Does the alcohol use disorders identification test-consumption identify the same patient population as the full 10-item alcohol use disorders identification test?

The aim of this study was to evaluate whether a computer-based 3-item version (Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]) of the Alcohol Use Disorders Identification Test (AUDIT) identifies alcohol use disorder (AUD) in the same patients as the full 10-item version in 809 women and 747 men in an anesthesiology preoperative assessment clinic. According to cutoffs used ( AUDIT: 5-8 points, AUDIT-C: 4-6 points), rate of disagreement (AUDIT-positive and AUDIT-C-negative or vice versa) ranged between 4% and 31% (men) and between 4% and 19% (women). In male patients, 15% were positive for both the AUDIT (≥8 points) and the AUDIT-C (≥6 points), 7% were positive for AUDIT-C only, and 4% were positive for AUDIT only. In female patients, using cutoffs of 5 more points (AUDIT) and 4 or more points (AUDIT-C), 16% were positive for both versions, 9% were positive for AUDIT-C only, and 2% were positive for AUDIT only. The AUDIT and AUDIT-C seem to identify AUD in differing patients.

Seizures after open heart surgery: comparison of ε-aminocaproic acid and tranexamic acid.

OBJECTIVE: Although the lysine analogs tranexamic acid (TXA) and aminocaproic acid (EACA) are used widely for antifibrinolytic therapy in cardiac surgery, relatively little research has been performed on their safety profiles, especially in the setting of cardiac surgery. Two antifibrinolytic protocols using either TXA or aminocaproic acid were compared according to postoperative outcome. DESIGN: A retrospective analysis. SETTING: A university-affiliated hospital. PARTICIPANTS: Six hundred four patients undergoing cardiac surgery. INTERVENTIONS: One cohort of 275 consecutive patients received TXA; a second cohort of 329 consecutive patients was treated with EACA. Except for antifibrinolytic therapy, the anesthetic and surgical teams and their protocols remained unchanged. MEASUREMENTS AND MAIN RESULTS: Besides major outcome criteria, namely postoperative bleeding, the need for allogeneic transfusions, operative revision because of bleeding, postoperative renal dysfunction, neurologic events, heart failure, and in-hospital mortality, the authors specifically sought differences between the groups concerning seizures. The 2 cohorts were comparable over a range of perioperative factors. Postoperative seizures occurred significantly more frequently in TXA patients (7.6% v 3.3%, p = 0.019), whereas EACA patients had a higher incidence of postoperative renal dysfunction (20.0% v 30.1%, p = 0.005). There were no differences in all other measured major outcome factors. CONCLUSION: Both lysine analogs are associated with significant side effects, which must be taken into account when performing risk-benefit analyses of their use. Their use should be restricted to patients at high risk for bleeding; routine use on low-risk patients undergoing standard surgeries should face renewed critical reappraisal.

A prospective, randomized, double-blind, multicenter study comparing remifentanil with fentanyl in mechanically ventilated patients.

PURPOSE: To compare the quality of analgesia provided by a remifentanil-based analgesia regime with that provided by a fentanyl-based regime in critically ill patients. METHODS: This was a registered, prospective, two-center, randomized, triple-blind study involving adult medical and surgical patients requiring mechanical ventilation (MV) for more than 24 h. Patients were randomized to either remifentanil infusion or a fentanyl infusion for a maximum of 30 days. Sedation was provided using propofol (and/or midazolam if required). RESULTS: Primary outcome was the proportion of patients in each group maintaining a target analgesia score at all time points. Secondary outcomes included duration of MV, discharge times, and morbidity. At planned interim analysis (n = 60), 50% of remifentanil patients (n = 28) and 63% of fentanyl patients (n = 32) had maintained target analgesia scores at all time points (p = 0.44). There were no significant differences between the groups with respect to mean duration of ventilation (135 vs. 165 h, p = 0.80), duration of hospital stay, morbidity, or weaning. Interim analysis strongly suggested futility and the trial was stopped. CONCLUSIONS: The use of remifentanil-based analgesia in critically ill patients was not superior regarding the achievement and maintenance of sufficient analgesia compared with fentanyl-based analgesia.

Changes in hepatic blood flow during whole body hyperthermia.

PURPOSE: Changes in blood flow distribution are important for heat dispersion and for supportive therapeutic strategies such as simultaneous whole body hyperthermia (WBH) and administration of chemotherapy. The aim of this clinical study was to determine changes in hepatic blood flow during WBH for the treatment of metastatic cancer. MATERIALS AND METHODS: This observational clinical study was part of a phase I/II feasibility study of WBH. WBH was induced using a radiant heat device. Hepatic blood flow was estimated using indocyanine green clearance measurements. The plasma disappearance rate of indocyanine green (PDR-ICG) was recorded in percent/min. We used an invasive thermo-dye-dilution technique to estimate hepatic blood flow, cardiac output, and volume status. Mean arterial blood pressure was also measured invasively. To determine the effects of hyperthermia the measurements were performed at defined temperature points. RESULTS: In 10 of 22 treatments the PDR-ICG fell below normal values during hyperthermia, which represented a significant fall in hepatic blood flow. Cardiac output, volume status, and mean arterial blood pressure did not differ between patients whose liver blood flow was reduced and those whose liver blood flow remained unchanged. CONCLUSIONS: We observed distinct reductions in hepatic blood flow during WBH, which suggested a significant redistribution of blood flow away from the core during WBH. This was not mirrored by global circulatory parameters.

Duration of fluid fasting and choice of analgesic are modifiable factors for early postoperative delirium.

BACKGROUND AND OBJECTIVE: Most therapeutic options for postoperative delirium are only symptom oriented; therefore, the best approach remains prevention. The aim of this study was to identify predisposing and precipitating factors for early postoperative delirium. METHODS: A total of 1002 patients were screened for delirium in an observational, cohort study. Nine hundred and ten patients were observed in the recovery room and 862 patients on the first postoperative day in the ward at the Charité-Universitaetsmedizin, Berlin. Delirium was measured with the nursing delirium screening scale. Risk factors were analysed in a multivariate analysis. RESULTS: Delirium was seen in 11.0% of the patients in the recovery room and in 4.2% of the patients on the ward. Delirium in the recovery room was associated with delirium on the ward (McNemar's test P = <0.001). Apart from age and site of surgery, we found the duration of preoperative fluid fasting to be a modifiable precipitating factor for delirium in the recovery room (odds ratio 2.69, 95% confidence interval 1.4-5.2) and on the ward (odds ratio 10.57, 95% confidence interval 1.4-78.6) and the choice of intraoperative opioid for delirium on the ward (odds ratio 2.27, 95% confidence interval 1.0-5.1). CONCLUSION: Duration of preoperative fluid fasting and the choice of intraoperative analgesic are risk factors for postoperative delirium, and their modification provides a promising approach to reduce the incidence of postoperative delirium.

Hypercapnia in late-phase ALI/ARDS: providing spontaneous breathing using pumpless extracorporeal lung assist.

OBJECTIVE: The fibroproliferative phase of late ALI/ARDS as described by Hudson and Hough (Clin Chest Med 27:671-677, 2006) is associated with pronounced reductions in pulmonary compliance and an accompanying hypercapnia complicating low tidal volume mechanical ventilation. We report the effects of extracorporeal CO(2) removal by means of a novel pumpless extracorporeal lung assist (p-ECLA) on tidal volumes, airway pressures, breathing patterns and sedation management in pneumonia patients during late-phase ARDS. DESIGN: Retrospective analysis. SETTING: Fourteen-bed university hospital ICU. PATIENTS: Ten consecutive late-phase ALI/ARDS patients with low pulmonary compliance, and severe hypercapnia. INTERVENTION: Gas exchange, tidal volumes, airway pressures, breathing patterns and sedation requirements before (baseline) and after (2-4 days) initiation of treatment with p-ECLA were analysed. Patients were ventilated in a pressure-controlled mode with PEEP adjusted to pre-defined oxygenation goals. MEASUREMENTS AND MAIN RESULTS: Median reduction in pCO(2) was 50% following institution of p-ECLA. Extracorporeal CO(2) removal enabled significant reduction in tidal volumes (to below 4 ml/kg predicted body weight) and inspiratory plateau pressures [30 (28.5/32.3) cmH(2)O, median 25, 75% percentiles]. Normalization of pCO(2) levels permitted significant reduction in the dosages of analgesics and sedatives. The proportion of assisted spontaneous breathing increased within 24 h of instituting p-ECLA. CONCLUSION: Elimination of CO(2) by p-ECLA therapy allowed reduction of ventilator-induced shear stress through ventilation with tidal volumes below 4 ml/kg predicted body weight in pneumonia patients with severely impaired pulmonary compliance during late-phase ARDS. p-ECLA treatment supported control of breathing pattern while sedation requirements were reduced and facilitated the implementation of assisted spontaneous breathing.

Alcohol use disorder and perioperative immune dysfunction.

The anesthesiological sequelae of long-term alcohol abuse include a three to fivefold increased risk of postoperative infection, prolonged intensive care unit stays and longer hospital stays. The cause of the higher infection rates is an altered immune response in long-term alcoholic patients. Preoperatively, the T helper cells 1 to T helper cells 2 ratio is depressed in long-term alcoholic patients and remains suppressed after surgery. The lower preoperative T helper cells 1 to T helper cells 2 ratio is predictive of later onset of infections. Postoperatively, the cytotoxic lymphocyte (Tc1/Tc2) ratio is decreased in long-term alcoholic patients and remains depressed for 5 days. The interleukin (IL)-6/IL-10 ratio and the lipopolysaccharide-stimulated interferon gamma/IL-10 ratio in whole blood cells are decreased after surgery in long-term alcoholic patients. Depressed Tc1/Tc2, IL-6/IL-10 and lipopolysaccharide-stimulated interferon gamma/IL-10 ratios in the postoperative period are predictive of subsequent postoperative infections. Perioperative interventions should aim to minimize dysregulation of the immune system.

Isolated tumour cells in pathological node-negative lymph nodes adversely affect prognosis in cancer of the oesophagus or oesophagogastric junction.

AIMS: To determine the prevalence of isolated tumour cells (ITC) in lymph nodes of patients with pathological node-negative (pN0) tumours and to assess their impact on disease-free and overall survival. METHODS: Paraffin embedded lymph nodes from oesophagogastrectomy specimens were examined immunohistochemically using monoclonal anti-cytokeratin antibody (MNF118). Clinical and pathological features were summarised and overall and relapse-free survival were estimated. RESULTS: Isolated tumour cells were detected in 12 of 146 patients (8%), and 24 of 1694 (1%) lymph nodes. With a median follow-up time of 28 months (range 0-160 months), both relapse-free and overall survival were significantly (p<0.05) associated with the presence of ITC in pN0 lymph nodes. There was no significant difference in the prevalence of ITC between patients who underwent multimodal therapy and those treated with surgery alone. CONCLUSIONS: ITC in pN0 lymph nodes may be less frequent than previously considered, but their presence is associated with poorer outcomes compared with true node negative disease.

[Implementation of standard operating procedures for the initial empirical antimicrobial therapy for adults--a new computer program at the University Hospital Charité]. / Einführung von SOPs zur initialen kalkulierten Antibiotikatherapie bei Erwachsenen--Ein neues Computerprogramm an der Charité.

Nowadays 40-50 % of the patients receive inappropriate antibiotic treatment. Evidence based recommendations are not considered and there is an increasing burden of resistant pathogens. Therefore, standard operating procedures (SOPs) should be implemented considering guidelines and resistant species in the specific ICU. The authors developed algorithms and generated a user friendly computer program available for all ICU physicians all the time.