Importance Effective therapy has not been established for patients with agitated delirium receiving mechanical ventilation. Objective To determine the effectiveness of dexmedetomidine when added to standard care in patients with agitated delirium receiving mechanical ventilation. Design, setting, and participants The Dexmedetomidine to Lessen ICU Agitation (DahLIA) study was a double-blind, placebo-controlled, parallel-group randomized clinical trial involving 74 adult patients in whom extubation was considered inappropriate because of the severity of agitation and delirium. The study was conducted at 15 intensive care units in Australia and New Zealand from May 2011 until December 2013. Patients with advanced dementia or traumatic brain injury were excluded. Interventions Bedside nursing staff administered dexmedetomidine (or placebo) initially at a rate of 0.5 µg/kg/h and then titrated to rates between 0 and 1.5 µg/kg/h to achieve physician-prescribed sedation goals. The study drug or placebo was continued until no longer required or up to 7 days. All other care was at the discretion of the treating physician. Main outcomes and measures Ventilator-free hours in the 7 days following randomization. There were 21 reported secondary outcomes that were defined a priori. Results Of the 74 randomized patients (median age, 57 years; 18 [24%] women), 2 withdrew consent later and 1 was found to have been randomized incorrectly, leaving 39 patients in the dexmedetomidine group and 32 patients in the placebo group for analysis. Dexmedetomidine increased ventilator-free hours at 7 days compared with placebo (median, 144.8 hours vs 127.5 hours, respectively; median difference between groups, 17.0 hours [95% CI, 4.0 to 33.2 hours]; P = .01). Among the 21 a priori secondary outcomes, none were significantly worse with dexmedetomidine, and several showed statistically significant benefit, including reduced time to extubation (median, 21.9 hours vs 44.3 hours with placebo; median difference between groups, 19.5 hours [95% CI, 5.3 to 31.1 hours]; P Conclusions and relevance Among patients with agitated delirium receiving mechanical ventilation in the intensive care unit, the addition of dexmedetomidine to standard care compared with standard care alone (placebo) resulted in more ventilator-free hours at 7 days. The findings support the use of dexmedetomidine in patients such as these. Trial registration clinicaltrials.gov Identifier: NCT01151865.

/pdf/effect-of-dexmedetomidine-added-to-standard-care-on-1xw5glxgy7.pdf

Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial

Background
Noninvasive positive-pressure ventilation (NPPV) provides ventilatory support without the need for an invasive airway. Interest has emerged in using NPPV to facilitate earlier removal of an endotracheal tube and to decrease complications associated with prolonged intubation.

Objectives
We evaluated studies in which invasively ventilated adults with respiratory failure of any cause (chronic obstructive pulmonary disease (COPD), non-COPD, postoperative, nonoperative) were weaned by means of early extubation followed by immediate application of NPPV or continued IPPV weaning. The primary objective was to determine whether the noninvasive positive-pressure ventilation (NPPV) strategy reduced all-cause mortality compared with invasive positive-pressure ventilation (IPPV) weaning. Secondary objectives were to ascertain differences between strategies in proportions of weaning failure and ventilator-associated pneumonia (VAP), intensive care unit (ICU) and hospital length of stay (LOS), total duration of mechanical ventilation, duration of mechanical support related to weaning, duration of endotracheal mechanical ventilation (ETMV), frequency of adverse events (related to weaning) and overall quality of life. We planned sensitivity and subgroup analyses to assess (1) the influence on mortality and VAP of excluding quasi-randomized trials, and (2) effects on mortality and weaning failure associated with different causes of respiratory failure (COPD vs. mixed populations).

Search methods
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 5, 2013), MEDLINE (January 1966 to May 2013), EMBASE (January 1980 to May 2013), proceedings from four conferences, trial registration websites and personal files; we contacted authors to identify trials comparing NPPV versus conventional IPPV weaning.

Selection criteria
Randomized and quasi-randomized trials comparing early extubation with immediate application of NPPV versus IPPV weaning in intubated adults with respiratory failure.

Data collection and analysis
Two review authors independently assessed trial quality and abstracted data according to prespecified criteria. Sensitivity and subgroup analyses assessed (1) the impact of excluding quasi-randomized trials, and (2) the effects on selected outcomes noted with different causes of respiratory failure.

Main results
We identified 16 trials, predominantly of moderate to good quality, involving 994 participants, most with chronic obstructive pulmonary disease (COPD). Compared with IPPV weaning, NPPV weaning significantly decreased mortality. The benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.24 to 0.56) versus mixed populations (RR 0.81, 95% CI 0.47 to 1.40). NPPV significantly reduced weaning failure (RR 0.63, 95% CI 0.42 to 0.96) and ventilator-associated pneumonia (RR 0.25, 95% CI 0.15 to 0.43); shortened length of stay in an intensive care unit (mean difference (MD) -5.59 days, 95% CI -7.90 to -3.28) and in hospital (MD -6.04 days, 95% CI -9.22 to -2.87); and decreased the total duration of ventilation (MD -5.64 days, 95% CI -9.50 to -1.77) and the duration of endotracheal mechanical ventilation (MD - 7.44 days, 95% CI -10.34 to -4.55) amidst significant heterogeneity. Noninvasive weaning also significantly reduced tracheostomy (RR 0.19, 95% CI 0.08 to 0.47) and reintubation (RR 0.65, 95% CI 0.44 to 0.97) rates. Noninvasive weaning had no effect on the duration of ventilation related to weaning. Exclusion of a single quasi-randomized trial did not alter these results. Subgroup analyses suggest that the benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD versus mixed populations.

Authors' conclusions
Summary estimates from 16 trials of moderate to good quality that included predominantly participants with COPD suggest that a weaning strategy that includes NPPV may reduce rates of mortality and ventilator-associated pneumonia without increasing the risk of weaning failure or reintubation.

/pdf/noninvasive-positive-pressure-ventilation-as-a-weaning-wz46y0qq46.pdf

Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure

https://redintensiva.cl/images/guias_sedacion_analgesia.pdf

Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo

"Introduccion: El optimo manejo de la sedacion, analgesia y delirium ofrece al paciente critico comodidad y seguridad, facilita el buen desarrollo de medidas de soporte y manejo integral y disminuye complicaciones, impactando en un mejor desenlace. Objetivo: Actualizar la Guia de practica clinica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto criticamente enfermo publicada en Medicina Intensiva en el 2007 y dar recomendaciones para el manejo de la sedacion, analgesia y delirium. Metodologia: Se reunio un grupo de 21 intensivistas procedentes de 9 paises de la Federacion Panamericana e Iberica de Sociedades de Medicina Critica y Terapia Intensiva, 3 de ellos ademas especialistas en epidemiologia clinica y metodologia para elaboracion de guias. Se acogio la propuesta del Grading of Recommendations Assessment, Development and Evaluation Working Group para emitir el grado de recomendacion y evaluar la calidad de la evidencia. La fuerza de las recomendaciones fue calificada como 1 = fuerte, o 2 = debil, y la calidad de la evidencia como A = alta, B = moderada, o C = baja. Expertos en busqueda de literatura apoyaron con esta estrategia de busqueda: MEDLINE a traves de PUBMED, bases de datos de la biblioteca Cochrane a traves de The Cochrane Library y la base de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud. Los miembros asignados a las 11 secciones de la guia, basandose en la revision de la literatura, presentaron las recomendaciones, sustentadas y discutidas en sesiones plenarias, aprobando aquellas que superaron el 80% del consenso. La elaboracion de las guias conto con el soporte de la Asociacion Colombiana de Medicina Critica y Cuidado Intensivo. Resultados: Para la elaboracion de la guia fueron finalmente seleccionadas 467 referencias, observandose un importante aumento en el numero y calidad de los estudios, permitiendo realizar 64 fuertes recomendaciones con evidencia alta y moderada, contrastando con las 28 de la edicion anterior. Conclusiones: Esta guia contiene recomendaciones y sugerencias basadas en la mejor evidencia para el manejo de la sedacion, analgesia y delirium del paciente critico, incluyendo un paquete de medidas (bundle). Se destacan: evaluacion del dolor y la agitacion/sedacion mediante escalas; usar inicialmente opioides para el control de la analgesia, adicionando tecnicas multimodales para disminuir consumo de opioides; promover el menor nivel de sedacion necesario, evitando la sobresedacion; en caso de requerir medicamentos sedantes, escoger el mas apropiado, evitando el uso rutinario de benzodiazepinas; por ultimo, identificar factores de riesgo para delirium, prevenirlo, diagnosticarlo y manejarlo, con el medicamento mas conveniente, ya sea haloperidol, antipsicoticos atipicos o dexmedetomidina, evitando el uso de benzodiazepinas y disminuyendo el uso de opioides. © 2013 Elsevier Espana, S.L. y SEMICYUC. Todos los derechos reservados"

/pdf/guias-de-practica-clinica-basadas-en-la-evidencia-para-el-mu2p41imfz.pdf

Guías de práctica clínica basadas en la evidencia para el manejo de la sedoanalgesia y delirium en el paciente adulto críticamente enfermo

Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients

Pectus deformities and cardiac problems sometimes require simultaneous surgery. We report our experience of performing this surgery and review the relevant literature. We performed simultaneous pectus deformity correction and open-heart surgery in six patients between 1999 and 2006. The pectus deformities were pectus carinatum in one patient and pectus excavatum in five patients. The cardiac problems were coronary artery disease in one patient, an atrioseptal defect (ASD) with a ventricular septal defect (VSD) in one, a VSD in one, mitral valve insufficiency with left atrial dilatation in one, and an ascending aortic aneurysm with aortic valve insufficiency caused by Marfan’s syndrome in two. We corrected the pectus deformities using the modified Ravitch’s sternoplasty in all patients. First, while the patient was supine, we resected the costal cartilage; then, after completing the cardiac surgery, the sternum was closed and the additional time required for the pectus operation was calculated for each patient. Patients were examined 1, 4, and 6 months postoperatively. The average operation time was 102 min, and there were no major complications. The pectus bars were removed 4–6 months postoperatively. Good cardiac and cosmetic results were achieved in all patients, who were followed up for 5 years. Concomitant pectus deformity correction and open-heart surgery can be performed safely, eliminating the risks of a second operation in a staged procedure.

Simultaneous open-heart surgery and pectus deformity correction.

Objective(s): To evaluate the use of bilevel positive airway pressure (BiPAP) ventilation in early extubation after fast-track cardiac surgery. Design: Prospective observational study. Setting: Postoperative intensive care. Patients: Sixty consecutive patients eligible for early extubation after cardiac surgery. Patients were predominantly male (42 men [70%]) and middle aged (54.62 ± 10.66 years). Interventions: Patients were randomly assigned to continuous pressure or BiPAP (Group I or Group II, respectively) and were extubated as soon as possible. Measurements: Blood gases and haemodynamics were determined on arrival in the ICU (baseline, or T0) and 1, 2, 4, 6, 8, and 12 hours later. All data were expressed as (±SD) and analysed using the Student t-test and Mann-Whitney test (continuous data) or χ 2 test (categorical data). P < 0.05 was considered statistically significant. Main results: PaCO2 levels were statistically significantly higher in Group II than in Group I at 2, 4, 6, 8, and 12 hours (P < 0.05, P < 0.01). Within each group, PaCO2 levels were statistically significantly higher at 4, 6, 8, and 12 hours than at baseline (P < 0.01 ). Extubation time was significantly longer in Group I than in Group II 7.90 (7.90 [2.13] vs 3.83 [1.20], P=0.001). Respiratory rates were significantly higher in Group II than in Group I after 2, 4, and 6 hours (P < 0.01). Pmax was higher in Group I than in Group II after 1 hour but similar up to 4 hours. Conclusions: Early extubation and weaning to BiPAP ventilation after cardiac surgery is safe and effective.

/pdf/early-extubation-and-weaning-with-bilevel-positive-airway-5bpsewd7e0.pdf

Early extubation and weaning with bilevel positive airway pressure ventilation after cardiac surgery (Weaning with BiPAP ventilation after cardiac surgery)

Hydatid disease rarely involves the aortic wall. We report a case of hydatidosis involving the ascending aorta and the left atrium. The patient underwent replacement of the ascending aorta with a prosthetic Dacron graft and left atrial cystectomy. At the 6-month follow-up, she was leading a normal life.

Hydatid cyst in the wall of the ascending aorta

Coronary artery stabilization causes endothelial damage: an electron microscopic study on dogs.

Initiation of cardiopulmonary-bypass leads to a remarkable decrease in mean arterial pressure. We designed this study to investigate if methylene blue which is a cyclic-Guanosine Mono Phosphate inhibitor can substitute phenylephrine in this hypotensive situation. Seventeen mongrel dogs were organized as three groups. Methylene blue was administered to seven subjects and phenylephrine to another seven. No manipulation was made in the control group. We took blood samples just before the drugs were administered, after the initiation of cardiopulmonary-bypass and at approximately 15th minute of cardiopulmonary-bypass. Mean arterial pressure levels of the control group after initiation of cardiopulmonary bypass were significantly lower than methylene blue and phenyephrine groups. In the methylene blue and control groups, final cortisol levels were statistically similar but lower than the phenylephrine group. We conclude that single dose methylene blue can be used effectively for hypotensive periods after the initiation of cardiopulmonary-bypass with less stress hormone release.

/pdf/blood-cortisol-levels-on-cardiopulmonary-bypass-after-1hwje0nfes.pdf

Blood Cortisol Levels On Cardiopulmonary Bypass After Methylene Blue Administration

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