Anesthesiology 2012;117:180–187

IT seems implausible that an injection of a simple, off-the-shelf, intravenous nutritional solution could be acutely life-saving for a patient with severe drug overdose. But dozens of published case reports support this observation, first made more than a decade ago in a rodent model of bupivacaine toxicity. It is even more surprising that such a simple formulation can rapidly reverse severe clinical toxicity from a variety of vastly disparate medications with distinct pharmacodynamics and mechanisms of action. This review will focus on the clinical application of lipid emulsion therapy in resuscitation from drug-related toxicity and will provide an introduction to the development of the method, guidelines for its use, and insights into potential controversies and future applications.

Background
Weinberg et al. first showed in 1998 that an infusion of a soybean oil emulsion normally used as a total parenteral nutrition solution could prevent (by pretreatment) or improve resuscitation from cardiovascular collapse caused by severe bupivacaine overdose in the intact, anesthetized rat. Subsequent studies from the same laboratory confirmed these findings in isolated rat heart and anesthetized dog. Under the latter experimental model, return of spontaneous circulation after a bupivacaine challenge occurred in all animals receiving lipid, but in none of the saline controls. This study was accompanied by an editorial asking whether lipid might be the long-sought “silver bullet” for local anesthetic systemic toxicity (LAST). Since then, the effectiveness of lipid emulsion infusion in reversing LAST has been confirmed in other laboratories and by systematic analysis4 in the clinical setting, as well.

Anesth Anal, 2012;115:527-533

Laparoscopic cholecystectomy is associated with postoperative pain of moderate intensity in the early postoperative period. Recent randomized trials have demonstrated the efficacy of transversus abdominis plane (TAP) block in providing postoperative analgesia after abdominal surgery. We hypothesized that a TAP block may reduce pain while coughing and at rest for the first 24 postoperative hours, opioid consumption, and opioid side effects in patients undergoing laparoscopic cholecystectomy in day-case surgery.

Methods
In this randomized, double-blind study, 80 patients undergoing laparoscopic cholecystectomy in our day-case surgery unit were allocated to receive either bilateral ultrasound-guided posterior TAP blocks (20 mL 0.5% ropivacaine) or placebo blocks. Postoperative pain treatment consisted of oral acetaminophen 1000 mg × 4, oral ibuprofen 400 mg × 3, IV morphine (0–2 hours postoperatively), and oral ketobemidone (2–24 hours postoperatively). The primary outcome was postoperative pain scores while coughing calculated as area under the curve for the first 24 postoperative hours (AUC/24 h). Secondary outcomes were pain scores at rest (AUC/24 h), opioid consumption, and side effects. Patients were assessed 0, 2, 4, 6, 8, and 24 hours postoperatively. Group-wise comparisons of visual analog scale (VAS) pain (AUC/24 h) were performed with the 2-sample t test. Morphine and ketobemidone consumption were compared with the Mann-Whitney test for unpaired data. Categorical data were analyzed using the χ2 test.

Results
The primary outcome variable, VAS pain scores while coughing (AUC/24 h), was significantly reduced in the TAP versus the placebo group (P = 0.04); group TAP: 26 mm (SD 13) (weighted average level) versus group placebo: 34 (18) (95% confidence interval): 0.5–15 mm). VAS pain scores at rest (AUC/24 h) showed no significant difference between groups. Median morphine consumption (0–2 hours postoperatively) was 7.5 mg (interquartile range: 5–10 mg) in the placebo group compared with 5 mg (interquartile range: 0–5 mg) in the TAP group (P < 0.001). The odds ratio of a random patient in group TAP having less morphine consumption than a random patient in group placebo was P (group TAP < group placebo) = 0.26 (confidence interval: 0.15, 0.37) where 0.5 represents no difference between groups. There were no between-group differences in total ketobemidone consumption, levels of nausea and sedation, number of patients vomiting, or consumption of ondansetron.

Conclusions
TAP block after laparoscopic cholecystectomy may have some beneficial effect in reducing pain while coughing and on opioid requirements, but this effect is probably rather small.

Curr Opin Crit Care 2012;18:350-357

This review discusses the importance of intravenous fluid dose and composition in surgical ICU patients. On the basis of updated physiologic postulates, we suggest guidelines for the use of crystalloids and colloids. Goal-directed fluid therapy is advocated as a means for avoiding both hypovolemia and hypervolemia.

Recent findings
Integrity of the endothelial surface layer (ESL) and ‘volume context’ are key determinants of fluid disposition. During critical illness the ESL is compromised. Optimal resuscitation may be guided by functional measures of fluid responsiveness with some caveats. The best approach may be to use physiologically balanced crystalloids for hypovolemic resuscitation and colloids for euvolemic hemodynamic augmentation.

Summary
The routine replacement of unmeasured presumed fluid deficits is not appropriate. In critically ill patients, resuscitation with intravenous fluids should produce a demonstrable enhancement of perfusion. Individualized goal-directed therapy using functional hemodynamic parameters can optimize resuscitation and ‘deresuscitation’.

Curr Opin Crit Care 2012;18:358-365

To identify the recent literature supporting the ability of anesthesiologists to impact morbidity and mortality outside of the immediate intraoperative period.

Recent findings
Hemodynamic management designed to optimize cardiac output and stroke volume can significantly lower the risk of perioperative morbidity, and, in some cases, mortality. The implications of the POISE trial, which upended the previously accumulating data in support of indiscriminate perioperative β-blockade by demonstrating worsened outcomes, were supported by high-quality, propensity-matched, prospectively collected data. Data supporting the safety of colloid use has been threatened by the retraction of 88 publications of a single author, as well as prospective, nonrandomized data, suggesting increased renal morbidity in critically ill patients receiving synthetic colloids. Large datasets continue to suggest an association between red blood cell transfusion and mortality. Analysis of the operating room strongly implicates anesthesia providers as a potential mechanism for bacterial contamination.

Summary
Anesthesiologists should consider implication of goal-directed therapy in high-risk surgical patients, adhere to the American College of Cardiology/American Heart Association guidelines with regard to perioperative β-blockade, critically assess the data to support their choice of synthetic colloids over crystalloids, explore all possible strategies for avoiding perioperative transfusion, and be cognizant of their potential contribution to perioperative infectious morbidity.

Pediatrics. 2011;128:857-866.

The objective of this randomized controlled trial was to evaluate the risk of hyponatremia following administration of a isotonic (0.9% saline) compared to a hypotonic (0.45% saline) parenteral maintenance solution (PMS) for 48 hours to postoperative pediatric patients.

Methods
Surgical patients 6 months to 16 years of age with an expected postoperative stay of >24 hours were eligible. Patients with an uncorrected baseline plasma sodium level abnormality, hemodynamic instability, chronic diuretic use, previous enrollment, and those for whom either hypotonic PMS or isotonic PMS was considered contraindicated or necessary, were excluded. A fully blinded randomized controlled trial was performed. The primary outcome was acute hyponatremia. Secondary outcomes included severe hyponatremia, hypernatremia, adverse events attributable to acute plasma sodium level changes, and antidiuretic hormone levels.

Results
A total of 258 patients were enrolled and assigned randomly to receive hypotonic PMS (N = 130) or isotonic PMS (N = 128). Baseline characteristics were similar for the 2 groups. Hypotonic PMS significantly increased the risk of hyponatremia, compared with isotonic PMS (40.8% vs 22.7%; relative risk: 1.82 [95% confidence interval: 1.21–2.74]; P = .004). Admission to the pediatric critical care unit was not an independent risk factor for the development of hyponatremia. Isotonic PMS did not increase the risk of hypernatremia (relative risk: 1.30 [95% confidence interval: 0.30–5.59]; P = .722). Antidiuretic hormone levels and adverse events were not significantly different between the groups.

Conclusions
Isotonic PMS is significantly safer than hypotonic PMS in protecting against acute postoperative hyponatremia in children.

Curr Opin Crit Care 2012;18:318-325

Pulmonary embolism remains one of the leading causes of cardiovascular mortality. The wide range of reported mortality rates reflects heterogeneity in comorbidity and severity of pulmonary embolism. Optimizing risk stratification to prognose pulmonary embolism patients appears to be important to improve management, treatment and clinical outcome.

Recent findings
Hemodynamic status is the most important short-term prognostic factor. High-risk pulmonary embolism or massive pulmonary embolism is defined by the patient response more than the clot size: patients with circulatory shock including sustained hypotension should receive thrombolytic therapy in absence of contraindications. Nonmassive or normotensive pulmonary embolism can be further stratified using clinical features, imaging (echocardiography, computed tomography) and biomarkers (troponins, natriuretic peptides): low-risk pulmonary embolism, evaluated by clinical model (Pulmonary Embolism Severity Index; PESI) can potentially be treated as outpatients; and intermediate-risk pulmonary embolism, which can be further stratified into less-severe and more-severe intermediate risk. The last may benefit from intensive clinical surveillance but the risk–benefit ratio for thrombolysis has been inadequately quantified to make any strong recommendation. New anticoagulants may transform traditional pulmonary embolism treatment.

Summary
Optimizing risk stratification of patients with normotensive pulmonary embolism before they develop overt hemodynamic instability is the challenge of current pulmonary embolism management. Treatment strategy has to integrate this risk stratification and new anticoagulants arrival.

Curr Opin Crit Care. 2012;18:301-307

Acute decompensated heart failure (ADHF) is characterized by a complex spectrum of pathophysiology that emerges as a common clinical disease state, which manifests as a failure of the circulation to provide for the needs of the body systems. Whereas ADHF is often characterized by the findings of pulmonary congestion and dyspnea, a variety of clinical presentations are possible, with each requiring differing management strategies. This review examines the approach of the four-quadrant clinical profile for differentiation of the ADHF patient during the emergent resuscitative phase of the decompensation.

Recent findings
Clinical and diagnostic information can be used to determine the relative degree of pulmonary congestion and peripheral tissue perfusion in patients suspected of ADHF. This information can be used in a four-quadrant approach to differentiate patients into pathophysiologic categories. These profiles can then be translated into management strategies from a physiology based perspective in which the specific mechanisms of the failure are targeted.

Summary
ADHF can present in a variety of clinical forms in the emergent setting. Categorization of the ADHF patient according to their individual hemodynamic profile can assist in management decisions during the emergent resuscitative phase of the decompensation based upon an approach that targets causative pathophysiologic mechanisms.

The review aims to describe the scope of the problem and potential therapeutic intervention for the management and risk stratification of patients with atrial fibrillation in the emergency department and acute care setting.

Recent findings
Atrial fibrillation is the most common arrhythmia prompting admission to the hospital. Management strategies include determining the trigger of the arrhythmia, rate control, and potential cardioversion. In the acute care setting the treatment is often dependent on the timing of the onset of arrhythmia. In those patients presenting with symptoms of less than 48 h of duration management may consist of rate control, pharmacologic, or electrical cardioversion. Recent studies suggest no difference in long-term outcomes with rate and rhythm control. In patients with symptoms greater that 48 h rate control is the initial option with potential for cardioversion as an outpatient. There are recent advances in ablation that provide additional options to patients with paroxysmal atrial fibrillation. An essential component of the treatment strategy for these patients is risk stratification for stroke and the initiation of long-term anticoagulation in appropriate patients.

Summary
Management of atrial fibrillation is guided by underlying causes of the atrial fibrillation and duration of symptoms.

Curr Op Crit Care 2012;18:295-300

Numerous implementation studies have demonstrated the benefit of bundled care in the initial treatment of patients with severe sepsis and septic shock, but the relative value of each component of these bundles remains uncertain. Recent studies have attempted to further define the optimal supportive and adjunctive treatments for these patients.

Recent findings
The choice of optimal intravenous resuscitation fluid for the emergency treatment of severe sepsis remains uncertain. Albumin appears safe, although safety concerns have arisen regarding the use of hydroxyethyl starch. Norepinephrine and vasopressin appear superior to dopamine as vasopressors of choice. Several studies have successfully incorporated lactate clearance into resuscitation strategies, albeit with differing protocols. Although corticosteroids may hasten improvement, there does not appear to be a mortality benefit in heterogeneous patients with sepsis, leaving their role uncertain.

Summary
Recent negative studies have questioned the role of previously promising adjunctive treatments. However, recent clinical trials and meta-analytic data continue to refine the relative importance of various components of sepsis bundles.

N Engl J Med 2012; 367:124-134

Hydroxyethyl starch (HES) is widely used for fluid resuscitation in intensive care units (ICUs), but its safety and efficacy have not been established in patients with severe sepsis.

Methods
In this multicenter, parallel-group, blinded trial, we randomly assigned patients with severe sepsis to fluid resuscitation in the ICU with either 6% HES 130/0.42 (Tetraspan) or Ringer’s acetate at a dose of up to 33 ml per kilogram of ideal body weight per day. The primary outcome measure was either death or end-stage kidney failure (dependence on dialysis) at 90 days after randomization.

Results
Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer’s acetate (relative risk, 1.17; 95% confidence interval [CI], 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal-replacement therapy versus 65 patients (16%) assigned to Ringer’s acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline.

Conclusions
Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer’s acetate.

N Engl J Med.  2012;366:2093-2101

Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown.

Methods
We conducted a retrospective cohort study involving ICUs that participated in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical information system from 2009 through 2010, linking a survey of ICU staffing practices with patient-level outcomes data from adult ICU admissions. Multivariate models were used to assess the relationship between nighttime intensivist staffing and in-hospital mortality among ICU patients, with adjustment for daytime intensivist staffing, severity of illness, and case mix. We conducted a confirmatory analysis in a second, population-based cohort of hospitals in Pennsylvania from which less detailed data were available.

Results
The analysis with the use of the APACHE database included 65,752 patients admitted to 49 ICUs in 25 hospitals. In ICUs with low-intensity daytime staffing, nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for death, 0.62; P=0.04). Among ICUs with high-intensity daytime staffing, nighttime intensivist staffing conferred no benefit with respect to risk-adjusted in-hospital mortality (odds ratio, 1.08; P=0.78). In the verification cohort, there was a similar relationship among daytime staffing, nighttime staffing, and in-hospital mortality. The interaction between nighttime staffing and daytime staffing was not significant (P=0.18), yet the direction of the findings were similar to those in the APACHE cohort.

Conclusions
The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing.

Anesth Analg, 2012;115:613-615

A 31-year-old woman at 32 weeks’ gestation presented with an ST segment elevation myocardial infarction with subsequent bare metal stent placement. A multidisciplinary team coordinated the delivery plan, including anticoagulation and delivery mode. Because the patient was at high risk for stent thrombosis, clopidogrel was discontinued after 4 weeks and bridged with eptifibatide for 7 days. Eptifibatide was stopped for induction of labor. Twelve hours after eptifibatide was discontinued, hemostatic function was assessed with thromboelastography before initiating neuraxial analgesia. A successful operative vaginal delivery was performed, followed by an uncomplicated recovery. Clopidogrel was resumed 24 hours postpartum.

J Emerg Med. 2012;43:7-12.

The management of septic shock has undergone a significant evolution in the past decade. A number of trials have been published to evaluate the efficacy of low-dose corticosteroid administration in patients with septic shock.

Methods
The Sepsis Sub-committee of the American Academy of Emergency Medicine Clinical Practice Committee performed an extensive search of the contemporary literature and identified seven relevant trials.

Results
Six of the seven trials reported a mortality outcome of patients in septic shock. Analysis of the data revealed that the relative risk (RR) of 28-day all-cause mortality in septic shock patients who received low-dose corticosteroids was 0.92 (95% confidence interval [CI] 0.79–1.07). All seven trials reported data concerning shock reversal or the withdrawal of vasopressors. Pooled results revealed that the RR of shock reversal is 1.17 (95% CI 1.07–1.28), which suggests that there may be significant improvement in shock reversal after corticosteroid administration. It is important to understand that two of the seven studies reviewed were disproportionately represented and accounted for 799 of 1005 patients (80%) considered for this recommendation.

Conclusions
The evidence suggests that low-dose corticosteroids may reverse shock faster; however, mortality is not improved for the overall population.

Curr Opin Crit Care 2012;18:377-384

A number of less-invasive haemodynamic monitoring devices have been introduced in recent years, largely replacing the pulmonary artery catheter (PAC) as a standard monitoring tool. Apart from tracking cardiac output (CO), these monitors provide additional haemodynamic parameters. The aim of this article is to review the most widely used less-invasive monitoring modalities, their technical characteristics and limitations regarding their clinical performance.

Recent findings
The utilization of CO monitoring in the perioperative setting has been shown to be associated with improved outcomes if integrated into a haemodynamic optimization strategy. These findings provide the basis of recent recommendations for perioperative monitoring.

Summary
An array of monitoring modalities have been introduced that can reliably track CO in the perioperative setting and make the PAC dispensable in most clinical situations. In order to be used safely and efficiently, knowledge regarding the inherent monitoring techniques and their limitations, their clinical validity and the utility of the parameters provided is crucial.

Curr Opin Crit Care 2012;18:385-392

The aim of this review is to summarize important publications in enhanced recovery during 2010–2011 and to highlight key themes. Specifically, we focus on updated systematic reviews of high-quality clinical trials of enhanced recovery in colorectal surgery, exemplar studies of enhanced recovery in other specialties, and exploration of which elements of the enhanced recovery package might be associated with improved patient outcome.

Recent findings
An expanding evidence base of clinical trials and implementation evaluations supports the effectiveness of enhanced recovery programmes in improving outcome following major elective surgery. The majority of this literature derives from the study of patients undergoing colorectal surgery, but increasingly enhanced recovery is spreading to other surgical specialties. The combination of reduced length of hospital stay (a surrogate for morbidity) with no increase in readmissions to hospital suggests that morbidity is reduced with enhanced recovery. Inconsistency in morbidity reporting limits the value of pooling data between studies, but within study comparisons in general support this conclusion. Patients adhering to an enhanced recovery programme return to normal function faster than those following traditional care pathways.

Summary
Enhanced recovery adoption is likely to continue to grow (range of specialties and penetration within specialties). This progression is supported by the available published data.

Critical Care 2012, 16:R76

Patients with septic shock require fluid, but the optimum amount is unknown. Therefore we assessed patient characteristics and outcome associated with fluid volume in unselected patients with septic shock including those with three days of shock.

Methods
We conducted a prospective, multicenter, observational study of all adult patients with septic shock during a 3-month study period at six general ICUs: three in university hospitals and three in regional hospitals. After day 1 and 3 of shock, patients were divided into two groups according to the overall median fluid volumes. Characteristics between these groups were compared using non-parametric and Chi-square statistics.

Results
The 164 included patients received median 4.0 l (IQR 2.3-6.3) of fluid during the first day of septic shock. Patients receiving higher volumes (> 4.0 l) on day 1 had higher p-lactate (3.4 (2.2-5.5) vs. 2.0 (1.6-3.0) mmol l-1, P < 0.0001) compared to those receiving lower volumes. In contrast simplified acute physiology score (SAPS) II (54 (45-64) vs. 54 (45-67), P = 0.73), sequential organ failure assessment (SOFA) score (11 (9-13) vs. 11 (9-13), P = 0.78) and 90-day mortality (48 vs. 53%, P = 0.27) did not differ between groups. The 95 patients who still had shock on day 3 had received 7.5 l (4.3 – 10.8) of fluid by the end of day 3. Patients receiving higher volumes (> 7.5 l) had higher p-lactate (2.6 (1.7-3.4) vs. 1.9 (1.6-2.4) mmol l-1, P < 0.01) on day 3 and lower 90-day mortality (40 vs. 62%, P = 0.03) than those receiving lower volumes in spite of comparable admission SAPS II (53 (46-67) vs. 55 (49-62), P = 0.47) and SOFA scores on day 3 (10 (8-13) vs. 11 (10-14), P = 0.33).

Conclusions
In this cohort of unselected ICU patients with septic shock, initial fluid volume was not associated with mortality. In patients with shock for three days or more, higher fluid volumes including crystalloids, colloids and blood products were associated with reduced mortality.

Anesth Analg 2009;108:616-622

Recent studies have emphasized the importance of perioperative fluid restriction. However, fluid restriction regimens may increase the likelihood of insufficient perioperative fluid administration or may result in excess intravascular crystalloid replacement. We postulate that the use of transesophageal echocardiography may reduce the amount of crystalloid administered during open and laparoscopic colorectal surgery.

Methods
Fifteen ASA I and II patients scheduled for open colorectal surgery, and 15 patients scheduled for laparoscopic surgery were studied. Lactated Ringer’s solution was infused during the procedures. Left ventricular end diastolic volume index (LVEDVI) and cardiac index were assessed throughout surgery and used to guide the rate of lactated Ringer’s solution administration. Statistical analysis was performed with Student’s t-test for unpaired samples.

Results
The rate of crystalloid administration required to maintain baseline LVEDVI and cardiac index was 5.9 ± 2 mL · kg−1 · h−1 for open surgery and 3.4 ± 0.8 mL · kg−1 · h−1 for laparoscopic surgery (P < 0.01). This slower rate for laparoscopic surgery was offset by the longer surgical duration.

Conclusion
The rate of crystalloid solution to maintain baseline LVEDVI and cardiac index was greater in open surgery than laparoscopic surgery, and lower than commonly recommended for colorectal surgery.

Implications
Transesophageal echocardiography guidance suggests that crystalloid replacement therapy for colorectal surgery is approximately 6 mL · kg−1 · h−1 for open procedures and 3 mL · kg−1 · h−1 for laparoscopic procedures.

J Clin Gastroenterol 2008;42:676-679. 
 
The addition of a bedtime H2 receptor antagonist (H2RA) to proton pump inhibitor (PPI) b.i.d. to inhibit nocturnal acid breakthrough (NAB) is controversial. H2RA tolerance has been documented suggesting limitations in its long-term effect.

Aim
To compare the intragastric pH and NAB occurring with twice daily PPI with or without the addition of a H2RA.

Method
Multichannel intraluminal impedance-pH studies in 100 patients were reviewed. Fifty-eight patients (female 41; mean age, 54 y; range, 17 to 85) were studied on twice daily PPI. Forty-two patients (female 36; mean age, 53 y; range 20 to 85) were studied on a PPI b.i.d.+H2RA for at least 1 month at bedtime. The percentage time of intragastric pH<4 (upright, recumbent, and total) and NAB were compared between the groups.

Results
In the patients with PPI b.i.d. 64% had NAB, compared with only 17% of patients on PPI b.i.d. and H2RA q.h.s. (P<0.001). The percent time intragastric pH<4 for patients on PPI b.i.d. was significantly higher (P<0.01) compared with patients on PPI b.i.d.+H2RA q.h.s. during upright (29.1+/-3.0 vs. 18.3+/-2.9), recumbent (33.5+/-3.4 vs. 12.5+/-3.1), and entire period (31.5+/-2.8 vs. 18.0+/-3.0).

Conclusions
The addition of a bedtime H2RA reduces the percentage time of the intragastric pH<4 and also NAB. H2RA should be considered as adjunct therapy in whom greater suppression of gastric acid control is considered desirable.

Critical Care 2012, 16:R60

Apolipoprotein M (apoM) is present in 5% of high-density lipoprotein (HDL) particles in plasma. It is a carrier of sphingosine-1-phosphate (S1P), which is important for vascular barrier protection. The aim was to determine the plasma concentrations of apoM during sepsis and systemic inflammatory response syndrome (SIRS) and correlate them to levels of apolipoprotein A-I (apoA1), apolipoprotein B (apoB), HDL-, and low-density lipoprotein (LDL)-cholesterol.

Methods
Plasma samples from patients with (1), severe sepsis with shock (n = 26); (2), severe sepsis without shock (n = 44); (3), sepsis (n = 100); (4), infections without SIRS (n = 43); and (5) SIRS without infection (n = 20) were analyzed. The concentrations of apoM, apoA1, and apoB were measured with enzyme-linked immunosorbent assays (ELISAs). Total, HDL-, and LDL-cholesterol concentrations were measured with a commercial HDL/LDL cholesterol test.

Results
ApoM concentrations correlated negatively to acute-phase markers. Thus, apoM behaved as a negative acute-phase protein. Decreased values were observed in all patient groups (P < 0.0001), with the most drastic decreases observed in the severely sick patients. ApoM levels correlated strongly to those of apoA1, apoB, HDL, and LDL cholesterol. The HDL and LDL cholesterol levels were low in all patient groups, as compared with controls (P < 0.0001), in particular, HDL cholesterol. ApoA1 and apoB concentrations were low only in the more severely affected patients.

Conclusions
During sepsis and SIRS, the plasma concentrations of apoM decrease dramatically, the degree of decrease reflecting the severity of the disease. As a carrier for barrier-protective S1P in HDL, the decrease in apoM could contribute to the increased vascular leakage observed in sepsis and SIRS.

Contin Educ Anaesth Crit Care Pain 2011;11:177-180

Laparoscopic techniques offer major benefits to the patient such as minimized incision size and trauma with reduced postoperative discomfort, shortened recovery rates, and a lower incidence of postoperative wound infections. These factors all contribute to shorter in-patient stay and reduced perioperative morbidity. Consequently, many major procedures that once required prolonged postoperative recovery such as anterior resection of the rectum or radical cystectomy are now increasingly performed using laparoscopic techniques to improve patient outcomes.1

However, laparoscopic surgery is not without its own specific risks, either due to the risks associated with individual laparoscopic techniques or due to the physiological changes associated with the creation of a pneumoperitoneum. As a result, anaesthetic techniques for laparoscopic surgery must be refined to anticipate these differences from open surgery.