Is the combination of nitrous oxide and hyperventilation in elective neurosurgical operations useful?

The use of nitrous oxide (N2O) and hyperventilation (HV) in elective neurosurgery is controversially discussed. The emphasis of the study was to show the effects of N2O and/or moderate hyperventilation (paCO2 31.0 +/- 1.2 mmHg) on parameters of cerebral metabolism: jugularvenous oxygen saturation (SjVO2), cerebral extraction of oxygen (CEO2), arterial jugularvenous difference of oxygen contents (AJDO2), arterial jugularvenous difference of lactate (AJDL) and glucose (AJDGL) and lactate-oxygen index (LOI). The study was approved by the Ethics Committee of the University of Leipzig. Forty patients undergoing an elective craniotomy for brain tumour resection were divided into four groups: group 1: n = 10, N2O + normoventilation (NV), group 2: n = 10, N2O + hyperventilation (HV), group 3: n = 10, O2/air + NV, group 4: n = 10, O2/air + HV. N2O + HV led to a significant decrease in SjVO2 from 68.1 +/- 10.7% to 49.7 +/- 5.6%. O2/Air + HV produced a drop from 67.1 +/- 11.1% to 49.8 +/- 7.7%. CEO2 increased significantly in the group N2O + HV from 30.6 +/- 10.6% to 49.6 +/- 5.5% and in the group O2/Air + HV from 31.7 +/- 11.1% to 50.0 +/- 7.8%. AJDO2 increased significantly in the group N2O + HV from 5.79 +/- 1.54 ml% to maximal 8.49 +/- 1.10 ml% and in the group O2/Air + HV from 5.29 +/- 1.76 ml% to maximal 8.03 +/- 1.76 ml%. In the normoventilation-groups 1 and 3, no significant changes in SjVO2, CEO2 and AJDO2 were observed between MP2 and 4. The parameters AJDL, AJDGL and LOI did not show any significant changes in any of the four groups. The described data represent a reduction of cerebral oxygenation, but deleterious effects caused by cerebral ischaemia could not be observed. Based on our data, hyperventilation and its combination with N2O should not be used routinely in neuroanaesthesia.     

Is there a need for liver disease monitoring in HIV patients in Africa?

Liver disease is one of the leading causes of death in HIV-infected individuals from Europe and North America and has been attributed mainly to coinfection with hepatotropic viruses. Little data, however, has so far become available on liver disease in HIV-infected individuals from Africa. Results from a first study on liver disease staging by Fibroscan(?) in a large group of HIV-infected patients from rural Uganda suggest unexpectedly high rates of advanced fibrosis. These results were independent from hepatitis status, initiating a discussion on the need for future liver disease monitoring in these particular patient groups.     

Is jugular bulb oximetry monitoring associated with outcome in out of hospital cardiac arrest patients?

Journal of Clinical Monitoring and Computing - Cerebral protection against secondary hypoxic-ischemic brain injury is a key priority area in post-resuscitation intensive care management in...     

How accurate is pulse oximetry in patients with burn injuries?

Pulse oximetry is a noninvasive method of measuring arterial oxygen saturation. The value of oximetry in patients with burn injuries has been questioned because of a theoretic inaccuracy in the presence of carboxyhemoglobin. We studied pulse oximetry in 27 intubated patients with burn injuries to determine the accuracy of the method and then to determine whether oximetry could replace indwelling catheters presently used for arterial blood gas analysis. Oximeter and arterial blood gas saturation data correlated closely, with a coefficient of 0.820. The pulse oximeter predicted "adequate" ventilation in 78% of patients with a readout of 99% or above. The arterial PO2 was greater than or equal to 90 torr in 90% of patients with oximetric readouts greater than or equal to 98% and in 10% of patients with readouts less than 95%. Pulse oximetry is an accurate adjunct in the management of patients with burn injuries and in addition provides continuous real-time data not available with arterial blood gas sampling.     

Is field intubation useful?

The establishment and maintenance of an adequate airway is often the single most important initial therapy provided to a victim of severe injury. This may be accomplished by simple techniques such as placement of an oral or nasopharyngeal airway as well as bag-mask ventilation techniques. More advanced techniques such as endotracheal intubation require a higher level of training and expertise for both prehospital and hospital providers. Although paramedics routinely practice endotracheal intubation in the field, there are increasing reports on the many potential risks associated with these procedures as well as increased morbidity and mortality in both pediatric and adult patients. These data have important implications for field airway management in the critically ill trauma patient.     

Is liver disease a threat to patients with metabolic disorders?

The association of metabolic disorders with liver disease is receiving increasing attention in the gastroenterological community. Cohort studies have shown that advanced liver disease may stem from metabolic disorders, via fatty liver, non-alcoholic steatohepatitis, cryptogenic cirrhosis, and eventually hepatocellular carcinoma. In both obesity and diabetes, deaths from cirrhosis are higher than expected, mainly in subjects with no or moderate alcohol consumption, but high rates of fatty liver disease have been associated with all features of the metabolic syndrome. Also the risk of hepatocellular carcinoma is higher than normal, being dependent on body mass index (BMI) in obesity, and independent of age, BMI, gender and race in diabetes. Finally, metabolic liver disease may interact with hepatitis C virus infection, increasing the risk of steatosis and liver disease progression, as well as reducing the chances of an effective antiviral treatment. There is evidence that treatments aimed at reducing insulin resistance are also effective in improving liver histology. Although cardiovascular disease remains the major cause of increased morbidity and excess mortality in metabolic disorders, the risk of progressive liver disease should no longer be underestimated, being a threat to millions of people at risk in the present epidemics of obesity and diabetes, and therapeutic strategies need to be tested.     

Is inhaled prophylactic heparin useful for prevention and management of pneumonia in ventilated ICU patients?

PurposeThe purpose was to determine the efficacy of prophylactic inhaled heparin for the prevention and treatment of pneumonia in patients receiving mechanical ventilation (MV).MethodsA phase 2, double-blind, randomized controlled trial stratified for study center and patient type (nonoperative, postoperative) was conducted in 3 university-affiliated intensive care units. Patients aged at least 18 years and requiring invasive MV for more than 48 hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 U in 2 mL), or nebulization with 0.9% sodium chloride (2 mL) 4 times daily with the main outcome measures, the development of ventilator-associated pneumonia (VAP), ventilator-associated complication, and Sequential Organ Failure Assessment scores in patients with admission pneumonia or developing VAP. Trial registration: ACTRN12612000038897.ResultsA total of 214 patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP using either Klompas criteria (6%-7%, P = 1.00) or clinical diagnosis (24%-26%, P = .85).ConclusionLow-dose nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.     

Is external ventricular drainage useful in primary intraventricular hemorrhages?

Nontraumatic primary intraventricular hemorrhage (PIVH) is characterized by direct bleeding into the neuroventricular system. A very rare condition, PIVH accounts for 3% of all spontaneous intracerebral hemorrhages. Hypertension is a major cause of PIVH. Reports about PIVH in the literature are infrequent and it appears to be a relatively benign condition. Between 1998 and 2001, 15 patients with PIVH were evaluated in the Departments of Neurosurgery of Yüzüncü Yil and Pamukkale Universities; their prognosis and results of treatment with external ventricular drainage (EVD) were recorded. The diagnosis was established easily and rapidly with computed tomography. Prognoses of the patients were made by the Glasgow Coma Score (GCS). Hypertension was the most common etiology (n=9, 60%); the prognosis for survivors (73.3%) was good (mortality, 26.6%). Elderly patients, who scored low on the GCS, and patients with coagulopathy had poor prognoses. All patients with PIVH underwent surgery with EVD within 24 hours of their hospital admission. Applying EVD had positive results and influenced the prognosis and early and late complications of PIVH accordingly.     

Is training in solution-focused working useful to community matrons?

This article evaluates the usefulness of a small initiative to train community matrons (CMs) in solution-focused (SF) approaches, from the perspective of the CMs. A SF approach is a psychologically sophisticated, yet relatively easy-to-use psychological model for enhancing care and wellbeing which can help to empower patients and promote self-care. Data from questionnaires completed by CMs immediately post training and from qualitative interviews conducted 12 months later suggest that training in SF approaches is considered useful, useable and relevant by the nurses themselves. More specifically, CMs reported that SF approaches allowed them to work alongside patients to investigate and amplify patients' own expertise in 'living well' despite their difficulties, contributing to improved patient self-management, less reliance on the CM, and greater job satisfaction for the CM. SF approaches seem to resonate with the current NHS drive for greater efficiency and better patient-centred care.     

Is FENO50 useful diagnostic tool in suspected asthma?

Background: Asthma diagnosis is based on the presence of symptoms and the demonstration of airflow variability. Airway inflammation measured by fractional exhaled nitric oxide, measured at a flow rate of 50 ml/s (FE_NO50) remains a controversial diagnostic tool. Aim: To assess the ability of FE_NO50 to identify bronchial hyperresponsiveness (BHR) to methacholine (provocative concentration of methacholine causing a 20% fall in FEV₁; PC20M ≤ 16 mg/ml) and to establish whether or not symptoms relate to FE_NO50 and PC20M in patients with no demonstrated reversibility to β₂‐agonist. Methods: We conducted a prospective study on 174 steroid naive patients with respiratory symptoms, forced expiratory volume in 1 s (FEV₁) ≥ 70% predicted and no demonstrated reversibility to β₂‐agonist. Patients answered to a standardised symptom questionnaire and underwent FE_NO50 and methacholine challenge. Receiver‐operating characteristic (ROC) curve and logistic regression analysis assessed the relationship between PC20M and FE_NO50, taking into account covariates (smoking, atopy, age, gender and FEV₁). Results: A total of 82 patients had a PC20M ≤ 16 mg/ml and had significantly higher FE_NO50 (19 ppb vs. 15 ppb; p < 0.05). By constructing ROC curve, we found that FE_NO50 cut‐off value of 34 ppb was able to identify not only BHR with high specificity (95%) and positive predictive value (88%) but low sensitivity (35%) and negative predictive value (62%). When combining all variables into the logistic model, FE_NO50 (p = 0.0011) and FEV₁ (p < 0.0001) were independent predictors of BHR whereas age, gender, smoking and atopy had no influence. The presence of diurnal and nocturnal wheezing was associated with raised FE_NO50 (p < 0.001 and p < 0.05, respectively). Conclusion: The value of FE_NO50 > 34 ppb has high predictive value of PC20M < 16 in patients with suspected asthma in whom bronchodilating test failed to demonstrate reversibility or was not indicated. However, FE_NO50 ≤ 34 ppb does not rule out BHR and should prompt the clinician to ask for a methacholine challenge.