Simplified postoperative nausea and vomiting impact scale for audit and post-discharge review.
Br J Anaesth. 2012 Jan 29;
Authors: Myles PS, Wengritzky R
Abstract
BACKGROUND: /st>Postoperative nausea and vomiting (PONV) is common but many episodes may be trivial or transient. The aim of the study was to develop a simple-to-use measure of the intensity and clinical impact of PONV. METHODS: /st>We re-analysed data from a study enrolling 163 patients recovering from surgery and anaesthesia that had experienced or were at increased risk of developing PONV. A range of measures of PONV characteristics and quality of recovery were collected. We devised a simplified nausea-vomiting impact scale based on patients’ assessment of the impact of their nausea on their postoperative recovery and the number of times they experienced vomiting. We then undertook further tests of construct and discriminant validity, and reliability and responsiveness, of the impact scale using psychometric methodology. RESULTS: /st>Around one in five patients with PONV had features that could classify them as having clinically important PONV. We found that patients with clinically important PONV had a much poorer quality of recovery (P<0.0005), needed more antiemetic administrations for treatment (P<0.0005), and were more likely to have consequences and complications of PONV (all P<0.01), when compared with those with lesser degrees of PONV. A change in clinically important PONV status can be reliably detected with the PONV impact scale. CONCLUSIONS: /st>We have devised and validated a simplified PONV impact scale that can be used to identify those with clinically important PONV. The avoidance of clinically important PONV could be used as a quality indicator or outcome measure after surgery.
PMID: 22290456 [PubMed - as supplied by publisher]
Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy.
Br J Anaesth. 2012 Jan 29;
Authors: Woodcock TE, Woodcock TM
Abstract
I.V. fluid therapy does not result in the extracellular volume distribution expected from Starling’s original model of semi-permeable capillaries subject to hydrostatic and oncotic pressure gradients within the extracellular fluid. Fluid therapy to support the circulation relies on applying a physiological paradigm that better explains clinical and research observations. The revised Starling equation based on recent research considers the contributions of the endothelial glycocalyx layer (EGL), the endothelial basement membrane, and the extracellular matrix. The characteristics of capillaries in various tissues are reviewed and some clinical corollaries considered. The oncotic pressure difference across the EGL opposes, but does not reverse, the filtration rate (the ‘no absorption’ rule) and is an important feature of the revised paradigm and highlights the limitations of attempting to prevent or treat oedema by transfusing colloids. Filtered fluid returns to the circulation as lymph. The EGL excludes larger molecules and occupies a substantial volume of the intravascular space and therefore requires a new interpretation of dilution studies of blood volume and the speculation that protection or restoration of the EGL might be an important therapeutic goal. An explanation for the phenomenon of context sensitivity of fluid volume kinetics is offered, and the proposal that crystalloid resuscitation from low capillary pressures is rational. Any potential advantage of plasma or plasma substitutes over crystalloids for volume expansion only manifests itself at higher capillary pressures.
PMID: 22290457 [PubMed - as supplied by publisher]
Analysis of patterns of three-phase bone scintigraphy for patients with complex regional pain syndrome diagnosed using the proposed research criteria (the ‘Budapest Criteria’).
Br J Anaesth. 2012 Jan 30;
Authors: Moon JY, Park SY, Kim YC, Lee SC, Nahm FS, Kim JH, Kim H, Oh SW
Abstract
BACKGROUND: /st>Three-phase bone scintigraphy (TPBS) is an established objective diagnostic method for complex regional pain syndrome (CRPS), but its validity remains controversial. The aims of this study were: (i) to re-evaluate the diagnostic performance of TPBS, and (ii) to suggest new TPBS criteria based on the proposed research criteria for CPRS in Budapest (the 2003 Budapest research criteria). METHODS: /st>The medical records of 228 consecutive patients, evaluated using the Budapest research criteria, were retrospectively analysed. Of these, 116 patients were included in the present study, and 69 of 116 were diagnosed to have CRPS based on these criteria. The diagnostic performance of TPBS was assessed by determining its sensitivity, specificity, and positive and negative likelihood ratios, and new criteria for TPBS were identified by pattern analysis using the Budapest research criteria. RESULTS: /st>The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of TPBS for the diagnosis of CRPS according to the Budapest research criteria were 40.0, 76.5, 1.73, and 0.78, respectively. Furthermore, D-D-D, D-D-S, and D-D-I patterns [i.e. according to decreased (D), symmetrical (S), or increased (I) tracer uptake during Phases I, II, and III] of TPBS were found to be positively predictive for CRPS. CONCLUSIONS: /st>The diagnostic value of a positive TPBS for CRPS is low from the view point of the Budapest research criteria. Our findings suggest that a diagnosis of CRPS using the Budapest research criteria should be considered when decreased patterns of TPBS are observed during Phases I and II.
PMID: 22293544 [PubMed - as supplied by publisher]
Outcomes and prognostic factors in patients with haematological malignancy admitted to a specialist cancer intensive care unit: a 5 yr study.
Br J Anaesth. 2012 Jan 31;
Authors: Bird GT, Farquhar-Smith P, Wigmore T, Potter M, Gruber PC
Abstract
BACKGROUND: /st>Long-held assumptions of poor prognoses for patients with haematological malignancies (HM) have meant that clinicians have been reluctant to admit them to the intensive care unit (ICU). We aimed to evaluate ICU, in-hospital, and 6 month mortality and to identify predictors for in-hospital mortality. METHODS: /st>A cohort study in a specialist cancer ICU of adult HM patients admitted over 5 yr. Data acquired included: patient characteristics, haematological diagnosis, haematopoietic stem cell transplant (HSCT), reason for ICU admission, and APACHE II scores. Laboratory values, organ failures, and level of organ support were recorded on ICU admission. Predictors for in-hospital mortality were evaluated using uni- and multivariate analysis. RESULTS: /st>Of 199 patients, median age was 58 yr [inter-quartile range (IQR) 46-66], 51.7% were emergency admissions, 42.2% post-HSCT, 51.9% required mechanical ventilation, median APACHE II was 21 (IQR 16-25), and median organ failure numbered 2 (IQR 1-4). ICU, in-hospital, and 6 month mortalities were 33.7%, 45.7%, and 59.3%, respectively. Univariate analysis revealed bilirubin >32 µmol litre(-1), mechanical ventilation, ≥2 organ failures, renal replacement therapy, vasopressor support (all P<0.001), graft-vs-host disease (P=0.007), APACHE II score (P=0.02), platelets ≤20×10(9) litre(-1) (P=0.03), and proven invasive fungal infection (P=0.04) were associated with in-hospital mortality. Multivariate analysis revealed that ≥2 organ failures [odds ratio (OR) 5.62; 95% confidence interval (95% CI), 2.30-13.70] and mechanical ventilation (OR 3.03; 95% CI, 1.33-6.90) were independently associated with in-hospital mortality. CONCLUSIONS: /st>Mortality was lower than in previous studies. Mechanical ventilation and ≥2 organ failures were independently associated with in-hospital mortality. ‘Traditional’ variables such as neutropenia, transplantation status, and APACHE II score no longer appear to be predictive.
PMID: 22298243 [PubMed - as supplied by publisher]
Use of sugammadex in a ‘can’t intubate, can’t ventilate’ situation.
Br J Anaesth. 2012 Jan 26;
Authors: Curtis R, Lomax S, Patel B
Abstract
A 78-yr-old woman presented for a panendoscopy to investigate dysphonia and dysphagia. Intubation was anticipated to be difficult but possible, and mask ventilation was anticipated to be possible. After induction of anaesthesia and after three attempts at intubation, a ‘can’t intubate, can ventilate’ situation deteriorated to a ‘can’t intubate, can’t ventilate’ (CICV) situation. Rocuronium-induced neuromuscular block was successfully reversed with sugammadex, as evidenced by the restoration of diaphragmatic movement, the ability of the patient to move her limbs, and the presence of a train-of-four nerve stimulation with no fade; however, ventilation was still not possible. A cricothyroid puncture using a Ravussin needle was performed successfully to provide emergency oxygenation. A tracheostomy was performed to allow the panendoscopy. CICV situations are rare anaesthetic emergencies. While sugammadex can be relied upon to reverse rocuronium-induced neuromuscular block, it should not be relied upon to rescue all CICV events, especially where airway instrumentation has led to airway swelling. The availability of sugammadex does not obviate the need for emergency tracheal access in the event of failed oxygenation. The presence of head and neck pathology should lead to the consideration of securing the airway awake.
PMID: 22287458 [PubMed - as supplied by publisher]
Anti-emetic effect of ondansetron and palonosetron in thyroidectomy: a prospective, randomized, double-blind study.
Br J Anaesth. 2012 Jan 25;
Authors: Moon YE, Joo J, Kim JE, Lee Y
Abstract
BACKGROUND: /st>Palonosetron is a new potent 5-hydroxytryptamine 3 antagonist. Although this drug is thought to be more effective in patients receiving opioid-based patient-controlled analgesia (PCA), clinical data are lacking. This study compared the effects of i.v. ondansetron and palonosetron administered at the end of surgery in preventing postoperative nausea and vomiting (PONV) in high-risk patients receiving i.v. PCA after thyroidectomy. METHODS: /st>A total of 100 female non-smoking subjects were randomly assigned into a palonosetron group or an ondansetron group. Ondansetron was given as an 8 mg bolus and 16 mg was added to the i.v. PCA mixture. In the palonosetron group, 0.075 mg was injected as a bolus only. Fentanyl-based PCA was provided for 24 h after operation. The incidence of nausea and vomiting, severity of nausea, requirement for rescue anti-emetics, and adverse effects were evaluated during 0-2 and 2-24 h. RESULTS: /st>The incidence of PONV during the 24 h postoperative period was lower in the palonosetron group than in the ondansetron group (42% vs 62%, P=0.045). No differences were observed between the groups during the first 2 h. However, the incidence of nausea and vomiting and nausea severity were significantly lower in the palonosetron group than in the ondansetron group during 2-24 h. The only difference in the use of rescue anti-emetics was at 2-24 h (10% with palonosetron compared with 28% with ondansetron, P=0.02). CONCLUSIONS: /st>Palonosetron is more effective than ondansetron for high-risk patients receiving fentanyl-based PCA after thyroidectomy, especially 2-24 h after surgery.
PMID: 22277663 [PubMed - as supplied by publisher]
Effect of different quantities of a sugared clear fluid on gastric emptying and residual volume in children: a crossover study using magnetic resonance imaging.
Br J Anaesth. 2012 Jan 25;
Authors: Schmitz A, Kellenberger CJ, Lochbuehler N, Fruehauf M, Klaghofer R, Fruehauf H, Weiss M
Abstract
BACKGROUND: /st>Gastric emptying in the first 2 h after 7 ml kg(-1) of sugared clear fluid has recently been investigated in healthy children using magnetic resonance imaging (MRI). This study aims to compare gastric volume and emptying half-life during 1 h after 3 or 7 ml kg(-1) sugared clear fluid intake. METHODS: /st>Fourteen healthy volunteer children aged 11.1 (8.2-12.5) yr were investigated prospectively after administration of 3 and 7 ml kg(-1) diluted raspberry syrup in a randomized order, after overnight fasting (baseline). Gastric content volume (GCV(w)) was assessed with a 1.5 Tesla MRI scanner in a blinded fashion. Data are presented as median (range) and compared using the Wilcoxon test. RESULTS: /st>Baseline GCV(w) was 0.39 (0.04-1.00) and 0.34 (0.07-0.75) before intake of 3 and 7 ml kg(-1) syrup, respectively (P=0.93). GCV(w) was 0.45 (0.04-1.55)/1.33 (0.30-2.60) ml kg(-1) 60 min after ingestion of 3/7 ml kg(-1) syrup (P=0.002). Thus GCV(w) had declined to baseline after 3 ml kg(-1) (P=0.39) but not after 7 ml kg(-1) (P=0.001) within 60 min. T(1/2) was 20 (10-62)/27 (13-43) min (P=0.73) after 3/7 ml kg(-1). CONCLUSION: /st>In healthy volunteer children, residual GCV(w) 1 h after intake of 3 ml kg(-1) syrup is significantly smaller than that after 7 ml kg(-1) and within the range of baseline.
PMID: 22277664 [PubMed - as supplied by publisher]
BACKGROUND: /st>Dexmedetomidine is a highly selective and potent α(2)-adrenoceptor agonist registered for sedation of patients in intensive care units. There is little information on factors possibly affecting its pharmacokinetics during long drug infusions in critically ill patients. We characterized the pharmacokinetics of dexmedetomidine in critically ill patients during long-term sedation using a population pharmacokinetic approach. METHODS: /st>Twenty-one intensive care patients requiring sedation and mechanical ventilation received dexmedetomidine with a loading dose of 3-6 µg kg(-1) h(-1) in 10 min and a maintenance dose of 0.1-2.5 µg kg(-1) h(-1) for a median duration of 96 h (range, 20-571 h). Cardiac output (CO), laboratory and respiratory parameters, and dexmedetomidine concentrations in arterial plasma were measured. The pharmacokinetics was determined by population analysis using linear multicompartment models. RESULTS: /st>The pharmacokinetics of dexmedetomidine was best described by a two-compartment model. The population values (95% confidence interval) for elimination clearance, inter-compartmental clearance, central volume of distribution, and volume of distribution at steady state were 57.0 (42.1, 65.6), 183 (157, 212) litre h(-1), 12.3 (7.6, 17.0), and 132 (96, 189) litre. Dexmedetomidine clearance decreased with decreasing CO and with increasing age, whereas its volume of distribution at steady state was increased in patients with low plasma albumin concentration. CONCLUSIONS: /st>The population pharmacokinetics of dexmedetomidine was generally in line with results from previous studies. In elderly patients and in patients with hypoalbuminaemia, the elimination half-life and the context-sensitive half-time of dexmedetomidine were prolonged.
PMID: 22277665 [PubMed - as supplied by publisher]
BACKGROUND: /st>Postoperative delirium (PD) is a serious complication after major surgery in elderly patients. PD is well defined and characterized by reduced attention and disorientation. Multimodal optimization of perioperative care (the fast-track methodology) enhances recovery, and reduces hospital stay and medical morbidity. No data on PD are available in fast-track surgery. The aim of this study was to evaluate the incidence of PD after fast-track hip (THA) and knee arthroplasty (TKA) with anticipated length of stay (LOS) of <3 days. METHODS: /st>In a prospective multicentre study to evaluate postoperative cognitive dysfunction, we included 225 non-demented patients with a mean age of 70 yr undergoing either THA or TKA in a fast-track set-up. Anaesthesia and postoperative pain management were standardized with limited opioid use. Nursing staff were trained to look for symptoms of PD which was assessed during interaction with healthcare professionals. Patients were invited for a clinical follow-up 1-2 weeks after surgery. RESULTS: /st>Clinical follow-up was performed in 220 patients at a mean of 12.0 days after surgery while five patients were followed up by telephone. The mean LOS was 2.6 days (range 1-8 days). Twenty-two patients received general anaesthesia, and the rest had spinal anaesthesia. No patients developed PD (95% confidence interval 0.0-1.6%). CONCLUSIONS: /st>A fast-track set-up with multimodal opioid-sparing analgesia was associated with lack of PD after elective THA and TKA in elderly patients.
PMID: 22277666 [PubMed - as supplied by publisher]
Third-generation FloTrac/Vigileo does not reliably track changes in cardiac output induced by norepinephrine in critically ill patients.
Br J Anaesth. 2012 Jan 19;
Authors: Monnet X, Anguel N, Jozwiak M, Richard C, Teboul JL
Abstract
BACKGROUND: /st>The ability of the third-generation FloTrac/Vigileo software to track changes in cardiac index (CI) induced by volume expansion and norepinephrine in critically ill patients is unknown. METHODS: /st>In subjects with circulatory failure, we administered volume expansion (20 subjects) and increased (20 subjects) or decreased (20 subjects) the dose of norepinephrine. We measured arterial pressure waveform-derived CI provided by the third-generation FloTrac/Vigileo device (CI(pw)) and transpulmonary thermodilution CI (CI(td)) before and after therapeutic interventions. RESULTS: /st>Considering the pairs of measurements performed before and after all therapeutic interventions (n=60), a bias between the absolute values of CI(pw) and CI(td) was 0.26 (0.94) litre min(-1) m(-2) and the percentage error was 54%. Changes in CI(pw) tracked changes in CI(td) induced by volume expansion with moderate accuracy [n=20, bias=-0.11 (0.54) litre min(-1) m(-2), r(2)=0.26, P=0.02]. When changes in CI(td) were induced by norepinephrine (n=40), a bias between CI(pw) and CI(td) was 0.01 (0.41) litre min(-1) m(-2) (r(2)=0.11, P=0.04). The concordance rates between changes in CI(pw) and CI(td) induced by volume expansion and norepinephrine were 73% and 60%, respectively. The bias between changes in CI(pw) and CI(td) significantly correlated with changes in total systemic vascular resistance (r(2)=0.41, P<0.0001). CONCLUSIONS: /st>The third-generation FloTrac/Vigileo device was moderately reliable for tracking changes in CI induced by volume expansion and poorly reliable for tracking changes in CI induced by norepinephrine.
PMID: 22265900 [PubMed - as supplied by publisher]
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