30 Jun 09
Posted in Anesthesia at 22:14 by Laci
By C Lee, J Jahr, K Candiotti, B Warriner, M Zornow, M Naguib
Anesthesiology 2009;110:1020-1025
Rocuronium in intubation doses provides similar intubation conditions as succinylcholine, but has a longer duration of action. This study compared time to sugammadex reversal of profound rocuronium-induced neuromuscular block with time to spontaneous recovery from succinylcholine.
Methods
One hundred and fifteen adult American Society of Anesthesiologists Class I-II surgical patients were randomized to this multicenter, safety-assessor-blinded, parallel group, active-controlled, Phase IIIa trial. Anesthesia was induced and maintained with propofol and an opioid. Neuromuscular transmission was blocked and tracheal intubation facilitated with 1.2 mg/kg rocuronium or 1 mg/kg succinylcholine. Sugammadex (16 mg/kg) was administered 3 min after rocuronium administration. Neuromuscular function was monitored by acceleromyography. The primary efficacy endpoint was the time from the start of relaxant administration to recovery of the first train-of-four twitch (T1) to 10%.
Results
One hundred and ten patients received study treatment. Mean times to recovery of T1 to 10% and T1 to 90% were significantly faster in the rocuronium-sugammadex group (4.4 and 6.2 min, respectively), as compared with the succinylcholine group (7.1 and 10.9 min, respectively; all P < 0.001). Timed from sugammadex administration, the mean time to recovery of T1 to 10%, T1 to 90%, and the train-of-four (T4/T1) ratio to 0.9 was 1.2, 2.9, and 2.2 min, respectively. Reoccurrence of the block was not observed. There were no serious adverse events related to study treatments.
Conclusion
Reversal of profound high-dose rocuronium-induced neuromuscular block (1.2 mg/kg) with 16 mg/kg sugammadex was significantly faster than spontaneous recovery from 1 mg/kg succinylcholine.
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27 Jun 09
Posted in Infection, Procalcitonin at 11:01 by Laci
By M Hochreiter, T Köhler, A Schweiger, F Sixtus Keck, B Bein, T von Spiegel and S Schroeder
Critical Care 2009, 13:R83
The development of resistance by bacterial species is a compelling issue to reconsider indications and administration of antibiotic treatment. Adequate indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care setting. Until recently, no laboratory marker has been available to differentiate bacterial infection from viral or non-infectious inflammatory reaction; however, over the past years, procalcitonin (PCT) is the first among a large array of inflammatory variables that offers this possibility. The present study aimed to investigate the clinical usefulness of PCT for guiding antibiotic therapy in surgical intensive care patients.
Methods
All patients requiring antibiotic therapy based on confirmed or highly suspected bacterial infections and at least two concomitant systemic inflammatory response syndrome criteria were eligible. Patients were randomly assigned to either a PCT-guided (study group) or a standard (control group) antibiotic regimen. Antibiotic therapy in the PCT-guided group was discontinued, if clinical signs and symptoms of infection improved and PCT decreased to <1 ng/ml or the PCT value was >1 ng/ml, but had dropped to 25 to 35% of the initial value over three days. In the control group antibiotic treatment was applied as standard regimen over eight days.
Results
A total of 110 surgical intensive care patients receiving antibiotic therapy after confirmed or high-grade suspected infections were enrolled in this study. In 57 patients antibiotic therapy was guided by daily PCT and clinical assessment and adjusted accordingly. The control group comprised 53 patients with a standardized duration of antibiotic therapy over eight days. Demographic and clinical data were comparable in both groups. However, in the PCT group the duration of antibiotic therapy was significantly shorter than compared to controls (5.9 +/- 1.7 versus 7.9 +/- 0.5 days, P < 0.001) without negative effects on clinical outcome.
Conclusions
Monitoring of PCT is a helpful tool for guiding antibiotic treatment in surgical intensive care patients. This may contribute to an optimized antibiotic regimen with beneficial effects on microbial resistance and costs in intensive care medicine.
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25 Jun 09
Posted in Sedation at 2:17 by Laci
By DW Dowdy, OJ Bienvenu, VD Dinglas, PA Mendez-Tellez, J Sevransky, C Shanholtz, DM Needham
Crit Care Med 2009;37:1702-1707
To evaluate intensive care-related factors as predictors of depressive symptoms 6 months after acute lung injury (ALI).
Design
Prospective cohort study.
Setting
Thirteen intensive care units (ICUs) in four hospitals in Baltimore, MD.
Patients
Consecutive ALI survivors (n = 160; 71% from medical ICUs) screened for depressive symptoms at 6 months post-ALI.
Interventions
None.
Measurements and main results
We prospectively measured 12 features of critical illness and ICU care and used multivariable regression to evaluate associations with depressive symptoms as measured by the Hospital Anxiety and Depression Score. The prevalence of a positive screening for depression (score >=8) at 6 months post-ALI was 26%. Depressive symptoms were significantly associated with surgical (vs. medical or trauma) ICU admission (relative risk [RR] 2.2, 95% confidence interval [CI] 1.1-4.2), maximum daily Sequential Organ Failure Assessment Score of >10 (RR 2.1, 95% CI 1.1-3.5), and mean daily ICU benzodiazepine dose of >=75 mg of midazolam equivalent (RR 2.1, 95% CI 1.1-3.5).
Conclusions
Depressive symptoms at 6 months post-ALI are common and potentially associated with ICU-related factors. Mechanisms by which critical illness and intensive care management associate with depressive symptoms merit further investigation.
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16 Jun 09
Posted in Pre-operatie evaluation at 2:58 by Laci
By D J Correll, D L Hepner, C Chang, L Tsen, N Hevelone, A Bader
Anesthesiology 2009;110:1217-22
Age is often the sole criterion for determining the need for preoperative electrocardiograms. However, screening electrocardiograms have not been shown to add value above clinical information. This study was designed to determine whether it is possible to target electrocardiograms ordering to patients most likely to have an abnormality that would affect management and if age alone is predictive of significant electrocardiograms abnormalities.
Methods
A list was developed of electrocardiograms abnormalities considered significant enough to impact management, as well as a list of patient factors believed to increase cardiovascular risk. Electrocardiograms in all patients over 50 yr of age presenting for preoperative evaluation during a 2-month period were reviewed.
Results
A total of 1,149 electrocardiograms were reviewed, with 89 patients (7.8%) having at least one significant abnormality. These patients were compared with a group of 195 patients who had electrocardiograms that did not contain significant abnormalities. Patients at higher risk of having a significantly abnormal electrocardiograms that would potentially affect management were those older than 65 yr of age or who had a history of heart failure, high cholesterol, angina, myocardial infarction, or severe valvular disease. Five patients (0.44%) had an abnormal electrocardiograms in the absence of risk factors. The sensitivity of the model is 87.6%.
Conclusion
Age greater than 65 yr remains an independent predictor for significant preoperative electrocardiograms abnormalities. The specific clinical risk factors that were found have a high sensitivity and identified all but 0.44% of patients with electrocardiograms abnormalities that may affect preoperative management.
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