Anthony Chau

Prevalence and Outcomes of Pharmaceutical Industry—Sponsored Clinical Trials Involving Clozapine, Risperidone, or Olanzapine

Objective: The literature continues to highlight the debate on the ethics and merits of trials sponsored by the pharmaceutical industry. This study attempts to determine the prevalence and outcomes of industry-sponsored trials involving clozapine, risperidone, or olanzapine. Methods: We searched the literature from January 1, 1990, to December 31, 2001, to capture all eligible clinical trials involving clozapine, risperidone, or olanzapine. The primary outcome measured was the clinical outcome of industry-sponsored studies. Secondary outcome measures included the following parameters: disclosure of any sponsorship and financial support, author(s) employed by the industry, use of comparator drug(s) within the trial, sample size, blinding, and use of placebo. Results: The database comprised 372 articles. Of these trials, 124 (33.3%) were sponsored by the pharmaceutical industry. In general, trials sponsored by Eli Lilly or Janssen had better research design than trials not funded by the pharmaceutical industry. With regard to authorship, more trials funded by Eli Lilly (74.6%) were coauthored by an employee of the company, compared with trials funded by either Janssen (23.3%) or Novartis/Sandoz (5.6%). Further, more trials sponsored by Eli Lilly reported positive outcomes (92.1%), compared with Janssen-sponsored trials (88.4%) and Sandoz/Novartis-sponsored trials (72.2%). No negative results were reported in any of the industry-funded trials. Conclusions: One-third of the published clinical trials involving clozapine, risperidone, or olanzapine were funded by their respective manufacturer. The reported outcomes of the sponsored trials highly favour the manufacturers product.

Beware the airway filter: deadspace effect in children under 2 years.

Background : Filters are increasingly used in breathing circuits as they protect the circuit from contamination and facilitate humidification of inspired gas. The use of filters, however, can augment the anatomical deadspace. This can be significant in children because they have much smaller tidal volumes.

A Jehovah’s Witness child with hemophilia B and factor IX inhibitors undergoing scoliosis surgery

Purpose: To describe the successful perioperative hemostatic management of a Jehovah’s Witness patient with hemophilia B and anaphylactic inhibitors to factor IX, undergoing scoliosis surgery.Clinical features: A 14 ½-yr-old boy with severe hemophilia B who had a history of anaphylactic inhibitors to factor IX was scheduled to undergo corrective scoliosis surgery. He was initially started on epoetin alfa and iron supplementation to maximize preoperative red cell mass. Additionally, he was placed on a desensitization protocol of recombinant coagulation factor IX (rFIX) and was then treated with activated recombinant coagulation factor VII (rFVIIa) during the postoperative period. Tranexamic acid was given concomitantly. The intraoperative blood loss was approximately 350 mL. The nadir hemoglobin concentration was 111 g·L−1 on postoperative days one and two. On postoperative day 11, the patient was stable and discharged home with a hemoglobin of 138 g·L−1. He did not require blood transfusion and no adverse events were observed.Conclusions: The use of rFIX, rFVIIa, erythropoetin, iron, and tranexamic acid before, during and after scoliosis surgery may be a viable and safe option for hemophilia patients with inhibitors, who refuse blood products.RésuméObjectif: Décrire la prise en charge hémostatique péri-opératoire réussie d’un patient Témoin de Jéhovah souffrant d’hémophilie de type B et présentant des inhibiteurs anaphylactiques de forte teneur du facteur IX, lors d’une chirurgie de la scoliose.Éléments cliniques: Un garçon de 14 ans et demi souffrant d’hémophilie de type B et présentant des antécédents d’inhibiteurs anaphylactiques du facteur IX devait subir une chirurgie de correction de scoliose. On lui a d’abord administré de l’époiétine alpha et des suppléments de fer pour maximiser la masse érythrocytaire avant l’opération. De plus, il a reçu un traitement de désensibilisation à l’aide de facteur IX recombinant (rFIX), puis a été traité avec du facteur VII recombinant activé (rFVIIa) après l’opération. Il a simultanément reçu de l’acide tranexamique. Les pertes sanguines peropératoires étaient d’environ 350 mL. La concentration d’hémoglobine a atteint un minimum de 111 g·L−1 les premier et deuxième jours après l’opération. Le onzième jour postopératoire, le patient était stable et a pu recevoir son congé de l’hôpital. Son hémoglobine était alors 138 g·L−1. Il n’a pas nécessité de transfusion sanguine et il n’y a pas eu d’événements indésirables.Conclusion: L’administration de rFIX, de rFVIIa, d’érythropoiétine, de fer et d’acide tranexamique avant, pendant et après une chirurgie de correction de scoliose pourrait constituer une option viable et sécuritaire pour les patients hémophiles présentant des inhibiteurs et refusant la transfusion de produits sanguins.

Perioperative implications of sodium-glucose cotransporter-2 inhibitors: a case series of euglycemic diabetic ketoacidosis in three patients after cardiac surgery

PurposeSodium-glucose cotransporter-2 inhibitors (SGLT2i) comprise the newest class of oral hypoglycemic agents approved for treating type II diabetes mellitus (DM-II). Their use, however, has been associated with the rare development of euglycemic diabetic ketoacidosis (euDKA). We present three cases of euDKA that occurred following elective coronary artery bypass grafting surgery. The role of the anesthesiologist in the prevention, diagnosis, and management of this complication is also discussed.Clinical featuresThree patients receiving chronic SGLT2i therapy for DM-II (discontinued one to two days preoperatively) underwent cardiac surgery. On the first postoperative day, each exhibited nausea, vomiting, and tachypnea. Although these nonspecific postoperative findings are common, our patients also exhibited anion gap metabolic acidosis (pH < 7.3, anion gap > 12 mmol·L−1) with lower than anticipated serum glucose levels of < 14 mmol·L−1. Serum and urine ketone analyses confirmed a diagnosis of euDKA. After insulin and dextrose infusions were initiated, rapid resolution of the metabolic abnormalities occured.ConclusionsAnesthesiologists should recognize that patients receiving SGLT2i preoperatively are at risk of developing euDKA. Hence, based on the pharmacokinetics of SGLT2i, discontinuing the medication at least two days prior to surgery should minimize the risk. Diagnosing euDKA is challenging and often delayed because of its nonspecific signs and symptoms. When suspected, serum and urine ketones should be monitored to reduce the time to diagnosis and treatment.RésuméObjectifLes inhibiteurs du cotransporteur sodium-glucose de type 2 (SGLT2i) englobent la classe la plus récente d’agents hypoglycémiques oraux approuvés pour le traitement du diabète de type II. Leur utilisation a toutefois été associée à l’apparition rare d’une acidocétose diabétique euglycémique. Nous présentons trois cas d’acidocétose diabétique euglycémique survenus à la suite d’une chirurgie de pontage aortocoronarien. Le rôle de l’anesthésiologiste dans la prévention, le diagnostic et la prise en charge de cette complication est également discuté.Éléments cliniquesTrois patients recevant une thérapie de SGLT2i pour le traitement de leur diabète de type II (interrompue un à deux jours avant leur opération) ont subi une chirurgie cardiaque. Au premier jour postopératoire, les trois patients ont souffert de nausées, de vomissements et de tachypnée. Bien que ces résultats postopératoires non spécifiques soient courants, nos patients ont également souffert d’une acidose métabolique à trou anionique (pH < 7.3, trou anionique > 12 mmol·L−1) et des taux de glycémie sérique plus bas qu’anticipés à < 14 mmol·L−1. Les analyses cétoniques sériques et dans l’urine ont confirmé le diagnostic d’acidocétose diabétique euglycémique. Suite à l’amorce de perfusions d’insuline et de dextrose, les anomalies métaboliques se sont rapidement résolues.ConclusionLes anesthésiologistes devraient être sensibilisés au fait que les patients recevant des SGLT2i en période préopératoire courent un risque d’acidocétose diabétique euglycémique. Par conséquent, si l’on se fonde sur la pharmacocinétique des SGLT2i, l’interruption du traitement au moins deux jours avant la chirurgie devrait minimiser le risque. Le diagnostic de l’acidocétose diabétique euglycémique est difficile à poser et souvent retardé en raison de ses signes et symptômes non spécifiques. Lorsqu’elle est suspectée, les cétones sériques et dans l’urine devraient être mesurées afin de réduire le délai jusqu’au diagnostic et au traitement.

Dural Puncture Epidural Technique: a Novel Method for Labor Analgesia

In recent years, the dural puncture epidural (DPE) technique has emerged as a novel method of labor analgesia. The DPE technique involves the technical elements of a combined spinal epidural (CSE) technique but avoids the direct administration of intrathecal medications. The underlying mechanism responsible for the unique blockade qualities of the DPE technique is believed to be the translocation of medications from the epidural space into the dural sac; laboratory studies have found a positive correlation between translocation flux and the size of dural perforation. Clinically, earlier and greater sacral spread and dermatomal block symmetry have been observed in obstetric and surgical patients receiving the DPE technique compared to the epidural (EPL) technique. Moreover, the DPE technique appears to have fewer side effects than the CSE technique. The DPE technique appears to offer a paradigm shift in obstetric analgesia and anesthesia, but further investigation is warranted.