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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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Lefrant JY, Benhamou D, Fischer MO, Pirracchio R, Allaouchiche B, Bastide S, Biais M, Blet A, Bouvet L, Brissaud O, Brull SJ, Capdevila X, Clausen N, Cuvillon P, Dadure C, David JS, Eley V, Forget P, Fujii T, Godier A, Gopalan D, Guinot PG, Hasanin A, Joannes-Boyau O, Kerever S, Kipnis É, Landau R, Le Guen M, Legrand M, Lorne E, Mercier F, Mongardon N, Myatra SN, Nicolas-Robin A, Peters MJ, Quintard H, Rello J, G Richebe P, Roberts JA, Sanfilippo F, Schneider A, T Sofonea M, Treggiari M, Veyckemans F, Von Ungern-Sternberg BR, Zeidan A, Zieleskiewicz L, Zielinska M, Milman A, Roquilly A. Comments on: Reducing the Risks of Nuclear War-The Role of Health Professionals. Anaesth Crit Care Pain Med 2023; 43:101314. [PMID: 37863196 DOI: 10.1016/j.accpm.2023.101314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Affiliation(s)
- Jean-Yves Lefrant
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France.
| | - Dan Benhamou
- Paris Sud University, Department of Anaesthesia and Intensive Care Medicine, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | | | - Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, 1001 Potrero Avenue, San Francisco, USA
| | | | | | - Matthieu Biais
- Société Heva, Lyon, France; University Hospital Centre Bordeaux, Department of Anaesthesiology and Critical Care Medicine, Bordeaux, France
| | - Alice Blet
- Lyon University Hospital, Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Lionel Bouvet
- Lyon University Hospital, Department of Anaesthesiology and Intensive Care, Femme-Mère-Enfant Hospital, Lyon, France
| | - Olivier Brissaud
- University Hospital Centre Bordeaux, Pediatric Intensive Care Unit, Bordeaux, France
| | - Sorin J Brull
- Mayo Clinic, College of Medicine and Science, Department of Anesthesiology and Perioperative Medicine, Jacksonville, Florida, United States of America
| | - Xavier Capdevila
- Montpellier University Hospital Centre, Department of Anaesthesia and Intensive Care, Montpellier, France
| | - Nicola Clausen
- Department of Anesthesiology and Intensive Care, University Hospital Odense, Denmark
| | - Philippe Cuvillon
- Nîmes University Hospital, CHU Carémeau, Critical Care and Emergency Medicine, Pain Dept, Nîmes, France
| | - Christophe Dadure
- Lapeyronie Hospital, Pediatric Anesthesia Department, Montpellier, France
| | - Jean-Stéphane David
- Civil Hospices of Lyon, Department of Anaesthesiology and Critical Care Medicine, Lyon, France
| | - Victoria Eley
- Royal Brisbane and Women's Hospital, Department of Anaesthesia and Perioperative Medicine, Herston, Australia
| | - Patrice Forget
- University of Aberdeen Institute of Applied Health Sciences, Aberdeen, United Kingdom
| | | | - Anne Godier
- The Fondation Adolphe de Rothschild Hospital, Paris, France
| | - Dean Gopalan
- University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
| | | | - Ahmed Hasanin
- Department of Anaesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Olivier Joannes-Boyau
- University Hospital Centre Bordeaux, Department of Anaesthesiology and Critical Care Medicine, Bordeaux, France
| | - Sébastien Kerever
- Paris University, Lariboisière University Hospital, Departments of Anaesthesiology and Critical Care, Paris, France
| | - Éric Kipnis
- Lille University School of Medicine, Loos, France
| | - Ruth Landau
- Columbia University Vagelos College of Physicians and Surgeons, New York, United States of America
| | - Morgan Le Guen
- Hospital Foch, Department of Anaesthesiology, Suresnes, France
| | - Matthieu Legrand
- University of California, Zuckerberg San Francisco General Hospital and Trauma Center, Department of Anaesthesia and Perioperative Medicine, San Francisco, California, United States of America
| | - Emmanuel Lorne
- Clinique du Millénaire, Department of Anesthesiology and Intensive Care (Akomé), Montpellier, France
| | - Frédéric Mercier
- Paris-Saclay University, Antoine-Béclère Hospital, Department of Anaesthesia and Critical Care Medicine, Clamart, France
| | | | - Sheila Nainan Myatra
- Homi Bhabha National Institute - Tata Memorial Hospital, Department of Anaesthesiology, Critical Care and Pain, Mumbai, India
| | - Armelle Nicolas-Robin
- Pediatric Palliative Care Mobile Team, University Hospital Robert-Debré, Assistance Publique - Hôpitaux de Paris, Paris University, Paris, France
| | - Mark John Peters
- Great Ormond Street Hospital for Children Paediatric Intensive Care Unit, London, United Kingdom
| | - Hervé Quintard
- Geneva University Hospitals Intensive Care Service, Genève, Switzerland
| | - Jordi Rello
- International University of Cataluna, Faculty of Medicine and Health Sciences, Sant Cugat del Valles, Spain
| | - Philippe G Richebe
- University of Montreal, Department of Anesthesiology and Pain Medicine, Montréal, Quebec, Canada
| | | | - Filippo Sanfilippo
- Policlinico, Department of Anaesthesia and Intensive Care, Catania, Italy
| | - Antoine Schneider
- Lausanne University Hospital Adult Intensive Care Unit, Vaud, Switzerland
| | - Mircea T Sofonea
- Infectious Diseases and Vectors Ecology Genetics Evolution and Control, Montpellier, France
| | - Miriam Treggiari
- Yale University School of Medicine, Department of Anesthesiology, New Haven, Connecticut, United States of America
| | - Francis Veyckemans
- Lille University Hospital, Department of Paediatric Resuscitation, Lille, France
| | | | - Ahed Zeidan
- King Fahad Specialist Hospital-Dammam, Department of Anesthesiology, Dammam, Saudi Arabia
| | - Laurent Zieleskiewicz
- Aix-Marseille University, University Hospital of Marseille, Department of Anaesthesia and Intensive Care Medicine, Marseille, France
| | - Marzena Zielinska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Alexandre Milman
- Editorial Office Anaesthesia Critical Care and Pain Medicine, Société Française d'Anesthésie et Réanimation, Paris, France
| | - Antoine Roquilly
- University of Nantes - Anaesthesiology and Intensive Care Unit, Nantes, France
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Bombardieri AM, Heifets BD, Treggiari M, Albers GW, Steinberg GK, Heit JJ. Cervical sympathectomy to treat cerebral vasospasm: a scoping review. Reg Anesth Pain Med 2023; 48:513-519. [PMID: 36424089 DOI: 10.1136/rapm-2022-103999] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Received: 08/16/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND/IMPORTANCE Delayed cerebral ischemia (DCI) is the second-leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (aSAH), and is associated with cerebral arterial vasospasm (CAV). Current treatments for CAV are expensive, invasive, and have limited efficacy. Cervical sympathetic block (CSB) is an underappreciated, but potentially highly effective therapy for CAV. OBJECTIVE To provide a comprehensive review of the preclinical and human literature pertinent to CSB in the context of CAV. EVIDENCE REVIEW This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a literature search using Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science until February 2022, to identify abstracts, conference proceedings, and full-text papers pertinent to cervical sympathectomy and CAV in animal/adult patients. FINDINGS We included six human and six experimental studies. Human studies were mostly prospective observational, except one retrospective and one randomized clinical trial, and used various imaging modalities to measure changes in arterial diameter after the block. Studies that used digital subtraction angiography showed an improvement in cerebral perfusion without change in vessel diameter. Transcranial Doppler studies found an approximately 15% statistically significant decrease in velocities consistent with arterial vasodilatation. Overall, the results suggest an increase in cerebral arterial diameter and neurological improvement in patients receiving a CSB. Animal studies demonstrate that sympathetic system ablation vasodilates cerebral vasculature and decreases the incidence of symptomatic vasospasm. CONCLUSIONS This scoping review suggests that CSB may be a viable option for treatment and prevention of CAV/DCI in patients with aSAH, although the included studies were heterogeneous, mostly observational, and with a small sample size. Further research is needed to standardize the technique and prove its effectiveness to treat patients suffering of CAV/DCI after aSAH.
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Affiliation(s)
- Anna Maria Bombardieri
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Boris D Heifets
- Anesthesiology and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Treggiari
- Anesthesiology and Perioperative Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregory W Albers
- Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary K Steinberg
- Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Stanford University School of Medicine, Stanford, California, USA
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Ohnuma T, Chihara S, Costin B, Treggiari M, Bartz RR, Raghunathan K, Krishnamoorthy V. Epidemiology, Resistance Profiles, and Outcomes of Bloodstream Infections in Community-Onset Sepsis in the United States. Crit Care Med 2023; 51:1148-1158. [PMID: 37276351 DOI: 10.1097/ccm.0000000000005870] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To describe frequency of positive blood cultures, patterns of pathogens' characteristics and their resistance profile in patients with blood cultures drawn due to a presumed diagnosis of community-onset sepsis, and to examine the association between blood culture-positive pathogens and hospital mortality. DESIGN Retrospective cohort study. SETTING Two hundred one U.S. hospitals from 2016 to 2020 using the Premier Healthcare Database. SUBJECTS Adult patients presenting with community-onset sepsis who had blood cultures collected within 2 days of hospital admission. We defined sepsis using the U.S. Centers for Disease Control Adult Sepsis Event Surveillance criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 147,061 patients with community-onset sepsis. The number of blood culture-positive sepsis episodes was 21,167 (14%) and the number of nonblood culture-positive sepsis episodes was 20,326 (14%). Among patients with blood culture-positive sepsis, Gram-negative rods were isolated in 55% of patients, Gram-positive cocci were isolated in 47%. Of those, methicillin-resistant Staphylococcus aureus (MRSA) was 11%, ceftriaxone-resistant Enterobacterales /extended-spectrum β-lactamase was 7%, and carbapenem-resistant Enterobacterales was 1.3%. The crude in-hospital mortality was 17% for culture-negative sepsis, 13% for nonblood culture-positive sepsis, and 17% for blood culture-positive sepsis. In multilevel logistic regression models, compared with culture-negative sepsis, blood culture-positive sepsis (adjusted odds ratio [aOR], 0.89; 95% CI, 0.85-0.94) and nonblood culture-positive sepsis (aOR, 0.82; 95% CI, 0.78-0.87) were associated with lower odds of in-hospital mortality. Acinetobacter species, Pseudomonas aeruginosa , methicillin-sensitive Staphylococcus aureus , and MRSA were associated with higher in-hospital mortality, whereas Escherichia coli , Klebsiella species, Proteus species, and Streptococcus species were associated with lower in-hospital mortality. CONCLUSIONS In patients hospitalized with community-onset sepsis, the prevalence of blood culture-positive sepsis was 14%. Among positive blood culture sepsis resistant organisms were infrequent. Compared with culture-negative sepsis, blood culture-positive sepsis and nonblood culture-positive sepsis were associated with lower in-hospital mortality.
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Affiliation(s)
- Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Shingo Chihara
- Section of Infectious Diseases, Department of Internal Medicine, Virginia Mason Medical Center, Seattle, WA
| | - Blair Costin
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Miriam Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Raquel R Bartz
- Department of Anaesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
- Veterans Affairs Anesthesiology Service Division, Durham VA Medical Center, Durham, NC
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Zaky A, Melvin RL, Benz D, Davies J, Panayotis V, Maddox W, Shah R, Lynch T, Beck A, Hearld K, McElderry T, Treggiari M. Economic Evaluation of Anesthesiology-Led Cardiac Implantable Electronic Device Service. Healthcare (Basel) 2023; 11:1864. [PMID: 37444698 DOI: 10.3390/healthcare11131864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/16/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Implementation of an anesthesiology-led cardiac implantable electronic device (CIED) service can be viewed to have economic and efficiency challenges. This study evaluates the cost savings of an anesthesiology-led CIED service. METHODS A total of 830 patients presented in the pre-implementation period from 1 March 2016 to 31 December 2017, and 1981 patients presented in the post-implementation period from 1 January 2018 to 31 October 2021. Interrupted time-series analysis for single-group comparisons was used to evaluate the cost savings resulting from reduction in operating room (OR) start delays for patients with CIEDs. RESULTS OR start-time delay was reduced by 10.6 min (95%CI: -20.5 to -0.83), comparing pre- to post-implementation. For an OR cost of USD 45/min, we estimated the direct cost to the department to be USD 1.68/min. The intervention translated into a total cost reduction during the intervention period of USD 250,000 (USD 18,000 to USD 470,000) per year for the institution and USD 9800 (USD 730 to USD 17,000) per year for the department. The yearly cost of employing a full-time team of CIED specialists would have been USD 135,456. The service triggered electrophysiology consultation on 13 device malfunctions. CONCLUSIONS An anesthesiology-led CIED service resulted in substantial cost savings, increased OR efficiency and patient safety.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Ryan L Melvin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - David Benz
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - James Davies
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Vardas Panayotis
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - William Maddox
- Department of Cardiology, Division of Electrophysiology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Ruchit Shah
- Department of Cardiology, Division of Electrophysiology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Tom Lynch
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Adam Beck
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Kristine Hearld
- School of Health Professionals, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Tom McElderry
- Department of Cardiology, Division of Electrophysiology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Miriam Treggiari
- Department of Anesthesiology and Perioperative Medicine, Duke University, Durham, NC 27708, USA
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Hatfield J, Ohnuma T, Soto AL, Komisarow JM, Vavilala MS, Laskowitz DT, James ML, Mathew JP, Hernandez AF, Goldstein BA, Treggiari M, Raghunathan K, Krishnamoorthy V. Utilization and Outcomes of Extracorporeal Membrane Oxygenation Following Traumatic Brain Injury in the United States. J Intensive Care Med 2022; 38:440-448. [PMID: 36445019 DOI: 10.1177/08850666221139223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives: Describe contemporary ECMO utilization patterns among patients with traumatic brain injury (TBI) and examine clinical outcomes among TBI patients requiring ECMO. Design: Retrospective cohort study. Setting: Premier Healthcare Database (PHD) between January 2016 to June 2020. Subjects: Adult patients with TBI who were mechanically ventilated and stratified by exposure to ECMO. Results: Among patients exposed to ECMO, we examined the following clinical outcomes: hospital LOS, ICU LOS, duration of mechanical ventilation, and hospital mortality. Of our initial cohort (n = 59,612), 118 patients (0.2%) were placed on ECMO during hospitalization. Most patients were placed on ECMO within the first 2 days of admission (54.3%). Factors associated with ECMO utilization included younger age (OR 0.96, 95% CI (0.95–0.97)), higher injury severity score (ISS) (OR 1.03, 95% CI (1.01–1.04)), vasopressor utilization (2.92, 95% CI (1.90–4.48)), tranexamic acid utilization (OR 1.84, 95% CI (1.12–3.04)), baseline comorbidities (OR 1.06, 95% CI (1.03–1.09)), and care in a teaching hospital (OR 3.04, 95% CI 1.31–7.05). A moderate degree (ICC = 19.5%) of variation in ECMO use was explained at the individual hospital level. Patients exposed to ECMO had longer median (IQR) hospital and ICU length of stay (LOS) [26 days (11–36) versus 9 days (4–8) and 19.5 days (8–32) versus 5 days (2–11), respectively] and a longer median (IQR) duration of mechanical ventilation [18 days (8–31) versus 3 days (2–8)]. Patients exposed to ECMO experienced a hospital mortality rate of 33.9%, compared to 21.2% of TBI patients unexposed to ECMO. Conclusions: ECMO utilization in mechanically ventilated patients with TBI is rare, with significant variation across hospitals. The impact of ECMO on healthcare utilization and hospital mortality following TBI is comparable to non-TBI conditions requiring ECMO. Further research is necessary to better understand the role of ECMO following TBI and identify patients who may benefit from this therapy.
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Affiliation(s)
- Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alexandria L. Soto
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan M. Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Michael L. James
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | | | | | | | - Miriam Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Population Health Sciences, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Population Health Sciences, Duke University, Durham, NC, USA
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Neuman MD, Feng R, Ellenberg SS, Sieber F, Sessler DI, Magaziner J, Elkassabany N, Schwenk ES, Dillane D, Marcantonio ER, Menio D, Ayad S, Hassan M, Stone T, Papp S, Donegan D, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Hoeft MA, Tierney A, Gaskins LJ, Horan AD, Brown T, Dattilo J, Carson JL, Looke T, Bent S, Franco-Mora A, Hedrick P, Newbern M, Tadros R, Pealer K, Vlassakov K, Buckley C, Gavin L, Gorbatov S, Gosnell J, Steen T, Vafai A, Zeballos J, Hruslinski J, Cardenas L, Berry A, Getchell J, Quercetti N, Bajracharya G, Billow D, Bloomfield M, Cuko E, Elyaderani MK, Hampton R, Honar H, Khoshknabi D, Kim D, Krahe D, Lew MM, Maheshwer CB, Niazi A, Saha P, Salih A, de Swart RJ, Volio A, Bolkus K, DeAngelis M, Dodson G, Gerritsen J, McEniry B, Mitrev L, Kwofie MK, Belliveau A, Bonazza F, Lloyd V, Panek I, Dabiri J, Chavez C, Craig J, Davidson T, Dietrichs C, Fleetwood C, Foley M, Getto C, Hailes S, Hermes S, Hooper A, Koener G, Kohls K, Law L, Lipp A, Losey A, Nelson W, Nieto M, Rogers P, Rutman S, Scales G, Sebastian B, Stanciu T, Lobel G, Giampiccolo M, Herman D, Kaufman M, Murphy B, Pau C, Puzio T, Veselsky M, Apostle K, Boyer D, Fan BC, Lee S, Lemke M, Merchant R, Moola F, Payne K, Perey B, Viskontas D, Poler M, D'Antonio P, O'Neill G, Abdullah A, Fish-Fuhrmann J, Giska M, Fidkowski C, Guthrie ST, Hakeos W, Hayes L, Hoegler J, Nowak K, Beck J, Cuff J, Gaski G, Haaser S, Holzman M, Malekzadeh AS, Ramsey L, Schulman J, Schwartzbach C, Azefor T, Davani A, Jaberi M, Masear C, Haider SB, Chungu C, Ebrahimi A, Fikry K, Marcantonio A, Shelvan A, Sanders D, Clarke C, Lawendy A, Schwartz G, Garg M, Kim J, Caruci J, Commeh E, Cuevas R, Cuff G, Franco L, Furgiuele D, Giuca M, Allman M, Barzideh O, Cossaro J, D'Arduini A, Farhi A, Gould J, Kafel J, Patel A, Peller A, Reshef H, Safur M, Toscano F, Tedore T, Akerman M, Brumberger E, Clark S, Friedlander R, Jegarl A, Lane J, Lyden JP, Mehta N, Murrell MT, Painter N, Ricci W, Sbrollini K, Sharma R, Steel PAD, Steinkamp M, Weinberg R, Wellman DS, Nader A, Fitzgerald P, Ritz M, Bryson G, Craig A, Farhat C, Gammon B, Gofton W, Harris N, Lalonde K, Liew A, Meulenkamp B, Sonnenburg K, Wai E, Wilkin G, Troxell K, Alderfer ME, Brannen J, Cupitt C, Gerhart S, McLin R, Sheidy J, Yurick K, Chen F, Dragert K, Kiss G, Malveaux H, McCloskey D, Mellender S, Mungekar SS, Noveck H, Sagebien C, Biby L, McKelvy G, Richards A, Abola R, Ayala B, Halper D, Mavarez A, Rizwan S, Choi S, Awad I, Flynn B, Henry P, Jenkinson R, Kaustov L, Lappin E, McHardy P, Singh A, Donnelly J, Gonzalez M, Haydel C, Livelsberger J, Pazionis T, Slattery B, Vazquez-Trejo M, Baratta J, Cirullo M, Deiling B, Deschamps L, Glick M, Katz D, Krieg J, Lessin J, Mojica J, Torjman M, Jin R, Salpeter MJ, Powell M, Simmons J, Lawson P, Kukreja P, Graves S, Sturdivant A, Bryant A, Crump SJ, Verrier M, Green J, Menon M, Applegate R, Arias A, Pineiro N, Uppington J, Wolinsky P, Gunnett A, Hagen J, Harris S, Hollen K, Holloway B, Horodyski MB, Pogue T, Ramani R, Smith C, Woods A, Warrick M, Flynn K, Mongan P, Ranganath Y, Fernholz S, Ingersoll-Weng E, Marian A, Seering M, Sibenaller Z, Stout L, Wagner A, Walter A, Wong C, Orwig D, Goud M, Helker C, Mezenghie L, Montgomery B, Preston P, Schwartz JS, Weber R, Fleisher LA, Mehta S, Stephens-Shields AJ, Dinh C, Chelly JE, Goel S, Goncz W, Kawabe T, Khetarpal S, Monroe A, Shick V, Breidenstein M, Dominick T, Friend A, Mathews D, Lennertz R, Sanders R, Akere H, Balweg T, Bo A, Doro C, Goodspeed D, Lang G, Parker M, Rettammel A, Roth M, White M, Whiting P, Allen BFS, Baker T, Craven D, McEvoy M, Turnbo T, Kates S, Morgan M, Willoughby T, Weigel W, Auyong D, Fox E, Welsh T, Cusson B, Dobson S, Edwards C, Harris L, Henshaw D, Johnson K, McKinney G, Miller S, Reynolds J, Segal BS, Turner J, VanEenenaam D, Weller R, Lei J, Treggiari M, Akhtar S, Blessing M, Johnson C, Kampp M, Kunze K, O'Connor M, Looke T, Tadros R, Vlassakov K, Cardenas L, Bolkus K, Mitrev L, Kwofie MK, Dabiri J, Lobel G, Poler M, Giska M, Sanders D, Schwartz G, Giuca M, Tedore T, Nader A, Bryson G, Troxell K, Kiss G, Choi S, Powell M, Applegate R, Warrick M, Ranganath Y, Chelly JE, Lennertz R, Sanders R, Allen BFS, Kates S, Weigel W, Li J, Wijeysundera DN, Kheterpal S, Moore RH, Smith AK, Tosi LL, Looke T, Mehta S, Fleisher L, Hruslinski J, Ramsey L, Langlois C, Mezenghie L, Montgomery B, Oduwole S, Rose T. Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial. Ann Intern Med 2022; 175:952-960. [PMID: 35696684 DOI: 10.7326/m22-0320] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING 46 U.S. and Canadian hospitals. PARTICIPANTS Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION Spinal or general anesthesia. MEASUREMENTS Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION Missing outcome data and multiple outcomes assessed. CONCLUSION Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (R.F., S.S.E.)
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (R.F., S.S.E.)
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland (F.S.)
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland (J.M.)
| | - Nabil Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (E.S.S.)
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada (D. Dillane)
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.R.M.)
| | - Diane Menio
- Center for Advocacy for the Rights and Interests of the Elderly, Philadelphia, Pennsylvania (D.M.)
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Manal Hassan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Trevor Stone
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (T.S.)
| | - Steven Papp
- Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada (S.P.)
| | - Derek Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (D. Donegan)
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York (M.M.)
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina (J.D.J.)
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (C.L.)
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts (B.S.)
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York (S. Azim)
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia (R.H.)
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada (K.C.)
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut (R.S.)
| | - Barry Perlman
- Oregon Health and Science University, Portland, Oregon (B.P.)
| | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida (J.S.)
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania (E.H.)
| | - Mark A Hoeft
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, Vermont (M.A.H.)
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - Lakisha J Gaskins
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Annamarie D Horan
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.D.H.)
| | - Trina Brown
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - James Dattilo
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.L.C.)
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Schenning KJ, Yanez D, Higgins J, Tekkali P, Quinn JF, Treggiari M. P4-553: PREOPERATIVE ASSESSMENT OF COGNITIVE FUNCTION IN OLDER SURGICAL PATIENTS: CORRELATION OF MINI-COG WITH NEUROPSYCHOLOGICAL TESTS. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.08.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - David Yanez
- Oregon Health & Science University; Portland OR USA
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Fink RJ, Young A, Yanez ND, Hom M, Mai J, Treggiari M, Merkel M. Cohort Study of Albumin versus Lactated Ringer's for Postoperative Cardiac Surgery Fluid Resuscitation in the Intensive Care Unit. Pharmacotherapy 2018; 38:1241-1249. [DOI: 10.1002/phar.2195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Ryan J. Fink
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | | | - N. David Yanez
- OHSU/PSU School of Public Health Oregon Health & Science University Portland Oregon
| | - Marissa Hom
- Pharmaceutical Services University of California, San Francisco Medical Center San Francisco California
| | - Jennifer Mai
- Department of Pharmacy Services Oregon Health & Science University Portland Oregon
| | - Miriam Treggiari
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | - Matthias Merkel
- Anesthesiology & Perioperative Medicine Knight Cardiovascular Institute Oregon Health & Science University Portland Oregon
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Gipson G, Tran K, Hoang C, Treggiari M. Comparison of enteral ethanol and benzodiazepines for alcohol withdrawal in neurocritical care patients. J Clin Neurosci 2016; 31:88-91. [PMID: 27262870 DOI: 10.1016/j.jocn.2016.02.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/14/2016] [Indexed: 10/21/2022]
Abstract
We designed a study to evaluate the use of benzodiazepines and ethanol in patients being assessed for alcohol withdrawal and compare outcomes between the two agents. This is a retrospective chart review of patients admitted to neurocritical care or neurosurgical services who were at risk for ethanol withdrawal between June 2011 and September 2015. Patients were divided into two groups based on the first medication administered for alcohol withdrawal management, either benzodiazepine (n=50) or enteral ethanol (n=50). The primary endpoint was the maximum change in Clinical Institute Withdrawal Assessment of Alcohol scale (CIWA) score within the first 24hours. Secondary endpoints included maximum and minimum CIWA score in 5days, length of stay, and change in Glasgow Coma Scale. Study groups differed by mortality risk, level of coma at admission, and other clinical characteristics, with the ethanol group appearing less severely ill. There was no significant difference between the two groups in the maximum change in CIWA score at 24hours (-0.97, 95%CI: -3.21 to 1.27, p=0.39). Hospital and intensive care unit length of stay was 6.5 days and 1 day shorter for the ethanol group (p=0.03 and p=0.02, respectively). In summary, enteral ethanol was preferentially used in patients who are more likely to be capable of tolerating oral intake. We found that the change from baseline in CIWA score or other physiologic variables was not substantially different between the two agents. The overall utility of benzodiazepines and enteral ethanol remains unclear for this population and further study is needed to determine superiority.
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Affiliation(s)
- Gregory Gipson
- Department of Pharmacy, UW Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA.
| | - Kim Tran
- Department of Pharmacy, UW Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Cuong Hoang
- Department of Pharmacy, UW Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Miriam Treggiari
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR 97239, USA
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Diringer MN, Bleck TP, Claude Hemphill J, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MDI, Wolf S, Zipfel G. Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15:211-40. [DOI: 10.1007/s12028-011-9605-9] [Citation(s) in RCA: 754] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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12
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Galton C, Deem S, Yanez ND, Souter M, Chesnut R, Dagal A, Treggiari M. Open-Label Randomized Trial of the Safety and Efficacy of a Single Dose Conivaptan to Raise Serum Sodium in Patients with Traumatic Brain Injury. Neurocrit Care 2011; 14:354-60. [DOI: 10.1007/s12028-011-9525-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Treggiari M, Retsch-Bogart G, Mayer-Hamblett N, Khan U, Kronmal R, Ramsey B, Accurso F. Comparative efficacy and safety of four randomized regimens to treat early Pseudomonas aeruginosa infection in children with cystic fibrosis. J Cyst Fibros 2010. [DOI: 10.1016/s1569-1993(10)60210-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rozet I, Vavilala MS, Lindley AM, Visco E, Treggiari M, Lam AM. Cerebral Autoregulation and CO2 Reactivity in Anterior and Posterior Cerebral Circulation During Sevoflurane Anesthesia. Anesth Analg 2006; 102:560-4. [PMID: 16428561 DOI: 10.1213/01.ane.0000184817.10595.62] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [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: 11/05/2022]
Abstract
The purpose of the study was to compare cerebral autoregulation (CA) and CO2 reactivity (CO2R) between the anterior and posterior circulation under sevoflurane anesthesia. We studied 9 adult ASA physical status I patients (22-47 yr) scheduled for elective orthopedic surgery. Blood flow velocity in the middle cerebral artery (Vmca) and in the basilar artery (Vba) were measured using transcranial Doppler ultrasonography. For CA testing, arterial blood pressure was increased using phenylephrine infusion. CA was quantified with the autoregulatory index (ARI). CO2R was investigated at PaCO2 of 30 +/- 2.8 mm Hg, 39.4 +/- 2.6 mm Hg, and 48.7 +/- 2.8 mm Hg. Linear regression analysis was used for CO2R. We found ARI was preserved in both arteries: ARImca (middle cerebral artery) = 0.72 +/- 0.2; ARIba (basilar artery) = 0.66 +/- 0.2; P = 0.5. With regard to CO2R, Vmca increased with slope of 1.7 cm/s/mm Hg PaCO2, Vba increased with slope of 1.5 cm/s/mm Hg PaCO2; P = 0.83. Absolute Vmca was higher compared with Vba; P < 0.05. We conclude that in healthy individuals under 0.5 MAC of sevoflurane and small-dose remifentanil: 1) mean flow velocities of BA are less than those of MCA; 2) autoregulation and CO2R are preserved in the basilar artery and are similar to those of MCA.
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Affiliation(s)
- Irene Rozet
- Department of Anesthesiology, University of Washington, Seattle, Washington, USA.
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Abstract
OBJECTIVE In spontaneously breathing patients, indexes predicting hemodynamic response to volume expansion are very much needed. The present review discusses the clinical utility and accuracy of indexes tested as bedside indicators of preload reserve and fluid responsiveness in hypotensive, spontaneously breathing patients. DATA SOURCE We conducted a literature search of the MEDLINE database and the trial register of the Cochrane Group. STUDY SELECTION Identification of reports investigating, prospectively, indexes of fluid responsiveness in spontaneously breathing critically ill patients. All the studies defined the response to fluid therapy after measuring cardiac output and stroke volume using the thermodilution technique. We did not score the methodological quality of the included studies before the data analysis. DATA EXTRACTION A total of eight prospective clinical studies in critically ill patients were included. Only one publication evaluated cardiac output changes induced by fluid replacement in a selected population of spontaneously breathing critically ill patients. DATA SYNTHESIS Based on this review, we can only conclude that static indexes are valuable tools to confirm that the fluid volume infused reaches the cardiac chambers, and therefore these indexes inform about changes in cardiac preload. However, respiratory variation in right atrial pressure, which represents a dynamic measurement, seems to identify hypotension related to a decrease in preload and to distinguish between responders and nonresponders to a fluid challenge. CONCLUSIONS Further studies should address the question of the role of static indexes in predicting cardiac output improvement following fluid infusion in spontaneously breathing patients.
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Merlani PG, Pasquina P, Granier JM, Treggiari M, Rutschmann O, Ricou B. Factors associated with failure of noninvasive positive pressure ventilation in the emergency department. Acad Emerg Med 2005; 12:1206-15. [PMID: 16293895 DOI: 10.1197/j.aem.2005.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [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: 11/10/2022]
Abstract
OBJECTIVES To determine the factors associated with failure of noninvasive positive pressure ventilation (NPPV) in patients presenting with acute respiratory failure to the emergency department (ED). METHODS The authors retrospectively analyzed patients admitted to the ED for acute respiratory failure (defined as a PaCO2 level >45 mm Hg, and pH < or = 7.35 or a PaO2/FiO2 ratio < 250 mm Hg) and who were treated with NPPV. NPPV was delivered routinely according to an institutional protocol. Failure of NPPV was defined as the requirement of endotracheal intubation at any time. RESULTS A total of 104 patients were included. NPPV failed in 31% (32/104), and the mortality was significantly higher in this group (12/32 [44%]) compared with patients who were not intubated (2/72 [3%]) (p < 0.0001). Factors associated with failure of NPPV were Glasgow Coma Scale score < 13 at ED admission (odds ratio [OR], 3.67; 95% confidence interval [CI] = 1.33 to 10.07), pH < or = 7.35 (OR, 3.23; 95% CI = 1.25 to 8.31), and respiratory rate (RR) > or =20 min(-1) (OR, 3.86; 95% CI = 1.33 to 11.17) after one hour of NPPV. The negative predictive value for NPPV failure was 86% (95% CI = 70% to 95%) for RR > or =20 min(-1). In the multivariate analysis, pH < or = 7.35 and RR > or =20 min(-1) after one hour of NPPV were independently associated with NPPV failure (adjusted ORs, 3.51; 95% CI = 1.29 to 9.62 and 3.55; 95% CI = 1.13 to 11.20, respectively). CONCLUSIONS Patients with pH < or = 7.35 and an RR > or =20 min(-1) after one hour of NPPV had an increased risk of subsequent endotracheal intubation.
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Affiliation(s)
- Paolo G Merlani
- Division of Surgical Intensive Care, Department of Anesthesiology, Pharmacology, and Surgical Intensive Care, University of Geneva Hospital, Geneva, Switzerland.
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Treggiari M, Benevento A, Caronno R, Dionigi R. [The evaluation of the efficacy of drapes and gowns of nonwoven fabric versus drapes and gowns of cotton in reducing the incidence of postoperative wound infections]. MINERVA CHIR 1992; 47:49-54. [PMID: 1553053] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The importance of the preparation of an operative field which will guarantee satisfactory conditions of asepsis during the entire operation is an indispensible premise for controlling the development of postoperative wound infections. This paper compared the efficacy of disposable clothes and gowns in TNT FABRIC 450* in relation to cotton gowns in reducing the incidence of postoperative wound infections. Cotton items were used for 25 subjects out of a group of 50 operated patients and nonwoven fabric (TNT FABRIC 450*) items were used for the other 25. Thorough bacteriological tests were performed in each patient before, during and after the operation. On the basis of the duration of the operation, it was observed that TNF FABRIC 450* was as efficacious as cotton in controlling postoperative infections in those operations with a short or medium duration; it offered greater protection in lengthy operations, with a higher risk of endogenous and exogenous contamination. It was also observed that disposable items were indispensable in patients treated with radioactive materials and offered greater safety in seropositive patients.
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Affiliation(s)
- M Treggiari
- Dipartimento di Chirurgia, Università degli Studi di Pavia, Sede di Varese
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