OBJECTIVE: Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by a perception and psychomotor disorder, with a negative impact on postoperative recovery. As the use of inhalation anesthesia is associated with a higher incidence of ED, we investigated whether titrating the depth of general anesthesia with BIS monitor can reduce the incidence of ED. DESIGN: Randomized, prospective, and double-blind. SETTING: Patients undergoing endoscopic adenoidectomy under general anesthesia according to a uniform protocol. PATIENTS: A total of 163 patients of both sexes aged 3-8 years were enrolled over 18 months. INTERVENTIONS: Immediately after the induction of general anesthesia, a bispectral index (BIS) electrode was placed on the patient's forehead. In the study group, the depth of general anesthesia was monitored with the aim of achieving BIS values of 40-60. In the control group, the dose of sevoflurane was determined by the anaesthesiologist based on MAC (minimum alveolar concentration) and the end-tidal concentration. MEASUREMENTS: The primary objective was to compare the occurrence of ED during the PACU (post-anesthesia care unit) stay in both arms of the study. The secondary objective was to determine the PAED score at 10 and 30 min in the PACU and the need for rescue treatment of ED. MAIN RESULTS: 86 children were randomized in the intervention group and 77 children in the control group. During the entire PACU stay, 23.3% (38/163) of patients developed ED with PAED score >10: 35.1% (27/77) in the control group and 12.8% (11/86) in the intervention group (p = 0.001). Lower PAED scores were also found in the intervention group at 10 (p < 0.001) and 30 (p < 0.001) minutes compared to the control group. The need for rescue treatment did not differ between groups (p = 0.067). CONCLUSION: Individualization of the depth of general anesthesia with BIS monitoring is an effective method of preventing ED in children. CLINICAL TRIAL REGISTRATION: NCT04466579.
- MeSH
- celková anestezie * škodlivé účinky MeSH
- dítě MeSH
- inhalační anestezie * škodlivé účinky MeSH
- lidé MeSH
- pooperační delirium * epidemiologie prevence a kontrola etiologie MeSH
- předškolní dítě MeSH
- probouzení z anestezie MeSH
- prospektivní studie MeSH
- sevofluran MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mužské pohlaví MeSH
- předškolní dítě MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
BACKGROUND Acute kidney injury (AKI) is a common cause of organ failure in patients after major trauma and is associated with increased morbidity and mortality. Early identification of patients at risk enables the implementation of a bundle of supportive care, which reduces the incidence of AKI. The primary objective of our study was to investigate whether the levels of biomarkers on admission predicted the onset of early AKI in patients with serious injuries. MATERIAL AND METHODS This prospective observational study included 98 adult patients of both sexes with a serious injury (injury severity score >16). At admission, blood samples were taken, and creatinine, neutrophil gelatinase-associated lipocalin (NGAL), high mobility group box 1 (HMGB-1), and markers of rhabdomyolysis (creatine kinase, myoglobin) were evaluated. The patients were provided with standard resuscitation care, and the occurrence of AKI was monitored during the first 7 days after admission to the Intensive Care Unit, according to the Kidney Disease Improving Global Outcomes diagnostic criteria. RESULTS AKI occurred in 25 (25.5%) patients, in whom the admission levels of HMGB-1, NGAL, creatinine, and myoglobin were significantly higher than in non-AKI patients (48.3±98.4 vs 113.0±209.4 μg/L, P=0.006; 150.2±349.9 vs 181.4±152.2 μg/L, P=0.004; 83.1±20.8 vs 118.8±32.2 μmol/L, P<0.005; 2734.4±2214.5 vs 4182.3±2477.1 μg/L, P=0.008, respectively). Creatine kinase was 14.5±9.2 μkat/L in non-AKI patients and 13.7±7.9 μkat/L in AKI patients (P=0.916). CONCLUSIONS Admission levels of HMGB-1, NGAL, creatinine, and myoglobin predicted the risk of AKI in severely injured patients.
- MeSH
- akutní poškození ledvin * diagnóza etiologie MeSH
- biologické markery MeSH
- dospělí MeSH
- kreatinin MeSH
- kreatinkinasa MeSH
- lidé MeSH
- lipokalin-2 MeSH
- myoglobin * MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
Pooperační nevolnost a zvracení (PONV) je častou pooperační komplikací, která postihuje 20-30 % dětí, u vysoce rizikových výkonů stoupá incidence až k 80 %. PONV vedle subjektivního dyskomfortu zvyšuje pooperační morbiditu a ohrožuje dítě dehydratací, dehiscencí operační rány a následným krvácením. Dochází k prodloužení pobytu na dospávacím pokoji a celkové doby hospitalizace. Management PONV spočívá v identifikaci rizikových pacientů a zahájení adekvátní prevence. Lékem volby je dexametazon nebo ondansetron, u vysoce rizikových dětí jejich kombinace. V případě selhání prevence je indikace k podání antiemetika z jiné farmakologické skupiny.
Postoperative nausea and vomiting (PONV) is a common postoperative complication with overall incidence of 20-30 %, however, with high risk procedures it increases up to 80 %. PONV is the main cause of the patient ́s discomfort, worsens perioperative morbidity and put the child at risk of dehydratation, dehiscence of surgical wound and bleeding. PONV prolongs the lenght of stay (PACU, in-hospital care). The cornerstone of PONV management is the identification of high risk pediatric patients and an adequate pre-operative pharmacological prevention. Dexamethasone and ondansetron (or their combination) are the first line medications. In case of failure, rescue therapy should be provided with other pharmacological agents.
- MeSH
- antiemetika MeSH
- dexamethason aplikace a dávkování terapeutické užití MeSH
- dítě MeSH
- lidé MeSH
- ondansetron aplikace a dávkování terapeutické užití MeSH
- pooperační nevolnost a zvracení * diagnóza farmakoterapie prevence a kontrola MeSH
- rizikové faktory MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- Publikační typ
- přehledy MeSH
Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most severe form. The use of excessive ventilation forces can exacerbate the lung condition and lead to ventilator-induced lung injury (VILI); mechanical energy (ME) or power can characterize such forces applied during MV. The ME metric combines all MV parameters affecting the respiratory system (ie, lungs, chest, and airways) into a single value. Besides evaluating the overall ME, this parameter can be also related to patient-specific characteristics, such as lung compliance or patient weight, which can further improve the value of ME for characterizing the aggressiveness of lung ventilation. High ME is associated with poor outcomes and could be used as a prognostic parameter and indicator of the risk of VILI. ME is rarely determined in everyday practice because the calculations are complicated and based on multiple equations. Although low ME does not conclusively prevent the possibility of VILI (eg, due to the lung inhomogeneity and preexisting damage), individualization of MV settings considering ME appears to improve outcomes. This article aims to review the roles of bedside assessment of mechanical power, its relevance in mechanical ventilation, and its associations with treatment outcomes. In addition, we discuss methods for ME determination, aiming to propose the most suitable method for bedside application of the ME concept in everyday practice.
- MeSH
- agrese MeSH
- dýchání MeSH
- hrudník MeSH
- lidé MeSH
- poškození plic mechanickou ventilací * MeSH
- syndrom dechové tísně * MeSH
- umělé dýchání MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Postdischarge nausea and vomiting (PDNV) cause substantial pediatric morbidity with potentially serious postoperative complications. However, few studies have addressed PDNV prevention and treatment in pediatric patients. Here we searched the literature and processed it in a narrative review describing PDNV incidence, risk factors, and management in pediatric patients.. A successful strategy for reducing PDNV considers both the pharmacokinetics of the antiemetic agents and the principle of multimodal prophylaxis, utilizing agents of different pharmacologic classes. Since many highly effective antiemetic agents have relatively short half-lives, a different approach must be used to prevent PDNV. A combination of oral and intravenous medications with longer half-lives, such as palonosetron or aprepitant, can be used. In addition, we designed a prospective observational study with the primary objective of determining PDNV incidence. In our study group of 205 children, the overall PDNV incidence was 14.6% (30 of 205), including 21 children suffering from nausea and 9 suffering from vomiting.
- MeSH
- antiemetika * terapeutické užití MeSH
- dítě MeSH
- lidé MeSH
- následná péče MeSH
- pooperační nevolnost a zvracení prevence a kontrola farmakoterapie MeSH
- pozorovací studie jako téma MeSH
- propuštění pacienta MeSH
- prospektivní studie MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Patient self-inflicted lung injury (P-SILI) is a life-threatening condition arising from excessive respiratory effort and work of breathing in patients with lung injury. The pathophysiology of P-SILI involves factors related to the underlying lung pathology and vigorous respiratory effort. P-SILI might develop both during spontaneous breathing and mechanical ventilation with preserved spontaneous respiratory activity. In spontaneously breathing patients, clinical signs of increased work of breathing and scales developed for early detection of potentially harmful effort might help clinicians prevent unnecessary intubation, while, on the contrary, identifying patients who would benefit from early intubation. In mechanically ventilated patients, several simple non-invasive methods for assessing the inspiratory effort exerted by the respiratory muscles were correlated with respiratory muscle pressure. In patients with signs of injurious respiratory effort, therapy aimed to minimize this problem has been demonstrated to prevent aggravation of lung injury and, therefore, improve the outcome of such patients. In this narrative review, we accumulated the current information on pathophysiology and early detection of vigorous respiratory effort. In addition, we proposed a simple algorithm for prevention and treatment of P-SILI that is easily applicable in clinical practice.
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.
- MeSH
- antikoagulancia škodlivé účinky MeSH
- antithrombiny terapeutické užití MeSH
- hemokoagulace MeSH
- heparin * škodlivé účinky MeSH
- lidé MeSH
- mimotělní membránová oxygenace * škodlivé účinky metody MeSH
- retrospektivní studie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Použití ECMO metod v posledních letech zaznamenalo významný rozmach především kvůli pandemii SARS‐CoV- 2. Mnoho pracovišť, která měla s ECMO jen malé, nebo žádné zkušenosti, aktuálně vlastní příslušnou přístrojovou techniku a jsou schopna tuto metodu použít v reálné klinické praxi. Pronační poloha (PP) se z původní pozice záchranné intervence dostala na přední místo mezi metodami, které by měly být již standardně použity u pacientů s těžkou formou akutního respirační ho selhání. Kombinace pronace a ECMO podpory měli v posledních letech značnou pozornost. Z tohoto důvodu se tento text, ač rokem v přehledu 2022, stručně ve své první části zabývá shrnutím medicíny založené na důkazech publikací za posledních několik let věnujících se tomuto tématu. Použití PP i v jiných klinických stavech než v rámci umělé plicní ven tilace (UPV), např. u pacientů při vědomí na neinvazivní ventilační podpoře, je popsáno v další části tohoto textu. Dalším tématem je práce týkající se správného nastavení UPV v při použití PP a vliv PP u těhotných pacientek s covidem-19. Inha lační preparáty a jejich užití k sedaci pacientů na UPV aktuálně patří k často diskutovaným tématům v rámci optimalizace intenzivní péče. Naopak ventilátorem indukovaná dysfunkce hlavních dýchacích svalů, především bránice, je v rámci kritické péče závažným tématem již delší dobu. V rámci UPV, ale i při použití extrakorporální membránové oxygenace (ECMO) je pacient vystaven riziku hyperoxemie. Negativní vliv tohoto stavu v rámci UPV, ale i během ECMO podpory, je závěrečným tématem tohoto článku.
The use of ECMO methods has experienced a significant boom in recent years, mainly due to the SARS-CoV-2 pandemic. Many workplaces that had little or no experience with ECMO currently possess the relevant technology and can use this method in real clinical practice. The prone position (PP) has changed from the original position of rescue intervention to the leading position among the methods that should be considered standard in patients with a severe form of acute respiratory failure. Thus, the combination of pronation and ECMO support has received considerable attention in recent years. This text, although a year in the 2022 review, briefly discusses available evidence-based medicine publications over the past few years devoted to this topic. The use of PP in clinical conditions other than mechanical ventilation (MV), e.g. in conscious patients on non-invasive ventilatory support, is described in the next section of this text. Another topic is the correct setting of MV while using PP and the effect of PP in pregnant patients with COVID-19. Inhalational anesthetics and their use for sedation of patients on UPV are currently among the frequently discussed topics within the optimization of intensive care. Conversely, ventilator-induced dysfunction of the main respiratory muscles, especially the diaphragm, has been a serious topic in critical care for a long time. Next, critically ill patients are at risk of hyperoxemia both as part of MV and ECMO support. The negative impact of this condition is the final topic of the article.
