50 research outputs found
Koroner arter bypass greftleme cerrahisi sırasında deksmedetomidin kullanımının serebral etkileri
No full textKardiyopulmoner bypass’ın (KPB) olumsuz serebral etkilerine karşı tam koruma
sağlayacak bir farmakolojik ajan konusunda henüz bir fikir birliği sağlanamadığından bu
konudaki arayışlar devam etmektedir. Çalışmamızın amacı hemodinamik stabilite
sağlamadaki üstünlüğü bilinen ve hayvan çalışmalarında da nöroprotektif özelliği olduğu
gösterilen deksmedetomidinin koroner arter bypass greftleme (KABG) cerrahisi sırasında
ortaya çıkan serebral iskemik hasara karşı koruyucu etkisi olup olmadığını belirlemektir.
Etik Kurulu onayı ve hastaların izinleri alındıktan sonra KABG yapılacak 50-70 yaşları
arası 24 hasta çalışmaya alındı. Hastalar randomize olarak deksmedetomidin alan (Grup D,
n = 12) ve almayanlar (Grup K, n = 12) şeklinde iki gruba ayrıldı. Standart anestezi
indüksiyonu sonrası tüm hastalara juguler bulb kateteri takılıp bazal kan örnekleri alındı.
Grup D’ye 10 dk içinde 1 μg/kg bolus ve ardından 0.7 μg/kg/sa dozunda deksmedetomidin
infüzyonu verildi. Hastalardan indüksiyon sonrası, KPB’nin 10.dakikasında, kros-klemp
kalkışından 1 dk. sonra, KPB çıkışından 1 dk. sonra, ameliyat sonunda ve postoperatif 24.
saatte arteriyel ve juguler venöz kan örnekleri alınarak kan gazı analizleri ile S-100B
proteini, nöron spesifik enolaz (NSE) ve laktat değerlerinin ölçümleri yapıldı. Elde edilen
değerler gruplar arasında Mann-Whitney U testi ile grup içinde Wilcoxon testi ile
karşılaştırıldı.
Grup D ve Grup K arasında arteriyel ve juguler venöz pH, PO2, PCO2 değerleri ve O2
saturasyonları açısından herhangi bir fark bulunmadı. S-100B, NSE ve arteriyel-juguler
venöz laktat farkı değerleri açısından da iki grup bulguları benzerdi. Postoperatif dönemde
hiç bir hastada klinik olarak nörolojik bir komplikasyon izlenmedi.
Sonuç olarak, KPB sırasında ve sonrasında gerek S-100B ve NSE gerekse laktat farkları
açısından literatürle uyumlu değişiklikler izlediğimiz hastalarımızda deksmedetomidin
grubunda kontrol grubundan farklı sonuçlar olmaması, deksmedetomidinin nöroprotektif
etkisinin bulunmadığını düşündürmektedir. Daha yüksek ilaç dozları kullanılarak
yapılacak çalışmalarla farklı sonuçlar elde edilebilir
Organisation, staffing and resources of critical care units in Kenya
No full textObjectiveTo describe the organisation, staffing patterns and resources available in critical care units in Kenya. The secondary objective was to explore variations between units in the public and private sectors.Materials and methodsAn online cross-sectional survey was used to collect data on organisational characteristics (model of care, type of unit, quality- related activities, use of electronic medical records and participation in the national ICU registry), staffing and available resources for monitoring, ventilation and general critical care.ResultsThe survey included 60 of 75 identified units (80% response rate), with 43% (n = 23) located in government facilities. A total of 598 critical care beds were reported with a median of 6 beds (interquartile range [IQR] 5-11) per unit, with 26% beds (n = 157) being non functional. The proportion of ICU beds to total hospital beds was 3.8% (IQR 1.9-10.4). Most of the units (80%, n = 48) were mixed/general units with an open model of care (60%, n = 36). Consultants-in-charge were mainly anesthesiologists (69%, n = 37). The nurse-to-bed ratio was predominantly 1:2 with half of the nurses formally trained in critical care. Most units (83%, n = 47) had a dedicated ventilator for each bed, however 63% (n = 39) lacked high flow nasal therapy. While basic multiparametric monitoring was ubiquitous, invasive blood pressure measurement capacity was low (3% of beds, IQR 0-81%), and capnography moderate (31% of beds, IQR 0-77%). Blood gas analysers were widely available (93%, n = 56), with 80% reported as functional. Differences between the public and private sector were narrow.ConclusionThis study shows an established critical care network in Kenya, in terms of staffing density, availability of basic monitoring and ventilation resources. The public and private sector are equally represented albeit with modest differences. Potential areas for improvement include training, use of invasive blood pressure and functionality of blood gas analysers
Respiratory System Mechanics During Low Versus High Positive End-Expiratory Pressure in Open Abdominal Surgery: A Substudy of PROVHILO Randomized Controlled Trial
No full textIn the 2014 PROtective Ventilation using HIgh versus LOw positive end-expiratory pressure (PROVHILO) trial, intraoperative low tidal volume ventilation with high positive end-expiratory pressure (PEEP = 12 cm H2O) and lung recruitment maneuvers did not decrease postoperative pulmonary complications when compared to low PEEP (0-2 cm H2O) approach without recruitment breaths. However, effects of intraoperative PEEP on lung compliance remain poorly understood. We hypothesized that higher PEEP leads to a dominance of intratidal overdistension, whereas lower PEEP results in intratidal recruitment/derecruitment (R/D). To test our hypothesis, we used the volume-dependent elastance index %E2, a respiratory parameter that allows for noninvasive and radiation-free assessment of dominant overdistension and intratidal R/D. We compared the incidence of intratidal R/D, linear expansion, and overdistension by means of %E2 in a subset of the PROVHILO cohort. In 36 patients from 2 participating centers of the PROVHILO trial, we calculated respiratory system elastance (E), resistance (R), and %E2, a surrogate parameter for intratidal overdistension (%E2 > 30%) and R/D (%E2 < 0%). To test the main hypothesis, we compared the incidence of intratidal overdistension (primary end point) and R/D in higher and lower PEEP groups, as measured by %E2. E was increased in the lower compared to higher PEEP group (18.6 [16…22] vs 13.4 [11.0…17.0] cm H2O·L; P < .01). %E2 was reduced in the lower PEEP group compared to higher PEEP (-15.4 [-28.0…6.5] vs 6.2 [-0.8…14.0] %; P < .05). Intratidal R/D was increased in the lower PEEP group (61% vs 22%; P = .037). The incidence of intratidal overdistension did not differ significantly between groups (6%). During mechanical ventilation with protective tidal volumes in patients undergoing open abdominal surgery, lung recruitment followed by PEEP of 12 cm H2O decreased the incidence of intratidal R/D and did not worsen overdistension, when compared to PEEP ≤2 cm H2
Association between pre-operative biological phenotypes and postoperative pulmonary complications: An unbiased cluster analysis
No full textBACKGROUND: Biological phenotypes have been identified within several heterogeneous pulmonary diseases, with potential therapeutic consequences. OBJECTIVE: To assess whether distinct biological phenotypes exist within surgical patients, and whether development of postoperative pulmonary complications (PPCs) and subsequent dependence of intra-operative positive end-expiratory pressure (PEEP) differ between such phenotypes. SETTING: Operating rooms of six hospitals in Europe and USA. DESIGN: Secondary analysis of the 'PROtective Ventilation with HIgh or LOw PEEP' trial. PATIENTS: Adult patients scheduled for abdominal surgery who are at risk of PPCs. INTERVENTIONS: Measurement of pre-operative concentrations of seven plasma biomarkers associated with inflammation and lung injury. MAIN OUTCOME MEASURES: We applied unbiased cluster analysis to identify biological phenotypes. We then compared the proportion of patients developing PPCs within each phenotype, and associations between intra-operative PEEP levels and development of PPCs among phenotypes. RESULTS: In total, 242 patients were included. Unbiased cluster analysis clustered the patients within two biological phenotypes. Patients with phenotype 1 had lower plasma concentrations of TNF-α (3.8 [2.4 to 5.9] vs. 10.2 [8.0 to 12.1] pg ml; P < 0.001), IL-6 (2.3 [1.5 to 4.0] vs. 4.0 [2.9 to 6.5] pg ml; P < 0.001) and IL-8 (4.7 [3.1 to 8.1] vs. 8.1 [6.0 to 13.9] pg ml; P < 0.001). Phenotype 2 patients had the highest incidence of PPC (69.8 vs. 34.2% in type 1; P < 0.001). There was no interaction between phenotype and PEEP level for the development of PPCs (43.2% in high PEEP vs. 25.6% in low PEEP in phenotype 1, and 73.6% in high PEEP and 65.7% in low PEEP in phenotype 2; P for interaction = 0.503). CONCLUSION: Patients at risk of PPCs and undergoing open abdominal surgery can be clustered based on pre-operative plasma biomarker concentrations. The two identified phenotypes have different incidences of PPCs. Biologic phenotyping could be useful in future randomised controlled trials of intra-operative ventilation. TRIAL REGISTRATION: The PROtective Ventilation with HIgh or LOw PEEP trial, including the substudy from which data were used for the present analysis, was registered at ClinicalTrials.gov (NCT01441791)
Epidemiology, Clinical Characteristics, and Outcomes of 4546 Adult Admissions to High-Dependency and ICUs in Kenya: A Multicenter Registry-Based Observational Study
No full textOBJECTIVES: To describe clinical, management, and outcome features of critically ill patients admitted to ICUs and high-dependency units (HDUs) in Kenya. DESIGN: Prospective registry-based observational study. SETTING: Three HDUs and eight ICUs in Kenya. PATIENTS: Consecutive adult patients admitted between January 2021 and June 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were entered in a cloud-based platform using a common data model. Study endpoints included case-mix variables, management features, and patient-centered outcomes. Patients with COVID-19 were reported separately. Of the 3892 of 4546 patients without COVID-19, 2445 patients (62.8%) were from HDUs, and 1447 patients (37.2%) were from ICUs. Patients had a median age of 53 years (interquartile range [IQR] 38-68), with HDU patients being older but with a lower severity (Acute Physiology and Chronic Health Evaluation II 6 [3-9] in HDUs vs. 12 [7-17] in ICUs; p < 0.001). One in four patients was postoperative with 604 (63.4%) receiving emergency surgery. Readmission rate was 4.8%. Hypertension and diabetes were prevalent comorbidities, with a 4.0% HIV/AIDS rate. Invasive mechanical ventilation was applied in 3.4% in HDUs versus 47.6% in ICUs (p < 0.001), with a duration of 7 days (IQR 3-21). There was a similar use of renal replacement therapy (4.0% vs. 4.7%; p < 0.001). Vasopressor use was infrequent while half of patients received antibiotics. Average length of stay was 2 days (IQR 1-5). Crude HDU mortality rate was 6.5% in HDUs versus 30.5% in the ICUs (p < 0.001). Of the 654 COVID-19 admissions, most were admitted in ICUs (72.3%) with a 33.2% mortality. CONCLUSIONS: We provide the first multicenter observational cohort study from an African ICU National Registry. Distinct management features and outcomes characterize HDU from ICU patients
The Effect of Gabapentin Premedication on the Emergence Delirium in Pediatric Patients Undergoing Circumcision Under Sevoflurane Anesthesia
No full textEffects of Positive End-Expiratory Pressure on the Risk of Postoperative Pulmonary Complications in Patients Undergoing Elective Craniotomy
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