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Objective To determine the effect of perioperative β blocker treatment in patients having non-cardiac surgery. Design Systematic review and meta-analysis. Data sources Seven search strategies, including searching two bibliographic databases and hand searching seven medical journals. Study selection and outcomes We included randomised controlled trials that evaluated β blocker treatment in patients having non-cardiac surgery. Perioperative outcomes within 30 days of surgery included total mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal cardiac arrest, non-fatal stroke, congestive heart failure, hypotension needing treatment, bradycardia needing treatment, and bronchospasm. Results Twenty two trials that randomised a total of 2437 patients met the eligibility criteria. Perioperative β blockers did not show any statistically significant beneficial effects on any of the individual outcomes and the only nominally statistically significant beneficial relative risk was 0.44 (95% confidence interval 0.20 to 0.97, 99% confidence interval 0.16 to 1.24) for the composite outcome of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal cardiac arrest. Methods adapted from formal interim monitoring boundaries applied to cumulative meta-analysis showed that the evidence failed, by a considerable degree, to meet standards for forgoing additional studies. The individual safety outcomes in patients treated with perioperative β blockers showed a relative risk for bradycardia needing treatment of 2.27 (95% CI 1.53 to 3.36, 99% CI 1.36 to 3.80) and a nominally statistically significant relative risk for hypotension needing treatment of 1.27 (95% CI 1.04 to 1.56, 99% CI 0.97 to 1.66). Conclusion The evidence that perioperative β blockers reduce major cardiovascular events is encouraging but too unreliable to allow definitive conclusions to be drawn.

Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS. We conducted a model-based cost–consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses. The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309). The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS. Les lésions myocardiques après chirurgie non cardiaque (CNC) sont majoritairement asymptomatiques et fortement associées au risque de mortalité dans les 30 jours; toutefois, dans la plupart des cas, elles ne sont pas détectées en l’absence d’une surveillance systématique de la troponine T. Nous avons évalué les coûts et les conséquences d’une telle surveillance pour détecter les lésions myocardiques après CNC. Nous avons mené une analyse coût–conséquence modélisée pour comparer la surveillance systématique de la troponine T aux soins habituels seuls (mesure de la troponine T seulement s’il y a présence de symptômes d’ischémie) sur la fréquence de détection de lésions myocardiques après CNC. Les données ayant servi à l’analyse provenaient des patients canadiens ayant participé à l’étude de cohorte VISION, qui visait à évaluer les complications vasculaires chez les patients de 45 ans et plus ayant subi une CNC. Nous avons mené des analyses de probabilité avec 10 000 itérations et des analyses de sensibilité approfondies. Les données portaient sur 6021 patients (48 % du sexe masculin; âge moyen de 65 ans [écart-type de 12 ans]). Le taux de mortalité dans les 30 jours associé à une lésion myocardique après CNC était de 9,6 %. Nous avons déterminé que le coût marginal de la détection de la présence d’une lésion par surveillance de la troponine T était de 1632 $ (dollars canadiens en 2015). Le rapport coût–efficacité était plus bas pour les sous-groupes de patients à risque élevé de lésion myocardique après CNC, comme les patients de 65 ans et plus ou ceux ayant des antécédents d’athérosclérose ou de diabète (1309 $), que pour leurs pairs. Les coûts associés à un programme de surveillance de la troponine T pour détecter les lésions myocardiques après CNC étaient modérés. Le coût marginal estimé par gain de santé indique que la mise en oeuvre de ce type de programme pourrait être une option intéressante, surtout pour les patients à risque élevé de lésion myocardique après CNC.

Acute renal failure (ARF) occurs in up to 10% of critically ill patients, with significant associated morbidity and mortality. The optimal mode of renal replacement therapy (RRT) remains controversial. This retrospective study compared continuous renal replacement therapy (CRRT) and intermittent hemodialysis (IHD) for RRT in terms of intensive care unit (ICU) and hospital mortality, and renal recovery. We reviewed the records of all patients undergoing RRT for the treatment of ARF over a 12-month period. Patients were compared according to mode of RRT, demographics, physiologic characteristics, and outcomes of ICU and hospital mortality and renal recovery using the Chi square, Student's t test, and multiple logistic regression as appropriate. 116 patients with renal insufficiency underwent RRT during the study period. Of these, 93 had ARF. The severity of illness of CRRT patients was similar to that of IHD patients using APACHE II (25.1 vs 23.5, P = 0.37), but they required significantly more intensive nursing (therapeutic intervention scale 47.8 vs 37.6, P = 0.0001). Mortality was associated with lower pH at presentation (P = 0.003) and increasing age (P = 0.03). Renal recovery was significantly more frequent among patients initially treated with CRRT (21/24 vs 5/14, P = 0.0003). Further investigation to define optimal timing, dose, and duration of RRT may be beneficial. Although further study is needed, this study suggests that renal recovery may be better after CRRT than IHD for ARF. Mortality was not affected significantly by RRT mode.

Background Venous thromboembolism (VTE) is a common complication of critical illness with important clinical consequences. The Prophylaxis for ThromboEmbolism in Critical Care Trial (PROTECT) is a multicenter, blinded, randomized controlled trial comparing the effectiveness of the two most common pharmocoprevention strategies, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) dalteparin, in medical-surgical patients in the intensive care unit (ICU). E-PROTECT is a prospective and concurrent economic evaluation of the PROTECT trial. Methods/Design The primary objective of E-PROTECT is to identify and quantify the total (direct and indirect, variable and fixed) costs associated with the management of critically ill patients participating in the PROTECT trial, and, to combine costs and outcome results to determine the incremental cost-effectiveness of LMWH versus UFH, from the acute healthcare system perspective, over a data-rich time horizon of ICU admission and hospital admission. We derive baseline characteristics and probabilities of in-ICU and in-hospital events from all enrolled patients. Total costs are derived from centers, proportional to the numbers of patients enrolled in each country. Direct costs include medication, physician and other personnel costs, diagnostic radiology and laboratory testing, operative and non-operative procedures, costs associated with bleeding, transfusions and treatment-related complications. Indirect costs include ICU and hospital ward overhead costs. Outcomes are the ratio of incremental costs per incremental effects of LMWH versus UFH during hospitalization; incremental cost to prevent a thrombosis at any site (primary outcome); incremental cost to prevent a pulmonary embolism, deep vein thrombosis, major bleeding event or episode of heparin-induced thrombocytopenia (secondary outcomes) and incremental cost per life-year gained (tertiary outcome). Pre-specified subgroups and sensitivity analyses will be performed and confidence intervals for the estimates of incremental cost-effectiveness will be obtained using bootstrapping. Discussion This economic evaluation employs a prospective costing methodology concurrent with a randomized controlled blinded clinical trial, with a pre-specified analytic plan, outcome measures, subgroup and sensitivity analyses. This economic evaluation has received only peer-reviewed funding and funders will not play a role in the generation, analysis or decision to submit the manuscripts for publication. Trial registration Clinicaltrials.gov Identifier: NCT00182143 . Date of registration: 10 September 2005.

Purpose: Guillain-Barré syndrome (GBS) is an acute immunologic attack of the peripheral nerves causing rapidly ascending weakness and areflexia. Occasionally, weakness is severe enough to leave patients paralyzed and without adequate respiratory function. In such patients, intensive care unit (ICU) admission is required. Infrequently, GBS occurs in patients already admitted to the ICU. When this occurs, it can be difficult to distinguish GBS from critical illness neuropathy (CIN). However, it is important to consider GBS in these cases, since treatment options are available, and early treatment is associated with significantly improved outcome. Clinical features: A 28-yr-old man involved in a motor vehicle collision sustained multiple injuries, including T6–T7 thoracic vertebrae fracture. Magnetic resonance imaging identified spinal cord compression at T6–T7, without brain or cervical cord injury. Shortly after admission, the patient developed marked autonomic instability with fluctuating temperatures and severe hypotension. Lower extremity weakness rapidly worsened to paraplegia and new weakness developed affecting bilateral upper extremities and face. Electrodiagnostic studies showed severe axonal polyneuropathy, with denervation in all extremities. The cerebrospinal fluid protein concentration was 5.03 g·L −1 . The patient was treated empirically for the possibility of GBS. Six months later, the patient recovered significant strength in his face and extremities, including his legs. Conclusions: Guillain-Barré syndrome in trauma patients is rare and is limited to case reports following head trauma. This case also highlights the similarities and the subtle differences between GBS and CIN. Ultimately, definitive diagnosis of GBS may not be possible; however, an empiric course of intravenous immunoglobulins or plasma-exchange may be warranted, if GBS is a reasonable possibility.

[...] SureStep®Flexx® data points were included only when the sample was collected within 15 min of the blood gas analyzer sample. [...] the authors concede that the NICE-SUGAR protocol contained many factors that might explain the increased prevalence of hypoglycemic events in the intensively treated group. A more cogent argument would have included details of hypoglycemic events along with the actual bias associated with the glucosemeasuring device and the patient's hematocrit. Because these data are not presented, the premise that a hematocrit effect, or device performance, caused hypoglycemic events in the NICE-SUGAR study is unfounded.

Methemoglobinemia is an uncommon cause of tissue hypoxemia that can be life-threatening if not promptly identified and treated. It can occur after exposure to an oxidizing agent from contaminated well water or from nitroglycerin, sodium nitroprusside, or certain local anesthetics. During oropharyngeal use of topical anesthetics for transesophageal echocardiography, systemic drug uptake is unpredictable and unexplained complications can ensue. Treatment of acquired methemoglobinemia may require methylene blue, as oxygen is not usually sufficient. Avoidance of the oxidizing agent, probably benzocaine in the cases presented, is prudent.