Heart failure due to 'stress cardiomyopathy': a severe manifestation of the opioid withdrawal syndrome.

Takotsubo cardiomyopathy (TTC) is a transient left ventricular (LV) dysfunction due to akinesia of the LV mid-apical segments ('apical ballooning') in the absence of critical coronary stenoses which can be complicated in the acute phase by heart failure, mitral regurgitation, life-threatening ventricular arrhythmias, or apical LV thrombosis. The syndrome is typically precipitated by intense emotional or physical stress; however, other causes of sympathetic overstimulation including administration of exogenous sympathomimetics or withdrawal of sympathetic antagonists can trigger TTC. We report the case of a patient who unexpectedly developed an 'apical ballooning' with severe reduction in the LV systolic function and heart failure after the withdrawal of methadone. The case supports the concept that increased sympathetic activity secondary to opioids withdrawal can trigger a stress-induced severe LV dysfunction. Physicians should be aware that the abrupt discontinuation of a long-term therapy with opioids may lead to serious cardiac complications. The administration of clonidine may be considered to prevent early clinical manifestations of addictive withdrawal, including TTC.

Brugada ECG disclosed by acute malaria: is it all about fever and propofol?

Brugada syndrome is an electrical cardiac disease predisposing to ventricular arrhythmias in which typical electrocardiographic (ECG) features consist of nonischemic repolarization abnormalities in the right precordial leads V1-V3. The appearance of a Brugada-ECG pattern is increasingly observed in critically ill patients and is traditionally attributed to the effect of body temperature and/or drug modulation on cardiac ion channels ("acquired Brugada syndrome"). A patient with complicated malaria in whom Brugada-ECG abnormalities appeared in concomitance with fever and propofol administration is presented. The repolarization changes did not disappear until the patient's clinical course improved.

Sleep-related adductor laryngeal dystonia causing sleep apnea: a sleep-related breathing disorder diagnosed with sleep endoscopy and treated with botulinum toxin.

OBJECTIVES/HYPOTHESIS: Obstructive sleep apnea syndrome (OSAS) is a chronic condition, characterized by recurrent episodes of upper airway collapse during sleep, which affects up to 5% of adults in the Western population. The muscle tone of the human body ordinarily relaxes during sleep, thus causing airway obstruction and leading to sleep apnea. We report a case of a 68-years old male in which dystonic closure of the larynx during sleep caused OSAS. The sleep endoscopy was crucial in establishing the diagnosis of laryngeal dystonia. A botulinum toxin injection in the vocal cord improved the OSAS. These findings define a novel sleep-related breathing disorder.

Perioperative care for the older outpatient undergoing ambulatory surgery.

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

Direct cost analysis of intensive care unit stay in four European countries: applying a standardized costing methodology.

OBJECTIVES: The objective of the present study was to measure and compare the direct costs of intensive care unit (ICU) days at seven ICU departments in Germany, Italy, the Netherlands, and the United Kingdom by means of a standardized costing methodology. METHODS: A retrospective cost analysis of ICU patients was performed from the hospital's perspective. The standardized costing methodology was developed on the basis of the availability of data at the seven ICU departments. It entailed the application of the bottom-up approach for "hotel and nutrition" and the top-down approach for "diagnostics," "consumables," and "labor." RESULTS: Direct costs per ICU day ranged from €1168 to €2025. Even though the distribution of costs varied by cost component, labor was the most important cost driver at all departments. The costs for "labor" amounted to €1629 at department G but were fairly similar at the other departments (€711 ± 115). CONCLUSIONS: Direct costs of ICU days vary widely between the seven departments. Our standardized costing methodology could serve as a valuable instrument to compare actual cost differences, such as those resulting from differences in patient case-mix.

Effect of recombinant activated factor VII in critical bleeding: clinical experience of a single center.

Recombinant activated factor VII (rFVIIa) has been successfully used ''off-label'' in patients with refractory life-threatening hemorrhage. Intravenous rFVIIa was given to 31 patients unresponsive to standard therapy with blood products and surgical reexploration, who were bleeding due to trauma, surgery, organ transplantation, liver cirrhosis, ruptured uterus. We recorded their coagulation and hematologic profiles, acid-base balance, blood loss, number of red blood cells (RBC), plasma and platelet transfusions, complications, and survival. rFVIIa (mean dose 132.2 +/- 56.3 microg/kg) effectively contained the hemorrhage in 28/31 (90.3%) cases, with a mean reduction in blood loss from 12.4 +/- 10.2 to 2.7 +/- 2.2 L (P < .0001). The need for RBC, platelet, and plasma transfusion decreased significantly after rFVIIa, with a consequent significant improvement in clotting of test hematocrit, pH, and bicarbonates. Four patients had adverse events potentially related to rFVIIa. The survival rates after 1 and 30 days were 48.4% and 29.1%, respectively.

Economics and outcome in the intensive care unit.

PURPOSE OF REVIEW: Medical care costs represent a large proportion of the gross domestic product in developed countries, and intensive care units (ICUs) consume a significant amount of those resources. The aim of this review is to analyze how the healthcare cost problem is studied in critically ill patients. RECENT FINDINGS: Permanent staffing and other overhead costs have the greatest impact on ICU costs. A growing number of studies from around the world are quantifying the costs of ICU care. Mechanical ventilation, particularly in severely ill patients, and sepsis management are responsible for much of the economic burden in the ICU. New expensive therapies and life support systems make formal economic analyses necessary. SUMMARY: Although economic justification should not be the only issue to influence treatments offered in the ICU, increasing use of tools such as cost-benefit analyses is needed to help with medical decisions on the critically ill patient.

Initial evaluation of a new optic laryngoscope blade.

We report on a new optic laryngoscope blade that provides two views of the larynx during tracheal intubation. The availability of an alternative direct view of the larynx may improve the ability of anesthesia providers to observe the tracheal tube passing through the vocal cords when using a Macintosh laryngoscope blade. The optic port improved visualization of passage of the endotracheal tube in obese patients. However, further studies are needed in patients with difficult airways to determine whether this new blade will ease the ability of practitioners to insert a tracheal tube.