Background: The clinical benefits associated with the use of the bispectral index (BIS) to monitor the depth of sedation during flexible fiberoptic bronchoscopy (FFB) are questionable. Objectives: To evaluate the added value in terms of procedural safety and patients' awareness of monitoring sedation depth using the BIS compared to conventional clinical judgment alone in patients undergoing FFB under propofol sedation. Methods: The cohort included 81 patients undergoing diagnostic or therapeutic bronchoscopy under propofol sedation that were prospectively randomized to guide the depth of sedation by BIS monitoring (BIS group; n = 40) or conventional monitoring (control group; n = 41). Results: The mean durations of the procedure were 18 and 19 min in the BIS and control groups, respectively. No significant difference was noted in the dosage of propofol used between the BIS and control groups (168.7 vs. 167.3 mg, respectively). Average sedation-related oxygen saturation drop and transcutaneous CO2 rise were not significantly different between groups. There was also no significant difference in the percentage of patients that required either hemodynamic support (5 vs. 7.5%, respectively), oxygen supplementation by 100% O2 mask (67.5 vs. 82.5%, respectively) or Ambu face mask manual ventilation (2.5 vs. 5%, respectively) between the groups. No significant difference was noted in terms of patients' awareness during the procedure, which was assessed following recovery by a structured Brice interview. Conclusion: Using BIS to guide the depth of sedation during propofol sedation in patients undergoing FFB of relatively short duration offers no clinically significant advantages over conventional monitoring.
Background: Midazolam is commonly used for sedation during flexible bronchoscopy because of its relatively wide therapeutic window. Recently, sedation with propofol for bronchoscopy has gained popularity, although concern has been raised regarding its potential ability to induce severe respiratory depression. Objectives: The aim of this study was to evaluate the safety of sedation under midazolam + alfentanil compared to propofol. Methods: We conducted a prospective randomized trial using continuous transcutaneous carbon dioxide tension monitoring. The study group included 115 patients undergoing bronchoscopy, prospectively randomized to receive sedation with either midazolam + alfentanil (n = 59) or propofol (n = 56). Results: Intra-procedural carbon dioxide tension values were higher in the midazolam + alfentanil group than in the propofol group (maximum 53.72 vs. 49.49 mm Hg, mean 46.78 vs. 43.78 mm Hg), but the differences did not reach statistical significance (p = 0.149 and 0.193, respectively). Carbon dioxide tension values were significantly higher in the midazolam + alfentanil group than in the propofol group at 5 and 10 min following procedure (51.7 vs. 49.3 mm Hg, p = 0.026, and 50.8 vs. 42.7 mm Hg, p < 0.01, respectively), and significantly more patients in the midazolam + alfentanil group needed oxygen supplementation or airway support (24 vs. 8 patients, respectively). Conclusion: Midazolam + alfentanil and propofol are equally safe for sedation during bronchoscopy. Sedation with propofol, using small boluses at short intervals, does not cause excessive respiratory drive depression and represents an excellent alternative to traditional sedation agents.
Critical Care 2017, 21(Suppl 1):P349 Introduction Imbalance in cellular energetics has been suggested to be an important mechanism for organ failure in sepsis and septic shock. We hypothesized that such energy imbalance would either be caused by metabolic changes leading to decreased energy production or by increased energy consumption. Thus, we set out to investigate if mitochondrial dysfunction or decreased energy consumption alters cellular metabolism in muscle tissue in experimental sepsis. Methods We submitted anesthetized piglets to sepsis (n = 12) or placebo (n = 4) and monitored them for 3 hours. Plasma lactate and markers of organ failure were measured hourly, as was muscle metabolism by microdialysis. Energy consumption was intervened locally by infusing ouabain through one microdialysis catheter to block major energy expenditure of the cells, by inhibiting the major energy consuming enzyme, N+/K + -ATPase. Similarly, energy production was blocked infusing sodium cyanide (NaCN), in a different region, to block the cytochrome oxidase in muscle tissue mitochondria. Results All animals submitted to sepsis fulfilled sepsis criteria as defined in Sepsis-3, whereas no animals in the placebo group did. Muscle glucose decreased during sepsis independently of N+/K + -ATPase or cytochrome oxidase blockade. Muscle lactate did not increase during sepsis in naïve metabolism. However, during cytochrome oxidase blockade, there was an increase in muscle lactate that was further accentuated during sepsis. Muscle pyruvate did not decrease during sepsis in naïve metabolism. During cytochrome oxidase blockade, there was a decrease in muscle pyruvate, independently of sepsis. Lactate to pyruvate ratio increased during sepsis and was further accentuated during cytochrome oxidase blockade. Muscle glycerol increased during sepsis and decreased slightly without sepsis regardless of N+/K + -ATPase or cytochrome oxidase blocking. There were no significant changes in muscle glutamate or urea during sepsis in absence/presence of N+/K + -ATPase or cytochrome oxidase blockade. ConclusionsThese results indicate increased metabolism of energy substrates in muscle tissue in experimental sepsis. Our results do not indicate presence of energy depletion or mitochondrial dysfunction in muscle and should similar physiologic situation be present in other tissues, other mechanisms of organ failure must be considered. , and long-term follow up has shown increased fracture risk [2]. It is unclear if these changes are a consequence of acute critical illness, or reduced activity afterwards. Bone health assessment during critical illness is challenging, and direct bone strength measurement is not possible. We used a rodent sepsis model to test the hypothesis that critical illness causes early reduction in bone strength and changes in bone architecture. Methods 20 Sprague-Dawley rats (350 ± 15.8g) were anesthetised and randomised to receive cecal ligation and puncture (CLP) (50% cecum length, 18G needle single pass through anterior and posterior wa...
The American Heart Association scientific statement on cardiac arrest in pregnancy did not endorse extracorporeal life support for lack of cohort data. We studied all pregnancy and peripartum cases of extracorporeal life support in 1 medical center (n = 11), including collapse due to infection (n = 6, 55%), thromboembolism (n = 3, 27%), and cardiac disease (n = 2, 18%). Half of the cases (n = 5, 45%) involved extracorporeal cardiopulmonary resuscitation. Most mothers survived (n = 7, 64% [95% confidence interval, 32%-88%]). Deaths were attributable to oxygenator blockage (n = 1) and late sepsis (n = 3). The 2 unique clinical challenges were maintenance of high peripartum cardiac outputs and balancing anticoagulation with hemostasis.
(Anesth Analg. 2017;125(4):1275–1280) Extracorporeal life support (ECLS) has been used in severe cases of maternal H1N1 infection, cardiogenic shock, massive pulmonary embolism, and peripartum hemorrhage. However, although the Society for Obstetric Anesthesia and Perinatology (SOAP) suggested ECLS as an appropriate therapy for maternal salvage, the American Heart Association did not endorse the SOAP recommendation at that time due to the lack of cohort data on maternal outcome. Currently, cohort data are available. The authors of the present study contributed to this data and described a consecutive cohort of 11 women placed on ECLS for salvage due to maternal death/near-demise during pregnancy and the peripartum period.
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