Cuff-shaving procedure. A rescue treatment for exit-site infection unresponsive to medical therapy

We performed 41 cuff-shaving procedures in 38 patients on continuousambulatory peritoneal dialysis (CAPD) with exit-site infectionunresponsive to medical treatment. Cuff shaving was performedon three patients with two catheters each. This procedure waseffective in eliminating 50% of S. aureus exit-site infectionand all S. epidermidis exit-site infection, but was ineffectivein Gram-negative exit-site infection. After cuff-shaving procedure,20 catheters (49%) were removed; 11 for persistent tunnel infectionand nine because of development of secondary peritonitis. Theprobability of catheter survival at 1 year was 50% and remainedstable thereafter. Cuff-shaving procedure may be a valuablemode of therapy for treating patients with S. aureus and/orS. epidermidis exit-site infection unresponsive to medical treatment.     

Painful haematuria following central venous catheter infection.

Case A 55-year-old female presented with gross haematuria and lowback pain. Her previous medical history included type 2 diabetesmellitus and hypertension for more than 10 years. Two monthsearlier, she had undergone left lobectomy of the liver for intrahepaticduct stones. The post-operative course was complicated by methicillin-resistantStaphylococcus aureus (MRSA) bacteraemia associated with centralvenous catheter infection. The catheter was removed, and treatmentwith intravenous vancomycin was begun. Her fever gradually subsidedafter a 2-week course of antibiotic therapy. Cardiac auscultation     

On-line continuing education--another step forward

From the start of 2007, both the British Journal of Anaesthesiaand our continuing medical education (CME) journal ContinuingEducation in Anaesthesia, Critical Care and Pain (CEACCP) willbe making multiple choice questions (MCQs) for CME availableon-line through the journals' websites. The BJA has a commitmentto providing continuing medical education and we have been atthe forefront of the     

Management of life-threatening haemoptysis

Massive haemoptysis represents a major medical emergency thatis associated with a high mortality. Here we present two casesof life-threatening haemoptysis, the first caused by ruptureof an aortic aneurysm into the lung in a 37-yr-old woman withpolyarteritis nodosa and the second caused by massive bleedingfrom an angiectatic vascular malformation in the right mainbronchus in a 21-yr-old woman. Fibreoptic bronchoscopy playedan essential role in the diagnostic process and management ofthe respiratory tract. Diagnosis in the first case was obtainedby CT scan and the aneurysm was treated surgically. In the secondcase, bronchial arteriography contributed to both definitivediagnosis and treatment. Initial cardiorespiratory management,diagnostic procedures and definitive therapy are described andreviewed. Adequate early management of the cardiorespiratorysystem is essential to the outcome. Aggressive measures to elucidatethe cause of haemoptysis and prompt therapy are warranted becauseof the high risk of recurrence. Br J Anaesth 2002; 88: 291–5     

Inverse relationship between serum cholinesterase activity and the administration of cyclophosphamide: an Index of cyclophosphamide therapy

To determine whether serum cholinesterase activity can be amonitoring index of cyclophosphamide therapy in patients withsteroid-resistant glomerulopathy, we compared the cholinesteraseactivity of 37 patients who received a combined therapy thatincluded the use of cyclophosphamide, prednisolone, antiplateletdrugs, and anticoagulant drugs, with the cholinesterase activityof 25 patients who received prednisolone therapy that excludedcyclophosphamide from the combined therapy. In the prednisoloneand the combined groups, cholinesterase activity declined asshown in the following formula: Y=371–26.4xlog(X): (r²=0.28),Y=444–147.7xlog(X): (r²=0.95), respectively. (Y: cholinesteraseactivity, X: the day after treatment). In the combined therapygroup, the prevalence of adverse reactions following treatmentin the subgroup below 200 U/I of cholinesterase activity wassignificantly greater (P<0.01) than that in the subgroupabove 200 U/I of cholinesterase activity. However, there wasno significant difference (P<0.25) in the prevalence of adversereactions between the subgroups with more or less than 184 U/Iof cholinesterase activity following treatment. These resultssuggest the importance of not going below 200 U/I of cholinesteraseactivity after treatment when the normal cholinesterase activityrange is between 300 and 760 U/I (e.g. less than 65% of thelowest value of the normal range of other hospitals) in orderto eliminate the hazards of cyclophosphamide to the patientswith steroid-resistant glomerulopathy.     

Essential Cardiac Catheterization

Essential Cardiac Catheterization is a concise new book of 10chapters. It covers various aspects of diagnostic cardiac catheterizationand is primarily aimed at cardiologists in training. Productionof the book has been supported by an educational grant fromthe medical technology company Medtronic. The authors are cardiologists     

PHYSIOLOGICAL CORTISOL SUBSTITUTION OF LONG-TERM STEROID-TREATED PATIENTS UNDERGOING MAJOR SURGERY

In 22 patients undergoing elective surgery, adrenal functionwas assessed before and on the day of surgery. Patients receivingcorticosteroid therapy but with a normal cortisol response toa corticotropin stimulation test (group II, n = 8) were notgiven hydrocortisone on the day of operation. Their cortisolconcentration increased in a manner similar to patients (groupI, n = 8) who had never had corticosteroid treatment. The plasmacortisol concentrations in these two groups were less than insubjects (group III, n = 6) with an impaired cortisol responseto corticotropin stimulation, who were given hydrocortisone25 mg at the induction of anaesthesia followed by a continuousinfusion of hydrocortisone 100 mg during the next 24h. Therewere no clinical signs of circulatory insufficiency in any group.The low-dose hydrocortisone therapy regimen is sufficient forsubstitution of adrenal function during surgery and in the earlypostoperative phase. It could lead to mild oversubstitutionin patients with impaired adrenal insufficiency undergoing majorsurgery.     

Effectiveness of low-dose erythropoietin in predialysis chronic renal failure patients

Recombinant human erythropoietin (rHuEpo) has been shown tobe both effective and usually safe in patients with chronicrenal failure who have not yet reached the stage requiring dialysis.There are, however, disturbing reports on the possibility ofdeterioration of the reserve renal function in association withrHuEpo therapy. Most of the published studies have used rHuEpoin doses of 50–150 U/kg three times weekly subcutaneously.An open-label trial of rHuEpo therapy was conducted on 21 patientswith chronic renal failure treated sequentially at a referralhospital, rHuEpo was used in doses of 50 U/kg twice weekly for4 weeks followed by 25 U/kg twice weekly for 8 weeks subcutaneously,a regimen substantially lower than current recommendations.This was associated with a gentle but significant increase inhaematocrit (P<0.05) and haemoglobin (P<0.05), while theserum creatinine and the reciprocal of the creatinine remainedstable, with a tendency to improve rather than worsen (P=0.06).We conclude that there is no need to aim at a rapid increasein haematocrit and haemoglobin by rHuEpo therapy; rather a gentleincrease using modest doses is both effective and safe.     

Modulation of platelet cytosolic calcium during erythropoietin therapy in uraemia

Erythropoietin therapy for uraemic anaemia is associated witha high rate of hypertensive and thrombotic complications. Themechanism is unknown, but a change in cellular calcium controlmay be relevant to changes in blood pressure and thrombosis. Platelets were utilized as a model of vascular smooth musclecells. The effects of erythropoietin therapy on platelet cellularcalcium, assessed by fura-2, were meas ured in 25 patients receivingrenal replacement therapy during a 6-month treatment period. Three patients failed to reach a target haemoglobin and wereexcluded from the analysis. Blood pressure increased in 11 ofthe remaining 22 subjects, eight requiring an increase in antihypertensivemedication. There were no differences in cellular calcium controlbetween the group in whom blood pressure rose and patients withstable blood pressure. Overall there was a fall of 24% in restingcytosolic calcium (baseline 69.2 ± 5.1 to 52.5 ±3.0 nmol/1, P<0.05) after 3 months of erythropoietin therapy.There was no change in the thrombin-stimulated peak responsein the presence of extracellular calcium during therapy, althoughthrombin-stimulated intracellular release also fell at 3 months(baseline 769±61 versus 3 months 559±49nmol/l,P<0.01 This study suggests that intracellular free calcium controlwithin platelets improves in response to erythropoietin therapy.However these changes appear not to be related to the developmentof hypertension.     

Withdrawal of renal replacement therapy in Newcastle upon Tyne: 1964-1993

BACKGROUND: Termination of renal replacement therapy (RRT) is common inNorth America and Australia but is considered to be rare inEurope. METHODS: In order to review the phenomenon of RRT termination in allpatients treated in Newcastle upon Tyne between 1964 and 1993a retrospective study of clinical case notes was undertaken.In all RRT patients sex, age at start of RRT, renal diagnosisand history of RRT were recorded. In addition, mortality dataand marital and residential status were recorded in all patientswho died, and Karnofsky index, bodyweight, complications, historyof bereavement, place of death, overall survival, survival afterwithdrawal of treatment, other medical problems, higher mentalfunction and surgical history in all patients stopping treatment. RESULTS: 1639 patients started RRT between 1964 and September 1993 inclusive.Eighty-eight patients were identified in whom death was a resultof treatment being stopped (17% of all deaths). The first wasin 1985. In these patients, age was greater (62 vs 47 years,P<0.001) and diabetes was more prevalent (15 vs 7%, P<0.03)than in the total RRT population. The Karnofsky index was 70at the start and 33 at with-drawal of treatment (P<0.001).The Karnofsky index at the start of RRT was weakly related tothat at withdrawal and overall survival (r=0.36 and 0.28 respectively,P<0.01). The Karnofsky index at treatment withdrawal correlatedwith the following survival (r=0.40, P<0.001). The mediansurvival of patients stopping treatment was significantly lowerthan in all RRT patients (16 vs 74 months, P<0.00l) and themajority survived less than 2 years. After dialysis withdrawalthe median survival was 8 days, 15 patients survived 3 daysor less and 19 more than 10 days. The majority (80%) receivedterminal care in hospital. At treatment withdrawal 11 patientswere demented and 34 showed signs of early dementia. Seventy-eightpatients (89%) stopped treatment as a consequence of multiplemedical problems. The possibility of dialysis withdrawal wasraised by physicians in 50.5%, the patient in 23.8% and thepatients' relatives in 21.9% of cases. Four patients (3.8%)committed suicide. CONCLUSIONS: Death from dialysis termination is a relatively common causeof death in RRT patients in Newcastle upon Tyne. These patientsare older with a higher prevalence of diabetes. In 89% of casesthe decision to stop treatment was related to multiple medicalproblems with a recent deterioration. Physicians raised theissue of withdrawal in the majority of cases and most patientssubsequently received terminal care in hospital.     

Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures

Background. A prospective, randomized controlled trial comparingconventional intraoperative fluid management with two differingmethods of invasive haemodynamic monitoring to optimize intraoperativefluid therapy, in patients undergoing proximal femoral fracturerepair under general anaesthesia. Methods. Ninety patients randomized to three groups; conventionalintraoperative fluid management (Gp CON, n=29), and two groupsreceiving additional repeated colloid fluid challenges guidedby central venous pressure (Gp CVP, n=31) or oesophageal Dopplerultrasonography (Gp DOP, n=30). Primary outcome measures weretime to medical fitness to discharge, hospital stay and postoperativemorbidity. Results. The fluid challenge resulted in significantly greaterperioperative changes in central venous pressure between GpCVP and Gp CON (mean 5 (95% confidence interval 3–7) mmHg) (P<0.0001). Important perioperative changes were alsoshown in Gp DOP with increases of 49.4 ms (19.7–79.1 ms)in the corrected flow time, 13.5 ml (7.4–19.6 ml) in strokevolume, and 0.9 (0.49–1.39) litre min^–1 in cardiacoutput. As a result, fewer patients in Gp CVP and Gp DOP experiencedsevere intraoperative hypotension (Gp CON 28% (8/29), Gp CVP9% (3/31), Gp DOP 7% (2/30), P=0.048 (chi-squared, 2 degreesof freedom (df)). No differences were seen between the threegroups when major morbidity and mortality were combined, P=0.24(chi-squared, 2 df). Postoperative recovery for survivors, asdefined by time to be deemed medically fit for discharge, wassignificantly faster, in comparison with Gp CON, in both theGp CVP (10 vs 14 (95% confidence interval 8–12 vs 12–17)days, P=0.008 (t-test)), and Gp DOP (8 vs 14 (95% confidenceinterval 6–12 vs 12–17) days, P=0.023 (t-test).There were no significant differences between groups, for survivors,with respect to acute orthopaedic hospital and total hospitalstay. Conclusions. Invasive intraoperative haemodynamic monitoringwith fluid challenges during repair of femoral fracture undergeneral anaesthetic shortens time to being medically fit fordischarge. Br J Anaesth 2002; 88: 65–71     

Effects of prophylactic or therapeutic application of bovine haemoglobin HBOC-200 on ischaemia-reperfusion injury following acute coronary ligature in rats

Background. Haemoglobin-based oxygen carriers (HBOCs) are assessedas blood substitutes in patients with perioperative anaemiaincluding patients at risk for perioperative cardiac ischaemia.There is controversy as to whether HBOCs are beneficial or deleteriousduring ischaemia–reperfusion (I–R). Therefore theeffects of HBOC-200 on I–R injury were evaluated in arandomized placebo-controlled animal trial. Methods. Animals were randomized to receive either placebo i.v.without I–R (sham group, n=9), placebo i.v. with I–R(control group, n=10), HBOC-200 0.4 g kg^–1 i.v. priorto I–R (prophylaxis group, n=12) or HBOC-200 0.4 g kg^–1i.v. during I–R (therapy group, n=15). I–R consistedof 25 min of acute ligature of the left coronary artery followedby 120 min of reperfusion. Measurements included assessmentof the area at risk and infarct size using triphenyl tetrazoliumchloride (TTC) stain, DNA single-strand breaks (in situ nicktranslation with autoradiography/densitometry) and cardiac arrhythmias. Results. Infarct size within the area at risk was 62 (SD 15)%(control), 46 (10)% (prophylaxis, P<0.025 vs control) and61 (9)% (therapy, P<0.85 vs control). The frequency of DNAsingle-strand breaks was reduced vs control in the sham (P<0.01)and prophylaxis (P<0.04) groups and was almost the same inthe therapy group (P<0.75). The severity of cardiac arrhythmiasduring ischaemia was lower compared with control in the sham(P<0.001) and prophylaxis (P<0.039) groups, but therewas no difference in the therapy group. Conclusion. This study demonstrates that neither prophylacticnor therapeutic application of the cell-free haemoglobin solutionHBOC-200 aggravates cardiac I–R injury. Furthermore, theprophylactic approach may offer a new opportunity for pretreatmentof patients at risk for perioperative ischaemic cardiac events. The results were presented in part at the Congress of the EuropeanSociety of Anaesthesia, Glasgow, UK, June 2003 (‘BestAbstract Award’), and at the Annual Meeting of the AmericanSociety of Anesthesiologists, San Francisco, CA, USA, October2003. Declaration of interest. T. G. Standl has received lecture honorariaand travel fees from Biopure Corporation, Boston, MA, the manufacturerof HBOC. The Department of Anaesthesiology, University Hospital,Hamburg-Eppendorf, received restricted grants from Biopure Corporation,Boston, MA, between 1994 and 1998 for animal and clinical phaseII and III trials. M.A. Burmeister is Vice President Researchand Development, Hospital Care Division, B. Braun MelsungenAG, Melsungen, Germany. B. Braun, a global health care supplier,cooperated with Biopure Corporation, Boston, MA, on HBOC developmentuntil 1996. The work presented in this paper was done independentlyof and without any support from B. Braun.     

Incidence of Cytomegalovirus Infections in Renal Transplant Patients Treated With Conventional or Cyclosporin Therapy

The incidence and severity of cytomegalovirus (CMV) infectionwas examined in groups of consecutive renal transplant patients:group A (50 patients) transplanted from August 1984 to October1985 received cyclosporin (from the day of transplantation)and steroid therapy; group B (50 patients) transplanted betweenJune and July 1984 received conventional therapy (azathioprineand steroids, and antilymphocyte globulin for 14 days). In groupsA and B there were respectively 5 (10%) and 14 (28%) seronegativepatients prior to transplantation (CMV antibody titre <128by ELISA); the overall incidence of CMV was 38% vs 74% (P<0.001);the incidence of primary infection was 0% (0 of 5) vs 36% (5of 14) (NS); the incidence of secondary infection was 42% (19of 45) vs 89% (32 of 36) (P<0.00001); and the total incidenceof symptomatic infection was 10% vs 26% (P< 0.04). Thus weconclude that initial cyclosporin therapy leads to a reductionin CMV infection.     

Cyclosporin in primary haploidentical live-donor kidney transplantation: is it worthwhile?

Two consecutive prospective randomized trials were performedto study three immunosuppres-sive protocols in 195 kidney transplantrecipients. Only adult primary renal transplant recipients withone haplotype HLA mismatch were included. All patients receivedkidneys from living related donors and had previous donor non-specificblood transfusions. Study I included 112 recipients who wererandomly assigned to receive either azathioprine (Aza) and prednisolone(P) (n =54) or cyclosporin (CsA) and P (n =58). Patients inthis study were followed up for 3–6 years (mean 50 ±8months). Study II included 83 recipients who were randomly assignedto receive either triple therapy of Aza-CsA-P (n =41) or conventionaltherapy of Aza-P (n =42). Patients in this study were followedup for a period of 32 ±10 (range 26–43) months. Analysis of data in the two studies demonstrated the absenceof statistically significant differences in graft or patientsurvival rates over short- and long-term follow-up periods amongrecipients of the conventional immunotherapy and those receivingthe CsA-P or the triple therapy. The overall frequency of acuterejection episodes was not significantly different between thetwo treatment groups of each study. Serum creatinine was significantlyhigher in the CsA-P group while the incidence of infection wassignificantly lower in the triple group. When switching from one regimen to another is considered, atleast 75% of the one-haplotype HLA mismatched live-related donorrenal transplants could be maintained on conventional immunotherapywith comparable degree of success to those treated with theCsA-P or the triple therapy. However, in at least 15% of patientswith conventional immunotherapy, CsA could reverse ongoing rejectionsand can therefore be considered as a rescue treatment.     

EFFICIENCY OF TWO VARIABLE PERFORMANCE TECHNIQUES OF OXYGEN THERAPY IN RELIEVING POSTOPERATIVE HYPOXAEMIA

The efficiency of two patient-dependent, variable performancetechniques of oxygen therapy in relieving hypoxaemia after upperabdornir,al surgery was compared. A high-flow system delivereda humidified mixture of oxygen 2 litre min^–1 and air 13litre min^–1 through a cannula inserted into the anteriornares. The low-flow system delivered 2 litre min^–1 ofdry oxygen into the nasopharynx through a catheter. Thirteenotherwise healthy patients received either high-flow oxygentherapy for 30 mm followed by low-flow oxygen therapy for afurther 30 mm after operation or the same therapy in reverseorder. With the patients breathing room air, arterial hypoxaemiacould be demonstrated with Pao₂ inversely related to age. Theincrease of Pao₂ during either oxygen treatment was significantlygreater with the low flow system.     

Improvement of Anaemia With Desferrioxamine in Haemodialysis Patients

We have prospectively investigated the effect of desferrioxamine(DFO)administration (2 g i.v. after every haemodialysis session for6 months) on the normocytic and normochromic anaemia of sevenhaemodialysis patients. None had either clinical or analyticaldata characteristic of chronic aluminium intoxication. At theend of DFO therapy, the haematocrit had increased from 20.5±2.7%to 30.4±7.7% (P< 0.005), and the transfusional requirementsdecreased from 3.5±2.2 units (range 1–8 units)in the 6 months prior to DFO, to 0.7±0.9 units (range0–2 units) during DFO administration (P<0.01). No transfusionwas required during the second half of the DFO therapy period.Serum ferritin decreased from 1059±532 nmol/l (2649±1331ng/ml) to 507±403 nmol/l (1268±1008 ng/ml) (P<0.025).Two months after DFO withdrawal the haematocrit value fell significantlyto 22.2±1.6% (P<0.01). DFO therapy was restarted inone patient at a lower dose (1 g i.v. after every haemodialysissession) and an increase of haematocrit from 23.8% to 40.2%was again observed after 3 months of treatment. The toleranceto DFO was excellent. We conclude that DFO therapy should beconsidered in haemodialysis patients with severe anaemia andincreased blood transfusion requirements.     

Web-based continuing education

Continuing Education in Anaesthesia, Critical Care and Pain(CEACCP) Volume 1, Number 1 was published in February 2001;its mission is to provide an easily accessible, up-to-date sourceof continuing medical education for anaesthetists. It is thesister     

Does continuous renal replacement therapy favourably influence the outcome of the patients?

Continuous haemodialysis and continuous haemofiltration areefficient and safe techniques for the treatment of acute renalfailure. Theoretical advantages are improved haemodynamic stabilityand easier fluid removal. All 15 available studies comparingintermittent (522 patients) with continuous (651 patients) renalreplacement therapy have been reviewed. From these studies itcannot be established, whether the use of a continuous insteadof an intermittent treatment modality improves the outcome inpatients with acute renal failure. Reviewing all 67 publishedstudies dealing with continuous renal replacement therapy revealeda trend to a decreasing mortality rate (P<0.08) over thelast 11 years, whereas the mean age and the severity of illnessof the patients, measured by the APACHE II score, did not change.In order to establish whether the quality of treatment has improvedas a function of time, two quality factors (QF) were created,i.e. QF for age (mean age/mean mortality rate of the patientstreated) and QF for severity of diseases (mean APACHE II/meanmortality rate). Both QF improved from 1984 until 1994, whenanalyzed for continuous (P<0.001) or intermittent (P<0.001)treatment modality. Thus the quality of treatment of patientswith acute renal failure improved during the last decade. However,there is no evidence with respect to survival rate that a continuousrenal replacement therapy is superior to an intermittent one.     

Aluminium-related osteodystrophy and desferrioxamine treatment: role of phosphorus

We investigated (1) the prevalence of aluminium overload among96 patients with symptomatic bone disease haemodialysed from1987 to 1989 in the Sao Paulo area, Brazil; (2) the effect of6 months desferrioxamine (DFO) treatment (1–2 g/week).All patients underwent a first bone biopsy. Aluminium overload(extent of stainable bone aluminium more than 20% trabecularsurface) was observed in 74 of 96 patients. Forty overloadedpatients were divided into patients with high bone formationrate (BFR) (group 1; n=17) and patients with low BFR (group2; n=23), and had a second biopsy after DFO therapy. In bothgroups aluminium surface was reduced after treatment (P<0.001),osteoblast surface (P<0.02-P<0.01) and plasma parathyroidhormone (iPTH) (P<0.01) increased. In group 1 BFR remainedhigh. In group 2 BFR remained low in 16 patients (2a) and increasedin seven (P<0.02) (2b). In group 2a plasma phosphorus wasbelow that in group 2b patients, before (P<0.03) and after(P<0.01) DFO. The histological features of group 2a patientsresembled hypophos-phataemic osteomalacia, those of group 2bpatients aluminium osteodystrophy. These data show a high prevalence of aluminium overload in Brazilianpatients. Low-dose DFO therapy was safe, decreased bone pain,prevented fractures, and reduced stainable bone aluminium. Bonelesions only partially improved, suggesting that low phosphorusintake and/or plasma calcitriol concentrations may have preventedimprovement of bone formation and mineralization.     

Critical Care for Postgraduate Trainees. A. Brooks, K. Girling, B. Riley and B. Rowlands (editors). Published by Hodder Arnold, London. Pp. 173; indexed; illustrated. Price {pound}34.95. ISBN 0-340-80967-1

Critical Care for Postgraduate Trainees is intended to providetrainees in higher surgical, medical and anaesthetic trainingprogrammes with an up-to-date resource in critical care. Itprovides a succinct summary of the key topics in critical caremedicine along with discussion of recent advances, key papersand evidence-based practice where appropriate. Each chapterbegins with a box highlighting possible viva topics for thefacts