High volume peritoneal dialysis for acute renal failure

Background. Peritoneal dialysis (PD) is still widely used for acute renal failure (ARF) in developing countries despite concerns about its inadequacy. Continuous PD has been evaluated in ARF by analyzing the resolution of metabolic abnormality and normalization of plasma pH, bicarbonate, and potassium.Methodology: A prospective study was performed on 30 ARF patients who were assigned to high-dose continuous PD (Kt/V = 0.65 per session) via a flexible catheter (Tenckhoff) and automated PD with a cycler. Fluid removal, pH and metabolic control, protein Loss, and patient outcome were evaluated.Results: Patients received 236 continuous PD sessions; 76% were admitted to ICUs. APACHE II score was 32.2 +/- 8.65. BUN concentrations stabilized after 3 sessions, creatinine after 4, and bicarbonate and pH after 2. Fluid removal was 2.1 +/- 0.62 L/day. Creatinine and urea clearances were 15.8 +/- 4.16 and 17.3 +/- 5.01 mL/minute respectively. Normalized creatinine clearance and urea Kt/V values were 110.6 +/- 22.5 L/week/1.73 m(2) body surface area and 3.8 +/- 0.6 respectively. Solute reduction index was 41% +/- 6.5% per session. Serum albumin values remained stable in spite of considerable protein tosses (median 21.7 g/day, interquartile range 9.1 - 29.8 g/day). Regarding ARF outcome, 23% of patients presented renal function recovery, 13% remained on dialysis after 30 days of follow-up, and 57% died.Conclusion: High-dose continuous PD by flexible catheter and cycler was an effective treatment for ARF. It provided high solute removal, allowing appropriate metabolic and pH control, and adequate dialysis dose and fluid removal. Continuous PD can therefore be considered an alternative to other forms of renal replacement therapy in ARF.

The pre-emptive effect of epidural ketamine on wound sensitivity in horses tested by using von Frey filaments

Objective To evaluate the pre-emptive analgesic effect of pre-incisional epidural ketamine.Study Design A blinded, randomized experimental study.Animals Sixteen mixed breed mares, 17.6 +/- 2.8 years old, weighing 352 +/- 32 kg.Methods In a pilot study, an incision was made on one lateral thigh using a lidocaine block and no further analgesics, and it was verified that the nociceptive threshold was lower on the incised side than nonincised side (p < 0.05), and that von Frey filaments evoked a pain response. The 16 animals were divided into group A (ketamine, n = 9) and B (saline, n = 7). An epidural catheter was inserted 24 hours before the trials, the thigh was shaved bilaterally, and the right side was blocked (incised side) using lidocaine. Twenty-five minutes later, ketamine (A) or saline (B) was administered epidurally. Five minutes later, a 10-cm. skin incision was made on the right side, and then sutured. Nociceptive threshold was determined with von Frey filaments at 1, 3, and 5 cm. around the incision at 15-minute intervals for 2 hours, then at 4, 6, and 8 hours. Behavioral alterations, heart and respiratory rates were recorded. Nociceptive thresholds from these points were averaged to obtain mean values at each time, converted to a logarithmic scale, and submitted to a nonparametric analysis (Mann-Whitney and one-way repeated measures anova test,p less than or equal to 0.05).Results After 8 hours, the global range score revealed reduced hyperalgesia (p < 0.01) around the incision in 92% (4.65-4.27) of evaluated intervals in group A (ketamine). There were no significant changes in behavior, heart and respiratory rates,Conclusions It was concluded that pre-emptive epidural ketamine reduced post-incisional pain in the horse, and that von Frey filaments were able to quantify cutaneous sensitivity after tissue damage.Clinical relevance Epidural ketamine injection can reduce post-incisional sensitivity in the horse.

Sympathetic hyperactivity, respiratory failure, pruritus, and anesthesia after unintentional epidural injection of potassium chloride: Case report

Background and Objectives. A combination of epidural and general anesthesia has been widely used to attenuate the surgical stress response and to provide postoperative analgesia. This case report illustrates the use of this anesthetic technique. Analgesia was induced with local anesthetic in the immediate postoperative period using unintentional 19.1% potassium chloride (KCI) as diluent. Methods. An ASA I male patient was scheduled for surgical correction of idiopathic megaesophagus under continuous epidural anesthesia combined with general anesthesia. In the postoperative period, while preparing 10 mt 0.125% bupivacaine to be administered through the epidural catheter for pain control, 5 mt 19.1% KCI was unintentionally used as diluent, resulting in a 9.55% potassium solution concentration. Results. The patient developed warmness of the lower limbs, tachycardia, hypertension, intense pruritus on the chest, agitation, exacerbation of sensory and motor blocks, and respiratory failure secondary to pulmonary edema, requiring ventilatory support. Total recovery was observed after 24 hours. Conclusions. Epidurally injected potassium leads to severe clinical manifestations caused by autonomic dysfunction, spinal cord irritation, and possible release of histamine. Despite continuous recommendations, ampule misidentification still happens in hospitals, frequently leading to serious accidents.

Cortisol in saliva and plasma of cattle after ACTH administration and milking

Interest in the measurement of salivary cortisol has increased recently because saliva can be easily collected before and after an imposed stress. This study evaluated the relationship between plasma and salivary concentrations of cortisol following ACTH administration in calves ( experiment 1) and machine milking of adult cows ( experiment 2). A catheter was inserted into the jugular vein of all animals 72 h before the beginning of experiments. Blood and saliva samples were collected before and after ACTH administration (0.6 IU/kg BW) in calves or before and after machine milking of cows. Using a cotton swab, each saliva sample was taken immediately following the blood sample. In general, cortisol profiles were similar in plasma and saliva and correlated in both experiments; however, plasma concentrations were significantly higher than salivary concentrations. In addition, the differences between cortisol concentrations measured in saliva and plasma within each experiment varied substantially between animals and samples. Furthermore, in experiment 2, nearly 10% of salivary samples were below limits of detection. The sharp peaks in cortisol after ACTH administration in both the plasma and saliva were reflected adrenal stimulation. In addition, increases in cortisol in response to milking in both the plasma and saliva suggest that salivary sampling is a reliable option when studying cortisol responses to normal physiological events.

Assessment of brachial plexus blockade in chickens by an axillary approach

Objective To assess the brachial plexus block in chickens by an axillary approach and using a peripheral nerve stimulator.Study design Prospective, randomized, double-blinded study.Animals Six, 84-week old, female chickens.Methods Midazolam (1 mg kg(-1)) and butorphanol (1 mg kg(-1)) were administered into the pectoralis muscle. Fifteen minutes later, the birds were positioned in lateral recumbency and following palpation of the anatomic landmarks, a catheter was inserted using an axillary approach to the brachial plexus. Lidocaine or bupivacaine (1 mL kg(-1)) was injected after plexus localization by the nerve stimulator. Sensory function was tested before and after blockade (carpus, radius/ulna, humerus and pectoralis muscle) in the blocked and unblocked wings. The latency to onset of motor and sensory block and the duration of sensory block were recorded. A Friedman nonparametric one-way repeated-measures ANOVA was used to compare scores from baseline values over time and to compare the differences between wings at each time point.Results A total of 18 blocks were performed with a success rate of 66.6% (12/18). The latency for motor block was 2.8 +/- 1.1 and 3.2 +/- 0.4 minutes for lidocaine and bupivacaine, respectively. The latencies for and durations of the sensory block were 6.0 +/- 2.5 and 64.0 +/- 18.0 and 7.8 +/- 5.8 and 91.6 +/- 61.7 minutes for lidocaine and bupivacaine, respectively. There was no statistical difference between these times for lidocaine or bupivacaine. Sensory function was not abolished in nonblocked wings.Conclusions and clinical relevance The brachial plexus block was an easy technique to perform but had a high failure rate. It might be useful for providing anesthesia or postoperative analgesia of the wing in chickens and exotic avian species that have similar wing anatomy.

Cauda equina syndrome after spinal tetracaine: Electromyographic evaluation-20 years follow-up

CAUDA equina syndrome (CES) has long been recognized as a rare complication of spinal anesthesia.(1) CES has been described after administration of spinal anesthetics with lidocaine(2) and bupivacaine.(3) In 1991,(4) CES was reported after continuous spinal anesthesia with 1% tetracaine. In 1980, at our university hospital, six adult female patients underwent perineal gynecologic surgery using a spinal anesthetic of 2 ml tetracaine, 1.2%, in 10% glucose. The concentration of the injected tetracaine was unknown by the anesthetists. In all cases, lumbar puncture was performed at the L3-L4 interspace with a disposable spinal needle while the patients were in the sitting position. CES was first diagnosed 72 h or later postoperatively; previous diagnosis was not possible because patients had an indwelling urethral catheter. The diagnosis of CES was confirmed in all patients. During the past year, after institutional approval and informed consent, clinical, magnetic resonance imaging, electromyographic examinations, and conduction studies were performed in three of the above patients. Examinations were not possible on the other three patients because one had recently died, another could not be located, and the third refused to participate. T1 and T2 magnetic resonance image readings were obtained with Gadolinium contrast from a 0.5 Tesla General Electric apparatus (General Electric, Tokyo, Japan). Bilateral sensory and motor conduction studies of the sciatic nerve branches were obtained using a two-channel Nihon-Kohden Neuropack 2 (Nihom-Kohden Corporation, Tokyo, Japan). Electromyography was performed in accordance with conventional techniques.(5,6)

Sepsis and Neutropenia in Very Low Birth Weight Infants Delivered of Mothers with Preeclampsia

Objective To study the association between maternal preeclampsia and neonatal sepsis in very low birth weight newborns.Study design We studied all infants with birth weights between 500 g and 1500 g who were admitted to 6 neonatal intensive care units of the Brazilian Network on Neonatal Research for 2 years. Exclusion criteria were major malformations, death in the delivery room, and maternal chronic hypertension. Absolute neutrophil count was performed in the first 72 hours of life.Results A total of 911 very low birth weight infants (preeclampsia, 308; non-preeclampsia, 603) were included. The preeclampsia group had significantly higher gestational age, more cesarean deliveries, antenatal steroid, central catheters, total parenteral nutrition, and neutropenia, and less rupture of membranes >18 hours and mechanical ventilation. Both groups had similar incidences of early sepsis (4.6% and 4.2% in preeclampsia and non-preeclampsia groups, respectively) and late sepsis (24% and 22.1% in preeclampsia and non-preeclampsia groups, respectively). Vaginal delivery and neutropenia were associated with multiple logistic regressions with early sepsis, and mechanical ventilation, central catheter, and total parenteral nutrition were associated with late sepsis. Death was associated with neutropenia in very preterm infants.Conclusions Preeclampsia did not increase neonatal sepsis in very low birth weight infants, and death was associated with neutropenia in very preterm infants. (J Pediatr 2010; 157: 434-8).

Surveillance Programme for Healthcare Associated Infections in the State of São Paulo, Brazil. Implementation and the first three years' results

Governmental programmes should be developed to collect and analyse data on healthcare associated infections (HAIs). This study describes the healthcare setting and both the implementation and preliminary results of the Programme for Surveillance of Healthcare Associated Infections in the State of São Paulo (PSHAISP), Brazil, from 2004 to 2006. Characterisation of the healthcare settings was carried out using a national database. The PSHAISP was implemented using components for acute care hospitals (ACH) or long term care facilities (LTCF). The components for surveillance in ACHs were surgical unit, intensive care unit and high risk nursery. The infections included in the surveillance were surgical site infection in clean surgery, pneumonia, urinary tract infection and device-associated bloodstream infections. Regarding the LTCF component, pneumonia, scabies and gastroenteritis in all inpatients were reported. In the first year of the programme there were 457 participating healthcare settings, representing 51.1% of the hospitals registered in the national database. Data obtained in this study are the initial results and have already been used for education in both surveillance and the prevention of HAI. The results of the PSHAISP show that it is feasible to collect data from a large number of hospitals. This will assist the State of São Paulo in assessing the impact of interventions and in resource allocation. (C) 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Metabolic acidosis in healthy mules under general anaesthesia with halothane

Objective To report the severe metabolic acidosis identified in a group of 11 healthy mules anaesthetized with halothane for castration.Study design Data generated from a prospective study.Animals Eleven mules aged 2.5-8 years, weighing 230-315 kg and 11 horses aged 1.5-3.5 years, weighing 315-480 kg.Methods Animals were anaesthetized for castration as part of an electroencephalographic study. Preanaesthetic medication was acepromazine (0.03 mg kg(-1)) administered through a preplaced jugular venous catheter. Anaesthesia was induced 30-90 minutes later with intravenous thiopental (10 mg kg(-1)). After orotracheal intubation, anaesthesia was maintained with halothane vaporised in oxygen. The animals' lungs were ventilated to maintain the end-tidal CO(2) concentration between 3.9 and 4.5 kPa (29-34 mmHg). Anaesthetic monitoring included invasive blood pressure measurement via the auricular artery (mules) and submandibular branch of the facial artery (horses). Arterial blood gas samples were drawn from these catheters at three time points during surgery and pH, PaCO(2), base excess (ecf) and HCO(3)(-) were measured. Values were compared between groups using a Mann-Whitney test. p was taken as <0.05. Results are reported as median (range).Results PaCO(2) did not differ between groups but pH was significantly lower in mules [7.178 (7.00-7.29)] compared to horses [7.367 (7.24-7.43)] (p = 0.0002). HCO(3)(-) values were significantly lower in the mules [16.6 (13.0-22.3) mM] compared to horses [23.7 (20.9-23.7) mM] (p = 0.0001), whilst base excess (ecf) was significantly more negative in the mules [-11.4 (-1.27 to -16) mM] compared to horses [-1.3 (-5.8 to +2.4) mM] (p = 0.0004).Conclusion and clinical relevance This study demonstrated severe metabolic acidosis in healthy mules, which may have prompted intervention with drug therapies in a clinical arena. It is probable that the acidosis existed prior to anaesthesia and caused by diet, but other possible causes are considered.

Plasma concentrations of buprenorphine after epidural administration in conscious cats

Buprenorphine plasma concentrations were measured after administering buprenorphine (20 mu g/kg) into the lumbosacral epidural space of conscious cats chronically instrumented with an epidural catheter. Blood was collected from a jugular vein before injection and 15, 30, 45 and 60 min and 2, 3, 4, 5, 6, 8, 12 and 24 h after administration. Plasma buprenorphine concentrations were measured using ELISA. Background concentration (before injection) was 1.27 +/- 0.27 ng/mL (mean +/- SD). Including background concentration, the mean peak plasma concentration was obtained 15 min after injection (5.82 +/- 3.75 ng/mL), and ranged from 3.79 to 2.20 ng/mL (30 min-3 h), remaining between 1.93 and 1.77 ng/mL (412 h), and declined to 1.40 +/- 0.62 ng/mL at 24 h. Elimination half-life was 58.8 +/- 40.2 min and clearance 56.7 +/- 21.5 mL/min. Results indicate early rapid systemic uptake of buprenorphine from epidural administration with plasma concentrations similar to using buccal or IM routes by 15 min postinjection. (C) 2010 Elsevier Ltd. All rights reserved.

Treatment of Pythiosis in Equine Limbs Using Intravenous Regional Perfusion of Amphotericin B

Objective To evaluate the effects of intravenous regional limb perfusion (IRLP) administration of amphotericin B in horses to treat pythiosis after surgical excision and thermocautery. Study Design Case series. Animals Horses (n = 12) with Pythium insidiosum infection of the distal aspect of the thoracic or pelvic limbs. Methods After surgical excision of granulation tissue and thermocautery, 50 mg amphotericin B was administered by IRLP through a catheter placed in a superficial vein of the affected limb next to the lesion after placing a tourniquet above the injection site. The lesions and locomotor system were evaluated before treatment and at 7, 14, 21, 28, 35, and 60 days. Results Ninety-two percent of horses treated with amphotericin B had complete lesion resolution 35 or 60 days after 1 or 2 IRLP treatments, respectively. IRLP induced limb edema and pain during regional palpation in 42%, and inflammation of the injection site in 33% of horses; however these signs resolved after 14 days. Conclusions IRLP administration of amphotericin B was effective for treating pythiosis in equine limbs, resolving infection with manageable side effects.

Agreement between direct, oscillometric and Doppler ultrasound blood pressures using three different cuff positions in anesthetized dogs

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Comparative study of epidural xylazine or clonidine in horses

Objective To evaluate the cardiorespiratory and behavioural effects of epidural xylazine (XYL) or clonidine (CLO) in horses.Study design Blinded, randomized experimental study.Twelve healthy Arabian yearling horses weighing 117-204 kg were randomly allocated into two groups: XYL (n = 6) and CLO (n = 6).Methods An epidural catheter was inserted and a facial arterial catheter was placed and the next day the horses were restrained in stocks. Baseline values for heart (HR) and respiratory (RR) rates, arterial pressure and behavioural responses were evaluated before (TO) and 10, 20, 30, 45, 60, 90 and 120 minutes after epidural injection (T10-T120). The horses received 0.2 mg kg(-1) of XYL or 5 mu g kg(-1) CLO; adjusted to (3.4 + (body weight in kg x 0.013) mL with saline. Data were analysed by the Kolmogorov-Smirnov test, one-way ANOVA with repeated measures, and one-way ANOVA followed by a Student-Newman-Keuls test or Fisher's exact test, as necessary. Significance was set at p <= 0.05.Results Sedation and ataxia were seen at T10, persisting until T120 in four and three horses, respectively, in XYL and all horses in CLO respectively. Two XYL and one CLO horses became recumbent at T45 and T25 respectively. Penile prolapse occurred in four of five males at T30 and T45, in the XYL and CLO groups, respectively, resolving by T120. Tail relaxation was present from T10 to T120 in all horses in XYL and in four horses in CLO. Head drop was observed from T20 to T60 and from T10 to T120 in XYL and CLO respectively. Respiratory rate decreased significantly only at T45 in the CLO group. Heart rate and arterial blood pressure remained stable.Conclusions and clinical relevance Epidural CLO and XYL produce similar cardiorespiratory and behavioural changes but neither would be safe to use clinically at the doses used in this study.

Variability on red blood cell transfusion practices among Brazilian neonatal intensive care units

BACKGROUND:Guidelines for red blood cell (RBC) transfusions exist; however, transfusion practices vary among centers. This study aimed to analyze transfusion practices and the impact of patients and institutional characteristics on the indications of RBC transfusions in preterm infants.STUDY DESIGN and METHODS:RBC transfusion practices were investigated in a multicenter prospective cohort of preterm infants with a birth weight of less than 1500 g born at eight public university neonatal intensive care units of the Brazilian Network on Neonatal Research. Variables associated with any RBC transfusions were analyzed by logistic regression analysis.RESULTS:Of 952 very-low-birth-weight infants, 532 (55.9%) received at least one RBC transfusion. The percentages of transfused neonates were 48.9, 54.5, 56.0, 61.2, 56.3, 47.8, 75.4, and 44.7%, respectively, for Centers 1 through 8. The number of transfusions during the first 28 days of life was higher in Center 4 and 7 than in other centers. After 28 days, the number of transfusions decreased, except for Center 7. Multivariate logistic regression analysis showed higher likelihood of transfusion in infants with late onset sepsis (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.8-4.4), intraventricular hemorrhage (OR, 9.4; 95% CI, 3.3-26.8), intubation at birth (OR, 1.7; 95% CI, 1.0-2.8), need for umbilical catheter (OR, 2.4; 95% CI, 1.3-4.4), days on mechanical ventilation (OR, 1.1; 95% CI, 1.0-1.2), oxygen therapy (OR, 1.1; 95% CI, 1.0-1.1), parenteral nutrition (OR, 1.1; 95% CI, 1.0-1.1), and birth center (p < 0.001).CONCLUSIONS:The need of RBC transfusions in very-low-birth-weight preterm infants was associated with clinical conditions and birth center. The distribution of the number of transfusions during hospital stay may be used as a measure of neonatal care quality.

Comparison of the effects of epidural or intravenous methadone on the minimum alveolar concentration of isoflurane in dogs

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)