Cooling muscles following exercise

Abstract

Cooling has a long history as an aid to muscle recovery after exercise.

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Nurse-driven analgesia and sedation in pediatric patients with univentricular hearts requiring extracorporeal life support after first-stage palliation surgery: A pilot study

Summary

Background

Few data are available regarding requirements of sedation and analgesia in children during extracorporeal life support.

Aims

The aim of this study was to evaluate if children with functionally univentricular hearts on extracorporeal life support after first-stage palliation surgery have higher requirement of analgesics and sedatives compared with children without extracorporeal life support using a goal-directed nurse-driven analgesia and sedation protocol.

Methods

This prospective observational matched case-control pilot study was conducted at a cardiac pediatric intensive care unit of a tertiary referral center. Seventeen patients with functionally univentricular hearts including hypoplastic left heart syndrome who were on extracorporeal life support after first-stage palliation surgery were enrolled from July 2012 to January 2017. Seventeen matched patients served as controls. Doses of morphine, midazolam, clonidine, and muscle relaxants as well as sedation scores (COMFORT behavior scale and the nurse interpretation of sedation scale) were assessed according to a nurse-driven protocol every 8 hours up to 120 hours after first-stage palliation surgery.

Results

Sedation scores were equal in the extracorporeal life support group and in the control group at most points in time. There was no significant difference in cumulative doses of morphine and midazolam. However, children of the extracorporeal life support group received higher doses of midazolam and morphine at some points in time.

Conclusion

A nurse-driven protocol for analgesia and sedation of children with extracorporeal life support is feasible. Patients with extracorporeal life support do not need deeper sedation levels and have not higher cumulative sedation requirements than children without extracorporeal life support.

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A retrospective comparison of thoracic epidural infusion and multimodal analgesia protocol for pain management following the minimally invasive repair of pectus excavatum

Summary

Background

Pain management following minimally invasive repair of pectus excavatum is variable. We recently adopted a comprehensive multimodal analgesic protocol that standardizes perioperative analgesic management. We hypothesized that patients managed with this protocol would use more opioids postoperatively, have similar pain control, and shorter length of stay compared to patients managed with thoracic epidural infusion.

Aims

We retrospectively compared opioid consumption, pain scores, and length of stay between a cohort of patients managed with our multimodal analgesic protocol and a cohort managed with a thoracic epidural infusion.

Methods

This retrospective cohort comparison includes patients, 8 to 21 years of age, managed with either thoracic epidural infusion (n = 21) or multimodal analgesic protocol (n = 29) following minimally invasive repair of pectus excavatum from January 1, 2011 through September 15, 2015. The primary outcome, total daily opioid consumption in morphine equivalents, is presented as an average by postoperative day. Secondary outcomes included median daily pain score and length of stay.

Results

Patients were similar in age, weight, sex, and physical status. Patients managed with thoracic epidural infusion received less opioid (morphine equivalents—mg/kg) intraoperatively compared to multimodal analgesic protocol (difference of mean [95% confidence interval] 0.22 [0.16-0.28] P ≤ .01) but required more total opioid through postoperative day 3 (difference of mean [95% confidence interval] 1.2 [0.26-2.14] P = .01). We did not observe a difference in pain scores. Median length of stay was 1 day less in patients managed with multimodal analgesic protocol (difference of median [95% confidence interval] 1 [0.3-1.7] P = .003).

Conclusion

Implementation of a standardized comprehensive multimodal analgesic protocol following minimally invasive repair of pectus excavatum resulted in equivalent analgesia with a modest reduction in length of stay when compared to thoracic epidural. We did not observe an opioid sparing effect in our thoracic epidural which may reflect technique variability.

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A quality improvement initiative to increase the safety of pediatric emergency airway management

Summary

Background

Emergency airway management is commonly associated with life-threatening hypoxia and hypotension which may be preventable.

Aims

The aim of this quality improvement study was to reduce the frequency of intubation-related hypoxia and hypotension.

Methods

This prospective quality improvement study was conducted over 4 years in the Emergency Department of The Royal Children's Hospital, Melbourne, Australia. A preintervention cohort highlighted safety gaps and was used to design study interventions, including an emergency airway algorithm, standardized airway equipment, a preintubation checklist and equipment template, endtidal carbon dioxide monitoring, postintubation team debriefing, and multidisciplinary team training. Following implementation, a postintervention cohort was used to monitor the impact of study interventions on clinical process and patient outcome. Process measures were as follows: use of a preintubation checklist, verbalization of an airway plan, adequate resuscitation prior to intubation, induction agent dose titration, use of apneic oxygenation, and use of endtidal carbon dioxide to confirm endotracheal tube position. The primary outcome measure was first pass success rate without hypoxia or hypotension. Potential harms from study interventions were monitored.

Results

Forty-six intubations were included over one calendar year in the postintervention cohort (compared to 71 in the preintervention cohort). Overall clinical uptake of the 6 processes measures was 85%. First pass success rate without hypoxia or hypotension was 78% in the postintervention cohort compared with 49% in the preintervention cohort (absolute risk reduction: 29.0%; 95% confidence interval 12.3%-45.6%, number needed to treat: 3.5). No significant harms from study interventions were identified.

Conclusions

Quality improvement initiatives targeting emergency airway management may be successfully implemented in the emergency department and are associated with a reduction in adverse intubation-related events.

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Role of ultrasound measuring position and ventilation pressure in determining correct tube size in children

Summary

Background

Ultrasound measurements of the airway are useful for determining correctly sized, uncuffed endotracheal tubes in children.

Aims

The primary objective of this study was to evaluate the influence of ventilation pressure on the sonographically measured tracheal diameter at different levels.

Methods

A total of 100 patients (under 7 years) were enrolled in this study. Six sonographic measurements of minimal transverse diameters at 3 locations (vocal chords, cricoid cartilage, and proximal trachea) and at 2 different ventilation pressures (0 and 15 mbar) were performed before the intubation procedure. The intubating anesthesiologists were blinded to the results of the ultrasound measurements. The rate of agreement of the outer diameter of the correctly sized endotracheal tube (reference) with the 6 sonographic diameters was determined. In addition, the correct tube sizes were compared with the results of traditional prediction methods (Penlington's and Cole's formula in children ≥1 year and a decision table in children <1 year).

Results

Best rate of agreement resulted from cricoid cartilage (70% and 83% at 0 and 15 mbar).

Conclusions

The airway level selected for ultrasound and airway pressure during measurement determines the rate of agreement between the measurement result and correct ETT size.

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Endothelial tubes – another window into lymphatic function

Abstract

The endothelium isolated as an intact tube of cells offers a powerful approach to study endothelial cell function.

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Songbird chemical signals reflect uropygial gland androgen sensitivity and predict aggression: implications for the role of the periphery in chemosignaling

Abstract

Chemical signals can provide useful information to potential mates and rivals. The production mechanisms of these signals are poorly understood in birds, despite emerging evidence that volatile compounds from preen oil may serve as chemosignals. Steroid hormones, including testosterone (T), may influence the production of these signals, yet variation in circulating T only partly accounts for this variation. We hypothesized that odor is a T-mediated signal of an individual's phenotype, regulated in part by androgen sensitivity in the uropygial gland. We quantified natural variation in chemosignals, T, uropygial gland androgen sensitivity, and aggressive behavior in dark-eyed juncos (Junco hyemalis). The interaction between circulating T and androgen receptor transcript abundance significantly correlated with volatile concentrations in male, but not female, preen oil. In both sexes, odorant variables correlated with aggressive response to an intruder. Our results suggest that preen oil volatiles could function as signals of aggressive intent, and, at least in males, may be regulated by local androgen receptor signaling in the uropygial gland. Because these behavioral and chemical traits have been linked with reproductive success, local regulation of androgen sensitivity in the periphery has the potential to be a target of selection in the evolution of avian olfactory signaling.

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