Anesthesia and analgesia
Randomized Controlled Trial Comparative Study
I.v. bolus oxytocin is used routinely during cesarean delivery to prevent postpartum hemorrhage. Its adverse hemodynamic effects are well known, resulting in a recent change in dose from 10 IU to 5. Whether a 5 IU bolus has any advantages over infusion alone is unclear. We tested the hypothesis that a 5 IU i.v. bolus of oxytocin before the initiation of a continuous infusion decreases the need for additional uterotonic drugs in the first 24 hours after delivery in women with risk factors for uterine atony undergoing cesarean delivery, compared with infusion alone. ⋯ We found that a 5 IU i.v. bolus of oxytocin added to an infusion did not alter the need for additional uterotonic drugs to prevent or treat postpartum hemorrhage in the first 24 hours in women undergoing cesarean delivery with risk factors for uterine atony, despite causing an initial stronger uterine contraction. Our study was not powered to find a difference in side effects between groups. These results suggest that an oxytocin infusion may be adequate without the need for a bolus, even in high-risk patients.
On January 12, 2010, a 7.0 M(L) earthquake devastated Haiti, the most impoverished nation in the Western hemisphere with extremely limited health care resources. We traveled to Milot, Haiti situated north of Port-au-Prince, to care for injured patients at Hôpital Sacré Coeur, an undamaged hospital with 74 beds and 2 operating rooms. The massive influx of patients brought by helicopter from the earthquake zone transformed the hospital to >400 beds and 6 operating rooms. ⋯ Postoperative care was limited to an 8-bed postanesthesia care unit/intensive care unit caring for patients with tetanus, diabetic ketoacidosis, pulmonary aspiration, acute renal failure due to crush, extreme anemia, sepsis, and other illnesses. Other important aspects of this journey included the professionalism of the health care personnel who prioritized patient care, adaptation to limited laboratory and radiological services, and provision of living arrangements. Although challenging from many perspectives, the experience was emotionally enriching and recalls the fundamental reasons why we selected medicine and anesthesiology as a profession.
The ability of an infusion set to deliver a specific amount of drug to the patient can be directly related to the presence of an antireflux valve and dead-space volume. In this study we quantified separately the impact of these 2 components on drug delivery. ⋯ Care providers must consider dead-space volume and the presence of an antireflux valve when choosing their infusion sets.
Randomized Controlled Trial
Dexmedetomidine is a highly selective α(2)-adrenoceptor agonist with sedative, anxiolytic, and analgesic properties that has minimal effects on respiratory drive. Its sedative and hypotensive effects are mediated via central α(2A) and imidazoline type 1 receptors while activation of peripheral α(2B)-adrenoceptors result in an increase in arterial blood pressure and systemic vascular resistance. In this randomized, prospective, clinical study, we attempted to quantify the short-term hemodynamic effects resulting from a rapid i.v. bolus administration of dexmedetomidine in pediatric cardiac transplant patients. ⋯ Rapid i.v. bolus administration of dexmedetomidine in this small sample of children having undergone heart transplants was clinically well tolerated, although it resulted in a transient but significant increase in systemic and pulmonary pressure and a decrease in HR. In the systemic system, there is a larger percent increase in the diastolic pressures than the systolic pressures and, furthermore, these transient increases in pressures were more pronounced in the systemic system than in the pulmonary system.
Women in labor who receive epidural analgesia are more likely to experience hyperthermia and overt clinical fever. The gradual development of modest hyperthermia observed in laboring women with epidural analgesia is not seen in those electing other forms of analgesia or unmedicated labor. Clinical fever is also far more likely in women laboring with epidural analgesia. ⋯ More ominously, maternal inflammatory fever is associated with neonatal brain injury, manifest as cerebral palsy, encephalopathy, and learning deficits in later childhood. At present, there are no safe and effective means to inhibit epidural-associated fever. Future research should define the etiology of this fever and search for safe and effective interventions to prevent it and to inhibit its potential adverse effects on the neonatal brain.