2012 April 21

Monitoring peripheral perfusion in critically ill patients at the bedside.

Curr Opin Crit Care Start a Discussion »

Apr 212012

Monitoring peripheral perfusion in critically ill patients at the bedside.

Curr Opin Crit Care. 2012 Apr 18;

Authors: van Genderen ME, van Bommel J, Lima A

Abstract
PURPOSE OF REVIEW: The goal of circulatory monitoring is the use of an accurate, continuous and noninvasive method that can easily assess tissue perfusion under clinical conditions. As peripheral tissues are sensitive to alterations in perfusion, the noninvasive monitoring of peripheral circulation could be used as an early marker of systemic haemodynamic derangement. We, therefore, aim to discuss the currently available methods that can be used at the bedside as well as the role of peripheral perfusion monitoring in critically ill patients. RECENT FINDINGS: The deterioration of peripheral circulation has frequently been observed in critically ill patients with the use of subjective assessment and several optical techniques. In various patient categories, more severe and persistent alterations have been associated with worse outcomes, and these associations were independent of systemic haemodynamic parameters. Interventions aimed at systemic parameters have an unpredictable effect on peripheral circulation parameters, especially during hyperdynamic conditions. Thus, it appears that changes in peripheral perfusion reflect changes in regional vasomotor tone rather than systemic blood flow. SUMMARY: Subjective assessments and optical techniques provide important information regarding peripheral circulation. Moreover, these techniques are relatively easy to implement and interpret at the bedside and can be applied during acute conditions. Further research is warranted to investigate the effects of therapeutic interventions on peripheral perfusion parameters and patient outcome.

PMID: 22517401 [PubMed - as supplied by publisher]

Link to Article at PubMed

Lactate as a hemodynamic marker in the critically ill.

Curr Opin Crit Care Start a Discussion »

Apr 212012

Lactate as a hemodynamic marker in the critically ill.

Curr Opin Crit Care. 2012 Apr 18;

Authors: Fuller BM, Dellinger RP

Abstract
PURPOSE OF REVIEW: An early quantitative resuscitation strategy improves outcome in critically ill patients. The hemodynamic endpoints of such a strategy have been a topic of debate in the literature. This review focuses on the use of lactate as a marker for risk stratification, lactate clearance as a hemodynamic endpoint, and its use compared to mixed venous oxygenation as a resuscitation goal. RECENT FINDINGS: Lactate clearance is associated with improved outcome across several cohorts of critically ill patients. Lactate levels and central venous oxygen saturations are frequently discordant. Targeting lactate clearance as part of a quantitative resuscitation strategy may be as effective as targeting central venous oxygen saturation. SUMMARY: Resuscitation of the critically ill patient should be aimed at the reversal of tissue hypoxia. The use of lactate as a hemodynamic marker and resuscitation endpoint makes physiologic sense, and is supported by the recent data. The use of lactate clearance versus other traditional endpoints of resuscitation, such as mixed venous oxygen saturation, should be based on the clinical characteristics and response of the individual patient.

PMID: 22517402 [PubMed - as supplied by publisher]

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Effect of Theophylline on Prevention of Contrast-Induced Acute Kidney Injury: A Meta-analysis of Randomized Controlled Trials.

Am J Kidney Dis Start a Discussion »

Apr 212012

Effect of Theophylline on Prevention of Contrast-Induced Acute Kidney Injury: A Meta-analysis of Randomized Controlled Trials.

Am J Kidney Dis. 2012 Apr 17;

Authors: Dai B, Liu Y, Fu L, Li Y, Zhang J, Mei C

Abstract
BACKGROUND: Whether treatment with adenosine receptor antagonists such as theophylline can prevent contrast-induced acute kidney injury (AKI) remains controversial. STUDY DESIGN: We conducted a meta-analysis of randomized controlled trials using MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), Web of Science (1986 to July 2011), and the Cochrane Central Register of Controlled Trials (1996 to July 2011), without language restriction. SETTING & POPULATION: Patients undergoing contrast procedures. SELECTION CRITERIA FOR STUDIES: Randomized controlled trials assessing adenosine antagonists versus control for prevention of contrast-induced AKI. INTERVENTION: Adenosine antagonists with or without N-acetylcysteine versus control with or without N-acetylcysteine. OUTCOMES: Contrast-induced AKI, change in serum creatinine level, requirement of dialysis, and in-hospital mortality. RESULTS: 16 trials (1,412 participants) were included. Theophylline significantly decreased the risk of contrast-induced AKI (13 trials, 1,222 patients; risk ratio, 0.48; 95% CI, 0.26-0.89; P = 0.02; I(2) = 45%) and had a protective effect on the absolute change in serum creatinine concentration (13 trials, 1,170 patients; standardized mean difference, -0.31 mg/dL; 95% CI, -0.50 to -0.11; P = 0.002; I(2) = 60%). Meta-regression showed a significant relation between the relative risk of contrast nephropathy and baseline serum creatinine level or Jadad score. No clear effects of treatment on risk of dialysis and in-hospital mortality were identified. LIMITATIONS: Power to assess clinical end points was limited. CONCLUSIONS: Theophylline treatment significantly reduced the incidence of contrast-induced AKI and had a modest improvement on kidney function after contrast exposure in the general population. However, beneficial effects of theophylline were not observed in patients with high baseline creatinine values (serum creatinine ?1.5 mg/dL). In addition, the long-term effect of this agent on more clinically important outcomes was not established. Future large-scale high-quality multicenter trials in participants with different underlying risks of contrast-induced AKI and that incorporate the evaluation of clinically relevant outcomes are required.

PMID: 22516682 [PubMed - as supplied by publisher]

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Beta-blocker management in high-risk patients presenting for non-cardiac surgery: before and after the POISE Trial.

anaesth intensive care Start a Discussion »

Apr 212012

Beta-blocker management in high-risk patients presenting for non-cardiac surgery: before and after the POISE Trial.

Anaesth Intensive Care. 2012 Mar;40(2):319-27

Authors: Leslie K, Myles PS, Halliwell R, Paech MJ, Short TG, Walker S

Abstract
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 perioperative beta-blockade was defined as heart rate <65 beats per minute for at least 80% of the perioperative period in patients prescribed beta-blockers. Effective perioperative beta-blockade was achieved in 22 (11.5%) of 191 patients prescribed perioperative beta-blockade in the first cohort (n=392) and seven (6%) of 118 patients in the second cohort (n=241) (P=0.10). 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.

PMID: 22417028 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Von Willebrand factor predicts major bleeding and mortality during oral anticoagulant treatment.

J Intern Med Start a Discussion »

Apr 212012

Von Willebrand factor predicts major bleeding and mortality during oral anticoagulant treatment.

J Intern Med. 2012 Mar;271(3):239-46

Authors: Lind M, Boman K, Johansson L, Nilsson TK, Järvholm LS, Jansson JH

Abstract
AIMS: Oral anticoagulation (OAC), predominantly with warfarin, is an effective treatment to prevent thromboembolic events. Serious bleeding is a frequent and feared treatment complication. In this longitudinal cohort study of OAC-treated patients, we aimed to evaluate the relationship between von Willebrand factor (VWF) levels and risk of bleeding complications, cardiovascular mortality and all-cause mortality.
METHODS AND RESULTS: A total of 719 patients receiving warfarin treatment were observed for a mean duration of 4.2 years. All bleeding complications causing hospitalization were registered and classified into clinically relevant bleeding (CRB) and major bleeding. Ischaemic stroke, peripheral arterial embolism, myocardial infarction, and death were also recorded. We identified 113 cases of CRB and 73 of major bleeding. In total, 161 deaths occurred during follow-up with cardiovascular disease identified as the cause of death in 110 patients. Patients in the highest tertile of VWF had a significantly increased risk of bleeding complications: hazard ratio (HR) 2.53 (95% CI 1.41-4.56) for major bleeding and HR 2.19 (95% CI 1.38-3.48) for CRB. VWF, expressed either in tertiles or as a continuous variable, showed a significant association with cardiovascular mortality (HR 1.68, 95% CI 1.40-2.01) and all-cause mortality (HR 1.77, 95% CI 1.52-2.05). In multivariate Cox regression analysis, the findings remained significant after adjusting for age, high-sensitivity C-reactive protein and creatinine.
CONCLUSIONS: Patients with high levels of VWF had an increased risk of bleeding complications, cardiovascular mortality and all-cause mortality during OAC treatment. Our findings imply that the use of VWF as a risk marker for thromboembolic events is complicated by the association of VWF with bleeding complications.

PMID: 21707795 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Net Clinical Benefit of Warfarin in Patients with Atrial Fibrillation: A Report from the Swedish Atrial Fibrillation Cohort Study.

Circulation Start a Discussion »

Apr 212012

Net Clinical Benefit of Warfarin in Patients with Atrial Fibrillation: A Report from the Swedish Atrial Fibrillation Cohort Study.

Circulation. 2012 Apr 18;

Authors: Friberg L, Rosenqvist M, Lip GY

Abstract
BACKGROUND: Known risk factors for bleeding during anticoagulant treatment are largely the same as those predicting thromboembolic events in patients with atrial fibrillation (AF). Our objective was to investigate how to maximize the likelihood of avoiding both stroke and bleeding. METHODS AND RESULTS: All 182,678 subjects with AF in the Swedish Hospital Discharge Register were studied for an average of 1.5 years (260,000 patient-years at risk). Patients were stratified according to risk scores using historic ICD-diagnostic codes in the register. Information about medication was obtained from the Swedish Drug Registry. Our primary endpoint was net benefit defined as number of avoided ischaemic strokes with anticoagulation minus number of excess intracranial bleedings with a weight of 1.5 to compensate for the generally more severe outcome with intracranial bleedings. The adjusted net clinical benefit favoured anticoagulation for almost all AF patients. The exception were patients at very low risk of ischaemic stroke with a CHA(2)DS(2)-VASc score =0 and moderately elevated bleeding risk (-1.7%/year). The results were broadly similar with CHADS(2), except for patients with very low embolic risk, where the CHA(2)DS(2)-VASc was able to identify those patients (n=6,205; 3.9% of all patients) who had no net clinical benefit or even some disadvantage from anticoagulant treatment. CONCLUSIONS: In almost all patients with AF, the risk of ischaemic stroke without anticoagulant treatment is higher than the risk of intracranial bleeding with anticoagulant treatment. Analysis of the net benefit indicates that more patients may benefit from anticoagulant treatment.

PMID: 22514252 [PubMed - as supplied by publisher]

Link to Article at PubMed

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