For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non-ECMO-referred patients.

OBJECTIVE -To evaluate a fully automated algorithm for the establishment of tight glycemic control in critically ill patients and to compare the results with different routine glucose management protocols of three intensive care units (ICUs) across Europe (Graz, Prague, and London).RESEARCH DESIGN AND METHODS -Sixty patients undergoing cardiac surgery (age 67 Ϯ 9 years, BMI 27.7 Ϯ 4.9 kg/m 2 , 17 women) with postsurgery blood glucose levels Ͼ120 mg/dl (6.7 mmol/l) were investigated in three different ICUs (20 per center). Patients were randomized to either blood glucose management (target range 80 -110 mg/dl [4.4 -6.1 mmol/l]) by the fully automated model predictive control (MPC) algorithm (n ϭ 30, 10 per center) or implemented routine glucose management protocols (n ϭ 30, 10 per center). In all patients, arterial glucose was measured hourly to describe the glucose profile until the end of the ICU stay but for a maximum period of 48 h. CONCLUSIONS -The data suggest that the MPC algorithm is safe and effective in controlling glycemia in critically ill postsurgery patients. RESULTS Diabetes Care 29:271-276, 2006E pidemiological studies have revealed a significant relationship between impaired glycemic control and poor outcome in patients with acute cardiovascular events (1-3), postoperative wound infections (4,5), and trauma (6). Patients with diabetes are affected, but patients with stress hyperglycemia with no previous diagnosis of diabetes also have a poor prognosis (1,2,7,8). Critical illness and trauma induce counterregulatory hormone release and alterations in carbohydrate metabolism such as enhanced hepatic gluconeogenesis, insulin resistance, and relative insulin deficiency (9,10).A growing body of evidence indicates that treatment of hyperglycemia improves clinical outcome (11). In a prospective randomized trial in Leuven, postoperative patients were treated with an intensive insulin protocol (12). Strict glycemic control (80 -110 mg/dl) resulted in a reduction of in-hospital mortality and a decrease in organ system dysfunction compared with moderate hyperglycemia (180 -200 mg/dl). In another study performed on a mixed medical-surgical population, the implementation of an intensive glucose management protocol led to decreased mortality, morbidity, and length of intensive care unit (ICU) stay of critically ill adult patients (13).Based on this clinical evidence, efforts have to be made to maintain strict glycemic control in critically ill patients. To achieve this goal, the implementation of complex intensive insulin infusion protocols based on frequent bedside glucose monitoring is required. Numerous guidelines have been developed and tested to implement tight glycemic control in ICUs (13-18). However, most of these guidelines still require user interventions or intuitive decisions of ICU staff.The development of a closed-loop control system that automatically regulates the dose of insulin based on glucose measurements could permit tight glycemic control without increasing the work-

Cardiac arrest in the peri-operative period is rare but associated with significant morbidity and mortality. Current reporting systems do not capture many such events, so there is an incomplete understanding of incidence and outcomes. As peri-operative cardiac arrest is rare, many hospitals may only see a small number of cases over long periods, and anaesthetists may not be involved in such cases for years. Therefore, a large-scale prospective cohort is needed to gain a deep understanding of events leading up to cardiac arrest, management of the arrest itself and patient outcomes. Consequently, the Royal College of Anaesthetists chose peri-operative cardiac arrest as the 7th National Audit Project topic. The study was open to all UK hospitals offering anaesthetic services and had a three-part design. First, baseline surveys of all anaesthetic departments and anaesthetists in the UK, examining respondents' prior peri-operative cardiac arrest experience, resuscitation training and local departmental preparedness. Second, an activity survey to record anonymised details of all anaesthetic activity in each site over 4 days, enabling national estimates of annual anaesthetic activity, complexity and complication rates. Third, a case registry of all instances of peri-operative cardiac arrest in the UK, reported confidentially and anonymously, over 1 year starting 16 June 2021, followed by expert review using a structured process to minimise bias. The definition of peri-operative cardiac arrest was the delivery of five or more chest compressions and/or defibrillation in a patient having a procedure under the care of an anaesthetist. The peri-operative period began with the World Health Organization `sign-in´checklist or first hands-on contact with the patient and ended either 24 h after the patient handover (e.g. to the recovery room or intensive care unit) or at discharge if this occured earlier than 24 h. These components described the epidemiology of peri-operative cardiac arrest in the UK and provide a basis for developing guidelines and interventional studies.

In this feasibility study the eMPC algorithm provided similar, effective and safe tight glucose control over 72 h in critically ill patients in two different ICUs. Further development is required to reduce glucose sampling interval while maintaining a low risk of hypoglycaemia.

SummaryEpidural abscess is a well-recognised but rare complication of epidural catheter placement. We have found only five previous reports of epidural abscess from noncatheter-related administration of steroids and/or local anaesthetic. We describe a further case which led to critical illness and emphasise the association between diabetes mellitus and epidural infection.Keywords Anaesthetic techniques, regional; epidural, caudal. Complications; epidural abscess, paraplegia, diabetes. ...................................................................................... Correspondence to: Dr M. G. A. Palazzo Accepted: 21 January 1997 Case historyA 53-year-old man, with noninsulin-dependent diabetes mellitus, was referred for specialist opinion by his general practitioner because of right buttock pain radiating into the posterolateral thigh and calf.Examination revealed straight leg raising limited to 75Њ on the left and 55Њ on the right. Knee reflexes were present and equal but ankle reflexes were absent. The plantar responses were equivocal and power was normal in both legs. A clinical diagnosis was made of lumbosacral nerve root compression due to intervertebral disc pathology and a caudal epidural injection was performed.A mixture of procaine hydrochloride and triamcinolone acetonide (unlicensed for epidural use) was drawn up from new sterile vials, the tops of which had been swabbed with 0.5% chlorhexidine in 70% spirit and allowed to dry. The skin was cleaned with 0.5% chlorhexidine in 70% spirit and allowed to dry. A new sterile 2'' 21G needle was introduced through the sacral hiatus using a no-touch technique (without the use of gloves, gown or mask). A total of 22 ml of 0.5% procaine hydrochloride with 80 mg of triamcinolone acetonide was slowly injected into the epidural space. After an initial administration of 10 ml, continued injection produced bilateral leg pain. However, within minutes of completing the procedure re-examination revealed that straight leg raising was full and painfree at 85Њ. On review 3 weeks later the patient reported significant coccygeal pain which had made sitting difficult. In addition he had experienced 4 days of bilateral leg pain, radiating into the posterior thighs and calves which had necessitated bed rest. Examination revealed pain-free spinal movements and straight leg raising was pain-free at 80Њ. His neurological status was unremarkable except for absent ankle reflexes. A further caudal injection was performed in an identical way to the first, including drug volume and dosage. However, bilateral leg pain was provoked after 5 ml had been injected.The following day he felt feverish and had a headache. He developed rigors and was admitted to hospital 3 days after the second epidural injection. On examination he was afebrile, had a stiff neck but no focal neurological signs. His bladder was distended. Haematological investigation showed a white blood cell count of 24.6 × 10 9 .l ᮊ 1997 Blackwell Science LtdAn L 4/5 and L 5 /S 1 bilateral foraminal and nerve root...

Computer simulations may provide resource-efficient means for preclinical evaluation of algorithms for glycemic control in the critically ill.

Summary Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3–4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapshot activity survey in all UK hospitals delivering anaesthesia, collecting patient‐level encounter data from all cases under the care of an anaesthetist. During November 2021, as part of NAP7, anaesthetists recorded details of all cases undertaken over 4 days at their site through an online survey capturing anonymous patient characteristics and anaesthetic details. Of 416 hospital sites invited to participate, 352 (85%) completed the activity survey. From these, 24,177 reports were returned, of which 24,172 (99%) were included in the final dataset. The work patterns by day of the week, time of day and surgical specialty were similar to previous NAP activity surveys. However, in non‐obstetric patients, between NAP5 (2013) and NAP7 (2021) activity surveys, the estimated median age of patients increased by 2.3 years from median (IQR) of 50.5 (28.4–69.1) to 52.8 (32.1–69.2) years. The median (IQR) BMI increased from 24.9 (21.5–29.5) to 26.7 (22.3–31.7) kg.m–2. The proportion of patients who scored as ASA physical status 1 decreased from 37% in NAP5 to 24% in NAP7. The use of total intravenous anaesthesia increased from 8% of general anaesthesia cases to 26% between NAP5 and NAP7. Some changes may reflect the impact of the COVID‐19 pandemic on the anaesthetic population, though patients with confirmed COVID‐19 accounted for only 149 (1%) cases. These data show a rising burden of age, obesity and comorbidity in patients requiring anaesthesia care, likely to impact UK peri‐operative services significantly.

Ninety-seven chronic alcoholics, both impaired and unimpaired, without clinically evident liver disease, showed significantly more cerebral atrophy on computed tomography than age-matched neurologic controls. Age was the variable most highly correlated with cerebral atrophy measurements, and it accounted for most of the correlations between atrophy and functional impairment, except in the Wernicke-amnesic group. Analysis of the slopes of atrophy scores versus age showed a more rapid "rate" of development of cerebral atrophy in alcoholics compared with controls. There were no correlations between liver biopsy scores (51 cases), drinking history (47 cases), or dietary intake (39 cases) and cerebral atrophy measurements.