29 Nov 09
Posted in Immunisation, Pre-operatie evaluation at 21:03 by Laci
By J Siebert, K Posfay-Barbe, W HAabre, C Siegrist
Pediatr Anesth 2007;17:410-410
Anesthesia and surgery exert immunomodulatory effects and some authors argue that they may exert additive or synergistic influences on vaccine efficacy and safety. Alternatively, inflammatory responses and fever elicited by vaccines may interfere with the postoperative course. There is a lack of consensus approach among anesthesiologists to the theoretical risk of anesthesia and vaccination. Few studies have assessed the influence of anesthesia and surgery on pediatric vaccine responses. We have undertaken an extensive review of articles published in English between 1970 and 2006 meeting the criteria: measurement of immune parameters following general anesthesia in children. By searching the major medical databases (OVID Medline, PubMed, ISI Web of Science) and references cited in the articles themselves, among 277 articles obtained none examined directly the influence of anesthesia/surgery on vaccine responses. Only 16 original reports assessed the influence of several anesthetic agents on various markers of immunity including lymphocyte numbers and functions. These results are reinterpreted here in view of our current understanding of the immune mechanisms underlying vaccine efficacy and adverse events. We conclude that the immunomodulatory influence of anesthesia during elective surgery is both minor and transient (around 48 h) and that the current evidence does not provide any contraindication to the immunization of healthy children scheduled for elective surgery. However, respecting a minimal delay of 2 days (inactivated vaccines) or 14–21 days (live attenuated viral vaccines) between immunization and anesthesia may be useful to avoid the risk of misinterpretation of vaccine-driven adverse events as postoperative complications.
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Posted in Immunisation, Pre-operatie evaluation at 20:54 by Laci
By J Short, J Van Dr Walt and D Zoanetti
Pediatr Anesth 2006;16:514-522
There is no direct evidence of any major interaction between immunization and commonly used anesthetic agents and techniques in children, but it is possible that immunosuppression caused by anesthesia and surgery may lead to decreased vaccine effectiveness or an increased risk of complications. In addition, diagnostic difficulty may arise if a recently immunized child suffers from postoperative pyrexia or malaise.
Aim
The aim of this study was to ascertain anesthetists’ attitudes and practices regarding anesthesia and immunization.
Methods
We conducted an international survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) and the Society for Paediatric Anaesthesia of New Zealand and Australia (SPANZA).
Results
Two hundred and ninety-six (52.1%) APAGBI and 86 (49.4%) SPANZA responses were analyzed. There was no consensus of approach to this theoretical risk among respondents. In total, 60% of respondents would anesthetize a child for elective surgery within 1 week of receiving a live attenuated vaccine, but 40% would not. Few hospitals have formal policies on this issue and government guidance is based on a lack of evidence for adverse events rather than positive evidence of safety.
Conclusions
There is a theoretical risk associated with anesthesia and surgery in recently immunized children. An international postal survey failed to find a consensus to this risk among pediatric anesthetists. From a risk management perspective, a review of the available evidence suggests that it would be prudent to adopt a cautious approach where the timing of elective surgery is discretionary. We therefore recommend that elective surgery and anesthesia should be postponed for 1 week after inactive vaccination and 3 weeks after live attenuated vaccination in children.
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25 Nov 09
Posted in Critical Care, Glycemic control at 6:35 by Laci
By Y Arabi, H Tamim, A Rishu
Critical Care Medicine 2009;37:2536-2544
To examine the predisposing factors for hypoglycemia in medical-surgical intensive care unit patients treated with intensive insulin therapy and to assess its association with mortality.
Design
Nested-cohort study within a randomized controlled trial.
Setting
Tertiary care intensive care unit.
Participants
Medical-surgical intensive care unit patients with admission blood glucose of >6.1 mmol/L or 110 mg/dL who were enrolled in a randomized controlled trial comparing intensive insulin therapy with conventional insulin therapy.
Interventions
None.
Exposure
Hypoglycemia was defined as blood glucose <=2.2 mmol/L or 40 mg/dL and intensive care unit mortality was the primary outcome.
Measurements and main results
Among the 523 patients included in the study, hypoglycemia occurred in 84 (16%). Intensive insulin therapy was independently associated with increased risk of hypoglycemia (adjusted odds ratio, 50.65; 95% confidence interval, 17.36-147.78; p < .0001). Other variables associated with an increased risk of hypoglycemia included female gender, diabetes, Acute Physiology and Chronic Health Evaluation II, mechanical ventilation, continuous veno-venous hemodialysis, and intensive care unit length of stay. When adjusted to potential confounders, hypoglycemia was not significantly associated with increased mortality (adjusted hazard ratio, 1.31; 95% confidence interval, .70-2.46; p = .40). Patients with admission blood glucose of <=10 mmol/L had an increased mortality with hypoglycemia (adjusted hazard ratio, 4.43; 95% confidence interval, 1.36-14.44; p = .01). Crude analysis showed significant association of mortality with blood glucose levels of <=1.2 mmol/L (adjusted hazard ratio, 2.92; 95% confidence interval, 1.05-8.11; p = .04). When adjusted analysis was performed, similar trend was seen but was not statistically significant (adjusted hazard ratio, 2.56; 95% confidence interval, .85-7.70; p = .10).
Conclusions
Our study showed significant increase of hypoglycemia with intensive insulin therapy. Although hypoglycemia was not independently associated with increased risk of death, increased mortality could not be excluded with severe hypoglycemia and in patients admitted with blood glucose of <=10 mmol/L.
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20 Nov 09
Posted in Burn at 1:11 by Laci
By B Latenser
Crit Care Med 2009;37:2819-2826
The goal of this concise review is to provide an overview of some of the most important resuscitation and monitoring issues and approaches that are unique to burn patients compared with the general intensive care unit population. Study Selection: Consensus conference findings, clinical trials, and expert medical opinion regarding care of the critically burned patient were gathered and reviewed. Studies focusing on burn shock, resuscitation goals, monitoring tools, and current recommendations for initial burn care were examined. Conclusions: The critically burned patient differs from other critically ill patients in many ways, the most important being the necessity of a team approach to patient care. The burn patient is best cared for in a dedicated burn center where resuscitation and monitoring concentrate on the pathophysiology of burns, inhalation injury, and edema formation. Early operative intervention and wound closure, metabolic interventions, early enteral nutrition, and intensive glucose control have led to continued improvements in outcome. Prevention of complications such as hypothermia and compartment syndromes is part of burn critical care. The myriad areas where standards and guidelines are currently determined only by expert opinion will become driven by level 1 data only by continued research into the critical care of the burn patient.
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