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Biomedical subjects

Jean-Jacques Eledjam

Publications and source records attributed to Jean-Jacques Eledjam.

At least 19 recordsLinked to original sources
PubMed2006

Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients.

RATIONALE: Critically ill patients are predisposed to oxyhemoglobin desaturation during intubation. OBJECTIVES: To find out whether noninvasive ventilation (NIV), as a preoxygenation method, is more effective at reducing arterial oxyhemoglobin desaturation than usual preoxygenation during orotracheal intubation in hypoxemic, critically ill patients. METHODS: Prospective randomized study performed in two surgical/medical intensive care units (ICUs). Preoxygenation was performed, before a rapid sequence intubation, for a 3-min period using a nonrebreather bag-valve mask (control group) or pressure support ventilation delivered by an ICU ventilator through a face mask (NIV group) according to the randomization. MEASUREMENTS AND MAIN RESULTS: The control (n = 26) and NIV (n = 27) groups were similar in terms of age, disease severity, diagnosis at admission, and pulse oxymetry values (Sp(O(2))) before preoxygenation. At the end of preoxygenation, Sp(O(2)) was higher in the NIV group as compared with the control group (98 +/- 2 vs. 93 +/- 6%, p < 0.001). During the intubation procedure, the lower Sp(O(2)) values were observed in the control group (81 +/- 15 vs. 93 +/- 8%, p < 0.001). Twelve (46%) patients in the control group and two (7%) in the NIV group had an Sp(O(2)) below 80% (p < 0.01). Five minutes after intubation, Sp(O(2)) values were still better in the NIV group as compared with the control group (98 +/- 2 vs. 94 +/- 6%, p < 0.01). Regurgitations (n = 3; 6%) and new infiltrates on post-procedure chest X ray (n = 4; 8%) were observed with no significant difference between groups. CONCLUSION: For the intubation of hypoxemic patients, preoxygenation using NIV is more effective at reducing arterial oxyhemoglobin desaturation than the usual method.

Aged↗
PubMed2006

Performance characteristics of five new anesthesia ventilators and four intensive care ventilators in pressure-support mode: a comparative bench study.

BACKGROUND: During the past few years, many manufacturers have introduced new modes of ventilation in anesthesia ventilators, especially partial-pressure modalities. The current bench test study was designed to compare triggering and pressurization of five new anesthesia ventilators with four intensive care unit ventilators. METHODS: Ventilators were connected to a two-compartment lung model. One compartment was driven by an intensive care unit ventilator to mimic "patient" inspiratory effort, whereas the other was connected to the tested ventilator. The settings of ventilators were positive end-expiratory pressures of 0 and 5 cm H2O, and pressure-support ventilation levels of 10, 15, and 20 cm H2O with normal and high "patient" inspiratory effort. For the anesthesia ventilators, all the measurements were obtained for a low (1 l/min) and a high (10 l/min) fresh gas flow. Triggering delay, triggering workload, and pressurization at 300 and 500 ms were analyzed. RESULTS: For the five tested anesthesia ventilators, the pressure-support ventilation modality functioned correctly. For inspiratory triggering, the three most recent anesthesia machines (Fabius, Drägerwerk AG, Lübeck, Germany; Primus, Drägerwerk AG; and Avance, GE-Datex-Ohemda, Munchen, Germany) had a triggering delay of less than 100 ms, which is considered clinically satisfactory and is comparable to intensive care unit machines. The use of positive end-expiratory pressure modified the quality of delivered pressure support for two anesthesia ventilators (Kion, Siemens AG, Munich, Germany; and Felix, Taema, Antony, France). Three of the five anesthesia ventilators exhibited pressure-support ventilation performance characteristics comparable to those of the intensive care unit machines. Increasing fresh gas flow (1 to 10 l/min) in the internal circuit did not influence the pressure-support ventilation performance of the anesthesia ventilators. CONCLUSION: Regarding trigger sensitivity and the system's ability to meet inspiratory flow during pressure-supported breaths, the most recent anesthesia ventilators have comparable performances of recent-generation intensive care unit ventilators.

Anesthesia, Inhalation↗
PubMed2006

Impact of systematic evaluation of pain and agitation in an intensive care unit.

OBJECTIVE: To measure the impact of implementation of the systematic evaluation of pain and agitation by nurses using the Behavioral Pain Scale (BPS), the Numerical Rating Scale (NRS) for pain, and the Richmond Agitation Sedation Scale (RASS) associated with medical staff education in analgesia and sedation management in intensive care unit (ICU) patients. DESIGN: Two-phase, prospective, controlled study. SETTING: Twelve-bed medical-surgical ICU in a university hospital. PATIENTS: Consecutive patients staying >24 hrs in ICU. INTERVENTIONS: BPS, NRS, and RASS were measured twice daily, at rest, by independent observers during 21 wks (control group) and after 4 wks of training, by nurses during 29 wks (intervention group). In the intervention group, the treating physician was alerted in case of pain defined by BPS>5 or NRS>3 or in case of agitation defined by RASS>1. MEASUREMENTS AND MAIN RESULTS: A total of 230 patients were included (control group, n=100; intervention group, n=130). Baseline characteristics were not significantly different. The incidence of pain and agitation decreased significantly in the intervention group: 63% vs. 42% (p=.002) and 29% vs. 12% (p=.002), respectively. Rate of severe pain and agitation events defined by NRS>6 and RASS>2, respectively, also decreased significantly. There were significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs. Compared with the control group, there was a marked decrease in the duration of mechanical ventilation (120 [interquartile range 48-312] vs. 65 (24-192) hrs, p=.01) and nosocomial infections rate (17% vs. 8%, p<.05) in the intervention group. There was no significant difference in median length of stay (9 [4, 15] vs. 7 [4, 13] days) and mortality in ICU (12 vs. 15%). CONCLUSIONS: Systematic evaluation of pain and agitation, and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation, duration of mechanical ventilation and nosocomial infections.

Aged↗
PubMed2006

Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study.

OBJECTIVES: To describe the current practice of physicians, to report complications associated with endotracheal intubation (ETI) performed in THE intensive care unit (ICU), and to isolate predictive factors of immediate life-threatening complications. DESIGN: Multiple-center observational study. SETTING: Seven intensive care units of two university hospitals. PATIENTS: : We evaluated 253 occurrences of ETI in 220 patients. INTERVENTIONS: From January 1 to June 30, 2003, data related to all ETI performed in ICU were collected. Information regarding patient descriptors, procedures, and immediate complications were analyzed. MEASUREMENTS AND MAIN RESULTS: The main indications to intubate the trachea were acute respiratory failure, shock, and coma. Some 148 ETIs (59%) were performed by residents. At least one severe complication occurred in 71 ETIs (28%): severe hypoxemia (26%), hemodynamic collapse (25%), and cardiac arrest (2%). The other complications were difficult intubation (12%), cardiac arrhythmia (10%), esophageal intubation (5%), and aspiration (2%). Presence of acute respiratory failure and the presence of shock as an indication for ETI were identified as independent risk factors for occurrence of complications, and ETI performed by a junior physician supervised by a senior (i.e., two operators) was identified as a protective factor for the occurrence of complications. CONCLUSIONS: ETI in ICU patients is associated with a high rate of immediate and severe life-threatening complications. Independent risk factors of complication occurrence were presence of acute respiratory failure and presence of shock as an indication for ETI. Further studies should aim to better define protocols for intubation in critically ill patients to make this procedure safer.

Aged↗
PubMed2005

Noninvasive positive pressure ventilation in patients with respiratory failure due to severe acute pancreatitis.

BACKGROUND: Patients with acute pancreatitis (AP) who require mechanical ventilation have high morbidity and mortality rates. Noninvasive positive pressure ventilation (NPPV) delivered through a mask has become increasingly popular for the treatment of acute respiratory failure (ARF) and may limit some mechanical ventilation complications. OBJECTIVES: The purpose of this retrospective, observational study was to evaluate our clinical experience with the use of NPPV in AP patients with ARF. METHODS: From 1997 to 2003, we documented clinical data, gas exchange and outcome of the 62 AP patients admitted to our intensive care unit. Patients who benefited from NPPV (success) were compared with those who failed (intubated). RESULTS: Twenty-nine patients were intubated at admission and 5 did not develop ARF. Of the 28 patients treated with NPPV, 15 were not intubated (54%). Both groups had a similar PaO(2)/FiO(2) ratio (142 +/- 21 vs. 133 +/- 20; p = 0.127) and severity of illness (Ranson and Balthazar scores). Presence of atelectasis, bilateral alveolar infiltrates and abdominal distension were associated with failure of NPPV. Oxygenation improved and respiratory rate decreased significantly only in the success group. Additionally, the length of stay at the intensive care unit was significantly lower in the success group. CONCLUSION: NPPV is feasible and safe to treat ARF in selected patients with AP who require ventilatory support.

Abdomen↗
PubMed2005

Effects of short vs. prolonged mechanical ventilation on antioxidant systems in piglet diaphragm.

OBJECTIVE: Prolonged controlled mechanical ventilation (MV) is known to induce diaphragmatic oxidative stress that seems to be an important factor reducing force-generating capacity. To better understand the cellular mechanisms involved, this work examined the effect of short vs. prolonged MV on antioxidant defense in the diaphragm. DESIGN AND SETTING: Prospective, randomized, controlled animal study in a university laboratory. METHODS: Eleven piglets (15-20 kg) were assigned to one of two groups: a long-MV group (n=6) ventilated for 3 days or a short-MV group (n=5) ventilated for 3 h. Force frequency curves of the transdiaphragmatic pressure (Pdi) were obtained in vivo by phrenic nerve pacing. Oxidative stress was evaluated by thiobarbituric reactive substance (TBARs) content and the enzymatic antioxidant activity of both superoxide dismutase (SOD) and glutathione peroxidase (GPx) in samples of diaphragm. RESULTS: Pdi decreased in the long-MV group by 30-35% over the 3 days at all frequencies compared to the short-MV group. Diaphragm TBARs content was significantly higher and SOD activity lower in long-MV animals than in short-MV animals after 72 h. GPx activity tended to be lower in diaphragms from long-MV animals, but this difference was not significant. CONCLUSIONS: This study shows that 3 days of MV in piglets is associated with a decrease in antioxidant activity which could emphasize oxidative stress and both contribute to the diaphragm dysfunction caused by MV.

Animals↗
PubMed2005

Volume-guaranteed pressure-support ventilation facing acute changes in ventilatory demand.

OBJECTIVE: To compare volume support ventilation (VSV) in which the pressure support level is continuously adjusted to deliver a preset tidal volume, with pressure support ventilation (PSV), in terms of patient behavior and ventilator response when ventilatory demand was increased by addition of dead space to the circuit. DESIGN AND SETTING: Randomized cross-over study in an intensive care unit university hospital. INTERVENTIONS: We assessed in ten patients being weaned off mechanical ventilation the effect of increasing the ventilatory demand by adding a heat-and-moisture exchanger to augment the dead space with a fixed level of PSV and VSV. MEASUREMENTS AND RESULTS: Arterial blood gases, breathing pattern, and respiratory effort parameters at the end of each of the four steps. Adding dead space significantly increased minute ventilation and PaCO2 values with both PSV and VSV. Indexes of respiratory effort (pressure-time index of respiratory muscles and work of breathing) increased with both ventilatory modes after dead-space augmentation. This increase was 2.5-4 times with VSV than with PSV and induced overt respiratory distress in two patients. The assistance delivered during VSV decreased significantly after dead-space augmentation, from 15.0+/-6.5 to 9.1+/-4.8 cmH2O, whereas no change occurred with PSV. CONCLUSIONS: With a fixed level of VSV, but not of PSV, an increase in ventilatory demand results in a decrease in the pressure support provided by the ventilator, opposite to the desired response. VSV may conceivably result in respiratory distress in clinical settings.

APACHE↗
PubMed2005

Are preoperative patterns of alcohol consumption predictive of relapse after liver transplantation for alcoholic liver disease?

Predictive factors for alcoholic relapse after liver transplantation (LT) performed for alcoholic liver disease (ALD) have been assessed in numerous studies, often with contradictory results. The aim of the study was to assess pretransplantation alcohol consumption characteristics on alcoholic relapse after LT. Patients transplanted for ALD for at least 6 months were included. An anonymous questionnaire assessed socio-demographic characteristics, medical history, and alcohol consumption before and after LT. Relapse was defined as any alcohol use after LT. Severe relapse was defined by heavy drinking: more than 21 units/week for males and 14 units/week for females. A total of 61 patients were studied. The mean follow up after LT was 49 +/- 34 months. Alcoholic relapse occurred in 32 of 61 patients (52%) and severe relapse in eight of 61 patients (13%). Risk factors for severe relapse were: length of abstinence before LT (P = 0.0001), more than one alcohol withdrawal before LT (P = 0.001), alcohol dependence (P = 0.05), alcohol abuse in first relatives (P = 0.05), and younger age (P = 0.05). Information on previous alcohol consumption (dependence, number of withdrawals, family history) helps to predict severe relapse after LT in patients with ALD, allowing early awareness and specific postoperative care.

Alcohol Drinking↗
PubMed2005

Cytomegalovirus infection in critically ill patients: associated factors and consequences.

OBJECTIVE: To determine the prevalence, associated findings, and consequences of cytomegalovirus (CMV) antigenemia in critically ill patients. DESIGN: A retrospective, case-control clinical study. SETTING: A 12-bed university hospital medical-surgical ICU. PATIENTS: Two hundred thirty-seven patients with fever for > 72 h, without proven evidence of bacteriologic and/or fungal origin, and whose pp65 antigenemia assays were studied. Patients with HIV infection and transplant recipients were excluded. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: CMV antigenemia was diagnosed within 20 +/- 12 days (mean +/- SD) after ICU admission in 17% patients in whom the pathology was suspected. The 40 patients in the CMV group were matched with 40 other patients in the control group. CMV infection was linked to renal failure (58% vs 33%, respectively; p = 0.02) and steroid use (55% vs 33%, respectively; p = 0.04). Patients with CMV had a significantly longer stay in the ICU (41 +/- 28 days vs 31 +/- 22 days, respectively; p = 0.04), a longer duration of mechanical ventilation (35 +/- 27 days vs 24 +/- 20 days, respectively; p = 0.03), a higher rate of nosocomial infection (75% vs 50%, respectively; p = 0.04), and a higher mortality (50% vs 28%, p = 0.02). CONCLUSIONS: CMV antigenemia is not an uncommon diagnosis in critically ill ICU patients with unexplained prolonged fever after 10 days of hospitalization, regardless of their immune system status. Although associated with a higher morbidity and mortality, the clinical significance of CMV is unknown. Further prospective studies should evaluate the impact on ICU outcome and whether CMV is truly a pathogen or simply another indicator of immunosuppression.

Adult↗
PubMed2005

Outcomes of patients with acute respiratory failure after abdominal surgery treated with noninvasive positive pressure ventilation.

OBJECTIVES: Little is known about the physiologic and clinical effects of noninvasive positive pressure ventilation (NPPV) in patients who have acute respiratory failure (ARF) after abdominal surgery. We evaluated our clinical experience with the use of NPPV in the treatment of ARF after abdominal surgery. METHODS: We prospectively evaluated NPPV use during a 2-year period in a medical-surgical ICU of a university hospital. We documented demographic and diagnostic data, gas exchange, and clinical outcomes. We compared patients who were not intubated to those who were intubated after a trial of NPPV. RESULTS: Of 72 patients with ARF after abdominal surgery who were treated with NPPV, 48 patients avoided intubation (67%). Patients in the intubated and nonintubated groups had similar demographic characteristics, and similar American Society of Anesthesiologists physical status and simplified acute physiology score II scores at admission. The intubated group had a significantly lower Pa(O2)/fraction of inspired oxygen (Fi(O2)) ratio (123 +/- 62 mm Hg vs 194 +/- 76 mm Hg, p < 0.01) and more extended bilateral alveolar infiltrates (67% vs 31%, p < 0.01) than the non-intubated group. Within the first NPPV observation period, the Pa(O2)/Fi(O2) increased (+ 36 +/- 29% [+/- SD], p = 0.04) and the respiratory rate decreased (28.2 +/- 3.4 breaths/min vs 23.1 +/- 3.8 breaths/min, p < 0.01) significantly only in the non-intubated group. The non-intubated group had significantly lower length of ICU stay (17.3 +/- 10.9 days vs 34.1 +/- 28.5 days, p < 0.01) and mortality rate (6% vs 29%, p < 0.01). CONCLUSION: NPPV may be an alternative to conventional ventilation in selected patients with ARF after abdominal surgery who require ventilatory support.

Abdomen↗
PubMed2005

A prospective study of agitation in a medical-surgical ICU: incidence, risk factors, and outcomes.

STUDY OBJECTIVES: Although agitation is thought to be common in the ICU, it has been poorly studied. We evaluated the incidence, risks factors, and outcomes of agitation in ICU. DESIGN: Prospective observational study. INTERVENTIONS: None. METHOD: All consecutive ICU admissions over an 8-month period were analyzed. MEASUREMENTS AND RESULTS: Two hundred eleven patients were admitted a total of 216 times during the period of the study. Twenty-nine patients were excluded from the study because their pathology findings did not allow an evaluation of their level of consciousness; 182 patients were actually enrolled. Agitation developed in 95 of 182 patients (52%). Agitation began 4.4 +/- 5.6 days (+/- SD) after admission to the ICU and lasted 3.9 +/- 4.1 days. Patients with agitation had a higher Simplified Acute Physiology Score II on ICU admission than those who did not have agitation (40 +/- 16 vs 33 +/- 13, p < 0.01). By stepwise logistic regression, the independent risks factors for development of agitation included psychoactive drug use at the time of ICU admission (odds ratio, 5.63; 95% confidence interval [CI], 1.32 to 23.70), history of alcohol abuse (odds ratio, 3.32; 95% CI, 1.12 to 10.00), dysnatremia (odds ratio, 4.95; 95% CI, 1.95 to 12.54), fever (odds ratio, 4.52; 95% CI, 1.80 to 11.49), use of sedatives in the ICU (odds ratio, 4.03; 95% CI, 1.62 to 10.40), and sepsis (odds ratio, 2.61; 95% CI, 1.03 to 6.58). Agitation was associated with a prolonged ICU stay (16 +/- 19 days vs 6 +/- 6 days, p = 0.0001), nosocomial infections (34% vs 7%, p < 0.0001), unplanned extubations (17% vs 2%, p = 0.003), and unplanned central venous catheter removal (16% vs 1%, p = 0.001), but not with mortality (12% in the agitation group vs 8% in patients without agitation). CONCLUSIONS: Agitation is a common event in a mixed medical-surgical ICU. It is associated with adverse outcomes including prolonged stay, nosocomial infections, and unplanned extubations. A better knowledge of incidence and risk factors should facilitate identification of patients at risk and decrease the incidence of agitation.

Documentation↗
PubMed2005

Patient-controlled analgesia.

Using a portable infusion pump, intravenous opioid patient-controlled analgesia (PCA) permits a patient to self-deliver a small bolus of opioid to achieve prompt relief without over sedation. Use of PCA for pain management is increasing in hospitals, largely because it can provide equivalent or better analgesia than conventional nurse-administered opioid analgesia, and patients are more satisfied with its use. There is no decisive pharmacological or clinical argument for the choice of one opioid rather than another. Thus, morphine remains the most frequently used opioid in PCA. The adjunction of non-opioid drugs to morphine in the PCA reservoir is still very controversial. A new investigational PCA transdermal system using iontophoresis to deliver fentanyl seems to provide an adequate pain control with the advantages of needle-free, preprogrammed, self-contained device. Whatever drug or device used, the overall success of the PCA technique relies mainly on the expert supervision of nurses or anesthesiologists in an Acute Pain Service. Indeed, PCA is effective and significant only on the condition that there is careful preoperative patient education and strict postoperative monitoring. In addition, preoperative patient selection allows to exclude patients with evidence of cognitive dysfunction or physical disabilities, making the use of the patient-controlled device impossible. Caution is required among patients with respiratory or renal insufficiency. In the future, the indispensable improvement in the management of postoperative pain should lead to a greater expansion of PCA. However, more pharmaco-economic evaluations will be needed on the cost-effectiveness issue.

Analgesia, Patient-Controlled↗
PubMed2004

Ophthalmic regional anesthesia: medial canthus episcleral (sub-tenon) single injection block.

BACKGROUND: The purpose of this study was to evaluate the efficacy and safety of episcleral single-injection anesthesia in a large number of patients. METHODS: Over a period of 5 yr, in four institutions, anesthesiologists involved in this prospective study completed a standardized form to evaluate single-injection medial canthus high-volume episcleral anesthesia. The success rate of the block was rated according to an akinesia score. The study parameters included demographic data, surgical procedure, and anesthetic management. All patients were followed up at least until postoperative day 1, and all complications, pain, and discomfort were noted. Statistical analysis was done to assess the risk factors for complications. RESULTS: A total of 2,031 patients were included in the study. The most frequent surgical procedures performed were phacoemulsification and posterior chamber artificial lens implantation (91.0%). A total of 66 complications (3.3%) occurred in 60 patients. One patient had a retrobulbar hemorrhage, and 59 had one or two more minor incidents or pain/discomfort with the procedure. The complications consisted of subconjunctival hematoma (1.3%), ocular hypertonia (0.4%), and chemosis (0.30%). Statistical analysis revealed that inexperience in the technique represented a risk factor for complications. CONCLUSIONS: This is the first survey of a large experience in episcleral single-injection anesthesia, a form of anesthesia that does not preclude sharp-needle complications and does require training. Only one complication occurred among 2,031 patients; however, a larger number of patients is needed to definitively evaluate the safety of episcleral single-injection anesthesia.

Adult↗
PubMed2003

Alcohol relapse after liver transplantation for alcoholic liver disease: does it matter?

BACKGROUND/AIMS: The aim of this study was to distinguish the types of alcohol consumption after liver transplantation (LT) for alcoholic cirrhosis and to assess the consequences of heavy drinking. METHODS: Patients transplanted for alcoholic cirrhosis were studied. Alcoholic relapse diagnosis was based upon patient's and family members' reports, liver enzyme tests, graft biopsy, and use of urine alcohol test. RESULTS: One hundred twenty-eight patients were studied, with a mean follow-up of 53.8 months. After LT, 69% of patients were abstinent, 10% were occasional drinkers, and 21% were heavy drinkers. Actuarial survival rates were not different, but three of the seven deaths observed among heavy drinkers were directly related to alcohol relapse. Although there was no difference between the three groups concerning the rejection rates, all rejection episodes observed in the group of heavy drinkers were related to poor compliance with immunosuppressive drugs. One heavy drinker developed alcoholic cirrhosis. CONCLUSIONS: The present study indicates that patients can resume heavy alcohol consumption after LT for alcoholic liver disease (ALD) and their grafts can be injured because of poor compliance with immunosuppressive drugs and alcohol-related liver injury. Although patient survival was not influenced by alcohol relapse, heavy alcohol consumption can be responsible for patients' death.

Adult↗
PubMed2003

Hemodynamic and cardiac electrophysiologic effects of lidocaine-bupivacaine mixture in anesthetized and ventilated piglets.

BACKGROUND: The sensory blockade induced by a lidocaine-bupivacaine mixture combines the faster onset of lidocaine and the longer duration of bupivacaine. The current study compared the effects of large doses lidocaine (16 mg/kg), bupivacaine (4 mg/kg), and a mixture of 16 mg/kg lidocaine-4 mg/kg bupivacaine on hemodynamic and cardiac electrophysiologic parameters in anesthetized and ventilated piglets. METHODS: After carotid artery cannulation, a double micromanometer measured mean aortic pressure, left ventricular end diastolic pressure, and the first derivative of left ventricular pressure. Electrocardiogram recording and a bipolar electrode catheter measured RR, PQ, QRS, QT C, JT C, AH, and HV intervals. Lidocaine, bupivacaine, or the mixture was administered intravenously over 30 s, and studied parameters were measured throughout 30 min. RESULTS: Mean aortic pressure decreased in all groups ( P < 0.05). The first derivative of left ventricular pressure was decreased in all groups ( P < 0.001) but to a greater extent with the mixture compared with lidocaine ( P < 0.04). RR, QT C, and JT C intervals were similarly increased in all groups ( P < 0.05). In all groups, PQ, AH, HV, and QRS intervals were widened ( P < 0.001). The lengthening of PQ was greater with bupivacaine ( P < 0.02). The lengthening of AH was greater and delayed with bupivacaine compared with lidocaine ( P < 0.03). The lengthening of HV and the widening of QRS were greater and delayed with bupivacaine ( P < 0.01). The widening of QRS was greater with the mixture than with lidocaine ( P < 0.01). CONCLUSIONS: The alterations of ventricular conduction parameters are greater with 4 mg/kg bupivacaine than with a mixture of 16 mg/kg lidocaine-4 mg/kg bupivacaine, whereas the hemodynamic parameters are similarly altered.

Anesthesia↗
PubMed2003

Postoperative patient-controlled analgesia in the elderly: risks and benefits of epidural versus intravenous administration.

Postoperative patient-controlled analgesia provided by the intravenous route using morphine (PCA) or by the epidural route using an opioid in combination with a local anaesthetic (patient-controlled epidural analgesia; PCEA) is not yet routinely used in the elderly. However, this modality theoretically provides adequate control of postoperative pain in such patients. Firstly, an assessment of the level of pain is particularly difficult in the elderly, and patient-controlled techniques that enable the self-administration of analgesic could resolve this problem. Secondly, these techniques provide a fine and controlled titration of analgesic doses. Since analgesic-induced adverse effects increase with age, the risk of overdose is therefore reduced. Thirdly, effective postoperative patient-controlled analgesia may attenuate detrimental physiologic responses, and contribute to improvement in patient outcomes. In the elderly, PCEA provides better pain relief, particularly for dynamic pain, and improves postoperative recovery with a low incidence of adverse effects compared with PCA. PCA and PCEA techniques have a good safety profile in the elderly only when there is careful preoperative patient selection and strict postoperative monitoring. Standard observation of vital signs, sedation and pain scores and assessment of mental status are required. Patient selection is necessary to identify those patients who may be incapable of using the device (e.g. patients with evidence of cognitive dysfunction or physical disabilities). In addition, caution is required among patients with respiratory, renal or hepatic insufficiency. PCA and PCEA are particularly useful for elderly patients undergoing major thoraco-abdominal surgery. However, there is a need for further research in elderly patients. In the future, improvements in the management of postoperative pain in the elderly will lead to a greater expansion of self-controlled techniques.

Aged↗
PubMed2002

Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test.

OBJECTIVE: To evaluate the incidence and identify factors associated with the occurrence of post-extubation stridor and to evaluate the performance of the cuff-leak test in detecting this complication. DESIGN: Prospective, clinical investigation. SETTING: Intensive care unit of a university hospital. PATIENTS: Hundred twelve extubations were analyzed in 112 patients during a 14-month period. INTERVENTION: A cuff-leak test before each extubation. MEASUREMENTS AND RESULTS: The incidence of stridor was 12%. When we chose the thresholds of 130 ml and 12% to quantify the cuff-leak volume, the sensitivity and the specificity of the test were, respectively, 85% and 95%. The patients who developed stridor had a cuff leak significantly lower than the others, expressed in absolute values (372+/-170 vs 59+/-92 ml, p<0.001) or in relative values (56+/-20 vs 9+/-13%, p<0.001). Stridor was associated with an elevated Simplified Acute Physiology Score (SAPS II), a medical reason for admission, a traumatic or difficult intubation, a history of self-extubation, an over-inflated balloon cuff at admission to ICU and a prolonged period of intubation. These results provide a framework with which to identify patients at risk of developing a stridor after extubation. CONCLUSION: A low cuff-leak volume (<130 ml or 12%) around the endotracheal tube prior to extubation is useful in identifying patients at risk for post-extubation stridor.

Airway Obstruction↗