Esmolol reduces perioperative ischemia in noncardiac surgery: a meta-analysis of randomized controlled studies.

OBJECTIVE: Literature increasingly has suggested how beta-blockers could be associated with reductions of mortality and morbidity in noncardiac surgery. Recently, the POISE trial showed that beta-blockers could be harmful in the perioperative period. The authors performed a meta-analysis to evaluate the clinical effects of esmolol in noncardiac surgery. DESIGN: Meta-analysis. SETTING: Hospitals. PARTICIPANTS: A total of 1765 patients from 32 randomized trials. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three investigators independently searched BioMedCentral and PubMed. Inclusion criteria were random allocation to treatment and comparison of esmolol versus placebo, other drugs, or standard of care in noncardiac surgery. Exclusion criteria were duplicate publications, nonhuman experimental studies, and no data on clinical outcomes. The use of esmolol was associated with a significant reduction of myocardial ischemia episodes (5/283 [1.76%] in the esmolol group v 16/265 [6.03%] in the control arm, odds ratio [OR] = 0.16 [0.05-0.54], p = 0.003). The authors did not observe significant differences regarding episodes of arrhythmias (8/236 [3.38%] v 22/309 [7.11%], OR = 0.52 [0.23-1.18], p = 0.12) and in the incidence of myocardial infarction (0/148 [0%] v 1/169 [0.59%], OR = 0.23 [0.01-6.09], p = 0.38). Esmolol-treated patients did not experience more episodes of hypotension (17/384 [4.42%] v 38/439 [8.65%], OR = 0.41 [0.22-0.79], p = 0.17) and bradycardia (25/342 [7.30%] v 17/406 [4.18%], OR = 1.42 [0.74-2.74], p = 0.42). CONCLUSIONS: Esmolol seemed to reduce the incidence of myocardial ischemia in noncardiac surgery without increasing the episodes of hypotension and bradycardia. Large randomized trials are necessary to confirm these promising results.

Oxygen and carbon dioxide levels in patients after cardiac arrest.

BACKGROUND: The relationship of PaO2 and PaCO2 levels with outcome after cardiac arrest (CA) is controversial. Few studies have analysed both PaO2 and PaCO2 in this setting and the overall exposure to different PaO2 and PaCO2 levels has not been taken into account. METHODS: We reviewed blood gas data obtained within the first 24 h from all comatose adult patients who were admitted to the intensive care unit after successful resuscitation from CA. Exposure times to different PaO2 and PaCO2 thresholds were reported as areas under the curve (AUC) and the time above these thresholds was then calculated. The primary outcome measure was neurological outcome assessed using the Cerebral Performance Category (CPC) score at 3 months. An unfavourable outcome was defined as a CPC of 3-5 and a favourable outcome as a CPC of 1-2. RESULTS: A total of 356 patients were studied, with a median number of 9 [6-11] blood gas measurements within the first 24 h after admission. The highest and lowest PaO2 and PaCO2 were similar in patients with unfavourable and favourable neurological outcomes. There were no differences in the AUCs or times over different thresholds of PaO2 and PaCO2 in the two groups. In a multivariable analysis, high blood lactate concentrations on admission, presence of shock and a non-shockable initial rhythm were significantly associated with unfavourable outcome. CONCLUSIONS: There was no association between exposure to various levels of PaO2 and PaCO2 and neurological outcome after cardiac arrest.

N-terminal B-natriuretic Peptide after coronary artery bypass graft surgery.

OBJECTIVE: To investigate N-terminal amino-acid sequence of the B-natriuretic peptide (NT-proBNP) release and its prognostic characteristics after coronary artery bypass graft surgery with and without cardiopulmonary bypass. DESIGN: Observational study. SETTING: Teaching hospital. PARTICIPANTS: One hundred eighty-four patients. INTERVENTIONS: The authors determined plasma concentrations of NT-proBNP just before anesthesia induction and 24 hours after the end of the surgery. MEASUREMENTS AND MAIN RESULTS: NT-proBNP concentrations (median [interquartile range]) increased from 270 (75-716) pg/mL preoperatively to 1,664 (978-3,193) pg/mL on postoperative day 1 (p < 0.001), and all postoperative values were higher than the preoperative ones. NT-proBNP concentrations at day 1 were correlated to those at day 0 (r(2) = 0.34, p < 0.001). Patients showing elevated concentration of cTnI at day 1 (>14 ng/mL) had significantly (p = 0.04) higher plasma NT-proBNP levels than patients with a low cardiac troponin I concentration. Patients with prolonged intensive care unit (ICU) stay (>4 days) showed at day 1 significantly higher (p = 0.003) plasma NT-proBNP levels than patients with ICU stay <4 days. Elevated NT-proBNP at day 1 was significantly (p = 0.001) associated with in-hospital mortality, 18,584 (11,896-29,158) pg/mL versus 1,597 (965-3,034) pg/mL in survivors. CONCLUSIONS: The present results show, for the first time, that postoperative NT-proBNP levels are associated with in-hospital mortality and prolonged ICU stay after CABG surgery. These findings support the prognostic value of postoperative plasma levels of NT-proBNP.

Acute Kidney Injury After Subarachnoid Hemorrhage.

BACKGROUND: Acute kidney injury (AKI) is common in critically ill patients and may contribute to poor outcome. Few data are available on the incidence and impact of AKI in patients suffering from nontraumatic subarachnoid hemorrhage (SAH). METHODS: We reviewed all patients admitted to our Department of Intensive Care with SAH over a 3-year period. Exclusion criteria were time from SAH symptoms to intensive care unit (ICU) admission >96 hours and ICU stay <48 hours. AKI was defined as sustained oligoanuria (urine output <0.5 mL/kg/h for 24 h) or an increase in plasma creatinine (≥0.3 mg/dL or a 1.5-fold increase from baseline level within 48 h). Neurological status was assessed at day 28 using the Glasgow Outcome Scale (GOS) (from 1=death to 5=good recovery; favorable outcome=GOS 4 to 5). RESULTS: Of 243 patients admitted for SAH during the study period, 202 met the inclusion/exclusion criteria (median age 56 y, 78 male). Twenty-five patients (12%) developed AKI, a median of 8 (4 to 10) days after admission. Independent predictors of AKI were development of clinical vasospasm, and treatment with vancomycin. AKI was more frequent in ICU nonsurvivors than in survivors (11/50 vs. 14/152, P=0.03), and in patients with an unfavorable neurological outcome than in other patients (17/93 vs. 8/109, P=0.03). Nevertheless, in multivariable regression analysis, AKI was not an independent predictor of outcome. CONCLUSIONS: AKI occurred in >10% of patients after SAH. These patients had more severe neurological impairment and needed more aggressive ICU therapy; AKI did not significantly influence outcome.

Prognostic implications of blood lactate concentrations after cardiac arrest: a retrospective study.

BACKGROUND: Elevated lactate concentration has been associated with increased mortality after out-of-hospital cardiac arrest (CA). We investigated the variables associated with high blood lactate concentrations and explored the relationship between blood lactate and neurological outcome in this setting. METHODS: This was a retrospective analysis of an institutional database that included all adult (> 18 years) patients admitted to a multidisciplinary Department of Intensive Care between January 2009 and January 2013 after resuscitation from CA. Blood lactate concentrations were collected at hospital admission and 6, 12, 24 and 48 h thereafter. Neurological outcome was evaluated 3 months post-CA using the Cerebral Performance Category (CPC) score: a CPC of 3-5 was used to define a poor outcome. RESULTS: Of the 236 patients included, 162 (69%) had a poor outcome. On admission, median lactate concentrations (5.3[2.9-9.0] vs. 2.5[1.5-5.5], p < 0.001) and cardiovascular sequential organ failure assessment (cSOFA) score (3[0-4] vs. 0[0-3], p = 0.003) were higher in patients with poor than in those with favourable outcomes. Lactate concentrations were higher in patients with poor outcomes at all time points. Lactate concentrations were similar in patients with out-of-hospital and in-hospital CA at all time points. After adjustment, high admission lactate was independently associated with a poor neurological outcome (OR 1.18, 95% CI 1.08-1.30; p < 0.001). In multivariable analysis, use of vasopressors and high PaO2 on admission, longer time to return of spontaneous circulation and altered renal function were associated with high admission lactate concentrations. CONCLUSIONS: High lactate concentrations on admission were an independent predictor of poor neurological recovery post-CA, but the time course was not related to outcome. Prolonged resuscitation, use of vasopressors, high PaO2 and altered renal function were predictors of high lactate concentrations.