Usefulness of pre-operative copeptin concentrations to predict post-operative outcome after major vascular surgery.

The aim of this study was to investigate whether preoperative determination of plasma copeptin levels in addition to plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) could help improve risk stratification in patients who undergo major vascular surgery. One hundred ninety-eight consecutive patients who underwent major vascular surgery (58.6% infrainguinal aortic reconstruction, 23.7% abdominal aortic aneurysm surgery, 17.7% carotid endarterectomy) were included in this study. Patients were monitored for in-hospital and long-term (2-years) major adverse cardiac events, consisting of cardiac death, nonfatal myocardial infarction, and emergent coronary revascularization. Overall, 40 patients (20.2%) reached the primary end point, and most of these events occurred during the index hospital stay (n = 18 [45%]). In univariate Cox regression analysis, increasing concentrations of copeptin were significant determinants of outcome as a continuous variable (hazard ratio [HR] 1.012, p = 0.005) and as a dichotomized variable according to the recommended cutoff of 14.0 pmol/L (HR 4.116, p <0.001). Subgroup analyses revealed that especially patients at low estimated risk according to plasma NT-pro-BNP levels were at significantly higher risk for worse outcomes with higher copeptin levels (HR 5.983, p = 0.002). In multivariate Cox regression analysis, copeptin concentrations >14 pmol/L were significant independent predictors of outcome (HR 2.842, p = 0.002) in addition to type of surgery, history of myocardial infarction, elevated levels of cardiac troponin T, and NT-pro-BNP levels. In conclusion, the results of this study suggest that preoperative determination of this new biomarker could substantially improve prediction of perioperative and postoperative outcomes in vascular surgery patients.

Arterial line in prehospital emergency settings - A feasibility study in four physician-staffed emergency medical systems.

BACKGROUND AND AIM OF THE STUDY: Arterial lines are widely used in operating rooms, critical care and emergency departments. Although invasive arterial blood pressure monitoring and arterial blood gas analysis are prehospitally available, the use of arterial lines in the field remains an exception. This study evaluates the feasibility, indications and therapeutic consequences of prehospital arterial line insertion. METHODS: Prospective observational study in four physician-staffed emergency medical systems (EMS), documenting patient status, indications, location of puncture, number of tries and time for puncture and therapeutic consequences. RESULTS: During the one-year observation period, arterial line placement succeeded in 115 (83.9%) of 137 patients. The median time for successful arterial cannulation was 2 min (IQR 1, 3 min; range: 30-600s), for preparing the invasive blood pressure monitoring 3 min (IQR 2, 4 min, range: 30-600s). Main indications were cardiopulmonary resuscitation (36.5%), post-resuscitation care (16.8%), respiratory insufficiency (24.1%) and unconsciousness (22.6%). Therapeutic consequences depended on whether the EMS was equipped with a blood gas analyzer or not and were, overall, reported in 51.3% of patients: fluids, vasoactive or antihypertensive therapy, correction of ventilation or acidosis. No complications occurred during the prehospital phase. CONCLUSION: The insertion of arterial lines is feasible under prehospital conditions, without delaying or complicating patient care. Indications originating from intrahospital use are also valid in the field. In particular when combined with arterial blood gas measurement, the use of arterial lines often leads to important therapeutic consequences.

Outcome of type C (AO) distal humeral fractures: follow-up of 22 patients with bicolumnar plating osteosynthesis.

BACKGROUND: In the last 40 years, 220 patients with type C distal humeral fractures (AO13-C1-3) were treated at our hospital operatively. Aim of this study is to present results of patients treated by dual plating osteosynthesis in the last decade and to compare them with our previous series (A-C). MATERIALS AND METHODS: From 1999 to 2008, 48 distal humeral fractures were treated operatively by perpendicular dual plating osteosynthesis. Twenty-two patients (mean age 43.5 years) were available for follow-up. These patients were allocated on the basis of retrospective evaluation, exploration of their medical history, x-rays based on the AO-classification, and functional outcome using CASSEBAUM, JUPITER, and Quick-DASH (Disabilities of the Arm, Shoulder and Hand) scores. RESULTS: The dominant side was affecting in 42.9%. Transolecranon approach was chosen in 86.4%. Good/excellent results were found in 86.4% (CASSEBAUM) and 81.8% (JUPITER). Mean Quick-DASH was 36.1 ± 28.4. Mean range of motion (ROM) was 0/10.9°/128.2°. Mean hospitalization time was 12.9 days, 22.7% were polytrauma patients. Early mobilization was possible in 81.8%. CONCLUSION: Early mobilization was possible in the majority of cases, which may be a prerequisite for satisfying functional results. Using new locking plates, early mobilization could be maintained even in an aging population.

Tight control of effectiveness of cardiac massage with invasive blood pressure monitoring during cardiopulmonary resuscitation.

The continuity of chest compression is the main challenge in prehospital cardiopulmonary resuscitation in the field as well as during transport. Invasive blood pressure monitoring with visible pulse waves by means of an arterial line set prehospitally allows for tight control of the effectiveness of chest compressions as well as of the impact of the administered epinephrine and also captures beginning fatigue of the rescuers. In this case, maintaining uninterrupted circulation through manual as well as mechanical chest compressions continued until the successful percutaneous coronary intervention saved the patients life without neurologic damage.

Penetrating neck trauma causing tracheal rupture, spinal cord injury, and massive pneumocephalus.

We describe a case in which tracheal, esophageal, and spinal cord injuries associated with massive pneumocephalus were caused by a flying chainsaw segment. To our knowledge, this is the first such case reported in the medical literature. The management challenges inherent in this exceedingly rare combination of injuries are discussed, and a novel theory explaining the possible pathophysiological mechanism that led to pneumocephalus in our patient is put forth.

Revised Cardiac Risk Index (Lee) and perioperative cardiac events as predictors of long-term mortality in patients undergoing endovascular abdominal aortic aneurysm repair.

OBJECTIVE: To determine if the Revised Cardiac Risk Index (Lee) is useful for stratification of patients by risk of both perioperative cardiac morbidity and long-term all-cause mortality in the setting of endovascular repair of abdominal aortic aneurysms. DESIGN: This study was designed as a retrospective review. SETTING: It was conducted at a single academic medical institution. PARTICIPANTS: The analysis included 225 patients with abdominal aortic aneurysms admitted to the authors' institution from 1999 to 2006. INTERVENTIONS: All patients underwent endovascular aortic aneurysm repair. MEASUREMENTS AND MAIN RESULTS: Data were collected from medical records, office charts, and physician quality-assurance databases. There were no in-hospital cardiac deaths. The major adverse cardiac event rate in the perioperative period was 6.2%. Long-term all-cause mortality was 23%. Univariate analysis showed that a history of coronary artery disease (CAD) (likelihood ratio [LR] = 8.7, p = 0.023), history of congestive heart failure (LR = 4, p = 0.042), and a Revised Cardiac Risk Index (RCRI) > or =3 (LR = 8.6, p = 0.004) were significant predictors for perioperative major adverse cardiac events. A history of CAD (LR = 10.7, p = 0.002), echocardiographic evidence of myocardial infarction (LR = 8.5, p = 0.006), exercise tolerance of only 1 block (LR = 8.4, p = 0.005), RCRI > or =3 (LR = 5.6, p = 0.022), and perioperative cardiac events (LR = 15.9, p < 0.0001) were significantly associated with long-term all-cause mortality. Perioperative cardiac events remained highly significant in predicting long-term mortality within the RCRI > or =3 subgroup (LR = 6.1, p = 0.019). CONCLUSIONS: The results of this study confirm that long-term mortality remains high after endovascular repair of abdominal aortic aneurysms. The Lee index may be a useful tool for stratification of high-risk patients from both a short- and long-term perspective in the setting of endoluminal graft repair.

Transdiaphragmatic repositioning of the heart in the setting of emergency laparotomy after blunt trauma.

Cardiac luxation after blunt trauma is a rare condition that carries a high mortality rate. We report a case of a left pericardial rupture with partial dislocation of the heart into the left pleural cavity and cardiac strangulation in a polytraumatized patient after a severe motor vehicle accident. This case is of special interest because the patient not only had cardiovascular compromise but was also actually in cardiac arrest and being resuscitated when an emergency repositioning of the heart through the diaphragm in the setting of damage control laparotomy restored circulation. This report stresses the need for a high index of suspicion for accurate early diagnosis of pericardial rupture.

The relationship between short-term mortality and quality of care for hip fracture: a meta-analysis of clinical pathways for hip fracture.

OBJECTIVES: To assess the association between use of clinical pathways for hip fracture and changes in the rates of five inpatient complications and short-term mortality. DESIGN: Meta-analysis of published studies examining clinical pathways for hip fracture, identified through systematic searches of electronic databases (MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials) and hand searches of selected article bibliographies. SETTING: Observational and interventional studies of clinical pathways for hip fracture examining rates of deep venous thrombosis, pressure ulcer, surgical site infection, urinary tract infection, pneumonia, and inpatient or 30-day mortality. PARTICIPANTS: Two reviewers. MEASUREMENTS: Reviewers independently assessed eligibility and quality of studies and extracted data for outcomes of interest. RESULTS: Meta-analysis of nine studies (4,637 patients) demonstrated lower odds of deep venous thrombosis (odds ratio (OR)=0.33, 95% CI=0.14-0.75), pressure ulcer (OR=0.48, 95% CI=0.30-0.75), surgical site infection (OR=0.48, 95% CI=0.25-0.89), and urinary tract infection (OR=0.71, 95% CI=0.52-0.98) in patients managed according to clinical pathways than in those receiving usual care. Statistically significant differences were not observed in the odds of pneumonia (OR=1.01, 95% CI=0.67-1.53) or in a combined outcome of in-hospital or 30-day mortality (OR=0.86, 95% CI=0.66-1.13). CONCLUSION: An association was observed between clinical pathway use and lower odds of four common complications of hospitalization after hip fracture; only a small, statistically insignificant association was observed between pathway use and changes in short-term mortality, suggesting that assessments of hospital quality based on short-term mortality may not reflect important improvements in patient outcomes that hospitals may achieve using clinical pathways.

Cricothyroidotomy on the scene in a patient with severe facial trauma and difficult neck anatomy.

We present a case of a patient with severe facial trauma who was treated at the scene by a physician-staffed trauma life support team. Because of massive oropharyngeal bleeding in addition to a difficult neck anatomy in a very obese patient, a cannot-intubate, cannot-ventilate situation occurred. Control of the airway could finally be achieved by surgical cricothyroidotomy. The current literature concerning emergency cricothyroidotomy is discussed.

Successful prolonged resuscitation involving the use of tenecteplase without neurological sequelae.

Prehospital cardiac arrest is associated with a very poor prognosis. We report a case of complete neurological recovery after prolonged resuscitation involving the use of tenecteplase in a patient with undifferentiated cardiac arrest with a return of spontaneous circulation after 1 hour of resuscitation, where basic life support was commenced immediately by a bystanding family member. Factors associated with an increased chance of survival from out-of-hospital cardiac arrest are discussed as well as the role of thrombolytics in cardiopulmonary resuscitation.

Levosimendan: current status and future prospects.

PURPOSE OF REVIEW: While patients with acute heart failure typically receive diuretics and vasodilators, contractile dysfunction and peripheral hypoperfusion also leads to a widespread use of inotropic agents despite the lack of evidence for efficacy or safety. Levosimendan, a calcium sensitizer and vasodilator, has been proposed to be superior to standard inotropes. In addition, further possible indications for levosimendan have been described, such as perioperative use, cardioprotection, cardiogenic shock, sepsis, and right ventricular dysfunction. RECENT FINDINGS: The mortality benefit of levosimendan has not been confirmed in two recent trials but the substance improves symptoms, decreases brain natriuretic peptide and is effective during beta-blocker treatment. The use of levosimendan as an add-on therapy in acute heart failure has been encouraged as well as its perioperative use. Levosimendan may also be useful during right ventricular dysfunction and septic shock due to its favorable effects on splanchnic perfusion. SUMMARY: Levosimendan is an established substance in the treatment of acute heart failure in several countries despite disappointing findings concerning a possible survival benefit in two recent clinical trials. Owing to its alternative mechanisms of action as compared with traditional cardiotonic agents, several promising clinical applications have arisen. Available evidence for the use of levosimendan in settings other than decompensated heart failure is currently limited.