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Circadian rhythm disruption in severe sepsis: the effect of ambient light on urinary 6-sulfatoxymelatonin secretion
Verceles AC et al. – Circadian rhythm was disrupted in patients with severe sepsis, as reflected by disordered diurnal variation of urinary 6-SMT excretion. Light levels were low, exhibited limited diurnal variation, and did not entrain circadian rhythms in these patients. Methods After excluding patients for renal failure or hepatic failure, blindness, and intracranial disease, seven patients were studied. No environmental manipulation was performed. Urinary 6-SMT specimens were obtained every 4h. Light was measured in 1min epochs for two sequential 24h periods and compared to 6-SMT levels. Results No significant differences among urinary 6-SMT levels were found across 4-h time periods or between the 2 days (range 1,190.26±1,040.81-4,738.57±5,543.08ng, 4h period p=0.09, 24h day p=0.50). Light levels were low and differed among 4h periods, but not 24h averages (minimum 2.32±3.65lux/min 00:01-04:00, maximum 70.11 ±79.12lux/min from 12:01-16:00, 4h period p=<0.001, 24h period p=0.53). There was no relationship between light levels and 6-SMT excretion. ...
Intensive Care Medicine, Intensive Care Medicine

Anesthetic Management of Patients Undergoing Pulmonary Vein Isolation for Treatment of Atrial Fibrillation Using High-Frequency Jet Ventilation
Elkassabany N et al. – The findings suggest that high-frequency jet ventilation is generally a safe technique that can be used in catheter ablation treatment under general anesthesia. Methods One hundred eighty-eight consecutive patients undergoing pulmonary vein isolation under general anesthesia with high-frequency jet ventilation. High-frequency jet ventilation was used as the primary mode of ventilation under general anesthesia. Results High-frequency jet ventilation was performed successfully throughout the ablation procedure in 175 cases of the study cohort. The remaining 13 patients had to be converted to conventional positive-pressure ventilation because of high PaCO2 or low PaO2 on arterial blood gas measurements. Variables associated with a shorter ablation time included a higher ejection fraction (p=0.04) and case volume performed by each electrophysiologist in the study group (p=0.001). ...
Journal of Cardiothoracic and Vascular Anesthesia, 01/31/2012

Postoperative neurological complications and risk factors for pre-existing silent brain infarction in elderly patients undergoing coronary artery bypass grafting
Ito A et al. – Patients with silent brain infarction (SBI) were ranked at moderate risk of neurological complications after coronary artery bypass grafting (CABG) between control and BI. Increased age, renal dysfunction, and preoperative cognitive impairment appeared to be strongly associated with SBI. Methods Four hundred forty-nine patients (≥60years old) scheduled for CABG underwent cerebral magnetic resonance imaging (MRI) and MR angiography preoperatively to assess cerebral infarctions and carotid and intracranial artery stenosis. Atherosclerosis of the ascending aorta was assessed by epiaortic ultrasound during surgery. Patients were sorted by their history of cerebrovascular disease (CVD) and the presence of infarction by MRI: SBI (infarction without CVD), BI (symptomatic brain infarction; CVD and infarction), and controls (no findings of either CVD or infarction). Results SBI was found in 35.5% of the 449 patients and increased with age. The prevalence of pre-existing multiple infarctions was less frequent in SBI than in BI. The incidence of postoperative stroke and cognitive dysfunction was 1.3% and 4.9% in controls (n=225), 5.7% and 15.2% in SBI (n=158), and 9.1% and 18.2% in BI (n=66). Patients with SBI were older and had more renal dysfunction and preoperative cognitive impairment. Stepwise logistic regression demonstrated that age, renal dysfunction, preoperative cognitive impairment, atherosclerosis of the ascending aorta, and intracranial arterial stenosis were associated significantly with SBI. ...
Journal of Anesthesia, 01/31/2012

Postoperative N-terminal Pro-Brain Natriuretic Peptide Level in Coronary Artery Bypass Surgery With Ventricular Dysfunction After Perioperative Glucose-Insulin-Potassium Treatment
Foroughi M et al. – Glucose-insulin-potassium (GIK) is of value in the reduction of post-cardiac surgery N-terminal (NT)-pro-brain natriuretic peptide (BNP elevation. Thus, its infusion should have a protective effect in patients with low ejection fraction undergoing coronary artery bypass graft (CABG) surgery. Methods Sixty-six patients with a low ejection fraction who required coronary artery surgery were selected. Patients were allocated to a GIK (n=36) or a control (n=30) group. The GIK group received GIK solution (500mL of dextrose in water (DW) 10% + 40 U of regular insulin+40mEq of KCl, and 2g of MgSO4) at a rate of 1mL/kg/h for 10hours preoperatively and until the removal of the aortic cross-clamp. The control group received half saline solution as placebo with an equivalent infusion rate during the same interval. Results Serum NT-proBNP levels were measured before starting the GIK, at the time of anesthesia induction, and 24 hours after surgery. The primary outcome measures were preoperative and postoperative NT-proBNP level. The amount of elevation in postoperative NT-proBNP concentrations was less prominent in the GIK group than in the control group (2,601±1,799pg/mL v 4,732±4,127pg/mL; p=0.02). The patients in the GIK group were extubated sooner (495±92minutes) than the control group (774±224minutes; p=0.002). The overall extubation time was 606±177minutes. Delayed requirement for mechanical ventilation was significantly more in the controls compared with the GIK group (45.8% v 13.9%, p=0.004). ...
Journal of Cardiothoracic and Vascular Anesthesia, 01/31/2012

A prospective randomized study of intraoperative thoracic epidural analgesia in off-pump coronary artery bypass surgery
Liang Y et al. – The authors conclude that general anesthesia (GA)A plus thoracic epidural anesthesia (TEA) has no impact on the outcomes of off-pump coronary artery bypass surgery (OPCABs), while its use leads to a higher requirement for vasoactive drug use. GA followed by patient-controlled TEA (PCTEA) facilitates the anesthesia administration, while it does not affect the extubation time and the postoperative analgesic effect. Methods Sixty-four patients, American Society of Anesthesiologists physical status II and III, who were scheduled for elective OPCABs, were offered an epidural catheter inserted at the T2-3 interspace and then randomized into 1 of 2 groups according to whether TEA was applied intraoperatively. The TEAperio group received GA plus TEA, while the TEApost group received GA alone. All groups had postoperative PCTEA. The number of requirements for vasoactive drugs and the extubation times were recorded. The analgesic effect was monitored by visual analog scale (VAS) pain scores. Heart rate, blood pressure, and blood gases were also monitored. The data are presented as mean values ±standard deviation, or medians with quartiles. Results The proportion of vasoactive drug use was significantly higher in the TEAperio group intraoperatively (before or during completion of anastomoses: 59.4 vs. 20.7%, p=0.004; after completion of anastomoses: 53.1 vs. 17.2%, p=0.007). There was no statistically significant difference in extubation times or VAS scores between the 2 groups. ...
Journal of Anesthesia, 01/31/2012

Cost Analysis of Abdominal, Laparoscopic, and Robotic-Assisted Myomectomies
Behera MA et al. In this costminimization analysis, abdominal myomectomy is the least expensive approach when compared to laparoscopy and roboticassisted laparoscopy....
Journal of Minimally Invasive Gynecology, 01/13/2012

Losing Loved One Increases Heart Attack Risk
Losing a close loved one, spouse, child, sibling, parent, or a friend is never easy. Now new research suggests that the days and weeks following the death of a close loved may increase one’s risk of having a heart attack. Psychological stress caused by intense grief can increase heart rate, blood pressure and blood clotting, which can raise the chance of a heart attack....
Ivanhoe, 01/13/2012

Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial
Unzueta C et al. – Recruitment of both lungs before instituting one-lung ventilation (OLV) not only decreased alveolar dead space but also improved arterial oxygenation and the efficiency of ventilation. Methods Subjects were randomly allocated to two groups: Control group: ventilation with tidal volume (VT) of 8 or 6mlkg^-1 for TLV and OLV, respectively ARS group: same ventilatory pattern with ARS consisting of 10 consecutive breaths at a plateau pressure of 40 and 20cm H2O PEEP applied immediately before and after OLV Volumetric capnography and arterial blood samples were recorded 5min (baseline) and 20min into TLV, at 20 and 40min during OLV, and finally 10min after re-establishing TLV. Results Twenty subjects were included in each group. In all subjects, the airway component of dead space remained constant during the study. Compared with baseline, the alveolar dead space ratio (VDalv/VTalv) increased throughout the protocol in the control but decreased in the ARS group. Differences in VDalv/VTalv between groups were significant (P<0.001). Except for baseline, all Pao2 values in kPa (sd) were higher in the ARS than in the control group (P<0.001), respectively [70 (7) and 55 (9); 33 (9) and 24 (10); 33 (8) and 22 (10); 70 (7) and 55 (10)]. ...
British Journal of Anesthesia, 01/13/2012

New method for quantitative assessment of airway calibre using a stereovision fibreoptic bronchoscope
Hayashi A et al. – The authors have confirmed that this new bronchoscopy system could provide relatively accurate quantitative data. This new system may be useful in the clinic to measure airway dimension and lesion sizes such as tumours. Methods The accuracy of the bronchoscopy system was confirmed by measuring the diameters of four plastic tubes and 36 airway calibres in 12 surgical patients under general anaesthesia. The measured diameters of the tubes and airway tracts were compared with the manufactured diameters of tubes and those measured by high-resolution computed tomography (HRCT)-based virtual bronchoscopy, respectively. Results Using the new bronchoscope system, tube diameters, 9, 12, 15, and 19mm, were measured as 9.9 (0.7), 12.8 (1.4), 16.3 (1.6), and 20.1 (2.0)mm, respectively. Airway calibres obtained by a stereovision bronchoscopy and HRCT-based virtual bronchoscopy were 8.66 (4.31) and 9.38 (5.09)mm, respectively. There is a significant correlation between airway calibres with the two measurement methods (r=0.975, P<0.01). ...
British Journal of Anesthesia, 01/13/2012

Blood glucose amplitude variability as predictor for mortality in surgical and medical intensive care unit patients
Meynaar IA et al. – Not all blood glucose amplitude variability (BGAV) measures were associated with mortality. Blood glucose amplitude variability as quantified by SD was consistently independently associated with hospital mortality. Methods A prospectively collected multicenter data set including all glucose measurements during intensive care unit (ICU) treatment and outcome was analyzed. The authors used logistic regression to assess the association between hospital mortality and standard deviation (SD), mean amplitude of glycemic excursions (MAGE), mean absolute glucose change per hour (MAG), and glycemic lability index (GLI). The analysis was adjusted for ICU, Acute Physiology And Chronic Health Evaluation IV-expected mortality, the presence of severe hypoglycemia, mean glucose, mean glucose measurement interval, and interaction between the latter 2. Results There were 855032 glucose measurements included of 20375 patients admitted to 37 Dutch ICUs in 2008 and 2009. Median Acute Physiology And Chronic Health Evaluation IV-predicted mortality was 14%, and median glucose was 7.3mmol/L. In all patients combined, adjusted hospital mortality was associated with SD and MAGE, but not with MAG and GLI. In surgical patients, adjusted hospital mortality was associated with SD, MAGE, and MAG, but not GLI. In medical patients, adjusted mortality was associated with SD but not with other BGAV measures. ...
Journal of Critical Care, 01/13/2012

Endothelial dysfunction assessed by brachial artery ultrasound in severe sepsis and septic shock
Becker L et al. – Brachial flow-mediated vasodilation (FMD) is altered in septic patients with hemodynamic instability, and its deterioration may be an early marker of unfavorable prognosis. Methods Adult patients admitted to the intensive care unit with severe sepsis or septic shock were consecutively included. Brachial artery FMD was measured upon admission, after 24 and 72hours. A group of apparently healthy subjects paired for sex and age was used as controls. Patients were followed up to discharge or death. Results The authors studied 42 patients (mean age, 51±19 years) with sepsis predominantly of abdominal or respiratory etiology (75%). Acute Physiology And Chronic Health Evaluation II risk score was 23±7, and intrahospital mortality rate was 33%. Flow-mediated vasodilation in septic patients was significantly lower than in healthy controls (1.5±7% vs 6±4%, P<.001). Most of the nonsurvivors (86%) showed a decline in sequential FMD analyses, whereas only 43% of survivors showed a reduction of FMD (P=.01). In nonsurvivors, FMD was significantly lower 72hours after sepsis onset (-3.3%±10% vs 5.2%±4%; P<.05; time-group interaction P value=.03). ...
Journal of Critical Care, 12/16/2011

Randomized double-blind study of remifentanil and dexmedetomidine for flexible bronchoscopy
Ryu JH et al. – Dexmedetomidine was associated with fewer incidents of oxygen desaturation and a reduced need for oral cavity suction than remifentanil during flexible bronchoscopy. However, dexmedetomidine was associated with a longer recovery time and poorer bronchoscopist satisfaction score. Methods Seventy-two patients undergoing elective flexible bronchoscopy were randomly assigned to a propofol–remifentanil group (Group PR, n=36) or a propofol–dexmedetomidine group (Group PD, n=36). The primary outcome was the incidence of oxygen desaturation. Haemodynamic variables, adverse events, need of oral cavity suction, cough scores, satisfaction scores of patients and bronchoscopists, levels of sedation, and recovery times were also compared. Results The incidence of oxygen desaturation was significantly lower in the PD group than in the PR group (P=0.01). There were no significant differences between groups in terms of level of sedation, oxygen saturation, mean arterial pressure, heart rate over time, cough scores, or patient satisfaction scores (P>0.05). However, cough scores and bronchoscopist satisfaction scores (P<0.01) were lower in the PD group. In addition, topical anaesthesia (P<0.01) was required more frequently and recovery time (P=0.00) was significantly longer in the PD group. However, oral suction (P=0.03) was required less frequently in the PD group. ...
British Journal of Anesthesia, 12/16/2011

Incidence and risk factors for sepsis in surgical patients: A cohort study
Elias ACGP et al. – This study showed that sepsis has high incidence and mortality in surgical patients admitted to the ICU. Urgent surgeries, mechanical ventilation, fluid resuscitation, and vasoactive drugs in the postoperative period and Sequential Organ Failure Assessment at ICU admission were risk factors for sepsis. Methods Data were prospectively collected from a cohort of surgical patients from January 2005 to December 2007. The authors analyzed the incidence of infection and sepsis and certain other variables from the pre-, intra-, and postoperative periods as risk factors for infection and sepsis. Results The authors studied 625 surgical patients. The mortality rate was 18.2%, and the mean age of the subjects was 53.1±18.8 years. The incidences of severe sepsis and septic shock were 5% and 11.5%, respectively. A multivariate analysis showed that the following variables were associated with sepsis in the postoperative period: urgent surgery (odds ratio, 2.63; 95% confidence interval [CI], 1.50-4.63), fluid resuscitation (odds ratio, 1.90; 95% CI, 1.18-3.05), vasoactive drugs (odds ratio, 2.58; 95% CI, 1.61-4.14), and mechanical ventilation (odds ratio, 5.51; 95% CI, 3.07-9.89). A Sequential Organ Failure Assessment was associated with infection or sepsis upon ICU admission (area under the curve, 0.737±0.019; 95% CI, 0.748-0.825). ...
Journal of Critical Care, 12/16/2011

Adverse events and clinical outcome associated with drotrecogin alfa-activated
Boyle A et al. – This large single-center case series demonstrates that drotrecogin alfa-activated (DAA) has an incidence of serious bleeding events (SBEs) similar to initial clinical trials. As expected, SBEs were associated with a poor outcome. Methods Prospectively collected data using a clinical guideline audit tool and database to track outcome and adverse events of DAA-treated severe sepsis patients were analyzed. Results Four hundred ninety-eight patients received DAA over an 8-year period. Hospital, critical care, and 28-day mortalities were 46.2%, 39.6%, and 35.1%, respectively. Contraindications were identified for 40 (8.0%) patients, of whom 24 (4.8%) had BBRs. Hospital mortality was 47.5% (19/40) for patients with any contraindication and 45.8% (11/24) for those with a BBR. Seventy-six (15.3%) bleeding events were reported; 22 (4.4%) were considered serious. Hospital mortality was 60.5% for patients with any bleeding event and 77.3% for those with SBEs. ...
Journal of Critical Care, 12/16/2011

Clinical sedation and bispectral index in burn children receiving gamma-hydroxybutyrate
Rousseau AF et al. – Bispectral index decreased after gamma-hydroxybutyrate (GHB) injection and was correlated with Observer’s Assessment of Alertness and Sedation (OAAS) score. Deep sedation can be safely achieved with IV doses of 25 or 50mg.kg-1, but the last dose was associated with prolonged duration of clinical sedation. Methods Thirty six children hospitalized in a burn care unit were included and randomly assigned into three groups (G) according to the single IV dose of GHB they received before burn wound care: 10mg.kg-1 in G10, 25mg.kg-1 in G25, or 50mg.kg-1 in G50. All patients received oral premedication (morphine and hydroxyzine) 30min before GHB injection. Respiratory rate, heart rate, pulse oximetry, and bispectral index (BIS) were continuously monitored. Depth of sedation was clinically assessed using Observer’s Assessment of Alertness and Sedation (OAAS) Score, every 2min until recovery (i.e., OAAS=4). Results Median age was 17.5 [12-34]months. Whatever the dose, BIS decreased after IV GHB. Nadir value of BIS was significantly lower in G25 and G50 than in G10, as was for OAAS score. Nadir values were reached after same delays in G25 and G50. Duration of sedation was dose-dependant. ...
Paediatric Anaesthesia, 12/16/2011

First-line Therapy with Coagulation Factor Concentrates Combined with Point-of-Care Coagulation Testing Is Associated with Decreased Allogeneic Blood Transfusion in Cardiovascular Surgery
Gorlinger K et al. – First-line administration of coagulation factor concentrates combined with point-of-care testing was associated with decreased incidence of blood transfusion and thrombotic/thromboembolic events. Methods In a retrospective cohort study including 3,865 patients, the authors analyzed the incidence of intraoperative allogeneic blood transfusions (primary endpoints) before and after algorithm implementation. Results Following algorithm implementation, the incidence of any allogeneic blood transfusion (52.5 vs. 42.2%; P<0.0001), packed red blood cells (49.7 vs. 40.4%; P<0.0001), and fresh frozen plasma (19.4 vs. 1.1%; P<0.0001) decreased, whereas platelet transfusion increased (10.1 vs. 13.0%; P=0.0041). Yearly transfusion of packed red blood cells (3,276 vs. 2,959 units; P<0.0001) and fresh frozen plasma (1986 vs. 102 units; P<0.0001) decreased, as did the median number of packed red blood cells and fresh frozen plasma per patient. The incidence of fibrinogen concentrate (3.73 vs. 10.01%; P<0.0001) and prothrombin complex concentrate administration (4.42 vs. 8.9%; P<0.0001) increased, as did their amount administered per year (179 vs. 702g; P=0.0008 and 162×103 U vs. 388×103 U; P=0.0184, respectively). Despite a switch from aprotinin to tranexamic acid, an increase in use of dual antiplatelet therapy (2.7 vs. 13.7%; P<0.0001), patients' age, proportion of females, emergency cases, and more complex surgery, the incidence of massive transfusion [(≥10 units packed red blood cells), (2.5 vs. 1.26%; P=0.0057)] and unplanned reexploration (4.19 vs. 2.24%; P=0.0007) decreased. Composite thrombotic/thromboembolic events (3.19 vs. 1.77%; P=0.0115) decreased, but in-hospital mortality did not change (5.24 vs. 5.22%; P=0.98). ...
Anesthesiology, 11/28/2011

The impact of hyperlactatemia on postoperative outcome after adult cardiac surgery
Kogan A et al. – Hyperlactatemia is common after cardiac surgery. Maximal lactate threshold ≥4.4mmol/l in the first 10h after operation accurately predicts postoperative mortality. Methods The authors performed a prospective observation study on 1,820 consecutive patients undergoing open heart surgery in a tertiary university medical center. Blood lactate levels were obtained from patients on admission to the cardiac surgical ICU and measured serially. Results All patients were divided into three groups according to their maximum blood lactate levels: group I (normolactatemia, lactate ≤2.2mmol/l), 332 patients; group II (mild hyperlactatemia, lactate 2.2-4.1mmol/l), 1,054 patients; and group III (severe hyperlactatemia, lactate ≥4.4mmol/l), 434 patients. Maximum blood lactate levels ≥4.4mmol/l during the first 10h post admission were associated with prolonged ventilation time, longer ICU stay, and increased mortality (P<0.001). ...
Journal of Anesthesia, 11/28/2011

Optimization of ventilator setting by flow and pressure waveforms analysis during noninvasive ventilation for acute exacerbations of COPD
Di Marco F et al. – The analysis of the waveforms generated by ventilators has a significant positive effect on physiological and patients' centered outcomes during acute exacerbation of chronic obstructive pulmonary disease (COPD). The acquisition of specific skills in this field should be encouraged. Methods The aim of the present randomized, multicentric, controlled study was to compare optimized ventilation, driven by the analysis of flow and pressure waveforms, to standard ventilation (same physician, same initial ventilator setting, same time spent at the bedside while the ventilator screen was obscured with numerical data always available). The primary aim was the rate of pH normalization at two hours, whilst secondary aims were changes in PaCO2, respiratory rate, and patient's tolerance to ventilation (all parameter evaluated at baseline, 30, 120, 360minutes and 24hours after the beginning of ventilation). Seventy patients (35 for each group) with acute exacerbation of COPD were enrolled. Results Optimized ventilation lead to a more rapid normalization of pH at 2hours (51 vs. 26% of patients), to a significant improvement of patient's tolerance to ventilation at 2hours, and to a higher decrease of PaCO2 at 2 and 6hours. Optimized ventilation induced physicians to use higher levels of external positive end-expiratory pressure, more sensitive inspiratory triggers and a faster speed of pressurization. ...
Critical Care, 11/28/2011

Late Compliance With the Sepsis Resuscitation Bundle
Castellanos–Ortega A et al. – Compliance with the resuscitation bundle even beyond the recommended time is associated with improvement in survival in patients with severe sepsis/septic shock. Methods This prospective, cohort study included 753 patients recruited from September 2005 until August 2010 with severe sepsis/septic shock in the three medical-surgical ICUs of a tertiary academic medical center. The authors assessed the compliance with the different tasks included in the resuscitation bundle. Furthermore, they ascertained within the first 6h after ICU admission the compliance with those tasks not carried out within their specific time limits; they have termed this variable “bundle improvement in the ICU. Results Septic shock was present in 88.1%. The overall in-hospital mortality was 31.6%. In 51.5%, there was bundle improvement in the ICU; this variable was associated with a lower risk of mortality (adjusted hazard ratio, 0.52 [95% confidence interval, 0.34-0.78]). That association was observed only when the time from severe sepsis onset to ICU admission was 6h or less. Importantly, similar results were found after excluding all patients with severe sepsis (rapid responders) and those with refractory shock (nonresponders). The task with highest improvement was the achievement of central venous oxygen saturation 70% or greater in 39% of patients. ...
Shock, 11/28/2011

Acute phase proteins and white blood cell levels for prediction of infectious complications in status epilepticus
Sutter R et al. – Single levels of C-reactive protein (CRP) and white blood cells (WBC) are not reliable for diagnosis of infections during status epilepticus (SE), while their linear changes over time significantly correlated with the presence of infections. In addition, low levels of CRP and procalcitonin (PCT) rule out hospital-acquired infections in SE patients. Methods All consecutive SE patients treated in the ICU from 2005 to 2009 were included. Clinical and microbiological records, measurements of CRP and WBC during SE were analyzed. Subgroup analysis was performed for additional PCT measurements in the first 48 hours of SE. Results 22.5% of 160 consecutive SE patients had infections during SE. Single levels of CRP and WBC had no association with the presence of infections. Their linear changes over the first three days after SE onset were significantly associated with the presence of infections (p=0.0012 for CRP, p=0.0137 for WBC). Levels of PCT were available for 31 patients and did not differ significantly in patients with and without infections. Sensitivity of PCT and CRP was high (94% and 83%) and the negative predictive value of CRP increased over the first three days to 97%. Specificity was low, without improvement for different cut-offs. ...
Critical Care, 11/28/2011

Vancomycin pharmacokinetic-pharmacodynamic parameters to optimize dosage administration in critically ill children
Giachetto GA et al. – Critically ill children show changes in pharmacokinetic parameters. Serum concentration monitorization is necessary for dosage individualization. Most children do not reach an area under the curve at 24hrs/minimal inhibitory concentration >400 with current dosage. Methods Children treated with vancomycin, hospitalized in the Intensive Care Unit of the Pediatric Hospital-Centro Hospitalario Pereira Rossell, were included. Samples to determine vancomycin serum concentration were obtained on first and third days of treatment, 1hr after the end of the third daily dose administration (maximum drug concentration) and 15mins before the fourth (minimum drug concentration). Half-life elimination, volume of distribution, clearance, and area under the curve at 24hrs were estimated. Vancomycin concentration values of 20-40microgram/mL (maximum drug concentration) and 5-10microgram/mL (minimum drug concentration) were considered therapeutic. Results Twenty-two children were included. On day 1, seven of 18 children for maximum drug concentration and 16 of 22 for minimum drug concentration reached concentrations in therapeutic range; on day 3, seven of 16 children for maximum drug concentration and 11 of 17 for minimum drug concentration did. Mean values of maximum drug concentration and minimum drug concentration were higher in children with negative water balance. Mean value of half-life elimination increased from day 1 to day 3. Considering a value of minimal inhibitory concentration for S. aureus of 1microgram/mL, nine of 18 children reached a relationship area under the curve at 24hrs/minimal inhibitory concentration >400 on day 1 and seven of 15 on day 3. Considering a minimal inhibitory concentration of 2microgram/mL, one child reached it on day 1 and one on day 3. ...
Pediatric Critical Care<, 11/08/2011

The association of age, illness severity, and glycemic status in a pediatric intensive care unit
Ognibene KL et al. – The youngest patients are at higher risk for spontaneous hypoglycemia, whereas hyperglycemia occurs more often in the older ages. Higher rates of hypo-/hyperglycemia were noted in sicker patients and in those requiring more therapeutic interventions. The results suggest that special consideration should be given to the safety of the youngest patients given their higher risk of hypoglycemia if an investigation of tight glycemic control is performed. Methods Thirty-two-bed university-affiliated pediatric intensive care unit. Children &lt;19 yrs old admitted between January and September 2006. The authors recorded all blood glucose measurements for up to 10 days of each pediatric intensive care unit visit and assessed rates of hypoglycemia and hyperglycemia based on age, medical vs. surgical therapy, length of stay, therapeutic intervention (Therapeutic Intervention Scoring System), and illness severity (Pediatric Risk of Mortality III). A total of 8853 blood glucose values in 616 patients were recorded. Results Spontaneous hypoglycemia was noted in 18.8% of patients &lt;1 yr compared with 5.1% to 11.3% of patients in older age groups. Hyperglycemia occurred in 47% of patients &lt;1 yr, which increased to 58.9% in patients 13-18yrs. Rates of hypoglycemia were not affected by medical/surgical status. Surgical patients had an increased risk of hyperglycemia. Rates of hypo- and hyperglycemia increased with higher Pediatric Risk of Mortality III, Therapeutic Intervention Scoring System, length of stay, and days of mechanical ventilation. Increased rates of hypo-/hyperglycemia were observed in patients who died. ...
Pediatric Critical Care, 11/08/2011

Rescue treatment with terlipressin in different scenarios of refractory hypotension in newborns and infants
Filippi L et al. – Terlipressin appears to be an effective rescue treatment in different scenarios of refractory neonatal hypotension. Further controlled studies are required to confirm its efficacy and safety. Methods All newborns with hypotension unresponsive to volume replacement and catecholamines, and treated with terlipressin, from January 2008 to December 2009. In this study, also an infant (11months old) born extremely preterm was included. Results Four hypotensive patients received as rescue therapy terlipressin, which produced a dramatic increase in mean arterial pressure, diuresis, and reduction of lactate levels. In three newborns, hypotension, associated with pulmonary hypertension, was resolved with terlipressin. Two of them (one with systemic inflammatory response syndrome, the other with congenital diaphragmatic hernia) died in the following days for causes unrelated to hypotension; the third (on mild hypothermia for hypoxic-ischemic encephalopathy) recovered. The authors report furthermore an infant with septic shock and on treatment with &beta;-blockers in whom terlipressin normalized blood pressure. In two patients, cranial Doppler ultrasonography showed the recovery of diastolic cerebral flow in the anterior cerebral artery and the normalization of resistance index within 30mins from the first dose of terlipressin. In two infants, hyponatremia was detected. ...
Pediatric Critical Care, 10/13/2011

Treatment with &beta;-Blockers and Incidence of Post-Traumatic Stress Disorder After Cardiac Surgery: A Prospective Observational Study
Tarsitani L et al. – The findings suggest that the use of &beta;-blockers might be protective against the development of post–traumatic stress disorder (PTSD) in women after cardiac surgery. Methods One hundred twenty-eight consecutive patients scheduled for elective cardiac surgery with cardiopulmonary bypass. Patients were interviewed within the surgical unit 1 to 3 days before cardiac surgery. Results Six months after surgery, participants were mailed the modified version of the Posttraumatic Stress Symptom Inventory 10. Of the 71 patients who completed the questionnaire and mailed it back at follow-up, 14 (19.7%) received a diagnosis of PTSD. Seven of 13 female patients who were not treated with &beta;-blockers received a diagnosis of PTSD compared with 0 of 12 who were treated with &beta;-blockers (p=0.005, Fisher exact test). In a general linear model, including sex and &beta;-blocker treatment as predictors, the Posttraumatic Stress Symptom Inventory 10 score was significantly predicted by &beta;-blockade (F=4.74, p=0.033), with a significant interaction between sex and &beta;-blockade (F=9.72, p=0.003). ...
Journal of Cardiothoracic and Vascular Anesthesia, 11/08/2011

Comparison of bedside and laboratory blood glucose estimations in critically ill children with shock
Ramachandran B et al. Capillary blood glucose estimation in children with shock was similar to the laboratory measurement in the midranges of glucose values. Methods All children admitted between July 2007 and September 2008 with shock as defined by the American College of Critical Care Medicine criteria were eligible for inclusion. Three hundred thirtyseven sets of simultaneous measurements were obtained from 52 children (age range, 3 months to 18 yrs; average Pediatric Risk of Mortality III score 9.6). Results The mean blood glucose measurement using capillary blood on a bedside glucometer was 135&plusmn;67mg/dL (7.5&plusmn;3.7mmol/L). The mean laboratory glucose was 130&plusmn;67mg/dL (7.2&plusmn;3.7mmol/L). The correlation coefficient between the measurements was 0.94. There were no differences between those with and without peripheral edema. Using BlandAltman plots, the mean difference between capillary samples vs. laboratory glucose was 6mg/dL (0.3mmol/L). The spread was wider at the higher ends of blood glucose values. ...
Pediatric Critical Care, 11/08/2011

Fiberoptic bronchoscopy under noninvasive ventilation and propofol target-controlled infusion in hypoxemic patients
Clouzeau B et al. – Fiberoptic bronchoscopy and bronchoalveolar lavage (FOB-BAL), under NIV and target-controlled (TCI) with propofol, is feasible and safe in nonintubated patients with acute respiratory failure (ARF). The TCI of propofol during FOB-BAL reduces patient discomfort with no significant adverse effects. Methods The first end point in the prospective investigation within an intensive care unit (ICU) was the avoidance of endotracheal intubation within 24 h. Secondary end points were changes in the PaO2/FiO2 ratio, hemodynamic stability, patient comfort, occurrence of adverse effects, and quality of FOB. Patients self-evaluated their comfort after FOB. Results Twenty-four FOBs were performed in 23 patients with ARF. PaO2/FiO2 before FOB was 181±50 (range 85-286). All patients tolerated FOB with BAL. None was intubated during the 2 h after FOB. Loss of consciousness was obtained with an effect site concentration of propofol of 1.49±0.46microgram/mL (range 2.6-0.6). No significant adverse events occurred. TCI propofol allowed us to obtain amnesia, patient comfort, and it did not impair airway protection. Any hemodynamic changes observed were modest and transient.
Intensive Care Medicine, 10/13/2011

Predicting the success of non-invasive ventilation in preventing intubation and re-intubation in the paediatric intensive care unit
James CS et al. – Parameters relating to respiratory and cardiovascular status can determine which patients will successfully avoid intubation or re-intubation when placed on non-invasive ventilation (NIV). Underlying disease and reason for admission should be considered when predicting the outcome of NIV. Methods Review of case notes and computerised data of every paediatric intensive care unit (PICU) admission over 7 years where NIV was commenced. Data immediately prior to commencing NIV and 2 h after its establishment was collected. Univariable and multivariable statistical analysis was performed to compare variables. Results Eighty-three patients commenced NIV attempting to avoid intubation and 64% succeeded. Those who failed required a higher FiO2 (0.56 vs. 0.47, p=0.038), had higher respiratory rates (53.3 vs. 40.3breaths/min, p=0.012) and lower pH (7.26 vs. 7.34, p=0.032) before NIV and higher FiO2 after NIV commenced (0.54 vs. 0.43, p=0.009). Those with a respiratory diagnosis were more likely to be successful. Patients with oncologic disease, particularly if septic, were less likely to avoid intubation using NIV. Multivariable models showed that after adjustment for mode of NIV and underlying diagnosis, respiratory rate before NIV was an independent predictor of success [adjusted odds ratio (OR) 0.95 (0.91, 0.99), p=0.01]. Eighty patients were extubated to NIV but 15 required re-intubation. Those re-intubated had a higher systolic blood pressure (104 vs. 77.9mmHg, p=0.001) and diastolic blood pressure (64.5 vs. 54.1mmHg, p=0.0037) after extubation. Multivariable models showed that systolic blood pressure 2 h after extubation was independently associated with outcome [adjusted OR 0.96 (0.93, 0.99), p=0.007].
Intensive Care Medicine, 10/13/2011

New insights into weaning from mechanical ventilation: left ventricular diastolic dysfunction is a key player
Papanikolaou J et al. – The findings suggest that left ventricular (LV) diastolic dysfunction is significantly associated with weaning outcome in critically ill patients with preserved LV systolic function. An E/E m ratio greater than 7.8 may identify patients at high risk of weaning failure. Methods Fifty critical care noncardiac patients who fulfilled predetermined criteria for weaning underwent DE before and at the end of spontaneous breathing trial (pre-SBT/end-SBT, respectively). “Conventional” mitral inflow analysis and “advanced” DE parameters [tissue Doppler imaging (TDI)-derived mitral/tricuspid annular velocities and color M-mode Doppler velocity of propagation (V p)] were used to assess left ventricular (LV) diastolic function/filling pressures. Weaning was considered successful if patients had been extubated after successful SBT and sustained spontaneous breathing for more than 48 h. Results Twenty-eight patients (56%) failed weaning: 23 patients failed SBT and 5 required reintubation within 48 h. Weaning failure was associated with the degree of LV diastolic dysfunction at pre-SBT (P=0.01). Patients who failed weaning presented evidence of increased LV filling pressures at pre-SBT, by demonstrating increased E/E m and E/V p ratios compared with patients with successful outcome (P&le;0.004); pre-SBT values of lateral E/E m greater than 7.8 and E/V p greater than 1.51 predicted weaning failure with an area under the curve, sensitivity (%), and specificity (%) of 0.86, 79, and 100, and 0.74, 75, and 73, respectively. Lateral E/E m was the only factor independently associated with weaning failure before SBT; OR (95% CI) 5.62 (1.17-26.96), P=0.03
Intensive Care Medicine, 10/13/2011

Tidal volume delivery during surfactant administration in the delivery room
Schmolzer GM et al. – Substantial tidal volume changes occur before, during and after surfactant administration in the delivery room. Complete airway obstruction is common. Monitoring respiratory function during this procedure may help to assess the delivered tidal volume and airway pressures after surfactant treatment. Methods The authors reviewed video recordings of the initial resuscitation in the delivery room of infants born at less than 32 weeks’ gestation between February 2007 and March 2010. Positive pressure ventilation was delivered with either a Neopuff T-piece or self-inflating bag. Respiratory parameters were recorded with a respiratory function monitor (RFM). Each RFM recording was analysed for 30s before and 2min after surfactant administration. Results Of 230 infants recorded during the study period 16 infants received surfactant in the delivery room. Their mean (standard deviation, SD) gestation and birth weight were 25 (1) weeks and 757 (249)g, respectively. Complete airway obstruction was seen in 4/16 (25%) infants. The median (interquartile range, IQR) duration of this obstruction was 16 (8-27)s. The median (IQR) expired tidal volume before surfactant delivery was 8.0 (5.2-11.2)mL/kg compared to 4.6 (4.1-7.3)mL/kg (p=0.03) after surfactant administration.
Intensive Care Medicine, 10/13/2011

Delivery of helium-oxygen mixture during spontaneous breathing: evaluation of three high-concentration face masks
Roche–Campo F et al. – Helium and oxygen gas (He-O2) administration via the usual high-concentration reservoir masks results in significant dilution by room air. The Hi-Ox80 mask minimized room air contamination and much more frequently achieved a pharyngeal He concentration higher than 50%. Methods This prospective randomized crossover study was performed in six healthy volunteers in a laboratory setting. Volunteers breathed a mixture of 78% He/22% O2 through each of the masks under two different breathing conditions (rest and hyperventilation: minute ventilation of 14.9&plusmn;6.1 and 26.7&plusmn;8.7Lmin-1, respectively) and four different He-O2 flow rates (7, 10, 12, and 15Lmin-1). Results A nasopharyngeal catheter was used to estimate He pharyngeal concentration (Fp [He]) in the airways in order to determine the percentage of contamination with room air (% air cont) at end-expiration. Under all testing conditions, the Hi-Ox80 mask presented a significantly lower % air cont. During resting breathing pattern, a Fp [He] higher than 50% was achieved in 54% of the tests performed with the Hi-Ox80 mask compared to 29% for the Heliox21 mask and only 17% for the standard mask. At hyperventilation, a Fp [He] higher than 50% was achieved in 17% of the tests performed with the Hi-Ox mask compared to 4% for the other two masks.
Intensive Care Medicine, 10/13/2011

Prospective randomized comparison of the EasyTube and the esophageal-tracheal Combitube airway devices during general anesthesia with mechanical ventilation
Gaitini LA et al. – The EasyTube (EzT) has distinct advantages over the esophageal–tracheal Combitube (ETC) in airway management, including shorter time to achieve an effective airway and easier insertion. Methods 80 adult, ASA physical status 1 and 2 patients scheduled for elective surgery. Patients’ tracheas were intubated with the EzT or the ETC in randomized fashion. Difficulty of insertion, time to achieve an effective airway, insertion success rate, maneuvers to achieve an effective airway, oropharyngeal leak pressure, intracuff pressure, ventilatory parameters, success rate of gastric tube insertion, and frequency of adverse effects were compared. Results Insertion was easier in the EzT than in ETC; insertion of the EzT was rated easy in 36 7cases and moderately difficult in 4 cases versus 26 and 14 cases, respectively, for the ETC (P=0.014). Less time was required to achieve an effective airway with the EzT than the ETC: 19.4&plusmn;5.3sec versus 30.6&plusmn;4.1seconds, respectively (P&lt;0.001). Oropharyngeal leak pressure was higher with the EzT than the ETC (34.3&plusmn;5.95 vs 31.6&plusmn;2.42cm H2O; P=0.011). Peak airway pressures for the EZT and the ETC were 22.2&plusmn;0.99cm H20 and 33.7&plusmn;1.82cm H2O, respectively (P&lt;0.001). Gastric tube insertion was successful with both devices; however, the EzT allowed insertion of gastric tubes of wider diameter. No severe perioperative adverse events were recorded for either device. ...
Journal of Clinical Anesthesia, 09/13/2011