Despite recent advances in medical care, mortality due to sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, remains high. Fluid resuscitation and vasopressors are the first-line treatment for sepsis in order to optimize hemodynamic instability caused by vasodilation and increased vascular permeability. However, these therapies, aimed at maintaining blood pressure and blood flow to vital organs, could have deleterious cardiac effects, as cardiomyocyte damage occurs in the early stages of sepsis. Recent experimental and clinical studies have demonstrated that a number of factors contribute to sepsis-induced cardiac dysfunction and the degree of cardiac dysfunction is one of the major prognostic factors of sepsis. Therefore, strategies to prevent further cardiomyocyte damage could be of crucial importance in improving the outcome of sepsis.Among many factors causing sepsis-induced cardiac dysfunction, sympathetic nerve overstimulation, due to endogenous elevated catecholamine levels and exogenous catecholamine administration, is thought to play a major role. β-adrenergic blockade therapy is widely used for ischemic heart disease and chronic heart failure and in the prevention of cardiovascular events in high-risk perioperative patients undergoing major surgery. It has also been shown to restore cardiac function in experimental septic animal models. In a single-center randomized controlled trial, esmolol infusion in patients with septic shock with persistent tachycardia reduced the 28-day mortality. Furthermore, it is likely that β-adrenergic blockade therapy may result in further beneficial effects in patients with sepsis, such as the reduction of inflammatory cytokine production, suppression of hypermetabolic status, maintenance of glucose homeostasis, and improvement of coagulation disorders.Recent accumulating evidence suggests that β-adrenergic blockade could be an attractive therapy to improve the prognosis of sepsis. We await a large multicenter randomized clinical trial to confirm the beneficial effects of β-adrenergic blockade therapy in sepsis, of which mortality is still high.
Hemodynamic monitoring is mandatory for perioperative management of cardiac surgery. Recently, the estimated continuous cardiac output (esCCO) system, which can monitor cardiac output (CO) non-invasively based on pulse wave transit time, has been developed. Patients who underwent cardiovascular surgeries with hemodynamics monitoring using arterial pressure-based CO (APCO) were eligible for this study. Hemodynamic monitoring using esCCO and APCO was initiated immediately after intensive care unit admission. CO values measured using esCCO and APCO were collected every 6 h, and stroke volume variation (SVV) data were obtained every hour while patients were mechanically ventilated. Correlation and Bland-Altman analyses were used to compare APCO and esCCO. Welch's analysis of variance, and four-quadrant plot and polar plot analyses were performed to evaluate the effect of time course, and the trending ability. A p-value < 0.05 was considered statistically significant. Twenty-one patients were included in this study, and 143 and 146 datasets for CO and SVV measurement were analyzed. Regarding CO, the correlation analysis showed that APCO and esCCO were significantly correlated (r = 0.62), and the bias ± precision and percentage error were 0.14 ± 1.94 (L/min) and 69%, respectively. The correlation coefficient, bias ± precision, and percentage error for SVV evaluation were 0.4, - 3.79 ± 5.08, and 99%, respectively. The time course had no effects on the biases between CO and SVV. Concordance rates were 80.3 and 75.7% respectively. While CO measurement with esCCO can be a reliable monitor after cardiovascular surgeries, SVV measurement with esCCO may require further improvement.
Background Tracheostomy is a necessary procedure for patients who require long-term mechanical ventilation support. There are two methods for tracheostomy in current use: surgical tracheostomy (ST) and percutaneous dilational tracheostomy (PDT). In the current study, we retrospectively compared the safety of both procedures performed in our intensive care unit (ICU). Methods In this study, we enrolled subjects who underwent tracheostomy in our ICU between January 2012 and March 2016. We excluded subjects who were <20 years old and underwent tracheostomy in the operating room. As a primary outcome, we evaluated the rate of complications between ST and PDT groups. The length of ICU stay, time to tracheostomy from intubation, and the rate of mechanical ventilation and mortality at 28 postoperative days were also examined as secondary outcomes. Results Compared with the ST group, the rate of all complications was lower in the PDT group (13.4% vs. 38.8%, p=0.007). Although the rate of intraoperative complications did not differ between the two groups (3.8% vs. 8.1%, p=0.62), relative to the ST procedure, the PDT procedure was associated with fewer postoperative complications (34.6% vs. 9.6%, p=0.003). Among postoperative complications, accidental removal of the tracheostomy tube and an air leak from the tracheostomy fistula were less frequent in the PDT group than the ST group. Between the two groups, there were no significant differences in their secondary outcomes. Conclusion This retrospective study indicates that relative to ST, PDT is a safer procedure to be performed in the ICU. Fewer postoperative complications following PDT might be attributed to the small skin incision made during this procedure.
Malignant hyperthermia (MH) is a rare but fatal complication that develops under general anesthesia. Reports on MH in patients over the age of 80 years are unusual. We experienced a case of MH in an 82-year-old patient during esophageal resection. Anesthesia was induced with propofol and succinylcholine, and maintained with sevoflurane. Neither masseter spasm nor rigidity of the limbs was seen during induction. Body temperature (BT) at induction was 36.0 degrees C. Three hours after incision, the level of end-tidal CO2 was elevated to 55 mmHg. We assumed that the rise in end-tidal CO2 had occurred due to secretions in the airway. However, the BT, which had risen at 3 h after incision, continued to rise, and about 60 min later, the BT exceeded 39.0 degrees C. A rise of more than 0.5 degrees C in less than 15 min was seen, and MH was suspected. With dantrolene administration, the BT decreased from 40.9 degrees C at maximum to 37.7 degrees C. With continuous infusion of dantrolene when the patient was transferred to the intensive care unit (ICU), BT remained within the normal range. The next day re-operation was performed, without further complications or recurrence of MH during the postoperative period. Because it is necessary to initiate treatment in the early stage of MH, as soon as possible, although MH prevalence is low in the elderly, it is important to suspect MH when hypercapnia and/or hyperthermia are seen.
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