Anaesthesia and intensive care
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Anaesth Intensive Care · Sep 2013
Type 2 diabetes mellitus, independent of insulin use, is associated with an increased risk of cardiac complications after vascular surgery.
Previous reports on the prognostic value of diabetes mellitus for cardiac complications after vascular surgery show divergent results, especially in regards to the role of type 2 diabetes as a cardiac risk factor, which remains unclear. The aim of this study was to assess the impact of type 2 diabetes on 30-day cardiac complications after vascular surgery. Patients undergoing elective vascular surgery between 2002 and 2011 were included in this retrospective cohort study. ⋯ In multivariate analysis, type 2 diabetes was associated with a significantly increased risk of 30-day cardiac complications (odds ratio 1.80; 95% confidence interval 1.25 to 2.60). Results were similar for type 2 diabetes patients managed with (odds ratio 1.84; 95% confidence interval 1.01 to 3.37) and without (odds ratio 1.79; 95% confidence interval 1.19 to 2.70) insulin. Type 2 diabetes is an independent risk factor for cardiac complications after vascular surgery and should be treated as such in preoperative cardiac risk stratification.
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Anaesth Intensive Care · Sep 2013
Diagnostic potential of open lung biopsy in mechanically ventilated patients with diffuse pulmonary infiltrates of unclear aetiology.
Acute respiratory failure with bilateral pulmonary infiltrates is a clinical problem with a wide differential diagnosis. We evaluated whether open lung biopsy offered a diagnosis and therapeutic guidance in cases of unclear diagnosis after non-invasive tests. For this purpose, we reviewed 60 cases of open lung biopsy performed between 2002 and 2009 in patients with acute respiratory failure and bilateral infiltrates at the intensive care unit of Ghent University Hospital. ⋯ Open lung biopsy contributed to patient management in 53 cases (88%) as it led to the initiation, modification or discontinuation of therapeutic drugs in 36, and contributed to the decision to continue or withdraw ventilator support in 17. Complications of open lung biopsy were noted in 14 patients (23%). We conclude that open lung biopsy was a useful diagnostic intervention in of a selected group of patients with acute respiratory failure and bilateral infiltrates of unclear clinical diagnosis, as it offered a specific diagnosis in 65%.
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Cricothyroidotomy is infrequently performed in the intensive care unit but may be a lifesaving procedure. The aim of this study was to determine the number of attempts required by trainees to gain adequate skills for a successful cricothyroidotomy (defined as lung inflation <60 seconds). The effect of training on time to completion of cricothyroidotomy was also studied. ⋯ Age, years of postgraduate practice and level of seniority appeared to be associated with earlier success. Consecutive attempts on a manikin led to an improvement in the time to completion of cricothyroidotomy and rate of a successful outcome (<60 seconds). We recommend that clinicians undergo at least five training attempts on a manikin to gain proficiency in cricothyroidotomy.
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Anaesth Intensive Care · Sep 2013
Home blood pressure monitoring in an anaesthetic pre-admission clinic.
We suspected that many high blood pressure measurements taken in our anaesthetic pre-assessment clinic and immediately prior to induction of anaesthesia were unusually elevated due to a 'white coat' effect. These high blood pressure measurements were causing late cancellations of surgery, even though white coat measurements may not be representative of the patient's usual blood pressure or of their risk of end-organ damage due to hypertension. In this audit, patients with high blood pressure in our pre-admission clinic were provided with training and a home blood pressure monitor to use prior to surgery. ⋯ A total of 33% of general practice clinic measurements were also ≥ 20 mmHg higher than average home measurements. White coat hypertension was common in our audit population. Relying on average home blood pressure measurements rather than 'one off' in-hospital measurements may have helped to prevent the postponement or cancellation of surgery for 13 patients who had recorded blood pressure ≥ 180/110 mmHg in our pre-admission clinic.
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Anaesth Intensive Care · Sep 2013
Phenytoin loading doses in adult critical care patients: does current practice achieve adequate drug levels?
Phenytoin is regularly employed in the critically ill for prophylaxis against or treatment of seizure disorders. No prior studies have examined current dosing practices in an Australasian intensive care unit (ICU) setting. The aims of this study were to: a) describe the adequacy of contemporary dosing in respect to free and total serum phenytoin concentrations; b) identify factors associated with therapeutic drug concentrations; and c) examine the accuracy of predictive equations that estimate free concentrations in this setting. ⋯ Twenty-six patients (49%) had suboptimal trough free concentrations, although this subgroup was significantly heavier and therefore received a lower per kilogram dose (12.8 [3.1] vs 16.3 [3.4] mg/kg, P=0.001). In multivariate analysis, larger weight adjusted doses (P=0.018), higher albumin concentration (P=0.034) and receiving phenytoin for an indication other than seizure (P=0.035), were associated with a greater likelihood of adequate concentrations. In conclusion, phenytoin dosing remains complex in critically ill patients, although lower per kilogram loading doses are strongly associated with free concentrations below the desired target.