ARTICLE TITLE: From the Centers for Disease Control and
Prevention. Toy-related injuries among children and teenagers--United
States, 1996.
ARTICLE SOURCE: JAMA (United States), Jan 28 1998, 279(4) p265
ARTICLE TITLE: Human cardiovascular and metabolic response to
acute, severe isovolemic anemia [see comments]
COMMENTS: Comment in: JAMA 1998 Jan 21; 279(3):238-9
ARTICLE SOURCE: JAMA (United States), Jan 21 1998, 279(3) p217-21
AUTHOR(S): Weiskopf RB; Viele MK; Feiner J; Kelley S; Lieberman
J;
ARTICLE TITLE: Perioperative blood transfusion and postoperative
mortality [see comments]
COMMENTS: Comment in: JAMA 1998 Jan 21; 279(3):238-9
ARTICLE SOURCE: JAMA (United States), Jan 21 1998, 279(3)
p199-205
AUTHOR(S): Carson JL; Duff A; Berlin JA; Lawrence VA; Poses RM; Huber
EC; O'Hara DA;
CONCLUSIONS: Perioperative transfusion in patients with hemoglobin
levels 80 g/L (8.0 g/dL) or higher did not appear to influence the
risk of 30- or 90-day mortality in this elderly population. At
hemoglobin concentrations of less than 80 g/L (8.0 g/dL), 90.5% of
patients received a transfusion, precluding further analysis of the
association of transfusion and mortality.
ARTICLE TITLE: What's so passive about passive smoking? Secondhand
smoke as a cause of atherosclerotic disease [editorial;
comment]
COMMENTS: Comment on: JAMA 1998 Jan 14; 279(2):119-24
ARTICLE SOURCE: JAMA (United States), Jan 14 1998, 279(2) p157-8
ARTICLE TITLE: The scientific misconduct process: a scientist's
view from the inside [comment]
COMMENTS: Comment on: JAMA 1998 Jan 7; 279(1):41-7
ARTICLE SOURCE: JAMA (United States), Jan 7 1998, 279(1) p62-4
AUTHOR(S): Youngner JS
ARTICLE TITLE: Evaluation of the research norms of scientists and
administrators responsible for academic research integrity [see
comments]
COMMENTS: Comment in: JAMA 1998 Jan 7; 279(1):62-4
ARTICLE SOURCE: JAMA (United States), Jan 7 1998, 279(1) p41-7
AUTHOR(S): Korenman SG; Berk R; Wenger NS; Lew V
ARTICLE TITLE: Sodium reduction and weight loss in the treatment
of hypertension in older persons: a randomized controlled trial of
nonpharmacologic interventions in the elderly (TONE). TONE
Collaborative Research Group [see comments]
COMMENTS: Comment in: JAMA 1998 Mar 18; 279(11):878-9
ARTICLE SOURCE: JAMA (United States), Mar 18 1998, 279(11)
p839-46
AUTHOR(S): Whelton PK; Appel LJ; Espeland MA; Applegate WB; Ettinger
WH Jr; Kostis JB; Kumanyika S; Lacy CR; Johnson KC; Folmar S; Cutler
JA
CONCLUSION: Reduced sodium intake and weight loss constitute a
feasible, effective, and safe nonpharmacologic therapy of
hypertension in older persons.
ARTICLE TITLE: Long-term postoperative cognitive dysfunction in
the elderly ISPOCD1 study. ISPOCD investigators. International Study
of Post-Operative Cognitive Dysfunction.
ARTICLE SOURCE: Lancet (England), Mar 21 1998, 351(9106) p857-61
AUTHOR(S): Moller JT; Cluitmans P; Rasmussen LS; Houx P; Rasmussen H;
Canet J; Rabbitt P; Jolles J; Larsen K; Hanning CD;
ARTICLE TITLE: The preoperative bleeding time test lacks clinical
benefit: College of American Pathologists' and American Society of
Clinical Pathologists' position article.
ARTICLE SOURCE: Arch Surg (United States), Feb 1998, 133(2)
p134-9
AUTHOR(S): Peterson P; Hayes TE; Arkin CF; Bovill EG; Fairweather RB;
Rock WA Jr; Triplett DA; Brandt JT
A history suggesting a possible bleeding disorder may require further
evaluation; such an evaluation may include performance of the
bleeding time test, as well as a determination of the platelet count,
the prothrombin time, and the activated partial thromboplastin time.
In the absence of a history of excessive bleeding, the bleeding time
fails as a screening test and is, therefore, not indicated as a
routine preoperative test.
ARTICLE TITLE: Spinal cord complications of thoracoabdominal
aneurysm surgery.
ARTICLE SOURCE: Br J Surg (England), Jan 1998, 85(1) p5-15
AUTHOR(S): Lintott P; Hafez HM; Stansby G
CONCLUSION: A combination of rapid surgery, left heart bypass for the
repair of more extensive aneurysms, free spinal drainage and the
avoidance of postoperative hypoxia and hypotension help to minimize
spinal cord ischaemia. No pharmacological agent has yet been shown
conclusively to improve outcome in the clinical setting.
ARTICLE TITLE: Perioperative allogeneic blood transfusion does not
cause adverse sequelae in patients with cancer: a meta-analysis of
unconfounded studies.
ARTICLE SOURCE: Br J Surg (England), Feb 1998, 85(2) p171-8
AUTHOR(S): McAlister FA; Clark HD; Wells PS; Laupacis A
CONCLUSION: Although more studies are required before a definitive
statement can be made, at this time there is no evidence that
allogeneic blood transfusion increases the risk of clinically
important adverse sequelae in patients with cancer undergoing
surgery.
ARTICLE TITLE: Is routine replacement of peripheral intravenous
catheters necessary?
ARTICLE SOURCE: Arch Intern Med (United States), Jan 26 1998, 158(2)
p151-6
AUTHOR(S): Bregenzer T; Conen D; Sakmann P; Widmer AF
CONCLUSIONS: The hazard for catheter-related
complications--phlebitis, catheter-related infections, and mechanical
complications--did not increase during prolonged catheterization. The
recommendation for routine replacement of peripheral intravenous
catheters should be reevaluated considering the additional cost and
discomfort to the patient.
ARTICLE TITLE: Influence of triple-lumen central venous catheters
coated with chlorhexidine and silver sulfadiazine on the incidence of
catheter-related bacteremia.
ARTICLE SOURCE: Arch Intern Med (United States), Jan 12 1998, 158(1)
p81-7
AUTHOR(S): Heard SO; Wagle M; Vijayakumar E; McLean S; Brueggemann A;
Napolitano LM; Edwards LP; O'Connell FM; Puyana JC; Doern GV
CONCLUSIONS: The use of CSS reduces the incidence of significant
bacterial growth on either the tip or intradermal segments of coated
triple-lumen catheters but has no effect on the incidence of
catheter-related bacteremia. In this patient population, catheters
coated with CSS provide no additional benefit over uncoated
catheters.
ARTICLE TITLE: Risk of hospitalization for upper gastrointestinal
tract bleeding associated with ketorolac, other nonsteroidal
anti-inflammatory drugs, calcium antagonists, and other
antihypertensive drugs.
ARTICLE SOURCE: Arch Intern Med (United States), Jan 12 1998, 158(1)
p33-9
AUTHOR(S): Garcia Rodriguez LA; Cattaruzzi C; Troncon MG; Agostinis
L
1.8). CONCLUSIONS: The excess risk of major upper gastrointestinal
tract complications associated with outpatient use of ketorolac
suggests an unfavorable risk-benefit assessment compared with other
NSAIDs. More data are required to reduce the uncertainty about the
apparent small increased risk of upper gastrointestinal tract
bleeding in patients using calcium channel blockers.
ARTICLE TITLE: Preoperative autologous donation decreases
allogeneic transfusion but increases exposure to all red blood cell
transfusion: results of a meta-analysis. International Study of
Perioperative Transfusion (ISPOT) Investigators.
ARTICLE SOURCE: Arch Intern Med (United States), Mar 23 1998, 158(6)
p610-6
AUTHOR(S): Forgie MA; Wells PS; Laupacis A; Fergusson D
CONCLUSIONS: Preoperative autologous donation of blood decreases
exposure to allogeneic blood but increases exposure to any
transfusion (allogeneic and/or autologous). There is a direct
relationship between the transfusion rate in the control group and
the benefit derived from preoperative autologous donation. This
suggests that other methods of decreasing blood transfusion, such as
surgical technique and transfusion protocols, may be as important as
preoperative autologous donation of blood.
ARTICLE TITLE: Prevention of peripheral venous catheter
complications with an intravenous therapy team: a randomized
controlled trial.
ARTICLE SOURCE: Arch Intern Med (United States), Mar 9 1998, 158(5)
p473-7
AUTHOR(S): Soifer NE; Borzak S; Edlin BR; Weinstein RA
CONCLUSIONS: An IV therapy team significantly reduced both local and
bacteremic complications of peripheral IV catheters. Timely
replacement of the catheter appeared to be the most important factor
in reducing the occurrence of complications.
ARTICLE TITLE: Decreasing publication bias.
ARTICLE SOURCE: Clin Pharmacol Ther (United States), Jan 1998, 63(1)
p1-3
AUTHOR(S): Reidenberg MM
ARTICLE TITLE: Postoperative hyponatraemic encephalopathy: water
intoxication.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Feb 1998, 68(2)
p165-8
AUTHOR(S): Hughes PD; McNicol D; Mutton PM; Flynn GJ; Tuck R; Yorke
P
ARTICLE TITLE: Unplanned return to the operating room.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Feb 1998, 68(2)
p143-6
AUTHOR(S): Isbister WH
ARTICLE TITLE: Studies of the surgical scrub.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Jan 1998, 68(1)
p65-7
AUTHOR(S): Poon C; Morgan DJ; Pond F; Kane J; Tulloh BR
intervals. RESULTS: The first stage showed that a single wash episode
failed to provide lasting bacterial colony count reductions on
fingertip cultures. The second showed that enduring colony count
reductions occur whether friction rubbing of the hands was used or
not, and the third showed that a 30 s wash was as effective as
washing for longer periods in reducing fingertip flora. CONCLUSIONS:
These findings suggest that prolonged vigorous pre-operative
scrubbing is unnecessary, although more than a cursory wash is
required to produce lasting fingertip antisepsis.
ARTICLE TITLE: Cost-effectiveness analysis of nocturnal oximetry
as a method of screening for sleep apnea-hypopnea syndrome.
ARTICLE SOURCE: Chest (United States), Jan 1998, 113(1) p97-103
AUTHOR(S): Epstein LJ; Dorlac GR
ARTICLE TITLE: Venous thromboembolism in the intensive care unit:
the last frontier for prophylaxis [editorial; comment]
COMMENTS: Comment on: Chest 1998 Jan; 113(1):162-4
ARTICLE SOURCE: Chest (United States), Jan 1998, 113(1) p5-7
AUTHOR(S): Goldhaber SZ
ARTICLE TITLE: Utilization of venous thromboembolism prophylaxis
in a medical-surgical ICU [see comments]
COMMENTS: Comment in: Chest 1998 Jan; 113(1):5-7
ARTICLE SOURCE: Chest (United States), Jan 1998, 113(1) p162-4
AUTHOR(S): Ryskamp RP; Trottier SJ
ABSTRACT: STUDY OBJECTIVE: To assess the utilization of venous
thromboembolism (VTE) prophylaxis in a medical-surgical ICU. DESIGN:
Prospective cohort study. SETTING: A closed (mandatory critical care
consult) medical-surgical ICU of a large community teaching hospital.
INTERVENTIONS: The medical records of consecutive medical-surgical
ICU admissions were evaluated by a single investigator during a
3-month period. Risk factors for VTE and the type and timing of VTE
prophylaxis were recorded. MEASUREMENTS AND RESULTS: Of 308
admissions evaluated, 209 were included in the study. VTE prophylaxis
was administered within the first 24 h of ICU admission to 179 of the
209 study patients or 86%. Fifty-three percent (n=111) were surgical
patients and 47% (n=98) were medical patients. The study patients had
an average of 4.4 risk factors for VTE. Thirty study patients (14%)
did not receive VTE prophylaxis. CONCLUSION: Eighty-six percent of
the medical-surgical patients included in this study received VTE
prophylaxis. The utilization of VTE prophylaxis described in this
study is higher compared to previously published data. The nature of
physician coverage in our medical-surgical ICU (closed unit),
consistent practice patterns of a designated ICU staff, and a
continuing medical education program involving VTE prophylaxis are
the factors believed to be responsible for these results.
ARTICLE TITLE: Opinions regarding the diagnosis and management of
venous thromboembolic disease. ACCP Consensus Committee on Pulmonary
Embolism. American College of Chest Physicians.
ARTICLE SOURCE: Chest (United States), Feb 1998, 113(2) p499-504
ARTICLE TITLE: A review of why and how we may use beta-blockers in
congestive heart failure.
ARTICLE SOURCE: Chest (United States), Mar 1998, 113(3) p800-8
AUTHOR(S): Constant J
ARTICLE TITLE: Risk of patients with severe aortic stenosis
undergoing noncardiac surgery.
ARTICLE SOURCE: Am J Cardiol (United States), Feb 15 1998, 81(4)
p448-52
AUTHOR(S): Torsher LC; Shub C; Rettke SR; Brown DL
Although aortic valve replacement remains the primary treatment for
patients with severe AS, selected patients with severe AS, who are
otherwise not candidates for aortic valve replacement, can undergo
noncardiac surgery with acceptable risk when appropriate
intraoperative and postoperative management is used.
ARTICLE TITLE: Effect of early captopril treatment on blood
adrenaline levels in acute myocardial infarction (the substudy of
ISIS-4). International Study of Infarct Survival-4.
ARTICLE SOURCE: Am J Cardiol (United States), Feb 1 1998, 81(3)
p335-9
AUTHOR(S): Budaj A; Herbaczynska-Cedro K; Kokot F; Ceremuzynski L
Results suggest that suppression of sympathetic activity contributes
to the beneficial effects of treatment with angiotensin-converting
enzyme inhibitors in the early phase of acute myocardial
infarction.
ARTICLE TITLE: Antiarrhythmic drugs: a reorientation in light of
recent developments in the control of disorders of rhythm.
ARTICLE SOURCE: Am J Cardiol (United States), Mar 19 1998, 81(6A)
p3D-13D
AUTHOR(S): Singh BN
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (75 references); REVIEW,
TUTORIAL
ABSTRACT: Numerous developments in our knowledge of arrhythmias
during the past decade or so have had a major influence on
antiarrhythmic drug therapy. It has become increasingly evident that
arrhythmias merit treatment not only for the relief of symptoms, with
improvement in quality of life, but also for the prolongation of
survival by decreasing arrhythmic deaths. No longer can mere
suppression of arrhythmias, symptomatic or asymptomatic, be equated
with prolonged survival. We now know that antiarrhythmic drugs that
act by blocking sodium channels can increase mortality and that the
most important determinants of arrhythmia mortality are the degree
and nature of ventricular dysfunction. ------<snip>
ARTICLE TITLE: Can antiarrhythmic drugs survive survival
trials?
ARTICLE SOURCE: Am J Cardiol (United States), Mar 19 1998, 81(6A)
p24D-34D
AUTHOR(S): Pratt CM; Waldo AL; Camm AJ
ARTICLE TITLE: Antiarrhythmic drugs: rethinking targets,
development strategies, and evaluation tools.
ARTICLE SOURCE: Am J Cardiol (United States), Mar 19 1998, 81(6A)
p21D-23D
AUTHOR(S): Rosen MR
ARTICLE TITLE: Haemodilution tolerance in patients with mitral
regurgitation.
ARTICLE SOURCE: Anaesthesia (England), Jan 1998, 53(1) p20-4
AUTHOR(S): Spahn DR; Seifert B; Pasch T; Schmid ER
ABSTRACT: Haemodynamic parameters and oxygen consumption were
determined in 20 patients with mitral regurgitation before and after
a 12 ml.kg-1 isovolaemic exchange of blood for 6% hydroxyethyl
starch. During haemodilution, mean (SEM) haemoglobin concentration
decreased from 13.0 (0.4) to 10.3 (0.4) g.dl-1 (p = 0.001). With
cardiac filling pressures maintained at predilution levels, cardiac
index increased from 1.84 (0.08) to 1.94 (0.08) l.min-1.m-2 (p =
0.025) while systemic vascular resistance decreased from 1556 (86) to
1425 (83) dyne.s.cm-5 (p = 0.002) and oxygen extraction increased
from 31.7 (1.1) to 37.3 (1.4)% (p = 0.001) resulting in an unchanged
oxygen consumption. The haemodynamic response to haemodilution was
not affected by the patients' cardiac rhythm, i.e. whether it was
sinus rhythm or atrial fibrillation. In conclusion, isovolaemic
haemodilution to a haemoglobin of 10.3 g.dl-1 is well tolerated in
patients with mitral regurgitation. Compensatory mechanisms include
both an increase in cardiac index and an increase in oxygen
extraction.
ARTICLE TITLE: Blood transfusion facilitating difficult weaning
from the ventilator.
ARTICLE SOURCE: Anaesthesia (England), Feb 1998, 53(2) p181-4
AUTHOR(S): Schonhofer B; Bohrer H; Kohler D
ABSTRACT: We report a case series of five anaemic patients
(haemoglobin: 8.7 +/- 0.8 g.dl-1) with chronic obstructive lung
disease in whom trials of weaning from the ventilator were
unsuccessful. After transfer to our regional weaning centre, blood
was transfused to increase the haemoglobin value to 12 g.dl-1 or
higher. Subsequently, all patients were weaned successfully. We
conclude from our experience that in anaemic patients with chronic
obstructive lung disease there should not be a fixed transfusion
threshold. In anaemic patients in whom difficulty in weaning from the
ventilator is experienced, blood transfusion should be tailored to
the individual patient's needs. Transfusion in those with chronic
obstructive airways disease may lead to successful weaning.
ARTICLE TITLE: Quantifying meaningful changes in pain.
ARTICLE SOURCE: Anaesthesia (England), Feb 1998, 53(2) p121-5
AUTHOR(S): Campbell WI; Patterson CC
ABSTRACT: One hundred and thirty-eight nurses were asked to indicate
the smallest meaningful reduction in pain from each of four
hypothetical pain intensities: 100, 75, 50 and 25, on 100 mm visual
analogue scales. The median values for the smallest meaningful
reductions in pain were 31, 24, 18 and 10 mm, respectively,
representing reductions in pain intensity of 31%, 32%, 36% and 40%,
respectively. These tests were repeated in 110 patients before and
after they had a lower third molar extraction under general
anaesthesia. The patients' expectations of pain relief, pre- and
postoperatively, were very similar to those observed in the nurses.
For each of the four hypothetical pain intensities the median values
for meaningful reductions in pain became greater following surgery.
The pre-operative median reductions from the hypothetical pains 100,
75, 50 and 25 mm were 26, 20, 15 and 11 mm (26%, 27%, 29% and 44%),
respectively. The corresponding postoperative reductions were 31, 24,
19 and 12 mm (31%, 32%, 38% and 48%). To achieve a meaningful
reduction in pain postoperatively in 50% of patients it is necessary
to reduce pain as represented by the visual analogue scale, by
between 31 and 48%, depending on its initial intensity.
ARTICLE TITLE: Anaesthesia for caesarean section in patients with
aortic stenosis: the case for general anaesthesia [editorial;
comment]
COMMENTS: Comment on: Anaesthesia 1998 Feb; 53(2):169-73
ARTICLE SOURCE: Anaesthesia (England), Feb 1998, 53(2) p109-12
AUTHOR(S): Whitfield A; Holdcroft A
ARTICLE TITLE: Anaesthesia for caesarean section in patients with
aortic stenosis: the case for regional anaesthesia [editorial;
comment]
COMMENTS: Comment on: Anaesthesia 1998 Feb; 53(2):169-73
ARTICLE SOURCE: Anaesthesia (England), Feb 1998, 53(2) p107-9
AUTHOR(S): Brighouse D
ARTICLE TITLE: Regional anaesthesia with a subarachnoid
microcatheter for caesarean section in a parturient with aortic
stenosis [see comments]
COMMENTS: Comment in: Anaesthesia 1998 Feb; 53(2):107-9; Comment in:
Anaesthesia 1998 Feb; 53(2):109-12
ARTICLE SOURCE: Anaesthesia (England), Feb 1998, 53(2) p169-73
ABSTRACT: We present a woman in her first pregnancy, with known
aortic stenosis prior to conception, who successfully underwent
regional anaesthesia for an elective Caesarean section using a
subarachnoid microcatheter. The anaesthetic management of patients
with aortic stenosis requiring noncardiac surgery is a complex and
contentious matter, particularly when the situation is compounded by
the physiological changes accompanying pregnancy and delivery. This
is the first reported use of a subarachnoid microcatheter in such a
patient. The choice of technique is discussed and compared with other
options for providing anaesthesia.
TITLE: Prophylactic atenolol reduces postoperative myocardial
ischemia. McSPI Research Group [see comments]
COMMENTS: Comment in: Anesthesiology 1998 Jan; 88(1):2-5
ARTICLE SOURCE: Anesthesiology (United States), Jan 1998, 88(1)
p7-17
AUTHOR(S): Wallace A; Layug B; Tateo I; Li J; Hollenberg M; Browner
W; Miller D; Mangano DT
ABSTRACT: BACKGROUND: Perioperative myocardial ischemia occurs in
20-40% of patients at risk for cardiac complications and is
associated with a ninefold increase in risk for perioperative cardiac
death, myocardial infarction, or unstable angina, and a twofold
long-term risk. Perioperative atenolol administration reduces the
risk of death for as long as 2 yr after surgery. This randomized,
placebo-controlled, double-blinded trial tested the hypothesis that
perioperative atenolol administration reduces the incidence and
severity of perioperative myocardial ischemia, potentially explaining
the observed reduction in the risk for death. METHODS: Two-hundred
patients with, or at risk for, coronary artery disease were
randomized to two study groups (atenolol and placebo). Monitoring
included a preoperative history and physical examination and daily
assessment of any adverse events. Twelve-lead electrocardiography
(ECG), three-lead Holter ECG, and creatinine phosphokinase with
myocardial banding (CPK with MB) data were collected 24 h before
until 7 days after surgery. Atenolol (0, 5, or 10 mg) or placebo was
administered intravenously before induction of anesthesia and every
12 h after operation until the patient could take oral medications.
Atenolol (0, 50, or 100 mg) was administered orally once a day as
specified by blood pressure and heart rate. RESULTS: During the
postoperative period, the incidence of myocardial ischemia was
significantly reduced in the atenolol group: days 0-2 (atenolol 17 of
99 patients; placebo, 34 of 101 patients; P = 0.008) and days 0-7
(atenolol, 24 of 99 patients; placebo, 39 of 101 patients; P =
0.029). Patients with episodes of myocardial ischemia were more
likely to die in the next 2 yr (P = 0.025). CONCLUSIONS:
Perioperative administration of atenolol for 1 week to patients at
high risk for coronary artery disease significantly reduces the
incidence of postoperative myocardial ischemia. Reductions in
perioperative myocardial ischemia are associated with reductions in
the risk for death at 2 yr.
ARTICLE TITLE: Aprotinin decreases blood loss and homologous
transfusions in patients undergoing major orthopedic surgery.
ARTICLE SOURCE: Anesthesiology (United States), Jan 1998, 88(1)
p50-7
AUTHOR(S): Capdevila X; Calvet Y; Biboulet P; Biron C; Rubenovitch J;
d'Athis F
CONCLUSION: Aprotinin treatment during major orthopedic surgery
significantly reduces both blood loss and consequent homologous blood
transfusion requirements.
ARTICLE TITLE: Variability in transfusion practice for coronary
artery bypass surgery persists despite national consensus guidelines:
a 24-institution study. Institutions of the Multicenter Study of
Perioperative Ischemia Research Group.
ARTICLE SOURCE: Anesthesiology (United States), Feb 1998, 88(2)
p327-33
ABSTRACT: BACKGROUND: An estimated 20% of allogeneic blood
transfusions in the United States are associated with cardiac
surgery. National consensus guidelines for allogeneic transfusion
associated with coronary artery bypass graft (CABG) surgery have
existed since the mid- to late 1980s. The appropriateness and
uniformity of institutional transfusion practice was questioned in
1991. An assessment of current transfusion practice patterns was
warranted. METHODS: The Multicenter Study of Perioperative Ischemia
database consists of comprehensive information on the course of
surgery in 2,417 randomly selected patients undergoing CABG surgery
at 24 institutions. A subset of 713 patients expected to be at low
risk for transfusion was examined. Allogeneic transfusion was
evaluated across institutions. Institution as an independent risk
factor for allogeneic transfusion was determined in a multivariable
model. RESULTS: Significant variability in institutional transfusion
practice was observed for allogeneic packed red blood cells (PRBCs)
(27-92% of patients transfused) and hemostatic blood components
(platelets, 0-36%; fresh frozen plasma, 0-36%; cryoprecipitate, 0-17%
of patients transfused). For patients at institutions with liberal
rather than conservative transfusion practice, the odds ratio for
transfusion of PRBCs was 6.5 (95% confidence interval [CI],
3.8-10.8) and for hemostatic blood components it was 2 (95% CI,
1.2-3.4). Institution was an independent determinant of transfusion
risk associated with CABG surgery. CONCLUSIONS: Institutions continue
to vary significantly in their transfusion practices for CABG
surgery. A more rational and conservative approach to transfusion
practice at the institutional level is warranted.
ARTICLE TITLE: FDA public health advisory.
ARTICLE SOURCE: Anesthesiology (United States), Feb 1998, 88(2)
p27A-28A
AUTHOR(S): Lumpkin MM
MAJOR SUBJECT HEADING(S): Anesthesia, Epidural; Anesthesia, Spinal;
Anticoagulants [contraindications]; Hematoma, Epidural
[etiology]; Heparin, Low-Molecular-Weight
[contraindications]; United States Food and Drug
Administration
MINOR SUBJECT HEADING(S): Aged; Anticoagulants [adverse
effects]; Enoxaparin [adverse effects]
[contraindications]; Heparin, Low-Molecular-Weight
[adverse effects]; Product Surveillance, Postmarketing;
United States
This is the warning about epidurals and anticoagulants
ARTICLE TITLE: Is calcium a coronary vasoconstrictor in vivo?
ARTICLE SOURCE: Anesthesiology (United States), Mar 1998, 88(3)
p735-43
AUTHOR(S): Crystal GJ; Zhou X; Salem MR
Dog experiments
ARTICLE TITLE: Myocardial infarction after noncardiac surgery
[see comments]
COMMENTS: Comment in: Anesthesiology 1998 Mar; 88(3):561-4
ARTICLE SOURCE: Anesthesiology (United States), Mar 1998, 88(3)
p572-8
AUTHOR(S): Badner NH; Knill RL; Brown JE; Novick TV; Gelb AW
ABSTRACT: BACKGROUND: In this study, the authors intensively
monitored isoenzyme and electric activity of the heart for the first
7 days after noncardiac surgery in a large group of patients at risk
for postoperative myocardial infarction (PMI). METHODS: After
institutional review board approval and written informed consent were
received, 323 patients, aged 50 yr or older, who had ischemic heart
disease and presented for noncardiac surgery, were enrolled in this
prospective, blinded study. After operation, patients had daily
clinical assessments, electrocardiograms, and measurements of
creatine kinase (CK), CK-2 (mass and activity), and Troponin-T on the
operative night, twice daily on postoperative days 1-4, and then
daily on days 5-7. A diagnosis of PMI was made if the total CK was
174 U/l and in the presence of two of the following: (1) CK-2/CK
(mass or activity) 5%, (2) new Q waves lasting or = 0.04 s and 1 mm
deep in at least two contiguous leads, (3) Troponin-T was 0.2
microg/l, or (4) a positive result of pyrophosphate scan. RESULTS:
Eighteen of the 323 patients (5.6%) had a PMI, of which 3 (17%) were
fatal. Only 3 of 18 patients had chest pain, whereas 10 of 18
patients (56%) had other clinical findings. The electrocardiographic
classification of the PMI was Q wave in 6, non-Q wave in 10, and
indeterminate in 2. The PMIs occurred on the day of operation in 8,
on day one in 6, on day two in 3, and on day four in 1 patient.
CONCLUSIONS: This study determined that PMI was an early event, only
occasionally associated with chest pain, and usually non-Q wave in
nature.
ARTICLE TITLE: Does acute normovolemic hemodilution reduce
perioperative allogeneic transfusion? A meta-analysis. The
International Study of Perioperative Transfusion.
ARTICLE SOURCE: Anesth Analg (United States), Jan 1998, 86(1)
p9-15
AUTHOR(S): Bryson GL; Laupacis A; Wells GA
ABSTRACT: The objective of this study was to systematically review
the literature and to statistically summarize the evidence evaluating
acute normovolemic hemodilution (ANH). Prospective, randomized,
controlled trials of ANH that reported either the proportion of
patients exposed to allogeneic blood or the units of allogeneic blood
transfused were included. All types and languages of publication were
eligible. Of 1573 identified publications, 24 trials (containing a
total of 1218 patients) were included in the meta-analysis. When all
trials were pooled, ANH reduced the likelihood of exposure to
allogeneic blood (odds ratio [OR] 0.31, 95% confidence
interval [CI] 0.15, 0.62) and the total units of allogeneic
blood transfused (weighted mean difference [WMD] -2.22 U, 95%
CI -3.57, -0.86). However, there was marked heterogeneity of the
results. In trials using a protocol to guide perioperative
transfusion, ANH failed to reduce either the likelihood of
transfusion (OR 0.64, 95% CI 0.31, 1.31) or the units administered
(WMD -0.25 U, 95% CI -0.60, 0.10). Adverse events were incompletely
reported. It is possible that biased experimental design is, in part,
responsible for the reported efficacy of this technique.
Implications: after a systematic literature review, 24 randomized
trials examining the role of acute normovolemic hemodilution were
identified, pooled, and summarized using statistical techniques. Many
studies reported an impressive reduction in blood transfused. Closer
examination suggests that these reductions in blood exposure may be
due to flawed study design.
ARTICLE TITLE: Renal protection in patients undergoing
cardiopulmonary bypass with preoperative abnormal renal function
[see comments]
COMMENTS: Comment in: Anesth Analg 1998 Jan; 86(1):1-2
ARTICLE SOURCE: Anesth Analg (United States), Jan 1998, 86(1)
p3-8
AUTHOR(S): Lema G; Urzua J; Jalil R; Canessa R; Moran S; Sacco C;
Medel J; Irarrazaval M; Zalaquett R; Fajardo C; Meneses G
ABSTRACT: We prospectively studied the effects of renal protection
intervention in 17 patients with preoperative abnormal renal function
(plasma creatinine 1.5 mg/dL) scheduled for elective coronary
surgery. Patients were randomized to either dopamine 2.0
micrograms.kg-1.min-1 (Group 1, n = 10) or perfusion pressure 70 mm
Hg during cardiopulmonary bypass (CPB) (Group 2, n = 7). Glomerular
filtration rate and effective renal plasma flow were measured with
inulin and 125I-hippuran clearances before the induction of
anesthesia, after sternotomy and before CPB, during hypo- and
normothermic CPB, after sternal closure, and 1 h postoperatively.
Plasma and urine electrolytes were measured, and free water, osmolar,
and creatinine clearances, as well as fractional excretion of sodium
and potassium, were calculated before and after surgery. Significant
differences between groups were found before CPB for glomerular
filtration rate (higher in Group 1), urine output (2.0 vs 0.29 mL/min
in Group 1 versus Group 2), urinary creatinine (66 vs 175 mg/dL),
urinary osmolarity (370 vs 627 mOsm/L), osmolar clearance (2.1 vs 0.7
mL/min), and urinary potassium (33 vs 71 mEq/L). There were no
differences between groups during hypo- and normothermic CPB. After
CPB, the only difference was a slightly higher urinary creatinine in
Group 2. Renal plasma flow was lower than normal in all patients
before the induction of anesthesia. A nonsignificant trend toward
increased flow was seen during hypothermic CPB. Filtration fraction
was high before CPB, which suggests efferent arteriolar
vasoconstriction, descending toward normal during and after CPB. The
same pattern of changes was present in both groups. In conclusion,
there were no clinically relevant differences between the two
treatment modalities during and after CPB. However, significant
differences were observed before CPB, when dopamine seemed to
partially revert renal vasoconstriction. Implications: Two protective
interventions were compared in patients undergoing heart surgery to
prevent deterioration of renal function; these were dopamine infusion
throughout the operation and phenylephrine infusion during
cardiopulmonary bypass. We found clinically relevant differences only
during surgery before cardiopulmonary bypass.
ARTICLE TITLE: The visual analog scale in the immediate
postoperative period: intrasubject variability and correlation with a
numeric scale.
ARTICLE SOURCE: Anesth Analg (United States), Jan 1998, 86(1)
p102-6
AUTHOR(S): De Loach LJ; Higgins MS; Caplan AB; Stiff JL
ABSTRACT: The visual analog scale (VAS) has been used to assess the
efficacy of pain management regimens in patients with acute
postoperative pain, but its usefulness has not been confirmed in
postoperative pain studies. We studied 60 subjects in the immediate
postoperative period. The specific data collected were: VAS scores
versus an 11-point numeric pain scale; repeatability in VAS scores
over a short time interval; and change in VAS scores from one
assessment period to the next versus a verbal report of change in
pain. The correlation coefficients for VAS scores with the 11-point
pain scale were 0.94, 0.91, and 0.95. The repeatability coefficients
were 17.6, 23.0, and 13.5 mm. Of the 56 patients who completed all
three assessments, only 16 (29%) had repeatability within 5 mm on all
three. Some of the changes in VAS scores between assessments were in
the direction opposite the verbally reported changes in pain (31%);
however, most (92%) were within 20 mm. There was no correlation
between the level of sedation, previous pain experience, anxiety, or
anticipated pain with consistency in VAS scores. We conclude that any
single VAS score in the immediate postoperative period should be
considered to have an imprecision of +/- 20 mm. Implications: The
visual analog scale was developed for assessing chronic pain but is
often used in studies of postoperative pain. This study finds that
the visual analog scale correlates well with a verbal 11-point scale
but that any individual determination has an imprecision of +/- 20
mm.
ARTICLE TITLE: Ischemic insult, kidney viability, and renal
function [editorial; comment]
COMMENTS: Comment on: Anesth Analg 1998 Jan; 86(1):3-8
ARTICLE SOURCE: Anesth Analg (United States), Jan 1998, 86(1)
p1-2
AUTHOR(S): Gelman S
MAJOR SUBJECT HEADING(S): Cardiopulmonary Bypass; Ischemia
[physiopathology]; Kidney [physiopathology]
MINOR SUBJECT HEADING(S): Dopamine [pharmacology]; Kidney
[blood supply] [drug effects]; Phenylephrine
[pharmacology]
ARTICLE TITLE: The effects of red-cell scavenging, hemodilution,
and active warming on allogenic blood requirements in patients
undergoing hip or knee arthroplasty.
ARTICLE SOURCE: Anesth Analg (United States), Feb 1998, 86(2)
p387-91
AUTHOR(S): Schmied H; Schiferer A; Sessler DI; Meznik C
ABSTRACT: Since 1993, we have progressively adopted three techniques
to reduce transfusion requirements during major orthopedic surgery:
red-cell scavenging, acute normovolemic hemodilution, and active
patient warming. We retrospectively evaluated all 821 elective hip
and knee arthroplasties performed in our institution beginning with
July 1993. Target minimal hematocrits were guided by patient ages and
cardiovascular status. The first approximately 500-mL blood loss was
replaced with crystalloid at a ratio of 3 mL for each milliliter of
blood loss. Additional blood loss was replaced with colloid,
hemodilution blood (when available), and scavenged red cells (when
available). Allogenic transfusions were then administered as
necessary to maintain target hematocrits, which were prospectively
defined based on the patient ages and cardiovascular health.
Univariate analysis was applied initially. Significant predictors of
transfusion requirement were subsequently entered into a stepwise
multiple regression to account for confounding factors, including
age, type of anesthesia (regional versus general) and type of surgery
(primary versus hardware replacement). Postoperative hemoglobin
concentrations were similar over the years of study and among the
patients given each treatment. During the study period, allogenic
blood requirements decreased from 1.3 +/- 1.7 U/patient to 0.6 +/-
1.4 U/patient (mean +/- SD). Both univariate and regression analyses
indicated that each treatment significantly reduced transfusion
requirements (P 0.05). We conclude that red-cell scavenging,
hemodilution, and active cutaneous warming each reduce allogenic
blood requirements during hip and knee arthroplasties. Implications:
We retrospectively evaluated three strategies to reduce overall blood
loss: red-cell scavenging, acute normovolemic hemodilution, and
active patient warming. During the study period, allogenic blood
requirements decreased by a factor of 2. Each treatment contributed
to this reduction. We therefore conclude that each treatment reduces
allogenic blood requirements during hip and knee arthroplasties.
ARTICLE TITLE: The comparative effects of postoperative analgesic
therapies on pulmonary outcome: cumulative meta-analyses of
randomized, controlled trials.
ARTICLE SOURCE: Anesth Analg (United States), Mar 1998, 86(3)
p598-612
AUTHOR(S): Ballantyne JC; Carr DB; de Ferranti S; Suarez T; Lau J;
Chalmers TC; Angelillo IF; Mosteller F
ABSTRACT: We performed meta-analyses of randomized, control trials to
assess the effects of seven analgesic therapies on postoperative
pulmonary function after a variety of procedures: epidural opioid,
epidural local anesthetic, epidural opioid with local anesthetic,
thoracic versus lumbar epidural opioid, intercostal nerve block,
wound infiltration with local anesthetic, and intrapleural local
anesthetic. Measures of forced expiratory volume in 1 s (FEV1),
forced vital capacity (FVC), vital capacity (VC), peak expiratory
flow rate (PEFR), PaO2, and incidence of atelectasis, pulmonary
infection, and pulmonary complications overall were analyzed.
Compared with systemic opioids, epidural opioids decreased the
incidence of atelectasis (risk ratio [RR] 0.53, 95%
confidence interval [CI] 0.33-0.85) and had a weak tendency
to reduce the incidence of pulmonary infections (RR 0.53, 95% CI
0.18-1.53) and pulmonary complications overall (RR 0.51, 95% CI
0.20-1.33). Epidural local anesthetics increased PaO2 (difference
4.56 mm Hg, 95% CI 0.058-9.075) and decreased the incidence of
pulmonary infections (RR 0.36, 95% CI 0.21-0.65) and pulmonary
complications overall (RR 0.58, 95% CI 0.42-0.80) compared with
systemic opioids. Intercostal nerve blockade tends to improve
pulmonary outcome measures (incidence of atelectasis: RR 0.65, 95% CI
0.27-1.57, incidence of pulmonary complications overall: RR 0.47, 95%
CI 0.18-1.22), but these differences did not achieve statistical
significance. There were no clinically or statistically significant
differences in the surrogate measures of pulmonary function (FEV1,
FVC, and PEFR). These analyses support the utility of epidural
analgesia for reducing postoperative pulmonary morbidity but do not
support the use of surrogate measures of pulmonary outcome as
predictors or determinants of pulmonary morbidity in postoperative
patients. IMPLICATIONS: When individual trials are unable to produce
significant results, it is often because of insufficient patient
numbers. It may be impossible for a single institution to study
enough patients. Meta-analysis is a useful tool for combining the
data from multiple trials to increase the patient numbers. These
meta-analyses confirm that postoperative epidural pain control can
significantly decrease the incidence of pulmonary morbidity.
ARTICLE TITLE: Meta-analysis. Unresolved issues and future
developments.
ARTICLE SOURCE: BMJ (England), Jan 17 1998, 316(7126) p221-5
AUTHOR(S): Davey Smith G; Egger M
ARTICLE TITLE: Spurious precision? Meta-analysis of observational
studies.
ARTICLE SOURCE: BMJ (England), Jan 10 1998, 316(7125) p140-4
AUTHOR(S): Egger M; Schneider M; Davey Smith G
ARTICLE TITLE: Audit commission tackles anaesthetic services
[editorial]
ARTICLE SOURCE: BMJ (England), Jan 3 1998, 316(7124) p3-4
AUTHOR(S): Smith A