Thursday March 5, 2009
Influence of Nebulized Unfractionated Heparin and N-Acetylcysteine in Acute Lung Injury after Smoke Inhalation Injury

Andrew Miller did an interesting study to see effect of addition of nebulized unfractionated heparin, and NAC in lung injury after smoke inhalation. They studied 30 mechanically ventilated adult subjects who were admitted within 48 hours of their bronchoscopy confirmed smoke inhalation injury over a 5-year period.

The experimental group was treated with nebulized heparin sulfate, N-acetylcystine, and albuterol sulfate. Controls received ventilation support and albuterol sulfate. The authors calculated acute physiology and chronic health evaluation (APACHE)-III scores on admission in addition to daily LIS for 7 days.

The experimental group showed significant improvement in (Lung Injury Scores) LISs, respiratory resistance and compliance measurements, and hypoxia scores as compared with controls throughout the duration of the study. There was a statistically significant survival benefit in the experimental group that was most pronounced in patients with APACHE-III scores more > 35. Survival for the control vs. experimental group was 0.5714 ± 0.1497 vs. 0.9375 ± 0.0605, respectively, (risk ratio -0.0055; 95% confidence interval -0.0314-0.0204; hazard ratio 1.003; number needed to treat 2.7)

Conclusion: The use of aerosolized unfractionated heparin and N-acetylcystine attenuates lung injury and the progression of acute respiratory distress syndrome in ventilated adult patients with acute lung injury following smoke inhalation.


Reference:

Miller A, Rivero A, Zaid S, Smith D, Elamin E. Influence of Nebulized Unfractionated Heparin and N-Acetylcysteine in Acute Lung Injury after Smoke Inhalation Injury. Journal of Burn Care & Research:Volume 2009; 30(2): 249-256

Wednesday March 4, 2009
Hypothermia after cardiac arrest: Have we gone overboard

Frieberg and Neilsen looked at the two published trial for this purpose.

Objective: The aim of the study was to evaluate the actual use of hypothermia in clinical practice, safety aspects, resource utilization, and outcome in large cohorts of patients.

Method: They looked at the two published studies from two separate registries, including 2205 cardiac arrest patients in 39 different sites, of whom 869 (39%) were treated with induced hypothermia. Another registry, The Hypothermia Registry, includes 1108 patients from 37 sites in six European countries and one center in the United States; a large majority, or 952 patients (86%), were treated with hypothermia.

Conclusions: Hypothermia is feasible to implement, that it seems reasonably safe, and that the outcome compares well with previous reports. They also conclude that the treatment with hypothermia after cardiac arrest is more widely applied than what is strictly evidence based.


Editors' comment: Institutions need to develop, implement and follow guidelines for post-cardiac arrest therapeutic hypothermia to avoid indiscriminate use and save costs.


Reference:

Frieberg H, Nielsen N. Hypothermia after Cardiac Arrest: Lessons Learned from National Registries. Journal of Neurotrauma. ahead of print. doi:10.1089/neu.2008.0637.

Tuesday March 3, 2009
Minimally invasive craniopuncture therapy for basal ganglia bleed

Study by Wen-Zhi Wang from china help to shed some light on this issue. They evaluated the effects of minimally invasive craniopuncture therapy compared with conservative treatment in treating intracerebral hemorrhage (25–40 ml) in the basal ganglion.

Method: A multicenter, randomized control clinical trial comprised 465 cases of hemorrhage in the basal ganglion from 42 hospitals in China. Three hundred and seventy-seven patients with hemorrhage were randomly assigned to receive

• minimally invasive craniopuncture therapy (n=195) or
• conservative control treatment (n=182)

The main indices of evaluation were

• the degree of neurological impairment at the 14th day after treatment,
• activities of daily living at the end of the 3rd month and
• the case fatality within 3 months

Results:

• Improvement of neurological function in the minimally invasive craniopuncture group was significantly better than that in the control group at the 14th day (χ2=7·93, P=0·02).
• At the end of the 3rd month, there was a significant difference between the two groups in activities of daily living score (χ2=23·13, P<0·001).>The proportion of dependent survival patients (modified Rankin scale >2) in the craniopuncture group (40·9%) was significantly lower than that in the conservative group (63·0%) at the end of the 3rd month (χ2=16·95, P<0·01).>There was no significant difference in the cumulative fatality rates within three months between the two groups [6·7% (13/195) in the craniopuncture group and 8·8% (16/182) in the conservative group].

Conclusions: Minimally invasive craniopuncture technique can improve the independent survival of patients with small basal ganglion hemorrhage. It is a safe and practical technique in treating cerebral hemorrhage.



Reference: click to get abstract

Zhi Wnag W, Jiang B, Mei Liu H, et al. Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China International Journal of Stroke 2009; 4(1): 11-16

Monday March 2, 2009


Q: Why oxygen should be administered to every patient with suspected PE, even when the arterial PO2 is perfectly normal?


Answer; Oxygen should be administered to every patient with suspected PE, even when the arterial PO2 is perfectly normal, because increased alveolar oxygen may help to promote pulmonary vascular dilatation.

Sunday March 1, 2009


Q: In which clinical condition, usually a lower maintenance dose of warfarin is required?


Answer; In thyrotoxic atrial fibrillation

The recommended loading dose of warfarin in thyrotoxic atrial fibrillation is similar to euthyroid patients, but a lower maintenance dose is required because of accelerated clearance of vitamin K-dependent clotting factors.



Reference:

Shenfield GM. Influence of thyroid dysfunction on drug pharmacokinetics. Clin Pharmacokinet. 1981;6:275-297