Archive for the ‘2009’ Tag

Renal Intensity – How High ?

The ANZICS group appear to have done it again; that is taken a single centre trial done in Europe, repeated it in a sensible and pragmatic way but in a much larger, adequately powered multi centre setting and determined an evidence based outcome. It’s something of a shame that again the evidence based outcome doesn’t support the optimism of the initial trial.
This time the therapy in question is the ‘dose’ of RRT (renal replacement therapy). A previous trial by influential group led by Ronco suggested a survival benefit of 35mls/kg/hr effluent flow rate as opposed to 20ml/kg/hr. A major US study (the Veterans/NIH study) showed no difference in mortality but was limited in its application is the UK because of the relatively large proportion of patients who received intermittent heamodialysis, and the slightly complicated rationale for choosing which patients received which therapy. Most UK ICUs would provide only CVVH (or variants) to ICU patients.
Intensity of Renal Replacement Therapy in Critically Ill Patients. RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lo S, McArthur C, McGuinness S, Myburgh J, Norton R, Scheinkestel C, Su S.   N Engl J Med.   2009 Oct 22;361(17):1627-3.

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Derby’s Finest

Two excellent recent articles from local clinicians that had to be featured on Critical Insight. An upcoming post will include a review article on Ketamine in ICU, but first…

Should we really be more “balanced” in our fluid prescribing ? Morris, C. Boyd, A. Reynolds, N. Anaesthesia, 2009 Jul;64(7):703.

A very good editorial questioning the rush away from hypercholreamic solutions despite the lack of clear evidence of benefit. They’re making a habit of insightful editorials. Without stealing their thunder, they make some excellent points regarding the potential physiological impact of negative anions (such as lactate and acetate) in situations of poor organ perfusion. A question the editorial doesn’t ask which springs to mind – how are we to assess the risk of fluid regimens without having to repeat the SAFE study for every potential option? At the same time can we tolerate the introduction of new fluids into the critically ill with very little evidence base ?

Dopexamine & Meta-analysis

Meta-analyses of the effects of dopexamine in major surgery: do all roads lead to Rome? J. J. Pandit. Anaesthesia. 64;6:585-8. (Editorial)

Meta-analyses of the effect of dopexamine on hospital mortality. Gopal et al. Anaesthesia. 64;6:589-94.

Effect of dopexamine infusion on mortality following major surgery: individual patient data multi-regression analysis of published clinical trials. Crit Care Med. 2008 Apr;36(4):1323-9

Two recent meta-analysis have been published in answer to the question “does dopexamine reduce mortality in high risk general surgical patients”, with conflicting results. Pearse’s group found no difference in mortality using the entire data set, but a 50% mortality reduction with low-dose infusions. Gopal’s group found no difference using essentially the same data set, but a different statistical methodology. Panjit’s accompanying editorial does an excellent job of dissecting out why such apparent large differences might arise from the same data, and is recommended.

The take home message for me is that the results of combining heterogeneous studies together into meta-analysis tell us more about the statistical method than they do about the clinical question. Does dopexamine have a role? Is it the dopamine renal failure story all over again? I’m afraid we’ll need more data…..

Bleedin’ starch

Rapidly Degradable Hydroxyethyl Starch Solutions Impair Blood Coagulation After Cardiac Surgery:A Prospective Randomized Trial. Schramko, A. A et al. Anesth Analg 2009;108:30-6

Thanks to Lynsey Davies & the QMC journal club for reviewing this recent paper. Although the numbers are small, and their end points may not be clinically significant, the potential implications for routine use of starches are important. Especially since the publication of the VISEP trial. You can find Dr. Davies’s presentation in the blue box, named starch and coagulation.

Dexmedetomidine vs Midazolam

Dexmedetomidine vs Midazola for sedation of critically ill patients : A randomised control trial. Riker, R. et al. JAMA 301 (5) 489-99.

This prospective, double blind, multicentred RCT compared the alpha agonist dexmedotomdine against midazolam. It was designed to assess safety & efficacy. A total of 375 patients expected to be ventilated for > 24hrs were randomised to either agent targeted to a RASS score of between -2 to +1. Primary outcome measure was period of time within target range, secondary end points included delirium scores & duration of ventilation Continue reading

Management of Subarachnoid Heamorrhage

Management of aneurysmal subarachnoid heamorrhage. Dringer. M. Critical Care Medicine 37 (2) Feb 2009; 432-440.

A useful & comprehensive educational review article from CCM on the management of SAH, highlighted for interest. Unfortunately for copyright reasons we can’t provide a link to the pdf, but you can access it from the above link if you have an ATHENS account.