22 Jan 07
Posted in Anesthesia, Anticoagulation, Pre-operatie evaluation at 20:08 by Laci
By CL Grines, RO Bonow, DE Casey Jr, TJ Gardner, PB Lockhart, DJ Moliterno, P O’Gara and P Whitlow
Circulation 2007; 115:813-818
Dual antiplatelet therapy with aspirin and a thienopyridine has been shown to reduce cardiac events after coronary stenting. However, many patients and healthcare providers prematurely discontinue dual antiplatelet therapy, which greatly increases the risk of stent thrombosis, myocardial infarction, and death. This advisory stresses the importance of 12 months of dual antiplatelet therapy after placement of a drug-eluting stent and educating the patient and healthcare providers about hazards of premature discontinuation. It also recommends postponing elective surgery for 1 year, and if surgery cannot be deferred, considering the continuation of aspirin during the perioperative period in high-risk patients with drug-eluting stents.
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10 Jan 07
Posted in Mechanical ventilation, Tracheostomy at 19:59 by Laci
By C Clec’h, C Alberti, F Vincent, M Garrouste-Orgeas, A de Lassence, D Toledano et al on behalf of the OUTCOMEREA study group
Critical Care Medicine 2007;35:132-138
To examine the association between the performance of a tracheostomy and intensive care unit and postintensive care unit mortality, controlling for treatment selection bias and confounding variables.
Design
Prospective, observational, cohort study.
Setting
Twelve French medical or surgical intensive care units.
Patients
Unselected patients requiring mechanical ventilation for >=48 hrs enrolled between 1997 and 2004.
Measurements and Main Results
Two models of propensity scores for tracheostomy were built using multivariate logistic regression. After matching on these propensity scores, the association of tracheostomy with outcomes was assessed using multivariate conditional logistic regression. Results obtained with the two models were compared. Of the 2,186 patients included, 177 (8.1%) received a tracheostomy. Both models led to similar results. Tracheostomy did not improve intensive care unit survival (model 1: odds ratio, 0.94; 95% confidence interval, 0.63-1.39; p = .74; model 2: odds ratio, 1.12; 95% confidence interval, 0.75-1.67; p = .59). There was no difference whether tracheostomy was performed early (within 7 days of ventilation) or late (after 7 days of ventilation). In patients discharged free from mechanical ventilation, tracheostomy was associated with increased postintensive care unit mortality when the tracheostomy tube was left in place (model 1: odds ratio, 3.73; 95% confidence interval, 1.41-9.83; p = .008; model 2: odds ratio, 4.63; 95% confidence interval, 1.68-12.72, p = .003).
Conclusions
Tracheostomy does not seem to reduce intensive care unit mortality when performed in unselected patients but may represent a burden after intensive care unit discharge.
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Posted in Fluid management, PA catheter at 19:54 by Laci
By D Osman, C Ridel, P Ray, X Monnet, N Anguel, C Richard, J-L Teboul
Critical Care Medicine. 2007;35:64-68
Values of central venous pressure of 8-12 mm Hg and of pulmonary artery occlusion pressure of 12-15 mm Hg have been proposed as volume resuscitation targets in recent international guidelines on management of severe sepsis. By analyzing a large number of volume challenges, our aim was to test the significance of the recommended target values in terms of prediction of volume responsiveness.
Design
Retrospective study.
Setting
A 24-bed medical intensive care unit.
Patients
All consecutive septic patients monitored with a pulmonary artery catheter who underwent a volume challenge between 2001 and 2004.
Intervention
None.
Measurements and Main Results
A total of 150 volume challenges in 96 patients were reviewed. In 65 instances, the volume challenge resulted in an increase in cardiac index of >=15% (responders). The pre-infusion central venous pressure was similar in responders and nonresponders (8 +/- 4 vs. 9 +/- 4 mm Hg). The pre-infusion pulmonary artery occlusion pressure was slightly lower in responders (10 +/- 4 vs. 11 +/- 4 mm Hg, p < .05). However, the significance of pulmonary artery occlusion pressure to predict fluid responsiveness was poor and similar to that of central venous pressure, as indicated by low values of areas under the receiver operating characteristic curves (0.58 and 0.63, respectively). A central venous pressure of <8 mm Hg and a pulmonary artery occlusion pressure of <12 mm Hg predicted volume responsiveness with a positive predictive value of only 47% and 54%, respectively. With the knowledge of a low stroke volume index (<30 mL[middle dot]m-2), their positive predictive values were still unsatisfactory: 61% and 69%, respectively. When the combination of central venous pressure and pulmonary artery occlusion pressure was considered instead of either pressure alone, the degree of prediction of volume responsiveness was not improved.
Conclusion
Our study demonstrates that cardiac filling pressures are poor predictors of fluid responsiveness in septic patients. Therefore, their use as targets for volume resuscitation must be discouraged, at least after the early phase of sepsis has concluded.
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Posted in ScvO2 at 19:47 by Laci
By H Bracht, M Haenggi, B Jeker, N Wegmueller, F Porta, D Tueller, J Takala and S M Jakob
Critical Care 2007, 11:R2
It has been shown that early central venous oxygen saturation (ScvO2)-guided optimization of hemodynamics can improve outcome in septic patients. The early ScvO2 profile of other patient groups is unknown. The aim of this study was to characterize unplanned admissions in a multidisciplinary intensive care unit (ICU) with respect to ScvO2 and outcome.
Methods
98 consecutive unplanned admissions to a multidisciplinary intensive care unit [age: 63 (19 to 83) years (median, range), acute simplified physiology score (SAPS II): 43 (11 to 93)] with a clinical indication for a central venous catheter were included in the study. ScvO2 was assessed at ICU arrival and 6 hours later, but was not used to guide treatment. Length of stay in ICU (LOSICU) and hospital (LOShospital) and 28-day mortality were recorded.
Results
ScvO2 was 70 +/- 12% (mean +/- SD) at admission and 71 +/- 10% 6 hours later (p: 0.484). Overall 28-day mortality was 18%, LOSICU was 3 (1 to 28) days and LOShospital was 19 (1 to 28) days. Patients with ScvO2 <60% at admission had higher mortality than patients with ScvO2 >60% (29 vs. 17%, p<0.05). Changes in ScvO2 during the first 6 hours were not predictive of LOSICU, LOShospital or mortality.
Conclusions
Low ScvO2 in unplanned admissions and high SAPS II scores are associated with increased mortality. Standard ICU treatment increased ScvO2 in patients with a low admission ScvO<2, but the increase was not associated with length of stay in ICU or in hospital.
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