Anaesthesia and intensive care
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Anaesth Intensive Care · Mar 2012
The influence of unrestricted use of sugammadex on clinical anaesthetic practice in a tertiary teaching hospital.
This retrospective audit identified an association between the introduction of unrestricted access to sugammadex and a fall in 'anaesthetic theatre time'. Mean hospital stay was also observed to be 0.8 days shorter after introduction of sugammadex, but was not statistically significant after adjusting for confounders.
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Anaesth Intensive Care · Mar 2012
EditorialSugammadex: restricted vs unrestricted or selective vs non-selective?
Neville Gibbs and Peter Kam outline three evidence-based indications for use of sugammadex in 2012, even with its high cost:
Early reversal of rocuronium when suxamethonium is contraindicated. For example in ECT for patients with a pseudocholinesterase deficiency or neuromuscular denervation conditions.
Reversal of rocuronium when even very mild residual neuromuscular block carries significant patient risk. For example, patients with neuromuscular disorders such as myotonic dystrophy or myasthenia gravis; and patients with severe pulmonary disease with limited reserve.
Unplanned early reversal of rocuronium during a failed intubation where rapid reversal may allow awakening of the patient.
Rescue from residual paralysis despite having given neostigmine.
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Anaesth Intensive Care · Mar 2012
Review Meta AnalysisPrevention of gastrointestinal bleeding due to stress ulceration: a review of current literature.
Our objective was to audit our current stress ulcer prophylaxis protocol (routine prescription of ranitidine and early enteral feeding) by identifying whether routine prescription of histamine-2 receptor antagonists or proton pump inhibitors as prophylaxis against stress-related mucosal disease and subsequent upper gastrointestinal bleeding is supported in the literature. We also aimed to ascertain what literature evidence supports the role of early enteral feeding as an adjunctive prophylactic therapy, as well as to search for burn-patient specific evidence, since burn patients are at high risk for developing this condition, with the aim of changing our practice. PubMed and Cochrane databases were searched for relevant articles, yielding seven randomised controlled trials comparing histamine-2 receptor antagonists and proton pump inhibitors in the prevention of upper gastrointestinal bleeding associated with stress-related mucosal disease and three separate meta-analyses. ⋯ However, enteral feeding was found to be safe and effective in preventing clinically significant upper gastrointestinal bleeding. Patients able to tolerate feeds demonstrated no additional benefit with concomitant pharmacological prophylactic therapy. Since all burn patients at the Royal Adelaide Hospital are fed from very early in their admission, the literature suggests that we, like our intensive care unit colleagues, should abolish our reliance on pharmacological prophylaxis, the routine prescription of which is not supported by the evidence.
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Anaesth Intensive Care · Mar 2012
Randomized Controlled TrialBeta-blocker management in high-risk patients presenting for non-cardiac surgery: before and after the POISE Trial.
The POISE Trial was a randomised, placebo-controlled, double-blind study of the effectiveness of perioperative beta-blockade in preventing cardiac events including death in 8351 patients. Our hypothesis was that knowledge of the results of the POISE Trial would either increase or decrease the use of effective perioperative beta-blockade, depending on the result. Patients presenting for non-cardiac surgery and at risk of perioperative cardiac events were recruited in two cohorts before and after the release of the POISE Trial results. ⋯ Effective heart rate control was achieved in 29 (9%) patients prescribed perioperative beta-blockers compared with 10 (3%) patients not prescribed perioperative beta-blockers (P=0.001). The rate of implementation of effective beta-blockade was low before POISE and this did not change significantly after publication. Our finding does not provide reliable evidence of a change in practice as a result of the POISE Trial.
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Anaesth Intensive Care · Mar 2012
Comparative StudyComparison of outcomes by modality for critically ill patients requiring renal replacement therapy: a single-centre cohort study adjusting for time-varying illness severity and modality exposure.
Prolonged intermittent renal replacement therapy (PIRRT) is a recently defined acute modality for critically ill patients, and in theory combines the superior detoxification and haemodynamic stability of continuous renal replacement therapy (CRRT) with the operational convenience and low cost of intermittent haemodialysis (iHD). We performed a retrospective cohort study for all critically ill adults treated with renal replacement therapy at our centre in Auckland, New Zealand from 1 January 2002 to 31 December 2008. The exposure of interest was modality (PIRRT, CRRT, iHD). ⋯ With PIRRT as the reference, the adjusted hazard ratios for patient hospital mortality were 1.31 (0.60 to 2.90) for CRRT and 1.22 (0.21 to 2.29) for iHD. Corresponding estimates for mortality at 90 days were 0.96 (0.39 to 2.36) and 2.22 (0.49 to 10.11), respectively, reflecting the poorer longer-term prognosis of patients still on iHD at hospital discharge with delayed or non-recovery of acute kidney injury. Our study supports the recent increased use of PIRRT, which within limits can be regarded as safe and effective.