Intrathekale Opioidmedikation zur perioperativen Analgesie bei schwer behinderten Kindern mit Wirbelsäulenoperationen

Zusammenfassung: Hintergrund: An gesunden Kindern konnte gezeigt werden, dass intrathekal verabreichte Opioide eine sichere und effektive perioperative Analgesie bei wirbelsäulenchirurgischen Eingriffen ermöglichen. Das Ziel der vorliegenden Untersuchung ist es, ihre Anwendbarkeit bei schwer- und schwerstbehinderten Kindern für wirbelsäulenchirurgische Eingriffe zu überprüfen. Methode: Mit Zustimmung der lokalen Ethikkommission wurden Patienten vom Status3 und 4 der Klassifikation der American Society of Anesthesiologists (ASA), die sich einem wirbelsäulenchirurgischen Eingriff unterziehen mussten, retrospektiv untersucht. Zusätzlich zur Allgemeinanästhesie mit Sevofluran oder i.v.-verabreichtem Propofol erhielten die Patienten vor der Operation 20µg/kgKG Morphin und 1,5µg/kgKG Sufentanil intrathekal. Nach Beendigung des Eingriffs wurde eine Nalbuphindauerinfusion gestartet. Der Bedarf an zusätzlichen intra- und postoperativen Analgetika, der Zeitpunkt der Extubation, die postoperativen Schmerz-Scores und die arteriellen Kohlendioxidpartialdruck- (paCO2)-Werte sowie das Auftreten unerwünschter Nebenwirkungen wurden untersucht. Ergebnisse: Es wurden 28Patienten im Alter von 2,8 bis 18,5Jahren (Median 11,6Jahre) untersucht. Unmittelbar im OP konnten 17Patienten extubiert werden; bei 11Patienten entschied man sich zu einer verzögerten Extubation. Bis auf einen Patienten mit postoperativer Massivtransfusion konnten alle innerhalb von 24h extubiert werden. Eine adäquate postoperative Analgesie mit Schmerz-Scores ≤3 wurde mithilfe der Kombination von intrathekal verabreichten Opioiden mit Nalbuphin postoperativ bei 26 von 28Patienten (93%) erreicht. Bei 2Patienten war der Wechsel auf eine i.v.-Morphin-Gabe erforderlich. Postoperative Übelkeit und Erbrechen ("postoperative nausea and vomiting", PONV), Pruritus und leichte Hypoventilation mit paCO2-Werten zwischen 5,2 bis 9,7kPa (Median 6,3kPa) waren die beobachteten Nebenwirkungen. Schlussfolgerung: Der Einsatz intrathekal verabreichter Opioide, ergänzt durch eine postoperative Nalbuphininfusion, erlaubt in den allermeisten Fällen eine frühzeitige Extubation ohne persistierende Atemdepression und ist eine praktikable sowie effektive Methode zur postoperativen Analgesie bei schwer behinderten Kindern nach wirbelsäulenchirurgischen Eingriffe

Effect of sirolimus on malignancy and survival after kidney transplantation: systematic review and meta-analysis of individual patient data

Objective To examine risk of malignancy and death in patients with kidney transplant who receive the immunosuppressive drug sirolimus.Design Systematic review and meta-analysis of individual patient data.Data sources Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to March 2013.Eligibility Randomized controlled trials comparing immunosuppressive regimens with and without sirolimus in recipients of kidney or combined pancreatic and renal transplant for which the author was willing to provide individual patient level data. Two reviewers independently screened titles/abstracts and full text reports of potentially eligible trials to identify studies for inclusion. All eligible trials reported data on malignancy or survival.Results the search yielded 2365 unique citations. Patient level data were available from 5876 patients from 21 randomized trials. Sirolimus was associated with a 40% reduction in the risk of malignancy (adjusted hazard ratio 0.60, 95% confidence interval 0.39 to 0.93) and a 56% reduction in the risk of non-melanoma skin cancer (0.44, 0.30 to 0.63) compared with controls. the most pronounced effect was seen in patients who converted to sirolimus from an established immunosuppressive regimen, resulting in a reduction in risk of malignancy (0.34, 0.28 to 0.41), non-melanoma skin cancer (0.32, 0.24 to 0.42), and other cancers (0.52, 0.38 to 0.69). Sirolimus was associated with an increased risk of death (1.43, 1.21 to 1.71) compared with controls.Conclusions Sirolimus was associated with a reduction in the risk of malignancy and non-melanoma skin cancer in transplant recipients. the benefit was most pronounced in patients who converted from an established immunosuppressive regimen to sirolimus. Given the risk of mortality, however, the use of this drug does not seem warranted for most patients with kidney transplant. Further research is needed to determine if different populations, such as those at high risk of cancer, might benefit from sirolimus.PfizerOttawa Hosp, Res Inst, Ottawa, ON K1H 7W9, CanadaUniv Ottawa, Ottawa, ON, CanadaCairo Univ, Cairo Kidney Ctr, Cairo, EgyptLimites Med Res, Vacallo, SwitzerlandUniv Manitoba, Dept Pediat & Childs Hlth, Winnipeg, MB, CanadaLund Univ, Dept Nephrol & Transplantat, Malmo, SwedenUniversidade Federal de São Paulo, Hosp Rim & Hipertensao, São Paulo, BrazilAddenbrookes Hosp, Dept Renal Med, Cambridge, EnglandNorthwestern Univ, Feinberg Sch Med, Chicago, IL 60611 USAMaastricht Univ, Med Ctr, Maastricht, NetherlandsSt Louis Hosp, Dept Nephrol, Paris, FranceHosp JW Goethe, Div Nephrol, Frankfurt, GermanyUniv Munich, Dept Surg, Munich, GermanyGoethe Univ Frankfurt, JW Goethe Clin, Clin Dermatol Venerol & Allergol, Frankfurt, GermanyInst Klin Expt Med, Dept Nephrol, Prague, Czech RepublicUniv Cambridge, Addenbrookes Hosp, Dept Surg, NIHR Cambridge Biomed Res Ctr, Cambridge CB2 2QQ, EnglandUniversidade Federal de São Paulo, Hosp Rim & Hipertensao, São Paulo, BrazilWeb of Scienc

Renal association clinical practice guideline in post-operative care in the kidney transplant recipient

These guidelines cover the care of patients from the period following kidney transplantation until the transplant is no longer working or the patient dies. During the early phase prevention of acute rejection and infection are the priority. After around 3-6 months, the priorities change to preservation of transplant function and avoiding the long-term complications of immunosuppressive medication (the medication used to suppress the immune system to prevent rejection). The topics discussed include organization of outpatient follow up, immunosuppressive medication, treatment of acute and chronic rejection, and prevention of complications. The potential complications discussed include heart disease, infection, cancer, bone disease and blood disorders. There is also a section on contraception and reproductive issues.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and AD depending on the quality of the evidence that the recommendation is based on

Intraoperative ultrasound for localization of patent left internal mammary artery grafts in repeat cardiothoracic surgery.

Schellenberg, A. G., Marshall, M. B., & Salgo, I. S. (2001). Intraoperative ultrasound for localization of patent left internal mammary artery grafts in repeat cardiothoracic surgery. Journal of cardiothoracic and vascular anesthesia, 15(2), 228–230. https://doi.org/10.1053/jcan.2001.2197

EFFECTS OF MELATONIN ON LIPID PEROXIDATION INDUCED BY OXYGEN RADICALS

We here report the activity of the neurohormone melatonin (MLT) as a scavenger of free radicals in two different experimental models: (a) linoleic acid peroxidation initiated by different free radical-generating systems and (b) a multilamellar vesicle system composed of dilinoleoylphosphatidylcholine. In system (a) linoleic acid peroxidation, induced by either the water-soluble initiator 2,2'-azobis (2-amidinopropane) dihydrochloride (ABAP) or Fe2+-EDTA addition to 2.6 mM linoleic acid dispersed in SDS-phosphate buffer, was evaluated as the formation of conjugated dienes, measured spectrophotometrically at 236 nm. MLT did not reduce the rate of peroxidation induced by ABAP, but did reduce, in a concentration-dependent fashion, the rate of the reaction activated by Fe2+-EDTA. In system (b) multilamellar vesicles were used as the substrate for lipid peroxidation, initiated by Fe2+-EDTA and determined by means of malonaldehyde (MDA) and 4-hydroxyalkenal (4-HDA) content. MLT was found to be slightly more effective in system (b) than in the dispersed linoleic acid system (see a). These results show that MLT inhibits lipid damage induced by oxygen free radicals. However, MLT is only about one one-hundredth as effective an antioxidant as vitamin E in the micelles system