Neutrophil function and cardiopulmonary bypass in humans. The effects of glucose and non-glucose containing bypass pump priming fluids

Defective polymorphonuclear neutrophil function during cardiopulmonary bypass (CPB) has been implicated as a cause of postoperative infection following open-heart surgery. Neutrophil function is known to be impaired in poorly controlled diabetics with elevations of blood glucose concentrations of the order which occur frequently during CPB when glucose containing priming fluids are used. Neutrophil function, as measured by bactericidal assay, and neutrophil and whole blood luminol dependent chemiluminescence, was studied in two groups of 1 2 patients undergoing coronary artery bypass graft surgery. Patients received either a glucose or non-glucose containing bypass pump-priming fluid. Postoperatively neutrophil luminol-dependent chemiluminescence was significantly increased in both groups (glucose prime groups p < 0.01, non-glucose prime group p < 0.01). Whole blood chemiluminescence was increased significantly intra and postoperatively in the glucose prime group ( p < 0.02, p < 0.02 respectively) but the increase was not significant in the non-glucose prime group. Bactericidal activity remained unchanged during and after surgery in both groups (mean bactericidal index intraoperatively 96.4 glucose group, 96.2 non-glucose group; postoperatively 99.7 glucose group, 99.7 non-glucose group). These data suggest that glucose containing bypass priming fluids do not modulate significantly the function of circulating neutrophils after CPB. Neutrophil function was not decreased after surgery, and other factors may be responsible for the reported higher incidence of bacterial infection after CPB.

A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery

Intra-operative oesophageal Doppler monitor-guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra-operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra-operative fluid management using an oesophageal Doppler-guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra-operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5-8 [4-25]) days in the oesophageal Doppler monitor group compared with 7 (5-9 [4-42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra-operative oesophageal Doppler-guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.

Development and feasibility study of an algorithm for intraoperative goaldirected haemodynamic management in noncardiac surgery

This study developed an evidence-based, goal-directed haemodynamic management algorithm to standardize intraoperative haemodynamic therapy. A systematic literature search identified three haemodynamic management goals: stroke volume optimization by fluid therapy; maintenance of a target mean arterial pressure by vasopressor therapy; maintenance of a target cardiac index≥2.5 l/min per m2 by inotropic therapy. The algorithm was adapted to international standards and consensus was reached through a modified Delphi method at international meetings. Implementation of the algorithm into routine intraoperative management in noncardiac surgery was shown to be feasible. Compared with conventional haemodynamic management, use of the algorithm significantly reduced length of hospital stay, requirement for ventilation and incidence of prolonged hospital stay, thereby resulting in reduced hospital costs.

Key performance indicators in intensive care medicine. A retrospective matched cohort study

Expert panel consensus was used to develop evidence-based process indicators that were independent risk factors for the main clinical outcome parameters of length of stay in the intensive care unit (ICU) and mortality. In a retrospective, matched data analysis of patients from five ICUs at a tertiary university hospital, agreed process indicators (sedation monitoring, pain monitoring, mean arterial pressure [MAP] >or= 60 mmHg, tidal volume [TV] <or= 6 ml/kg body weight, peak inspiratory pressure [PIP] <or= 35 cmH(2)O and blood glucose [BG] >or= 80 and <or= 130 mg/dl) were validated using a prospective dataset of 4445 consecutive patients. After matching for age, sex and ICU, 634 patients were analysed. Logistic regression of the 634 patients showed that monitoring analgesia and sedation, MAP >or= 60 mmHg and BG >or= 80 mg/dl were relevant for survival. Linear regression of the 634 patients showed that analgesia monitoring, PIP <or= 35 cmH(2)O and TV <or= 6 ml/kg were associated with reduced length of ICU stay. Linear regression on all 4445 patients showed analgesia, sedation monitoring, MAP >or= 60 mmHg, BG >or= 80 mg/dl and <or= 130 mg/dl, PIP <or= 35 cmH(2)O and TV <or= 6 ml/kg were associated with reduced length of ICU stay, indicating that adherence to evidence-based key process indicators may reduce mortality and length of ICU stay.

Predicting upper limb recovery after stroke: the place of early shoulder and hand movement

OBJECTIVE

To assess the predictive value of early shoulder and hand movement after stroke for subsequent hand movement and function.

DESIGN

An inception cohort design following 71 patients for 3 months after first stroke.

SETTING

Rehabilitation medicine units in three Sydney teaching hospitals.

PATIENTS

A consecutive sample of 71 first-stroke patients, mean age 67 years, was assessed for upper limb function. Those with preexisting impairment in the hemiplegic limb, early good recovery in hand function, or impaired comprehension were excluded. Data were available for 65 patients at 1 month, 50 at 2 months, and 46 at 3 months.

MAIN OUTCOME MEASURES

Hand movement and hand function were assessed at 1, 2, and 3 months. A standardized hand movement scale and four specific hand function tasks were used. The outcome variables were (1) "good" hand movements, ie, independent index finger extension or opposition of finger/s to thumb and (2) ability to perform one of the specified hand function tasks.

RESULTS

Initial shoulder shrug predicted good hand movement (odds ratios 7.3, 7.0, 6.0) and hand function (odds ratios 13.8, 5.3, 11.3) at 1, 2, and 3 months, respectively. Initial presence of synergistic hand movement predicted good hand movement (odds ratios 10, 13.8, 12.2) at 1, 2, and 3 months and hand function (odds ratios 27.9, 7.5) at 1 and 2 months. Initial active shoulder abduction predicted good hand movement at 1 month and hand function at 1 and 2 months only.

CONCLUSIONS

Early shoulder shrug and synergistic hand movements are useful bedside predictors of hand outcome after stroke.

A pilot study of eye movement during mammography interpretation: eyetracker results and workstation design implications

Digital mammography can potentially improve mammography image and interpretation quality. On-line interpretation from a workstation may improve interpretation logistics and increase availability of comparison images. Interpretation of eight 4k- x 5k-pixel mammograms on two to four 2k- x 2.5k-pixel monitors is problematic because of the time spent in choosing which images display on which monitors, and zooming and roaming on individual images that are too large to display completely at full resolution. The authors used an eyetracker to measure radiologists viewing behavior during mammography interpretation with film on a viewbox. It was observed that a significant portion of the mammographers' time is spent viewing "comparison pairs" (typically two or more comparisons per case), such as the left mediolateral and craniocaudal images or old and new images. From the eyetracker measurements, we estimated that the number of image display, roam, and zoom operations decreases from an average of 64 for one monitor to 31 for four monitors, with the largest change going from one to two monitors. We also show that fewer monitors with a faster response time is superior to more monitors with a slower response time. Finally, the authors demonstrate the applicability of time-motion analysis to mammographic workstation design.

Management of tracheomalacia in association with congenital tracheo-oesophageal fistula

Tracheomalacia is commonly associated with oesophageal atresia and tracheo-oesophageal fistula. Severe cases may present with life threatening cyanotic and apnoeic attacks following surgical repair of the oesophageal atresia. The anaesthetic, and surgical management (by tracheopexy), of such a case are described.