Effects of age on onset time and duration of sensory blockade in ultrasound guided supraclavicular block Abstract

Background and purpose: Involutive changes of brachial plexus occur with aging. The aim of this study was to determine if these changes would effect onset time and duration of sensory blockade in all four distal nerves of brachial plexus in middle aged (65 years). Materials and methods: Middle aged (N=22) and elderly patients (N=22) undergoing upper limb surgery received an ultrasound guided supraclavicular block with a mixture of local anesthetics (50 : 50, 0.5% levobupivacaine, 2% lidocaine). The prospective, observer-blinded study method is a previously validated step-up/step-down sequential model where the local anesthetic volume for each following patient is determined by the outcome of the previous block. The starting volume was 30 ml. Only the blocks with complete sensory blockade in all four regions of distal nerves were analyzed for the onset time and duration of sensory blockade. Results and conclusions: The mean (SD) block onset time was 25.8±0.6 min and the mean (SD) block duration was 151.5±8.9 min in the entire middle aged group. In the entire elderly group, the mean (SD) block onset time was 21±0.82 min and the mean (SD) block duration was 195.75±14.99 min. The difference in both, onset time and duration was significant (P=0.0002, 95%CI 3.352–6.248; P=0.0023, 95% CI 65.63–22.95, respectively). In conclusion, local anesthetics have a faster onset time and longer duration of sensory blockade in elderly due to alterations of peripheral nerves and increased sensitivity to local anesthetics

ACUTE RESPIRATORY DISTRESS SYNDROME AND OTHER RESPIRATORY DISORDERS IN SEPSIS

Akutni respiracijski distresni sindrom (ARDS) se uobičajeno razvija u bolesnika s prisutnim rizičnim čimbenicima (npr. sepsa, pneumonija, akutni pankreatitis, politrauma, višestruke transfuzije krvi i krvnih pripravaka i sl.) koji aktiviraju sustavni upalni odgovor. Sepsa je jedan od najčešćih čimbenika koji može dovesti do razvoja ARDS-a. ARDS povezan sa sepsom pokazuje sporiji oporavak plućne funkcije uz manju uspješnost odvajanja bolesnika od strojne ventilacije. Vrlo je važno uz sve ostale mjere liječenja sepse obratiti posebnu pozornost optimalizaciji strojne respiracijske potpore u skladu s trenutnim stanjem pluća. Svake je godine dostupno sve više podataka o mogućnostima liječenja bolesnika s ARDS-om uz pomoć posebno prilagođenih načina strojne ventilacije pri čemu važnu ulogu imaju: izbor optimalnog poštednog modaliteta, primjena potpomognute ventilacije i adekvatno podešavanje pozitivnog tlaka na kraju izdaha (engl. positive end-expiratory pressure - PEEP). Međutim, što iz ovih eksperimentalnih i kliničkih podataka možemo prenijeti u svakodnevnu kliničku praksu? U ovom članku izneseni su načini adekvatne prilagodbe poštedne ventilacije kao mjere s dokazanim učinkom na smanjenje mortaliteta ove skupine bolesnika ako se sustavno i dosljedno primjenjuje.Acute respiratory distress syndrome (ARDS) develops in patients with predisposing conditions that induce systemic infl ammatory response such as sepsis, pneumonia, acute pancreatitis, major trauma, or multiple transfusions. Sepsis is the most common cause of ARDS. Sepsis-related ARDS patients have signifi cantly lower PaO2 /FiO2 ratios than patients with non-sepsis-related ARDS. Furthermore, their recovery from lung injury is prolonged, weaning from mechanical ventilation less successful, and extubation rate slower. Clinical outcomes in patients with sepsis-related ARDS are also worse, associated with signifi cantly higher 28-day and 60-day mortality rates (31.1% vs. 16.3% and 38.2% vs. 22.6%, respectively). It is extremely important to optimally adjust ventilator setting to current condition of lungs, while providing all other therapeutic measures in the treatment of sepsis, severe sepsis and septic shock. The pool of data on treatment possibilities for patients with ARDS grows every year, with specifi cally designed mechanical ventilation strategies. Ventilator modes and adequate positive end-expiratory pressure (PEEP) settings play a major role in these strategies. However, how can we best apply these experimental and clinical data to everyday clinical practice? This article emphasizes protective ventilation as a measure that is proven to reduce mortality in this group of patients, when systematically and consistently applied

Intraoperative transfusion practices in Europe

© 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.Background: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. Methods: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. Results: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl-1 and increased to 9.8 (1.8) g dl-1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Conclusions: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl-1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1–2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08–1.15) and the HR for discharge was 0.78 (95% CI: 0.74–0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05–1.15) and HR for discharge was 0.82 (95% CI: 0.78–0.87). Preoperative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended