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#61
10.02.2005, 12:58
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#63
10.02.2005, 15:49
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Расскажите, а зачем вообще нужен внутривенный соталол? Что им лечить то? Вот тут пытался вспомнить, применялся он у нас когда-нибудь и не смог. Спросил у директора аптеки - тот тоже не смог припомнить. Из всех внутривенных аритмиков амио - как святая вода, прокаинамайд - редко, но все-же. Дофетилайд - дорого. Внутривенный хинидин однажды применял сам, но только для лечения фальципарум с полиорганной недостаточностью.
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#65
10.02.2005, 18:08
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Из недавнего по в/в соталолу попалась публикация из Австралии:
Am Heart J. 2004 Jan;147(1):E3. Rapid loading of sotalol or amiodarone for management of recent onset symptomatic atrial fibrillation: a randomized, digoxin-controlled trial. Thomas SP, Guy D, Wallace E, Crampton R, Kijvanit P, Eipper V, Ross DL, Cooper MJ. Department of Cardiology, Emergency Medicine, Westmead Hospital, Westmead, New South Wales, Australia. BACKGROUND: Amiodarone and sotalol are commonly used for the maintenance of sinus rhythm, but the efficacy of these agents administered as high-dose infusions for rapid conversion of atrial fibrillation is unknown. Use in this context would facilitate drug initiation in patients in whom ongoing prophylactic therapy is indicated. METHODS: We assessed the efficacy and safety of rapid high-dose intravenous infusions of amiodarone and sotalol for heart rate control and rapid reversion to sinus rhythm in patients who came to the emergency department with recent-onset symptomatic atrial fibrillation. Patients (n = 140) were randomized to receive 1.5mg/kg of sotalol infused in 10 minutes, 10mg/kg of amiodarone in 30 minutes, or 500 microg of digoxin in 20 minutes. Electrical cardioversion was attempted for patients not converting to sinus rhythm within 12 hours. RESULTS: The rapid infusion of sotalol or amiodarone resulted in more rapid rate control than digoxin. Each of the 3 trial strategies resulted in similar rates of pharmacological conversion to sinus rhythm (amiodarone, 51%; sotalol, 44%; digoxin, 50%; P = not significant). The overall rates of cardioversion after trial drug infusion and defibrillation were high for all groups (amiodarone, 94%; sotalol, 95%,; digoxin, 98%; P = not significant), but there was a trend toward a higher incidence of serious adverse reactions in the amiodarone group. CONCLUSION: The rapid infusion of sotalol or amiodarone in patients with symptomatic recent-onset atrial fibrillation results in rapid control of ventricular rate. Even with high-dose rapid infusions, all 3 agents are associated with a poor overall reversion rate within 12 hours. Almost all patients were returned to sinus rhythm with a combination of pharmacological therapy and electrical cardioversion. О в/в применении антиаритмиков указывают немцы: Drugs such as lidocaine, procainamide, sotalol, amiodarone, or magnesium were recommended for treatment of ventricular tachyarrhythmias in intensive care patients. Amiodarone is a highly efficacious antiarrhythmic agent for many cardiac arrhythmias, ranging from atrial fibrillation to malignant ventricular tachyarrhythmias, and seems to be superior to other antiarrhythmic agents. Из Trappe HJ, Brandts B, Weismueller P. Arrhythmias in the intensive care patient. Curr Opin Crit Care. 2003 Oct;9(5):345-55.
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#67
13.02.2005, 21:03
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Цитата:
CARDIOVERSION Most cardioversions are scheduled in advance. There is adequate time for optimal preparation of the patient and the equipment. Patients scheduled for elective cardioversion need sedation and airway management for a very short period of time. Occasionally, anesthesia is needed for emergency cardioversion. This is almost always a result of an acute change causing severe hemodynamic instability. In this situation, adherence to basic ACLS protocols will provide a satisfactory plan of action. The algorithms indicate what medications and procedures are to be employed. Elective cardioversions are often performed in areas near the operating room, usually in the PACU. They are typically performed early in the morning before these sites fill with patients following surgery. Additional anesthesia personnel are available should help be needed, and the site is well stocked with additional drugs, airway management equipment, and anesthetic agents. Atrial fibrillation and atrial flutter are the most common dysrhythmias treated with elective cardioversion. These will occur spontaneously or subsequent to valvular heart disease or recent coronary artery bypass grafting. Supraventricular tachycardias, which are refractory to medical management, are also treated with cardioversions. Although the procedure is brief, a detailed history and physical examination should be performed for each patient. The current health status, use of concurrent medications, particularly heparin or coumadin, and history of prior gastroesophageal reflux are important considerations. Patients should be kept NPO in preparation for the procedure. A high level of anticoagulation is often required before cardioversion is performed. This will decrease the chance that thrombotic emboli will be showered into the pulmonary or systemic vascular systems. Any history of previous thromboembolization should be noted, and a brief neurologic assessment performed immediately prior to the procedure. This will allow assessment of acute post-procedure CNS dysfunction. Many of these patients will have coexisting cardiovascular disease and myocardial dysfunction. Standard monitoring is routinely employed. Invasive monitoring is rarely required for cardioversion. The patient's physical status and general medical condition will dictate special monitoring needs. Intubating equipment, medications, supplemental oxygen, and a method to provide positive-pressure ventilation, suction, and resuscitation equipment should be readily available. A variety of iv agents have been used successfully, including the benzodiazepines, thiopental, methohexital, etomidate, and propofol.37,38,39,40,41 and 42 Although midazolam is associated with longer recovery times, reversal with flumazenil is effective and causes a more rapid awakening.37,41,42 and 43 Etomidate provides more hemodynamic stability than many of the other agents; however, the myoclonus, which it induces in 40% of patients, may interfere with ECG interpretation. In some centers, this side-effect precludes its use. Propofol produces hypotension when given as a bolus because it is a direct myocardial depressant. A slow induction with a low-dose infusion can attenuate this drop in systemic blood pressure.38,41 Adequate preoxygenation is performed before the induction of anesthesia. The onset of unconsciousness is often delayed in these patients because the dysrhythmia decreases the cardiac output and prolongs the circulation time. Once the patient is assessed and the level of anesthesia is found to be adequate, a synchronized countershock is administered. The airway is maintained and ventilation supported until the patient regains consciousness. The patient must be closely monitored following cardioversion for recurrence of the dysrhythmia or a different rhythm disturbance. Once the patient is awake and alert, outpatient discharge or admission to a monitored bed is individualized. Some centers are routinely performing transesophageal echocardiographic examinations immediately prior to cardioversion in order to evaluate for the present of thrombus in the atria.44 This complicates the anesthetic management since the patient must be sufficiently obtunded to tolerate esophageal placement of the probe, yet control of the airway is not readily achieved. One approach is to topically anesthetize the patient's airway prior to the procedure so that deep levels of sedation can be avoided. И это касается в основном плановой кардиоверсии, а не экстренной, когда пациент и без того еле дышит...
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#68
14.02.2005, 13:42
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По моему опыту в/в формы амиодарона и соталола идельны для удержания синусового ритма после восстановления при помощи электрической кардиоверсии. По крайней мере они эффективны, а побочные эффекты достаточно редки ("пируэт" я наблюдал однажды на фоне нашей терапии).
Что касается тяжести состояния таких больных, часто нестабильность гемодинамики обусловлена именно ФП, поэтому кардиоверсия будет полезна для стабилизации.
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#69
14.02.2005, 18:04
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На амиодароне пируэты и впрямь редки, с соталолом хуже. Требуется тщательное мониторирование QT. Честно говоря, больные у которых нестабильность гемодинамики связана с мерцалкой попадались мне не так часто, хотя я работаю в БИТ. Но если оно так, конечно ЭИТ - средство выбора.
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#70
28.03.2005, 05:39
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#71
28.03.2005, 14:11
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Приветствую Вас и надеюсь на Вашу активность на страницах форума Анестезиология и МКС.
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#72
03.04.2005, 07:53
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#73
15.05.2005, 21:15
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"...Наблюдающийся в настоящее время процесс разделения единой специальности анестезиологии-реаниматологии, который мы сейчас наблюдаем, имеет немало негативных последствий. Исчезает преемственность ведения больного в операционной и в послеоперационной палате, врачи - анестезиологи не понимают реанимационных проблем и разучиваются лечить нескольких больных одновременно, как это требуют условия реанимации. Врачи - реаниматологи часто не умеют обеспечить простое анестезиологическое пособие в реанимационном отделении. Анестезиологическое и реаниматологическое сообщество пытается об этом прискорбном факте стыдливо молчать, но… «жизнь богаче теорий!» Нарастающий поток специальных знаний, необходимый для работы в операционной и в отделении реанимации делает практически решенной проблему разделения специальности...." ЦАРЕНКО С.В.
НИИСП им. Н.В.Склифосовского, г. Москва, Россия
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#74
17.05.2005, 05:12
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Для Бруксы
Пусть я буду слабее, но сидеть в Интенсивке - увольте или пристрелите. Дежурил в этот викэнд, позвали меня в Интенсивку проводить наркоз для больного с катотонической шизофренией. Психиаторы решили провести электроковульсивную терапию.Дежурил Интенсивист с терапевтическим бэкграундом наркоз, который давать права не имеет. Испоганили пол-воскресенья ( пока то, пока это). Но лучше так, чем закрывать 24 кровати с двумя резидентами.
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#75
19.05.2005, 18:15
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Линейный вид
