Andrew Silvers

Remifentanil, Fentanyl, and Cardiac Surgery: A Double-blinded, Randomized, Controlled Trial of Costs and Outcomes

Remifentanil may be beneficial in patients undergoing coronary artery bypass graft surgery, by promoting hemodynamic stability, reducing drug requirements, and attenuating the neurohumoral “stress response.” We enrolled 77 cardiac surgical patients in a double-blinded, randomized trial and randomly allocated them to one of three groups: remifentanil infusion at 0.83 &mgr;g · kg−1 · min−1 (Group R); fentanyl bolus, small dose, at 12 &mgr;g/kg (Group FLD); and fentanyl bolus, moderate dose, at 24 &mgr;g/kg (Group FMD). We found a significant difference in the median time to tracheal extubation: Group FLD, 6.5 h; Group R, 7.3 h; and Group FMD, 9.7 h (P = 0.025). Group R patients had similar times to those of Groups FLD (P = 0.14) and FMD (P = 0.30). Group FLD patients had a longer length of hospital stay (P = 0.030). Patients in Group R had a significantly infrequent rate of hypertension but a frequent rate of hypotension (P < 0.01). The urinary cortisol excretion was larger in Group FLD patients (P < 0.0005), and urine flow was smaller (P < 0.0005). Remifentanil was associated with a propofol dose reduction (P = 0.0005) and a concomitant higher bispectral index (P = 0.032). Three Group FLD patients, but none in groups FMD and R, had postoperative myocardial infarctions (P = 0.032). Remifentanil has larger drug acquisition costs but does not increase the total hospital costs associated with cardiac surgery.

Trauma Resuscitation Errors and Computer-Assisted Decision Support

HYPOTHESIS This project tested the hypothesis that computer-aided decision support during the first 30 minutes of trauma resuscitation reduces management errors. DESIGN Ours was a prospective, open, randomized, controlled interventional study that evaluated the effect of real-time, computer-prompted, evidence-based decision and action algorithms on error occurrence during initial resuscitation between January 24, 2006, and February 25, 2008. SETTING A level I adult trauma center. PATIENTS Severely injured adults. MAIN OUTCOME MEASURES The primary outcome variable was the error rate per patient treated as demonstrated by deviation from trauma care algorithms. Computer-assisted video audit was used to assess adherence to the algorithms. RESULTS A total of 1171 patients were recruited into 3 groups: 300 into a baseline control group, 436 into a concurrent control group, and 435 into the study group. There was a reduction in error rate per patient from the baseline control group to the study group (2.53 to 2.13, P = .004) and from the control group to the study group (2.30 to 2.13, P = .04). The difference in error rate per patient from the baseline control group to the concurrent control group was not statistically different (2.53 to 2.30, P = .21). A critical decision was required every 72 seconds, and error-free resuscitations were increased from 16.0% to 21.8% (P = .049) during the first 30 minutes of resuscitation. Morbidity from shock management (P = .03), blood use (P < .001), and aspiration pneumonia (P = .046) were decreased. CONCLUSIONS Computer-aided, real-time decision support resulted in improved protocol compliance and reduced errors and morbidity. Trial Registration clinicaltrials.gov Identifier: NCT00164034.

Prediction of Neurological Outcome Using Bispectral Index Monitoring in Patients with Severe Ischemic-Hypoxic Brain Injury Undergoing Emergency Surgery

Background:Predicting outcome from ischemic-hypoxic brain injury can be difficult in patients rushed to the operating room for time-critical emergency surgery. The authors chose to evaluate the prognostic ability of bispectral index (BIS) in this setting. Methods:Twenty-five critically ill, unconscious patients with ischemic-hypoxic brain injury undergoing emergency surgery were prospectively studied. Clinical evaluation, laboratory investigations, BIS, and burst suppression ratio were recorded before and during surgery. Neurologic outcome of the patients was measured according to the Glasgow outcome scale at 30 days after injury, with poor neurologic outcome defined as severe disability or death. Results:The incidence of poor neurologic outcome was 68%. Neither clinical judgment (P = 0.40) nor pupillary responses (P = 0.21) were predictive of neurologic outcome after surgery. An abnormal BIS trace was strongly associated with poor neurologic outcome, positive likelihood ratio 6.6 (95% CI 1.7–36.4; exact test P = 0.002). Some BIS values were significantly different when comparing patients with and without poor outcome: c-statistics for the average BIS and maximal electroencephalographic burst-suppression were 0.80 (95% CI 0.62–0.98; P = 0.017) and 0.84 (95% CI 0.68–0.99; P = 0.007), respectively. A normal BIS (P < 0.0005) but not clinical judgment (P = 0.16) could identify a group of patients more likely to survive with a good neurologic outcome. Conclusions:BIS, when compared with clinical judgment and routine laboratory tests, provides useful information that may identify patients with a good chance of recovery after ischemic-hypoxic brain injury requiring emergency surgery.

Anesthesia for bilateral sequential lung transplantation: Experience of 64 cases

OBJECTIVES To review the experience of anesthesia for bilateral sequential lung transplantation (BSLTx) and describe factors associated with outcome. DESIGN Case series. SETTING University hospital. PARTICIPANTS Sixty-four adult patients undergoing BSLTx. INTERVENTIONS Descriptive and inferential statistical analysis. MEASUREMENTS AND MAIN RESULTS Details of anesthetic technique, patient, and perioperative characteristics are presented. Mean (SD) lung allograft ischemic times were 320 (81) minutes for the first lung and 446 (93) minutes for the second lung. Mean (SD) duration of surgery was 8.5(2) hours, and median time to extubation was 28 hours. There was a reduction in the use of cardiopulmonary bypass, from 10 of 19 (53%) in 1992 to 1993 to 10 of 45 (22%) in 1994 to 1996, p = 0.016. There was an association between time to extubation and duration of surgery (Spearman rank correlation, p = 0.33, p = 0.008), but no association with intraoperative fluid administration (p = 0.18, p = 0.16), or inotrope requirements (p = 0.06, p = 0.65). Predictors of in-hospital mortality were preoperative renal impairment (p = 0.034), early reoperation (p = 0.005), and delay in extubation (p = 0.013); and for 12-month mortality was patient age (p = 0.01). The actuarial survival rates were 90%, 73%, and 58% at 30 days, 1 year, and 2 years, respectively. CONCLUSIONS Anesthesia for BSLTx is a most challenging procedure, for which maintenance of tissue oxygenation and right ventricular perfusion are essential. Recent advances include use of inhaled nitric oxide, ventilator management that reduces dynamic hyperinflation, and permissive hypercapnia. Analysis of outcome from a large case series such as this enables the anesthesiologist to be more aware of the important features of anesthesia for BSLTx, as well as identify potential areas of improvement.

Analgesia Best Practice After Cardiac Surgery

Sources of pain after cardiac surgery include sternotomy, rib retraction, conduit harvest, and drain tubes sites. An analgesic regimen should consider individual patient characteristics, including age, preoperative history of pain and response to analgesics, comorbidities, and psychologic state. Intraoperative and postoperatively administered opioids remain the mainstay of therapy, but adjunctive analgesics such as paracetamol, nonsteroidal anti-inflammatory drugs and tramadol, and regional techniques, can reduce opioid consumption and opioid-induced respiratory depression. This may facilitate earlier tracheal extubation, mobilization, and recovery.

Dabigatran anticoagulation and Stanford type A aortic dissection: not always a lethal coincidence?

tive dose of dexmedetomidine for LMA insertion would have been obtained if we waited for 15 min. However, during anaesthesia induction, where loss of consciousness is achieved with a hypnotic drug like propofol in our study, the situation is different than when dexmedetomidine is used alone in patients, and even more so in volunteers. In addition, Uzümcügil and colleagues also reported that when dexmedetomidine 1 μg/kg was given 2 min before propofol induction, LMA insertion conditions were comparable with a situation where a combination of propofol and fentanyl 1 μg/kg was given. The haemodynamic effects may also be different during anaesthesia induction, and we did not observe any clinical change in mean arterial pressure before LMA insertion. Therefore, concerning LMA insertion conditions and haemodynamic effects, it may be appropriate to insert an LMA 2 min after dexmedetomidine, instead of 15 min, in the busy clinical setting during anaesthesia induction. Conflicts of interest: The authors confirm that there are no conflicts of interest.