Nursing Programme (original) (raw)
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Continuous infusion of propofol for sedation of pediatric patients following open-heart surgery
Critical Care
Background: Whole body hyperthermia induced by radiative systems has been used in therapy of malignant diseases for more than ten years. Von Ardenne and co-workers have developed the 'systemiche Krebs-Mehrschritt-Therapic' (sKMT), a combined regime including whole body hyperthermia of 42°C, induced hyperglycaemia and relative hyperoxaemia with additional application of chemotherapy. This concept has been employed in a phase I/II clinical study for patients with metastatic colorectal carcinoma at the Virchow-Klinikum since January 1997. Methods: The sKMT concept was performed eleven times under intravenous general anaesthesia, avoiding volatile anaesthetics. Core temperatures of up to 42°C were reached stepwise by warming with infrared-A-radiation (IRATHERM 2000®). During the whole procedure blood glucose levels of 380-450 mg/dl were maintained as well as PaO 2 levels above 200 mmHg. Extensive invasive monitoring was performed in all patients including measurements with the REF-Ox-Pulmonary artery catheter with continuous measuring of mixed venous saturation (Baxter Explorer®) and invasive monitoring of arterial blood pressure. Data for calculation of hemodynamic and gas exchange parameters were collected four times, at temperatures of 37°C, 40°C, 41.8-42°C and 39°C, during measurements FiO 2 was 1.0 at all times. Fluids were given in order to keep central-venous and Wedge pressure within normal range during the whole procedure. Statistics were performed using the Wilcoxon Test. Results: Statistically significant differences were found between heart rate, cardiac index and systemic vascular resistance comparing data at 37°C and 42°C. Heart rate and cardiac index increased to a maximum at 42°C (P < 0.0001) whereas systemic vascular resistance had its minimum at 42°C (P < 0.0001). Mean arterial pressure dropped with increasing temperature, differences were not significant. Calculation of stroke volume index and ventricular volumes showed only a slight decrease in endsystolic volumes with increasing temperature, the resulting differences in right ventricular ejection fraction were marginally significant (P = 0.038) comparing 42°C to baseline. Right ventricular stroke work index as well as mean pulmonary arterial pressure increased at 42°C (P = 0.0115 and P = 0.0037), pulmonary vascular resistance only dropped little compared to systemic vascular resistance, left ventricular stroke work index even dropped with increasing temperature, though showing no significant difference. Values for mixed venous oxygen saturation did not vary during therapy, pulmonary right-left shunt showed a temperature associated increase (P = 0.0323) to a maximum at 42°C. Conclusion: Under the procedure of sKMT cardiac function in patients, who do not have any pre-existing cardiac impairment, can be maintained almost unchanged, ie with normal right and left ventricular pressure, despite an increase in right ventricular stroke work Acknowledegment: Supported by Deutsche Krebshilfe.
Part 12: Pediatric Advanced Life Support
Many key issues in the review of the pediatric advanced life support literature resulted in refinement of existing recommendations rather than in new recommendations. New information or updates are provided about fluid resuscitation in febrile illness, atropine use before tracheal intubation, use of amiodarone and lidocaine in shock-refractory VF/pVT, TTM after resuscitation from cardiac arrest in infants and children, and post–cardiac arrest management of blood pressure. In specific settings, when treating pediatric patients with febrile illnesses, the use of restrictive volumes of isotonic crystalloid leads to improved survival. This contrasts with traditional thinking that routine aggressive volume resuscitation is beneficial. Routine use of atropine as a premedication for emergency tracheal intubation in non-neonates, specifically to prevent arrhythmias, is controversial. Also, there are data to suggest that there is no minimum dose required for atropine for this indication. If invasive arterial blood pressure monitoring is already in place, it may be used to adjust CPR to achieve specific blood pressure targets for children in cardiac arrest. Amiodarone or lidocaine is an acceptable antiarrhythmic agent for shock-refractory pediatric VF and pVT in children. Epinephrine continues to be recommended as a vasopressor in pediatric cardiac arrest. For pediatric patients with cardiac diagnoses and IHCA in settings with existing extracorporeal membrane oxygenation protocols, ECPR may be considered. Fever should be avoided when caring for comatose children with ROSC after OHCA. A large randomized trial of therapeutic hypothermia for children with OHCA showed no difference in outcomes whether a period of moderate therapeutic hypothermia (with temperature maintained at 32°C to 34°C) or the strict maintenance of normothermia (with temperature maintained 36°C to 37.5°C) was provided. Several intra-arrest and post–cardiac arrest clinical variables were examined for prognostic significance. No single variable was identified to be sufficiently reliable to predict outcomes. Therefore, caretakers should consider multiple factors in trying to predict outcomes during cardiac arrest and in the post-ROSC setting. After ROSC, fluids and vasoactive infusions should be used to maintain a systolic blood pressure above the fifth percentile for age. After ROSC, normoxemia should be targeted. When the necessary equipment is available, oxygen administration should be weaned to target an oxyhemoglobin saturation of 94% to 99%. Hypoxemia should be strictly avoided. Ideally, oxygen should be titrated to a value appropriate to the specific patient condition. Likewise, after ROSC, the child's Paco should be targeted to a level appropriate to each patient's condition. Exposure to severe hypercapnia or hypocapnia should be avoided. 2 Recommendations for Fluid Resuscitation 2015 (New): Early, rapid IV administration of isotonic fluids is widely accepted as a cornerstone of therapy for septic shock. Recently, a large randomized controlled trial of fluid resuscitation conducted in children with severe febrile illnesses in a resource-limited setting found worse outcomes to be associated with IV fluid boluses. For children in shock, an initial fluid bolus of 20 mL/kg is reasonable. However, for children with febrile illness in settings with limited access to critical care resources (ie, mechanical ventilation and inotropic support), administration of bolus IV fluids should be undertaken with extreme caution, as it may be harmful. Individualized
Canadian Journal of Anaesthesia, 1995
The purpose of the studywas to compare cardiac output (CO) measurement by continuous (CTD) with that by conventional thermodilution (TD) in critically ill patients. In 19 of 20 critically ill patients requiring a pulmonary artery catheterism, 105 paired CO measurements were performed by both CTD and TD Regression analysis showed that: CTD CO = L18 TD CO -0.47. Correlation coefficient was 0.96. Bias and limit of agreement were -0.8 and 2.4 L" rain -1, respectively. When a Bland and Altman diagram was constructed according to cardiac index ranges, biases were -0.2 and -0.3 and-0.8 L" min -1" m -2 and limits of agreement were 0.3, 0.7 and L6 L. rain -1" ra -2 for low (<2.5 L" rain -1" m-2), normal (between 2.5 and 4.5 L" min -t" m -z) and high (~ 4.5 L" rain -t" m -z) cardiac indexes, respectively. It is concluded that CTD, compared with TD, is a reliable method of measuring CO especially when cardiac index is _<4.5 L" min -l" m -2.
Normothermia for Pediatric and Congenital Heart Surgery: An Expanded Horizon
Frontiers in Pediatrics, 2015
Cardiopulmonary bypass (CPB) in pediatric cardiac surgery is generally performed with hypothermia, flow reduction and hemodilution. From October 2013 to December 2014, 55 patients, median age 6 years (range 2 months to 52 years), median weight 18.5 kg (range 3.2-57 kg), underwent surgery with normothermic high flow CPB in a new unit.There were no early or late deaths. Fifty patients (90.9%) were extubated within 3 h, 3 (5.5%) within 24 h, and 2 (3.6%) within 48 h. Twenty-four patients (43.6%) did not require inotropic support, 31 (56.4%) received dopamine or dobutamine: 21 ≤5 mcg/kg/min, 8 5-10 mcg/kg/min, and 2 >10 mcg/kg/min. Two patients (6.5%) required noradrenaline 0.05-0.1 mcg/kg/min. On arrival to ICU and after 3 and 6 h and 8:00 a.m. the next morning, mean lactate levels were 1.9 ± 09, 2.0 ± 1.2, 1.6 ± 0.8, and 1.4 ± 0.7 mmol/L (0.6-5.2 mmol/L), respectively. From arrival to ICU to 8:00 a.m. the next morning mean urine output was 3.8 ± 1.5 mL/kg/h (0.7-7.6 mL/kg/h), and mean chest drainage was 0.6 ± 0.5 mL/kg/h (0.1-2.3 mL/kg/h). Mean ICU and hospital stay were 2.7 ± 1.4 days (2-8 days) and 7.2 ± 2.2 days (4-15 days), respectively. In conclusion, normothermic high flow CPB allows pediatric and congenital heart surgery with favorable outcomes even in a new unit. The immediate post-operative period is characterized by low requirement for inotropic and respiratory support, low lactate production, adequate urine output, minimal drainage from the chest drains, short ICU, and hospital stay.