Anaesthesia and intensive care
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Anaesth Intensive Care · Mar 2014
ReviewCopper removal strategies for Wilson's disease crisis in the ICU.
Wilson's disease is a rare, inherited, autosomal recessive disorder of copper metabolism which leads to an accumulation of copper in body tissues. If a patient develops a Wilson's crisis, mortality can approach 100%. The treatment of such patients is mostly organ support but a possible treatment goal is to try to rapidly remove copper from their system. ⋯ We found 11 case reports where therapeutic plasma exchange was used and six case reports where various forms of albumin dialysis were used as techniques for rapidly reducing serum copper levels. To date, the case reports are encouraging that therapeutic plasma exchange and albumin dialysis can either delay or prevent the need for liver transplantation in patients with fulminant hepatic failure due to Wilson's disease. However, these case reports are mainly in the paediatric or young adult population, thus further studies in adults are warranted.
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Anaesth Intensive Care · Mar 2014
Randomized Controlled TrialEffects of different general anaesthetic techniques on immune responses in patients undergoing surgery for tongue cancer.
The aim of this study was to investigate the effects of different general anaesthesia techniques on immune responses in patients undergoing surgery for tongue cancer. Sixty American Society of Anesthesiologists physical status 1 or 2 patients undergoing elective reconstructive surgery for tongue cancer were randomised to three groups. Group 1 received propofol induction and maintenance (TIVA), group 2 received propofol induction and sevoflurane maintenance (MIXED) and group 3 received sevoflurane induction and maintenance (SEVO). ⋯ The percentages of CD3(+) cells, CD3(+)CD4(+) cells and natural killer cells, and the CD4(+)/CD8(+) ratios were significantly lower in the MIXED groups and SEVO groups but not the TIVA group at T6 as compared with T0 (P <0.05). There were minor but statistically significant differences in the percentages of CD3(+) cells, CD3(+)CD4(+) cells and natural killer cells, and the CD4(+)/CD8(+) ratios between the SEVO group and the TIVA group at T2approxT6 (P <0.05). These findings suggest that propofol has slightly less effect on cellular immune responses than sevoflurane.
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Anaesth Intensive Care · Mar 2014
Intravenous infusion of sterile water for the treatment of hypernatraemia.
Little research has been carried out into the infusion of intravenous sterile water for the treatment of hypernatraemia, and it remains a contentious issue. We conducted a review of the literature and extract results following an extensive search of Medline 1946, Embase 1974, ProQuest, evidence-based practice resources, national and international guideline sites and the publications of various professional bodies. The review is presented on the infusion of sterile water (hypotonic fluid) to lower serum sodium level in those circumstances when enteral supplementation of water is not possible, such as in postoperative patients or when other isotonic fluids (such as 5% dextrose in water infusion) are less than ideal-for example, hyperglycaemic patients on an insulin infusion. Absence of guidelines has limited the use of sterile water, even as an off-label drug when it can be administered relatively safely via a central line.
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Anaesth Intensive Care · Mar 2014
Estimation of glomerular filtration rate to adjust vancomycin dosage in critically ill patients: superiority of the Chronic Kidney Disease Epidemiology Collaboration equation?
The purpose of this study was to determine the best estimate of glomerular filtration rate (GFR) to adjust vancomycin (VAN) dosage in critically ill patients. Seventy-eight adult intensive care unit patients received a 15 mg/kg loading dose of VAN plus a 30 mg/kg/day continuous infusion. Steady-state concentration was measured 48 hours later and the dose was adjusted to obtain a target concentration ranging from 20 to 25 mg/l. ⋯ For VAN dose adjustments in intensive care unit patients, Cockcroft formula and Modification of Diet in Renal Disease should be used with caution. In clinical practice, the physician does not have at their disposal the patient's measured CLCR when prescribing. The CKD-EPI appears to be the best predictor of clearances of vancomycin for calculation of a therapeutic VAN regimen.
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Anaesth Intensive Care · Mar 2014
Glycaemic control and long-term outcomes following transition from modified intensive insulin therapy to conventional glycaemic control.
This retrospective observational cohort study compared glycaemic control and long-term outcomes following transition from a modified intensive insulin therapy (mIIT) regimen to conventional glycaemic control (CGC) in adult patients admitted to a tertiary adult general intensive care unit, during two 24-month periods, before and after the publication of the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial. The before NICE-SUGAR cohort received mIIT (target glycaemic ranges 4.4 to 7.0 mmol/l), while the after NICE-SUGAR cohort received CGC (target glycaemic range 7.1 to 9.0 mmol/l). A total of 5202 patients were included in the study. ⋯ Changes in recommended glycaemic control were translated into practice, with increased glycaemic indices and decreased rates of severe and moderate hypoglycaemia after the introduction of CGC. The associated decrease in 90-day mortality suggests mIIT was not superior to CGC, despite a lower hypoglycaemia rate than in previous IIT trials. Our findings support the continued use of CGC.