Anesthesia and analgesia
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Anesthesia and analgesia · Jun 2004
Comparative StudyBrief postoperative delirium in hip fracture patients affects functional outcome at three months.
It is unclear how brief postoperative delirium (DEL) affects functional outcomes. In this study, we sought to determine if patients with brief postoperative DEL (<6-wk duration) have different living situations when compared with non-DEL patients after hip fracture repair. In a prospective study, patients admitted to the geriatric hip fracture service were assessed every postoperative day for the presence of DEL using the confusion assessment method (CAM) score. Patients were reassessed at 6 wk and 3 mo postoperatively for CAM score, current living situation, and activities of daily living. Group comparisons were tested after dividing patients into two groups: DEL (DEL; [+] CAM at any time during the postoperative period while in the hospital); no-DEL (no DEL; [-] CAM throughout the postoperative period while in the hospital). The study included 92 patients of whom 26 (28%) were CAM (+) after surgery. At 6 wk follow-up, n = 81; at 3 mo follow-up, n = 76. Eight patients died during the study. At 6 wk and 3 mo, a larger percentage of DEL patients were not living with a family member (27% versus 8% patients not living with a family member at 3 mo follow-up in DEL and no-DEL, respectively). There was no difference in activities of daily living by 3 mo. We conclude that brief postoperative DEL lasting <6 wk is a determining factor for poor long-term functional outcome after hip fracture repair, because it significantly impacts the ability to live independently. ⋯ Brief postoperative delirium lasting <6 wk is a determining factor for poor long-term functional outcome after hip fracture repair, because it significantly impacts the ability to live independently.
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Anesthesia and analgesia · Jun 2004
Comparative StudyHeparinase-modified thrombelastography in term and preterm neonates.
Thrombelastography (TEG) appears to be a promising test to assess coagulation in infants and children. TEG enables a rapid assessment of hemostatic function with only 300 microL of whole blood and provides information about plasmatic coagulation, platelet function, and fibrinolysis. In this study, we used TEG to assess the coagulation system of preterm and term neonates to determine the effects of their deficient coagulation factor levels on global hemostatic function. Heparinase-modified TEG, platelet and red blood cell count, plasma fibrinogen, and prothrombin time were assessed in four groups of clinically stable infants: severely preterm (gestational age [GA], 27-31 wk), moderately preterm (GA, 32-36 wk), term (GA, 36-40 wk), and former preterm (corrected GA, 34-40 wk). Healthy adult volunteers served as a control group. When compared with the adult group, thromboelastography revealed no defects in coagulation from groups of clinically stable infants, documenting the functional integrity of coagulation despite, in part, decreased conventional coagulation variables. Because clinically stable preterm and term infants show a relatively small incidence of bleeding, despite prolonged conventional coagulation tests, TEG may better reflect the hemostatic potential of these patients compared with conventional coagulation tests. ⋯ This study assessed the coagulation of preterm and term infants by thrombelastography and found functional integrity of coagulation despite, in part, decreased conventional coagulation variables.
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Anesthesia and analgesia · Jun 2004
Comparative StudyMuscular injury after succinylcholine and electroconvulsive therapy.
Both succinylcholine and seizures cause muscular injury during electroconvulsive therapy. We compared the muscular damage in two groups of patients. The psychiatric patient group received succinylcholine for electroconvulsive therapy. The surgical patient group received succinylcholine for endotracheal intubation. Serum myoglobin was measured as a marker for muscular injury and myalgic symptoms were also recorded. Serum myoglobin increased from baseline in both groups at 5 and 20 min. The surgical patients, however, had a higher myoglobin level than the psychiatric patients at 5 and 20 min after the administration of succinylcholine (P < 0.001). The median (range) of myoglobin concentration at 20 min in psychiatric patients was 32.6 (23.1-60.1) ng/mL, compared with 61.2 (31.6-1687.0) ng/mL in surgical patients. The incidence of myalgia was not different between the two groups. In conclusion, we unexpectedly conclude that the psychiatric patients who received electroconvulsive therapy had less effect of muscular damage associated with succinylcholine than the surgical patients did. ⋯ Both succinylcholine and electroconvulsive therapy cause muscular injury. However, we unexpectedly found that psychiatric patients who received succinylcholine and electroconvulsive therapy had less muscular damage than surgical patients who received succinylcholine for intubation. Therefore, appropriate use of succinylcholine can attenuate the muscular damaging effect from the therapy.
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Anesthesia and analgesia · Jun 2004
A simple, fast, easy method to identify the evidence base in pain-relief research: validation of a computer search strategy used alone to identify quality randomized controlled trials.
Clinicians need a simple, fast, reliable, and inexpensive way of identifying the evidence base relevant to their clinical practice. It is often believed that the only way to identify all relevant evidence is to perform hand-searches of the literature to supplement computer searches; this is complex and labor intensive. However, most of quality randomized controlled trials cited in systematic reviews in pain medicine are listed in computer databases. We performed two studies to investigate the efficiency-in terms of sensitivity, specificity, and precision-of three computer search strategies: Optimally Sensitive Search Strategy, which is used by the Cochrane Collaboration; RCT.pt, a standard MEDLINE strategy; and DBRCT.af, which is a new single-line computer algorithm based on the assumption that double-blinded, randomized controlled trials would be indexed with "double-blind," "random," or variations of these terms in MEDLINE and EMBASE. DBRCT.af was found to be highly sensitive (97%) in identifying quality randomized controlled trials in pain medicine. The precision (ratio of randomized controlled trials to the number of nonrandomized trials identified) was 82%, and the specificity in excluding the nonrandomized controlled trials was 98%. We conclude that clinicians can now use DBRCT.af to update and conduct de novo systematic reviews in pain-relief research. ⋯ Quality evidence about what is good clinical practice in pain treatment is buried in the medical literature among large quantities of other information. This article describes how any clinician with access to the Internet can identify those quality studies reliably, quickly, and inexpensively.
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Anesthesia and analgesia · Jun 2004
Comparative StudyTreatment of uncontrolled hemorrhagic shock after liver trauma: fatal effects of fluid resuscitation versus improved outcome after vasopressin.
In a porcine model of uncontrolled hemorrhagic shock, we evaluated the effects of vasopressin versus an equal volume of saline placebo versus fluid resuscitation on hemodynamic variables and short-term survival. Twenty-one anesthetized pigs were subjected to severe liver injury. When mean arterial blood pressure was <20 mm Hg and heart rate decreased, pigs randomly received either vasopressin IV (0.4 U/kg; n = 7), an equal volume of saline placebo (n = 7), or fluid resuscitation (1000 mL each of lactated Ringer's solution and hetastarch; n = 7). Thirty minutes after intervention, surviving pigs were fluid resuscitated while bleeding was surgically controlled. Mean (+/- SEM) arterial blood pressure 5 min after the intervention was significantly (P < 0.05) higher after vasopressin than with saline placebo or fluid resuscitation (58 +/- 9 versus 7 +/- 3 versus 32 +/- 6 mm Hg, respectively). Vasopressin improved abdominal organ blood flow but did not cause further blood loss (vasopressin versus saline placebo versus fluid resuscitation 10 min after intervention, 1343 +/- 60 versus 1350 +/- 22 versus 2536 +/- 93 mL, respectively; P < 0.01). Seven of 7 vasopressin pigs survived until bleeding was controlled and 60 min thereafter, whereas 7 of 7 saline placebo and 7 of 7 fluid resuscitation pigs died (P < 0.01). We conclude that vasopressin, but not saline placebo or fluid resuscitation, significantly improves short-term survival during uncontrolled hemorrhagic shock. ⋯ Although IV fluid administration is the mainstay of nonsurgical management of trauma patients with uncontrolled hemorrhagic shock, the efficacy of this strategy has been discussed controversially. In this animal model of severe liver trauma with uncontrolled hemorrhagic shock, vasopressin, but not saline placebo or fluid resuscitation, improved short-term survival.