Area Under the Curve of Finger Photoplethysmography as an Evaluation Measure for Sympathetic Activity During Lumbar Epidural Anaesthesia.

OBJECTIVE: To detect changes in finger photoplethysmography after administration of epidural anaesthesia as a surrogate method for evaluating autonomic nervous system activity. METHODS: We included a total of 46 patients scheduled for elective surgical procedures under lumbar epidural anaesthesia. A Biopac SS4LA pulse plethysmograph transducer was used for photoplethysmography recording, and the device was placed on the first toe of the right leg. The first standard lead of the electrocardiogram was simultaneously measured with the finger photoplethysmography. First measurement was done before the administration of epidural anaesthesia, and second measurement was done 25 minutes post administration of epidural anaesthesia. RESULTS: The area under the curve of the finger photoplethysmography statistically significantly increased 25 minutes after administration of epidural anaesthesia compared with the first measurement (p=0.0001). The amplitude of the finger photoplethysmography as well as the pulse transit time also statistically significantly increased after administration of epidural anaesthesia. CONCLUSION: The area under the curve reflects the changes in sympathetic activity after epidural anaesthesia below the block level. It can be used for the detection of the degree of sympathetic block and, respectively, for epidural block success. Future prospects include detection of sympathetic block cessation as an indicator for discharge from the awakening room and beginning of patient verticalisation.

Postantibiotic effect of colistin alone and combined with vancomycin or meropenem against Acinetobacter spp. with well defined resistance mechanisms.

Previous studies found short postantibiotic effect of colistin on Acinetobacter baumannii. Many studies have evaluated the potential for synergy between colistin and other antibiotics against A. baumannii. The aim of this study was to determine in vitro synergy and postantibiotic effect (PAE) of colistin alone and combined with other antibiotics (vancomycin or meropenem) against eight carbapenem-non-susceptible Acinetobacter spp. strains with defined resistance mechanisms. It was hypothesised that vancomycin or meropenem would prologue the PAE of colistin since it was previously found that they exert synergism with colistin in time-kill kinetics and chequerboard analysis. After exposure of 1 hour colistin alone exhibited the negative ( - 0.07 hour) (OXA-143), short (0.2-1.82 hours) (OXA-24, OXA-58, OXA-72, VIM-1+OXA-23, OXA-58+NDM-1, ISAba1/OXA-69) or moderate PAE (3.2 hours) for OXA-23 positive strain. When combined with vancomycin, the PAE was moderate (1.7-4 hours) with OXA-23, OXA-23+VIM-1, OXA-72 and OXA-24 positive strains while with OXA-58, OXA-143, OXA-58/NDM-1 and ISAba1/OXA-69 positive strains, it was not possible to calculate mean duration of PAE because there was no regrowth after exposure to antibiotics or it was longer than 5 hours. The combination with meropenem resulted in short (0.2 hours) (OXA-143), moderate (2.4-3.73 hours) (OXA-24, OXA-58, OXA-23, OXA-23+VIM-1), long PAE of 5 hours (OXA-23) or longer than 5 hours (OXA-58+VIM-1, ISAba1/OXA-69). From the clinical point of view, the prolongation of colistin PAE when combined with other antibiotics could provide a rationale for the modification of the dosing interval and could be important for the optimization of the treatment regimen and the minimization of drug-induced side effects.

Acute Coronary Syndrome with ST-segment Elevation in Pregnancy: Anesthetic Management of Delivery.

Acute coronary syndrome (ACS) during pregnancy is rare but may be associated with high risk complications. Approximately 150 myocardial infarctions (MI) during pregnancy have been documented in literature worldwide, but we didn't find one with myocardial aneurysm. We describe 2 patients with acute MI; both with ST segment elevation (STEMI), 1 case complicated with heart failure, formation of a myocardial aneurysm and broad QRS arrhythmia; another with uncomplicated course, and their anesthetic management during delivery. Acute MI is rare in reproductive age usually developing in women with cardiovascular risk factors. There is concern about its rising incidence due to the increase of average maternal age. Our cases show that there might be some undiscovered risk factors for pregnancy related myocardial infarction.

[Sympathetic activity of S-(+)-ketamine low doses in the epidural space]. / Atividade simpática de cetamina S-(+) em doses baixas no espaço epidural.

BACKGROUND AND OBJECTIVES: S-(+)-ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S-(+)-ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S-(+)-ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block. METHODS: The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S-(+)-ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non-competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann-Whitney U-test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects. RESULTS: 40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S-(+)-ketamine. Value p<0.05 has been taken as a limit of statistical significance. CONCLUSIONS: Low dose of S-(+)-ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S-(+)-ketamine administered epidurally did not deepen sympathetic block. Adding 25mg of S-(+)-ketamine to 0.5% bupivacaine does not deprive sympathetic tonus below the level of epidural block at the moment of most expressed sympathetic block and has no effect on sympathetic tonus above the block level.

Peripheral arterial catheter related infections in the neurosurgical intensive care unit.

Intravascular device infections could be serious complications with significant contributable morbidity and mortality. The aim of this prospective clinical study is to demonstrate the infection rate related to peripheral arterial catheters and their clinical significance in neurosurgical intensive care unit (ICU) patients. After removal, all arterial catheter tips were cultivated by semiquantitative method and clinical data were collected. During a period of two years, 186 arterial catheters were placed in 105 neurosurgical ICU patients. In 6 cases (3.2%) infection was presumably related to the arterial catheter. The rate of such probable catheter related infections was found to be 5/1000 catheter days. The isolated microorganisms were: Methicillin resistant Staphylococcus epidermidis (MRSE) in 4 cases, Corynebacterium species and Candida albicans each in one case respectively. Thirteen cases (7.0%) were interpreted as contamination and one as colonization. An association was found between the presence of infection from different sources and significant bacterial growth on the catheter. Patients with positive catheter culture had a significantly longer ICU stay, more cumulative catheter days, and a higher mortality rate than those with sterile catheters. We can conclude that the rate of probable peripheral arterial catheter related infection is low. A higher mortality rate in patients who experienced probable catheter related infection does not seem to be a consequence of the aforementioned infection. A more suitable explanation would be that patients with nosocomial infections and higher mortality risk have prolonged ICU stays. There is an increased chance of developing a catheter related infection in those patients who have more cumulative catheter days.

Sympathetic activity of S-(+)-ketamine low doses in the epidural space.

BACKGROUND AND OBJECTIVES: S-(+)-ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S-(+)-ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S-(+)-ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block. METHODS: The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S-(+)-ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non-competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann-Whitney U-test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects. RESULTS: 40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S-(+)-ketamine. Value p<0.05 has been taken as a limit of statistical significance. CONCLUSIONS: Low dose of S-(+)-ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S-(+)-ketamine administered epidurally did not deepen sympathetic block. Adding 25mg of S-(+)-ketamine to 0.5% bupivacaine does not deprive sympathetic tonus below the level of epidural block at the moment of most expressed sympathetic block and has no effect on sympathetic tonus above the block level.

Sympathetic activity of S-(+)-ketamine low doses in the epidural space / Atividade simpática de cetamina S-(+) em doses baixas no espaço epidural / Actividad simpática de la ketamina S(+)-en dosis bajas en el espacio epidural

BACKGROUND AND OBJECTIVES: S-(+)-ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S-(+)-ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S-(+)-ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block. METHODS: The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S-(+)-ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non-competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann-Whitney U-test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects. RESULTS: 40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S-(+)-ketamine. Value p < 0.05 has been taken as a limit of statistical significance. CONCLUSIONS: Low dose of S-(+)-ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S-(+)-ketamine administered epidurally did not deepen sympathetic block. Adding 25 ...

JUSTIFICATIVA E OBJETIVOS: cetamina S-(+) é um anestésico intravenoso e simpaticomimético com propriedades de anestésico local. Tem efeito analgésico e de anestésico local quando administrada por via epidural, mas não há dados que relatem se cetamina S-(+) em doses baixas tem efeitos simpaticomiméticos. O objetivo deste estudo foi determinar se cetamina S-(+) em doses baixas, administrada por via epidural em combinação com anestésico local, tem algum efeito sobre o sistema nervoso simpático, tanto sistêmico quanto abaixo do nível do bloqueio anestésico. MÉTODOS: o estudo foi conduzido com dois grupos de pacientes submetidos à anestesia epidural. Anestesia local (bupivacaína a 0,5) foi administrada a um grupo (controle), enquanto anestesia local em combinação com cetamina S-(+) foi administrada ao outro grupo (teste). Idade, altura, peso, pressão arterial sistólica e diastólica e pressão arterial média foram medidos. O método imunoquímico de inibição enzimática não competitiva (Cat Combi Elisa) foi usado para determinar as concentrações de catecolaminas (adrenalina e noradrenalina). O ensaio imunoenzimométrico com substrato luminescente em uma máquina chamada Vitros Eci foi usado para determinar a concentração de cortisol. O tempo de transição do pulso foi medido com fotopletismografia. Para análise estatística, os testes de Wilcoxon, U de Mann-Whitney e Anova de Friedman foram usados. Pressão arterial, pulso e concentrações de adrenalina, noradrenalina e cortisol foram medidos para estimar os efeitos simpáticos sistêmicos. RESULTADOS: receberam bupivacaína a 5% 40 pacientes do grupo controle e 40 do grupo teste receberam bupivacaína a 0,5% com cetamina S-(+). Um valor de p < 0,05 foi ...

JUSTIFICACIÓN Y OBJETIVOS: la ketamina S(+) es un anestésico intravenoso y simpaticomimético con propiedades de anestésico local. Posee un efecto analgésico y de anestésico local cuando se administra por vía epidural, pero no existen datos que informen si la ketamina S(+) en bajas dosis tiene efectos simpaticomiméticos. El objetivo de este estudio fue determinar si la ketamina S(+) en bajas dosis y administrada por vía epidural en combinación con el anestésico local tiene algún efecto sobre el sistema nervioso simpático, tanto sistémico como por debajo del nivel del bloqueo anestésico. MÉTODOS: el estudio fue realizado con 2 grupos de pacientes sometidos a anestesia epidural. A un grupo (grupo control) se le administró la anestesia local (bupivacaína al 0,5), mientras que a otro se le administró la anestesia local en combinación con la ketamina S(+). La edad, altura, peso, presión arterial sistólica y diastólica y la presión arterial media se midieron. El método inmunoquímico de inhibición enzimática no competitiva (Cat Combi ELISA) se usó para determinar las concentraciones de catecolaminas (adrenalina y noradrenalina). El ensayo inmunoenzimométrico con sustrato lumínico en una máquina llamada Vitros Eci fue usado para determinar la concentración de cortisol. El tiempo de transición del pulso fue medido usando la fotopletismografía. Para el análisis estadístico se usaron los test de Wilcoxon, U de Mann-Whitney y ANOVA de Friedman. La presión arterial, pulso y concentraciones de adrenalina, noradrenalina y cortisol fueron medidos para estimar los efectos simpáticos sistémicos. RESULTADOS: cuarenta pacientes del grupo control recibieron bupivacaína al 5% y 40 pacientes del grupo test recibieron bupivacaína al 0,5% con ketamina ...

Empirical antibiotic therapy of sepsis in surgical intensive care unit.

Retrospective study was conducted in surgical intensive care unit (ICU) in Clinical Hospital Center Zagreb in 2005. The aim of study was to create guidelines for empirical antibiotic therapy of sepsis in ICU for unknown causative agent based on antimicrobial susceptibility of causative bacteria. Thirty-two patients with severe sepsis were included in study and from medical records their clinical and microbiological data were analyzed. Antimicrobial susceptibility of the strains isolated from the blood-culture was tested by disk diffusion method according to CLSI (Clinical Laboratory Standard Institution). We used APACHE II score to predict the severity of illness. Mann-Whitney test and chi2 test were used to test statistical significance difference between results. Acinetobacter baumannii and Pseudomonas aeruginosa were the predominant causative agent. Acinetobacter baumannii was displaying excellent susceptibility to ampicillin+sulbactam and carbapenems, whereas Pseudomonas aeruginosa was showed good susceptibility on ceftazidim and carbapenems. Methicillin-resistant Staphylococcus aureus (MRSA), third predominant causative agent exhibiting good susceptibility to vancomycin and linezolide. The recommended therapy is empirical antibiotic therapy and should cover all important pathogens.

Microbiological surveillance of the surgical intensive care unit in Zagreb--a pivot for guideline-based therapy of severe sepsis.

The aim of this retrospective study was to create guidelines for therapy of severe sepsis in surgical intensive care unit (ICU) for unknown causative agent based on antimicrobial susceptibility of causative bacteria. Seventy-four patients with severe sepsis from surgical ICU in 2003.-2005. were included in study. Their clinical and microbiological data were analyzed from the medical records. Antimicrobial susceptibility of the strains isolated from the blood-culture was tested by disk diffusion method according to CLSI (Clinical Laboratory Standard Institution). APACHE II score was used to predict the severity of illness. Statistical significance difference between results was tested by Mann-Whitney test and chi2 test. Important problem remained type of sepsis: mono-agent sepsis presented less therapeutic problem than sepsis caused with two or more agents (mixed sepsis). Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa and Acinetobacter baumannii were predominant causative agents in both type of sepsis. There was remarkable increase of A. baumannii prevalence in 2005 compared to 2004 and to 2003. There was also decrease of MRSA prevalence in 2004 and 2005 compared to 2003. P. aeruginosa were the predominant causative agents in 2004. MRSA displayed good susceptibility to vancomycin and linezolide, whereas P. aeruginosa showed excellent susceptibility to ceftazidime and carbapenems. A. baumannii, third predominant causative agent, exhibited excellent susceptibility to ampicillin+ sulbactam and carbapenems. The recommended therapy is empirical and should cover all important pathogens.

Hyperbaric oxygenation combined with streptokinase for treatment of arterial thromboembolism of the lower leg.

Thromboembolic occlusion of peripheral arteries is a common problem in patients referred to vascular surgery departments. Standard treatments include catheter aspiration techniques, use of fibrinolytic agents and surgical thrombendarterectomy. Recent reports have described the use of hyperbaric oxygen therapy in patients with limb ischemia, yet their main focus has been on patients with chronic disorders. We present the case of a 74-year-old woman with atrial fibrillation and acute thromboembolic occlusion of the posterior tibial artery. The patient presented with severe pain in the right calf, unresponsive to non-opioid parenteral analgesia and accompanied by coldness, numbness and partial motor palsy of the right foot. After 60 minutes of oxygenation in a hyperbaric chamber with a pressure of 2.2 bar, the pain receded, although without signs of restored blood flow in the occluded artery. After fibrinolytic therapy with streptokinase, patency of the posterior tibial artery was verified by return of palpable pulsations and color Doppler ultrasonography. By combining hyperbaric oxygenation and streptokinase in the treatment of lower-leg arterial thromboembolism we achieved regression of ischemic pain, prolongation of the survival time of tissues compromised by ischemia and resolved the cause of the ischemia. We believe the use of this therapeutic strategy in selected cases of peripheral arterial thromboembolism is justified.