Pleural fluid glucose: A predictor of unsuccessful pleurodesis in a preselected cohort of patients with malignant pleural effusion.

PURPOSE: To assess whether exclusion of patients with conditions that could lead to large fluctuations of serum glucose, would increase the accuracy of pleural fluid glucose in predicting pleurodesis outcome in patients with malignant pleural effusion subjected to bleomycin pleurodesis. METHODS: A retrospective analysis of 162 patients with recurrent, symptomatic malignant pleural disease was performed. Patients with diabetes mellitus or other causes of hyperglycemia were excluded, as pleural fluid glucose has been reported to be sensitive to serum glucose fluctuations. Assessment of pleurodesis outcome was based on radiologic appearance 30 days post-bleomycin pleurodesis. RESULTS: Successful pleurodesis was achieved in 64.8% of patients. Univariate analysis showed that pleural fluid glucose (p<0.001), pH (p<0.001), total proteins (p<0.001), albumin (p<0.001) and cholesterol (p<0.05) were significantly lower in patients with pleurodesis failure, while LDH was significantly higher (p<0.05). Pleural fluid glucose was the only independent predictor of pleurodesis outcome and with a cut-off point of 65 mg/dl had a high sensitivity (90.7%) with an acceptable specificity (76.8%) (p<0.001). The regression model exhibiting the highest predictive accuracy included pleural fluid glucose and albumin (sensitivity 89.3%, specificity 84.5%, p<0.001). Furthermore, a product of glucose and albumin less than 152 could predict pleurodesis failure with 88.9% sensitivity and 82.8% specificity (p<0.001). CONCLUSIONS: Pleural glucose levels may reliably predict pleurodesis failure in patients without conditions that could lead to hyperglycemia, and its accuracy can increase if combined with pleural fluid albumin in an-easy-to calculate formula.

Continuous chest compressions improve survival and neurologic outcome in a swine model of prolonged ventricular fibrillation.

INTRODUCTION: Evidence suggests that any interruptions, including those of rescue breaths, during cardiopulmonary resuscitation (CPR) have significant, detrimental effects on survival. The 2010 International Liaison Committee on Resuscitation guidelines strongly emphasized on the importance of minimizing interruptions during chest compressions. However, those guidelines also stress the need for ventilations in the case of prolonged cardiac arrest (CA), and it is not at present clear at which point of CA the necessity of providing ventilations overcomes the hemodynamic compromise caused by chest compressions' interruption. METHODS: Ventricular fibrillation was electrically induced in 20 piglets (19 ± 2 kg) and left untreated for 8 minutes. Animals were randomized to receive 2 minutes of either chest compression-only CPR (group CC) or standard 30:2 compressions/ventilations CPR (group S) before defibrillation. Resuscitated animals were monitored under anesthesia for 4 hours and then were awakened and placed in a maintenance facility for 24 hours. RESULTS: There was no significant difference among groups for both return of spontaneous circulation and 1-hour survival. There was a significant difference in 24-hour survival (group CC, 7/10 vs group S, 2/10; P = .025). Blood lactate levels were significantly lower in group CC compared with group S in both 1 (P = .019) and 4 hours (P = .034) after return of spontaneous circulation. Furthermore, group CC animals exhibited significantly higher mean Neurologic Alertness Score (58 ± 42.4 vs 8 ± 16.9) (P < .05). CONCLUSION: In this swine CA model, where defibrillation was first attempted at 10 minutes of untreated ventricular fibrillation, uninterrupted chest compressions resulted in significantly higher survival rates and higher 24-hour neurologic scores, compared with standard 30:2 CPR.

Conventional direct laryngoscopy versus videolaryngoscopy with the GlideScope®: a neonatal manikin study with inexperienced intubators.

We hypothesized that because the view of the glottis is better with videolaryngoscopes, successful intubation in neonates would be accomplished in a shorter time with the GlideScope (®) (Verathon, Inc., Bothell, WA) videolaryngoscope (GVL). Forty-five students of the University of Athens, inexperienced in both techniques, participated in the study (21 medical students and 24 nursing students, crossover randomized study). Following a brief educational session, each participant practiced and attempted intubation on a neonatal manikin using conventional laryngoscope and GVL, as many times as required to secure the airway. The time required to successful intubation and the number of attempts with each device were recorded. No significant difference was observed between the number of attempts required for successful intubation with either laryngoscope. The time required for the first successful intubation with the conventional laryngoscope was significantly shorter compared with that required with the GVL ( P = 0.0013). There was no difference regarding the time required for the successful intubation between medical and nursing students, using the conventional laryngoscope or the GVL. The number of attempts to successful intubation with either device did not differ. The time required for intubation with the GVL was longer, and this is probably due to a design flaw.

A formula for the stratified selection of patients with paroxysmal atrial fibrillation in the emergency setting: a retrospective pilot study.

BACKGROUND: Amiodarone is a commonly used medication in the treatment of atrial fibrillation (AF) of recent onset. STUDY OBJECTIVES: The aim of the study was to identify a possible formula for selecting Emergency Department (ED) patients with paroxysmal AF who will spontaneously restore sinus rhythm (SR), successfully restore SR with the use of loading intravenous (i.v.) amiodarone, or require 24-h maintenance amiodarone infusion. METHODS: This retrospective pilot study included 141 patients with recent-onset AF. Patients who did not restore SR spontaneously received i.v. amiodarone (5 mg/kg) within a period of 30 min. In case of no response, an additional dosage of 1000 mg of i.v. amiodarone was administered over a period of 24 h. Binary logistic regression models were used to determine the predictors of spontaneous conversion and the response to amiodarone administration. RESULTS: The formula ([heart rate/systolic blood pressure] + 0.1 × number of past AF incidences) was chosen as the one with the highest combined sensitivity and specificity. This index identified the patients who spontaneously restored SR (cutoff point 1.31 with 78.6% sensitivity and 77.9% specificity), whereas for patients who responded to the loading i.v. amiodarone dose, the use of the index (cutoff point 1.24) exhibited 84.1% sensitivity and 75.3% specificity. CONCLUSIONS: This formula may be a useful and reliable bedside diagnostic tool to identify AF patients most likely to spontaneously convert, or respond to loading amiodarone administration in the emergency setting. The use of this index also can assist in patient risk stratification.

Peripartum Management of Gitelman Syndrome for Vaginal Delivery: A Case Report and Review of Literature.

We describe the anesthetic management of a spontaneous vaginal delivery at 38 weeks' gestation in a 36-year-old patient with Gitelman syndrome (GS). GS is a rare autosomal recessive renal tubulopathy characterized by hypomagnesemia, hypocalciuria, and secondary aldosteronism, which results in hypokalemia and metabolic alkalosis. To minimize any increase in catecholamine levels and consequent risk of ventricular arrhythmias, a labor epidural analgesia was administered using ropivacaine and fentanyl, along with intravenous magnesium and potassium supplementation. Ropivacaine was substituted for routine bupivacaine to decrease the risk of drug-induced cardiotoxicity. In the event of a cesarean section, the anesthetic plan was to continue with top-up epidural anesthesia and in case of failure, to convert to general anesthesia using propofol and rocuronium for induction. Delivery outcome was successful and uneventful.

Hydroxyethyl starch 6% (130/0.4) ameliorates acute lung injury in swine hemorrhagic shock.

BACKGROUND: Traumatic hemorrhage induces acute lung injury. The aim of this study was to assess whether lactated Ringer's solution or 6% hydroxyethyl starch 130/0.4 would have different effects on acute lung injury following hemorrhagic shock. METHODS: Twenty healthy pigs (19 ± 2 kg) were subjected to hemorrhage and were randomly allocated to two groups: Group A (10 pigs) who received lactated Ringer's solution and Group B (10 pigs) who received hydroxyethyl starch 130/0.4. Hemodynamic response and serum lactate were measured at predetermined phases. Four hours after fluid resuscitation animals were euthanized. Lungs were harvested, and tissue samples were collected. Focal thickening of the alveolar membranes, vascular congestion, number of activated neutrophils, alveolar edema, interstitial neutrophil infiltration, intraalveolar infiltration, and alveolar hemorrhage were assessed. Each feature was given a score from 0 to 3 (0 = absence, 3 = severe). The wet/dry ratio was also calculated, and with the use of Evans blue dye extravasation method, capillary permeability was assessed. RESULTS: The total histology score of Group A differed significantly from that of Group B, being significantly lower in Group B animals P = 0.048. The wet/dry weight ratio was significantly higher in the lactated Ringer's group (median [range]) (Group A, 5.1 [0.5]; Group B, 4.9 [0.3]; P = 0.009). The Evans blue dye extravasation method was utilized to study the lung capillary permeability. The animals in Group B showed a marked reduction in microvascular capillary permeability compared with the animals in Group A (Group A, 58.5 [21] mg/g; Group B, 51.5 [14] mg/g; P = 0.017). CONCLUSIONS: Our study indicates that resuscitation after hemorrhagic shock with hydroxyethyl starch 130/0.4 led to less lung edema and less microvascular permeability in this swine model.

Factors influencing arrival of patients with acute myocardial infarction at emergency departments: implications for community nursing interventions.

AIM: This paper identifies the characteristics of Greek patients with acute myocardial infarction who have long prehospital delays and identifies the factors that are specifically associated with these delays. BACKGROUND: The time between the first appearance of symptoms until the hospitalization of the patient with myocardial infarction correlates statistically significantly with in-hospital and long-term mortality. METHODS: The study took place in two Greek coronary care units from 1 June 2007 to 31 July 2008. From 232 consecutive patients with myocardial infarction, 160 were enrolled. Data were collected by a trained hospital staff nurse, who interviewed all patients within 48 hours of hospital admission. RESULTS: Smokers arrived statistically significantly sooner at the hospital than non-smokers [smokers' prehospital time delay: 78.9 (sd = 3.2) minutes vs. non-smokers' prehospital time delay: 98.2 (sd = 4.1) minutes, Mann-Whitney U-test, Z = -2.5, P < 0.05]. Patients with hyperlipidaemia arrived with a mean delay of 13 minutes less than normolipidaemic patients. Those with inferior ST segment elevation myocardial infarction exhibited statistically significantly shorter delay times than those with anterior or lateral (inferior vs. anterior, P = 0.003, inferior vs. lateral, P = 0.024, anova with Bonferroni-Holm post hoc test, F = 7.5, P = 0.001). CONCLUSION: Community nurses should educate all patients about myocardial infarction, not only those at high risk but also those without known risk factors for ischaemic heart disease.

Videolaryngoscopy in the management of the difficult airway: a comparison with the Macintosh blade.

BACKGROUND AND OBJECTIVE: Several studies have shown that videolaryngoscopes can provide better laryngeal exposure than conventional laryngoscopy. These studies, however, did not exclusively focus on patients with an anticipated difficult intubation. The aim of the present study was to assess whether a videolaryngoscope would provide better laryngeal exposure than conventional laryngoscopy and therefore facilitate intubation in cases of difficult laryngoscopy. METHODS: One hundred and twelve patients with an estimated difficult intubation, scheduled to undergo surgical operations, requiring general anaesthesia and endotracheal intubation, were included in the study. Direct laryngoscopy with a Macintosh blade was performed, followed by videolaryngoscopy and intubation attempt(s). The laryngeal views obtained by each method were recorded according to the Cormack/Lehane scale. RESULTS: The percentage of Cormack-Lehane I and II views obtained by conventional laryngoscopy rose from 63.4 to 90.2% (P < 0.0005) with videolaryngoscopy, whereas Cormack-Lehane III and IV views declined from 36.6 to 9.8% (P < 0.0005). Intubation was successful in 98.2% of the cases. CONCLUSION: In patients with an anticipated difficult airway, videolaryngoscopy significantly improved the laryngeal exposure thus facilitating endotracheal intubation.

Nitroglycerin and epinephrine improve coronary perfusion pressure in a porcine model of ventricular fibrillation arrest: a pilot study.

BACKGROUND: Cardiac arrest remains one of the leading causes of death worldwide. European Resuscitation Council Guidelines for Resuscitation 2005 recommend epinephrine for its treatment. OBJECTIVES: To estimate whether the administration of a vasodilatator such as nitroglycerin in combination with epinephrine during cardiopulmonary resuscitation would improve resuscitation outcome in an established model of ventricular fibrillation. DESIGN: Prospective, randomized, blinded, controlled study. SETTING: Animal research laboratory. Ventricular fibrillation was induced in 20 Landrace/Large-White pigs. It remained untreated for 8 min before attempting resuscitation precordial compressions, mechanical ventilation, and electrical defibrillation. Animals were randomized into two groups, 10 animals each. Group A received saline as placebo (10 mL dilution, bolus) and epinephrine (0.02 mg/kg). Group B received nitroglycerin (50 microg/kg) and epinephrine (0.02 mg/kg) during cardiopulmonary resuscitation. Electrical defibrillation was attempted after 10 min of ventricular fibrillation. RESULTS: Four animals in group A restored spontaneous circulation in comparison to eight in Group B. Coronary perfusion pressure (p < 0.0001) was significantly increased in Group B during cardiopulmonary resuscitation. CONCLUSION: A vasodilatator, when administered in combination with a vasopressor such as epinephrine during cardiopulmonary resuscitation, increases coronary perfusion pressure.

Nurses are more efficient than doctors in teaching basic life support and automated external defibrillator in nurses.

BACKGROUND: Cardiac arrest (CA) is a leading cause of death worldwide. The European Resuscitation Council (ERC) has developed basic life support/automated external defibrillation (BLS/AED) courses for uniform training in out-of-hospital CA. OBJECTIVE: The present study compares the resuscitation skills of two groups of nursing staff, one taught by newly trained ERC nurse-instructors and the other by newly trained doctor-instructors. METHOD: Eighteen doctors and 18 nurses were asked to teach a total of 108 nurses in a (BLS/AED) course. One month after its completion, all 108 nurses were asked to be re-evaluated, with the use of the objective structured clinical examination. CONCLUSIONS: No statistical significant difference between the two groups was noted in the written test, in contrast with data collected from the practice skills check-list. Nurses in group A could easily identify the patient in cardiac arrest but had difficulties concerning chest compressions and handling the AED. Nurses in group B were more focused during the performances, used AED more accurately and continued cardiopulmonary resuscitation with no delays. Nurses prove to be more efficient in training nurses.

Pharmacokinetics of moxifloxacin in non-inflamed cerebrospinal fluid of humans: implication for a bactericidal effect.

OBJECTIVES: To evaluate the ability of moxifloxacin to penetrate healthy brain barriers. METHODS: Fifty patients received a single oral dose of 400 mg as an antimicrobial prophylaxis regimen for a short urological procedure under spinal anaesthesia. Serum and cerebrospinal fluid (CSF) were sampled at different time intervals post-drug intake and patients were divided into five groups, as follows: group I: 0.5-1 h; group II: 1-2 h; group III: 2-4 h; group IV: 4-6 h; and group V: 6-8 h. Concentrations of moxifloxacin were estimated after analysis by an HPLC system. Bactericidal activity of CSF samples of groups III and IV was assessed by a microdilution technique against two penicillin-resistant isolates of Streptococcus pneumoniae with MICs of moxifloxacin of 0.19 and 0.125 mg/L, respectively. RESULTS: Mean CSF concentrations of moxifloxacin of groups I, II, III, IV and V were 0.19, 0.87, 3.00, 4.07 and 1.82 mg/L, respectively. The mean bactericidal activity of CSF of group III was 8 and that of group IV was 4. CONCLUSIONS: Single oral intake of 400 mg moxifloxacin is accompanied by good penetration through healthy meninges within 2-6 h post-dose and reached adequately high levels in human CSF exerting satisfactory bactericidal activity against penicillin-resistant S. pneumoniae. These results render novel perspectives for a role of moxifloxacin in CNS infections.

Vasopressin and epinephrine in the treatment of cardiac arrest: an experimental study.

BACKGROUND: Epinephrine remains the drug of choice for cardiopulmonary resuscitation. The aim of the present study is to assess whether the combination of vasopressin and epinephrine, given their different mechanisms of action, provides better results than epinephrine alone in cardiopulmonary resuscitation. METHODS: Ventricular fibrillation was induced in 22 Landrace/Large-White piglets, which were left untreated for 8 minutes before attempted resuscitation with precordial compression, mechanical ventilation and electrical defibrillation. Animals were randomized into 2 groups during cardiopulmonary resuscitation: 11 animals who received saline as placebo (20 ml dilution, bolus) + epinephrine (0.02 mg/kg) (Epi group); and 11 animals who received vasopressin (0.4 IU/kg/20 ml dilution, bolus) + epinephrine (0.02 mg/kg) (Vaso-Epi group). Electrical defibrillation was attempted after 10 minutes of ventricular fibrillation. RESULTS: Ten of 11 animals in the Vaso-Epi group restored spontaneous circulation in comparison to only 4 of 11 in the Epi group (p = 0.02). Aortic diastolic pressure, as well as, coronary perfusion pressure were significantly increased (p < 0.05) during cardiopulmonary resuscitation in the Vaso-Epi group. CONCLUSION: The administration of vasopressin in combination with epinephrine during cardiopulmonary resuscitation results in a drastic improvement in the hemodynamic parameters necessary for the return of spontaneous circulation.

Comparison of blind intubation through the I-gel and ILMA Fastrach by nurses during cardiopulmonary resuscitation: a manikin study.

OBJECTIVES: To investigate whether nursing staff can successfully use the I-gel and the intubating laryngeal mask Fastrach (ILMA) during cardiopulmonary resuscitation. BACKGROUND: Although tracheal intubation is considered to be the optimal method for securing the airway during cardiopulmonary resuscitation, laryngoscopy requires a high level of skill. METHODS: Forty five nurses inserted the I-gel and the ILMA in a manikin, with continuous and without chest compressions. RESULTS: Mean intubation times for the ILMA and I-gel without chest compressions were 20.60 ± 3.27 and 18.40 ± 3.26 s, respectively (p < 0.0005). ILMA proved more successful than the I-gel regardless of compressions. Continuation of compressions caused a prolongation in intubation times for both the I-gel (p < 0.0005) and the ILMA (p < 0.0005). CONCLUSION: In this mannequin study, nursing staff can successfully intubate using the I-gel and the ILMA as conduits with comparable success rates, regardless of whether chest compressions are interrupted or not.

A comparison of the i-gel and classic LMA insertion in manikins by experienced and novice physicians.

OBJECTIVE: Airway management is of utmost importance in critical patients, for whom endotracheal intubation remains the gold standard. However, it is a difficult skill to acquire and success rates in novices are unacceptably low. Supraglottic devices constitute promising alternatives. The aim of this study was to assess the use of laryngeal mask airway (LMA) classic LMA (cLMA) and a relatively new supraglottic device, the i-gel, in experienced and novice doctors in a manikin setting. METHODS: The study population comprised 116 doctors. After a brief educational session and presentation of cLMA and i-gel, participants were randomly allocated to insert both devices in an adult manikin. Insertions were performed using a size-4 cLMA and a size-4 i-gel. The primary endpoints were the success rate for each device and the duration of the insertion attempt. Secondary endpoint was the perception of ease of use with each device. RESULTS: First attempt success rate was 90.5% for i-gel and 63.8% for cLMA (P<0.001). I-gel use reduced insertion times (13.32±4.99 s vs. 17.99±6.87 s, P<0.001) and was related with significantly higher first attempt success rates than cLMA in novices (90 vs. 48.3%, P<0.001). In addition, i-gel use provided almost equal success rates for experienced and novice doctors (91 vs. 90%, P=not significant), whereas cLMA use resulted in significantly lower success rates for novices (48.3 vs. 80.4%, P<0.001). CONCLUSION: In this manikin setting i-gel significantly improved success rates and insertion time compared with cLMA. Most importantly, i-gel use resulted in high first pass success rates for novice doctors, equal to those achieved by experienced doctors.

An intraoperative case of spontaneous restoration of circulation from asystole: a case of lazarus phenomenon.

This case report refers to a victim of intraoperative cardiac arrest, who restored spontaneous circulation despite of cessation of cardiopulmonary resuscitation (CPR). The victim, a 53-year-old man, was undergoing a surgical investigation and rehabilitation of a thigh hematoma. Two minutes after discontinuation of a 46 min CPR, a normotensive sinus node rhythm appeared at monitor. Despite of lack of an adequate explanation, the authors believe that the combination of the high total dose of adrenaline with the cessation of mechanical ventilation might augment venous return and lead to restoration of spontaneous circulation.