Anaesthesia and intensive care
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Anaesth Intensive Care · Nov 2018
Observational StudyPeripheral tissue oxygenation and the number of organs transplanted per donor.
Current donor management practices target macrohaemodynamic parameters, but it is unclear if this leads to improvements in microvascular perfusion and tissue oxygenation; the latter may have more impact on organ status. In a recent preclinical study we determined that brain death impaired tissue perfusion and oxygen utilisation in swine while pharmacologic correction of these deficits improved organ function and reduced markers of tissue injury. As a first step in translating the preclinical findings, we conducted a prospective observational study to determine if there was an association between peripheral tissue oxygenation (measured by near-infrared spectroscopy) in deceased by neurological criteria human donors and the number of organs transplanted. ⋯ A 5% rise in tissue oxygenation was associated with an increase of 0.47 organs transplanted (95% confidence intervals 0.16 to 0.78) after adjusting for age (P=0.004). No such correlations were observed for the macrohaemodynamic or macro-oxygenation parameters (including arterial blood oxygenation). The results of this clinical trial are consistent with our preclinical work and support the postulate that targeting the microvasculature to improve tissue perfusion and tissue oxygen delivery in human donors has the potential to increase the quantity of organs suitable for transplant.
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Anaesth Intensive Care · Nov 2018
Multicenter Study Observational StudyVitamin D status and supplementation in adult patients receiving extracorporeal membrane oxygenation.
The prevalence of vitamin D deficiency in critical illness is known to be high and associated with adverse clinical outcomes. Patients receiving extracorporeal membrane oxygenation (ECMO) may be at increased risk of vitamin D deficiency due to high severity of acute illness. Challenges with drug dosing in ECMO patients are recognised due to increased volume of distribution and drug absorption to circuit components. ⋯ Of the 12 ECMO patients who received cholecalciferol, six patients (50%) achieved correction of deficiency compared to 36/38 (95%) non-ECMO patients (P=0.001). The prevalence of vitamin D deficiency is higher in ECMO patients compared to other critically ill adults. Correction of deficiency with single dose cholecalciferol is not reliable; higher or repeated doses should be considered to correct deficiency.
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Anaesth Intensive Care · Nov 2018
The effect of preload on electromyographic train-of-four ratio at the first dorsal interosseous muscle during spontaneous recovery from neuromuscular blockade.
Accurate and reliable quantitative neuromuscular function monitoring is desirable for the optimal management of neuromuscular blockade, selection of the most appropriate reversal agent and dosage, and assessing the completeness of reversal to exclude residual neuromuscular blockade. Applying preload to the thumb may affect the precision of electromyography. This study compared the precision and agreement of electromyography with and without preload during recovery from non-depolarising neuromuscular blockade. ⋯ Train-of-four ratios with preload demonstrated a bias of +0.038 (95% CI 0.037 to 0.042) compared to electromyography without, with 95% limits of agreement of 0.035-0.111. Preload significantly improved the precision of electromyographic train-of-four ratios, with 95% of consecutive measurements differing by less than 3%. Furthermore, electromyography with preload demonstrated a positive bias of 0.04 compared with electromyography alone, the clinical significance of which requires further research.
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Anaesth Intensive Care · Nov 2018
An audit of the diagnostic accuracy of rotational thromboelastometry for the identification of hypofibrinogenaemia and thrombocytopenia during cardiopulmonary bypass.
We audited the diagnostic accuracy of ROTEM® (TEM Innovations, GmbH, Munich, Germany) measurements of hypofibrinogenaemia (fibrinogen <1.5 g/l) and thrombocytopenia (platelet count <100 x 109/l) in 200 adult non-transplant patients during cardiopulmonary bypass (CPB). Blood samples were obtained for FIBTEM (assay for the fibrin part of the clot), PLTEM (calculated platelet-specific component), and laboratory measurements simultaneously. Our thresholds for FIBTEM and PLTEM were A10 (clot firmness 10 minutes after clotting time) ≤8 mm, and <35 mm respectively. ⋯ These findings indicate that during CPB FIBTEM A10 ≤8 mm and PLTEM A10 <35 mm have greater accuracy in identifying the absence of hypofibrinogenaemia and thrombocytopenia respectively than their presence. On the basis of these results we would be reassured by FIBTEM A10 values >8 mm and PLTEM A10 values ≥35 mm, but would continue to use laboratory measurements for confirmation. We would not use FIBTEM A10 ≤8 mm or PLTEM A10 <35 mm values alone to guide replacement therapy unless clinical conditions warranted an immediate decision before laboratory measurements were available.