Archive for the ‘Anaesthesia’ Tag

Special K – time for a reappraisal ?

2 recent articles highlight the potential benefit of an often overlooked induction agent in critically ill patients.

Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Jabre, P. et al. Lancet. Volume 374, Issue 9686, Pages 293 – 300, 25 July 2009.

This multicentre, randomised, blinded trial in 65 french ICUs & 12 field teams enrolled 655 patients to either etomidate or ketamine for emergent intubation for critical illness. Patients were analysed only if they remained in ICU after day 3 (469). Adequate and reasonable power calculation, including predetermined septic & trauma subgroups. Primary end point was maximal SOFA score within 3 days (chosen as etomidate’s effects on adrenocortical axis thought to last <48 hrs). Secondary end points included intubation conditions, and 28 day ICU stay, catecholamine requirement, mortality & adrenocortical insufficiency. Continue reading

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…..