Vasoactive Drug Therapy Research Articles

Haemodynamic effect of dexmedetomidine during paediatric kidney transplantation.

Dexmedetomidine is increasingly used for its ability to stabilise haemodynamic status during general anaesthesia. However, there is currently no data on paediatric kidney transplant recipients (pKTR). This study investigates the haemodynamic impact of dexmedetomidine administered perioperatively in pKTR. From 2019 to 2023, a retrospective study was conducted at Nantes University Hospital involving all pKTR under 18 years of age. The study compared intraoperative haemodynamic parameters between patients administered dexmedetomidine during kidney transplantation (DEX group) and those who did not receive it (no-DEX group). Mean arterial pressure (MAP) and heart rate (HR) were monitored throughout the duration of anaesthesia and compared. Graft function was assessed based on creatinine levels and glomerular filtration rate (GFR) at specific intervals. The perioperative use of fluids and vasoactive drugs, as well as their administration within 24 h post-surgery, were analysed. Thirty-eight patients were enrolled, 10 in the DEX group and 28 in the no-DEX group. Intraoperative HR was similar between the groups; however, MAP was higher in the DEX group (mean difference 9, standard deviation (SD, 1-11) mmHg, p = 0.039). No differences were found regarding the use of fluid and vasoactive drug therapy between groups. GFR at 1 month post-transplantation was significantly elevated in the DEX group (p = 0.009). pKTR receiving intraoperative dexmedetomidine exhibited higher perioperative MAP compared to those not administered dexmedetomidine. Additionally, the DEX group demonstrated superior graft function at 1 month. The direct impact of dexmedetomidine on immediate postoperative graft function in pTKR warrants further investigation in a prospective multicentre randomised study.

Risk factors for postoperative acute kidney injury after major abdominal surgery.

Acute kidney injury (AKI) worsens the outcome in a significant number of hospitalized patients. Risk models mainly address cardiac surgery, while significantly less attention is paid to AKI after major abdominal surgery (MAS). This study aims to evaluate the incidence, along with risk factors, and intrahospital outcomes of AKI after MAS. Our retrospective study included 200 adult patients treated with MAS (in the same institution). Exclusion criteria were obstructive nephropathy, contrast-induced nephropathy, and dialysis dependence whether due to end-stage renal disease (ESRD) or AKI before MAS. Data on preoperative, intraoperative, as well as postoperative variables were collected from patients' medical history and electronic medical records. AKI was diagnosed in 33 (16.5%) patients, with 2 patients treated with hemodialysis. The multivariate logistic regression model showed that the number of intraoperative blood transfusions (p=0.01), pneumonia (p<0.001), and vasoactive drug use (p=0.02) were independently associated with postoperative AKI. Each blood transfusion administered increased the risk of developing AKI by 1.41, vasoactive drug use by 4.13, and the risk of AKI in those with pneumonia was 15.32 times higher. The lethal outcome was observed significantly more frequently in patients with AKI (39.4 vs. 4.8%, p<0.001). Identification of independent predictors of AKI after MAS such as the number of transfusions during surgery, sepsis, pneumonia, and the need for vasoactive drug therapy could help prevent AKI and lower the probability of lethal outcomes after MAS.

Retracted: Vasoactive Drug Therapy and Clinical Nursing of Patients with Cardiovascular Disease

Retracted: Vasoactive Drug Therapy and Clinical Nursing of Patients with Cardiovascular Disease

Epidemiology and clinical characteristics of pediatric sepsis in PICUs of China: A national cross-sectional study.

Epidemiology and clinical characteristics of pediatric sepsis in PICUs of China: A national cross-sectional study.

Precision fluid and vasoactive drug therapy for critically ill patients.

There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.

Enteral nutrition in critically ill patients under vasoactive drug therapy: The NUTRIVAD study.

Enteral nutrition (EN) in critically ill patients requiring vasoactive drug (VAD) support is controversial. This study assesses the tolerability and safety of EN in such patients. This prospective observational study was conducted in 23 intensive care units (ICUs) over 30 months. Inclusion criteria were a need for VADs and/or mechanic circulatory support (MCS) over a minimum of 48 h, a need for ≥48 h of mechanical ventilation, an estimated life expectancy >72 h, and ≥72 h of ICU stay. Patients with refractory shock were excluded. EN was performed according to established protocols during which descriptive, daily hemodynamic and efficacy, and safety data were collected. An independent research group conducted the statistical analysis. Of 200 patients included, 30 (15%) required MCS and 145 (73%) met early multiorgan dysfunction criteria. Mortality was 24%. Patients needed a mean dose of norepinephrine in the first 48 h of 0.71 mcg/kg/min (95% CI, 0.63-0.8) targeting a mean arterial pressure of 68 mm Hg (95% CI, 67-70) during the first 48 h. EN was started 34 h (95% CI, 31-37) after ICU admission. Mean energy and protein delivered by EN/patient/day were 1159 kcal (95% CI, 1098-1220) and 55.6 g (95% CI, 52.4-58.7), respectively. Daily energy balance during EN/patient/day was -432 (95% CI, -496 to -368). One hundred and fifty-four (77%) patients experienced EN-related complications. However, severe complications, such as mesenteric ischemia, were recorded in only one (0.5%) patient. EN in these patients seems feasible, safe, and unrelated to serious complications. Reaching the energy target only through EN is difficult.

Vasoactive Drug Therapy and Clinical Nursing of Patients with Cardiovascular Disease.

Cardiovascular disease (CVD) is a common human disease with a large number of patients. Vasoactive drugs have a good effect on the contraction and expansion of blood vessels, which can provide certain help for the management of cardiovascular diseases. However, the clinical care of cardiovascular disease has always been based on the superficial resistance level of body fat, weight, and so on, which is unfavorable for the real recovery of patients with cardiovascular disease. This article aims to quantitatively evaluate the effects of clinical care based on vasoactive drug therapy and intrinsic factors of cardiovascular disease. For the treatment of vasoactive drugs, this paper selects the principle of action of the adrenal hormone to judge and analyze the expansion and contraction of the cardiovascular disease. For the clinical nursing of patients with cardiovascular disease, based on multivariate logistic regression, this paper selects internal factors such as age and blood pressure to model the nursing effect. Experiments have shown that the logistic regression model established in this paper can evaluate well the recovery effect of patients with cardiovascular disease. The AUC value of the model reached around 0.9. This showed that the clinical care of patients with cardiovascular disease can not only rationally judge the recovery effect through the model but also adjust the physical and mental conditions of patients with cardiovascular disease according to the coefficients of the model to achieve the best recovery effect.

Utilizing reclassification to explore characteristics and prognosis of KDIGOSCr AKI subgroups: a retrospective analysis of a multicenter prospective cohort study

Background Acute kidney injury (AKI) is widespread in the intensive care unit (ICU) and affects patient prognosis. According to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, the absolute and relative increases of serum creatinine (Scr) are classified into the same stage. Whether the prognosis of the two types of patients is similar in the ICU remains unclear. Methods According to the absolute and relative increase of Scr, AKI stage 1 and stage 3 patients were divided into stage 1a and 1b, stage 3a and 3b groups, respectively. Their demographics, laboratory results, clinical characteristics, and outcomes were analyzed retrospectively. Results Of the 345 eligible cases, we analyzed stage 1 because stage 3a group had only one patient. Using 53 or 61.88 µmol/L as the reference Scr (Scrref), no significant differences were observed in ICU mortality (P53 =0.076, P61.88 =0.070) or renal replacement therapy (RRT) ratio, (P53 =0.356, P61.88 =0.471) between stage 1a and 1b, but stage 1b had longer ICU length of stay (LOS) than stage 1a (P53 <0.001, P61.88 =0.032). In the Kaplan-Meier survival analysis, no differences were observed in ICU mortality between stage 1a and 1b (P53 =0.378, P61.88 =0.255). In a multivariate analysis, respiratory failure [HR = 4.462 (95% CI 1.144–17.401), p = 0.031] and vasoactive drug therapy [HR = 4.023 (95% CI 1.584–10.216), p = 0.003] were found to be independently associated with increased risk of death. Conclusion ICU LOS benefit was more prominent in KDIGOSCr AKI stage 1a patients than in stage 1 b. Further prospective studies with a larger sample size are necessary to confirm the effectiveness of reclassification.

Chinese expert consensus on the diagnosis and treatment of severely and critically ill patients with coronavirus disease 2019.

Chinese expert consensus on the diagnosis and treatment of severely and critically ill patients with coronavirus disease 2019.

1228 A CASE OF PULMONARY HYPERTENSION AND SEVERE OBSTRUCTIVE SLEEP APNEA IN A PEDIATRIC PATIENT WITH DOWN SYNDROME

Abstract Introduction Children with Down syndrome (DS) are at risk for obstructive sleep apnea (OSA) and related health consequences. Adherence to treatment plans, especially positive airway pressure (PAP), can be difficult for people with DS. We present a case of a pediatric patient with DS who developed pulmonary arterial hypertension (PAH) due to poor adherence of OSA therapy. Report of Case A 4-year-old male with a past medical history of DS was diagnosed with severe OSA and hypoventilation at 18 months of age – AHI 27, (oAHI 27), CO2 above 50 mmHg for 53.2% of total sleep time (TST)). A titration study showed that on a bi-level pressure (BPAP) of 11/6 cm H2O his OSA was improved – AHI 5.9 (oAHI 3.7), O2 nadir of 93%. The family attempted PAP at home but discontinued after 2 weeks. He underwent an adenoidectomy at 22 months of age and tonsillectomy and repeat adenoidectomy at 40 months of age. Patient presents to the emergency center with respiratory distress. Chest films showed cardiomegaly. Echocardiogram revealed evidence of worsening PAH (tricuspid regurgitation of 3.5-3.8 m/s and flattening of the interventricular septum). He was admitted to the pediatric intensive care unit for further management of his PAH attributed to his underlying uncorrected OSA and hypoventilation. Repeat polysomnogram showed continue severe OSA and hypoventilation – AHI 30.3 (oAHI 30.3) CO2 above 50 mmHg for 89% of TST. Repeat titration study showed that a pressure of 11/7 cm H2O improved his OSA– AHI 6.4 (oAHI 6.4) CO2 max of 52 mmHg. Treatment with BPAP was initiated prior to discharge. Repeat echocardiogram 2 months after admission showed improvement of the PAH while on BPAP without additional vasoactive drug therapy. Conclusion Children with DS are at high risk for OSA. Although treatment can be difficult, proper management of the OSA essential to preventing potential serious health consequences.

Is additional 5-day vasoactive drug therapy necessary for acute variceal bleeding after successful endoscopic hemostasis?: A systematic review and meta-analysis.

Background:Vasoactive drugs and endoscopic therapy have been widely used in the management of acute variceal bleeding of cirrhosis patients. The current standard regimen of vasoactive drugs is in combination with endoscopic therapy and continues for up to 5 days; however, the necessity of vasoactive drugs after endoscopic hemostasis was still controversial. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs after hemorrhage control by endoscopic therapy.Methods:A search was conducted of PubMed, EMBASE, and Cochrane Library databases until June, 2018. Lan DeMets sequential monitoring boundary was constructed to assess the reliability and conclusiveness of our major results.Results:Seven studies (639 patients) and 4 studies (435 patients) were included in the analyses to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs therapy, respectively. Our analyses showed that adjuvant vasoactive drugs facilitated endoscopic hemostasis and reduced very early re-bleeding rate both in sclerotherapy (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.34–0.78, P = .23, I2 = 31%) and band ligation (RR 0.48, 95% CI 0.27–0.83, P = .07, I2 = 62%). However, the 3 to 5-day therapy duration was not superior to a shorter course in very early re-bleeding rate and mortality rate in 42 days (RR 1.77, 95% CI 0.64–4.89, P = .70, I2 = 0%; RR 0.95, 95% CI 0.43–2.13, P = .81, I2 = 0%, respectively).Conclusion:Additional 5-day vasoactive drug after endoscopic hemostasis may significantly ameliorate very early re-bleeding rate, However, the 3 to 5 days’ adjuvant regimen was not superior to a shorter course.

Impact of the implementation of vasoactive drug protocols on safety and efficacy in the treatment of critically ill patients

The correct management of high-alert medications is a priority issue in expert recommendations for improving the clinical safety of patients. Objectives were to assess the impact of the implementation of vasoactive drug (VAD) protocols on safety and efficacy in the treatment of critically ill patients. A prospective before-and-after study on the implementation of different VAD protocols, comparing medication errors (MEs) rates, mean intensive care unit (ICU) stay, mean blood pressure (MAP), heart rate (HR) and oxygen saturation. The study included 432 patients. There was a statistically significant decrease in prescribing errors (55·9%), validation errors (68·1%) and medication administration records (MAR) errors (78·8%). No differences were found between the two phases in ICU stay, MAP, HR and oxygen saturation. Implementation of protocols decreases variability in clinical practice, reduces the incidence of MEs and maintains the effectiveness of VAD therapy in critically ill patients.

Treatment of acute esophageal variceal bleeding in cirrhotic patients

Esophageal variceal bleeding is the most dangerous complication in cirrhotic patients and is accompanied by high mortality. Treatment strategy involves early diagnosis, maintaining vital body functions and specific therapy aimed at the provision of local hemostasis and reduction of portal pressure. To this end, it is currently recommended to combine vasoactive drug (mainly, terlipressin or somatostatin) therapy with endoscopic methods of hemostasis (sclerotherapy or ligation). The use of Sengstaken-Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. Although transjugular intrahepatic portosystemic shunting is an extremely useful technique for the treatment of acute bleeding from esophageal varices, currently it is viewed as second-line therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt for technical or organizational reasons or due to anatomic problems. Among surgical operations described in the literature are various kinds of portocaval anastomoses and azygoportal disconnection procedure. To improve the results of treatment of cirrhotic patients with acute esophageal variceal bleeding it seems important to stratify them by risk groups, which will allow one to tailor therapeutic approaches to the expected results. For example, to initiate early use of more aggressive methods in patients with predictors of poor outcomes, and to protect individuals with a good prognosis from unnecessary invasive procedures. It is hoped that further research will refine this hypothesis.

Influence of Acute Kidney Injury Defined by the Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease Score on the Clinical Course of PICU Patients.

To evaluate the predictive value of the pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease criteria for disease course severity in patients with or without acute kidney injury admitted to a PICU. Retrospective cohort study. A 12-bed PICU at a tertiary referral center in Southern Brazil. All patients admitted to the study unit over a 1-year period. A database of all eligible patients was analyzed retrospectively. Patients were classified by pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease score at admission and worst pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease score during PICU hospitalization. The outcomes of interest were length of PICU stay, duration of mechanical ventilation, duration of vasoactive drug therapy, and mortality. The Pediatric Index of Mortality 2 was used to assess overall disease severity at the time of PICU admission. Of 375 patients, 169 (45%) presented acute kidney injury at the time of admission and 37 developed acute kidney injury during PICU stay, for a total of 206 of 375 patients (55%) diagnosed with acute kidney injury during the study period. The median Pediatric Index of Mortality 2 score predicted a mortality rate of 9% among non-acute kidney injury patients versus a mortality rate of 16% among acute kidney injury patients (p = 0.006). The mortality of patients classified as pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease F was double that predicted by Pediatric Index of Mortality 2 (7 vs 3.2). Patients classified as having severe acute kidney injury (pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease I + F) exhibited higher mortality (14.1%; p = 0.001) and prolonged PICU length of stay (median, 7 d; p = 0.001) when compared with other patients. Acute kidney injury is a very frequent occurrence among patients admitted to PICUs. The degree of acute kidney injury severity, as assessed by the pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease criteria, is a good predictor of morbidity and mortality in this population. Pediatric Index of Mortality 2 tends to underestimate mortality in pediatric patients with severe acute kidney injury.

643

Introduction: Most admissions to Intensive Care (ICU) are unplanned and associated with acute illness, however, co-morbidities also have an impact on survival. Patients with colorectal cancer represent the largest group of cancer patients admitted to ICU. It is unknown which factors are important at determining survival, and whether it is the features associated with the underlying malignancy or the acute illness that has the largest impact upon prognosis. Methods: We used routinely collected data from West of Scotland ICUs linked to Scottish Cancer registry data to identify patients (aged 16 and over) who had been admitted to ICU between 1st January 2000 and 31st December 2011 and who had a diagnosis of colorectal cancer (ICD10 coding C18-C20) within the previous five years. We used multivariable logistic regression analysis to identify factors associated with ICU outcome. Results: During the study period 3650 patients with colorectal cancer were admitted to ICU. Thirteen percent had two or more admissions. The majority of patients (93%) were admitted from surgical specialties with 78% admitted immediately post-operatively. Of those who had undergone a surgical procedure, 34% were performed as an emergency. Median time from diagnosis to ICU admission was 43 (IQR 14-104) days. Median age 71 (IQR 64-78) years; APACHE II score 13 (IQR 0-19); 59% were men. Duke's tumour staging was 12% A, 34% B, 32% C and 10% D with 12% unknown. Organ support was provided by invasive mechanical ventilation (51% of patients), vasoactive drug therapy (51%), and renal replacement therapy (9%). The proportion of patients receiving no, one, two, or three organ support were 35%, 26%, 31%, and 8%. Mortality in ICU was 14.8% (13.0 to 16.7%) among emergency patients, 3.1% (2.3 to 4.0%) among elective patients and 27.1% (24.2 to 30.0%) among non-surgical patients. ICU mortality among Dukes stage A was 9.1% (6.7 to 11.9%), B 11.1% (9.5 to 12.8%), C 11.4% (9.7 to 13.2%), and D 13.9% (10.7 to 17.5%). Mortality was 21.6% (18.0 to 25.5%) among patients with unknown stage. ICU mortality by the number of organs supported was 0.9% (0.1 to 3.2%) for no organ support, 4.8% (2.1 to 9.2%) for one organ support, 20.3% (14.9 to 26.6%) for two organ support, and 39.6% (25.8 to 54.7%) for three organ support. Age, severity score, tumor stage, emergency surgery, being a non-surgical patient and organ support were each independently associated with mortality during ICU when modeled by multivariable logistic regression. Conclusions: Mortality among colorectal cancer patients admitted to ICU was most strongly associated with severity of illness, admitting specialty (surgical or medical), nature of surgery, and number of organs supported during the stay. Tumor stage was independently associated with mortality during ICU stay but showed a smaller differential across stage categories compared to other patient characteristics.

644

Introduction: Patients with cancer may require intensive care (ICU) due to drug-related toxicity, organ dysfunction, or surgical complications. In the past, admission of cancer patients to the ICU was considered controversial due to the high mortality rates in this group of patients. More recently this effect appears to be diminishing possibly due to improvements in patient selection and supportive care. However, studies of patients with cancer include a large proportion of surgical patients in whom ICU outcomes are favourable. We therefore aimed to describe the ICU cancer population and to assess outcomes in cancer patients admitted to ICU with a medical diagnosis. Methods: We used routinely collected data from West of Scotland ICUs linked to Scottish Cancer registry to identify patients (aged 16 or over) admitted to ICU between 1st January 2000 and 31st December 2011. Patients who had a diagnosis of a malignant cancer (excluding non-melanoma skin cancer) within the previous 5-years were identified. We compared these patients to patients without cancer. Non-cancer patients had no diagnosis of cancer between 1984 and date discharged from ICU. Results: 49451 individual patients were admitted to an ICU during the study period. A malignant neoplasm had been diagnosed in 9704 (20%). The majority were diagnosed in the year prior to admission (7704, 85%). The number of admissions by major cancer type were as follows - colorectal 4223 (41% of admissions with cancer), stomach 692 (7%), lung 669 (6%), oesophageal 588 (6%) and bladder 425 (4%). 17% of cancer patients were admitted from a medical specialty compared to 50% of non-cancer patients. Of the patients admitted with a medical diagnosis, median age of patients with cancer was 65 (IQR 57-73) vs 56 (41-69) years for patients without cancer and median APACHE II score was 20 (9-27) vs 18 (10-25). The proportion of medical cancer and non-cancer patients in which organ support was provided was by invasive mechanical ventilation (71% vs 75%); vasoactive drug therapy (58% vs 46%); renal replacement therapy (20% vs 14%). The proportion of cancer patients with greater than one supported organ was 53% compared to 43% of patients without cancer. Mortality in ICU among medical cancer patients was 37.9% (95% CI 35.7 - 40.1%) compared to 25.8% (25.2 - 26.4%) in non-cancer patients. ICU mortality among cancer patients who did not receive organ support was 6.2% (1.7-15.0%) and 4.7% (3.3-6.4%) for non-cancer patients. Among patients who received three organ support mortality was 60.0% (45.1 - 73.6%) and 49.4% (44.9 -53.9%) among cancer and non-cancer patients respectively. Conclusions: Cancer patients admitted to ICU from a medical specialty tend to be older and have higher severity of illness scores. As a result there is a higher requirement for multi-organ support. Irrespective of the number of organs supported ICU mortality is higher among those patients with cancer.

Advances in the Evaluation and Management of Children with Portal Hypertension

Portal hypertension commonly accompanies advanced liver disease and gives rise to severe and life-threatening complications, including hemorrhage from esophageal varices. Diagnosis of portal hypertension in children currently relies on finding evidence of splenomegaly and the formation of portosystemic collaterals. There is a paucity of pediatric data to support the use of primary prophylaxis against variceal hemorrhage. A combination of vasoactive drug and endoscopic therapy should be used to manage variceal bleeding. Prevention of rebleeding is best achieved by endoscopic variceal ligation. Rex bypass surgery is the optimal therapy for prevention of further bleeding from portal vein thrombosis. Options to manage recurrent bleeding while on preventative therapy include surgical portosystemic shunt, Rex bypass, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. Management of gastric varices may require injection of cyanoacrylate glue or TIPS.

Guidelines for the diagnosis and treatment of extrahepatic portal vein obstruction (EHPVO) in children

Introduction. Extrahepatic portal vein obstruction is an important cause of portal hypertension among children. The etiology is heterogeneous and there are few evidences related to the optimal treatment. Aim and methods. To establish guidelines for the diagnosis and treatment of EHPVO in children, a group of gastroenterologists and pediatric surgery experts reviewed and analyzed data reported in the literature and issued evidence-based recommendations.Results. Pediatric EHPVO is idiopathic in most of the cases. Digestive hemorrhage and/or hypersplenism are the main symptoms. Doppler ultrasound is a non-invasive technique with a high degree of accuracy for the diagnosis. Morbidity is related to variceal bleeding, recurrent thrombosis, portal biliopathy and hypersplenism. Endoscopic therapy is effective in controlling acute variceal hemorrhage and it seems that vasoactive drug therapy can be helpful. For primary prophylaxis of variceal bleeding, there are insufficient data for the use of beta blockers or endoscopic therapy. For secondary prophylaxis, sclerotherapy or variceal band ligation is effective; there is scare evidence to recommend beta-blockers. Surgery shunt is indicated in children with variceal bleeding who fail endoscopic therapy and for symptomatic hypersplenism; spleno-renal or meso-ilio-cava shunting is the alternative when Mesorex bypass is not feasible due to anatomic problems or in centers with no experience.Conclusions. Prospective control studies are required for a better knowledge of the natural history of EHPVO, etiology identification including prothrombotic states, efficacy of beta-blockers and comparison with endoscopic therapy on primary and secondary prophylaxis.

Antiplatelet and anticoagulant drugs for prevention of restenosis/reocclusion following peripheral endovascular treatment.

Peripheral arterial disease (PAD) is frequently treated by balloon angioplasty. Restenosis/reocclusion of the dilated segments occurs often, depending on length of occlusion, lower leg outflow, stage of disease and presence of cardiovascular risk factors. To prevent reocclusion, patients are treated with antithrombotic agents. This is an update of a review first published in 2005. To determine whether any antithrombotic drug is more effective in preventing restenosis or reocclusion after peripheral endovascular treatment, compared to another antithrombotic drug, no treatment, placebo or other vasoactive drugs. For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched 14 February 2012) and CENTRAL (2012, Issue 1). We selected randomised controlled trials (RCTs). Participants were patients with symptomatic PAD treated by endovascular revascularisation of the pelvic or femoropopliteal arteries. Interventions were anticoagulant, antiplatelet or other vasoactive drug therapy compared with no treatment, placebo or any other vasoactive drug. Clinical endpoints were reocclusion, restenosis, amputation, death, myocardial infarction, stroke, major bleeding and other side effects, such as minor bleeding, puncture site bleeding, gastrointestinal side effects and haematoma. We independently extracted and assessed details of the number of randomised patients, treatment, study design, patient characteristics and risk of bias. Analysis was based on intention-to-treat data. To examine the effects of outcomes such as reocclusion, restenosis, amputation and major bleeding, we computed odds ratios (OR) with 95% confidence intervals (CI) using a fixed-effect model. Twenty-two trials with a total of 3529 patients are included (14 in the original review and a further eight in this update). For the majority of comparisons, only one trial was available so results were rarely combined in meta-analyses. Individual trials were generally small and risk of bias was often unclear due to limitations in reporting. Three trials reported on drug versus placebo/control; results were consistently available for a maximum follow-up of only six months. At six months post intervention, a statistically significant reduction in reocclusion was found for high-dose acetylsalicylic acid (ASA) combined with dipyridamole (DIP) (OR 0.40, 95% CI 0.19 to 0.84), but not for low-dose ASA combined with DIP (OR 0.69, 95% CI 0.44 to 1.10; P = 0.12) nor in major amputations for lipo-ecraprost (OR 0.89, 95% CI 0.44 to 1.80). The remaining trials compared different drugs; results were more consistently available for a longer period of 12 months. At 12 months post intervention, no statistically significant difference in reocclusion/restenosis was detected for any of the following comparisons: high-dose ASA versus low-dose ASA (OR 0.98, 95% CI 0.64 to 1.48; P = 0.91), ASA/DIP versus vitamin K antagonists (VKA) (OR 0.65, 95% CI 0.40 to 1.06; P = 0.08), clopidogrel and aspirin versus low molecular weight heparin (LMWH) plus warfarin (OR 0.31, 95% CI 0.06 to 1.68; P = 0.18), suloctidil versus VKA: reocclusion (OR 0.59, 95% CI 0.20 to 1.76; P = 0.34), restenosis (OR 1.87, 95% CI 0.66 to 5.31; P = 0.24) and ticlopidine versus VKA (OR 0.71, 95% CI 0.37 to 1.36; P = 0.30). Treatment with cilostazol resulted in statistically significantly fewer reocclusions than ticlopidine (OR 0.32, 95% CI 0.13 to 0.76; P = 0.01). Compared with aspirin alone, LMWH plus aspirin significantly decreased occlusion/restenosis (by up to 85%) in patients with critical limb ischaemia (OR 0.15, 95% CI 0.06 to 0.42; P = 0.0003) but not in patients with intermittent claudication (OR 1.73, 95% CI 0.97 to 3.08; P = 0.06) and batroxobin plus aspirin reduced restenosis in diabetic patients (OR 0.28, 95% CI 0.13 to 0.60). Data on bleeding and other potential gastrointestinal side effects were not consistently reported, although there was some evidence that high-dose ASA increased gastrointestinal side effects compared with low-dose ASA, that clopidogrel and aspirin resulted in fewer major bleeding episodes compared with LMWH plus warfarin, and that abciximab resulted in more severe bleeding episodes. There is limited evidence suggesting that restenosis/reocclusion at six months following peripheral endovascular treatment is reduced by use of antiplatelet drugs compared with placebo/control, but associated information on bleeding and gastrointestinal side effects is lacking. There is also some evidence of variation in effect according to different drugs with cilostazol reducing reocclusion/restenosis at 12 months compared with ticlopidine and both LMWH and batroxobin combined with aspirin appearing beneficial compared with aspirin alone. However, available trials are generally small and of variable quality and side effects of drugs are not consistently addressed. Further good quality, large-scale RCTs, stratified by severity of disease, are required.

Post Cardiac Arrest Syndrome

Out-of-hospital cardiac arrest (OHCA) is a common initial presentation of cardiovascular disease, affecting up to 325 000 people in the United States each year.1 In a recent meta-analysis of >140 000 patients with OHCA, survival to hospital admission was 23.8%, and survival to hospital discharge was only 7.6%.2 In patients who initially achieve return of spontaneous circulation (ROSC) after OHCA, the significant subsequent morbidity and mortality are due largely to the cerebral and cardiac dysfunction that accompanies prolonged whole-body ischemia. This syndrome, called the post cardiac arrest syndrome, comprises anoxic brain injury, post cardiac arrest myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathology3,4 (Table 1). The contribution of each of these components in an individual patient depends on various factors, including prearrest comorbidities, duration of the ischemic insult, and cause of the cardiac arrest. This review focuses on therapeutic strategies and recent developments in managing patients who are initially resuscitated from cardiac arrest. View this table: Table 1. Post Cardiac Arrest Syndrome: Pathophysiology and Potential Treatment Strategies There are 3 major aspects that require consideration in the management of the post cardiac arrest patient. After resuscitation, a decision must be made in relation to the appropriate triage of the OHCA patient. The next phase of management concerns the in-hospital treatment, which must address each component of the postarrest syndrome as appropriate for the individual patient. Finally, there are issues relating to prognostication and the deployment of various secondary prevention measures. Our recommended treatment algorithm is summarized in the Figure. This ideally follows from the implementation of basic and advanced life support measures, including effective cardiopulmonary resuscitation and defibrillation when appropriate, which are major determinants of outcome.2 Such an approach to care may be further modified according to the presence of other comorbidities and precipitating factors, which should be assessed …