12 Aug 10
Posted in General at 0:11 by Laci
By S Christensen, R Thomsen, M Johansen, L Pedersen, R Jensen, K Larsen, A Larsson, E Tønnesen, H Sørensen
Crit Care. 2010;14(2):R29
Statins reduce risk of cardiovascular events and have beneficial pleiotropic effects; both may reduce mortality in critically ill patients. We examined whether statin use was associated with risk of death in general intensive care unit (ICU) patients.
Methods
Cohort study of 12,483 critically ill patients > 45 yrs of age with a first-time admission to one of three highly specialized ICUs within the Aarhus University Hospital network, Denmark, between 2001 and 2007. Statin users were identified through population-based prescription databases. We computed cumulative mortality rates 0–30 days and 31–365 days after ICU admission and mortality rate ratios (MRRs), using Cox regression analysis controlling for potential confounding factors (demographics, use of other cardiovascular drugs, comorbidity, markers of social status, diagnosis, and surgery).
Results
1882 (14.3%) ICU patients were current statin users. Statin users had a reduced risk of death within 30 days of ICU admission [users: 22.1% vs. non-users 25.0%; adjusted MRR = 0.76 (95% confidence interval (CI): 0.69 to 0.86)]. Statin users also had a reduced risk of death within one year after admission to the ICU [users: 36.4% vs. non-users 39.9%; adjusted MRR = 0.79 (95% CI: 0.73 to 0.86)]. Reduced risk of death associated with current statin use remained robust in various subanalyses and in an analysis using propensity score matching. Former use of statins and current use of non-statin lipid-lowering drugs were not associated with reduced risk of death.
Conclusions
Preadmission statin use was associated with reduced risk of death following intensive care. The associations seen could be a pharmacological effect of statins, but unmeasured differences in characteristics of statin users and non-users cannot be entirely ruled out.
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Posted in Anesthesia, Pre-operatie evaluation at 0:01 by Laci
By W Flu, J van Kuijk, S Hoeks, R Kuiper, O Schouten, D Goei, A Elhendy et al
Anesthesiology 2010;112:1316-1324
The prognostic value of heart failure symptoms on postoperative outcome is well acknowledged in perioperative guidelines. The prognostic value of asymptomatic left ventricular (LV) dysfunction remains unknown. This study evaluated the prognostic implications of asymptomatic LV dysfunction in vascular surgery patients assessed with routine echocardiography.
Methods
Echocardiography was performed preoperatively in 1,005 consecutive vascular surgery patients. Systolic LV dysfunction was defined as LV ejection fraction less than 50%. Ratio of mitral-peak velocity during early and late filling, pulmonary vein flow, and deceleration time was used to diagnose diastolic LV dysfunction. Troponin-T measurements and electrocardiograms were performed routinely perioperatively. Multivariate regression analyses evaluated the relation between LV function and the study endpoints, 30-day cardiovascular events, and long-term cardiovascular mortality.
Results
Left ventricular dysfunction was diagnosed in 506 (50%) patients of which 80% were asymptomatic. In open vascular surgery (n = 649), both asymptomatic systolic and isolated diastolic LV dysfunctions were associated with 30-day cardiovascular events (odds ratios 2.3, 95% confidence interval [CI] 1.4–3.6 and 1.8, 95% CI 1.1–2.9, respectively) and long-term cardiovascular mortality (hazard ratios 4.6, 95% CI 2.4–8.5 and 3.0, 95% CI 1.5–6.0, respectively). In endovascular surgery (n = 356), only symptomatic heart failure was associated with 30-day cardiovascular events (odds ratio 1.8, 95% CI 1.1–2.9) and long-term cardiovascular mortality (hazard ratio 10.3, 95% CI 5.4–19.3).
Conclusions
This study demonstrated that asymptomatic LV dysfunction is predictive for 30-day and long-term cardiovascular outcome in open vascular surgery patients. These data suggest that preoperative risk stratification should include not only solely heart failure symptoms but also routine preoperative echocardiography to risk stratify open vascular surgery patients.
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02 Aug 10
Posted in Tracheostomy at 0:54 by Laci
Editorial by D Scales and N Ferguson
JAMA 2010;303:1537-1538
Endotracheal intubation is the most common procedure for airway control for patients requiring mechanical ventilation. Extubation is performed once patients have improved so that mechanical ventilation can be discontinued. For patients who require prolonged mechanical ventilation, replacement of the endotracheal tube with a tracheotomy is often considered. The most common reason for tracheotomy insertion in the intensive care unit (ICU) is to provide access for prolonged mechanical ventilation. From observational data, between 6% and 11% of mechanically ventilated patients receive a tracheotomy after a median of 9 to 12 days; however, there is significant variability around both patient selection and timing.
Tracheotomy practice is variable in large part because what constitutes prolonged mechanical ventilation (ie, the optimal timing for tracheotomy) is not known. Defining and predicting the need for prolonged ventilation has been a major methodological challenge. Research on tracheotomy timing involves evaluating a 2-part study……
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Posted in Tracheostomy at 0:50 by Laci
By P Terragni, M Antonelli, R Fumagalli, C Faggiano, M Berardino, F Pallavicini, A Miletto et al
JAMA 2010;303:1483-1489
Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources.
Objective
To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days.
Design, setting and patients
Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater.
Intervention
Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy).
Main outcome measures
The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive.
Results
Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15).
Conclusion
Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia.
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