Catecholamine Support Research Articles

Comparison of propofol and isoflurane anesthesia in orthotopic pig‐to‐baboon cardiac xenotransplantation

Orthotopic pig-to-baboon xenogeneic heart transplantation (oXHTx) is the only accepted preclinical animal model for cardiac xenotransplantation. We compared the hemodynamic stability of a propofol- and isoflurane-based anesthetic regimen during oXHTx. Hearts from 12 hDAF or hCD46 transgenic pigs (Sus scrofa; body weight 7 to 32 kg) were transplanted into baboons (Papio anubis and Papio hamadryas; body weight 9 to 26 kg) in the orthotopic life-supporting position. Animals received a propofol-based intravenous regimen or inhalation anesthesia with isoflurane. Analgesia was achieved with fentanyl in both groups. Systemic hemodynamic variables were measured before, during and after cardiopulmonary bypass (CPB) and the need for inotropic or vasoactive pharmacological support was compared before and after CPB. Global hemodynamic variables [i.e. heart rate, mean arterial pressure (MAP) and cardiac output] were not significantly different in propofol-anesthetized baboons compared to baboons anesthetized with isoflurane. Baboons anesthetized with isoflurane showed a trend towards less pharmacological support required to achieve an adequate MAP of >60 mmHg after CPB (propofol: epinephrine 0.13 [0.05; 0.16] and norepinephrine 0.15 [0.02; 0.16] microg/kg/min vs. isoflurane: epinephrine 0.05 [0.02; 0.08] and norepinephrine 0.06 [0.02; 0.19] microg/kg/min; no significant difference). Propofol and isoflurane appear to provide equal hemodynamic stability in orthotopic cardiac pig-to-baboon xenotransplantation prior to the start of CPB. The trend of a reduced catecholamine support needed after CPB, however, suggests that isoflurane may be the preferred drug for maintenance of anesthesia in this primate model.

Terlipressin as an adjunct vasopressor in refractory hypotension after tricyclic antidepressant intoxication

To report the management of cardiovascular failure refractory to standard catecholamine therapy with terlipressin in a patient with tricyclic antidepressant (TCA) intoxication. A 41-year-old woman, with suicidal ingestion of 11.25 g amitriptyline and 1500 mg diclofenac, was admitted to the emergency department. After 30 min in ventricular fibrillation, with ongoing CPR, she regained a potentially perfusing rhythm, but with hypotension refractory to standard catecholamine therapy with adrenaline, 2 microg/kg/min (norepinephrine); adrenaline, 1 microg/kg/min (epinephrine) until 55 min after admission. An injection of 1 mg terlipressin restored mean arterial blood pressure >65 mmHg within 10 min. Ten hours after admission to the intensive care unit, catecholamine support could be withdrawn because of a stable haemodynamic state. Within 7 days, all organ function recovered, and the patient regained full neurological function. Successful management of cardiovascular failure with terlipressin after TCA intoxication refractory to catecholamines suggests a potential role for terlipressin as an adjunct vasopressor in severely hypotensive patients.

Kasuistik interaktiv - Kreislaufdepression bei Narkoseeinleitung

Patients with coronary artery disease (CAD) undergoing noncardiac surgery (NCS) pose a special challenge for the anaesthesiologist, as the risk of serious perioperative cardiac complications, which represent a significant cause of morbidity and mortality, is increased in this population. Here we report about a patient with a solitary liver metastasis, who was admitted for hemihepatectomy. The patient with a known single vessel CAD, reporting no current cardiac problems, was cleared for the surgical procedure which carries a high risk of cardiac complications. Cardiology reports were present for evaluation. After an unremarkable placement of the peridural catheter and endotracheal intubation the patient presented with bradycardia and hypotension. Pharmacological resuscitation was initiated. After the patient was stabilized and the differential diagnosis suggested a cardiac problem, surgery was postponed. Following the end of anaesthesia, the patient remained in stable condition without catecholamine support. Coronary angiography on the next day revealed a progression of the CAD. The peridural catheter was removed before the intervention, Aspirin and clopidogrel were given on the same day. The patient was operated successfully without complications six weeks after the coronary intervention.

Propofol Infusion Syndrome???A Fatal Case at a Low Infusion Rate

To the Editor: We report the case of a 24-year-old male athlete who sustained a spinal injury, while competing in a Swiss wrestling contest. His third cervical vertebra was fractured, producing incomplete sensory and motor paraplegia. Upon admission to a regional hospital, the patient was treated with IV large-dose methylprednisolone (1). He unfortunately suffered from massive aspiration during initial magnetic resonance imaging, followed by acute respiratory distress syndrome (ARDS) and systemic inflammatory reaction syndrome (SIRS). The patient's trachea was intubated and his lungs were mechanically ventilated. He was sedated with propofol at a maximum infusion rate of 2.6 mg·kg−1· h−1. He required moderate adrenergic support. Cardiac troponin I (Trop I) and creatine kinase (CK) were increased 14 and 52 h after initiation of propofol sedation. (Fig. 1) The patient developed acute renal failure and was transferred to our hospital, a tertiary referral center, for further therapy. Before dialysis could be started, he suffered from pulseless bradycardia because of hyperkalemia, followed by massive cerebral edema. Further therapy was withheld, and the patient died.Figure 1.: Course of CK and Trop I levels and timing of medication. Immediately upon admission to the primary care hospital, steroids were given as an initial bolus infusion of 30 mg/kg followed by an infusion of 5.4 mg· kg−1 · h−1 for 23 h (1). Four hours after admission, sedation with propofol at a maximum infusion rate of 2.6 mg·kg−1 · h−1 (mean 1.9 mg· kg−1 · h−1) was started after tracheal intubation because of aspiration. The patient developed ARDS with an increasing need of catecholamine support 24 h after admission (dopamine: maximum 3.5 μg/min, norepinephrine: maximum 12 μg/min). Elevated CK was measured initially after 52 h (830 U/L) and increased Trop I after 14 h (3.56 ng/mL), after initializing sedation. Sedation with propofol was stopped upon admission to the tertiary referral hospital. Maximum level of CK and Trop I was 486,900 U/L and 6.3 ng/mL, respectively, on Day 6. The bars denote the timing of medication.Propofol infusion syndrome is defined by severe metabolic acidosis, rhabdomyolysis, renal failure, and cardiac failure in association with a prolonged propofol infusion, critical illness, and concurrent administration of catecholamines and steroids (2). Evidence for dose-dependent association between propofol use and propofol infusion syndrome (3) has led to guidelines recommending maximum propofol infusion rates of 4.8 mg· kg−1·h−1 (4) for long-term sedation in intensive care unit patients. Recent case reports describe propofol infusion syndrome after short-term (3–6 h) infusions, if infusion rates are high (5–7). Our patient presented with the features of propofol infusion syndrome. We have no other explanation for his rhabdomyolysis and cardiac failure. He received markedly less propofol than the maximum doses currently considered safe. To our knowledge, this is the first case of suspected propofol infusion syndrome in a patient receiving such low propofol infusion rates. We suggest considering alternative sedation regimes when risk factors for propofol infusion syndrome are present: ARDS, SIRS, and treatment with large-dose steroids or catecholamines. Tobias M. Merz, MD Bruno Regli, MD Hans-Ulrich Rothen, MD, PhD Clinic of Intensive Care Medicine University Hospital Bern Bern, Switzerland [email protected] Peter Felleiter, MD Intensive Care Unit Swiss Paraplegic Centre Nottwil Nottwil, Switzerland

Levosimendan for Weaning from Cardiopulmonary Bypass after Coronary Artery Bypass Grafting

Although cathecholamines are well-established agents of myocardial support during weaning from cardiopulmonary bypass (CPB), there has been little experience with a new inotropic agent, levosimendan. Our aim was to present our experience with levosimendan usage in patients manifesting failure-to-wean from CPB after coronary artery bypass grafting (CABG) when conventional inotropic and intraaortic balloon counterpulsation (IABP) therapies proved to be insufficient. Fifteen patients undergoing CABG received levosimendan as a loading dose of 12-24 microg/kg over 10 min, followed by a continuous infusion of 0.1-0.2 microg/(kg min) for 24h. Hemodynamic measurements were performed at baseline and at 1, 24 and 48 h postoperatively. Mean patient age was 63.2+/-2.2 years. CPB time was 149.7+/-19.5 min, while cross-clamp time was 67.8+/-10.5 min. All patients showed evidence of hemodynamic improvement with the start of levosimendan infusion and 14 patients (93.3%) were successfully weaned from CPB. Eight patients (53.3%) experienced significant increases in cardiac index and blood pressure leading to a lessening of the need for catecholamine support. Five patients (33.3%) were lost postoperatively in the ICU. Levosimendan appears to be useful in failure-to-wean from CPB after cardiotomy when conventional inotropic therapy proves inadequate.

Influence of eNOS Gene Polymorphisms (894G/T; - 786C/T) on Postoperative Hemodynamics After Cardiac Surgery

Differences in vascular reactivity have been associated with variable NO release due to 894G/T and -786C/T polymorphisms of the eNOS gene. Carriers of the 894T and -786C alleles are known to have enhanced vascular responsiveness to vasoconstrictor stimulation due to decreased NO generation. Thus, we hypothesized that eNOS gene polymorphism could influence perioperative hemodynamics and catecholamine support in patients undergoing cardiac surgery with CPB. In 105 patients undergoing elective CABG with CPB, systemic hemodynamics, cardiac index (CI), systemic and pulmonary vascular resistance indices (SVRI, PVRI) and catecholamine support were measured at baseline and 1 h, 4 h, 10 h and 24 h after CPB. Genotyping for the 894G/T and -786C/T eNOS gene polymorphisms was performed by polymerase chain reaction amplification. Patients were divided according to their genotype (894G/T: GG=group 1, GT and TT=group 2; -786C/T: TT=group 3, CT and CC=group 4). Genotype distribution for 894G/T polymorphism was 41% (GG), 52.4% (GT), 6.6% (TT) and for -786C/T polymorphism 37.1% (TT), 41.9% (CT) and 21% (CC). Pre- and intraoperative characteristics and systemic hemodynamics did not differ between groups. CI, SVRI and PVRI remained unaffected by genotype distribution. Statistical analysis of postoperative data revealed no difference between groups, especially for pharmacologic inotropic or vasopressor support. Also, coexistence of the 894T and -786C alleles had no impact on perioperative variables compared to homozygous 894G and -786T allele carriers. In contrast to current suggestions, the 894G/T and -786C/T genetic polymorphisms of the eNOS gene do not influence early perioperative hemodynamics after cardiac surgery with CPB.

Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective case control study

To compare surgical and endovascular stent graft (ESG) treatment of blunt thoracic aortic injury (BAI) in the emergency setting. Retrospective case control study in two surgical intensive care units of a university hospital. 30 patients who presented with BAI between 1995 and 2005: 17 treated surgically and 13 by ESG. The two groups were comparable for the severity of trauma and mean delay before treatment; the mean age was higher in the ESG group (46+/-18 vs. 35+/-15 years). In the surgical group time spent in the operating theater was longer (310+/-130 vs. 140+/-48 min) and blood losses higher (2000+/-1300 vs. no significant bleeding); aortic clamping time was 48+/-20 min. The mortality rate was 15% with ESG (n=2) and 23% with surgery (n=4). Complications of the procedure were more frequent in the surgical group (1 vs. 7). In the ESG group there was one pulmonary embolism. In the surgical group there were three neurological complications, one acute aortic dissection, one perioperative rupture, one periprosthetic leak, and one septic shock. Two complications (postoperative aortic dissection and paraplegia) appeared in the same patient in the surgical group. Intensive care unit length of stay, duration of mechanical ventilation, and catecholamine support were similar in the two groups. Stent graft for emergency treatment of BAI is efficient and is associated with fewer complications than surgical treatment.

Adrenergic inhibition of innate anti-viral response: PKA blockade of Type I interferon gene transcription mediates catecholamine support for HIV-1 replication

Type I interferons (IFN-α and -β) play a key role in anti-viral immunity, and we sought to define the molecular mechanisms by which the sympathetic nervous system (SNS) inhibits their effects. In peripheral blood leukocytes and plasmacytoid dendritic cells (pDC2), induction of interferon anti-viral activity by double-stranded RNA (poly-I:C) or CpG DNA was substantially inhibited by norepinephrine and by pharmacologic activation of the cAMP/PKA signaling pathway. This effect was specific to Type I interferons and driven by PKA-mediated repression of IFNA and IFNB gene transcription. Luciferase reporter analyses identified tandem interferon response factor-binding sites in positive regulatory domains I and III of the IFNB promoter as a key target of PKA inhibition. PKA suppression of Type I interferons was associated with impaired transcription of interferon response genes supporting the “anti-viral state”, and was sufficient to account for norepinephrine-induced enhancement of HIV-1 replication. Given the ubiquitous role of Type I interferons in containing viral replication, PKA-mediated inhibition of IFN transcription could explain the stimulatory effects of catecholamines on a broad range of viral pathogens.

Prognostic Significance of Inverted T Waves in Patients With Acute Pulmonary Embolism

The significance of inverted T waves remains unclear in patients with acute pulmonary embolism (PE). The relationship of the number of leads with inverted T waves to the severity of PE in 40 patients with acute PE was studied. Patients were classified into 3 groups according to the number of leads with inverted T waves on the admission electrocardiogram (ECG): 15 patients, <or=3 leads (group L); 12 patients, 4-6 leads (group M); and 13 patients, >or=7 leads (group H). In groups L, M and H, the rates of right ventricular dysfunction on echocardiography were 47%, 92% and 100% (p<0.01), respectively, and the rates of in-hospital complicated events (including death or the need for catecholamine support, cardiopulmonary resuscitation or mechanical cardiovascular support because of hemodynamic instability) were 0%, 8% and 46% (p=0.004), respectively. On multivariate analysis, arterial hypotension at presentation (odds ratio (OR) 8.96, p=0.049) and inverted T waves in >or=7 leads on the admission ECG (OR 16.8, p=0.037) were the only independent predictors of in-hospital complicated events. The number of leads with inverted T waves may be a useful and simple marker of increased risk for early complications in patients with acute PE.

Reality confusion in spontaneous confabulation

A woman produced spontaneous confabulations after rupture of an anterior communicating artery aneurysm. She confused currently irrelevant with currently relevant information in implicit memory; confabulations about people concerned only new acquaintances; false reality could be induced by an intensive 5-minute discussion; and in a recognition task, she confused false repetitions in another modality with real item repetitions. The findings support the theory that the defect causing spontaneous confabulation precedes conscious memory processing.

Gastrointestinal manifestations in severe scorpion envenomation

To evaluate the type and incidence of gastrointestinal manifestations secondary to scorpion envenomation and their prognostic significance. All patients admitted to our ICU for scorpion envenomation were included in this retrospective chart review of a 13-year period (1990 - 2002). During the study period, 951 patients were admitted for scorpion envenomation and 72 (7.6%) died. Ages ranged from 0.5 to 90 years with a mean of 14.7 +/- 17.4 years. Gastrointestinal symptoms were present in 700 patients (73.6%): nausea in 24 (2.5%), vomiting in 687 (72.2%) and diarrhea in 41 patients (4.3%). At univariate analysis, the presence of diarrhea was associated with a fatal outcome (P < 0.05). Diarrhea was also correlated with other indicators of severe envenomation and poor prognosis: respiratory failure (P = 0.01), neurological failure (P < 0.0001), liver failure (P < 0.0001) and low blood pressure requiring catecholamine support (P = 0.02). The multivariate analysis showed that young age (age less than 5 years), fever > 38.5 degrees C, neurological failure and pulmonary edema were independent factors of severity. Digestive disorders were more frequent in children and in this subgroup diarrhea appeared to be associated with poor outcome. In a subset of patients for whom data were available, fatal cases demonstrated significantly higher liver enzymes levels on admission. In Tunisia, gastrointestinal symptoms are often observed in severe scorpion envenomations, especially in young patients. In children, diarrhea and elevated liver enzymes are associated with poor prognosis.

Beneficial hemodynamic response of transthoracic cardiac pacing in a 2 kg preterm neonate

To describe the beneficial hemodynamic effect of transthoracic external pacing compared with epicardial pacing in a 2 kg premature neonate with congenital complete heart block, hydrops and complex congenital heart disease. Transthoracic epicardial pacing was instituted at a rate of 120 beats/min to treat life-threatening bradycardia (HR 50-60 beats/min), hypotension (BP 45/20 mmHg) and severe lactic acidosis (pH 7.18, lactate 7.5 mmol/l) despite significant catecholamine support. Due to the size of the patient, the external pacing electrodes were placed on the back and front of the patient's chest. To achieve ventricular capture, the electric output had to be increased to 140 mA, resulting in symmetric chest movements. Transthoracic pacing resulted in an immediate improvement of the cardiovascular status, with an adequate blood pressure (BP 60/25 mmHg) and normalization of acid-base-balance. After the insertion of an epicardial pacemaker (paced rate at 140 beats/min), a significantly lower blood pressure was achieved (BP 50/25 mmHg), indicating an additive effect of the rhythmic chest movements to the blood pressure. Unfortunately, third-degree burns were detected on the patients back 1 day after pacemaker insertion. Transthoracic pacing is a life-saving option in an emergency situation, when maximal pharmacological support fails to maintain adequate cardiac output. It may have some additional beneficial effect on blood pressure generation in these patients. To prevent skin injury, the output used needs to be as low as feasible, and the period of pacing as brief as practicable.

Choc peranesthésique d'étiologie probablement anaphylactique à l'atracurium traité avec succès par circulation extracorporelle

We report the case of a 55-year-old woman ASA 2 scheduled for a cholecystectomy, who presented 25 minutes after the induction, a circulatory arrest probably due to a cardiac anaphylaxis attributed to atracurium. After 60 minutes of futile resuscitation without any spontaneous cardiac rhythm a percutaneous cardiopulmonary bypass (CPB) was initiated. Twenty minutes later and after three external electric shocks electric cardiac activity returned normal. The weaning was possible 120 minutes later with catecholamine support. She left the intensive care unit on postoperative day seven after a laparotomy secondary to splenic injury due to intensive cardiopulmonary resuscitation. She was discharged home without any neurologic or cardiac sequellae. Biological assessment done during the circulatory arrest and cutaneous tests performed ten weeks later confirmed an isolated allergy to atracurium. CPB is the most efficient support in case of reversible cardiac arrest but unfortunately the less accessible outside from cardiac surgery unit.

Low Weight in Congenital Heart Surgery: Is it the Right Way?

There is ample evidence that premature and low birth weight children have a poor outcome after congenital heart surgery. The aim of the present study was to characterize the perioperative factors which significantly influence the outcome of these babies following cardiac surgery, and to clarify whether the RACHS-1 and the Aristotle score are compatible for this complex kind of heart surgery. During the past 10 years, 108 children with a body weight of less than 3000 g were operated, including 43 premature babies. Mean weight at operation was 2.5 +/- 0.5 kg, mean age was 36.8 +/- 55 days. Fifty percent of the treatments were categorized into risk groups 4 and 6 and 54 % belonged to the complexity levels 3 and 4. Eighty-one operations (75 %) were performed using extracorporeal circulation. The 30 day mortality rate was 18 %, and the overall mortality rate was 30 %. The correlation between mortality rates and risk groups was significant ( p < 0.001). Other significant factors were preoperative acidosis ( p = 0.026), preoperative catecholamine support ( p < 0.001), prolonged ICU stay (> 7 days) after operation ( p < 0.001), and postoperative infection ( p = 0.019). In addition, X-clamp time ( p = 0.029) and palliative procedures ( p < 0.001) were significant factors for poor outcome. The results demonstrate that the mortality for correction of congenital heart defects in children weighing less than 3000 g depends on several factors. The risk groups of the RACHS-1 study and the complexity levels of the Aristotle score are useful tools to assess preoperative risk.

Experience and result of extracorporeal membrane oxygenation in treating fulminant myocarditis with shock: What mechanical support should be considered first?

Background Extracorporeal membrane oxygenation (ECMO), instead of ventricular assist device (VAD), could work as the first-line treatment of choice for fulminant myocarditis (FM) with profound shock if intraaortic balloon pumping was inadequate. We reviewed our experience in treating FM with ECMO and compared it with the literature that described the use of VAD. Methods Fifteen consecutive patients (age 27.1 ± 19.3 years) who had FM with profound shock were rescued with ECMO emergently. Hypotension, depressed left ventricular ejection fraction (19.1% ± 6.1%), and oliguria occurred in all patients with high-dose catecholamine (inotropic equivalents: 69.0 ± 37.7 μg/kg/min) and ventilator support. Before ECMO support, 6 patients received intraaortic balloon pumping support, 5 received external cardiac massage, 5 needed a temporary pacemaker, and 4 needed continuous hemofiltration. The pre-ECMO cardiac enzyme and liver enzyme levels were abnormally high. Results Fourteen patients (93.3%) could be weaned off mechanical support. Three of 14 successfully weaned patients died later as a result of complications. Survival to discharge was 73.3%, and none of survivors needed heart transplantation. The ECMO duration was 137.7 ± 74.5 hours. The ECMO-related neurological complication (6.7%) and the reexploration rate for hemostasis (8.9%) were lower than the myocarditis group supported by VAD from the literature review. The 11 survivors exhibited no cardiac dysfunction during the follow-up period. Conclusions Owning to advantages of fewer complications, easier application, and biventricular support, ECMO can be considered as the first-line treatment of mechanical support for FM with profound shock when intraaortic balloon pumping is inadequate or infeasible.

Gemtuzumab Ozogamicin (Mylotarg®) in Children with Refractory or Relapsed Acute Myeloid Leukemia

Background: Gemtuzumab ozogamicin (GO) is an immunoconjugate consisting of the CD33 antibody and calicheamicin, a potent cytotoxic agent. Developed for targeted treatment of CD33-positive AML, studies in adults showed its efficacy in relapsed and refractory AML. Patients and Method: We report 12 children with multiple relapsed or refractory AML receiving GO as compassionate use. 11 children had initially been treated according to the AML-BFM 93 or 98 protocol, 1 girl received relapse treatment (liposomal daunorubicin/FLAG) due to secondary AML. After relapse, 10 children received an intensive relapse therapy (AML-BFM 97 or international AML-Relapse Study 2001/01). 2 of them had been transplanted in first or second CR before GO therapy. Results: 5 of 12 children responded to treatment with blast reduction to below 5%, but no child achieved CR after GO. Time until reoccurrence of blasts in almost all children with GO response was 3–8 months. In 5 children stem cell transplantation (SCT) was performed after GO therapy. 4 of them suffered from further progression of AML, 1 boy is in second remission with a follow-up of 8 months. 2 children had severe side effects. An anaphylactic reaction with severe hypotension was managed by catecholamine support and intensive care. In 1 girl, who relapsed after SCT in first remission, a veno-occlusive disease of the liver occurred, but could be treated successfully with defibrotide. Conclusion: GO therapy can induce blast reduction in children who have no further conventional treatment options. Frequency and severity of adverse events are limited, and therapy seems to be feasible for children with a sufficient general condition. Controlled studies are necessary to learn more about efficacy and side effects, especially implications for further therapy.

Recently published papers: inflammation, elucidation, manipulation?

Recently published papers: inflammation, elucidation, manipulation?

Predictors of survival in unselected patients with acute myocardial infarction requiring continuous catecholamine support

Background: Several predictors of survival have been described in selected subgroups of patients suffering from acute myocardial infarction. However, data on unselected patients with acute myocardial infarction and cardiogenic shock, including patients with out-of hospital cardiac arrest, are missing. We aimed to assess predictors of survival for an unselected cohort of patients representative of clinical practice who experienced acute myocardial infarction and required continuous catecholamine support for circulatory failure. Methods: The study was performed at a 2000 bed university hospital. All consecutive patients admitted to our emergency department with acute myocardial infarction were prospectively enrolled in a clinical trial from 1993 to 2000. Design: A retrospective cohort study was performed on patients with myocardial infarction requiring catecholamine support within the first 24 h. Primary endpoint was in-hospital mortality. Results: The analysis was carried out on 262 patients, 189 men (72%), median age 65 years (IQR 53–73). Out-of-hospital cardiac arrest was reported in 47% (122/262). In-hospital mortality was 53% (138/262). Survivors as compared to non-survivors exhibited significant differences with respect to age (60 vs. 68 years, P<0.0001), systolic and diastolic blood pressure on admission (110 vs. 102 mmHg, P=0.01 and 64 vs. 58 mmHg, P=0.006, respectively), initial blood serum lactate (6.8 vs. 8.3, P=0.01), peak CKMB level (93 vs. 138 U/l, P=0.005), use of adrenaline (epinephrine) (38 vs. 68%, P<0.0001) and any attempt of revascularisation (76 vs. 63%, P=0.03). In a multivariate model younger age [OR 1.06 (CI 1.03–1.10), P<0.001], no use of adrenaline [OR 2.63 (CI 1.35–5.26) P=0.005] and lower peak CKMB [OR 1.01 (CI 1.01–1.01), P<0.0001] were independently associated with in-hospital survival. Conclusion: In unselected patients including CPR survivors with acute myocardial infarction requiring continuous catecholamine support, younger age, the absence of continuous adrenaline administration and a lower peak CKMB were independently associated with increased in-hospital survival.

When is the seriously ill patient ready to be fed?

After assessing the critically ill patient for risk of aspiration, the clinician still must decide if the patient is ready to be fed. The goal is to identify critically ill patients who are likely to tolerate enteral nutrition and attempt to minimize complications. A synthesis of the both clinical and animal studies to identify factors related to patient readiness for enteral nutrition. The key issue to be resolved is adequacy of resuscitation and restoration of mesenteric perfusion. Currently, there is no reliable clinical tool to measure gut perfusion. The best indicators currently are stabilization of vital signs, decreasing fluid and blood requirements, normalization of the base deficit, and lactate and removal of inotropic or vasopressor support. Most critically ill patients should be ready for enteral nutrition within 24 to 48 hours of intensive care unit admission. Critically ill patients who need catecholamine support, heavy sedation, or therapeutic neuromuscular blockade should probably not receive enteral nutrition until they have been stabilized.

Combined grafting of thoracic aortic aneurysm and cardiac repair using continuous cold-blood coronary perfusion.

For patients diagnosed with combined thoracic aortic aneurysms and cardiac lesions, we conduct a 1-stage operation for ascending and aortic arch grafting. We studied surgical outcome comparatively with patients undergoing aortic grafting alone. For descending and thoracoabdominal aortic grafting, we choose a 2-stage operation. Subjects were 80 patients undergoing ascending and aortic arch aneurysm repair between June 1994 and March 1999. Group 1 consisted of 30 undergoing simultaneous cardiac repair. Concomitant cardiac procedures involved 21 valvular, 5 coronary arterial, and 4 valvular and coronary arterial surgeries. Group 2 consisted of 50 undergoing aortic grafting alone. We used crystalloid cardioplegia and additional antegrade continuous cold-blood coronary perfusion in Group 1, and crystalloid cardioplegia alone in Group 2. Hospital mortality was 10% in Group 1 and 2% in Group 2. Surgery length, cardiopulmonary bypass time, and aortic cross-clamping time in Group 1 were significantly longer than Group 2. Myocardial ischemic time did not differ significantly. Postoperative ICU stay, mechanical ventilation time and catecholamine support time did not differ significantly. Actuarial survival was 66.9 +/- 13.1% at 52 months in Group 1 and 87.2 +/- 4.8% at 57 months in Group 2 (p = 0.2918). Simultaneous cardiac repair and ascending and aortic arch aneurysm repair were conducted using continuous cold-blood coronary perfusion. Hospital mortality and mid-term survival did not differ significantly between groups.