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Query: UMLS:C0243026 (sepsis)
 52,417 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The objective was to evaluate the influence of patient-controlled epidural analgesia (PCEA) using low doses of bupivacaine vs. ropivacaine, on labor pain, motor blockade, progression of labor, delivery and neonatal outcome. This randomized double blind study included 565 parturients. All received a 5-mL/h infusion and PCEA (5-mL boluses with a 20-min lockout, maximum volume 20 mL/h) of either 0.125% bupivacaine (n = 313: 165 nulliparous, 148 parous) or 0.2% ropivacaine (n = 252: 113 nulliparous, 139 parous). Pain score, lower limb motor block, sensory levels, local analgesic doses required, hemodynamic parameters, side effects and complications were assessed. Obstetric variables included cervical dilation at epidural insertion, incidence of ruptured membranes and their duration, use of oxytocin, fetal heart rate changes, duration of labor, mode and outcome of delivery, and use of invasive and non-invasive fetal monitoring. Neonatal characteristics included birth weight, Apgar scores, umbilical artery pH, serum bilirubin, hypoglycemia, need for assisted ventilation, sepsis or sepsis study, feeding difficulties and respiratory distress syndrome. Ropivacaine 0.2% was equianalgesic with 0.125% bupivacaine, but produced less motor block (P < 0.0001). There were no significant differences, however, in duration of labor, delivery type or neonatal outcome.
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PMID:Patient-controlled epidural analgesia for labor pain: effect on labor, delivery and neonatal outcome of 0.125% bupivacaine vs 0.2% ropivacaine. 1532 32

THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.
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PMID:What's new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature. 1579 48

Stress doses of hydrocortisone are known to have immunomodulatory effects in patients with hyperdynamic septic shock. The prognosis correlates with the presence and severity of septic encephalopathy. However, neurological evaluation is influenced by the use of analgesia sedation during artificial ventilation. The objective of this study was to demonstrate the effect of stress doses of hydrocortisone during the initial phase of human septic shock on the serum values of the neurospecific protein S-100B in comparison to the inflammation markers interleukin (IL)-8 in serum and polymorphonuclear (PMN) elastase in plasma. A total of 24 consecutive patients, who met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock, were enrolled in this prospective, randomized, double-blind, single-center trial. The severity of illness at recruitment was graded using the Acute Physiology and Chronic Health Evaluation II and the Simplified Acute Physiology Score II scoring systems. Multi-organ dysfunction syndrome was described by the Sepsis-related Organ Failure Assessment (SOFA) score. All patients were prospectively randomized to receive either stress doses of hydrocortisone or placebo. Hydrocortisone was started in 12 patients with a loading dose of 100 mg and followed by a continuous infusion of 0.18 mg/kg/h for 6 days. Median S-100B serum levels of the hydrocortisone group decreased from 0.32 ng/mL at study entry to 0.07 ng/mL 6 days later without significant differences compared to the placebo group. Initial IL-8 serum levels were significantly higher in the hydrocortisone group up to 12 h after study entry, and significantly decreased from 715 to 17 pg/mL at the end of the observation period. Median PMN elastase plasma levels were not affected by hydrocortisone infusion. Patients with initial S-100B serum levels > 0.50 ng/mL revealed significantly higher SOFA scores up to 30 h, IL-8 serum levels up to 12 h, and PMN elastase plasma levels up to 36 h after study entry than those patients with < or = 0.50 ng/mL. These effects were independent of the amount of fluid correction for hemodilution. Starting S-100B, IL-8 and PMN elastase values of the hydrocortisone group were within the ranges already known in patients with out-of-hospital cardiac arrest or severe traumatic brain injury. Stress doses of hydrocortisone resulted in a significant reduction in IL-8 serum, but not in S-100B serum and PMN elastase plasma concentrations in patients with hyperdynamic septic shock. For the first time, a similar extent of S-100B increase in serum of septic patients at the time of diagnosis was shown as reported for cardiac arrest or severe traumatic brain injury.
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PMID:Effect of stress doses of hydrocortisone on S-100B vs. interleukin-8 and polymorphonuclear elastase levels in human septic shock. 1584 28

Traumatic injury, surgical interventions and sepsis are amongst some of the clinical conditions that result in marked activation of neuroendocrine and opiate responses aimed at restoring haemodynamic and metabolic homeostasis. The central activation of the neuroendocrine and opiate systems, known collectively as the stress response, is elicited by diverse physical stressor conditions, including ischaemia, glucopenia and inflammation. The role of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system in counterregulation of haemodynamic and metabolic alterations has been studied extensively. However, that of the endogenous opiates/opioid system is still unclear. In addition to activation of the opiate receptor through the endogenous release of opioids, pharmacotherapy with opiate receptor agonists is frequently used for sedation and analgesia of injured, septic and critically ill patients. How this affects the haemodynamic, cardiovascular, metabolic and immune responses is poorly understood. The variety of opiate receptor types, their specificity and ubiquitous location both in the central nervous system and in the periphery adds additional complicating factors to the clear understanding of their contribution to the stress response to the various physical perturbations. This review aims at discussing scientific evidence gathered from preclinical studies on the role of endogenous opioids as well as those administered as pharmacological agents on the host cardiovascular, neuroendocrine, metabolic and immune response mechanisms critical for survival from injury in perspective with clinical observations that provide parallel assessment of relevant outcome measures. When possible, the clinical relevance and corresponding scenarios where this evidence can be integrated into our understanding of the clinical implications of opiate effects will be examined. Overall, the scientific basis to enhance clinical judgment and expectations when using opioid sedation and analgesia in the management of the injured, septic or postsurgical patient will be discussed.
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PMID:Opioids and opiates: analgesia with cardiovascular, haemodynamic and immune implications in critical illness. 1642 May 43

The necrotizing fasciitis is a medico-surgical emergency, characterized by the rapid speard of the infection in the subcutaneous tissue, involving fascia superficialis. Peaucity of cutaneous findings early in the course of the disease makes diagnosis a challenge for physician. Pain out of proportion to clinical findings, fever and signs of systemic toxicity are the keys in identification of necrotizing fasciitis. Delayed diagnosis lead to sepsis syndrom and/or multiple organ failure and correlate with poor oucome. Radiolographs, CT-scan or MRI are main radiologic studies, but such procedures should never delay surgical intervention. Intravenous antibiotics, fluid and electrolyte management and analgesia are needed in addition to radical debridment. Clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed treatments. Only prompt recognition and immediat care warrant a lower mortality and morbidity for this life-threatening infection.
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PMID:[Necrotizing fasciitis: diagnosis and treatments]. 1678 11

Sleep is an essential part of life with many important roles which include immunologic, cognitive and muscular functions. Of the working population 20% report sleep disturbances and in critically ill patients an incidence of more than 50% has been shown. However, sleep disturbances in the intensive care unit (ICU) population have not been investigated in detail. Sleep disturbances in ICU patients have a variety of reasons: e.g. patient-related pathologies like sepsis, acute or chronic pulmonary diseases, cardiac insufficiency, stroke or epilepsy, surgery, therapeutical interventions like mechanical ventilation, noise of monitors, pain or medication. Numerous scales and questionnaires are used to quantify sleep and the polysomnogramm is used to objectify sleep architecture. To improve sleep in ICU patients concepts are needed which include in addition to pharmacological treatment (pain reduction and sedation) synchronization of ICU activities with daylight, noise reduction and music for relaxation. In order to establish evidence-based guidelines, research activities about sleep and critical illness should be intensified. Questions to be answered are: 1) Which part of sleep disturbances in critically ill patients is directly related to the illness or trauma? 2) Is the grade of sleep disturbance correlated with the severity of the illness or trauma? 3) Which part is related to the medical treatment and can be modified or controlled? In order to define non-pharmacological and pharmacological concepts to improve sleep quality, studies need to be randomized and to include different ICU populations. The rate of nosocomial infections, cognitive function and respiratory muscle function should be considered in these studies as well. This will help to answer the question, whether it is useful to monitor sleep in ICU patients as a parameter to indicate therapeutical success and short-term quality of life. Follow-up needs to be long enough to detect adverse effects of withdrawal symptoms after termination of analgesia and sedation or delirium.
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PMID:[Sleep disturbances in critically ill patients]. 1695 22

We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6-month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty-five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X-ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in-hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia.
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PMID:Hospital admissions for acute painful crisis in Trinidad and Tobago. Are the British Committee for Standards in Haematology (BCSH) guidelines applicable? 1699 18

Most studies indicate that epidural analgesia during labor is associated with maternal fever, although the nature of this fever is unclear. The consequences of maternal fever may include increased neonatal evaluations for sepsis, the increased use of antibiotics, and prolonged hospital stay. However, the need for such measures after epidural analgesia during labor is controversial. This article discusses currently held views on this issue.
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PMID:Epidural analgesia during labor and maternal fever. 1701 10

Besides providing effective analgesia, thoracic epidural anesthesia (TEA) has been shown to decrease perioperative morbidity and mortality. Because of its vasodilatory properties in association with the sympathetic blockade, however, TEA may potentially aggravate cardiovascular dysfunctions resulting from sepsis and systemic inflammatory response syndrome. The objective of the present study was to assess the effects of TEA on hemodynamics, global oxygen transport, and renal function in ovine endotoxemia. After a baseline measurement in healthy sheep (n = 18), Salmonella typhosa endotoxin was centrally infused at incremental doses to induce and maintain a hypotensive-hypodynamic circulation using an established protocol. The animals were then randomly assigned to one of two groups. In the treatment group, continuous TEA was initiated with 0.1 mL.kg of 0.125% bupivacaine at the onset of endotoxemia and maintained with 0.1 mL.kg.h. In the control group, the same amount of isotonic sodium chloride solution was injected through the epidural catheter. In the animals surviving the entire experiment (n = 7 per group), cardiac index and mean arterial pressure decreased in a dose-dependent manner during endotoxin infusion. In the TEA group, neither systemic hemodynamics nor global oxygen transport were impaired beyond the changes caused by endotoxemia itself. Urinary output was increased in the TEA group as compared with the control group (P < 0.05). In this model of endotoxic shock, TEA improved renal perfusion without affecting cardiopulmonary hemodynamics and global oxygen transport.
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PMID:Effects of thoracic epidural anesthesia on hemodynamics and global oxygen transport in ovine endotoxemia. 1711 38

We report a case of necrotizing fasciitis of the lower limb. This medico-surgical emergency is a life-threatening invasive soft-tissue infection which primarily involves the fascia superficialis and rapidly extends along subcutaneous tissue with relative sparing of skin and underlying muscles. Clinical presentation includes fever, signs of systemic toxicity and pain out of proportion to clinical findings. Paucity of cutaneous findings early in the course of the disease makes diagnosis challenging. The confirmation of the diagnosis is often made after surgical debridement. Delay in diagnosis and/or treatment correlates with poor outcome, leading to sepsis and/or multiple organ failure. Radiologic studies including plain radiographs, CT-scan or MRI may help to diagnose necrotizing fasciitis. Prompt surgical debridement, intravenous antibiotics, fluids and electrolytes management and analgesia are mainstays of the therapy. Adjuvant treatments like clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed.
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PMID:Necrotizing fasciitis: case report and review of literature. 1740 95


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