22 Mar 09
Posted in Regional anaesthesia at 2:52 by Laci
By K Mukhtar and S Singh
British Journal of Anaesthesia 2009 102:143-144
Editor—Transversus abdominis plane (TAP) block is gaining popularity as a method for pain relief after abdominal surgery. As with any novel approach, the indications for this block are expanding. We report the successful use of TAP blocks for laparoscopic surgery in five patients. Four of the patients were aged between 14 and 17 yr and underwent laparoscopic appendicectomy. The fifth patient was 79 yr old and had a laparoscopic incisional hernia repair.
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20 Mar 09
Posted in Coronary artery disease at 16:07 by Laci
By M A Hlatky, D B Boothroyd, D M Bravata, E Boersma, J Booth, M M Brooks, D Carrié, T C Clayton et al
The Lancet, Early Online Publication, 20 March 2009
Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics.
Methods
We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients’ baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat.
Findings
Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5·9 years (IQR 5·0—10·0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0·91, 95% CI 0·82—1·02; p=0·12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0·70, 0·56—0·87); however, mortality was similar between groups in patients without diabetes (HR 0·98, 0·86—1·12; p=0·014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1·25 (0·94—1·66) in patients younger than 55 years, 0·90 (0·75—1·09) in patients aged 55—64 years, and 0·82 (0·70—0·97) in patients 65 years and older (p=0·002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics.
Interpretation
Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.
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Posted in Sepsis at 2:26 by Laci
By S Heemskerk, R Masereeuw, O Moesker, M Bouw, J van der Hoeven, W Peters, F Russel, P Pickkers on behalf of the APSEP Study Group
Crit Care Med 2009;37:417-423
Alkaline phosphatase (AP) attenuates inflammatory responses by lipopolysaccharide detoxification and may prevent organ damage during sepsis. To investigate the effect of AP in patients with severe sepsis or septic shock on acute kidney injury.
Design and setting
A multicenter double-blind, randomized, placebo-controlled phase IIa study (2:1 ratio).
Patients
Thirty-six intensive care unit patients (20 men/16 women, mean age 58 ± 3 years) with a proven or suspected Gram-negative bacterial infection, ≥2 systemic inflammatory response syndrome criteria (<24 hours), and <12 hours end-organ dysfunction onset were included.
Intervention
An initial bolus intravenous injection (67.5 U/kg body weight) over 10 minutes of AP or placebo, followed by continuous infusion (132.5 U/kg) over the following 23 hours and 50 minutes.
Measurements and main results
Median plasma creatinine levels declined significantly from 91 (73-138) to 70 (60-92) μmol/L only after AP treatment. Pathophysiology of nitric oxide (NO) production and subsequent renal damage were assessed in a subgroup of 15 patients. A 42-fold induction (vs. healthy subjects) in renal inducible NO synthase expression was reduced by 80% ± 5% after AP treatment. In AP-treated patients, the increase in cumulative urinary NO metabolite excretion was attenuated, whereas the opposite occurred after placebo. Reduced excretion of NO metabolites correlated with the proximal tubule injury marker glutathione S-transferase A1-1 in urine, which decreased by 70 (50-80)% in AP-treated patients compared with an increase by 200 (45-525)% in placebo-treated patients.
Conclusions
In severe sepsis and septic shock, infusion of AP inhibits the upregulation of renal inducible NO synthase, leading to subsequent reduced NO metabolite production, and attenuated tubular enzymuria. This mechanism may account for the observed improvement in renal function.
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16 Mar 09
Posted in Cardiac arrest/Resuscitation, Hypothermia at 23:07 by Laci
By M Tiainen, H J Parikka, M A Mäkijärvi, O S Takkunen, S J Sarna, R O Roine
Crit Care Med 2009;37:403-409
To evaluate the effects of therapeutic hypothermia (HT) of 33°C after cardiac arrest (CA) on cardiac arrhythmias, heart rate variability (HRV), and their prognostic value.
Design
Prospective, comparative substudy of a randomized controlled trial of mild HT after out-of-hospital CA, the European Hypothermia After Cardiac Arrest study.
Setting
Intensive care unit of a tertiary referral hospital (Helsinki University Hospital).
Patients
Seventy consecutive adult patients resuscitated from out-of-hospital ventricular fibrillation were randomly assigned either to therapeutic HT of 33°C or normothermia.
Interventions
Patients randomized to HT were cooled with an external cooling device for 24 hours and then allowed to rewarm slowly during 12 hours. In the normothermia group, the core temperature was kept <38°C by antipyretics and physical means. All patients received standard intensive care for at least 2 days.
Measurements and main results
Twenty-four hour ambulatory electrocardiography recordings were performed at 0-24 hours, at 24-48 hours, and at 14 days. The clinical outcome was assessed at 6 months after CA. The occurrence of premature ventricular beats was increased in the HT-treated group during the first two recordings, with no difference in the number of ventricular tachycardia or ventricular fibrillation episodes. All HRV values were significantly higher during the HT (p < 0.01), but no differences were observed 2 weeks later. In multivariate analysis, only shorter delay to restoration of spontaneous circulation (p = 0.009) and the sd of individual normal-to-normal intervals >100 msec of the 24-48-hour recording in the HT group (p = 0.018) predicted good outcome.
Conclusions
The use of therapeutic HT of 33°C for 24 hours after CA was not associated with an increase in clinically significant arrhythmias. Preserved 24 to 48-hour HRV may be a predictor of favorable outcome in patients with CA treated with HT.
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