SciCombinator

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Journal: Minerva anestesiologica

137

The prognosis of septic shock is tightly linked to the earliness of both appropriate antibiotic therapy and early hemodynamic resuscitation. This latter is essentially based on fluid and vasopressors administration. The step-by-step strategy, called “early goal-directed therapy” (EGDT) developed in 2001 and endorsed by the Surviving Sepsis Campaign (SSC) between 2004 and 2016 is no longer recommended. Indeed, recent multicenter randomized clinical trials showed no reduction in all-cause mortality, duration of organ support and in-hospital length of stay with EGDT in comparison with standard care. The most recent SCC guidelines have dropped the original EGDT by deleting the central venous pressure and the central venous oxygen saturation from the recommendations. Dynamic variables of fluid responsiveness are now recommended to be used after an initial fluid infusion of a fixed volume (30 mL/kg) during the first three hours of resuscitation. However, this approach is also questionable due to the lack of individualization at the early and crucial phase of resuscitation. In this review, we propose a more personalized approach for the early and later phases of fluid resuscitation during sepsis.

Concepts: Clinical trial, Blood pressure, Intensive care medicine, Shock, Septic shock, Sepsis, Hypotension, Surviving Sepsis Campaign

27

Background: Dexmedetomidine is a highly selective α2 agonist with analgesic, anxiolytic, and anti-inflammatory properties. We investigated the effect of a single dose of dexmedetomidine on patient-perceived quality of recovery and clinical recovery variables after modified radical mastectomy under general anesthesia in this randomized, double-blind, placebo-controlled study. Methods: After Institutional Review Board approval, ninety two female patients were randomly allocated to receive intravenously either saline (Group C, N.=46) or 0.5 μg/kg of dexmedetomidine (Group D, N.=46) five min before the end of surgery. The quality of recovery was assessed using a 40-item quality-of-recovery scoring system (QoR-40) preoperatively and 24 h after surgery. Pain intensity, rescue analgesics, and postoperative nausea and vomiting (PONV) were assessed at postanesthesia care unit (PACU), 1-6 h, and 6-24 h after surgery. Results: Postoperative global QoR-40 scores were higher in Group D compared with Group C (181 [175-187] vs. 174 [154.5-181.5], P=0.004); postoperative QoR-40 scores were improved in the dimensions of emotional state, physical comfort, and psychological support. Total amount of tramadol during 24 h after surgery was significantly lower in Group D than in Group C (54 vs. 76 mg, P=0.006). The incidence of PONV was lower in Group D than in Group C in PACU (21% vs. 43%, P=0.026) and 6-24 h period after surgery (10% vs. 41%, P=0.012). Heart rate and mean blood pressure were significantly lower in Group D as compared with Group C at 5 min after administration of dexmedetomidine, 1 min after extubation, and 20 min after arrival in PACU. Conclusion: The use of a single dose dexmedetomidine improved the quality of recovery and reduced analgesic requirements and the incidence of PONV in the early postoperative period after modified radical mastectomy.

Concepts: Randomized controlled trial, Anesthesia, Opioid, Analgesic, Vomiting, Mastectomy, Postoperative nausea and vomiting, Post anesthesia care unit

26

We wish to report here a practical approach to an ARDS patient as devised by a group of intensivists with different expertise. The referral scenario is an intensive care unit of a Community Hospital with limited technology, where a young doctor, alone, must deal with this complicate syndrome during the night. The knowledge of pulse oximetry at room air and at 100% oxygen allows to estimate the PaO2 and the cause of hypoxemia, shunt vs. VA/Q maldistribution. The ARDS severity (mild (200

Concepts: Patient, The Canon of Medicine, Respiratory physiology, Intensive care medicine, Mechanical ventilation, Pressure, Oxygen saturation, Capnography

26

With the increasing awareness of post intensive care syndrome and the unbridled development of post-ICU clinics in the Netherlands, guidelines for ICU after care are needed. The purpose of this study was to develop recommendations for the set-up of post-ICU clinics.

Concepts: South Africa, Germany, Netherlands, Belgium, Dutch people, Dutch language, Suriname, Kingdom of the Netherlands

26

Background: High volume hemofiltration (HVHF) has been proposed as method for blood purification, especially under the condition of systemic inflammatory syndromes. Our goal was to evaluate the effects of HVHF in critically ill patients. Methods: A systematic review and meta-analysis was conducted of randomized controlled trials containing original data comparing HVHF defined by a dose of > 50 ml/kg/h versus standard volume hemofiltration in critically ill patients. The primary outcome assessed was mortality. Additional endpoints assessed were renal recovery, vasopressor dependency, cytokine reduction and adverse events. Results: Four studies investigating continuous HVHF and three studies examining pulse high volume hemofiltration (PHVHF) using prescribed doses between 62 and 85 ml/kg/h met the criteria for this systematic review and provided data eligible for meta-analysis on a total of 558 patients. Metaanalyses did not show an effect of continuous HVHF (odds ratio (OR): 0.85; 95 % confidence interval (CI): 0.50 - 1.45; 4 trials; n = 473) or PHVHF (OR: 0.62; 95% CI: 0.22 - 1.74; 3 trials; n = 85) on mortality (both combined: OR: 0.85; 95 % CI: 0.60 - 1.22; 7 trials; n = 558). Continuous HVHF had no significant beneficial effect on renal recovery of survivors (OR: 0.62; 95 % CI: 0.17 - 1.97; 3 trials; n = 445). Inconsistent reports of a more rapid hemodynamic stabilization or improved cytokine clearance were mainly restricted to PHVHF. Conclusions: No clear overall beneficial effect of HVHF or PHVHF compared to standard volume hemofiltration can be detected.

Concepts: Epidemiology, Clinical trial, Medical statistics, Evidence-based medicine, Systematic review, Randomized controlled trial, Effect size, Meta-analysis

25

Potential neurotoxicity of anaesthetic drugs is currently one of the most intensely discussed issues in paediatric anaesthesia. Prospective human data are sorely lacking and there is an on going debate among experts in the field whether one should (or can) extrapolate animal data to humans. Data regarding the thoughts of practising anaesthetists regarding this topic have not been published.

Concepts: Human, Anesthesia, Opioid, Thought, Local anesthetic, Humans

25

25

Physical restraint is frequently used in the intensive care setting but little is known regarding its clinical scenario and effectiveness in preventing adverse events (AEs), defined as device removal.

Concepts: Clinical trial, Prevention, PReVENT, Medical restraint

24

The experience of intensive care for patients and their families is known to be very stressful and may result in both acute and chronic psychological problems that include sleep disturbance, depression, anxiety and post-traumatic stress disorder. While some non-modifiable risk factors for psychological harm are known, there are also a several modifiable risk factors that may be addressed using strategically planned interventions such as optimal communication techniques. Effective communication is increasingly being recognized as an essential non-technical skills for all intensive care clinicians. One situation which is central to communication in the ICU is the family meeting. Similar to other procedures in the ICU, training, practice, preparation and reflective review may improve performance when conducting family meetings and lead to better outcomes for patients and families.

Concepts: Anxiety, Family, Selective serotonin reuptake inhibitor, Posttraumatic stress disorder, Anxiety disorder

24

Both the optimal caloric intake and the best route of delivery of nutrition to critically ill patients fuel an intense debate. Recently, two large pragmatic, multicenter, controlled, randomized clinical trials evaluated these issues in large cohorts of patients. In the CALORIES study (Harvey et al. - N Engl J Med 2014; 371:1673-1684), the authors compared the parenteral with the enteral route as the most effective way to deliver early (e.g. within 36 hours from admission) nutritional support in critically ill adults in 33 English ICUs (n=2388). The primary endpoint, 30-day mortality (33.1% in the parenteral group and 34.2% in the enteral group), as well as the infection rate, were similar in both groups, while patients of the parenteral group experienced less hypoglycemia and vomiting than the enteral group. In the PermiT study (Arabi et al. - N Engl J Med 2015; 372:2398-2408), 894 enterally fed patients from 7 ICUs were randomized to a restrictive strategy for non-protein calories (e.g. “permissive underfeeding” - 40 to 60% of energy expenditure) or to standard feeding (70 to 100% of energy expenditure) for up to 2 weeks. The primary endpoint (90-day mortality) was similar in both groups (27.2% in the permissive-underfeeding group and 28.9% in the standard- feeding group) without significant differences in feeding intolerance, diarrhea or ICU-acquired infections. We herein discuss how these studies should be interpreted with regard to the existing evidence and propose some practical suggestions for nutrition management in the critically ill patient.

Concepts: Epidemiology, Clinical trial, Nutrition, Patient, Obesity, Illness, Dieting, Calorie