20 Dec 09

Defibrillator implantation early after myocardial infarction

Posted in Arrhythmia, Coronary artery disease, ICD at 0:01 by Laci

By G Steinbeck, D Andresen, K Seidl, J Brachmann, E Hoffmann et al; for the IRIS Investigators

NEJM 2009;361:1427-1436

The rate of death, including sudden cardiac death, is highest early after a myocardial infarction. Yet current guidelines do not recommend the use of an implantable cardioverter–defibrillator (ICD) within 40 days after a myocardial infarction for the prevention of sudden cardiac death. We tested the hypothesis that patients at increased risk who are treated early with an ICD will live longer than those who receive optimal medical therapy alone.

Methods
This randomized, prospective, open-label, investigator-initiated, multicenter trial registered 62,944 unselected patients with myocardial infarction. Of this total, 898 patients were enrolled 5 to 31 days after the event if they met certain clinical criteria: a reduced left ventricular ejection fraction (<40%) and a heart rate of 90 or more beats per minute on the first available electrocardiogram (ECG) (criterion 1: 602 patients), nonsustained ventricular tachycardia (>150 beats per minute) during Holter monitoring (criterion 2: 208 patients), or both criteria (88 patients). Of the 898 patients, 445 were randomly assigned to treatment with an ICD and 453 to medical therapy alone.

Results
During a mean follow-up of 37 months, 233 patients died: 116 patients in the ICD group and 117 patients in the control group. Overall mortality was not reduced in the ICD group (hazard ratio, 1.04; 95% confidence interval [CI], 0.81 to 1.35; P=0.78). There were fewer sudden cardiac deaths in the ICD group than in the control group (27 vs. 60; hazard ratio, 0.55; 95% CI, 0.31 to 1.00; P=0.049), but the number of nonsudden cardiac deaths was higher (68 vs. 39; hazard ratio, 1.92; 95% CI, 1.29 to 2.84; P=0.001). Hazard ratios were similar among the three groups of patients categorized according to the enrollment criteria they met (criterion 1, criterion 2, or both).

Conclusions
Prophylactic ICD therapy did not reduce overall mortality among patients with acute myocardial infarction and clinical features that placed them at increased risk.

15 Dec 09

Are epidurals worthwhile in vascular surgery?

Posted in Anesthesia, Pain medicine at 5:44 by Laci

By B Veering

Curr Op Anaesthes 2008;21:616-618

Patients undergoing major vascular surgery are at increased risk for postoperative complications due to the high incidence of comorbidities in this population. Epidural anaesthesia provides potential benefits but its effect on morbidity and mortality is unclear.

Recent findings
Existing studies fail to demonstrate improved clinical outcome and reduced mortality for epidural anaesthesia or combined epidural/general techniques compared with general anaesthesia. Postoperative epidural analgesia provides better pain relief and reduces the duration of postoperative mechanical ventilation.

Summary
Optimization of perioperative care rather than the anaesthetic technique may have potential benefit in improving postoperative outcome.

11 Dec 09

Year in review 2008: Critical Care – metabolism

Posted in Critical Care at 1:26 by Laci

By J Preiser

Critical Care 2009, 13:228

In 2008, the interest in metabolic and endocrine issues and their consequences in critically ill patients was high. A large proportion of the research papers related to these issues was related to the metabolism of glucose and its control and to the changes in body composition, including muscular weakness. In Critical Care, original reports from investigations of glucose physiology and clinical data from observational and interventional studies were published. Important reports of the effects of hormone analogues, such as vasopressin and hydrocortisone, and early antioxidants in selected subpopulations were also available in 2008.

09 Dec 09

Year in review 2008: Critical Care – respirology

Posted in Critical Care at 1:28 by Laci

By Zhang and A Slutsky

Critical Care 2009, 13:225

Original research contributions published in Critical Care in 2008 in the fields of respirology and critical care medicine are summarized. Eighteen articles were grouped into the following categories: acute lung injury and acute respiratory distress syndrome, mechanical ventilation, mechanisms of ventilator-induced lung injury, and tracheotomy decannulation and non-invasive ventilation.

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