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

This study evaluated early neurobehavioral outcomes in ventilated preterm infants randomized to receive morphine analgesia or placebo in the Neurological Outcomes and Pre-emptive Analgesia in Neonates (NEOPAIN) trial. Eight hundred and ninety-eight infants between 23 and 32 weeks of gestation were randomized to receive preemptive morphine analgesia (morphine) or placebo. Infants also received additional analgesia (AA) with open-label morphine. The Neurobehavioral Assessment of the Preterm Infant (NAPI) was used to evaluate 572 of 793 survivors (72.1%) at 36 weeks of postconceptual age. The Neonatal Medical Index (NMI) was used to evaluate the severity of medical complications. Regression analyses were used to determine the effect of covariates. Infants were equally distributed in morphine and placebo groups with similar neonatal and demographic characteristics. Infants assessed with the NAPI were more likely to have sepsis ( P = 0.03), bronchopulmonary dysplasia ( P = 0.02), and longer length of stay ( P = 0.008). Infants randomized to the morphine group had higher NMI scores (odds ratio [OR]; 95% confidence interval [CI]: 1.75; 1.23 to 2.50; P = 0.002). Use of AA was associated with higher NMI scores (OR; 95% CI: 4.5; 2.9 to 5.9; P < 0.001). Of the NAPI subscales, the (mean +/- standard deviation [SD]) popliteal angle cluster scores were significantly higher in the morphine group compared with placebo (51.2 +/- 33.2 versus 45.0 +/- 33.5; P = 0.03). AA use was associated with lower (mean +/- SD) MOTOR scores in the morphine group (48.2 +/- 16.1 versus 52.7 +/- 19.1; P = 0.03) and with lower POPLITEAL ANGLE cluster scores in both the morphine group (41.5 +/- 34.0 versus 59.5 +/- 30.1; P < 0.0001) and the placebo group (40.8 +/- 36.8 versus 49.4 +/- 28.0; P = 0.004). No differences were noted in the other NAPI subscales cluster scores in either subgroup. We conclude that morphine analgesia may result in subtle neurobehavioral differences in premature infants.
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PMID:Neurobehavior of preterm infants at 36 weeks postconception as a function of morphine analgesia. 1790 73

There are two optical isomers of the 2-(2-chlorophenyl)-2-(methylamino)-cyclohexanone ketamine: S(+) ketamine and R(-) ketamine. Effects of this drug are mediated by N-methyl-d-aspartate (NMDA), opioid, muscarinic and different voltage-gated receptors. Clinically, the anaesthetic potency of the S(+)-isomer is approximately three to four times that of the R(-)-isomer, which is attributable to the higher affinity of the S(+)-isomer to the phencyclidine binding sites on the NMDA receptors. Ketamine is water- and lipid-soluble, allowing it to be administered conveniently via various routes and providing extensive distribution in the body. Ketamine metabolism is mediated by hepatic microsomal enzymes. It causes bronchodilation and stimulation of the sympathetic nervous system and cardiovascular system. In clinics, ketamine and particularly S(+)-ketamine are used for premedication, sedation, and induction and maintenance of general anaesthesia, which is than termed "dissociative anaesthesia". Ketamine and its S(+)-isomer are ideal anaesthetic agents for trauma victims, patients with hypovolemic and septic shock and patients with pulmonary diseases. Even subanaesthetic doses of this drug have analgesic effects, so ketamine is also recommended for post-operative analgesia and sedation. The combination of ketamine with midazolam or propofol can be extremely useful and safe for sedation and pain relief in intensive care patients, especially during sepsis and cardiovascular instability. In the treatment of chronic pain ketamine is effective as a potent analgesic or substitute together with other potent analgesics, whereby it can be added by different methods. There are some important patient side-effects, however, that limit its use, whereby psycho-mimetic side-effects are most common.
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PMID:Ketamine. 1817 98

Postoperative pain can intensify the sympathoadrenergic reaction, which is commonly seen after surgery, and thus possibly pave the way for certain complications, such as coronary ischemia, bronchopneumonia, intestinal stasis, thromboembolism, infection, sepsis, and metabolic disturbances. Investigations of cardiovascular, respiratory, gastrointestinal, metabolic, and immunologic function indicate that high-quality pain relief can diminish postoperative organ impairment and failure. Some aspects of the improvements attributed to the quality of analgesia, such as prevention of tachycardia and hypertension, attenuation of hyperglycemia and catabolism, improvement of gastrointestinal motility and cellular immunity cannot be definitely distinguished from the effects of sympathetic blockade due to epidural analgesia with local anesthetics, however. There is another aspect of the problem. The better the quality of postoperative pain relief, the more likely it is that analgesia-related complications, such as respiratory depression (opioids), cardiovascular depression (epidural local anesthetics), renal failure (NSAIDs) and bladder dysfunction (epidural opioids and local anesthetics) will occur. The question of whether postoperative morbidity and mortality can be reduced by effective analgesia has been investigated in the past few years. Some studies indicate that better analgesia is advantageous for the patient, especially with respect to postoperative complications, hospital stay, long-term well being, and costs. In other clinical trials incorporating more patients, however, this hypothesis had to be rejected. At present, therefore, we cannot state that effective pain relief influences postoperative morbidity and mortality.
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PMID:[Influence of postoperative pain on morbidity and mortality.]. 1841 28

The safety of neuraxial analgesia in febrile patients is controversial. We performed an evidenced-based project in an effort to establish a guideline for our active obstetric clinical practice. Neuraxial anesthesia is generally safe for parturients, and complications are rare; however, serious adverse outcomes can result. Because of the devastating nature of the morbidity, the decision to proceed with a neuraxial anesthetic in the face of infection may be contentious. Fever and sepsis are considered relative contraindications to regional anesthesia; however, epidural anesthesia is a superior method of management of pain during labor. One must also consider that 30% to 40% of patients with chorioamnionitis require cesarean delivery. Because of the increased morbidity and mortality of general anesthesia in this population, it may be reasonable to proceed with regional anesthesia. Based on a review of the literature, it is difficult to estimate the risk of an infrequently occurring event. We recommend evaluation of each individual to determine the risks and benefits of the anesthetic. However, it is prudent to administer antibiotics before the regional anesthetic and adhere to strict aseptic technique. Postprocedure monitoring is essential for early detection and treatment of complications.
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PMID:Evidence-based anesthesia: fever of unknown origin in parturients and neuraxial anesthesia. 1856 28

The objective of this pilot study was to evaluate the safety and success of early tracheal extubation (ETE) as compared to delayed tracheal extubation (DTE) in single-lung transplantation (SLT) for chronic obstructive pulmonary disease (COPD). This retrospective observational study was undertaken at a university hospital. Fifty-seven adult patients who underwent SLT for COPD (1998-2003) were enrolled. The study cohort was divided into an ETE subgroup (tracheal extubation in the operating room) or a DTE subgroup (tracheal extubation in the intensive care unit). There were no significant differences in perioperative outcomes between subgroups (in-hospital mortality; length of stay; prolonged mechanical ventilation; primary graft dysfunction; pneumonia; atrial fibrillation; renal dysfunction; and, sepsis). The anesthetic technique associated with ETE in SLT for COPD was characterized by limited systemic anesthetics and perioperative thoracic epidural analgesia. Appropriate ETE in SLT for COPD is not only safe but also results in equivalent perioperative outcome when compared to the traditional technique of DTE. Future studies should be powered to examine whether ETE reduces native lung complications such as hyperinflation, pneumonia and pneumothorax.
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PMID:Early tracheal extubation in adults undergoing single-lung transplantation for chronic obstructive pulmonary disease: pilot evaluation of perioperative outcome. 1862 42

The cognitive dysfunctions observed in patients after anesthesia are due not only to the effects of but also to the surgery, the disease requiring surgery, and post-operative treatment. Initial cognitive recovery from anesthetic agents is usually fast, from several hours to several days, but can be delayed by postoperative treatment (analgesia, for example) that have deleterious cognitive effects. During the initial period after surgery, acute impairment of cognitive functions is seen in some patients at risk (major surgery, aged patients, brain sensitivity, or sepsis), specifically transitory (1-3 days in most cases) postoperative delirium. This delirium or confusion requires follow-up at 3 months to check cognitive functions, especially in aged patients. Cohort studies show that cognitive impairment can be objectively identified at one week after surgery with general anesthesia in around 40% of patients, regardless of age. This risk is reduced slightly by the use of loco-regional anesthesia. Cognitive dysfunction is still observed at 3 months after surgery in about 10-15% of patients older than 60 years and in about 6% of younger patients. In patients with a pre-existing cerebral disease with cognitive symptoms, the incidence of long-lasting additional cognitive impairment remains unknown. The mechanisms of this long-term cognitive dysfunction remain to be elucidated.
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PMID:[Postanesthesia cognitive dysfunction]. 1978 38

Continuous peripheral nerve blockade is often used for the management of postoperative pain, even in ambulatory patients. The reported incidence of infectious complications after continuous nerve blockade is low. We report a case of Staphylococcus aureus sepsis after total shoulder arthroplasty in a patient who presented to her surgeon 8 days postoperatively with lethargy and labored breathing. Preoperatively, the patient had received a continuous interscalene block for analgesia that was associated with a neck hematoma. After readmission, exploratory laparotomy, and extensive hospital stay, the patient was discharged to an extended care facility in good condition.
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PMID:Case report: continuous interscalene block associated with neck hematoma and postoperative sepsis. 2202 2

Penetrating and blunt force mechanisms frequently result in thoracic trauma. Thoracic injuries cover the spectrum from trivial to lethal, and more than half are associated with head, abdomen or extremity trauma. Fortunately over eighty percent of injuries can be managed non-operatively utilizing tube thoracostomy, appropriate analgesia and aggressive respiratory therapy. Patients requiring emergency thoracotomy are either in shock or have life threatening injuries and, as expected, have significant mortality and morbidity. Injury to the thorax directly accounts for approximately 25% of trauma related mortality and is a contributing factor in another 25%. Early mortality results from haemorrhage, catastrophic injury or associated head or abdominal trauma. Not unexpectedly, late deaths are related to sepsis and organ failure. Blunt injury to the thorax most commonly results from motor vehicle collisions, with motorcycle accidents, pedestrians struck and falls next in frequency. Stab wound and gunshot wounds comprise the vast majority of penetrating injuries. In general the mortality from penetrating injury is higher and related to vascular injury and shock. Mortality from blunt trauma often results from abdominal and, especially, head injury. Rapid assessment and interventions, such as tube thoracostomy and airway control, can be life saving. The patient's haemodynamic status drives early treatment, often necessitating emergency surgery. Detailed imaging studies are reserved for haemodynamically stable patients. The evaluation and treatment of specific thoracic injuries will be discussed, as well as some general principles in treating thoracic trauma.
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PMID:The diagnosis and treatment of non-cardiac thoracic trauma. 2043 98

Based on Capillary Gate Theory and Tissue Repair Theory, this paper describes the "Stress Repair Mechanism" (SRM) that maintains and repairs vertebrate tissues. It accounts for most of the mysterious manifestations of allostasis that remain unexplained by Hypothalamic-Pituitary-Axis (HPA) hormones and thereby enables the Universal Theory of Medicine predicted by Hans Selye. SRM activity explains hemodynamic physiology, capillary hemostasis, infarction, Korotkoff sounds, blood pressure, hypertension, diabetes, allostasis, allostatic load, anesthesia, analgesia, atherosclerosis, apoptosis, malignancy, eclampsia, sepsis, Multi-System Organ Failure (MSOF), the surgical stress syndrome, the fight or flight response, and numerous other manifestations of physiology and pathology. SRM function comprises the autonomic nervous system, the vascular endothelium, and the dynamic enzymatic interaction of blood-borne hepatic Factors VII, VIIIC, IX and X that produces thrombin, soluble fibrin and insoluble fibrin, whose combined effects account for all SRM manifestations. The vascular endothelium is a diaphanous neuroendocrine organ that lines all blood vessels and is the sole constituent of capillary walls. It secretes tissue factor into extravascular tissues, and insulates those tissues from the hepatic enzymes, so that tissue disruption exposes tissue factor to the enzymatic interaction and activates tissue repair. The vascular endothelium also releases nitric oxide and von Willebrand Factor into blood in accord with autonomic balance to regulate the enzymatic interaction to govern tissue perfusion and organ function. Therefore, continuously fluctuating combinations of nervous stimuli that affect autonomic balance and forces that disrupt tissues determine SRM activity.
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PMID:A stress repair mechanism that maintains vertebrate structure during stress. 2044 76

Women in labor who receive epidural analgesia are more likely to experience hyperthermia and overt clinical fever. The gradual development of modest hyperthermia observed in laboring women with epidural analgesia is not seen in those electing other forms of analgesia or unmedicated labor. Clinical fever is also far more likely in women laboring with epidural analgesia. It is possible that the observed slow increase in mean temperature is an artifact of averaging the temperature curves of a small group of women who eventually develop fever with a larger group who remain afebrile throughout labor. Selection bias confounds the association between epidural analgesia and fever, because women at risk for fever-due to longer duration of ruptured membranes, longer labor, more frequent cervical examinations, and other interventions-are also more likely to select epidural analgesia. However, even randomized trials have confirmed a higher incidence of fever in epidural-exposed women, suggesting a causal relationship. The mechanisms of epidural-associated fever remain incompletely understood. Altered thermoregulation and an antipyretic effect of opioids given to women without epidural analgesia may explain part of the phenomenon, but the most likely etiology is inflammation, most commonly in the placenta and membranes (chorioamnionitis). The consequences of maternal fever are diverse. Obstetricians are more likely to intervene surgically in laboring women with fever, and neonatologists are more likely to evaluate neonates of febrile women for sepsis. More ominously, maternal inflammatory fever is associated with neonatal brain injury, manifest as cerebral palsy, encephalopathy, and learning deficits in later childhood. At present, there are no safe and effective means to inhibit epidural-associated fever. Future research should define the etiology of this fever and search for safe and effective interventions to prevent it and to inhibit its potential adverse effects on the neonatal brain.
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PMID:Labor epidural analgesia and maternal fever. 2086 20


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