Management of atrial fibrillation–Part 2.

Compr Ther. 2008 Fall-Winter;34(3-4):134-42

Authors: Aronow WS

Many cardiologists prefer, especially in older patients, ventricular rate control plus warfarin rather than maintaining sinus rhythm with anti-arrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin.

PMID: 19137754 [PubMed - indexed for MEDLINE]

[Read more →]

Management of atrial fibrillation–Part 1.

Compr Ther. 2008 Fall-Winter;34(3-4):126-33

Authors: Aronow WS

Atrial fibrillation (AF) is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. Immediate cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain, hypotension, severe heart failure, or syncope. Pharmacologic treatments include beta-adrenergic blockade, calcium channel blockers, and amiodarone in selected patients.

PMID: 19137753 [PubMed - indexed for MEDLINE]

[Read more →]

Safety and Effectiveness of a Modification of Diet in Renal Disease Equation-Based Potassium Replacement Protocol(March).

Ann Pharmacother. 2009 Feb 24;

Authors: Chapman SA, Kaufenberg AJ, Anderson P, Khokhar A, Schrock CG

BACKGROUND: No data exist regarding the safety and effectiveness of a potassium replacement protocol for hospitalized patients when potassium replacement dosing regimens (KRDRs) are adjusted to Modification of Diet in Renal Disease estimation of glomerular filtration rate (MDRD GFR). OBJECTIVE: To evaluate the effectiveness and safety of a potassium replacement protocol in which KRDRs are prescribed based on MDRD GFR and serum potassium deficiency (Kdef). METHODS: Patients prescribed the potassium replacement order set were identified in a retrospective fashion. Serum potassium, prescriber-defined goal serum potassium, and MDRD GFR data were collected for patients who received protocol KRDRs. The KRDR to be administered is selected based on Kdef (goal serum potassium minus measured serum potassium) of 0.1-0.2, 0.3-0.5, or more than 0.5 mEq/L and the patients' MDRD GFR of greater than 70, 40-70, or less than 40 mL/min/1.73 m(2) (any patient undergoing dialysis is included in the <40 mL/min/1.73 m(2) group). Efficacy was evaluated by determining the change in serum potassium level (DeltaK) following potassium replacement, the number of KRDRs needed to achieve goal serum potassium, and the milliequivalents of potassium needed to achieve goal serum potassium levels. Safety was assessed by the incidence of serum potassium values greater than 5.0 mEq/L following replacement. RESULTS: One hundred forty-nine patients were evaluated. There were 184 protocol initiations and 257 KRDRs administered to achieve goal serum potassium levels. The DeltaK was 0.50 +/- 0.40 mEq/L (mean +/- SD) following KRDR. The DeltaK was similar between MDRD GFR groups. One hundred thirty six (73.9%) protocol initiations required 1 KRDR, and 168 (91.3%) protocol initiations required 1 or 2 KRDRs to achieve goal serum potassium. Patients whose MDRD GFR was 40-70 mL/min/1.73 m(2) were less likely to achieve goal serum potassium value after 1 KRDR (58.2% vs 79.6% >70 group and 84.6% <40 group). This was true regardless of the patient's goal serum potassium. One (0.54%) serum potassium greater than 5.0 mEq/L occurred following a KRDR. CONCLUSIONS: Our potassium replacement protocol based on MDRD GFR and Kdef effectively corrects hypokalemia. Fewer protocol initiations achieved goal serum potassium levels in the group with MDRD GFR 40-70 mL/min/1.73 m(2). Hyperkalemia rarely occurred following KRDR.

PMID: 19240261 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Continuous hypertonic saline therapy and the occurrence of complications in neurocritically ill patients*

Crit Care Med. 2009 Feb 24;

Authors: Froelich M, Ni Q, Wess C, Ougorets I, Härtl R

OBJECTIVE:: To evaluate potential side effects of continuous hypertonic 3% saline (CHS) as maintenance fluid in patients with brain injury. METHODS:: Retrospective chart analysis of prospectively collected data. PATIENTS:: Patients admitted to the neurosurgical intensive care unit for >4 days with traumatic brain injury, stroke, or subarachnoid hemorrhage with a Glasgow Coma Scale <9 and elevated intracranial pressure (ICP) or at risk of developing elevated ICP were included. Based on physician preference, one group was treated with 3% CHS at a rate of 1.5 mL/kg/bw as maintenance fluid. The other group received 0.9% normal saline (NS). Two percent saline was used in the CHS group to wean patients off 3% CHS or when sodium was above 155. Data on serum sodium, blood urea nitrogen, creatinine, ICP, infection rate, length of stay, rates of deep vein thrombosis, and pulmonary emboli and dural thrombosis were collected prospectively. RESULTS:: One hundred seven patients in the CHS group and 80 in the NS group met the inclusion criteria. The incidence of moderate hypernatremia (Na >155 mmol/L) and severe hypernatremia (Na >160 mmol/L) was significantly higher in the CHS therapy group than in the NS group. No significant relationship between CHS infusion and renal dysfunction was found. Moderate and severe hypernatremia was associated with a higher risk of elevated blood urea nitrogen and creatinine levels. Acute renal failure was not seen in these patients. A total of 53.3% in the CHS group and in 16.3% in the NS group (p < 0.0001) had raised ICP (>25 mm Hg), consistent with the physicians decision to use CHS in patients with elevated ICP. CONCLUSIONS:: CHS therapy was not associated with an increased rate of infection, deep vein thrombosis, or renal failure. However, there was a significant risk of developing hypernatremia. We conclude that CHS administration in patients with severe injuries is safe as long as sodium levels are carefully monitored.

PMID: 19242317 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Stressful intensive care unit medical crises: How individual responses impact on team performance*

Crit Care Med. 2009 Feb 24;

Authors: Piquette D, Reeves S, Leblanc VR

BACKGROUND:: Intensive care units (ICUs) are recognized as stressful environments. However, the conditions in which stressors may affect health professionals’ performance and well-being and the conditions that potentially lead to impaired performance and staff psychological distress are not well understood. OBJECTIVES:: The purpose of this study was to determine healthcare professionals’ perceptions regarding the factors that lead to stress responses and performance impairments during ICU medical crises. DESIGN:: A qualitative study in a university-affiliated ICU in Canada. METHODOLOGY:: We conducted 32 individual semistructured interviews of ICU nurses, staff physicians, residents, and respiratory therapists in a university-affiliated hospital. The transcripts of the audiotaped interviews were analyzed using an inductive thematic methodology. RESULTS:: Increased workload, high stakes, and heavy weight of responsibility were recognized as common stressors during ICU crises. However, a high level of individual and team resources available to face such demands was also reported. When the patient’s condition was changing or deteriorating unpredictably or when the expected resources were unavailable, crises were assessed by some team members as threatening, leading to individual distress. Once manifested, this emotional distress was strongly contagious to other team members. The ensuing collective anxiety was perceived as disruptive for teamwork and deleterious for individual and collective performance. CONCLUSIONS:: Individual distress reactions to ICU crises occurred in the presence of unexpectedly high demands unmatched by appropriate resources and were contagious among other team members. Given the high uncertainty surrounding many ICU medical crises, strategies aimed at preventing distress contagion among ICU health professionals may improve team performance and individual well-being.

PMID: 19242320 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Long-term outcome and quality-adjusted life years after severe sepsis*

Crit Care Med. 2009 Feb 24;

Authors: Karlsson S, Ruokonen E, Varpula T, Ala-Kokko TI, Pettilä V,

OBJECTIVE:: To study long-term mortality, quality of life (QOL), quality-adjusted life years (QALYs), and costs per QALY in an unselected intensive care unit (ICU) patient population with severe sepsis. DESIGN:: Prospective observational cohort study. SETTING:: Twenty-four ICUs in Finland. PATIENTS:: A total of 470 adult patients with severe sepsis who were treated in ICUs between November 1, 2004 and February 28, 2005. The QOL before critical illness was assessed in 252 patients and QOL after severe sepsis in 156 patients (58% of the patients surviving in April 30, 2006). Ninety-eight patients responded to both questionnaires. QOL was assessed by a generic EuroQol-5D (EQ-5D) measurement with summary index (EQsum) and visual analogue scale (VAS). MEASUREMENTS AND MAIN RESULTS:: The 2-year mortality after severe sepsis was 44.9% (211 of 470). The median response time for QOL assessment after severe sepsis was 17 months (interquartile range [IQR] 16-18). The median EQsum (75, IQR 56-92) and EQ VAS (66, IQR 50-80) were lower after severe sepsis than age- and sex-adjusted reference values (p < 0.001 and p < 0.001). The decrease between the mean EQsum reference value and that of severe sepsis patients was 12 (95% confidence interval [CI], 9-16). The difference between the mean EQ VAS reference values and the mean EQ VAS was 8 (95% CI, 5-11). The mean calculated QALYs after severe sepsis were 10.9 (95% CI, 9.7-12.1) and the calculated cost for one QALY was only 2139 &OV0556; for all survivors and nonsurvivors. CONCLUSIONS:: Two-year mortality after severe sepsis was high (44.9%) and the QOL was lower after severe sepsis than before critical illness as assessed by EQ-5D. However, the mean QALYs for the surviving patients were reasonable and the cost for one QALY was reasonably low, which makes intensive care in patients with severe sepsis cost effective.

PMID: 19242321 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Unfractioned heparin for treatment of sepsis: A randomized clinical trial (The HETRASE Study).

Crit Care Med. 2009 Feb 24;

Authors: Jaimes F, De La Rosa G, Morales C, Fortich F, Arango C, Aguirre D, Muñoz A

OBJECTIVE:: The primary aims of this study were to determine the effects of heparin on length of stay and change from baseline multiple organ dysfunction (MOD) score. Secondary objectives were to estimate the effects of heparin on 28-day all-cause mortality, and to determine the possible effect modification on 28-day all-cause mortality, in subgroups defined by site of infection and baseline values of Acute Physiology and Chronic Health Evaluation II score, MOD score, and d-dimer. DESIGN:: Randomized, double-masked, placebo-controlled, single-center clinical trial, testing low dose continuous infusion of unfractioned heparin (UFH) as complementary treatment for sepsis. SETTING:: Five hundred fifty bed University Hospital and referral center in Medellín, COmbia. PATIENTS:: Three hundred nineteen patients admitted at the emergency room with signs indicative of sepsis. INTERVENTIONS:: Patients were randomly assigned to receive placebo or UFH (500 units/hour for 7 days). MEASUREMENTS AND MAIN RESULTS:: The median length of stay in patients discharged alive in the placebo group was 12.5 days (interquartile range = 8-20), and 12 days (interquartile range = 8-19.5) in the heparin group (p = 0.976). The MOD score improved equally in the two treatments arms with an average decline of 0.13 and 0.11 per day for the placebo and heparin groups (p = 0.240), respectively. The overall 28-day mortality was 16% in the placebo group and 14% in the heparin group (p = 0.652). Subgroup analyses did not show any statistically significant reduction in 28-day mortality with UFH. There was only one serious adverse event on a patient who received heparin but it was fully resolved without complications. CONCLUSIONS:: Our findings suggested that UFH may be a feasible and safe intervention in sepsis. However, this study was not able to demonstrate a beneficial effect on the chosen primary outcomes or in the 28-day mortality rate.

PMID: 19242322 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures.

Crit Care Med. 2009 Feb 24;

Authors: Schweickert WD, Herlitz J, Pohlman AS, Gehlbach BK, Hall JB, Kress JP

OBJECTIVE:: Insertion of peripherally inserted central catheters (PICCs) at the bedside may result in tip malposition. This study was designed to evaluate whether the addition of ultrasound (US) inspection of the ipsilateral neck provides immediate recognition of PICCs in aberrant position facilitating catheter reposition before completion of the procedure. DESIGN:: Randomized, controlled trial. SETTING:: University-affiliated hospital. PATIENTS:: Totally, 300 patients ordered for PICC placement. INTERVENTIONS:: Patients were randomized to either postinsertion US inspection of the ipsilateral neck (intervention, n = 151) or to usual practice (control, n = 149). In the intervention group, catheters detected by US to be traveling within the ipsilateral internal jugular vein (IJ), were further adjusted before procedural completion. All procedures included US localization of the peripheral vein and postprocedural chest x-ray to assess catheter tip position. The primary end point was defined as the rate of PICC tip malposition in the ipsilateral IJ as detected by postprocedure chest x-ray. The secondary end point was procedure duration. MEASUREMENTS AND MAIN RESULTS:: In the control arm, 140 of 149 PICC placement attempts (94%) were completed, including 11 procedures with catheter tips terminating in the ipsilateral IJ (7.9%). In the intervention arm, 142 of 151 attempts (94.7%, p = 0.98) were completed; one procedure resulted in a catheter tip in the ipsilateral IJ (0.7%, p = 0.007). Eleven intervention procedures included successful PICC repositioning during the initial procedure based on US detection of malposition. The median duration of the procedure in the control group was 8 minutes (6-10.5 minutes) and increased to 9.0 minutes (7-11 minutes) in the intervention group. CONCLUSIONS:: Bedside PICC placement morbidity can be reduced via US inspection of the ipsilateral neck for PICC tip malposition in the IJ. This modality can guide catheters to be successfully repositioned during the initial procedure.

PMID: 19242336 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Epinephrine reduces cerebral perfusion during cardiopulmonary resuscitation*

Crit Care Med. 2009 Feb 24;

Authors: Ristagno G, Tang W, Huang L, Fymat A, Chang YT, Sun S, Castillo C, Weil MH

OBJECTIVE:: Epinephrine has been the primary drug for cardiopulmonary resuscitation for more than a century. The therapeutic rationale was to restore threshold levels of myocardial and cerebral blood flows by its alpha1 (alpha1) and alpha2 (alpha2)-adrenergic agonist vasopressor actions. On the basis of coincidental observations on changes in microvascular flow in the cerebral cortex, we hypothesized that epinephrine selectively decreases microvascular flow. DESIGN:: Randomized prospective animal study. SETTING:: University-affiliated research laboratory. SUBJECTS:: Domestic pigs. INTERVENTIONS:: Four groups of five male domestic pigs weighing 40 +/- 3 kg were investigated. After induction of anesthesia, endotracheal intubation was followed by mechanical ventilation. A frontoparietal bilateral craniotomy was created. Ventricular fibrillation was induced and untreated for 3 minutes before the start of precordial compression, mechanical ventilation, and attempted defibrillation. Animals were randomized to receive central venous injections during cardiopulmonary resuscitation (CPR) of 1) placebo, 2) epinephrine, 3) epinephrine in which both alpha1- and beta (beta)-adrenergic effects were blocked by previous administration of prazosin and propranolol, and 4) epinephrine in which both alpha2- and beta-adrenergic effects were blocked by previous administration of yohimbine and propranolol. MEASUREMENTS AND MAIN RESULTS:: Cerebral cortical microcirculatory blood flow (MBF) was measured with orthogonal polarization spectral imaging. Cerebral cortical carbon dioxide and oxygen tensions (Pbco2 and Pbo2) were concurrently measured using miniature tissue optical sensors. Each animal was resuscitated. No differences in the number of electrical shocks for defibrillation or in the duration of CPR preceding return of spontaneous circulation were observed. Yet when epinephrine induced increases in arterial pressure, it significantly decreased Pbo2 tension and increased Pbco2 tension. Epinephrine therefore significantly decreased MBF and increased indicators of cerebral ischemia. Reduced MBF and magnified brain tissue ischemia during and after cardiopulmonary resuscitation were traced to the alpha1-adrenergic agonist action of epinephrine. When the alpha2 effects of epinephrine were blocked, reduced MBF and tissue ischemia persisted. No differences in cardiac output, end tidal Pco2, arterial Po2 and Pco2, and brain temperature were observed before inducing cardiac arrest and following return of spontaneous circulation. CONCLUSIONS:: In this model, epinephrine through its alpha1-agonist action had adverse effects on cerebral microvascular blood flow such as to increase the severity of cerebral ischemia during CPR.

PMID: 19242339 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Review of studies of the impact on Gram-negative bacterial resistance on outcomes in the intensive care unit*

Crit Care Med. 2009 Feb 24;

Authors: Shorr AF

OBJECTIVE:: To review studies addressing mortality, length of stay (LOS), and cost of resistant Gram-negative bacterial infections in the intensive care unit (ICU). DATA SOURCES AND STUDY SELECTION:: A qualitative review of published studies identified through PubMed search was performed. Study exclusion criteria were population <40 adults or <39% of cases in the ICU. Criteria for judging study quality were prospective analysis, multicenter study, author-specified diagnostic criteria, appropriate control group defined as patients with infections caused by susceptible bacteria, adjustments for confounding factors, and use of cost. DATA EXTRACTION AND SYNTHESIS:: Twenty-one original studies and a meta-analysis, which included three of the original studies, were identified. Infections caused by mixed resistant Gram-negative bacteria, extended-spectrum beta-lactamase-producing Enterobacteriaceae, multidrug-resistant Pseudomonas aeruginosa, and Acinetobacter species were generally associated with increased mortality and LOS, especially in univariate analyses. Economic analyses performed in eight studies indicated that these resistant Gram-negative infections were also associated with increased patient charges or hospital costs. Associations sometimes disappeared in multivariate analyses after adjusting for variables significant in univariate analyses. CONCLUSION:: The collective findings of the studies in this review suggested that Gram-negative bacterial resistance increases the burden in the ICU as measured by mortality, LOS, and charges. More prospective studies are needed to explore methods for combating Gram-negative resistance, including prevention, education, and better antimicrobial therapy. For example, well-designed research is needed to determine the cost-effectiveness of appropriate empiric therapy with broad-spectrum agents active against resistant Gram-negative bacteria followed by de-escalation.

PMID: 19242341 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

The impact of adding 1 month of intensive care unit training in a categorical internal medicine residency program *

Crit Care Med. 2009 Feb 24;

Authors: Mullon JJ, Gajic O, Gali B, Ficalora RD, Kolars JC, Afessa B

OBJECTIVE:: To determine the impact of adding a month of critical care training in the postgraduate year (PGY)-2 on the critical care skills of PGY-3 residents. DESIGN:: Prospective, nonrandomized. SETTING:: The internal medicine (IM) residency program of a tertiary care medical center. STUDY SUBJECTS:: The study subjects included the 2005/2006 and 2006/2007 academic year IM residents. INTERVENTIONS:: The 2005/2006 IM residents (control group, n = 48) had 1 month of critical care training (internship year) before their 1-month PGY-3 rotations. The 2006/2007 residents (intervention group, n = 47) had an additional 1-month rotation in a multispecialty intensive care unit (ICU) during their second year. MEASUREMENTS AND MAIN RESULTS:: At the beginning of their last ICU month rotation, the intervention group's self-assessment (1-5 Likert scale) of their skills in internal jugular venous catheterization (3.4 vs. 2.4, p < 0.001) and management of severe sepsis (4.0 vs. 2.4, p < 0.001) and acute lung injury (3.3 vs. 2.6, p < 0.001) was higher than that of the control group. However, the observed success rates of endotracheal intubation (55.4% vs. 54.9%, p = 0.953) and central venous catheterization (78.1% vs. 80.8%, p = 0.488) were similar between the two groups. No difference was noted in the complication rates for endotracheal intubation or central venous catheterization between the control and intervention groups. End of ICU rotation examination results, attending evaluations, and the observed application of evidence-based practice in the management of severe sepsis were similar between the two groups. CONCLUSIONS:: Increasing IM residents' experience in the ICU resulted in modest, transient improvement of their perceived clinical skills in critical care procedures and management of severe sepsis and acute lung injury. However, no statistically significant and sustained improvement was noted in the observed cognitive or clinical skills.

PMID: 19242350 [PubMed - as supplied by publisher]

[Read more →]

Scientific evidence underlying the ACC/AHA clinical practice guidelines.

JAMA. 2009 Feb 25;301(8):831-41

Authors: Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC

CONTEXT: The joint cardiovascular practice guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA) have become important documents for guiding cardiology practice and establishing benchmarks for quality of care. OBJECTIVE: To describe the evolution of recommendations in ACC/AHA cardiovascular guidelines and the distribution of recommendations across classes of recommendations and levels of evidence. DATA SOURCES AND STUDY SELECTION: Data from all ACC/AHA practice guidelines issued from 1984 to September 2008 were abstracted by personnel in the ACC Science and Quality Division. Fifty-three guidelines on 22 topics, including a total of 7196 recommendations, were abstracted. DATA EXTRACTION: The number of recommendations and the distribution of classes of recommendation (I, II, and III) and levels of evidence (A, B, and C) were determined. The subset of guidelines that were current as of September 2008 was evaluated to describe changes in recommendations between the first and current versions as well as patterns in levels of evidence used in the current versions. RESULTS: Among guidelines with at least 1 revision or update by September 2008, the number of recommendations increased from 1330 to 1973 (+48%) from the first to the current version, with the largest increase observed in use of class II recommendations. Considering the 16 current guidelines reporting levels of evidence, only 314 recommendations of 2711 total are classified as level of evidence A (median, 11%), whereas 1246 (median, 48%) are level of evidence C. Level of evidence significantly varies across categories of guidelines (disease, intervention, or diagnostic) and across individual guidelines. Recommendations with level of evidence A are mostly concentrated in class I, but only 245 of 1305 class I recommendations have level of evidence A (median, 19%). CONCLUSIONS: Recommendations issued in current ACC/AHA clinical practice guidelines are largely developed from lower levels of evidence or expert opinion. The proportion of recommendations for which there is no conclusive evidence is also growing. These findings highlight the need to improve the process of writing guidelines and to expand the evidence base from which clinical practice guidelines are derived.

PMID: 19244190 [PubMed - in process]

[Read more →]

Related Articles

Reassessment of clinical practice guidelines: go gently into that good night.

JAMA. 2009 Feb 25;301(8):868-9

Authors: Shaneyfelt TM, Centor RM

PMID: 19244197 [PubMed - in process]

[Read more →]

Related Articles

Ability of hospitalized patients to identify their in-hospital physicians.

Arch Intern Med. 2009 Jan 26;169(2):199-201

Authors: Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D

PMID: 19171817 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Tailoring internal medicine training to improve hospitalist outcomes.

Arch Intern Med. 2009 Jan 26;169(2):204-5

Authors: Glasheen JJ, Cumbler EU

PMID: 19171821 [PubMed - indexed for MEDLINE]

[Read more →]