Three interesting articles that appeared in the past few months, all following a common theme of ‘protection with small changes’. Although only one is itself practice changing, together they challenge us to continue to look to how small practice changes may have significant protective and preventative effects in the lives of our patients.
Antihypertensives evening dosing
Hermida et al. (2019) published impressive results from the massive, 10-year Hygia Project, which randomised almost 20,000 patients to take anti-hypertensive medications at bedtime or awakening.
Not only did patients who took antihypertensives (of any class) in the evenings have better blood pressure control, they also received a 45% reduction in major cardiovascular outcomes, including CVD death, infarct, coronary revascularisation, heart failure and stroke!
Given that many critical care doctors briefly touch on the medications their patients are taking, a simple “you should ask your primary physician about when its best to take your blood pressure tablets” could have a disproportionately large impact on patient health.
Intravenous lidocaine and cognitive protection
Klinger et al. (2019) reported on their well-sized Duke University RCT looking for neuroprotection from intravenous lignocaine/lidocaine in cardiac surgery patients. Unfortunately no reduction in cognitive deficit was seen at either 6 weeks or 1 year, but it nonetheless hints at the potential for reducing long-term cognitive harm in high risk groups.
As noted in my summary we already know that maternal magnesium infusions are neuroprotective for premature infants, so it is not unreasonable that there may be similarly-simple neuroprotective interventions in other groups.
RIPC and renal protection
Finally, Zhou et al. (2019) revisited the at-first-glance bizarro world of remote ischaemic preconditioning (RIPC). Although only a small, single-center study, this very neat little RCT out of Shanghai showed a dramatic reduction in renal injury among open aortic-arch replacement patients receiving a standardised upper-arm 5+5-min x4 RIPC protocol.
Not practice changing due to the small size, wide confidence interval and conflicting results from earlier studies, but nonetheless an intriguing consideration.
What other small interventions might exist that have disproportionately great protective or preventative benefits for our patients?
Click through for metajournal summaries of each...
- Hermida RC, Crespo JJ, Domínguez-Sardiña M et al. Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. Eur. Heart J. 2019 Oct 22.
- Klinger RY, Cooter M, Bisanar T et al. Intravenous Lidocaine Does Not Improve Neurologic Outcomes after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology. 2019 Jun 1; 130 (6): 958-970.
- Zhou H, Yang L, Wang G et al. Remote Ischemic Preconditioning Prevents Postoperative Acute Kidney Injury After Open Total Aortic Arch Replacement: A Double-Blind, Randomized, Sham-Controlled Trial. Anesth. Analg. 2019 July 1; 129 (1): 287-293.