Does this patient have medical decision-making capacity?
JAMA. 2011 Jul 27;306(4):420-7
Authors: Sessums LL, Zembrzuska H, Jackson JL
Evaluation of the capacity of a patient to make medical decisions should occur in the context of specific medical decisions when incapacity is considered.
PMID: 21791691 [PubMed - in process]
Link to Article at PubMedDocumentation of cerebrospinal fluid opening pressure and other important aspects of lumbar puncture in acute headache.
Int J Clin Pract. 2010 Jun;64(7):930-5
Authors: Hewett R, Counsell C
Measuring cerebrospinal fluid (CSF) opening pressure by lumbar puncture (LP) is an essential tool in the investigation of patients with acute headache.
PMID: 20584226 [PubMed - indexed for MEDLINE]
Link to Article at PubMedRelationship of the internal jugular vein to the common carotid artery: implications for ultrasound-guided vascular access.
Eur J Anaesthesiol. 2011 May;28(5):351-5
Authors: Maecken T, Marcon C, Bomas S, Zenz M, Grau T
For cannulation of the internal jugular vein (IJV), ultrasound increases the number of first pass successes and reduces the rate of mechanical complications. A frequent complication of IJV access is the accidental injury of the common carotid artery (CCA), which can be dangerous in some circumstances. Landmarks and palpation of the CCA are used when ultrasound is not available. These conventional methods are based on the lateral position of the IJV to the CCA, and physicians traditionally employ head rotation to increase the success rates of IJV cannulation. Ultrasound scanning strictly from the anterior to posterior is not possible for this process because the probe must be adequately coupled to compensate for the curvature of the neck. Scans have been performed from different angles lateral to the neck, but misleadingly depict the relationship of the IJV to the CCA. In this study, the authors examined the effect of scanning at a 45° angle at the level of the cricoid on the depiction of the IJV in relation to the CCA. Furthermore, the influence of 30° head rotation to the contralateral side was also investigated.
PMID: 21150630 [PubMed - indexed for MEDLINE]
Link to Article at PubMedPrevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis.
Lancet Infect Dis. 2011 Jul 26;
Authors: Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI
BACKGROUND: We did a systematic review and random effects meta-analysis of randomised trials to assess the effect of oral care with chlorhexidine or povidone-iodine on the prevalence of ventilator-associated pneumonia versus oral care without these antiseptics in adults. METHODS: Studies were identified through PubMed, CINAHL, Web of Science, CENTRAL, and complementary manual searches. Eligible studies were randomised trials of mechanically ventilated adult patients receiving oral care with chlorhexidine or povidone-iodine. Relative risks (RR) and 95% CIs were calculated with the Mantel-Haenszel model and heterogeneity was assessed with the I(2) test. FINDINGS: 14 studies were included (2481 patients), 12 investigating the effect of chlorhexidine (2341 patients) and two of povidone-iodine (140 patients). Overall, antiseptic use resulted in a significant risk reduction of ventilator-associated pneumonia (RR 0.67; 95% CI 0.50-0.88; p=0.004). Chlorhexidine application was shown to be effective (RR 0.72; 95% CI 0.55-0.94; p=0.02), whereas the effect resulting from povidone-iodine remains unclear (RR 0.39; 95% CI 0.11-1.36; p=0.14). Heterogeneity was moderate (I(2)=29%; p=0.16) for the trials using chlorhexidine and high (I(2)=67%; p=0.08) for those assessing povidone-iodine use. Favourable effects were more pronounced in subgroup analyses for 2% chlorhexidine (RR 0.53, 95% CI 0.31-0.91), and in cardiosurgical studies (RR 0.41, 95% CI 0.17-0.98). INTERPRETATION: This analysis showed a beneficial effect of oral antiseptic use in prevention of ventilator-associated pneumonia. Clinicians should take these findings into account when providing oral care to intubated patients. FUNDING: None.
PMID: 21798809 [PubMed - as supplied by publisher]
Link to Article at PubMedIncreased mortality associated with meticillin-resistant Staphylococcus aureus (MRSA) infection in the Intensive Care Unit: results from the EPIC II study.
Int J Antimicrob Agents. 2011 Jul 27;
Authors: Hanberger H, Walther S, Leone M, Barie PS, Rello J, Lipman J, Marshall JC, Anzueto A, Sakr Y, Pickkers P, Felleiter P, Engoren M, Vincent JL,
Controversy continues regarding whether the presence of meticillin resistance increases mortality risk in Staphylococcus aureus infections. In this study, we assessed the role of meticillin resistance in survival of patients with S. aureus infection included in the EPIC II point-prevalence study of infection in critically ill patients performed on 8 May 2007. Demographic, physiological, bacteriological and therapeutic data were collected for 13796 adult patients in 1265 participating Intensive Care Units (ICUs) from 75 countries on the study day. ICU and hospital outcomes were recorded. Characteristics of patients with meticillin-sensitive S. aureus (MSSA) and meticillin-resistant S. aureus (MRSA) infections were compared. Co-morbidities, age, Simplified Acute Physiology Score (SAPS) II, site of infection, geographical region and MRSA/MSSA were entered into a multivariate model, and adjusted odds ratios (ORs) [95% confidence interval (CI)] for ICU and hospital mortality rates were calculated. On the study day, 7087 (51%) of the 13796 patients were classified as infected. There were 494 patients with MRSA infections and 505 patients with MSSA infections. There were no significant differences between the two groups in use of mechanical ventilation or haemofiltration/haemodialysis. Cancer and chronic renal failure were more prevalent in MRSA than in MSSA patients. ICU mortality rates were 29.1% and 20.5%, respectively (P<0.01) and corresponding hospital mortality rates were 36.4% and 27.0% (P<0.01). Multivariate analysis of hospital mortality for MRSA infection showed an adjusted OR of 1.46 (95% CI 1.03-2.06) (P=0.03). In ICU patients, MRSA infection is therefore independently associated with an almost 50% higher likelihood of hospital death compared with MSSA infection.
PMID: 21798720 [PubMed - as supplied by publisher]
Link to Article at PubMedSafety of prothrombin complex concentrates for rapid anticoagulation reversal of vitamin k antagonists. A meta-analysis.
Thromb Haemost. 2011 Jul 28;106(3)
Authors: Dentali F, Marchesi C, Pierfranceschi MG, Crowther M, Garcia D, Hylek E, Witt DM, Clark NP, Squizzato A, Imberti D, Ageno W
Prothrombin complex concentrates (PCCs) are recommended as the treatment of choice in warfarin-related coagulopathy. However, the risk of thromboembolic complications associated with their use is not well defined. We performed a meta-analysis to estimate the rate of thromboembolic complications in patients receiving vitamin K antagonists (VKAs) treated with PCCs for bleeding or before urgent surgery. Medline and Embase databases were searched. Two reviewers performed study selection and extracted data independently. Studies providing data on incidence of thromboembolic complications in VKA-treated patients were eligible for the study. Weighted mean proportion of the rate of thromboembolic complications and the mortality rate were calculated. Twenty-seven studies (1,032 patients) were included. Seven studies used 3-factor, and 20 4-factor PCCs. Twelve patients had a thromboembolic complication (weighted mean 1.4%; 95% CI 0.8-2.1), of which two were fatal. The incidence of thromboembolic events was 1.8% (95% CI 1.0-3.0) in patients treated with 4-factor PCCs, and 0.7% (95% CI 0.0-2.4) in patients treated with 3-factor PCCs. Total mortality rate was 10.6% (95% CI 5.9-16.6). In conclusion, our results suggest there is a low but quantifiable risk of thromboembolism in VKA-treated patients receiving PCCs for anticoagulation reversal. These findings should be confirmed in randomised, controlled trials.
PMID: 21800002 [PubMed - as supplied by publisher]
Link to Article at PubMed