Leonid A. Eidelman

Evaluation of triage decisions for intensive care admission

OBJECTIVEnTo assess physician decision-making in triage for intensive care and how judgments impact on patient survival.nnnDESIGNnProspective, descriptive study.nnnSETTINGnGeneral intensive care unit, university medical center.nnnINTERVENTIONSnAll patients triaged for admission to a general intensive care unit were studied. Information was collected for the patients age, diagnoses, surgical status, admission purpose, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mortality. The number of available beds at the time of triage and reasons for refused admission were obtained.nnnMEASUREMENTS AND MAIN RESULTSnOf 382 patients, 290 were admitted, 92 (24%) were refused admission, and 31 were admitted at a later time. Differences between admission diagnoses were found between patients admitted or not admitted (p < .001). Patients refused admission had higher APACHE II scores (15.6+/-1.5 admitted later and 15.8+/-1.4 never admitted) than did admitted patients (12.1+/-.4; p < .001). The frequency of admitting patients decreased when the intensive care unit was full (p < .001). Multivariate analysis revealed that triage to intensive care correlated with age, a full unit, surgical status, and diagnoses. Hospital mortality was lower in admitted (14%) than in refused patients (36% admitted later and 46% never admitted; p < .01) and in admitted patients with APACHE II scores of 11 to 20 (p = .02). The 28-day survival of patients was greater for admitted patients compared with patients never admitted (p = .01).nnnCONCLUSIONSnPhysicians triage patients to intensive care based on the number of beds available, the admission diagnosis, severity of disease, age, and operative status. Admitting patients to intensive care is associated with a lower mortality rate, especially in patients with APACHE scores of 11 to 20.

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

BackgroundAiming to clarify the mechanism of weight loss after the restrictive bariatric procedure of sleeve gastrectomy (LSG), the volumes and pressures of the stomach, of the removed part, and of the remaining sleeve were measured in 20 morbidly obese patients.MethodsThe technique used consisted of occlusion of the pylorus with a laparoscopic clamp and of the gastroesophageal junction with a special orogastric tube connected to a manometer. Instillation of methylene-blue-colored saline via the tube was continued until the intraluminal pressure increased sharply, or the inflated stomach reached 2,000xa0cc. After recording of measurements, LSG was performed.ResultsMean volume of the entire stomach was 1,553xa0cc (600–2,000xa0cc) and that of the sleeve 129xa0cc (90–220xa0cc), i.e., 10% (4–17%) and that of the removed stomach was 795xa0cc (400–1,500xa0cc). The mean basal intragastric pressure of the whole stomach after insufflations of the abdominal cavity with CO2 to 15xa0mmHg was 19xa0mmHg (11–26xa0mmHg); after occlusion and filling with saline it was 34xa0mmHg (21–45xa0mmHg). In the sleeved stomach, mean basal pressure was similar 18xa0mmHg (6–28xa0mmHg); when filled with saline, pressure rose to 43xa0mmHg (32–58xa0mmHg). The removed stomach had a mean pressure of 26xa0mmHg (12–47xa0mmHg). There were no postoperative complications and no mortality.ConclusionsThe notably higher pressure in the sleeve, reflecting its markedly lesser distensibility compared to that of the whole stomach and of the removed fundus, indicates that this may be an important element in the mechanism of weight loss.

Laparoscopic sleeve gastrectomy with minimal morbidity. Early results in 120 morbidly obese patients.

BackgroundIn recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique.MethodsA prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43u2009±u20095 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6–7xa0cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48xa0Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation.ResultsIntraoperative difficulties were encountered in four patients. There were no postoperative complications—no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7xa0months (range 2–31xa0months), percent of excess BMI lost reached 53u2009±u200924% and the BMI decreased from 43u2009±u20095 to 34u2009±u20095xa0kg/m2. Patient satisfaction scoring (1–4) at least 1xa0year after surgery was 3.6u2009±u20090.8.ConclusionsThe good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.

Perioperative ischemia and cardiac complications in major vascular surgery: Importance of the preoperative twelve-lead electrocardiogram

PURPOSEnTo investigate the associations between specific preoperative 12-lead electrocardiogram (ECG) abnormalities, perioperative ischemia, and postoperative myocardial infarction or cardiac death in major vascular surgery.nnnMETHODSnTwo prospective studies on perioperative myocardial ischemia performed in two tertiary university hospitals were combined to include 405 patients. All preoperative ECGs were analyzed according to the Sokolow-Lyon criteria for left ventricular hypertrophy by investigators who were blinded to the patients perioperative clinical course. Perioperative myocardial ischemia was detected by continuous ECG recording, and postoperative cardiac complications included myocardial infarction and cardiac death.nnnRESULTSnA total of 19 postoperative cardiac complications occurred (two cardiac deaths and 17 myocardial infarctions). Voltage criteria for left ventricular hypertrophy (78 patients, 19%) and ST segment depression greater than 0.5 mm (98 patients, 24.2%) on preoperative ECGs were both significantly associated with postoperative myocardial infarction or cardiac death (odds ratio, 4.2 and 4.7; p = 0.001 and 0.0005, respectively) and with longer intraoperative and postoperative myocardial ischemia. In each of the two study groups, a preoperative ECG abnormality that involved voltage criteria, ST segment depression, or both (134 patients, 33.1%) was more predictive of postoperative cardiac complications than any other preoperative clinical variable, including a history of myocardial infarction or angina pectoris, diabetes mellitus, pathologic Q-wave by ECG, or preoperative myocardial ischemia. The combined duration of intraoperative and postoperative ischemia and the preoperative ECG with either voltage criteria or ST segment depression were the only independent factors associated with adverse cardiac events by multivariate analysis (p < or = 0.0001 and p = 0.02, respectively).nnnCONCLUSIONnLeft ventricular hypertrophy and ST segment depression on preoperative 12-lead ECGs are important markers of increased risk for myocardial infarction or cardiac death after major vascular surgery.

Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy

The objectives of our study were to demonstrate the patterns and sites of the upper airway (UA) collapse in obstructive sleep apnea/hypopnea syndrome (OSAHS) patients, utilizing the sleep endoscopy technique, and to describe the technique and summarize our experience in a large series of patients. UA findings during sleep endoscopy with midazolam were examined prospectively in 55 surgical candidates with OSAHS. The uvulopalantine was the most common site of obstruction (89%), followed by the tongue base, hypopharynx and larynx (33% each), and nose (21%); 72% of the patients had multiple obstructions. There was a significant correlation between the number of obstructions and the respiratory distress index (RDI). Laryngeal obstruction was typically supraglottic. Hypopharyngeal obstruction involved concentric UA narrowing. Our findings emphasize the considerable rate of laryngeal and hypopharyngeal obstructions in patients with OSAHS and suggest that their misdiagnosis may explain at least part of the high surgical failure rate of UPPP for OSAHS patients. The number of obstruction sites correlates with respiratory distress index. Sleep endoscopy is safe and simple to perform.

Novel grading system for quantifying upper-airway obstruction on sleep endoscopy.

BackgroundThe aim of this study was to present a novel anatomically comprehensive and clinically applicable system for the quantification of sleep endoscopy findings in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS).MethodsFifty-five adult patients with a polysomnographic diagnosis of OSAHS were referred for midazolam-induced sleep endoscopy following failure of continuous positive airway pressure. Five anatomical sites of possible obstruction along the upper airway were documented: nose/nasopharynx (N), uvulopalatine plane (P), tongue base (T), larynx (L), and hypopharynx (H). Each involved site was assigned a severity grade of 1 (partial obstruction) or 2 (complete obstruction). The digits representing the obstruction pattern at each level were then added to yield a severity index (SI). The SI for each patient was determined by two independent observers. Findings were correlated with the respiratory disturbance index (RDI) and body mass index (BMI).ResultsThe SI was significantly correlated with the RDI (Rxa0=xa00.746, Pearson; Pxa0<xa00.0001) and predicted disease severity with 65% accuracy. There was no association with BMI. By site, the tongue base and hypopharynx were significantly correlated with obstruction severity; obstruction in the tongue base predicted disease severity with a sensitivity of 68.8 and sensitivity of 81.1.ConclusionOur easy-to-use endoscopic grading system provides physicians with an accurate picture of the pattern of the upper-airway system obstruction in patients with obstructive sleep apnea/hypopnea syndrome. It is a promising tool for estimating the location and severity of upper airway disease and may have implications for treatment planning.

Helium versus oxygen for tracheal gas insufflation during mechanical ventilation

OBJECTIVEnTo evaluate and compare the effect of tracheal gas insufflation using two gases with different physical properties, helium and oxygen, as an adjunct to conventional mechanical ventilation in patients with respiratory failure.nnnDESIGNnProspective, intervention study.nnnSETTINGnGeneral intensive care unit in a tertiary university medical center.nnnPATIENTSnSeven sedated and paralyzed patients with respiratory failure of various etiologies. All patients were ventilated in the volume-control mode (tidal volume 5 to 7 mL/kg). Inclusion criteria were PaCO2 of > or =50 torr (> or =6.7 kPa), together with peak inspiratory pressure of > or =35 cm H2O and respiratory rate of > or =14 breaths/min.nnnINTERVENTIONSnAll patients were intubated with an endotracheal tube that had an additional lumen opening at its distal end, through which tracheal gas insufflation was administered. The tracheal gas insufflation was applied continuously throughout the respiratory cycle at three flow rates (2, 4, and 6 L/min) with two gases, oxygen and helium, while the ventilatory settings were maintained constant.nnnMEASUREMENTS AND MAIN RESULTSnIn addition to airway pressures and arterial blood gases, the relative efficacy of tracheal gas insufflation with each gas was estimated using a coefficient of efficiency (which we defined as the change in PaCO2/peak inspiratory pressure) compared with baseline measurements. Tracheal gas insufflation with both gases decreased PaCO2 significantly (p < .05) at all flow rates. This effect was accompanied by an increase in airway pressure with both gases (oxygen and helium). However, at flow rates of 6 L/min, tracheal gas insufflation with helium resulted in lower peak inspiratory pressure than with oxygen. Tracheal gas insufflation with helium was more effective (as estimated by the coefficient of efficiency) than with oxygen at all flow rates (p < .05).nnnCONCLUSIONnIn volume-controlled, mechanically ventilated patients with respiratory failure, tracheal gas insufflation with helium might be suggested as an alternative to oxygen.

Early oral analgesia after fast-track cardiac anesthesia.

Objectif nL’analgesie orale apres la technique acceleree d’anesthesie cardiaque n’a pas ete etudiee. Le but de cette etude etait de comparer deux regimes d’analgesie a l’oxycodone per os.PurposeOral analgesia after “fast-track” cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.MethodsOne hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I)per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II)per os every 12 hr and placebo twice daily. Acetaminophen 500 mgper os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mgper os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.ResultsBaseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.ConclusionPeroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.RésuméObjectifL’analgésie orale après la technique accélérée d’anesthésie cardiaque n’a pas été étudiée. Le but de cette étude était de comparer deux régimes d’analgésie à l’oxycodone per os.MéthodesCent- vingt patients devant subir une chirurgie de revascularisation myocardique ont été aléatoirement répartis en deux groupes après l’opération : le groupe I a reçu 5 mg d’oxycodone à libération immédiate et 325 mg d’acétaminophène (Percocet- 5) per os quatre fois par jour, et le groupe II a reçu 10 mg d’oxycodone à libération contrôlée (OxyContin) per os chaque 12 h et un placebo deux fois par jour. L’acétaminophène (500 mg per os) a été utilisé comme médicament de sauvetage de première intention et l’oxycodone (5 mg per os à libération immédiate sous forme de sirop) comme médicament de sauvetage de seconde intention. L’intensité de la douleur a été évaluée à l’aide d’une échelle visuelle analogue le premier jour après l’opération, le matin suivant l’extubation, puis quatre fois par jour pendant quatre jours. L’utilisation de médicaments de sauvetage ainsi que les complications ont été enregistrées.RésultatsLes caractéristiques démographiques de base ainsi que celles en rapport avec l’opération furent similaires dans les deux groupes. Bien que le contrôle de la douleur ait été bon dans les deux groupes, les patients du groupe à libération immédiate ont ressenti moins de douleur durant les jours suivant l’opération (P = 0,003), ont eu besoin d’une dose significativement moindre de médicaments de sauvetage, et ont subi moins d’événements négatifs tels que la somnolence ou la nausée.ConclusionL’oxycodone peroral est efficace pour un contrôle de la douleur précoce après une technique accélérée d’anesthésie cardiaque. L’oxycodone / acétaminophène à libération immédiate semble fournir une meilleure analgésie et moins d’effets secondaires que l’oxycodone à libération contrôlée.

The Relationship Between Women’s Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women’s initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72–2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = −8.6%, 95% CI, 16.2%–1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01–1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01–1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86–0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

L’analgésie orale précoce après la technique accélérée d’anesthésie cardiaque

Objectif nL’analgesie orale apres la technique acceleree d’anesthesie cardiaque n’a pas ete etudiee. Le but de cette etude etait de comparer deux regimes d’analgesie a l’oxycodone per os.PurposeOral analgesia after “fast-track” cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.MethodsOne hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I)per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II)per os every 12 hr and placebo twice daily. Acetaminophen 500 mgper os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mgper os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.ResultsBaseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.ConclusionPeroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.RésuméObjectifL’analgésie orale après la technique accélérée d’anesthésie cardiaque n’a pas été étudiée. Le but de cette étude était de comparer deux régimes d’analgésie à l’oxycodone per os.MéthodesCent- vingt patients devant subir une chirurgie de revascularisation myocardique ont été aléatoirement répartis en deux groupes après l’opération : le groupe I a reçu 5 mg d’oxycodone à libération immédiate et 325 mg d’acétaminophène (Percocet- 5) per os quatre fois par jour, et le groupe II a reçu 10 mg d’oxycodone à libération contrôlée (OxyContin) per os chaque 12 h et un placebo deux fois par jour. L’acétaminophène (500 mg per os) a été utilisé comme médicament de sauvetage de première intention et l’oxycodone (5 mg per os à libération immédiate sous forme de sirop) comme médicament de sauvetage de seconde intention. L’intensité de la douleur a été évaluée à l’aide d’une échelle visuelle analogue le premier jour après l’opération, le matin suivant l’extubation, puis quatre fois par jour pendant quatre jours. L’utilisation de médicaments de sauvetage ainsi que les complications ont été enregistrées.RésultatsLes caractéristiques démographiques de base ainsi que celles en rapport avec l’opération furent similaires dans les deux groupes. Bien que le contrôle de la douleur ait été bon dans les deux groupes, les patients du groupe à libération immédiate ont ressenti moins de douleur durant les jours suivant l’opération (P = 0,003), ont eu besoin d’une dose significativement moindre de médicaments de sauvetage, et ont subi moins d’événements négatifs tels que la somnolence ou la nausée.ConclusionL’oxycodone peroral est efficace pour un contrôle de la douleur précoce après une technique accélérée d’anesthésie cardiaque. L’oxycodone / acétaminophène à libération immédiate semble fournir une meilleure analgésie et moins d’effets secondaires que l’oxycodone à libération contrôlée.