BACKGROUND: Dysfunction of the cough reflex as a result of the lingering effects of anaesthetics may lead to aspiration pneumonia or retained secretions after general anaesthesia. It is unknown whether low concentrations of propofol alter the cough reflex in the early period after anaesthesia. The objective of this study was to investigate the effect of low concentrations of propofol on the cough reflex sensitivity as assessed by the cough reflex threshold to an inhaled irritant. METHODS: Fifteen, ASA I-II, non-smoking patients undergoing elective colonoscopy were studied. Anaesthesia was induced and maintained with a blood target-controlled propofol infusion. Cough reflex threshold was measured with citric acid. Increasing concentrations of nebulized citric acid (2.5, 5, 10, 20, 40, 80, 160, 320, and 640 mg ml(-1)) were delivered during inspiration until a cough was evoked. The citric acid concentration eliciting one cough (C1) was defined as the cough reflex threshold. C1 was log transformed for statistical analysis (Log C1). Log C1 was measured before anaesthesia and during the recovery period with estimated decreasing propofol concentrations of 1.2, 0.9, 0.6, and 0.3 microg ml(-1). RESULTS: Log C1 (median; interquartile range) measured with propofol concentrations of 1.2, 0.9, 0.6, 0.3, and 0 microg ml(-1) were 1.9 (0.6), 1.9 (1.0), 1.9 (1.1), 1.9 (0.6), and 1.9 (0.7) mg ml(-1) (NS), respectively. However, light sedation was observed with propofol concentrations of 1.2 and 0.9 microg ml(-1). CONCLUSION: This study indicates that residual sedation after propofol anaesthesia for colonoscopy does not adversely affect the cough reflex.

Adult↗

PubMed2005

[Iliofascial block in prehospital for a quadriceps tendon rupture].

Explore the source record for details and available documents.

Adult↗

PubMed2004

Thiopental and isoflurane attenuate the decrease in hippocampal phosphorylated Focal Adhesion Kinase (pp125FAK) content induced by oxygen-glucose deprivation.

BACKGROUND: Thiopental and isoflurane exhibit neuroprotective effects against cerebral ischaemia. Here, we hypothesized that oxygen-glucose deprivation decreases the ATP-dependent phosphorylation process of Focal Adhesion Kinase (pp125FAK, a functionally important non-receptor tyrosine kinase), and that this phenomenon is attenuated by thiopental and isoflurane. METHODS: Rathippocampal slices were subjected to an anoxic-aglycaemic (or physiologic, control) challenge followed by 3-h reperfusion, and treated with various concentrations of thiopental and isoflurane. PP125FAK phosphorylation was measured by immunoblotting. Neuronal death was assessed by immunostaining with bis-benzimide. RESULTS: Significant neuronal death was detected after 30 min (but not 10) of anoxia-aglycaemia (40 (4) vs 14 (5)% of control, P<0.05). At 30 min, phosphorylated pp125FAK content was significantly decreased by anoxic glucose-free conditions (55 (27)% of control, P<0.05). This effect was markedly attenuated by thiopental (10 and 100 microM) and isoflurane (1 and 2%). Under control conditions, thiopental (1, 10, and 100 microM) and isoflurane (0.5, 1, and 2%) increased pp125FAK phosphorylation in a concentration-related fashion. This effect was blocked by chelerythrin and bisindolylmaleimide I and IX (10 microM, three structurally distinct inhibitors of protein kinase C, PKC) but not the N-methyl-D-aspartate (NMDA) receptor antagonist MK801 (10 microM). CONCLUSION: Phosphorylated pp125FAK content was markedly decreased in hippocampal slices subjected to oxygen-glucose deprivation. Thiopental and isoflurane significantly attenuated this phenomenon, possibly via PKC activation.

Adenosine Triphosphate↗

PubMed2004

Randomized clinical trial to assess the effect of an educational programme designed to improve nurses' assessment and recording of postoperative pain.

BACKGROUND: The aim of this study was to evaluate the impact of an intervention designed to improve postoperative pain assessment and recording by nurses. METHODS: This cluster randomized clinical trial included two intervals of 3 months each: a preintervention observational study (period 1) followed by a period of intervention (period 2). Six surgical wards were randomly assigned to receive either an experimental intervention, including educational seminars for nurses on pain, pain assessment and the use of a visual analogue scale (n = 3), or standard care (control group; n = 3). The main outcome measures were the percentage of patients in whom pain was assessed, number of pain assessments per patient and postoperative pain intensity scores. RESULTS: A total of 2278 patients were included. Significant improvements were found in the percentage of patients in whom pain was assessed and the number of daily pain assessments per patient in the intervention group between periods 1 and 2. In contrast, these outcomes were unchanged between the two intervals in wards randomized to standard care. During period 2, pain scores at 48 h were significantly decreased in the intervention wards compared with those in the control group. CONCLUSION: An educational programme dedicated to nurses strongly increased the use of regular pain assessment, and may have contributed to a modest improvement in postoperative analgesia.

Adolescent↗

PubMed2004

[Evaluation of the depth of sedation in neurocritical care: clinical scales, electrophysiological methods and BIS].

The primary goal of sedation is to achieve security and comfort of mechanically ventilated ICU patients. Delivery of pharmacologic agents must avoid over sedation, which increases morbidity by prolongation of the duration of mechanical ventilation. Similarly, under sedation may favour life-threatening events such as accidental extubation. Many clinical scales have been generated to regularly measure the level of sedation (consciousness and tolerance to the ICU environment). No electrophysiological monitor (BIS) has proved reliability for measuring the depth of sedation or analgesia yet. The presence of brain damage in ICU patients makes the level of sedation impossible to interpret. Glasgow coma scale, which is exclusively devoted to the consciousness domain, is the only recommendation that can be made in neurocritical care at the present time.

Craniocerebral Trauma↗

PubMed2003

Comparison between patient-controlled analgesia and subcutaneous morphine in elderly patients after total hip replacement.

BACKGROUND: The goal of this study was to evaluate the effectiveness on postoperative pain, and cognitive impact, of patient-controlled analgesia (PCA) compared with subcutaneous (s.c.) injections of morphine in elderly patients undergoing total hip replacement (THR). METHODS: Forty patients older than 70 yr were randomly assigned to two different postoperative analgesic techniques for 48 h: i.v. PCA morphine (dose, 1 mg; lockout interval, 8 min; PCA group) or regular s.c. morphine injections (SC group). Postoperative pain was assessed at rest and when moving, using a visual analogue scale (VAS) every 4 h. A Mini Mental Status (MMS) examination was used to assess cognitive functions before surgery, at 2 h, 24 h and 48 h after surgery, and at hospital discharge. Side-effects were also recorded systematically during the first 48 h after surgery. RESULTS: The PCA group showed significantly lower pain scores than the SC group both at rest and during mobilization. However, the clinical significance of pain scores was weak. There was no intergroup difference in postoperative MMS scores. The incidence of side-effects was similar in both groups. CONCLUSIONS: We conclude that in healthy elderly subjects undergoing THR, the flexibility of the analgesic regimen is more important than the route of administration with regard to efficacy, adverse effects and recovery of cognitive function.

Administration, Cutaneous↗

PubMed2002

Daily organ-system failure for diagnosis of persistent intra-abdominal sepsis after postoperative peritonitis.

OBJECTIVE: To evaluate the time-course of two organ failure scores (SOFA and Goris) after surgery for postoperative peritonitis in critically ill patients according to the persistence/nonpersistence of intraabdominal sepsis (IAS). DESIGN: Retrospective study. PATIENTS: Sixty-two consecutive patients (SAPSII = 38+/-14) admitted in the surgical ICU. METHODS: Patients were classified according to the persistence of IAS (IAS+, n=36) confirmed by a second laparotomy or the lack of IAS (IAS-, n=26) assessed by a favorable 30-day evolution without reintervention. Scores were calculated daily from day 0 preoperatively to postoperative day 5. RESULTS: In both groups, SOFA scores were higher on day 1 when compared to day 0 (8.3+/-3.1 vs 6.1+/-3.7 in the IAS+ group and 5.2+/-3.4 vs 2.7+/-2.7 in the IAS- group). In the IAS- patients, the SOFA score displayed a decrease starting on day 2 when compared to day 1 (4.4+/-3.6 vs 5.2+/-3.4, P=0.03). In contrast, in the IAS+ patients, the SOFA score remained unchanged until day 5. The time course of the Goris score was strictly similar to the SOFA scores. CONCLUSION: In critically ill patients with postoperative peritonitis, the postoperative time course of the SOFA and the Goris organ failure scores was different between patients with or without intra-abdominal persistent sepsis. The lack of improvement of one of these scores on postoperative day 2 may suggest persistent intraabdominal sepsis and supports the need for a new surgical exploration.

Analysis of Variance↗

PubMed2001

Reintubation after planned extubation in surgical ICU patients: a case-control study.

OBJECTIVES: Risk factors of reintubation were studied after planned extubation in a surgical ICU. METHODS: A retrospective case-control study was performed in patients ventilated more than 48 h. Case patients (CP; n=20) were those requiring reintubation within 72 h after planned extubation, and control patients ( n=20) were those successfully extubated. Controls were matched with CP for age, admission SAPS II, and duration of mechanical ventilation before extubation. RESULTS: CP had a significantly higher maximal respiratory rate during T tube trial and lower minimal SaO(2). More CP were treated with volume assist controlled (VAC) mode on the morning of extubation (60% vs. 25%). Multivariate analysis identified only VAC mode as an independent factor associated with reintubation. CP had longer ICU stay and a higher incidence of nosocomial pneumonia and tracheostomy. There was no difference in ICU mortality between CP and CTLP. CONCLUSIONS: The VAC mode of weaning of surgical ICU patients is associated with an increased incidence of reintubation and morbidity after planned extubation. This probably reflects the clinical condition of patients unable to tolerate pressure support.

Aged↗

PubMed2001

Effects of riluzole on N-methyl-D-aspartate-induced tyrosine phosphorylation in the rat hippocampus.

Since increased tyrosine phosphorylation has been observed in response to brain ischemia, we investigated whether riluzole (an inhibitor of glutamate neurotransmission with neuroprotective properties) affects tyrosine phosphorylation stimulated by N-methyl-D-aspartate (NMDA) in rat hippocampal slices. Riluzole produced an extremely potent concentration-related inhibition of NMDA (1 mM)-stimulated protein tyrosine phosphorylation (IC(50)=0.5+/-0.03 microM, mean+/-S.D.), but failed to affect that evoked by phorbol 12-myristate 13-acetate (PMA, an activator of protein kinase C, 0.1 and 1 microM). These results suggest that inhibition of tyrosine phosphorylation may contribute to the neuroprotective effects of riluzole against excitotoxic injury.

Animals↗

PubMed2001

Commentary. Balancing sedation and analgesia in the critically ill.

The authors have presented a template for a systematic approach to comforting critically ill patients that can be modified to suit institutional preferences. In this algorithm, the cause of patient discomfort is sought with the priority given to pain and then to anxiety. Special attention is directed to the identification of correctable causes of pain and anxiety with application of nonpharmacologic techniques or medications to control patient discomfort. This step is followed by subsequent reassessment of the need for sedation or anxiolysis and titration or discontinuation of therapy as able. The benefits of protocol-driven care are becoming increasingly evident, and the authors believe the algorithm outlined here provides a rational and practical approach to patient management. It also prompts the caregiver to reevaluate patients' needs and to keep to patients at target sedation levels. Doing so can promote cost effectiveness, reduce side effects caused by drugs, and decrease morbidity and ICU stay. Any treatment protocol or algorithm is simply a guide to therapy and cannot address every clinical situation. The importance of individualized care and physician or care team judgment must be emphasized.

Algorithms↗

PubMed2001

An outbreak of imipenem-resistant Acinetobacter baumannii in critically ill surgical patients.

OBJECTIVE: To describe an outbreak of imipenem-resistant Acinetobacter baumannii (IR-Ab) and the measures for its control, and to investigate risk factors for IR-Ab acquisition. DESIGN: An observational and a case-control study. SETTING: A surgical intensive care unit (ICU) in a university tertiary care hospital. METHODS: After admission to the ICU of an IR-Ab-positive patient, patients were prospectively screened for IR-Ab carriage upon admission and then once a week. Environmental cleaning and barrier safety measures were used for IR-Ab carriers. A case-control study was performed to identify factors associated with IR-Ab acquisition. Cases were patients who acquired IR-Ab. Controls were patients who were hospitalized in the ICU at the same time as cases and were exposed to IR-Ab for a similar duration as cases. The following variables were investigated as potential risk factors: baseline characteristics, scores for severity of illness and therapeutic intervention, presence and duration of invasive procedures, and antimicrobial administration. RESULTS: Beginning in May 1996, the outbreak involved 17 patients over 9 months, of whom 12 acquired IR-Ab (cases), 4 had IR-Ab isolates on admission to the ICU, and 1 could not be classified. Genotypic analysis identified two different IR-Ab isolates, responsible for three clusters. Ten of the 12 nosocomial cases developed infection. Control measures included reinforcement of barrier safety measures, limitation of the number of admissions, and thorough environmental cleaning. No new case was identified after January 1997. Eleven of the 12 cases could be compared to 19 controls. After adjustment for severity of illness, a high individual therapeutic intervention score appeared to be a risk factor for IR-Ab acquisition. CONCLUSION: The outbreak ended after strict application of control measures. Our results suggest that high work load contributes to IR-Ab acquisition.

Acinetobacter↗

PubMed2001

Predictive factors of early morphine requirements in the post-anaesthesia care unit (PACU).

Use of morphine by titration in the post-anaesthesia care unit (PACU) is often the first step in postoperative pain management. This approach provides rapid analgesia but shows a wide inter-individual variability in morphine requirements and may prolong patient stay in the PACU. The aim of this study was to identify the patient characteristics, surgical, anaesthetic, and postoperative factors predictive of early morphine requirements. The study included 149 patients undergoing various non-cardiac surgical procedures under general anaesthesia. In the multiple regression analysis of nine variables, only ethnicity (Caucasian), emergency surgery, major surgery, surgery exceeding 100 min, and pain score on arrival in PACU were predictive factors of morphine requirements. This observational study identifies for the first time independent predictive factors of morphine requirements in the early postoperative period. Future studies are warranted to evaluate the impact of intervention on these factors and any resulting improvement in postoperative pain treatment.

Adult↗

PubMed2001

The effects of FK506 on neurologic and histopathologic outcome after transient spinal cord ischemia induced by aortic cross-clamping in rats.

UNLABELLED: Spinal cord injury is a devastating complication of thoracoabdominal aortic surgery. We investigated the effect of the immunosuppressant FK506, a macrolide antibiotic demonstrated to have neuroprotective effects in cerebral ischemia models, in a rat model of transient spinal cord ischemia. Spinal cord ischemia was induced in anesthetized rats by using direct aortic arch plus left subclavian artery cross-clamping through a limited thoracotomy. Experimental groups were as follows: sham-operation; control, receiving only vehicle; FK506 A, receiving FK506 (1 mg/kg IV) before clamping; and FK506 B, receiving FK506 (1 mg/kg IV) at the onset of reperfusion. Neurologic status was assessed at 24 h and then daily up to 96 h with a 0 to 6 scale (0, normal function; 6, severe paraplegia). Rats were randomly killed at 24, 48, or 96 h, and spinal cords were harvested for histopathology. Physiologic variables did not differ significantly among experimental groups. All control rats suffered severe and definitive paraplegia. FK506-treated rats had significantly better neurologic outcome compared with control. Histopathologic analysis disclosed severe injury in the lumbar gray matter of all control rats, whereas most FK506-treated rats had less injury. These data suggest that FK506 can improve neurologic recovery and attenuate spinal cord injury induced by transient thoracic aortic cross-clamping. IMPLICATIONS: A single dose-injection of the immunosuppressant FK506 significantly improved neurologic outcome and attenuated spinal cord injury induced by transient thoracic aortic cross-clamping in the rat.

Animals↗

PubMed2001

The pharmacokinetics of cisatracurium in patients with acute respiratory distress syndrome.

UNLABELLED: Continuous neuromuscular blockade is often necessary in patients being treated for acute respiratory distress syndrome (ARDS) to optimize oxygenation. In this study, neuromuscular blockade (no response to two responses at the train-of-four stimulation at the orbicularis oculi muscle) was achieved in six patients with ARDS by a continuous infusion of cisatracurium. The plasma concentration of cisatracurium during the infusion averaged 1.00 (0.25-1.45) microg/mL, expressed as median (range). The clearance and half-life were 6.5 (3.3-7.6) mL. min(-1). kg(-1) and 25 (16-48) min, respectively. The laudanosine plasma concentrations were 0.70 (0.12-1.20) microg/mL. The pharmacokinetic variables of cisatracurium are similar to those of patients without organ failure undergoing elective surgery. Plasma laudanosine levels always remained well less that those associated with seizure activity in animal models. Long-term infusion of cisatracurium was not associated with any side effects. Cisatracurium is a suitable muscle relaxant when deep and continuous levels of muscle relaxation are required in patients treated for ARDS. IMPLICATIONS: We studied the pharmacokinetics of cisatracurium in six patients treated for respiratory distress syndrome by continuous muscle relaxation. A deep degree of neuromuscular blockade corresponding to abolition of two responses at the orbicularis oculi to train-of-four stimulation was obtained in all patients. The pharmacokinetic variables observed in these severely ill patients were similar to those of anesthetized patients. No accumulation of laudanosine was seen. Cisatracurium appears to be suitable when continuous muscle relaxation is required in critically ill patients.

Adult↗