Painful Recall in Elective Electrical Cardioversion with Propofol and the Need for Additional Analgesia.

INTRODUCTION: Electrical cardioversion (ECV) is a short but painful procedure for treating cardiac dysrhythmias. There is a wide variation regarding the medication strategy to facilitate this procedure. Many different sedative techniques for ECV are described. Currently, the optimal medication strategy to prevent pain in ECV has yet to be established. The role for additional analgesic agents to prevent pain during the procedure remains controversial, and evidence is limited. METHODS: We conducted a prospective multicenter study to determine the incidence of painful recall in ECV with propofol as a sole agent for sedation, in order to assess the indication for additional opioids. In all patients, sedation was induced with propofol titrated till loss of eyelash reflex and nonresponsiveness to stimuli, corresponding to Ramsay Sedation Score level 5-6. ECV was performed with extracardiac biphasic electrical shocks. The primary outcome was painful recall of the procedure, defined as numeric pain rating scale (NRS) ≥ 1. NRS ≥ 4 is considered inadequately treated pain. Secondary outcome parameters were pain at the side of the defipads and muscle pain after ECV. RESULTS: A total of 232 patients were enrolled in this study. Six patients were excluded due to missing data or violation of study protocol. Three patients reported recall of the procedure, and one patient (0.4%) reported recall of severe pain during the procedure with NRS 7. Two patients (0.9%) reported recall of mild pain with NRS 1-3. Complete amnesia was observed in 223 patients (98.7%), with NRS 0. The mean of the total dose of propofol was 1.1 mg/kg. Fifteen patients (6.6%) experienced pain at the side of the defipads, and six patients (2.7%) complained of muscle pain after the procedure. CONCLUSIONS: In this prospective multicenter study, propofol as a sole agent provided good conditions for ECV with a low incidence of recall. Effective sedation and complete amnesia was achieved in 98.7% of the patients, 0.4% of patients reported recall of severe pain during the procedure, and 0.9% of patients experienced mild pain during the ECV.

A rare stress cardiomyopathy in a patient with Guillain-Barré syndrome.

We report on a 39-year-old woman who was intubated because of progressive respiratory failure due to muscle weakness and mucous plugging because of Guillain- Barré syndrome. Shortly after uncomplicated intubation she developed hypotension and a profound tachycardia. The electrocardiogram showed sinus tachycardia with nonspecific ST-T segment changes. Echocardiography showed akinesia of the apex, septum and inferior left ventricular wall with an estimated left ventricular ejection fraction of 10%. It was concluded that the patient was suffering from takotsubo cardiomyopathy. Following treatment, she experienced a complete recovery. Takotsubo cardiomyopathy is a rare complication in Guillain-Barré syndrome; eight other cases have been reported in the literature.

Preventing ventriculostomy-related infections with antibiotic-impregnated drains in hospitals: a two-centre Dutch study.

This observational cohort study assessed the effect of the introduction of antibiotic-impregnated external ventricular drains (AI-EVDs), as opposed to plain silicone EVDs, on the occurrence of ventriculostomy-related infections (VRIs) in two Dutch hospitals, with no other changes to their clinical practice. VRI was defined using the criteria of the Centers for Disease Control and Prevention, and with a culture-based definition. A propensity-score-adjusted competing risks survival analysis showed that introduction of AI-EVDs did not significantly decrease the risk of VRIs in routine care, nor affect the bacterial aetiology, even after adjustment for confounding and competing events.

Ventilator setting in ICUs: comparing a Dutch with a European cohort.

BACKGROUND: From data collected during the third International Study on Mechanical Ventilation (ISMV), we compared data from a Dutch cohort with a European cohort. We hypothesised that tidal volumes were smaller and applied positive end-expiratory pressure (PEEP) was higher in the Netherlands, compared with the European cohort. We also compared use of non-invasive ventilation (NIV) and outcomes in both cohorts. METHODS: A post-hoc analysis of a prospective observational study of patients receiving mechanical ventilation. RESULTS: Tidal volumes were smaller (7.6 vs. 8.1 ml÷kg predicted bodyweight) in the Dutch cohort and applied PEEP was higher (8 vs. 6 cm H2O). Fewer patients admitted in the Netherlands received NIV as first mode of mechanical ventilation (7.1 vs. 16.7%). Fewer patients in the Dutch cohort developed an ICU-acquired pneumonia (4.5 vs. 12.3%, p < 0.01) and sepsis (5.7 vs. 10.9%, p = 0.03), but more patients were diagnosed as having delirium (15.8 vs. 4.6%, p < 0.01). ICU and in-hospital mortality rates were 19% and 25%, respectively, in Dutch ICUs vs. 26% and 33% in Europe (p = 0.06 and 0.03). CONCLUSION: Tidal volumes were smaller and applied PEEP was higher in the Dutch cohort compared with international data, but both Dutch and international patients received larger tidal volumes than recommended for prevention or treatment of acute respiratory distress syndrome. NIV as first mode of mechanical ventilation is less commonly used in the Netherlands. The incidence of ICU-acquired pneumonia is lower and of delirium higher in the Netherlands compared with international data.

Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

Troponin I in predicting cardiac or pulmonary complications and outcome in subarachnoid haemorrhage.

BACKGROUND: Patients with aneurysmal subarachnoid haemorrhage (SAH) are at risk of cardiac and pulmonary complications. Troponin I (cTnI), a reliable marker of myocardial injury, is frequently raised after SAH. AIMS: To investigate the additional value of (cTnI) in predicting cardiac or pulmonary complications and outcome in patients with SAH. METHODS: Admission cTnI was measured in a prospective series of patients admitted within 24 hours of SAH. By means of univariate and multivariate logistic regression models the additional prognostic value of raised cTnI (>0.3 microg/litre) was investigated compared with established prognosticators (clinical condition on admission, age, and amount of blood on admission computed tomography) for predicting the occurrence of pulmonary oedema, pulmonary gas exchange abnormalities, rhythm disturbances, inadequate cardiac performance, a combination of these complications, and poor outcome. Area under the operator characteristic curve (AUC-ROC) was used to assess additional prognostic value. RESULTS: Abnormal cTnI concentrations were found on admission in 35 of 68 patients. Abnormal cTnI concentrations and poor clinical condition independently predicted cardiac or pulmonary complications. After extending the model with World Federation of Neurological Surgeons scale and age in addition to abnormal cTnI, the AUC-ROC improved from 0.70 (95% confidence interval (CI), 0.57 to 0.83) to 0.83 (95% CI, 0.72 to 0.93). Abnormal cTnI also independently predicted poor outcome. The additional prognostic value of cTnI for poor outcome is limited. CONCLUSIONS: cTnI measurement is a powerful predictor for the occurrence of pulmonary and cardiac complications, but does not carry additional prognostic value for clinical outcome in patients with aneurysmal SAH.

The development of ventilator-associated pneumonia does not change aspects of mechanical ventilation.

OBJECTIVE: To evaluate whether the development of ventilator-associated pneumonia (VAP) is associated with changes in ventilation parameters. DESIGN: Matched case-control study. SETTING: Mixed intensive care unit of a university hospital. PATIENTS: From a large database we selected 33 patients with VAP, diagnosed with quantitative cultures of bronchoscopically obtained specimens. In addition, 33 other mechanically ventilated patients who did not develop VAP were selected (controls). Patients with VAP and controls were matched on seven variables representing severity of illness: duration of ventilation until matching, diagnosis on admission, renal function, liver function, preceding infection, preceding surgery and immunosuppressive therapy. Each patient with VAP was matched to a single control. Variables regarding type and mode of ventilation and interpretation of chest radiographs were not included in the matching procedure. MEASUREMENTS AND RESULTS: Characteristics of mechanical ventilation (mode of ventilation, tidal volume, expired minute ventilation, peak airway pressures, mean airway pressures, level of positive end-expiratory pressure, arterial oxygen tension(PaO2)/fractional inspired oxygen (FIO2) ratio), were compared on the day of diagnosis of VAP (or matching for controls) and 2 and 4 days before. Although there was a significant difference in PaO2/FIO2 ratios between cases and controls on the day of diagnosis of VAP, the change in PaO2/FIO2 ratios during the days of study were not statistically different between patients developing VAP and controls. No significant differences were found for any of the other variables of ventilation at any of the three time points studied, nor were there significant differences in changes of these parameters within individual patients. CONCLUSIONS: Characteristics and parameters of mechanical ventilation are not influenced by the development of VAP. It is, therefore, unlikely that these variables are useful in the diagnostic work-up of VAP.

Resolution of infectious parameters after antimicrobial therapy in patients with ventilator-associated pneumonia.

Although recommended durations of antimicrobial therapy for ventilator-associated pneumonia (VAP) range from 7 to 21 d, these are not based on prospective studies and little is known about the resolution of symptoms after start of antibiotics. Resolution of these symptoms was investigated in 27 patients. VAP was diagnosed on clinical, radiographic, and microbiological criteria, including quantitative cultures of bronchoalveolar lavage. All patients received appropriate antibiotic therapy. Highest temperatures, leukocyte counts, Pa(O(2))/FI(O(2)) ratios, and semiquantitative cultures of endotracheal aspirates were recorded from start of therapy until Day 14. Resolution was defined as the first day that these parameters fulfilled the following definition: temperature < or = 38 degrees C, leukocytes < or = 10 x 10(9)/L, Pa(O(2))/FI(O(2)) ratio > or = 25 kPa, and no or +1 of bacterial growth of etiologic pathogens in cultures of endotracheal aspirate. VAP was caused by Enterobacteriaceae (n = 14), P. aeruginosa (n = 7), S. aureus (n = 6), H. influenzae (n = 3), and S. pneumoniae (n = 1). H. influenzae and S. pneumoniae were eradicated from tracheal aspirates, whereas Enterobacteriaceae, S. aureus, and P. aeruginosa persisted, despite in vitro susceptibility to antibiotics administered. Significant improvements were observed for all clinical parameters, most apparently within the first 6 d after start of antibiotics. Newly acquired colonization, especially with P. aeruginosa and Enterobacteriaceae, occurred in the second week of therapy. Six patients developed a recurrent episode of VAP, four of them with P. aeruginosa. Clinical responses to therapy for VAP occur within the first 6 d of therapy, endotracheal colonization with Gram-negative bacteria persists despite susceptibility to therapy, and acquired colonization usually occurs in the second week of therapy and frequently precedes a recurrent episode.

Multiresistant bacteria as a hospital epidemic problem.

Since the introduction of antibiotics into clinical use, bacteria have protected themselves by developing antibiotic resistance mechanisms. Currently, there are increasing problems worldwide with multiresistant bacteria. These problems are especially evident within hospitals, where they frequently present as nosocomial epidemics. Currently, the most important nosocomial resistance problems on a global scale are caused by methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and Enterobacteriaceae with plasmid-encoded extended-spectrum beta-lactamases. In this review we describe the characteristics of nosocomial epidemics of these three groups of multiresistant nosocomial pathogens. Despite the differences in bacterial species, the differences in mechanisms of resistance, the different ecological niches and the different infections caused by these pathogens, there are striking similarities in the variables determining nosocomial spread. The existence of each of these multiresistant micro-organisms and their concurrent spread seem to result from extensive antibiotic use and lapses in compliance with infection control measures. Problems with these bacteria became evident as monoclonal outbreaks, soon followed by establishment of endemicity especially in intensive care units. Finally, endemicity seems to be established on general hospital wards and in chronic care facilities and nursing homes, creating a continuous influx of colonized patients into special care wards. High compliance with infection control measures and a prudent and more restrictive use of antibiotics are the key measures to prevent these epidemics.

Duodenal diverticulitis.

The case history of a 56-year-old woman with an acute abdomen is presented. Laboratory data, a plain abdominal X-ray and ultrasound examination provided no clues for a definite diagnosis. Surprisingly, a duodenal diverticulitis was found at operation. Some aspects and complications of duodenal diverticula are discussed.

First dose hypotension after captopril; can it be predicted? A study of 240 patients.

We have studied prospectively the acute blood pressure lowering effect on an oral dose of captopril, 25 mg in 240 hypertensive patients. The mean relative reduction of systolic and diastolic BP was 16 and 15% respectively and the mean time to the mean arterial pressure nadir was 59 minutes. Systolic BP fell by more than 30% in 4.6% of patients and diastolic BP and mean arterial pressure dropped by more than 30% in 4.2 and 3.3% of patients respectively. Patients over 60 years of age showed a significantly larger fall in systolic and diastolic BP. Patients with renal artery stenosis reached the BP nadir in a significantly shorter time compared with patients with essential hypertension (50.5 vs. 59.7 minutes, P less than 0.05) and showed a significantly larger fall in systolic BP (20.7 vs. 15.4%, P less than 0.05). A forward stepwise regression analysis showed that only baseline plasma renin activity had a significant relation to the fall in BP (P less than 0.01, R = 0.57). We conclude that according to our definition of a greater than 30% decrease of the mean arterial pressure, a first dose hypotension after captopril was seen in 3.3% of 240 patients. Captopril treatment should be introduced carefully since not all those patients at risk of hypotension can be identified in advance.

[9-year experience with continuous ambulatory peritoneal dialysis in one center]. / Ervaringen met continue ambulante peritoneale dialyse in één centrum gedurende 9 jaar.

The experience gained with CAPD in a group of 101 patients with terminal renal failure and a subgroup of 19 patients with diabetes mellitus was analysed. The actuarial patient survival was 81% after two years and 50% after five years. The combined patient-technique survival after two years was 48.8%. The most important reasons for drop-out were transplantation (25%) and death (24%). Death was method-related in 4 patients and caused by peritonitis in 2 of them. More often peritonitis was the cause of morbidity and temporary interruption (10 x) or of permanent abandoning of the method (11 x ). The peritonitis frequency during the whole period of nine years was 1 : 11.3 months. Use of the Y-connector Twinbag system and a U.V.-light system reduced the incidence substantially. However, faecal peritonitis remains a dangerous situation which cannot be prevented in this way. The mortality in patients with diabetes mellitus is high but not method-related. The incidence of peritonitis is not significantly different from that among patients without diabetes mellitus.