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Subramaniam A, Grauer R, Beilby D, Tiruvoipati R. Anesthetic management of a myotonic dystrophy patient with paraganglionoma. J Clin Anesth 2016; 34:21-8. [PMID: 27687340 DOI: 10.1016/j.jclinane.2016.03.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/10/2016] [Accepted: 03/10/2016] [Indexed: 02/08/2023]
Abstract
Myotonic dystrophy (DM), though rare, can significantly complicate anesthesia due to muscular and extra-muscular involvement. When this condition is compounded by a pheochromocytoma, anesthetizing such patients becomes extra challenging. We present a case report of a 61-year-old lady with congenital DM, with the whole gamut of associated features, was diagnosed with a noradrenaline secreting paraganglionoma following investigation of refractory hypertension. We anesthetized her for an open resection of the lesion. The conduct of anesthesia and recovery of this patient is described. Our experience suggests that anesthetizing these patients though challenging can be safely managed with relaxant general anesthesia and epidural analgesia with meticulous care pre, intra and post-surgical intervention.
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Affiliation(s)
- Ashwin Subramaniam
- Monash University, Clayton, Victoria, Australia; Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia
| | - Robert Grauer
- Box Hill Hospital, Eastern Health, Box Hill, Victoria, Australia
| | - David Beilby
- Box Hill Hospital, Eastern Health, Box Hill, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Monash University, Clayton, Victoria, Australia; Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia.
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Botha J, O'Brien Y, Malouf S, Cole E, Ansari ES, Green C, Tiruvoipati R. The Outcome and Predictors of Mortality in Patients Therapeutically Cooled Postcardiac Arrest. J Intensive Care Med 2016; 31:603-10. [PMID: 25572332 DOI: 10.1177/0885066614566792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 11/10/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE To review the outcomes of patients postcardiac arrest admitted to a metropolitan intensive care unit (ICU) where therapeutic hypothermia is practiced. MATERIALS AND METHODS Patients admitted from 2004 to 2012 were reviewed. The management protocol included cooling to 33°C for 24 hours. The primary outcome assessed was hospital mortality. Secondary outcome measures included mortality in patients admitted to ICU after in-hospital cardiac arrest (IHCA) when compared to those with out-of-hospital cardiac arrest (OHCA) and to review initial cardiac rhythm as an indicator of mortality. RESULTS A total of 330 patients were included. The overall hospital mortality was 58.1%. Hospital mortality was significantly higher in patients who had OHCA when compared to IHCA (62.5% vs 51%; P = .04). Patients who had asystole and pulseless electrical activity (PEA) had a higher mortality when compared to ventricular tachycardia/ventricular fibrillation (VT/VF) arrest (81.7% vs 67.8% vs 41.9%, respectively; P < .01). CONCLUSION Patients admitted to ICU postcardiac arrest after therapeutic cooling have a high mortality. An initial rhythm of VT/VF confers a mortality benefit when compared to asystole and PEA.
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Affiliation(s)
- John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia Faculty of Medicine, Nursing and Health Sciences, School of Public Health, Monash University, Melbourne, Victoria, Australia
| | - Yvette O'Brien
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Saada Malouf
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Elizabeth Cole
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Erum Sahid Ansari
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Cameron Green
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia Faculty of Medicine, Nursing and Health Sciences, School of Public Health, Monash University, Melbourne, Victoria, Australia
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Subramaniam A, Botha J, Tiruvoipati R. The limitations in implementing and operating a rapid response system. Intern Med J 2016; 46:1139-1145. [PMID: 26913367 DOI: 10.1111/imj.13042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 02/05/2023]
Abstract
Despite the widespread introduction of rapid response systems (RRS)/medical emergency teams (MET), there is still controversy regarding how effective they are. While there are some observational studies showing improved outcomes with RRS, there are no data from randomised controlled trials to support the effectiveness. Nevertheless, the MET system has become a standard of care in many healthcare organisations. In this review, we present an overview of the limitations in implementing and operating a RRS in modern healthcare.
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Affiliation(s)
- A Subramaniam
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia.
| | - J Botha
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
| | - R Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
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Tiruvoipati R, Haji K, Gupta S, Braun G, Carney I, Botha J. Low-flow veno-venous extracorporeal carbon dioxide removal in the management of severe status asthmatics: a case report. Clin Respir J 2016; 10:653-6. [PMID: 25515844 DOI: 10.1111/crj.12252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 11/18/2014] [Accepted: 12/07/2014] [Indexed: 02/05/2023]
Abstract
Status asthmaticus is a life-threatening condition that requires intensive care management. Most of these patients have severe hypercapnic acidosis that requires lung protective mechanical ventilation. A small proportion of these patients do not respond to conventional lung protective mechanical ventilation or pharmacotherapy. Such patients have an increased mortality and morbidity. Successful use of extracorporeal membrane oxygenation (ECMO) is reported in such patients. However, the use of ECMO is invasive with its associated morbidity and is limited to specialised centres. In this report, we report the use of a novel, minimally invasive, low-flow extracorporeal carbon dioxide removal device in management of severe hypercapnic acidosis in a patient with life threatening status asthmaticus.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia.
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia.
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
| | - Gary Braun
- Department of Respiratory Medicine, Frankston Hospital, Melbourne, Vic., Australia
| | - Ian Carney
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
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Foster E. A descriptive study of patients with Guillain-Barré syndrome. Australas Med J 2016. [DOI: 10.4066/amj.2016.2703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Green CR, Botha JA, Tiruvoipati R. Cognitive function, quality of life and mental health in survivors of our-of-hospital cardiac arrest: a review. Anaesth Intensive Care 2015; 43:568-76. [PMID: 26310406 DOI: 10.1177/0310057x1504300504] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There is growing interest in the long-term outcomes of patients surviving out-of-hospital cardiac arrest (OHCA). This paper aims to summarise the available literature on the long-term cognitive, health-related quality of life (QoL) and mental health outcomes of survivors of OHCA. Between 30% and 50% of survivors of OHCA experience cognitive deficits for up to several years post-discharge. Deficits of attention, declarative memory, executive function, visuospatial abilities and verbal fluency are commonly reported. Survivors of OHCA appear to report high rates of mental illness, with up to 61% experiencing anxiety, 45% experiencing depression and 27% experiencing post-traumatic stress. Fatigue appears to be a commonly reported long-term outcome for survivors of OHCA. Investigations of long-term QoL for these patients have produced mixed findings. Carers of survivors of OHCA report high rates of depression, anxiety and post-traumatic stress, with insufficient social and financial support. The heterogeneous range of instruments used to assess cognitive function and QoL prevent any clear conclusions being drawn from the available literature. The potential biases inherent in this patient population and the interaction between QoL, cognitive performance and mental health warrant further investigation, as does the role of post-discharge support services in improving long-term patient outcomes.
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Affiliation(s)
- C R Green
- Research Coordinator, Department of Intensive Care, Frankston Hospital, Frankston, Victoria
| | - J A Botha
- Director, Department of Intensive Care, Frankston Hospital, Frankston, and Adjunct Clinical Professor with the Faculty of Medicine, Nursing and Health Sciences, School of Public Health at Monash University, Melbourne, Victoria
| | - R Tiruvoipati
- Intensivist, Department of Intensive Care, Frankston Hospital, Frankston, and Adjunct Associate Professor with the Faculty of Medicine, Nursing and Health Sciences, School of Public Health at Monash University, Melbourne, Victoria
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Abstract
BACKGROUND Although atrial fibrillation is common in critically ill patients, no large studies on its impact on patient mortality in general intensive care units have been done. OBJECTIVE To evaluate the association between atrial fibrillation and hospital mortality in critically ill patients. METHODS In a retrospective cohort study, critically ill patients who had atrial fibrillation during a 2-year period were compared with patients who did not. The primary outcome was death during the hospital stay. Secondary outcomes were duration of mechanical ventilation and lengths of stay in the intensive care unit and hospital. RESULTS Among a total of 2018 first-time admissions to the intensive care unit during the study period, 421 patients (20.9%) had atrial fibrillation. Patients with atrial fibrillation had higher mortality, significantly longer duration of mechanical ventilation, and longer stays in the intensive care unit and in the hospital than did patients without this cardiac arrhythmia. However, multiple logistic regression analysis indicated that atrial fibrillation was not independently associated with a higher risk for death. CONCLUSION Atrial fibrillation may not be independently associated with hospital mortality.
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Affiliation(s)
- Sachin Gupta
- Sachin Gupta is a consultant, Department of Intensive Care Medicine, Frankston Hospital, Victoria, Australia, and was formerly a senior registrar, Department of Intensive Care, St Vincent's Hospital, Fitzroy, Victoria, Australia. Ravindranath Tiruvoipati is a consultant, Department of Intensive Care Medicine, Frankston Hospital, and an adjunct clinical associate professor, School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia. Cameron Green is a research coordinator, Department of Intensive Care Medicine, Frankston Hospital
| | - Ravindranath Tiruvoipati
- Sachin Gupta is a consultant, Department of Intensive Care Medicine, Frankston Hospital, Victoria, Australia, and was formerly a senior registrar, Department of Intensive Care, St Vincent's Hospital, Fitzroy, Victoria, Australia. Ravindranath Tiruvoipati is a consultant, Department of Intensive Care Medicine, Frankston Hospital, and an adjunct clinical associate professor, School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia. Cameron Green is a research coordinator, Department of Intensive Care Medicine, Frankston Hospital.
| | - Cameron Green
- Sachin Gupta is a consultant, Department of Intensive Care Medicine, Frankston Hospital, Victoria, Australia, and was formerly a senior registrar, Department of Intensive Care, St Vincent's Hospital, Fitzroy, Victoria, Australia. Ravindranath Tiruvoipati is a consultant, Department of Intensive Care Medicine, Frankston Hospital, and an adjunct clinical associate professor, School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia. Cameron Green is a research coordinator, Department of Intensive Care Medicine, Frankston Hospital
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Abstract
Therapeutic hypothermia (TH), where patients are cooled to between 32°C and 36°C for a period of 12-24 hours and then gradually rewarmed, may reduce the risk of ischemic injury to cerebral tissue following a period of insufficient blood flow. This strategy of TH could improve mortality and neurological function in patients who have experienced out-of-hospital cardiac arrest (OOHCA). The necessity of TH in OOHCA was challenged in late 2013 by a fascinating and potentially practice changing publication, which found that targeting a temperature of 36°C had similar outcomes to cooling patients to 33°C. This article reviews the current literature and summarizes the uncertainties and questions raised when considering cooling of patients at risk of hypoxic brain injury. Irrespective of whether TH or targeted temperature management is deployed in patients at risk of hypoxic brain injury, it would seem that avoiding hyperpyrexia is important and that a more rigorous approach to neurological evaluation is mandated.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital , Frankston, Victoria, Australia
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Tiruvoipati R, Gupta S, Haji K, Braun G, Carney I, Botha JA. Management of severe hypercapnia post cardiac arrest with extracorporeal carbon dioxide removal. Anaesth Intensive Care 2014; 42:248-52. [PMID: 24580392 DOI: 10.1177/0310057x1404200213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Normocapnia is recommended in intensive care management of patients after out-of-hospital cardiac arrest. While normocapnia is usually achievable, it may be therapeutically challenging, particularly in patients with airflow obstruction. Conventional mechanical ventilation may not be adequate to provide optimal ventilation in such patients. One of the recent advances in critical care management of hypercapnia is the advent of newer, low-flow extracorporeal carbon dioxide clearance devices. These are simpler and less invasive than conventional extracorporeal devices. We report the first case of using a novel, extracorporeal carbon dioxide removal device in Australia on a patient with out-of-hospital cardiac arrest where mechanical ventilation failed to achieve normocapnia.
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Affiliation(s)
- R Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria
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Ali A, Botha J, Tiruvoipati R. Fatal skin and soft tissue infection of multidrug resistant Acinetobacter baumannii: A case report. Int J Surg Case Rep 2014; 5:532-6. [PMID: 25016080 PMCID: PMC4147652 DOI: 10.1016/j.ijscr.2014.04.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 01/22/2014] [Accepted: 04/17/2014] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Acinetobacter baumannii is usually associated with respiratory tract, urinary tract and bloodstream infections. Recent reports suggest that it is increasingly causing skin and soft tissue infections. It is also evolving as a multidrug resistant organism that can be difficult to treat. We present a fatal case of multidrug resistant A. baumannii soft tissue infection and review of relevant literature. PRESENTATION OF CASE A 41 year old morbidly obese man, with history of alcoholic liver disease presented with left superficial pre-tibial abrasions and cellulitis caused by multidrug resistant (MDR) A. baumannii. In spite of early antibiotic administration he developed extensive myositis and fat necrosis requiring extensive and multiple surgical debridements. He deteriorated despite appropriate antibiotic therapy and multiple surgical interventions with development of multi-organ failure and died. DISCUSSION Managing Acinetobacter infections remains difficult due to the array of resistance and the pathogens ability to develop new and ongoing resistance. The early diagnosis of necrotizing soft tissue infection may be challenging, but the key to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. CONCLUSION A. baumannii is emerging as an important cause of severe, life-threatening soft tissue infections. Multidrug resistant A. baumannii soft tissue infections may carry a high mortality in spite of early and aggressive treatment. Clinicians need to consider appropriate early empirical antibiotic coverage or the use of combination therapy to include MDR A. baumannii as a cause of skin and soft tissue infections.
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Affiliation(s)
- Aqsa Ali
- Department of Intensive Care Medicine Frankston Hospital, Frankston, Victoria 3199, Australia.
| | - John Botha
- Department of Intensive Care Medicine Frankston Hospital, Frankston, Victoria 3199, Australia.
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Shekar K, Davies AR, Mullany DV, Tiruvoipati R, Fraser JF. To ventilate, oscillate, or cannulate? J Crit Care 2013; 28:655-62. [PMID: 23827735 DOI: 10.1016/j.jcrc.2013.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 03/09/2013] [Accepted: 04/17/2013] [Indexed: 02/05/2023]
Abstract
Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. Despite this, a number of patients develop hypoxemic respiratory failure refractory to lung-protective ventilation (LPV). The intensivist then faces the dilemma of either persisting with LPV using adjuncts (neuromuscular blocking agents, prone positioning, recruitment maneuvers, inhaled nitric oxide, inhaled prostacyclin, steroids, and surfactant) or making a transition to rescue therapies such as high-frequency oscillatory ventilation (HFOV) and/or extracorporeal membrane oxygenation (ECMO) when both these modalities are at their disposal. The lack of quality evidence and potential harm reported in recent studies question the use of HFOV as a routine rescue option. Based on current literature, the role for venovenous (VV) ECMO is probably sequential as a salvage therapy to ensure ultraprotective ventilation in selected young patients with potentially reversible respiratory failure who fail LPV despite neuromuscular paralysis and prone ventilation. Given the risk profile and the economic impact, future research should identify the patients who benefit most from VV ECMO. These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes.
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Affiliation(s)
- Kiran Shekar
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, The University of Queensland, Brisbane, Queensland, Australia.
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Botha J, Tiruvoipati R, Goldberg D. Futility of medical treatment in current medical practice. N Z Med J 2013; 126:58-71. [PMID: 24157992 DOI: pmid/24157992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Intensive care provides support for acute reversible organ failure and most patients who receive intensive care recover from their illness. In some patients organ failure may become irreversible and in these patients further treatment or organ support may be considered futile. Emerging technologies and expertise can enable the medical profession to prolong life / death indefinitely without curing or controlling the underlying disease process. Introduction of ultramodern organ supports such as extracorporeal life-support systems, ventricular assist devices and organ transplantation surgeries have introduced some degree of ambiguity in defining futility of care. Furthermore medico legal implications of futility of care introduce further complexities in defining and instituting futile treatments. In this review we discuss the evolution of the concept of futility of care, review the various meanings of the term "futility of care", explore the complexities of management when care is considered futile, offer suggestions as to how such patients and their families could be managed. We also review the legal framework when consensus is not achieved.
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Affiliation(s)
- John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria 3199, Australia.
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63
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Abstract
Lung protective ventilation limiting tidal volumes and airway pressures were proven to reduce mortality in patients with acute severe respiratory failure. Hypercapnia and hypercapnic acidosis is often noted with lung protective ventilation. While the protective effects of lung protective ventilation are well recognised, the role of hypercapnia and hypercapnic acidosis remains debatable. Some clinicians argue that hypercapnia and hypercapnic acidosis protect the lungs and may be associated with improved outcomes. To the contrary, some clinicians do not tolerate hypercapnic acidosis and use various techniques including extracorporeal carbon dioxide elimination to treat hypercapnia and acidosis. This review aims at defining the effects of hypercapnia and hypercapnic acidosis with a focus on the pros and cons of clearing carbon dioxide and the modalities that may enhance carbon dioxide clearance.
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Affiliation(s)
- R Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia.
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Tiruvoipati R, Chiezey B, Lewis D, Ong K, Villanueva E, Haji K, Botha J. Stress hyperglycemia may not be harmful in critically ill patients with sepsis. J Crit Care 2012; 27:153-8. [PMID: 21855283 DOI: 10.1016/j.jcrc.2011.06.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 06/13/2011] [Accepted: 06/18/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Stress hyperglycemia (SH) is commonly seen in critically ill patients. It has been shown to be associated with adverse outcomes in some groups of patients. The effects of SH on critically ill patients with sepsis have not been well studied. We aimed to evaluate the effects of SH in critically ill patients with sepsis. METHODS In this retrospective study, patients with sepsis admitted to intensive care unit (ICU) over a 5-year period were included. RESULTS Of 297 patients, 204 (68.7%) had SH during the study period. The mean blood glucose level in patients with SH was 8.7 mmol/L compared with 5.9 mmol/L in those without SH (P < .05). There were no statistically significant differences in age; sex; sepsis severity; cardiovascular, respiratory, and renal comorbidities; requirement of mechanical ventilation; inotropes; and Acute Physiology, Age, and Chronic Health Evaluation III and Simplified Acute Physiology 2 scores on ICU admission. Intensive care unit mortality was significantly lower in patients who had SH. The median duration of ICU and hospital length of stay was longer in patients with SH. On logistic regression analysis, the presence of SH was associated with reduced ICU mortality. Subgroup analysis revealed SH to be protective in patients with septic shock. CONCLUSION Stress hyperglycemia may not be harmful in critically ill patients with sepsis. Patients with SH had lower ICU mortality.
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Tiruvoipati R, Botha J, Peek G. Effectiveness of extracorporeal membrane oxygenation when conventional ventilation fails: valuable option or vague remedy? J Crit Care 2012; 27:192-8. [PMID: 21703814 DOI: 10.1016/j.jcrc.2011.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/22/2011] [Accepted: 04/23/2011] [Indexed: 02/08/2023]
Abstract
The mortality and morbidity of patients with severe acute respiratory distress syndrome (ARDS) remains high despite the advances in intensive care practice. The low-tidal-volume ventilation strategy (ARDS net protocol) has been shown to be effective in improving survival. Unfortunately, however, some patients have such severe ARDS that they cannot be managed with the ARDS net strategy. In these patients, rescue therapies such as high-frequency ventilation, prone ventilation, nitric oxide, and extracorporeal membrane oxygenation (ECMO) are considered. The CESAR trial has shown that an ECMO-based protocol improved survival without severe disability as compared with conventional ventilation. The recent increased incidence of severe respiratory failure due to H1N1 influenza pandemic has led to an increased use of ECMO. Although several reports showed ECMO use to be encouraging, some scepticism remains. In this article, we reviewed the usefulness of ECMO in patients with severe ARDS in the light of current evidence.
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Abstract
OBJECTIVE Patients with sepsis often have elevated cardiac troponin I even in the absence of coronary artery disease. The prognostic value of cardiac troponins in critically ill patients with sepsis remains debatable. Our objective was to evaluate the prognostic value of cardiac troponin I in critically ill patients with severe sepsis. METHODS In this retrospective study, we included patients with severe sepsis who had troponin assayed within 12 h of admission to intensive care over a 6 year period. Patients who had myocardial infarction at intensive care admission in the setting of sepsis were excluded. Included patients were classified into two groups based on their serum troponin I levels: low troponin group (troponin ≤ 0.1 µg/L) and elevated troponin group (troponin > 0.1 µg/L). The primary outcome of interest was hospital mortality. The secondary outcome measures included intensive care mortality, intensive care and hospital length of stay. RESULTS A total of 382 patients were admitted to intensive care with sepsis. Of these, 293 patients were included in analyses. There was a statistically significant difference in hospital (15% vs 36.1%; P < 0.01) and intensive care (11% vs 25%; P < 0.01) mortality, but not in intensive care and hospital duration of stay. Logistic regression analysis revealed temperature, simplified acute physiology score II and serum lactate to be independent predictors of hospital mortality. Cardiac troponin I was not an independent predictor of hospital mortality. CONCLUSION Critically ill patients with severe sepsis who had elevated troponin had increased hospital and intensive care mortality. However, cardiac troponin I did not independently predict hospital mortality.
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Tiruvoipati R, Ong K, Gangopadhyay H, Arora S, Carney I, Botha J. Hypothermia predicts mortality in critically ill elderly patients with sepsis. BMC Geriatr 2010; 10:70. [PMID: 20875107 PMCID: PMC2955035 DOI: 10.1186/1471-2318-10-70] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 09/27/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Advanced age is one of the factors that increase mortality in intensive care. Sepsis and multi-organ failure are likely to further increase mortality in elderly patients.We compared the characteristics and outcomes of septic elderly patients (> 65 years) with younger patients (≤ 65 years) and identified factors during the first 24 hours of presentation that could predict mortality in elderly patients. METHODS This study was conducted in a Level III intensive care unit with a case mix of medical and surgical patients excluding cardiac and neurosurgical patients.We performed a retrospective review of all septic patients admitted to our ICU between July 2004 and May 2007. In addition to demographics and co-morbidities, physiological and laboratory variables were analysed to identify early predictors of mortality in elderly patients with sepsis. RESULTS Of 175 patients admitted with sepsis, 108 were older than 65 years. Elderly patients differed from younger patients with regard to sex, temperature (37.2°C VS 37.8°C p < 0.01), heart rate, systolic blood pressure, pH, HCO3, potassium, urea, creatinine, APACHE III and SAPS II. The ICU and hospital mortality was significantly higher in elderly patients (10.6% Vs 23.14% (p = 0.04) and 19.4 Vs 35.1 (p = 0.02) respectively). Elderly patients who died in hospital had a significant difference in pH, HCO3, mean blood pressure, potassium, albumin, organs failed, lactate, APACHE III and SAPS II compared to the elderly patients who survived while the mean age and co-morbidities were comparable. Logistic regression analysis identified temperature (OR [per degree centigrade decrease] 0.51; 95% CI 0.306- 0.854; p = 0.010) and SAPS II (OR [per point increase]: 1.12; 95% CI 1.016-1.235; p = 0.02) during the first 24 hours of admission to independently predict increased hospital mortality in elderly patients. CONCLUSIONS The mortality in elderly patients with sepsis is higher than the younger patients. Temperature (hypothermia) and SAPS II scores during the first 24 hours of presentation independently predict hospital mortality.
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Affiliation(s)
| | - Kevin Ong
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - Himangsu Gangopadhyay
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - Subhash Arora
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - Ian Carney
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
| | - John Botha
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, 3199, Australia
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Tiruvoipati R, Lewis D, Haji K, Botha J. High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care 2010; 25:463-8. [PMID: 19781896 DOI: 10.1016/j.jcrc.2009.06.050] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 04/14/2009] [Accepted: 06/21/2009] [Indexed: 02/05/2023]
Abstract
PURPOSE Oxygen delivery after extubation is critical to maintain adequate oxygenation and to avoid reintubation. The delivery of oxygen in such situations is usually by high-flow face mask (HFFM). Yet, this may be uncomfortable for some patients. A recent advance in oxygen delivery technology is high-flow nasal prongs (HFNP). There are no randomized trials comparing these 2 modes. METHODS Patients were randomized to either protocol A (n = 25; HFFM followed by HFNP) or protocol B (n = 25; HFNP followed by HFFM) after a stabilization period of 30 minutes after extubation. The primary objective was to compare the efficacy of HFNP to HFFM in maintaining gas exchange as measured by arterial blood gas. Secondary objective was to compare the relative effects on heart rate, blood pressure, respiratory rate, comfort, and tolerance. RESULTS Patients in both protocols were comparable in terms of age, demographic, and physiologic variables including arterial blood gas, blood pressure, heart rate, respiratory rate, Glasgow Coma Score, sedation, and Acute Physiology and Chronic Health Evaluation (APACHE) III scores. There was no significant difference in gas exchange, respiratory rate, or hemodynamics. There was a significant difference (P = .01) in tolerance, with nasal prongs being well tolerated. There was a trend (P = .09) toward better patient comfort with HFNP. CONCLUSIONS High-flow nasal prongs are as effective as HFFM in delivering oxygen to extubated patients who require high-flow oxygen. The tolerance of HFNP was significantly better than in HFFM.
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Peek GJ, Elbourne D, Mugford M, Tiruvoipati R, Wilson A, Allen E, Clemens F, Firmin R, Hardy P, Hibbert C, Jones N, Killer H, Thalanany M, Truesdale A. Randomised controlled trial and parallel economic evaluation of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR). Health Technol Assess 2010; 14:1-46. [PMID: 20642916 DOI: 10.3310/hta14350] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES To determine the comparative effectiveness and cost-effectiveness of conventional ventilatory support versus extracorporeal membrane oxygenation (ECMO) for severe adult respiratory failure. DESIGN A multicentre, randomised controlled trial with two arms. SETTING The ECMO centre at Glenfield Hospital, Leicester, and approved conventional treatment centres and referring hospitals throughout the UK. PARTICIPANTS Patients aged 18-65 years with severe, but potentially reversible, respiratory failure, defined as a Murray lung injury score > or = 3.0, or uncompensated hypercapnoea with a pH < 7.20 despite optimal conventional treatment. INTERVENTIONS Participants were randomised to conventional management (CM) or to consideration of ECMO. MAIN OUTCOME MEASURES The primary outcome measure was death or severe disability at 6 months. Secondary outcomes included a range of hospital indices: duration of ventilation, use of high frequency/oscillation/jet ventilation, use of nitric oxide, prone positioning, use of steroids, length of intensive care unit stay, and length of hospital stay - and (for ECMO patients only) mode (venovenous/veno-arterial), duration of ECMO, blood flow and sweep flow. RESULTS A total of 180 patients (90 in each arm) were randomised from 68 centres. Three patients in the conventional arm did not give permission to be followed up. Of the 90 patients randomised to the ECMO arm, 68 received that treatment. ECMO was not given to three patients who died prior to transfer, two who died in transit, 16 who improved with conventional treatment given by the ECMO team and one who required amputation and could not therefore be heparinised. Ninety patients entered the CM (control) arm, three patients later withdrew and refused follow-up (meaning that they were alive), leaving 87 patients for whom primary outcome measures were available. CM consisted of any treatment deemed appropriate by the patient's intensivist with the exception of extracorporeal gas exchange. No CM patients received ECMO, although one received a form of experimental extracorporeal arteriovenous carbon dioxide removal support (a clear protocol violation). Fewer patients in the ECMO arm than in the CM arm had died or were severely disabled 6 months after randomisation, [33/90 (36.7%) versus 46/87 (52.9%) respectively]. This equated to one extra survivor for every six patients treated. Only one patient (in the CM arm) was known to be severely disabled at 6 months. Patients allocated to ECMO incurred average total costs of 73,979 pounds compared with 33,435 pounds for those undergoing CM (UK prices, 2005). A lifetime model predicted the cost per quality-adjusted life-year (QALY) of ECMO to be 19,252 pounds (95% confidence interval 7622 pounds to 59,200 pounds) at a discount rate of 3.5%. Lifetime QALYs gained were 10.75 for the ECMO group compared with 7.31 for the conventional group. Costs to patients and their relatives, including out of pocket and time costs, were higher for patients allocated to ECMO. CONCLUSIONS Compared with CM, transferring adult patients with severe but potentially reversible respiratory failure to a single centre specialising in the treatment of severe respiratory failure for consideration of ECMO significantly increased survival without severe disability. Use of ECMO in this way is likely to be cost-effective when compared with other technologies currently competing for health resources. TRIAL REGISTRATION Current Controlled Trials ISRCTN47279827.
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Affiliation(s)
- G J Peek
- Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, UK
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Bloomer MJ, Tiruvoipati R, Tsiripillis M, Botha JA. End of life management of adult patients in an Australian metropolitan intensive care unit: A retrospective observational study. Aust Crit Care 2010; 23:13-9. [PMID: 19914844 DOI: 10.1016/j.aucc.2009.10.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 07/31/2009] [Accepted: 10/12/2009] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Death in the intensive care unit is often predictable. End of life management is often discussed and initiated when futility of care appears evident. Respect for patients wishes, dignity in death, and family involvement in the decision-making process is optimal. This goal may often be elusive. PURPOSE Our purpose was to review the end of life processes and family involvement within our Unit. METHODS We conducted a chart audit of all deaths in our 10 bed Unit over a 12-month period, reviewing patient demographics, diagnosis on admission, patient acuity, expectation of death and not-for-resuscitation status. Discussions with the family, treatments withheld and withdrawn and extubation practices were documented. The presence of family or next-of-kin at the time of death, the time to death after withdrawal of therapy and family concerns were recorded. RESULTS There were 70 patients with a mean age of 69 years. Death was expected in 60 patients (86%) and not-for-resuscitation was documented in 58 cases (85%). Family discussions were held in 63 cases (90%) and treatment was withdrawn in 34 deaths (49%). After withdrawal of therapies, 31 patients (44%) died within 6h. Ventilatory support was withdrawn in 24 cases (36%). Family members were present at the time of death in 46 cases (66%). Family concerns were documented about the end of life care in only 1 case (1.4%). CONCLUSION Our data suggests that death in our Unit was often predictable and that end of life management was a consultative process.
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Affiliation(s)
- Melissa Jane Bloomer
- Peninsula Health, Continuing Education and Development Unit, Hastings Road, Frankston, VIC 3199, Australia.
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Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374:1351-63. [PMID: 19762075 DOI: 10.1016/s0140-6736(09)61069-2] [Citation(s) in RCA: 2176] [Impact Index Per Article: 145.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Severe acute respiratory failure in adults causes high mortality despite improvements in ventilation techniques and other treatments (eg, steroids, prone positioning, bronchoscopy, and inhaled nitric oxide). We aimed to delineate the safety, clinical efficacy, and cost-effectiveness of extracorporeal membrane oxygenation (ECMO) compared with conventional ventilation support. METHODS In this UK-based multicentre trial, we used an independent central randomisation service to randomly assign 180 adults in a 1:1 ratio to receive continued conventional management or referral to consideration for treatment by ECMO. Eligible patients were aged 18-65 years and had severe (Murray score >3.0 or pH <7.20) but potentially reversible respiratory failure. Exclusion criteria were: high pressure (>30 cm H(2)O of peak inspiratory pressure) or high FiO(2) (>0.8) ventilation for more than 7 days; intracranial bleeding; any other contraindication to limited heparinisation; or any contraindication to continuation of active treatment. The primary outcome was death or severe disability at 6 months after randomisation or before discharge from hospital. Primary analysis was by intention to treat. Only researchers who did the 6-month follow-up were masked to treatment assignment. Data about resource use and economic outcomes (quality-adjusted life-years) were collected. Studies of the key cost generating events were undertaken, and we did analyses of cost-utility at 6 months after randomisation and modelled lifetime cost-utility. This study is registered, number ISRCTN47279827. FINDINGS 766 patients were screened; 180 were enrolled and randomly allocated to consideration for treatment by ECMO (n=90 patients) or to receive conventional management (n=90). 68 (75%) patients actually received ECMO; 63% (57/90) of patients allocated to consideration for treatment by ECMO survived to 6 months without disability compared with 47% (41/87) of those allocated to conventional management (relative risk 0.69; 95% CI 0.05-0.97, p=0.03). Referral to consideration for treatment by ECMO led to a gain of 0.03 quality-adjusted life-years (QALYs) at 6-month follow-up [corrected]. A lifetime model predicted the cost per QALY of ECMO to be pound19 252 (95% CI 7622-59 200) at a discount rate of 3.5%. INTERPRETATION We recommend transferring of adult patients with severe but potentially reversible respiratory failure, whose Murray score exceeds 3.0 or who have a pH of less than 7.20 on optimum conventional management, to a centre with an ECMO-based management protocol to significantly improve survival without severe disability. This strategy is also likely to be cost effective in settings with similar services to those in the UK. FUNDING UK NHS Health Technology Assessment, English National Specialist Commissioning Advisory Group, Scottish Department of Health, and Welsh Department of Health.
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Affiliation(s)
- Giles J Peek
- Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, UK.
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Chalwin RP, Tiruvoipati R, Peek GJ. Fatal thrombosis with activated factor VII in a paediatric patient on extracorporeal membrane oxygenation. Eur J Cardiothorac Surg 2008; 34:685-6. [PMID: 18579402 DOI: 10.1016/j.ejcts.2008.05.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 04/14/2008] [Accepted: 05/19/2008] [Indexed: 02/05/2023] Open
Abstract
Bleeding remains a potential complication for patients requiring extracorporeal life support systems. Recombinant activated factor VII (rFVIIa) is one of the drugs used in controlling bleeding. Its use is generally found to be safe. We report a paediatric patient who developed fatal thrombosis with the use of rFVIIa whilst on extracorporeal membrane oxygenation and discuss the possible factors that lead to fatal thrombosis.
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Abstract
The mortality in patients presenting with ruptured abdominal aortic aneurysm remains high. In this study we aimed to assess the outcome and factors predicting the mortality in patients admitted to a teaching hospital with the diagnosis of ruptured abdominal aortic aneurysm. During the study period (July 2001 to July 2007) all patients admitted with a diagnosis of a ruptured abdominal aortic aneurysm were included. There was a total of 62 patients with a mean age of 76 years. The hospital mortality was 32.3% (20 patients). Twelve patients (19.4%) were discharged home, 25 patients (40.3%) were discharged to rehabilitation and five patients (8%) were discharged to other hospitals for further care. There was a significant difference between survivors and non-survivors in age, loss of consciousness at presentation and duration of hospital stay. Logistic regression analysis of these variables suggests the presence of chronic obstructive pulmonary disease (P=0.04, odds ratio 6.7, 95% confidence interval 1.1 to 41.3) and age (P=0.02, odds ratio 1.2, 95% confidence intervals 1.0 to 1.3) to be independently associated with mortality. These results compare favourably with published Australian as well as the international data.
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Affiliation(s)
- J A Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
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Thalanany MM, Mugford M, Hibbert C, Cooper NJ, Truesdale A, Robinson S, Tiruvoipati R, Elbourne DR, Peek GJ, Clemens F, Hardy P, Wilson A. Methods of data collection and analysis for the economic evaluation alongside a national, multi-centre trial in the UK: conventional ventilation or ECMO for Severe Adult Respiratory Failure (CESAR). BMC Health Serv Res 2008; 8:94. [PMID: 18447931 PMCID: PMC2387150 DOI: 10.1186/1472-6963-8-94] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 04/30/2008] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Extracorporeal Membrane Oxygenation (ECMO) is a technology used in treatment of patients with severe but potentially reversible respiratory failure. A multi-centre randomised controlled trial (CESAR) was funded in the UK to compare care including ECMO with conventional intensive care management. The protocol and funding for the CESAR trial included plans for economic data collection and analysis. Given the high cost of treatment, ECMO is considered an expensive technology for many funding systems. However, conventional treatment for severe respiratory failure is also one of the more costly forms of care in any health system. METHODS/DESIGN The objectives of the economic evaluation are to compare the costs of a policy of referral for ECMO with those of conventional treatment; to assess cost-effectiveness and the cost-utility at 6 months follow-up; and to assess the cost-utility over a predicted lifetime. Resources used by patients in the trial are identified. Resource use data are collected from clinical report forms and through follow up interviews with patients. Unit costs of hospital intensive care resources are based on parallel research on cost functions in UK NHS intensive care units. Other unit costs are based on published NHS tariffs. Cost effectiveness analysis uses the outcome: survival without severe disability. Cost utility analysis is based on quality adjusted life years gained based on the Euroqol EQ-5D at 6 months. Sensitivity analysis is planned to vary assumptions about transport costs and method of costing intensive care. Uncertainty will also be expressed in analysis of individual patient data. Probabilities of cost effectiveness given different funding thresholds will be estimated. DISCUSSION In our view it is important to record our methods in detail and present them before publication of the results of the trial so that a record of detail not normally found in the final trial reports can be made available in the public domain. TRIAL REGISTRATIONS The CESAR trial registration number is ISRCTN47279827.
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Affiliation(s)
- Mariamma M Thalanany
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Miranda Mugford
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Clare Hibbert
- Health Economics & Decision Science, School of Health & Related Research, University of Sheffield, S1 4DA, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, LE1 7RH, UK
| | - Ann Truesdale
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Steven Robinson
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | | | - Diana R Elbourne
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | | | - Felicity Clemens
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Polly Hardy
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Clinical Epidemiology and Biostatistics Unit, Royal Children's Hospital, Melbourne, Australia
| | - Andrew Wilson
- Department of Health Sciences, University of Leicester, LE1 7RH, UK
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Tiruvoipati R, Bangash M, Manktelow B, Peek GJ. Efficacy of prone ventilation in adult patients with acute respiratory failure: a meta-analysis. J Crit Care 2008; 23:101-10. [PMID: 18359427 DOI: 10.1016/j.jcrc.2007.09.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 09/03/2007] [Accepted: 09/24/2007] [Indexed: 02/05/2023]
Abstract
PURPOSE The use of prone ventilation in acute respiratory failure has been investigated by several randomized controlled trials in the recent past. To date, there has been no systematic review or meta-analysis of these trials. MATERIAL AND METHODS Systematic literature search was performed between 1966 and July 2006 to identify randomized trials evaluating prone ventilation. Outcome measures included mortality, changes in oxygenation, incidence of pneumonia, duration of mechanical ventilation, intensive care unit (ICU) and hospital stay, cost-effectiveness, and adverse effects including pressure sores, endotracheal tube, or intravascular catheter complications. RESULTS Prone ventilation was not associated with reduction in mortality, but improvement in oxygenation was statistically significant (mean difference, 21.2 mm Hg; P < .001). There was no significant difference in incidence of pneumonia, ICU stay, and endotracheal tube complications. There was a trend toward an increased incidence of pressure sores in prone ventilated patients (odds ratio = 1.95; 95% confidence interval, 0.09-4.15; P = .08). The data on other outcomes were not suitable for meta-analysis. CONCLUSIONS The use of prone ventilation is associated with improved oxygenation. It is not associated with a reduction in mortality, pneumonia, or ICU stay and may be associated with an increased incidence of pressure sores.
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Tiruvoipati R, Pandya H, Manktelow B, Smith J, Dodkins I, Elbourne D, Field D. Referral pattern of neonates with severe respiratory failure for extracorporeal membrane oxygenation. Arch Dis Child Fetal Neonatal Ed 2008; 93:F104-7. [PMID: 17595202 DOI: 10.1136/adc.2006.113167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) remains the mainstay of management in neonates with severe but potentially reversible respiratory failure. In the UK, ECMO is available only as a supraregional service at four centres. OBJECTIVE To explore regional variations in ECMO referrals and neonatal deaths due to severe respiratory failure in England, Wales and Northern Ireland. METHODS In this retrospective study, data regarding ECMO referrals due to neonatal respiratory failure from January to December 2002 were obtained from the four UK ECMO centres and then subdivided according to the Government Office Regions. Anonymised data regarding neonatal deaths was obtained from Confidential Enquiry into Maternal and Child Health. Neonatal deaths were classified into four groups (group 1: deaths potentially avoidable by ECMO; group 2: deaths where it was unclear whether ECMO would have been of benefit; group 3: neonates not eligible for ECMO; and group 4: data inadequate to classify deaths). RESULTS There was significant regional variation in the rates of both ECMO referral (0.10 to 0.46 per 1000 live births; (p<0.001)) and neonatal deaths (groups 1 and 2) (0.09 to 0.32 per 1000 live births; (p<0.001)). Regions with high referral rates for ECMO tended towards having higher group 1 plus group 2 neonatal death rates (correlation coefficient = 0.75). CONCLUSION It is possible that there are significant regional variations in the uptake of ECMO and in neonatal mortality due to severe respiratory failure. A confidential prospective study may further clarify these observations and identify the factors that might lead to these variations.
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Tiruvoipati R, Vinogradova Y, Faulkner G, Sosnowski AW, Firmin RK, Peek GJ. Predictors of outcome in patients with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation. J Pediatr Surg 2007; 42:1345-50. [PMID: 17706494 DOI: 10.1016/j.jpedsurg.2007.03.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The role of extracorporeal membrane oxygenation (ECMO) in patients with congenital diaphragmatic hernia is still evolving. The use of ECMO is invasive with potential complications during instrumentation for cannulation and heparinization. There are no reliable predictors of outcome in patients requiring ECMO. We aimed to identify (a) the factors that could predict outcome and (b) the incidence and relation of complications during ECMO to outcome. METHODS "Pre" ECMO (age, sex, birth weight, blood gasses, and ventilator settings) and "on" ECMO variables (mode of ECMO, use of nitric oxide, surfactant, liquid ventilation, inotropes, timing of repair, and complications on ECMO) were analyzed to identify predictors of outcome. RESULTS Fifty-two patients were included. The overall survival was 58%. Mean duration of ECMO (181 +/- 120 vs 317 +/- 156 hours, P = .001), use of nitric oxide (6 vs 10, P = .049), and renal complications (4 vs 14; P < .001) differed between survivors and nonsurvivors. The survival of patients requiring ECMO support for more than 2 weeks is significantly lower than that of patients requiring ECMO support for less than 2 weeks (18% vs 68%, P = .005). Multiple logistic regression revealed ECMO duration of 2 weeks or more and renal complications to be associated with mortality. CONCLUSION No pre-ECMO variable could be identified as predictor of mortality. Prolonged duration of ECMO and renal complications on ECMO were independently associated with mortality.
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Abstract
Liquid ventilation with perfluorocarbons is used in severe respiratory failure that cannot be managed by conventional methods. Very little is known about the use of liquid ventilation in paediatric patients with respiratory failure and there are no reports describing the distribution and excretion of perfluorocarbons in paediatric patients with severe respiratory failure. The aim of this report is to highlight the prolonged retention of perfluorocarbons in a paediatric patient, mimicking pulmonary calcification and misleading the interpretation of the chest CT scan. A 10-year-old girl was admitted to our intensive care unit with severe respiratory failure due to miliary tuberculosis. Extracorporeal membrane oxygenation (ECMO) was used to support gas exchange and partial liquid ventilation (PLV) with perfluorodecalin was used to aid in oxygenation, lavage the lungs and clear thick secretions. The patient developed a pneumothorax (fluorothorax) on the next day and PLV was discontinued. Multiple bronchoalveolar lavages were performed to clear thick secretions. With no improvement in lung function over the next month a CT scan of the chest was performed. This revealed extensive pulmonary fibrosis and multiple high attenuation lesions suggestive of pulmonary calcification. To exclude perfluorodecalin as the cause for high attenuation lesions, a sample of perfluorodecalin was scanned to estimate the Hounsfield unit density, which was similar to the density of high attenuation lesions on chest CT scan. High-density opacification should be interpreted with caution, especially following liquid ventilation.
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Affiliation(s)
- R Tiruvoipati
- Department of ECMO and Cardiac Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
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Tiruvoipati R, Moorthy T, Balasubramanian SK, Platt V, Peek GJ. Extracorporeal membrane oxygenation and extracorporeal albumin dialysis in pediatric patients with sepsis and multi-organ dysfunction syndrome. Int J Artif Organs 2007; 30:227-34. [PMID: 17417762 DOI: 10.1177/039139880703000308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in managing patients with potentially reversible cardio-respiratory failure refractory to conventional methods. Multiorgan dysfunction syndrome (MODS), usually due to sepsis, remains the main cause of mortality in such patients. We report a series of six pediatric patients with sepsis-induced MODS where extracorporeal albumin dialysis (EAD) was used while the patients were on ECMO. The age of the patients ranged between 1 month and 17 years. The mean pediatric index of mortality (PIM) score at admission was 67.5%. All these patients further deteriorated with MODS and EAD was used as rescue therapy. At institution of EAD, 4 patients had dysfunction of 4 organs and 2 patients had dysfunction of 5 organs. The number of EAD cycles ranged between 1 and 3. Three out of the 6 patients (50%) survived to discharge from the intensive care unit and two of the six patients (33%) survived to hospital discharge. According to our previous experience and published results, all these patients would have been expected to die. The present results suggest that EAD may prove to have a role in the treatment of pediatric patients with sepsis-induced MODS. Further research is required to identify the group of patients who would benefit most by EAD as well as understand the clearance of inflammatory mediators and other mechanisms involved with the use of EAD.
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Affiliation(s)
- R Tiruvoipati
- Department of ECMO, Glenfield Hospital, Groby Road, Leicester, United Kingdom.
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Balasubramanian SK, Tiruvoipati R, Amin M, Aabideen KK, Peek GJ, Sosnowski AW, Firmin RK. Factors influencing the outcome of paediatric cardiac surgical patients during extracorporeal circulatory support. J Cardiothorac Surg 2007; 2:4. [PMID: 17217529 PMCID: PMC1797039 DOI: 10.1186/1749-8090-2-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Accepted: 01/11/2007] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (ECMO) is a common modality of circulatory assist device used in children. We assessed the outcome of children who had ECMO following repair of congenital cardiac defects (CCD) and identified the risk factors associated with hospital mortality. METHODS From April 1990 to December 2003, 53 patients required ECMO following surgical correction of CCD. Retrospectively collected data was analyzed with univariate and multivariate logistic regression analysis. RESULTS Median age and weight of the patients were 150 days and 5.4 kgs respectively. The indications for ECMO were low cardiac output in 16, failure to wean cardiopulmonary bypass in 13, cardiac arrest in 10 and cardio-respiratory failure in 14 patients. The mean duration of ECMO was 143 hours. Weaning off from ECMO was successful in 66% and of these 83% were survival to hospital-discharge. 37.7% of patients were alive for the mean follow-up period of 75 months. On univariate analysis, arrhythmias, ECMO duration >168 hours, bleeding complications, renal replacement therapy on ECMO, arrhythmias and cardiac arrest after ECMO were associated with hospital mortality.On multivariate analysis, abnormal neurology, bleeding complications and arrhythmias after ECMO were associated with hospital mortality. Extra and intra-thoracic cannulations were used in 79% and 21% of patients respectively and extra-thoracic cannulation had significantly less bleeding complications (p = 0.031). CONCLUSION ECMO provides an effective circulatory support following surgical repair of CCD in children. Extra-thoracic cannulation is associated with less bleeding complications. Abnormal neurology, bleeding complications on ECMO and arrhythmias after ECMO are poor prognostic indicators for hospital survival.
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Affiliation(s)
| | | | - Mohammed Amin
- Department of Paediatric cardiology, Glenfield General Hospital, Leicester, LE3 9QQ, UK
| | - Kanakkande K Aabideen
- Department of Paediatric cardiology, Glenfield General Hospital, Leicester, LE3 9QQ, UK
| | - Giles J Peek
- Department of ECMO, Glenfield General Hospital, Leicester, LE3 9QQ, UK
| | | | - Richard K Firmin
- Department of ECMO, Glenfield General Hospital, Leicester, LE3 9QQ, UK
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Peek GJ, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, Killer H, Mugford M, Thalanany M, Tiruvoipati R, Truesdale A, Wilson A. CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res 2006; 6:163. [PMID: 17187683 PMCID: PMC1766357 DOI: 10.1186/1472-6963-6-163] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 12/23/2006] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND An estimated 350 adults develop severe, but potentially reversible respiratory failure in the UK annually. Current management uses intermittent positive pressure ventilation, but barotrauma, volutrauma and oxygen toxicity can prevent lung recovery. An alternative treatment, extracorporeal membrane oxygenation, uses cardio-pulmonary bypass technology to temporarily provide gas exchange, allowing ventilator settings to be reduced. While extracorporeal membrane oxygenation is proven to result in improved outcome when compared to conventional ventilation in neonates with severe respiratory failure, there is currently no good evidence from randomised controlled trials to compare these managements for important clinical outcomes in adults, although evidence from case series is promising. METHODS/DESIGN The aim of the randomised controlled trial of Conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR) is to assess whether, for patients with severe, but potentially reversible, respiratory failure, extracorporeal membrane oxygenation will increase the rate of survival without severe disability ('confined to bed' and 'unable to wash or dress') by six months post-randomisation, and be cost effective from the viewpoints of the NHS and society, compared to conventional ventilatory support. Following assent from a relative, adults (18-65 years) with severe, but potentially reversible, respiratory failure (Murray score >/= 3.0 or hypercapnea with pH < 7.2) will be randomised for consideration of extracorporeal membrane oxygenation at Glenfield Hospital, Leicester or continuing conventional care in a centre providing a high standard of conventional treatment. The central randomisation service will minimise by type of conventional treatment centre, age, duration of high pressure ventilation, hypoxia/hypercapnea, diagnosis and number of organs failed, to ensure balance in key prognostic variables. Extracorporeal membrane oxygenation will not be available for patients meeting entry criteria outside the trial. 180 patients will be recruited to have 80% power to be able to detect a one third reduction in the primary outcome from 65% at 5% level of statistical significance (2-sided test). Secondary outcomes include patient morbidity and health status at 6 months. DISCUSSION Analysis will be based on intention to treat. A concurrent economic evaluation will also be performed to compare the costs and outcomes of both treatments.
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Affiliation(s)
- Giles J Peek
- Department of Cardiothoracic Surgery, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Felicity Clemens
- Medical Statistics Unit, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
| | - Diana Elbourne
- Medical Statistics Unit, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
| | - Richard Firmin
- Department of Cardiothoracic Surgery, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Pollyanna Hardy
- Medical Statistics Unit, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
- Clinical Epidemiology and Biostatistics Unit, Royal Children's Hospital, Melbourne, Australia
| | - Clare Hibbert
- School of Health and Related Research, University of Sheffield and RTI Health Solutions, Williams House Manchester Science Park, Manchester ME15 6SE, UK
| | - Hilliary Killer
- Department of Cardiothoracic Surgery, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Miranda Mugford
- School of Medicine Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Mariamma Thalanany
- School of Medicine Health Policy and Practice, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Ravin Tiruvoipati
- Department of Cardiothoracic Surgery, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Ann Truesdale
- Medical Statistics Unit, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
| | - Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester, LE5 4PW, UK
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Balasubramanian SP, Wiener M, Alshameeri Z, Tiruvoipati R, Elbourne D, Reed MW. Standards of reporting of randomized controlled trials in general surgery: can we do better? Ann Surg 2006; 244:663-7. [PMID: 17060756 PMCID: PMC1856614 DOI: 10.1097/01.sla.0000217640.11224.05] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the quality of reporting of surgical randomized controlled trials published in surgical and general medical journals using Jadad score, allocation concealment, and adherence to CONSORT guidelines and to identify factors associated with good quality. SUMMARY BACKGROUND DATA Randomized controlled trials (RCTs) provide the best evidence about the relative effectiveness of different interventions. Improper methodology and reporting of RCTs can lead to erroneous conclusions about treatment effects, which may mislead decision-making in health care at all levels. METHODS Information was obtained on RCTs published in 6 general surgical and 4 general medical journals in the year 2003. The quality of reporting of RCTs was assessed under masked conditions using allocation concealment, Jadad score, and a CONSORT checklist devised for the purpose. RESULTS Of the 69 RCTs analyzed, only 37.7% had a Jadad score of > or =3, and only 13% of the trials clearly explained allocation concealment. The modified CONSORT score of surgical trials reported in medical journals was significantly higher than those reported in surgical journals (Mann-Whitney U test, P < 0.001). Overall, the modified CONSORT score was higher in studies with higher author numbers (P = 0.03), multicenter studies (P = 0.002), and studies with a declared funding source (P = 0.022). CONCLUSION The overall quality of reporting of surgical RCTs was suboptimal. There is a need for improving awareness of the CONSORT statement among authors, reviewers, and editors of surgical journals and better quality control measures for trial reporting and methodology.
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Affiliation(s)
- Sabapathy P Balasubramanian
- Academic Unit of Surgical Oncology, K Floor, Royal Hallamshire Hospital, University of Sheffield, S10 2JF, UK.
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Tiruvoipati R, Balasubramanian SP, Atturu G, Peek GJ, Elbourne D. Improving the quality of reporting randomized controlled trials in cardiothoracic surgery: the way forward. J Thorac Cardiovasc Surg 2006; 132:233-40. [PMID: 16872940 DOI: 10.1016/j.jtcvs.2005.10.056] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Revised: 09/13/2005] [Accepted: 10/28/2005] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the quality of reporting of randomized controlled trials in cardiothoracic surgery, to identify factors associated with good reporting quality, and to assess the awareness of the Consolidated Standards for Reporting of Trials statement and ascertain the views of authors reporting randomized controlled trials on the difficulties in conducting randomized controlled trials and the possible ways to further improve the reporting quality of randomized controlled trials in cardiothoracic surgery. METHODS Randomized controlled trials of cardiothoracic surgery published in principal cardiothoracic and 4 general medical journals in 2003 were included. The quality of reporting of randomized controlled trials was assessed by using allocation concealment, the Jadad score, and a Consolidated Standards for Reporting of Trials checklist devised for the purpose. A questionnaire survey of authors reporting randomized controlled trials in principal cardiothoracic journals in 2003 was conducted. RESULTS The overall reporting quality of the 64 randomized controlled trials included in the analysis was suboptimal as assessed by the 3 methods adopted. Most of the authors (63.5%) were not aware of the Consolidated Standards for Reporting of Trials statement; however, awareness was not associated with reporting quality. More than 65% of the authors responded that conducting randomized controlled trials in surgical specialties was difficult, and the main difficulties were blinding and obtaining a large-enough sample size to detect statistically significant differences. Fifty-four percent of the authors responded that endorsement of the Consolidated Standards for Reporting of Trials statement by the cardiothoracic journals may improve the reporting quality. CONCLUSIONS The quality of reporting randomized controlled trials in cardiothoracic surgery is suboptimal. Endorsement of the Consolidated Standards for Reporting of Trials statement by the cardiothoracic journals may improve the quality of reporting.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Cardiac Surgery and ECMO, Glenfield Hospital, Leicester, Leicester, United Kingdom.
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Abstract
PURPOSE OF REVIEW The increasing incidence of diffuse coronary artery disease in the current era challenges cardiac surgeons in accomplishing their goal of complete revascularisation. Although coronary endarterectomy is used with encouraging results in most institutions, there remains some controversy in its indications, technique, and results. The purpose of this review is to highlight the important evolutions of technique in the recent past. RECENT FINDINGS Despite the increased risk factors and comorbidities in patients presenting with diffuse coronary artery disease requiring coronary endarterectomy, the results of coronary endarterectomy are improving inline with the improvements in the results of conventional coronary artery bypass grafting surgery. The improving results of coronary endarterectomy in the left anterior descending artery are further clarified. The intra- and postoperative use of prostacyclin has been shown to be effective in reducing mortality and perioperative myocardial infarction. The technique of open coronary endarterectomy with on-lay patch bypass grafting has been shown to be safe and effective in reducing mortality and improving patency as compared with the closed (traction) method of coronary endarterectomy. The use of coronary endarterectomy was also found to be effective in the treatment of in-stent restenosis in the setting of diffuse coronary artery disease. The results of off-pump coronary endarterectomy are encouraging and comparable with the conventional coronary endarterectomy using cardiopulmonary bypass. SUMMARY With the increasing incidence of diffuse coronary artery disease and improving results of coronary endarterectomy, it is vital for cardiac surgeons to have coronary endarterectomy in their armamentarium to achieve complete coronary revascularisation.
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Tiruvoipati R, Balasubramanian SK, Khoshbin E, Hadjinikolaou L, Sosnowski AW, Firmin RK. Successful use of venovenous extracorporeal membrane oxygenation in accidental hypothermic cardiac arrest. ASAIO J 2005; 51:474-6. [PMID: 16156316 DOI: 10.1097/01.mat.0000169124.32865.d6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Cardiopulmonary bypass is usually used for rewarming and for providing cardiac support in patients with severe hypothermia and cardiovascular instability. We report the first case of accidental severe hypothermia associated with prolonged cardiac arrest that was successfully managed by venovenous extracorporeal membrane oxygenation.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of ECMO and Cardiac Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, United Kingdom
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Balasubramanian SK, Tiruvoipati R, Chatterjee S, Sosnowski A, Firmin RK. Extracorporeal membrane oxygenation with lepirudin anticoagulation for Wegener's granulomatosis with heparin-induced thrombocytopenia. ASAIO J 2005; 51:477-9. [PMID: 16156317 DOI: 10.1097/01.mat.0000169123.21946.31] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Venovenous extracorporeal membrane oxygenation with lepirudin anticoagulation was successfully used for a complicated case of Wegener's granulomatosis and heparin-induced thrombocytopenia. Interestingly, a linear correlation was found between activated partial thromboplastin time and activated clotting time during lepirudin anticoagulation.
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Tiruvoipati R, Loubani M, Lencioni M, Ghosh S, Jones PW, Patel RL. Coronary endarterectomy: impact on morbidity and mortality when combined with coronary artery bypass surgery. Ann Thorac Surg 2005; 79:1999-2003. [PMID: 15919299 DOI: 10.1016/j.athoracsur.2004.12.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Revised: 12/21/2004] [Accepted: 12/28/2004] [Indexed: 02/08/2023]
Abstract
BACKGROUND The results of coronary endarterectomy (CE) performed in addition to coronary artery bypass grafting (CABG) have been controversial. We aimed to examine the impact of CE performed in addition to CABG when compared with CABG alone in our unit. METHODS Patients who had CABG between January 1995 and December 2001 were included. They were divided into two groups, the CABG-only group and CABG and CE group. The following outcomes were compared: perioperative myocardial infarction, postoperative ventricular arrhythmias, cerebrovascular accident, renal impairment, and early mortality. RESULTS Of 5,782 patients who underwent CABG, 461 patients (8.6%) required CE in addition to CABG. There was a higher mortality and incidence of postoperative renal impairment in the group of patients who had CABG and CE, with no significant difference in other outcomes. However, the patients in the CABG and CE group had a higher incidence of male sex, previous myocardial infarctions, preoperative renal impairment, and poor left ventricular function, with longer cross-clamp and cardiopulmonary bypass times than in the CABG-only patients. Although female sex, renal impairment, nonelective surgery, impaired left ventricular function, and peripheral vascular disease were associated with increased mortality in all the patients, and use of statins and aspirin was associated with a reduction in mortality, CE was not a predictor of mortality. Furthermore, on propensity scores analysis, CE was not associated with increased mortality. CONCLUSIONS Coronary endarterectomy when combined with CABG seemed to be associated with a higher mortality than isolated CABG in our study groups, but this is related to comorbidities of these patients rather than the CE.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Cardiothoracic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Walsgrave Hospital, Coventry, United Kingdom.
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Tiruvoipati R, Naik RD, Loubani M, Billa GN. Surgical approach for pericardiectomy: a comparative study between median sternotomy and left anterolateral thoracotomy. Interact Cardiovasc Thorac Surg 2003; 2:322-6. [PMID: 17670058 DOI: 10.1016/s1569-9293(03)00074-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Pericardiectomy is the definitive treatment for constrictive pericarditis but the best surgical approach remains controversial. In this study we compared the results of pericardiectomy performed on 36 patients with constrictive pericarditis between 1995 and 2001. Pericardiectomy was performed by median sternotomy in 15 patients and by left anterolateral thoracotomy in 21 patients. All patients were reviewed at 6 weeks post operatively. Both groups of patients were similar in age, sex distribution, NYHA shortness of breath status, aetiology, presenting symptoms and duration of symptoms. Mortality was similar in the two groups with three deaths (14.2%) in the thoracotomy group and two deaths (13.3%) in the median sternotomy group. NYHA status improved in both thoracotomy (3.0+/-0.8 to 1.6+/-0.7; P=3.3x10(-6)) and median sternotomy (2.9+/-0.7 to 1.5+/-0.6; P=2.8x10(-5)) groups. The degree of improvement was not significant between the two groups (P=0.63). In addition ionotropic support and postoperative hospital stay were similar between the two groups. There was a higher incidence of wound infections (23.8 versus 6.6%; P=0.13) and pulmonary complications (23.8 versus 13.3%; P=0.33) associated with thoracotomy. In conclusion pericardiectomy improves NYHA status in all patients and mortality rates are similar in both the approaches.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Cardiothoracic Surgery, Osmania General Hospital, Hyderabad, Andhra Pradesh, India.
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