J. Oras

Elevated high-sensitive troponin T on admission is an indicator of poor long-term outcome in patients with subarachnoid haemorrhage: a prospective observational study

BackgroundPatients with subarachnoid haemorrhage (SAH) frequently develop cardiac complications in the acute phase after the bleeding. Although a number of studies have shown that increased levels of cardiac biomarkers after SAH are associated with a worse short-term prognosis, no prospective, consecutive study has assessed the association between biomarker release and long-term outcome. We aimed to evaluate whether the cardiac biomarkers, high-sensitive troponin T (hsTnT) and N-terminal pro B-type natriuretic peptide (NTproBNP), were associated with poor 1-year neurological outcome and cerebral infarction due to delayed cerebral ischaemia (CI-DCI).MethodsIn this single-centre prospective observational study, all consecutive patients admitted to our neurointensive care unit from January 2012 to December 2013 with suspected/verified SAH with an onset of symptoms <72 hours were enrolled. Blood samples for hsTnT and NTproBNP were collected during three consecutive days following admission. Patients were followed-up after 1 year using the Glasgow Outcome Scale Extended (GOSE). Poor neurological outcome was defined as GOSE ≤4.ResultsOne hundred and seventy seven patients with suspected SAH were admitted during the study period; 143 fulfilled inclusion criteria and 126 fulfilled follow-up. Forty-one patients had poor 1-year outcome and 18 had CI-DCI. Levels of hsTnT and NTproBNP were higher in patients with poor outcome and CI-DCI. In multivariable logistic regression modelling age, poor neurological admission status, cerebral infarction of any cause and peak hsTnT were independently associated with poor late outcome. Both peak hsTnT and peak NTproBNP were independently associated with CI-DCI.ConclusionIncreased serum levels of the myocardial damage biomarker hsTnT, when measured early after onset of SAH, are independently associated with poor 1-year outcome. Furthermore, release of both hsTnT and NTproBNP are independently associated with CI-DCI. These findings render further support to the notion that troponin release after SAH is an ominous finding. Future studies should evaluate whether there is a causal relationship between early release of biomarkers of myocardial injury after SAH and neurological sequelae.

Takotsubo syndrome in hemodynamically unstable patients admitted to the intensive care unit – a retrospective study

Takotsubo syndrome (TS) is an acute cardiac condition that is often triggered by critical illness but that has rarely been studied in the intensive care unit (ICU) setting. The aim of this study was to (i) estimate the incidence of TS in a hemodynamically unstable ICU‐population; (ii) identify predictors of TS in this population; (iii) study the impact of TS on prognosis and course of hospitalization.

Perioperative COX‐2 inhibitors may increase the risk of post‐operative acute kidney injury

In enhanced recovery protocols (ERP), a restrictive fluid regimen is proposed. Patients who undergo major surgery have an increased risk of post‐operative acute kidney injury (AKI). This combination may pose difficulties when ERP is used for patients undergoing major surgery. The aim of this study was to evaluate whether patients undergoing pancreatic surgery and treated with a restrictive fluid regimen are at greater risk of post‐operative AKI. Furthermore, if there was an increased risk of AKI, we aimed to identify its cause.

Anaesthetic‐induced cardioprotection in an experimental model of the Takotsubo syndrome – isoflurane vs. propofol

Takotsubo syndrome (TS) is an acute cardiac condition with a substantial mortality for which no specific treatment is available. We have previously shown that isoflurane attenuates the development of left ventricular (LV) dysfunction in an experimental TS‐model. We compared the effects of equi‐anaesthetic doses of isoflurane, propofol and ketamine+midazolam on haemodynamics, global and regional LV systolic function and the activation of intracellular metabolic pathways in experimental TS. We hypothesized that cardioprotection in experimental TS is specific for isoflurane.

Post-operative pain relief using local infiltration analgesia during open abdominal hysterectomy: a randomized, double-blind study

Post‐operative pain is common and often severe after open abdominal hysterectomy, and analgesic consumption high. This study assessed the efficacy of local infiltration analgesia (LIA) injected systematically into different tissues during surgery compared with saline on post‐operative pain and analgesia.

Speckle tracking-vs conventional echocardiography for the detection of myocardial injury-A study on patients with subarachnoid haemorrhage

Myocardial injury with regional wall motion abnormalities (RWMA) is common in subarachnoid haemorrhage (SAH). We hypothesized that the diagnostic performance of left ventricular (LV) global and regional longitudinal strain (GLS and RLS, respectively), assessed with speckle tracking echocardiography is superior to standard echocardiography for the detection of myocardial injury in SAH.

Isocapnic hyperventilation provides early extubation after head and neck surgery: A prospective randomized trial

Isocapnic hyperventilation (IHV) shortens recovery time after inhalation anaesthesia by increasing ventilation while maintaining a normal airway carbon dioxide (CO2)‐level. One way of performing IHV is to infuse CO2 to the inspiratory limb of a breathing circuit during mechanical hyperventilation (HV). In a prospective randomized study, we compared this IHV technique to a standard emergence procedure (control).

Early treatment with isoflurane attenuates left ventricular dysfunction and improves survival in experimental Takotsubo

Takotsubo syndrome (TS) is an acute cardiac condition, often triggered by critical illness, for which no specific treatment exists. Previously, we showed that isoflurane can prevent experimental TS. The aim of this study was to evaluate the potential treatment effects of isoflurane. Our primary hypothesis was that early treatment with isoflurane attenuates left ventricular akinesia in experimental TS.

Reply to What is the real incidence of Takotsubo syndrome in intensive care units

Sir, We thank professor Madias for the comments on our recent article “Takotsubo syndrome in hemodynamically unstable patients admitted to the Intensive Care Unit a retrospective study”, published in Acta Anesthesiologica Scandinavica. He has raised several interesting and important questions regarding the true incidence of Takotsubo syndrome in the intensive care unit, which we address below. First, we agree that the retrospective nature of our study precludes us from assessing the true incidence of TTS in an ICU population; and that it therefore would be very interesting to perform a prospective study to evaluate the true incidence of TTS. In such a study, one would have to perform serial echocardiographic examinations in all patients, which would be very resource intense. To our knowledge, only two minor prospective studies of TTS in the ICU have been conducted. These studies reported an incidence as high as 21%–28%. Such a high incidence is not what we recognize in daily clinical practice and the lower incidence (2%–4%) suggested by the present study seems more reasonable. The incidence of TTS might be affected by the ICU patient-mix. However, sepsis, respiratory failure and neurological emergencies are important causes of ICU admission in all ICUs (e.g. postoperative-, neuro-, medial-ICU). Therefore, TTS is probably seen in all ICU-units and it is important to be aware of these predictors regardless of what ICU you are working in. We agree with professor Madias that we could have underestimated the incidence of TTS. Patients with focal or atypical variants of TTS, as well as patients with coronary artery disease, could potentially have been misdiagnosed. Many of the 40 patients with non-ischemic RWMA but “not fulfilling TS criteria” were such patients. It is plausible that some of these patients might have suffered from TTS or “Takotsubo-like conditions” but retrospectively differentiating this from coronary artery disease is impossible if coronary angiography was not performed. In this regard, we have likely erred on the side of caution. Not to jeopardize the TTS-criteria, such patients could not be diagnosed with TTS in the present study. ICU patients often suffer from stress due to e.g. pain, sleep disturbances, multiple lines, noise and limited self-control. Obviously, this could trigger or predispose the patient for TTS. Together with an extensive physical stressful stimulus this would make ICU patients especially vulnerable for development of TTS. Inclusion of such variables would be interesting in future studies, as they could have an impact on the TTS incidence in the ICU. There is a need of a large prospective study, searching for TTS by serial echo examinations in consecutively admitted ICU patients, systematically evaluation of coronary artery disease to find out the true incidence and impact of TTS in the ICU. We hope to see such studies in the near future.

Reply to “Does use of perioperative COX‐2 inhibitors really increase risk of acute kidney injury?”

Sir, We are grateful for the comments from Professors Y. Y. Liu, F. S. Xue, H. X. Li, and for the opportunity to further discuss and clarify some of the aspects in the article. The raised issues are answered and explained point by point below. Serum creatinine levels were not corrected based on perioperative fluid balance, as described in the first section of the Discussion: ‘We acknowledge that the use of fluid overload adjusted serum creatinine (SCr) for these patients is a possibility; however, almost all studies regarding post-operative AKI are made with unadjusted values of SCr, which is the reason as to why we chose to present our data this way.’ Furthermore, the method of using fluid overload adjusted SCr in definition of acute kidney injury is not proposed by KDIGO. In our study, we recorded SCr preoperatively on the day of surgery, as well as post-operative day 1, 2, and 3. The first KDIGO criteria for AKI diagnosis is ‘Increase in SCr by ≥0.3 mg/dl (≥26.5 lmol/l) within 48 h’. In our study all of the patients who developed AKI did so on post-operative day 1. All of the patients in our study underwent surgery due to a pancreatic malignant condition. The routines in our hospital provide these patients with a nutritionist that closely monitor and optimize patients’ condition for 2–4 weeks before surgery. Malnutrition and hypoalbuminemia are actively searched for. When detected, it is treated actively in the weeks prior to surgery. There are serum albumin samples from each patient from 4 to 10 days prior to surgery that are within normal levels in all except five cases, three in the preERP group and two in the ERP group. It is unlikely that these patients entered the operating theater with clinically significant malnutrition or hypoalbuminemia. Concerning anemia, these patients are preoperatively assessed by an anesthetist 2–7 days prior to surgery. If anemia is found at this occasion it is treated. Furthermore, the patients also are checked for Hb on the day before surgery, and at several occasions during surgery and after surgery. It is highly unlikely that clinically significant anemia is present in these patients during the pre-, peri-, or post-operative phase. Furthermore, the two groups had the exact same treatment regarding malnutrition, hypoalbuminemia and anemia. It is therefore unlikely that the differences in post-operative AKI between the groups were caused by any of these factors. In our study, when comparing the total dose of norepinephrine (NA) administered in the two groups, the ERP group received a larger dose of NA (P = 0.03). There are diverging opinions regarding the relation of vasopressors and kidney function. It could be argued that in a normovolemic, well-monitored patient, the use of an intravenous infusion of norepinephrine to restore mean arterial pressure from 60 to 75 mmHg improves renal GFR and the renal oxygen supply/ demand as reported by Redfors et al. In the report by Kheterpal et al. that is referred to in the letter, there are several limitations, including lack of addressing the degree of intravenous hydration.