Comparison of diuretic strategies in diuretic-resistant acute heart failure: a systematic review and network meta-analysis.

OBJECTIVE: Up to 50% of patients hospitalized for acute heart failure (AHF) show resistance to diuretics. This condition contributes to a prolonged hospital length of stay and a higher risk of death. This review aimed to investigate whether a diuretic therapeutic approach more effective than furosemide alone exists for patients with diuretic-resistant AHF. MATERIALS AND METHODS: We identified all randomized controlled trials (RCTs) evaluating diuretic therapy in patients with diuretic-resistant AHF. We searched Pubmed, BioMed Central, and Cochrane CENTRAL databases. RESULTS: Six RCTs were identified, involving a total of 845 patients. The P-score ranges from 0.6663 for furosemide to 0.2294 for the tolvaptan-furosemide. We found no significant differences in efficacy for any drug comparison. CONCLUSIONS: None of the diuretics considered in RCTs performed to date (tolvaptan, metolazone, hydrochlorothiazide, indapamide) appear to be more effective than furosemide therapy alone for the treatment of patients with diuretic-resistant AHF.

Which regional anesthesia technique is the best for arthroscopic shoulder surgery in terms of postoperative outcomes? A comprehensive literature review.

OBJECTIVE: The literature offers numerous reviews and meta-analyses assessing the different regional anesthesia techniques employed for arthroscopic shoulder surgery (ATS) in terms of diverse outcome parameters. Most have focused on analgesic efficacy in the limited post-operative period as their primary outcome. Indeed, the most up-to-date guidelines are based on the results of comparisons that focus on analgesic efficacy and analgesic drug consumption. However, a correlation has yet to be demonstrated between post-operative analgesia and functional recovery; indeed, the latter has received relatively less research attention concerning the anesthetic technique despite its clinical importance. Here, we aimed to identify the best loco-regional anesthetic technique for ATS, considering all the evaluation parameters considered to date. MATERIALS AND METHODS: We performed a comprehensive literature review on ATS, searching for all the relative aspects of the regional anesthesia technique employed and the outcome parameters assessed. RESULTS: From the literature, it is not clear which technique is better than the others. No single technique was revealed as being the absolute best, independent of the outcome parameter considered, which included: post-operative analgesic effect, speed of functional recovery, ease, and safety of execution. CONCLUSIONS: The choice of anesthetic technique should be tailored to the patient and type of surgery. When comparing one type of loco-regional anesthesia against another, in addition to analgesic efficacy, a whole plethora of aspects need to be considered (i.e., feasibility, complications, contribution to functional recovery, etc.).

Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment.

Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.

Perioperative intra- and extravascular volume in liver transplant recipients.

UNLABELLED: Assessing adequate volemia to avoid fluid overload and pulmonary edema perioperatively in liver transplantation (LT) is a challenge both for the anesthetist and the intensivist. Volumetric preload indices, such as intrathoracic blood volume index (ITBVI), measured by transpulmonary thermodilution, and continuous end-diastolic volume index (EDVI), measured by pulmonary artery thermodilution, were shown to better reflect preload than central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP). An ITBVI increase soon after the graft reperfusion influenced pulmonary perfusion without an alteration of extravascular lung water index (EVLWI) and without impaired oxygenation. This study was designed to evaluate relationships between CVP, PAOP, ITBVI, EDVI, and stroke volume index (SVI) within 48 hours after LT. We also investigated the relationship between EVLWI and arterial partial pressure of oxygen and inspired oxygen fraction ratio (PaO(2)/FiO(2)). METHODS: We enrolled 125 patients (103 men and 22 women) undergoing LT. All patients were monitored with the PiCCO system (Pulsion Medical System) and with advanced pulmonary artery catheter connected to the Vigilance System. Hemodynamic-volumetric data were collected upon intensive care unit admission and every 8 hours up to 48 hours. Univariate and multivariate regression models were fitted to assess associations between SVI and EDVI, ITBVI, and filling pressures after adjusting for the right ventricular ejection fraction (RVEF, categorized as ≤30, 31-40, or >40) and the phase of the observation period. We also assessed associations between PaO(2)/FiO(2) and EVLWI. RESULTS: SVI was associated with EDVI, ITBVI, and RVEF. The models showing the best fit to the data were those including EDVI and ITBVI. Neither CVP nor PAOP showed correlation with SVI. EVLWI inversely correlated with PaO(2)/FiO(2). CONCLUSIONS: In the first 48 hours after LT, ITBVI and EDVI were associated with SVI assessment, whereas CVP and PAOP were not related. EVLWI significantly inversely correlated with PaO(2)/FiO(2).

Percutaneous versus surgical bedside tracheostomy in the intensive care unit: a cohort study.

BACKGROUND: To compare the outcomes, as well as the short and long term complications, of percutaneous dilational tracheostomy (PDT) and surgical tracheostomy (ST) at the bedside. METHODS: From 2003 to 2005, 367 consecutive patients underwent percutaneous tracheostomy in two general ICUs of a community hospital. Short and long term complications, procedural time, duration on mechanical ventilation, length of stay in the ICU and in the hospital, and mortality rates were compared to a historical cohort of 161 patients treated with surgical tracheostomy. Both groups were comparable in demographic characteristics and severity scores. RESULTS: As a whole, 528 mechanically ventilated patients underwent tracheostomy at the bedside. 161 patients received ST and 367 PDT by the single dilator technique. Only minor complications were observed in both groups of patients. PDT was performed more rapidly than ST (5.4+/-5.2 vs 19+/-10 min). STs were performed significantly later than PDT (12.4+/-6 days vs 8.7+/-5.8 days, P<0.05). The overall ICU stay and mean duration of mechanical ventilation were lower in the PDT than in the ST group (18.4+/-13.9 vs 23.3+/-15.8 days, P< 0.05 and 14.2+/-8.1 vs 20.1+/-10.4, P<0.05, respectively). There were no statistically significance differences in ICU and hospital outcome between the two techniques. CONCLUSION: Compared with ST, the main advantage of PDT is that it is more rapid and allows the tracheostomy to be performed earlier in the course of ventilatory failure. Early tracheostomy is associated with a shorter duration of mechanical ventilation and a reduced ICU length of stay.

Chain of survival: differences in early access and early CPR between policemen and high-school students.

Immediate activation of the emergency medical service (EMS) and cardiopulmonary resuscitation (CPR) increases the incidence of return of spontaneous circulation and the number discharged from hospital. The American Heart Association (AHA) and the European Resuscitation Council describe CPR as an ordinate sequence of eight steps. The objectives of this study were to assess the general knowledge of EMS and CPR and to analyse the retention of the CPR steps 2 months after a Basic Life Support (BLS)-course conducted according to AHA standards. We studied two populations from the same geographical area, law enforcement agents (LEA), since they are often the first to intervene, and high school students (HSS) since they are more likely to participate in such courses. HSS were more responsive and receptive than LEA. In order to increase the retention of the sequence of CPR steps, the number of steps should be reduced and refresher courses should be included in training programmes. Early access and early CPR are still not completely effective in the geographical area studied.