Saturday, June 11, 2005

NEJM -- Two-Years after Endovascular Repair of Abdominal Aortic Aneurysms

Very interesting Dutch study on Two-Year Outcomes after Conventional or Endovascular Repair of Abdominal Aortic Aneurysms in the NEJM. This is the first study to look at prolonged survival (2 years) after placing a tube stent into a dilated abdominal aorta (aneurysm) to prevent rupture. We know that early survival is better with the stent vs. open repair. But what about after the first month? This study shows that after two years, the survival is about the same:

" The cumulative rates of aneurysm-related death were 5.7 percent for open repair and 2.1 percent for endovascular repair. This advantage of endovascular repair over open repair was entirely accounted for by events occurring in the perioperative period, with no significant difference in subsequent aneurysm-related mortality. "

To try to explain this, the authors discuss the following possibilities:

"There may be two possible explanations for the convergence of survival curves in our study. One is that patients who have survived the stress of open repair may be somewhat less likely to die in the first few months after surgery than patients who have undergone endovascular repair, since the latter group has not been subjected to a conventional surgical procedure.
...[snip]...
Another possible explanation for the convergence of survival curves is the failure of endovascular repair to prevent rupture of the aneurysm."

I wonder about a third possibility: did patients having an open repair make lifestyle change that those having the less stressful endovascular repair did not? I ask because one of the frustrations in taking care of patients with vascular disease is the extent to which they do NOT change their eating or smoking habits and so need to come back for yet another procedure at yet another time. The study lists baseline characteristics (55% smoked in the open group and 64% smoked in the endovascular repair group. Half in each group had hyperlipidemia), but no characteristics are given at the two year point. Can the lack of survival advantage after endovascular repair be explained by differences in rates of smoking, hyperlipidemia, and other risk factors at two years?

And thanks to the power of Google, I've sent the lead author an e-mail with just this question!

8: 00 A.M., the lead author writes back:

"We haven't studied that in this 2-year analysis but it is part of our long-term study."



Saturday, April 23, 2005

An Anesthesiologists Thoughts on the Early Epidural 'News'

The New England Journal of Medicine just published The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor and it has gotten national attention, including a segment on the Today show on NBC on February 17th. There's nothing here which was not known before. It's a nice study nonetheless, but readers should be aware of several other issues.

There's really nothing here that's new or that we haven't known before. I've been using neuraxial narcotic in women not yet sufficiently dilated for local anesthetic for ten years. I don't like doing it because I find the incidence of prolonged decelerations in the fetal heart rate trace that sometimes occurs makes people very, very nervous. By 'people' I mean patient, family, nurses, obstetricians,......and yours truly. This study in fact confirms that tendency:

" There was a higher incidence of prolonged and late decelerations in heart rate in the intrathecal group after the initiation of analgesia. "

To be specific, the incidence of prolonged decels was 3.9% vs. 0.6% (p < 0.003). I'm not saying this is a reason to avoid the technique, only that the obstetrical service needs to be prepared for it when it happens and know how to deal with it.



Saturday, March 26, 2005

CMJ Review: Clostridium difficile-associated diarrhea in adults

The Canadian Medical Journal: Clostridium difficile-associated diarrhea in adults (free full-text)



Tuesday, March 22, 2005

NEJM: Two Articles On Schiavo Case

The NEJM will publish two article on the Schiavo case in an upcoming issue. Both are online now and free without a subscription:

Perspective
Terri Schiavo — A Tragedy Compounded
T.E. Quill

Legal Issues in Medicine
"Culture of Life" Politics at the Bedside — The Case of Terri Schiavo
G.J. Annas



Thursday, March 17, 2005

NEJM: The Serotonin Syndrome

Boyer and Shannon's article in the NEJM The Serotonin Syndrome is an excellent review/introduction to a syndrome every anesthesiologist should be familiar with but that had not been defined when I was in training. Excess serotonergic agonism can be triggered not only by certain drug overdoses, but also by many drugs anesthesiologist give frequently (fentanyl!).



Wednesday, February 16, 2005

NEJM -- The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor

NEJM --The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor

" Analgesia was initiated in the intrathecal group by a combined spinal–epidural technique. Intrathecal fentanyl (25 µg) was injected, an epidural catheter placed, and an epidural test dose administered. At the second request for analgesia, the cervix was again examined. Epidural analgesia was then initiated as follows: if the cervix was less than 4.0 cm in diameter, a 15-ml epidural bolus of bupivacaine (0.625 mg per milliliter) with fentanyl (2 µg per milliliter) was given, and if the cervix was 4.0 cm or greater in diameter, a 15-ml epidural bolus of bupivacaine (1.25 mg per milliliter) was given (Figure 1). In both instances, patient-controlled epidural analgesia was then begun. "

Bottom Line: Intrathecal fentanyl in women not yet at 4 cm cervical dilation does not increase C-section rate when compared to systemic opioids. Lots of great information to digest over the next several days...



Monday, February 14, 2005

Truth in Advertising

The availability of references and the sponsorship of original research cited in pharmaceutical advertisements (free full text):

" Results: In the 438 ads with medical claims, 126 contained no references and 312 contained 721 unique references. Of these ad references, 55% (396/721) cited journal articles and 19% (135/721) cited data on file. In contrast, in the sample of research article references, 88% (351/400) cited journal articles and 8% (33/400) cited books. Overall, 84% of the citations from the ads were available: 98% of journal articles, 86% of books, 71% of meeting abstracts or presentations and 20% of data-on-file references. In all, 99% of the sample of research article references were available. We determined that 58% of the original research cited in the pharmaceutical ads was sponsored by or had an author affiliated with the product's manufacturer, as compared with 8% of the articles cited in the research articles. "

[Via UK Medical News Today]

We shouldn't be surprised at these findings. It is just marketing, after all.



Sunday, February 13, 2005

Think CPAP Mask After Major Abdominal Surgery

JAMA just published Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial and those of us giving anesthesia for open major abdominal surgery should take note. Here's the abstract:

" Results Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). "

I remember the first time someone suggested using CPAP for the struggling patient in the recovery room after major abdominal surgery. I snorted and mumbled something under my breath about how the patient needed an endotracheal tube and should have taken the offered thoracic epidural. I went back to bed, convinced that I'd be called in an hour or two to intubate the patient who would by then certainly be in extremis. You know what? They never called me that night and this paper helps me understand why.

I think I need to modify my internal algorithm for post-anesthesia management of these often difficult cases to reflect the option of CPAP as a middle ground between mask oxygen and endotracheal intubation.



Saturday, February 12, 2005

Citation Classics in Anesthetic Journals

I was listening to some friends talk about taking a large set of information and making it more useful to the user when I thought about a project I helped with to try to remedy this with regard to the body of published literature in medicine. PubMed is the National Library of Medicine's big online database of medical articles (no, I didn't help with that). Searching for a term on PubMed usually gets lots of results but doesn't necessarily get you any closer to finding that key reference that people consider the classic or definitive paper in the field.

As a teacher in academic anesthesia, I saw residents (note the past tense) had little hope of finding the 'right' paper to read unless I gave it to them. If I said 'read about airway management' they would no doubt find some things about airway management, but probably not the paper on airway management. Unless of course they were able to search a subset of articles in PubMed defined in advance to be especially relevant to their field of study. That's how we conceived of the idea of 'Key References'--make it easy to assemble a list of references for whatever purpose. To make it easy, we used a unique identifier for each article called the PubMed ID Number (PMID). Seth Dillingham then wrote a plugin for Conversant that could take that PMID and go to the PubMed system and (politely) request information about the reference such as title, authors, citation, and even the abstract.

'Citation classics in anesthetic journals' by Baltussen and Kindler is comprised of 'seminal advances in anesthesia' which give 'a historic perspective on the scientific progress of this specialty'. The advantage of having them available online as a compilation lies in the fact that they 1) are searchable and 2) linked to related articles in PubMed (something which even the online version of the original article even does not do).

See for yourself: Citation Classics in Anesthetic Journals

After looking up all 100 PMID's for these articles I wrote to the journal editors and suggested they require authors to include PMID's for references they cite in each article but (apparently) failed to make a convincing enough case. Sort of like in, oh, 1995 when I suggested to the editors of another journal that they could put their articles online using Highwire Press and was told that they had their hands full putting back issues on CD.



Monday, February 7, 2005

Wired Magazine: Pain Management in Iraq

The Painful Truth: The Iraq war is a new kind of hell, with more survivors - but more maimed, shattered limbs - than ever. A revolution in battlefield medicine is helping them conquer the pain.

" For soldiers evacuated from the battlefield, the advantages of nerve blocks over traditional methods of pain control are clear. The wounded troops flying in and out of Landstuhl are often in misery or a narcotized stupor, while those treated with blocks remain awake and pain-free despite massive injuries. "

A great story about how military anesthesiologists are making a big difference for our wounded.

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