Minerva anestesiologica
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Minerva anestesiologica · Jan 2013
Review Meta AnalysisAn updated meta-analysis to understand the variable efficacy of drotrecogin alfa (activated) in severe sepsis and septic shock.
Significant debate continues over the efficacy of drotrecogin alpha activated (DAA) in sepsis. This updated meta-analysis provides an updated summary effect estimate and explores the reasons for outcome heterogeneity in placebo-controlled randomized clinical trials of DAA on 28-day all-cause mortality in patients with severe sepsis or septic shock. ⋯ DAA is not associated with improved survival in patients with severe sepsis or septic shock. Further studies should be done to determine whether changes in supportive therapy for sepsis explain the variable efficacy of DAA in randomized controlled clinical trials observed over time.
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Minerva anestesiologica · Jan 2013
ReviewThe best timing for defibrillation in shockable cardiac arrest.
High quality cardiopulmonary resuscitation (CPR, i.e. chest compressions and ventilations) and prompt defibrillation when appropriate (i.e. in ventricular fibrillation and pulseless ventricular tachycardia, VF/VT) are currently the best early treatment for cardiac arrest (CA). In cases of prolonged CA due to shockable rhythms, it is reasonable to presume that a period of CPR before defibrillation could partially revert the metabolic and hemodynamic deteriorations imposed to the heart by the no flow state, thus increasing the chances of successful defibrillation. Despite supporting early evidences in CA cases in which Emergency Medical System response time was longer than 5 minutes, recent studies have failed to confirm a survival benefit of routine CPR before defibrillation. ⋯ To take in account all the variables encountered when treating CA (heart condition before CA, time elapsed, metabolic and hemodynamic changes, efficacy of CPR, responsiveness to defibrillation attempt), it would be very helpful to have a real-time and non invasive tool able to predict the chances of defibrillation success. Recent evidences have suggested that ECG waveform analysis of VF, such as the derived Amplitude Spectrum Area, can fit the purpose of monitoring the CPR effectiveness and predicting the responsiveness to defibrillation. While awaiting clinical studies confirming this promising approach, CPR performed according to high quality standard and with minimal interruptions together with early defibrillation are the best immediate way to achieve resuscitation in CA due to shochable rhythms..
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Minerva anestesiologica · Jan 2013
ReviewMaternal hypotension during spinal anesthesia for caesarean delivery.
The aim of the study was to review maternal hypotension during caesarean delivery with spinal anesthesia. Obstetric complications, such as obstetric hemorrhage and problems related to concomitant maternal diseases are not considered. Reports of hypotension during spinal anesthesia for elective caesarean delivery are frequent (70-80%) when pharmacological prophylaxis is not used. ⋯ Preoperative tests and new monitoring devices are available to predict or permit early detection of hypotension, but their feasibility and reliability in routine clinical practice is not yet established. With these tools, it may become possible to tailor prophylaxis to the assessed risk of the individual. Combining a prophylactic vasopressor regimen with hydroxyethylstarch preloading, hydroxyethylstarch coloading or crystalloid coloading is the best method to decrease the incidence and severity of hypotension during spinal anesthesia for caesarean delivery.
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Minerva anestesiologica · Jan 2013
ReviewGlucose and insulin administration while maintaining normoglycemia: the GIN concept.
The benefits of tight glucose control in critically ill and surgical patients remains a subject of debate. While some studies demonstrated a survival benefit associated with intensive insulin therapy, more recent studies have failed to demonstrate this correlation. ⋯ If properly applied, this therapy potentially reduces the morbidity and mortality associated with hyperglycemia and confers the pharmacological advantages of hyperinsulinemia. Further understanding of the underlying molecular mechanisms, as well as the development of a continuous intravenous glucose monitoring device would facilitate the routine clinical use of GIN therapy.
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Minerva anestesiologica · Jan 2013
ReviewHow to assess positive end-expiratory pressure-induced alveolar recruitment?
Randomized trials fail to demonstrate a decrease in mortality when high Positive End-Expiratory Pressure (PEEP) is applied to patients with acute respiratory distress syndrome. Use of PEEP in all patients without taking into consideration specific lung morphology, potential for recruitment and risk of lung hyperinflation could be one of explanations. Assessment of alveolar recruitment in each individual patient appears to reach a good compromise between optimization of mechanical ventilation and reduction of lung injury due to systematic application of high PEEP. ⋯ Different methods are available to assess PEEP-induced alveolar recruitment. Lung ultrasound and P-V curve method can be easily used at bedside to assess lung recruitability and test optimal PEEP. Further development is required for bedside assessment combing alveolar recruitment with hyperinflation.