27 de julho de 2012

Obstructive Sleep Apnea and Incidence of Postoperative Delirium after Elective Knee Replacement in the Nondemented Elderly


Benjamin J. Flink, B.A., Sarah K. Rivelli, Elizabeth A. Cox, William D. White, Grace Falcone, R.N., Thomas P. Vail,  Christopher C. Young, Michael P. Bolognesi, Andrew D. Krystal, Paula T. Trzepacz, Richard E. Moon, Madan M. Kwatra

Anesthesiology, V 116 No 4 - April 2012

Background: Postoperative delirium, a common complication in the elderly, can occur following any type of surgery and is associated with increased morbidity and mortality; it may also be associated with subsequent cognitive problems. Effective therapy for postoperative delirium remains elusive because the causative factors of delirium are likely multiple and varied.

Methods: Patients 65 yr or older undergoing elective knee arthroplasty were prospectively evaluated for postoperative Diagnostic and Statistical Manual of Mental Disorders-IV delirium. Exclusion criteria included dementia, mini-mental state exam score less than 24, delirium, clinically significant central nervous system/neurologic disorder, current alcoholism, or any serious psychiatric disorder. Delirium was assessed on postoperative days 2 and 3 using standardized scales. Patients’ preexisting medical conditions were obtained from medical charts. The occurrence of obstructive sleep apnea was confirmed by contacting patients to check their polysomnography records. Data were analyzed using Pearson chi-square or Wilcoxon rank sum tests and multiple logistic regressions adjusted for effects of covariates.

Results: Of 106 enrolled patients, 27 (25%) developed postoperative delirium. Of the 15 patients with obstructive sleep apnea, eight (53%) experienced postoperative delirium, compared with 19 (20%) of the patients without obstructive sleep apnea (P 0.0123, odds ratio: 4.3). Obstructive sleep apnea was the only statistically significant predictor of postoperative delirium in multivariate analyses.

Conclusions: This is the first prospective study employing validated measures of delirium to identify an association between preexisting obstructive sleep apnea and postoperative delirium.

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25 de julho de 2012

Anticoagulation Options for Patients with Heparin-Induced Thrombocytopenia Requiring Renal Support in the Intensive Care Unit


Andrew Davenport


Centre for Nephrology, Division of Medicine, Department of Medicine, Royal Free and University College Medical School, London, UK

ABSTRACT

World wide, heparins are the most commonly used anticoagulants for renal replacement therapy (RRT). In the intensive care unit (ICU) keeping the RRT circuit patent is more difficult than during routine outpatient hemodialysis, as ICU patients typically have sepsis and/or inflammation resulting in activation of the procoagulant pathways, with reduced antithrombin.
One important cause of repeated RRT circuit clotting is heparin-induced thrombocytopenia (HIT), which should not be overlooked in patients with a reduced platelet count. If HIT is clinically suspected then all heparins should be withdrawn, and the patient systemically anticoagulated with either a direct thrombin inhibitor, such as argatroban and/or hirudin, or the heparinoid danaparoid. The availability and licensing of these alternative anticoagulants varies from country to country. Argatroban has to be continuously infused, which is an advantage for continuous RRT, but not for intermittent RRT, and can be monitored by activated partial thromboplastin time. Hirudin has a prolonged half life, which is extended by hirudin antibodies, and requires specialist monitoring to prevent over anticoagulation. Although the half life of danaparoid is increased in renal failure, it can be given as boluses for intermittent and continuous RRT, or by continuous infusion during continuous RRT, but requires factor Xa monitoring.

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17 de julho de 2012

Artigo recomendado: Lipid Emulsion Infusion - Resuscitation for Local Anesthetic and Other Drug Overdose


Guy L. Weinberg, M.D.
Anesthesiology, V 117 - No 1. July 2012

It seems implausible that an injection of a simple, off-theshelf, intravenous nutritional solution could be acutely life-saving for a patient with severe drug overdose. But dozens of published case reports support this observation, first made more than a decade ago in a rodent model of bupivacaine toxicity. It is even more surprising that such a simple formulation can rapidly reverse severe clinical toxicity from a variety of vastly disparate medications with distinct pharmacodynamics and mechanisms of action. This review will focus on the clinical application of lipid emulsion therapy in resuscitation from drug-related toxicity and will provide an introduction to the development of the method, guidelines for its use, and insights into potential controversies and future applications.

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12 de julho de 2012

Artigo recomendado: Aversive and Reinforcing Opioid Effects - A Pharmacogenomic Twin Study


Martin S. Angst, M.D., Laura C. Lazzeroni, Ph.D.,† Nicholas G. Phillips, M.S.,‡ David R. Drover, M.D.,§ Martha Tingle, R.N., Amrita Ray, Ph.D.,# Gary E. Swan, Ph.D., J. David Clark, M.D., Ph.D.††

Anesthesiology, V 117 - No 1 - July 2012

Background: The clinical utility of opioids is limited by adverse drug effects including respiratory depression, sedation, nausea, and pruritus. In addition, abuse of prescription opioids is problematic. Gaining a better understanding of the genetic and environmental mechanisms contributing to an individual’s susceptibility to adverse opioid effects is essential to identify patients at risk.

Methods: A classic twin study paradigm provided estimates for the genetic and familial (genetic and/or shared environment) contribution to acute adverse and affective opioid responses, all secondary outcomes of a larger dataset. One hundred twenty-one twin pairs were recruited in a single occasion, randomized, double-blind, and placebo-controlled study. The -opioid receptor agonist alfentanil and saline placebo were administered as target-controlled infusions under carefully monitored laboratory conditions. Measured outcomes included respiratory depression, sedation, nausea, pruritus, drug liking, and drug disliking. Demographic information was collected, and aspects of mood and sleep were evaluated.

Results: Significant heritability was detected for respiratory depression (30%), nausea (59%), and drug disliking (36%). Significant familial effects were detected for sedation (29%), pruritus (38%), dizziness (32%), and drug liking (26%). Significant covariates included age, sex, race, ethnicity, education, mood, and depression. Covariates affected sedation, pruritus, drug liking and disliking, and dizziness.

Conclusions: This study demonstrates that large-scale efforts to collect quantitative and well-defined opioid response data are not only feasible but also produce data that are suitable for genetic analysis. Genetic, environmental, and demographic factors work together to control adverse and reinforcing opioid responses, but contribute differently to specific responses.

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Boletim de Farmaco Vigilância da ANVISA (Agência Nacional de Vigilância Sanitária)


3 de julho de 2012

Artigo recomendado: Comparative Effectiveness of Regional versus General Anesthesia for Hip Fracture Surgery in Adults


Mark D. Neuman, M.D., M.Sc., Jeffrey H. Silber, M.D., Ph.D.,† Nabil M. Elkassabany, M.D.,‡ Justin M. Ludwig, M.A.,§ Lee A. Fleisher, M.D.

Anesthesiology 2012; 117:72–92

ABSTRACT

Background: Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery.

Methods: The authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the association of anesthesia type and outcomes according to fracture anatomy.

Results: Of 18,158 patients, 5,254 (29%) received regional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmonary complications (359 [6.8%] vs. 1,040 [8.1%], P < 0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < 0.0001) relative to general anesthesia. In subgroup analyses, regional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures.

Conclusions: Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia; this finding may be driven by a trend toward improved outcomes with regional anesthesia among patients with intertrochanteric fractures.

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