Intravenous immunoglobulin does not improve outcome in toxic epidermal necrolysis.

Intravenous Immunoglobulin (IVIG) has been proposed as a beneficial therapy for toxic epidermal necrolysis (TEN). However, this has been based on a limited amount of Class 5 evidence. To compare outcomes in TEN patients treated in our burn unit since 1999, when we began to use IVIG (IG group), with TEN patients treated between 1995 and 1999 who did not receive IVIG (control group). Retrospective cohort review of the records of all TEN patients admitted between April 5, 1995 and December 4, 2002. There were 16 patients in the IG group (age 53 +/- 21 years, with initial rash involving 65 +/- 29% TBSA) and 16 patients in the control group (age 52 +/- 20 years, with initial rash involving 65 +/- 27% TBSA). The IG group received 0.7 +/- 0.2 g/kg/day of IVIG for 4 +/- 1 days. There were no significant differences between the groups with respect to the length of stay, duration of mechanical ventilation, severity of systemic inflammatory response syndrome and multiple organ dysfunction syndrome, or the incidence of sepsis. Significant progression of the wound occurred in 13% of the IG patients and in 27% of control patients, whereas no wound progression was observed in 47% of the IG patients and in 18% of the control patients (P =.299). The time to healing did not differ between IG and control groups (11.2 +/- 3.6 vs 11.4 +/- 2.6 days, respectively). There was no significant difference in the mortality rate between the IG group (25%) and the control group (38%). There were no complications from IVIG aside from one case of hyponatremia from the hypotonic IVIG solution. Although there may have been a trend towards less severe wound progression in patients who received IVIG, this was not associated with any substantial improvement in outcome in our TEN patients. A prospective randomized study with a larger sample size is needed to confirm our findings.

Meta-analysis of antibiotic prophylaxis in breast reduction surgery.

BACKGROUND: Breast reduction surgery is a very common procedure; however, there is still no consensus as to whether antibiotics should be used perioperatively. OBJECTIVE: To review the world literature and perform a meta-analysis of studies comparing wound infection rates with antibiotic use in breast reduction surgery. METHODS: A literature search was performed using the MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Database of Clinical Trials, Embase and CINAHL databases. Subject headings and relevant subheadings for "Breast", "Breast Reduction", "Reduction Mammaplasty", "Mammaplasty" were combined with "Antibiotics" and "Antibacterial Agents". The list of titles was assessed by the study's authors and abstracts were reviewed. All relevant articles were then independently reviewed by the two primary authors, and Jadad scoring was used to assess the quality of the included articles. RESULTS: From the original search, three randomized controlled trials were included in the meta-analysis of preoperative antibiotics. The meta-analysis revealed a 75% reduction in wound infections with preoperative antibiotics (OR 0.25 [95% CI 0.09 to 0.72]). Because only one randomized controlled trial analyzed postoperative antibiotics, no meta-analysis could be performed. CONCLUSIONS: Preoperative antibiotics should routinely be used before breast reduction surgery. The use of postoperative antibiotics remains controversial. Additional randomized studies investigating postoperative antibiotics are needed.

HISTORIQUE: La chirurgie de réduction mammaire est une intervention très courante. On ne s'entend toutefois pas sur l'utilisation d'antibiotiques pendant la période périopératoire. OBJECTIF: Examiner les publications mondiales et effectuer une méta-analyse des études comparant le taux d'infection des plaies malgré l'utilisation des antibiotiques en cas de chirurgie de réduction mammaire. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse bibliographique dans les bases de données de MEDLINE, de la Cochrane Database of Systematic Reviews, de la Cochrane Database of Clinical Trials, d'Embase et de CINAHL. Les rubriques et les sous-rubriques pour Breast, Breast Reduction, Reduction Mammaplasty, Mammaplasty ont été combinées à Antibiotics et Antibacterial Agents. Les auteurs de l'étude ont évalué la liste des titres et révisé les résumés. Les deux auteurs principaux ont également fait une évaluation indépendante de tous les articles pertinents, puis l'échelle de Jadad a été utilisée pour déterminer la qualité des articles inclus. RÉSULTATS: À partir de la recherche originale, trois essais aléatoires et contrôlés ont été inclus dans la méta-analyse des antibiotiques préopératoires. La méta-analyse a révélé une réduction de 75 % des infections des plaies grâce aux antibiotiques préopératoires (RC 0,25 [95 % IC 0,09 à 0,72]). Puisque seulement un essai aléatoire et contrôlé a porté sur les antibiotiques postopératoires, aucune méta-analyse n'a pu être effectuée. CONCLUSIONS: Il faudrait toujours utiliser des antibiotiques préopératoires avant une chirurgie de réduction mammaire. L'utilisation d'antibiotiques postopératoires demeure controversée. Il faudra effectuer d'autres études aléatoires sur les antibiotiques postopératoires.

Empirical antibiotics use in soft tissue infections.

PURPOSE: Various antibiotics are available to treat soft-tissue infections. However, it is unclear if the empirical antibiotic is always appropriate or the most economical. OBJECTIVE: To determine the percentage of empirically treated wounds susceptible to the antibiotic therapy prescribed, and to determine the percentage of wounds treated with the most economical antibiotic therapy. METHODS: A retrospective chart review was performed on all charts with a diagnosis of 'soft-tissue infection' between January 1, 2005, and June 30, 2005, at St Joseph's Hospital, Hamilton, Ontario. Eligible charts were identified using the medical diagnosis coding system. The following diagnoses (including subheadings) were included: cellulitis, lymphangitis, abscess, carbuncle or furuncle. The following was extracted: patient demographics; soft-tissue diagnosis; name, dose and duration of antibiotics used; culture results; and Gram-stain results. A comparison between the empirical antibiotic prescribed and the microbiology result was made. An assessment was performed on the cost of the initial empirical antibiotic treatment compared with less-expensive effective alternatives. RESULTS: For soft-tissue infections with positive culture growth, empirical antibiotic treatment was appropriate in all abscess cases, 50% of ulcer cases and 83% of cellulitis cases. For cellulitis patients receiving a single empirical antibiotic, it was appropriate in 89% of cases. Only 42% of culture-positive patients were treated with the most economical regimen, multiple antibiotics being the most common fault. CONCLUSIONS: To be most economical, a single empirical antibiotic should be used to treat cellulitis. Culture results should be used to guide any antibiotic changes.

Anesthetic management of a patient with asymptomatic ventricular tachycardia.

There are many causes of ventricular arrhythmias in pediatric patients, even those with structurally normal hearts. However, in young patients with 'normal' hearts, sustained ventricular arrhythmias are relatively rare. The primary concern of the physician is to identify which patients have benign ventricular arrhythmia patterns and which are at risk for sudden cardiac death. Even in asymptomatic patients, the choice of anesthetic agents may be important to minimize precipitation of episodes of tachyarrhythmias. This clinical report describes the anesthetic considerations for an asymptomatic child with a history of sustained premature ventricular contractions, ventricular tachycardia, and bigeminy. This child had chronic serous otitis media requiring repeat tympanostomy and tube replacement. This case report outlines the initial cancellation of anesthesia because of sustained arrhythmias, and subsequent conduct of the anesthesia for the case, as well as the considerations in the selection of the drugs when a child presents with significant ventricular arrhythmia.