglobulina A , Adulto , Biópsia , Complemento C3b/análise , Via Alternativa do Complemento , Feminino , Mesângio Glomerular/imunologia , Antígenos HLA/análise , Antígeno HLA-B35 , Humanos , Imunoglobulina A/análise , Rim/patologia , Falência Renal Crônica/imunologia , Masculino , Pessoa de Meia-IdadeRESUMO
Vesicoureteric reflux (VUR) into transplanted kidneys has been cited as an often disregarded but frequent complication of transplantation which is associated with a glomerular lesion that resembles membranoproliferative glomerulonephritis, marked proteinuria, and graft failure. To determine the prevalence of this complication in our transplant population, all of our 23 patients with marked proteinuria and 27 controls without proteinuria had voiding cystourethrograms performed approximately two years after transplantation. In our population, VUR was infrequent (8%). Moreover, in the three of the four cases detected renal function has not deteriorated and three of the four do not have marked proteinuria. We cannot confirm the suggestion that VUR is a frequent cause of late renal allograft failure.
Assuntos
Rejeição de Enxerto , Transplante de Rim , Complicações Pós-Operatórias , Refluxo Vesicoureteral/complicações , Adolescente , Adulto , Feminino , Glomerulonefrite/etiologia , Humanos , Glomérulos Renais/patologia , Masculino , Pessoa de Meia-Idade , Proteinúria/etiologia , Transplante HomólogoRESUMO
Cystic fibrosis affects 1 in 1600-2500 live births and is inherited in an autosomal recessive manner. It primarily involves the respiratory, gastrointestinal and reproductive tracts, with impaired clearance of, and obstruction by, increasingly viscous secretions. Severe respiratory disease, diabetes and gastro-oesophageal reflux may result. Improvements in medical management and survival of cystic fibrosis patients means more are committing to pregnancies. Although guidance for anaesthesia in this patient group is available, management and outcome data associated with more severe cases are sparse. Patients with severe cystic fibrosis require multidisciplinary input and should be managed in a tertiary referral centre. Close monitoring of respiratory function and preoperative optimisation during pregnancy are mandatory. The risk of preterm labour and delivery is increased. Pregnancy and delivery can be managed successfully, even in patients with FEV1 <40% predicted. Neuraxial anaesthesia and analgesia should be the technique of choice for delivery. Postoperative care should be carried out in a critical care setting with the provision of postoperative ventilation if necessary.
Assuntos
Anestesia Epidural/métodos , Anestesia Obstétrica/métodos , Raquianestesia/métodos , Fibrose Cística/fisiopatologia , Agonistas alfa-Adrenérgicos , Adulto , Anestésicos Locais , Bupivacaína , Cesárea/métodos , Epinefrina , Evolução Fatal , Feminino , Seguimentos , Humanos , Lidocaína , Gravidez , Complicações na Gravidez , Índice de Gravidade de Doença , Adulto JovemRESUMO
Idiopathic intracranial hypertension is important for the obstetric anaesthetist as it is mostly seen in obese women of childbearing age. The incidence is likely to increase as the obesity pandemic grows. Management of labour analgesia in these patients can be complex and requires multidisciplinary input. We successfully managed labour analgesia in a parturient with idiopathic intracranial hypertension with an intrathecal catheter. The possibility of using this catheter as a cerebrospinal fluid drain and pressure monitor was considered and is discussed along with potential complications.
Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Injeções Espinhais , Pseudotumor Cerebral/complicações , Pseudotumor Cerebral/terapia , Adulto , Anestésicos Locais/administração & dosagem , Placa de Sangue Epidural , Bupivacaína/administração & dosagem , Cateterismo , Catéteres , Feminino , Humanos , Obesidade Mórbida/complicações , Cefaleia Pós-Punção Dural/terapia , GravidezAssuntos
Diálise Peritoneal Ambulatorial Contínua , Adulto , Idoso , Complicações do Diabetes , Estudos de Avaliação como Assunto , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal Ambulatorial Contínua/efeitos adversos , Diálise Peritoneal Ambulatorial Contínua/mortalidade , Peritonite/epidemiologia , Peritonite/etiologia , Fatores de RiscoAssuntos
Hipersensibilidade a Drogas , Resistência à Insulina , Insulina/efeitos adversos , Clorpropamida/uso terapêutico , Diabetes Mellitus/dietoterapia , Diabetes Mellitus/tratamento farmacológico , Dispneia/induzido quimicamente , Feminino , Humanos , Pessoa de Meia-Idade , Urticária/induzido quimicamenteRESUMO
A new laryngoscope has been designed, incorporating an adjustable mirror and a levered tip similar to the McCoy blade, in an attempt to bridge the gulf between simple direct laryngoscopy and fiberoptic laryngoscopy. Manual in-line neck stabilisation was used to simulate difficult laryngoscopy in 14 anaesthetised patients after full neuromuscular blockade. The best view at laryngoscopy was assessed using a standard Macintosh laryngsocope, a size 3 McCoy laryngoscope and the mirrored laryngoscope. The best laryngeal view obtained in all cases with the Macintosh blade was a grade 3. The mirrored laryngoscope improved this view in 10 cases (71%) compared with five cases (36%) with the McCoy laryngoscope (p = 0.005); in seven cases (50%), the view improved to a grade 1 compared with no cases when the McCoy was used (p = 0.02). We conclude that the mirrored laryngoscope offers considerable advantages over the Macintosh and the McCoy laryngoscopes in simulated difficult laryngoscopy, is simple to use and requires no special training.
Assuntos
Laringoscópios , Anestesia Geral , Desenho de Equipamento , Humanos , Intubação Intratraqueal , Laringoscopia/métodosRESUMO
The diagnostic value of the measurement of quantitative proteinuria in patients with a creatinine clearance of less than 10 ml/min was determined in patients seen in a single center over a 5-year period. All 126 patients in whom a definitive renal diagnosis was possible were included. Patients with glomerular disease excreted 6.1 +/- 0.6 g/day and patients with interstitial disease 1.5 +/- 0.3 g/day (p less than 0.001). In individual patients with end-stage renal disease, however, measurement of urinary protein excretion excluded (with 95% confidence levels) patients with interstitial diseases only when greater than 2.9 g/day. To examine the natural history of proteinuria in progressive renal disease, urinary protein, absolute and factored for glomerular filtration rate (GFR; creatinine clearance), was determined at 10 ml/min decrements in GFR for patients with membranoproliferative glomerulonephritis, idiopathic membranous glomerulonephritis and focal glomerulosclerosis. Quantitative urinary protein excretion was relatively constant as GFR fell but did fall significantly at less than 10 ml/min but only to 4.8-7.0 g/day at even that level. Urinary protein excretion/GFR increased as GFR fell, particularly at end stage where a highly significant four-fold rise was seen; an increase also occurred in patients with primary interstitial disease. Similar data were obtained for 34 randomly selected patients after at least 1 year of chronic hemodialysis. Although a significant decline in absolute urinary protein excretion occurred during the year of dialysis to levels not different between glomerular and interstitial disease, urinary protein excretion/unit GFR remained elevated. Increased urinary protein excretion/unit GFR may result from a functional adaptation of remaining nephrons in response to declining renal mass.
Assuntos
Falência Renal Crônica/urina , Proteinúria/diagnóstico , Creatinina , Nefropatias Diabéticas/urina , Taxa de Filtração Glomerular , Glomerulonefrite/urina , Glomerulosclerose Segmentar e Focal/urina , Humanos , Nefrite Intersticial/urinaRESUMO
Morphometric data on glomerular size are presented on three patients with solitary functioning kidneys and one with bilateral oligomeganephronic hypoplasia. Renal biopsy of each of two patients with a congenitally absent kidney (unilateral renal agenesis) and a patient with oligomeganephronie, all with proteinuria and renal insufficiency, reveal increases of mean glomerular diameters of at least 1.75X and mean glomerular volumes greater than 5X. These dimensions, which are in the range of maximal increases recorded for man, are associated in all three biopsies with focal sclerosis of the hypertrophied glomeruli. By contrast, the functionally fully-compensated solitary kidney of a patient who lost function of the contralateral kidney from acquired disease, is characterized by the absence of focal glomerulosclerosis and by glomerular enlargement of significantly lesser degree (increased mean diameter 1.24X and mean volume less than 2X). These observations correlate glomerular injury with glomerular size and suggest that in the setting of reduced nephron numbers, nephron destruction via focal glomerulosclerosis may be initiated when compensatory glomerular hypertrophy has reached its limits.
Assuntos
Glomerulonefrite/fisiopatologia , Glomerulosclerose Segmentar e Focal/fisiopatologia , Glomérulos Renais/patologia , Adulto , Biópsia , Feminino , Glomerulosclerose Segmentar e Focal/patologia , Humanos , Hipertrofia , Rim/anormalidades , Masculino , Pessoa de Meia-Idade , Néfrons/patologiaRESUMO
IgA nephropathy (IgAN) has been assumed to develop sporadically in individuals. We review the recent clinical and laboratory evidence that supports a genetic influence in the immunopathogenesis in some patients. These data include (1) families with multiple members with the disease not sharing a known nephrotoxic factor, (2) clustering of the birthplaces of ancestors of large pedigrees with multiple affected members, suggesting a "founder effect," (3) DNA alleles and protein phenotypes associated with IgAN (or a clinical subset) in some patient populations or that cosegregate with the disease in families with multiple affected members, and (4) immunologic abnormalities of patients shared by relatives with renal disease. However, the lack of understanding the fundamental pathogenetic mechanisms hinders progress in the pursuit of genetically controlled process in this disease. Furthermore, the diagnosis requires a renal biopsy, and no therapy has been proven effective. Therefore, asymptomatic family members with IgAN may forego the invasive diagnostic procedure necessary to establish the diagnosis, and instances of familial disease may not be investigated. Nonetheless, the increasing awareness of families with multiple affected members offers an opportunity to investigate the hypothesized genetic influence in the pathogenesis of IgAN.