Publications

Neuroprotective strategies that limit secondary tissue loss and/or improve functional outcomes have been identified in multiple animal models of ischemic, hemorrhagic, traumatic and nontraumatic cerebral lesions. However, use of these potential interventions in human randomized controlled studies has generally given disappointing results. In this paper, we summarize the current status in terms of neuroprotective strategies, both in the immediate and later stages of acute brain injury in adults. We also review potential new strategies and highlight areas for future research.

PRAM can provide reliable estimates of central arterial pressure.

Infections are frequent in patients admitted with SAP; most are intra-abdominal infections. Microbiology is diverse with gram-negative micro-organisms most frequently isolated. Most patients admitted to the ICU for SAP receive antibiotics at some point.

Introduction: Therapeutic hypothermia (TH) is often used to treat out-of-hospital cardiac arrest (OHCA) patients who also often simultaneously receive insulin for stress-induced hyperglycaemia.However, the impact of TH on systemic metabolism and insulin resistance in critical illness is unknown.This study analyses the impact of TH on metabolism, including the evolution of insulin sensitivity (S I ) and its variability, in patients with coma after OHCA.Methods: This study uses a clinically validated, model-based measure of S I .Insulin sensitivity was identified hourly using retrospective data from 200 post-cardiac arrest patients (8,522 hours) treated with TH, shortly after admission to the intensive care unit (ICU).Blood glucose and body temperature readings were taken every one to two hours.Data were divided into three periods: 1) cool (T <35°C); 2) an idle period of two hours as normothermia was re-established; and 3) warm (T >37°C).A maximum of 24 hours each for the cool and warm periods was considered.The impact of each condition on S I is analysed per cohort and per patient for both level and hour-to-hour variability, between periods and in six-hour blocks.Results: Cohort and per-patient median S I levels increase consistently by 35% to 70% and 26% to 59% (P <0.001) respectively from cool to warm.Conversely, cohort and per-patient S I variability decreased by 11.1% to 33.6% (P <0.001) for the first 12 hours of treatment.However, S I variability increases between the 18th and 30th hours over the cool to warm transition, before continuing to decrease afterward.Conclusions: OCHA patients treated with TH have significantly lower and more variable S I during the cool period, compared to the later warm period.As treatment continues, S I level rises, and variability decreases consistently except for a large, significant increase during the cool to warm transition.These results demonstrate increased resistance to insulin during mild induced hypothermia.Our study might have important implications for glycaemic control during targeted temperature management.

The awareness of the diagnostic difficulty and the documented high mortality risk of perioperative myocardial infarction (PMI) has led to the wide use of work up to rule out PMI after major noncardiac operations.This has caused stable postoperative patients to be kept in monitored hospital beds for extended periods of time and to be subjected to additional tests.We hypothesized that the mortality of PMI is high and, therefore, the wide use of postoperative work up to identify these patients is justifiable.We performed the following study to prove our hypothesis.All patients in the recovery room after major noncardiac operations who underwent work up to rule out PMI were identified and followed.The PMI work up included care in an electronically monitored unit, physical assessment, continuous ECG monitoring, and three 12lead electrocardiograms and cardiac enzymes obtained at six to eight hour intervals.Data collection included patient demographics; preoperative cardiac risk factors; incidence of intraoperative hypotension, hemorrhage and ECG changes; type of anesthesia and operative procedures and their durations; postoperative ECG and cardiac enzyme results; the incidence of PMI and patient outcome.Two hundred patients were studied; 85 males and 115 females.Their mean age was 62.9 years.Preexisting conditions included hypertension in 162 patients, peripheral arterial disease in 102, diabetes mellitus in 97, angina in 30, previous myocardial infarction in 41, and smoking in 107.Of 200 patients, 164 had an abnormal preoperative ECG.Vascular operations were performed in 104 patients, nonvascular abdominal operations in 48, and other operations in the remaining 48.Intraoperatively, hypotension occurred in 29 patients, blood loss of >500 ml in 25 and ECG changes in 10.There were no deaths.PMI occurred in 5/200 (2.5%) patients.Four had undergone vascular operations and one had had an abdominal operation.The mean age of the patients with PMI was 64.2 years.The duration of operation and blood loss were similar to those of patients without PMI.None of these patients developed cardiac failure or cardiogenic shock and none of them died. Conclusion:The incidence of PMI among patients undergoing noncardiac surgery is low and its mortality is negligible.Physicians should become more selective in the use of monitored beds and in the ordering of a work up to rule out PMI. P2