P. C. Bergonzi

Medical emergency team and non-invasive ventilation outside ICU for acute respiratory failure.

ObjectiveTo report data about “real-life” treatments with non-invasive ventilation for acute respiratory failure (ARF), managed outside intensive care units by anaesthesiologists acting as a medical emergency team.DesignObservational study; prospectively collected data over a 6-month period in a single centre.SettingNon-intensive wards in a University Hospital with 1,100 beds.PatientsConsecutive patients with ARF for whom a ventilatory support was indicated but tracheal intubation was not appropriated or immediately needed.InterventionsNone.Measurements and resultsPatient’s characteristics, safety data, short-term outcome and organizational aspects of 129 consecutive treatments were collected. The overall success rate was 77.5%, while 10.1% were intubated and 12.4% died (all of them were “do not attempt resuscitation” patients). The incidence of treatment failure varied greatly among different diseases. Complications were limited to nasal decubitus (5%), failure to accomplish the prescribed ventilatory program (12%), malfunction of the ventilator (2%) and excessive air leaks from face mask (2%) with no consequences for patients. Three patients became intolerant to NIV. The work-load for the MET was high but sustainable: on average NIV was applied to a new case every 34xa0h and more than three patients were simultaneously treated.ConclusionsUnder the supervision of a MET, in our institution NIV could be applied in a wide variety of settings, outside the ICU, with a high success rate and with few complications.

Mortality in multicenter critical care trials: An analysis of interventions with a significant effect

Objectives:We aimed to identify all treatments that affect mortality in adult critically ill patients in multicenter randomized controlled trials. We also evaluated the methodological aspects of these studies, and we surveyed clinicians’ opinion and usual practice for the selected interventions. Data Sources:MEDLINE/PubMed, Scopus, and Embase were searched. Further articles were suggested for inclusion from experts and cross-check of references. Study Selection:We selected the articles that fulfilled the following criteria: publication in a peer-reviewed journal; multicenter randomized controlled trial design; dealing with nonsurgical interventions in adult critically ill patients; and statistically significant effect in unadjusted landmark mortality. A consensus conference assessed all interventions and excluded those with lack of reproducibility, lack of generalizability, high probability of type I error, major baseline imbalances between intervention and control groups, major design flaws, contradiction by subsequent larger higher quality trials, modified intention to treat analysis, effect found only after adjustments, and lack of biological plausibility. Data Extraction:For all selected studies, we recorded the intervention and its comparator, the setting, the sample size, whether enrollment was completed or interrupted, the presence of blinding, the effect size, and the duration of follow-up. Data Synthesis:We found 15 interventions that affected mortality in 24 multicenter randomized controlled trials. Median sample size was small (199 patients) as was median centers number (10). Blinded trials enrolled significantly more patients and involved more centers. Multicenter randomized controlled trials showing harm also involved significantly more centers and more patients (p = 0.016 and p = 0.04, respectively). Five hundred fifty-five clinicians from 61 countries showed variable agreement on perceived validity of such interventions. Conclusions:We identified 15 treatments that decreased/increased mortality in critically ill patients in 24 multicenter randomized controlled trials. However, design affected trial size and larger trials were more likely to show harm. Finally, clinicians view of such trials and their translation into practice varied.

Sedation Interruption for Mechanically Ventilated Patients

In the study by Dr Mehta and colleagues,1 we have some concerns about the implementation of the protocols used. The degree of sedation in patients who are mechanically ventilated should provide them comfort and allow their cooperation

Sedation in paediatric patients affected by Metachromatic Leukodystrophy: A-626

compare the recovery from DES or SEV anaesthesia in elderly patients. Materials and Methods: 40 patients 65 years, ASA II–III scheduled for elective oncologic abdominal surgery were randomly assigned to receive either DES (n 20) or SEV (n 20) as inhalation agents for maintenance of anaesthesia (0.6–0.8 MAC) in 40% of oxygen. Induction of anaesthesia was performed with remifentanil (1 g/kg), propofol, rocuronium and maintained with remifentanil infusion (0.2–0.5 g/kg/min) and with selected inhaled anaesthetics (DES or SEV). At the end of the surgery, anaesthetics were discontinued and fresh gas flow was maintained with oxygen 100%. The times to spontaneous ventilation, eye opening, extubation and orientation to name and date of birth were recorded. Student t test was used for statistical analysis. Data are expressed as mean SD and p 0.05 was considered significant. Results and Discussions: Both groups were comparable in respect of demographic data, anaesthetic dosages and duration of anaesthesia, also BP and HR remained within 20% of baseline value. Recovery times were significantly shorter for desflurane than for sevoflurane. Conclusion(s): Desflurane was associated with a faster recovery than sevoflurane after anaesthesia for onchologic abdominal surgery in elderly patients. References: 1 Heavner JE, et al. Br J Anaesth 2003; 91: 502–6. 2 Chen X, et al. Anesth Analg 2001; 93: 1489–94. Paediatric anaesthesia and intensive care 163