23 Apr 06

Sugar, soap and statins – an unlikely recipe for the critically ill

Posted in Critical Care, Sepsis, Statin at 10:11 by Laci

By D Bacon and LG Forni

Critical Care 2006;10:140 http://ccforum.com/content/10/2/140

The eagerly awaited SOAP (Sepsis Occurrence in Acutely ill Patients) study is published and its observational data provide much of interest, not least in generating further hypotheses on improving treatment in this challenging group. Glycaemic control in the critically ill is once more the focus of attention, and we discuss three studies in this area. Not least among these reports is that from the van den Bergh group, who provide further data on their intensive insulin protocol in a more heterogeneous group, namely medical intensive care unit patients. Finally, we discuss another good reason to take statins.

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Pro-Con Debate: Steroid use in ACTH non-responsive septic shock patients with high baseline cortisol levels

Posted in Critical Care, Sepsis, Steroid at 10:09 by Laci

By D Annane, E Fan and MS Herridge

Critical Care 2006;10:210  http://ccforum.com/content/10/2/210

Steroid use in critically ill, vasopressor-dependant, septic patients has gained increased acceptance in recent years with the publication of encouraging data. However, with renewed interest and/or attention comes increased debate and analysis. As a result, it is not surprising to find that there is still significant controversy with regards to the role of steroids in many patients. In this article, two expert groups debate the role of steroid use in a septic shock patient with arguably no clear evidence of adrenal insufficiency.

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16 Apr 06

The choice of catecholamines in septic shock: more and more good arguments to strengthen the known position, but don’t lose the faith!

Posted in Critical Care, Inotropic support, Sepsis at 14:30 by Laci

By A Meier-Hellmann

Critical Care 2006;10:127 http://ccforum.com/content/10/2/127

The choice of catecholamines for hemodynamic stabilisation in septic shock patients has been an ongoing debate for several years. Several studies have investigated the regional effects in septic patients. Because of an often very small sample size, because of inconsistent results and because of methodical problems in the monitoring techniques used in these studies, however, it is not possible to provide clear recommendations concerning the use of catecholamines in sepsis. Prospective and adequate-sized studies are necessary because outcome data are completely lacking.

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15 Apr 06

Perioperative risk of bradyarrhythmias in patients with asymptomatic chronic bifascicular block or LBBB: Does an additional first-degree AV block make any difference?

Posted in Anesthesia, Arrhythmia, Pre-operatie evaluation at 17:37 by Laci

By A Gauss, C Hubner, P Radermacher, M Georgieff, W Schutz

Anesthesiology 1998,88:679-687

Background
The incidence of perioperative bradyarrhythmias in patients with bifascicular or left bundle branch block (LBBB) and the influence of an additional first-degree atrioventricular (A-V) block has not been evaluated with 24-h Holter electrocardiographic monitoring. Therefore the authors assessed the rate of block progression and bradyarrhythmia in these patients.

Methods
Patients (n = 106) with asymptomatic bifascicular block or LBBB with or without an additional first-degree A-V block scheduled for surgery under general or regional anesthesia were enrolled prospectively. Three patients were excluded. Of the 103 remaining, 56 had a normal P-R interval and 47 had a prolonged one. Holter monitoring (CM2, CM5) was applied to each patient just before induction of anesthesia and was performed for 24 h. The primary endpoint of the study was the occurrence of block progression. As secondary endpoints, bradycardias < 40 beats/min with hemodynamic compromise (systolic blood pressure < 90 mmHg) or asystoles > 5 s were defined.

Results
Block progression to second-degree A-V block and consecutive cardiac arrest occurred in one case of LBBB without a prolonged P-R interval. Severe bradyarrhythmias with hypotension developed in another eight patients: asystoles > 5 s occurred in two cases and six patients had bradycardias < 40/min. Pharmacotherapy was successful in these eight patients. There was no significant difference for severe bradyarrhythmias associated with hemodynamic compromise between patients with and without P-R prolongation (P = 1.00).

Conclusions
In patients with chronic bifascicular block or LBBB, perioperative progression to complete heart block is rare. However, the rate of bradyarrhythmias with hemodynamic compromise proved to be relevant. Because an additional first-degree A-V block did not increase the incidence of severe bradyarrhythmias and pharmacotherapy by itself was successful in nearly all cases, routine prophylactic insertion of a temporary pacemaker in such patients should be questioned.

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