Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether adrenaline might be a useful addition to a protocol for the management of cardiac arrests for patients shortly after cardiac surgery. Altogether 889 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that the European Resuscitation Council and the American Heart Association both recommend 1 mg of adrenaline as soon as pulseless electrical activity or asystole is identified or after the second failed shock if the rhythm is VF/pulseless VT. However, they acknowledge that the evidence behind this recommendation is lacking and based entirely on animal studies which have as yet not been successfully replicated in human studies to show a benefit of survival to hospital discharge. They acknowledge that the current evidence is insufficient to support or refute the use of adrenaline in arrests and the International Liaison Committee on Resuscitation grade the recommendation to give adrenaline in cardiac arrests as 'indeterminate'. Thus, in the particular situation of a patient who arrests shortly after cardiac surgery where the chance of restoring sinus rhythm either by defibrillation or by an emergency re-sternotomy is high, and where adrenaline could in this situation be highly dangerous once sinus rhythm is restored, we recommend that 1 mg of adrenaline forms no part of the resuscitation protocol for patients who arrest after cardiac surgery.     

Should clopidogrel be stopped prior to urgent cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether clopidogrel should be stopped prior to urgent cardiac surgery. Altogether 143 papers were identified using the below mentioned search and all major international guidelines were included. Fourteen presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that there are two issues to address when considering this topic. Firstly, whether recent clopidogrel administration causes an increase in blood loss during cardiac surgery, and secondly, whether there is a risk to the patient of withholding clopidogrel and delaying surgery. In answer to the first issue, a meta-analysis of 11 cohort studies and also many additional papers have clearly shown recent clopidogrel administration within 5-7 days of surgery is associated with an increased chest drainage of 30-100%, an increase in blood product usage, and a 2-5 times increase in the need for re-exploration. In answer to the second issue, data from the major trials that provide the basis for the current era of clopidogrel therapy also suggest that witholding clopidogrel prior to a revascularization procedure is associated with a 1% increase in the risk of myocardial infarction. Despite this small increased risk, The American College of Cardiology recommend witholding clopidogrel for 5-7 days when clinically feasible.     

Should amiodarone or lidocaine be given to patients who arrest after cardiac surgery and fail to cardiovert from ventricular fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the administration of amiodarone or lidocaine in patients with refractory VT/VF after cardiac surgery results in successful cardioversion. Altogether more than 434 papers were found using the reported search, from which 23 articles were used to answer the clinical question. No randomized trials have been found in which amiodarone was studied in patients with refractory VF/VT after cardiac surgery. Recommendations on the use of amiodarone in patients with refractory VF/VT in both European and American 2005 Guidelines on Resuscitation are mainly based on expert consensus and are supported by a few randomized trials in patients with out-of-hospital cardiac arrest. We would therefore recommend that amiodarone is the first line drug that should be used in patients with refractory ventricular arrhythmias after cardiac surgery that persist after three failed attempts at cardioversion. Lidocaine should only be used if amiodarone is not available or if its use is contraindicated. Amiodarone should be administered as an intravenous bolus of 300 mg after the third unsuccessful shock.     

Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether open chest cardiac massage is superior to closed chest compressions in patients suffering cardiac arrest following cardiac surgery. Using the reported search, 527 papers were identified. Fifteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that over 18 good quality animal studies have consistently demonstrated the superiority of open chest cardiac massage, with the cardiac index and coronary perfusion pressures often more than doubling. There are fewer human studies but they have shown that closed chest massage generates a cardiac index of around 0.6 l/min/m(2) which rises to 1.3 l/min/m(2) or more with open-chest-CPR, accompanied by even bigger improvements in coronary perfusion pressure. ILCOR recommends prompt conversion to open-chest-cardiac massage in patient's shortly post-cardiac surgery, and we would support this intervention if simple resuscitative efforts such as defibrillation, pacing or atropine fail, in order to significantly improve the quality of cardiopulmonary resuscitation.     

No escape from a VSD device? Complete heart block and cardiac arrest associated with a ventricular septal defect occluder device

A 15 month old boy with a ventricular septal defect (VSD) underwent percutaneous device closure of the VSD. Five days later he collapsed; on arrival to hospital he was asystolic and received prolonged cardio-pulmonary resuscitation (CPR) with intermittent return of spontaneous circulation (ROSC). He had recurrent episodic complete heart block with no ventricular escape rhythm, associated with loss of cardiac output, unresponsive to transcutaneous pacing. He was transferred to theatre, while receiving CPR, for urgent removal of the VSD device. Estimated total 'down time' was 70 min. The device was removed and patch closure of the VSD was performed. He made a full neurological recovery. Device closure of septal defects has become widespread. We discuss the incidence and type of arrythmias associated with their use. This case highlights an uncommon but life threatening complication of a VSD device. It also highlights that good quality CPR may lead to positive outcomes following pediatric cardiac arrest.     

Extracorporeal circulation and cardiac arrest in an awake patient: a safe approach for single lung pulmonary artery stenting?

We describe the anesthetic concept and approach in a single lung patient scheduled for pulmonary artery stenting due to recurrence of a pulmonary artery sarcoma after left pneumectomy.     

Uncontrolled organ donation following prehospital cardiac arrest: a potential solution to the shortage of organ donors in the United Kingdom?

Uncontrolled donation after cardiac death (DCD) could increase the donor pool in the UK. Air ambulance (AA) teams may be well placed to recruit these donors. They cover large geographical areas, have short transfer times and tasked predominantly to life‐threatening cases. The potential to recruit from this pool of donors was reviewed. Seventy‐five month activity of an AA unit was analysed identifying patients who entered prehospital cardiac arrest (PHCA). Patients over 70 years of age were excluded as were those whose cardiac arrest was unwitnessed. A minimum potential donor pool was estimated based upon patients dying of medical causes. Rates of bystander resuscitation, mechanism of death and patient demographic data were observed. During 10 022 missions 534 patients entered PHCA. A total of 106 patients met inclusion criteria. There were 12 paediatric cases; 39 cases of 17–50 year olds and 55 cases of 50–70 year olds. Medical and traumatic causes of death accounted for 60 and 46 cases respectively. Bystander resuscitation efforts were provided in 47% of cases. A regional AA could contribute to a national uncontrolled DCD programme. Given that there are 31 AA’s in England and Wales, we estimate that there could be a minimum of 300 additional potential donors annually.     

Blogs and Twitter in medical publications: too unreliable to quote, or a change waiting to happen?

With the ubiquitous connectivity offered by the Internet, social media sites (like Twitter and Facebook) and personal publishing platforms (blogs) are proliferating rapidly. In this new, evolving scenario of social media, these tools become an important medium to disseminate information at a lightning speed. However, the conventional medical publication model is less than eager to regard them as equivalent to traditional modes of information dissemination. In this article we examine the role played by social media as a critic of the medical publication system, and how it acts as a safeguard by building a platform for post-publication peer review.     

When Should We Order a CT Scan and When Should We Rely on the Results to Diagnose an Acute Appendicitis?

OBJECTIVE: The objective of this study was to retrospectively analyze the last 100 consecutive emergency appendectomies performed in the authors' institution, which is a community-based teaching hospital, and look at the accuracy of the CT scan in the diagnosis of acute appendicitis. DESIGN: Retrospective clinical study. SETTING: A 600-bed community-based teaching hospital. METHODS: The last 100 consecutive emergency appendectomies, which were performed at New York Methodist Hospital in 2004, were retrospectively analyzed. The collected data included the demographics of the patients, relevant history, physical examination, laboratory and radiological tests, and pathology results. The statistical analyses were performed using the JMP version 3.2 software (SAS Institute Inc., Cary, North Carolina). An alpha value of 0.05 was used in all statistical analyses, and p values were considered as being statistically significant at or below the alpha value of 0.05. RESULTS: There was no statistically significant correlation between the acute appendicitis and some of the typical presenting symptoms and signs of acute appendicitis (rebound tenderness, low-grade fever, elevated white blood cell count, and anorexia). The sensitivity, specificity, positive predictive value, and negative predictive value of the CT scan in this retrospective analysis were 96%, 75%, 98.5%, and 50%, respectively, with an overall efficiency of 95%. However, the sensitivity, specificity, positive predictive value, and negative predictive value of the CT scan increased after reevaluation of the false-positive, false-negative, and inconclusive CT results by an experienced radiologist in a blind fashion (97%, 100%, 100%, and 71%, respectively). The correlation between the CT scan and the pathology result was statistically significant when the CT result was positive or negative (p = 0.0001). CONCLUSION: The CT scan is indicated when the clinical presentation is equivocal, and it will be helpful if the result is positive or interpreted as negative only by an experienced radiology attending.     

From distinct to indistinct,the life cycle of a medical heresy. Is osteopathic distinctiveness an anachronism?

Osteopathy began life as a medical heresy. In the USA, osteopathy embraced medicine and surgery, with an inevitable diminution of distinctiveness. Osteopaths elsewhere practice in much the same way as a century ago. Limited to manual intervention, categorised as ‘allied’, ‘complementary’ or ‘alternative’, distinctiveness is now diminished by similarity with other professional groups. In contrast though to late nineteenth century practice, osteopaths today are the beneficiaries of hitherto unimaginable medical and scientific knowledge, and the target of an omnipresent societal demand for evidence-based practice (EBP), that is requiring of professional and institutional support through explicit policy. There is an urgent need to overcome a cultural torpitude within osteopathy to subject any and all aspects of practice to robust scientific scrutiny, and in particular to relinquish those aspects that have assumed the dimensions of a bloated sacred cow, whose chief requirement for sustenance is faith. To manifest both distinctiveness and professional visibility, determined engagement with science (the evidence), and with other communities whether in clinical practice or in the basic sciences is now imperative. Marginalisation through progressive irrelevance is a poor alternative.     

Is There a Relationship between Chronic Bladder Dysfunction and Somatic Symptoms in other Body Regions? 1. Clinical Observations

Objective: Investigation of patients with chronic bladder dysfunction regarding associated general symptoms and complaints in the cervico-facial, upper and lower extremity regions. Patients and methods: We retrospectively evaluated history, physical and special neurourological examination and urodynamic studies in 213 patients with non-neurogenic bladder dysfunction. Results: 22 patients out of 213 patients with chronic bladder dysfunction reported reproducible associated symptoms involving the temporo-mandibular joint, the distal forearm/hand or feet and headache. There was an obvious clinical connection regarding the severity of bladder dysfunction and associated symptoms and possible relief of both by successful treatment. Conclusion: Symptomatic lower urinary tract dysfunction may accompanied by specific muscular and or sensory disturbances in different areas of the body. These associated pathologies in patients without neurological disease can be explained by functional changes in a complex autonomic peripheral and central nervous network.