Anesthesia and analgesia
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Anesthesia and analgesia · Sep 1998
Clinical TrialPredictive factors of outcome in severely traumatized children.
To identify risk factors associated with death in traumatized children, we prospectively studied 507 consecutive patients (7+/-4 yr) admitted to a level I pediatric trauma center over a 3-yr period. Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS) were calculated. Age, injury mechanism, injury pattern, and initial critical care were recorded. Univariate and multivariate analyses were performed for potential risk factors associated with mortality. Receiver operating characteristic curves were used to determine threshold values of variables identified by univariate analysis. Most children suffered from blunt trauma (99.6%), and head trauma was noted in 85%. Median values (range) of GCS scores, PTS, and ISS were 10 (3-15), 7 (-4 to 12), and 16 (3-75), respectively. The mortality rate was 12%. Using multivariate analysis, death was significantly associated with an ISS > or = 25 (odds ratio [OR] 22.2, 95% confidence interval 2.8-174.9), GCS score < or = 7 (OR 4.77, 1.8-12.7), emergency blood transfusion > or = 20 mL/kg (OR 4.3, 2.1-9.1), and PTS < or = 4 (OR 3.7, 1.4-9.7). An ISS > or = 25, GCS score < or = 7, immediate blood transfusion > or = 20 mL/kg, and PTS < or = 4 were significant and independent risk factors of death in an homogenous population of severely injured children. The probability of traumatic death was therefore 0 (95% confidence interval 0-0.0135) in children with no one of these threshold values in the four predictive factors and 0.63 (95% confidence interval 0.47-0.76) in those children with all the threshold values. ⋯ Methods used for evaluating outcome of trauma patients have essentially been derived from adult series, and attempts to apply them to children have usually been inaccurate. Univariate and multivariate analyses were performed to identify risk factors associated with death in severely traumatized children, and Receiver operating characteristic curves were used to determine threshold values.
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Anesthesia and analgesia · Sep 1998
Comparative StudyDisparity of isoflurane effects on left and right ventricular afterload and hydraulic power generation in swine.
The interaction between myocardial and vascular effects of anesthetics has a potential impact on how these drugs influence performance of the heart. Most studies have focused on volatile anesthetic effects on the left ventricle (LV) and systemic circulation. Whether the right ventricle (RV) and pulmonary circulation respond in a similar fashion, however, is unclear. In the present study, we therefore examined the dose-related effects of isoflurane on LV and RV contractility and total afterload and related changes to simultaneous effects on the hydraulic power generated by each chamber. Two groups of swine were studied: one received no additional treatment before isoflurane (ISO, n = 6), and the other received hexamethonium, atropine, and propranolol to produce autonomic blockade before isoflurane administration (ISO+AB, n = 4). For each experiment, measurements were made of RV and LV regional segment lengths and pressures, along with proximal aortic and pulmonary arterial (PA) blood flow and pressure during the administration of 0, 0.5, 1.0, and 1.5 minimum alveolar anesthetic concentration (MAC) isoflurane. Contractility was assessed by calculating the regional preload recruitable stroke work slope (PRSW). Afterload was characterized in both nonpulsatile and pulsatile terms by calculating aortic input impedance magnitude (Z). From these data, total arterial resistance (R), characteristic impedance (ZC), and vascular compliance (C) were determined with reference to a three-element Windkessel model of the circulation. Additionally, steady-state (WSS), oscillatory (WOS), and total (WT) hydraulic power output of each ventricle was calculated. In the ISO group, isoflurane produced a nearly threefold greater decrease of peak systolic pressure in the LV than in the RV, yet the dose-related decrease of regional PRSW was virtually the same in both chambers. In the aorta, isoflurane produced a maximal 25% reduction in R at 1.0 MAC and doubled C without a significant change in ZC. Alternatively, PA R was increased from baseline at 1.0 and 1.5 MAC, whereas ZC was increased from all other values at 1.5 MAC. PA C was not altered by isoflurane. In ISO+AB pigs, PA ZC at baseline was higher than that evident in ISO animals but was not altered by isoflurane. In contrast, baseline aortic R was lower in ISO+AB pigs but was still modestly reduced by 1.0 MAC isoflurane. In ISO animals, WT and WSS from both ventricles demonstrated dose-related decreases, but the reductions in LV WTand WSS were greater than those for the RV at all doses. Accordingly, the power requirement per unit flow decreased for the LV but remained constant for the RV. WOS for both ventricles was also reduced by isoflurane. However, the LV WOS to WT ratio increased, which indicates that more power was lost to the system by pulsation. In contrast, reductions in RV WT and WOS were nearly parallel at all isoflurane doses, and the WOS to WT ratio was unchanged. In the ISO+AB group, isoflurane-induced alterations in LV and RV power characteristics were similar to those in the ISO group. These data indicate that, despite similar effects on biventricular contractility, isoflurane exerts qualitatively different effects on RV and LV afterload, in part via alteration in autonomic nervous activity, that influence the distribution of power output between steady-state and pulsatile components. ⋯ In this study, we examined the effects of isoflurane on cardiac performance in swine and found that, although the drug depresses contraction of both the left and right ventricles similarly, it has different effects on forces that oppose the ejection of blood. These findings demonstrate that the two interdependent pumps that comprise the heart can be influenced differently by anesthetic drugs.
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Anesthesia and analgesia · Sep 1998
Postanesthesia care unit length of stay: quantifying and assessing dependent factors.
Postanesthesia care unit (PACU) monitoring reduces morbidity and is the standard of care for postsurgical patients. PACUs require large nurse to patient ratios, which contributes to the cost of care. Despite the importance and cost of PACU length of stay (LOS), no standards have been established. We performed an observational study of 340 PACU patients to measure actual and medically appropriate PACU LOS (the time required to achieve a medically stable condition for safe PACU discharge), to identify factors related to LOS, and to create a LOS prediction index. Mean (+/- SD) actual LOS was 95+/-43 min, and appropriate PACU LOS was 71+/-37 min. Appropriate PACU LOS predictors were anesthetic time, anesthetic technique, and amount of intraoperative fluids. Actual LOS was >30 min longer than the medically appropriate LOS for 20% (68 of 340) of the patients. Frequent causes of excessive LOS were waiting for physician release or laboratory or radiographic results. Appropriate LOS may be related primarily to anesthetic factors, and nonmedical issues account for a significant amount of PACU LOS. ⋯ Most patients are stabilized immediately after surgery in a postanesthesia care unit (PACU) until their discharge to a hospital ward. However, there are no standards for appropriate PACU length of stay (LOS). In this study, we measured actual and appropriate PACU LOSs and evaluated clinical factors that may influence PACU LOS.
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Anesthesia and analgesia · Sep 1998
The effects of desflurane on cardiac function as measured by conductance volumetry in swine.
The purpose of the investigation was to assess the effects of desflurane (DES) on left ventricular heart function during basal barbiturate anesthesia in a closed-pericardium, closed-chest acute swine model. The study was performed in 11 normoventilated adult pigs. Hemodynamic measurements were obtained using arterial, central venous, and pulmonary artery catheters, as well as a conductance volumetry and tip manometry catheter placed in the left ventricle. Hemodynamic measurements were recorded during basal pentobarbital anesthesia and with the addition of 1%, 2%, 4%, and 6% DES. DES dose-dependently decreased mean arterial pressure, systemic vascular resistance, left ventricular end-systolic pressure, dP/dtMAX and dP/dtMIN. At doses >1%, decreases in CO, stroke volume, ejection fraction, end-systolic elastance, preload recruitable stroke work, preload adjusted maximal power, and peak filling rate were observed. Heart rate decreased at 4% and 6% DES. Isovolumetric relaxation time increased only at 6% DES. We conclude that smaller doses of DES have a significant cardiodepressive effect in the setting of barbiturate infusion, as measured by conductance volumetry. ⋯ Desflurane, in very small doses, depressed cardiac function during pentobarbital anesthesia with ketamine and benzodiazepine premedication in swine, as assessed by conductance volumetry and left ventricular pressure and volume relationship analysis. These results suggest that desflurane, in combination with certain anesthetics, can be cardiodepressive even in very small doses.