Regional cerebral blood flow and cellular environment in subarachnoid hemorrhage: A thermal doppler flowmetry and microdialysis study

Background Cerebral microdialysis enables assessment of regional metabolic physiology and provides biomarkers for clinical correlation in critical conditions, such as subarachnoid hemorrhage (SAH). The aim of our current study was to investigate the correlation between regional cerebral blood flow and microdialysis parameters (glucose, lactate, glycerol, pyruvate concentrations, and lactate/pyruvate metabolic ratio) in patients with SAH. Materials and methods Twenty-one patients with SAH were enrolled in our retrospective study. Cerebral blood flow (CBF) based on thermal diffusion methodology, the thermal coefficient K, and microdialysis biochemical markers were recorded. The duration of the brain monitoring was 10 days. Results Microdialysis glucose concentration was inversely related to the cerebral temperature and to the L/P ratio. Furthermore, it was positively correlated to all other microdialysis parameters but glycerol. The K coefficient was strongly and positively correlated with the temperature and marginally with the CBF. The L/P ratio was positively correlated with glycerol, while it was inversely correlated with the CBF. Patients who died had elevated L/P ratio and K coefficient compared to the survivors in our series. Conclusions Thermal conductivity coefficient may change over time as cerebral injury progresses and tissue properties alter. These alterations were found to be associated with the microdialysis metabolite concentrations and the CBF itself. The microdialysis biochemical indices of cell stress and death (glycerol, L/P ratio) were positively related to each other, while the measured L/P metabolic ratio was higher among patients who died

Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort

Objectives:We utilized the database of the Defining Antibiotic Levels in Intensive care unit patients (DALI) study to statistically compare the pharmacokinetic/pharmacodynamic and clinical outcomes between prolonged-infusion and intermittent-bolus dosing of piperacillin/tazobactam and meropenem in critically ill patients using inclusion criteria similar to those used in previous prospective studies.Methods: This was a post hoc analysis of a prospective, multicentre pharmacokinetic point-prevalence study (DALI), which recruited a large cohort of critically ill patients from 68 ICUs across 10 countries.Results: Of the 211 patients receiving piperacillin/tazobactam and meropenem in the DALI study, 182 met inclusion criteria. Overall, 89.0% (162/182) of patients achieved the most conservative target of 50% fT(> MIC) (time over which unbound or free drug concentration remains above the MIC). Decreasing creatinine clearance and the use of prolonged infusion significantly increased the PTA for most pharmacokinetic/pharmacodynamic targets. In the subgroup of patients who had respiratory infection, patients receiving beta-lactams via prolonged infusion demonstrated significantly better 30 day survival when compared with intermittent-bolus patients [86.2% (25/29) versus 56.7% (17/30); P=0.012]. Additionally, in patients with a SOFA score of >= 9, administration by prolonged infusion compared with intermittent-bolus dosing demonstrated significantly better clinical cure [73.3% (11/15) versus 35.0% (7/20); P=0.035] and survival rates [73.3% (11/15) versus 25.0% (5/20); P=0.025].Conclusions: Analysis of this large dataset has provided additional data on the niche benefits of administration of piperacillin/tazobactam and meropenem by prolonged infusion in critically ill patients, particularly for patients with respiratory infections

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Infected total knee arthroplasty. Basic science, management and outcome

Numbers of primary elective total knee arthroplasties (TKAs) are steadily increasing and so is the number of revisions. The most common complications after primary TKA are pneumonia, pulmonary embolism and wound or periprosthetic joint infection [1] (Fig. 22.1). Surgical site infection (SSI) is one of the most serious complications of TKA and may be the most common cause of early failure and revision [2, 3]. In Britain, it is estimated that 25 % of TKA revisions are due to infection [4]. The rate of periprosthetic infection varies across different studies. An average rate of 1 % is reported, although there are studies which present higher rates in primary (0.5-2 %) and revision surgery (2-5 %) [3]. Lower rates (0.31 %) are also reported from specialized centers with ultraclean operating theatres [5-7]. Infection after TKA leads to an increased risk of patient morbidity and mortality and to a higher cost for treatment. It is estimated that the annual cost of periprosthetic joint infection revisions exceeds $566 million in the United States and is growing [8]. The average cost of in hospital care is estimated to be double in SSI compared to non SSI patients [5]. The higher cost is related to extended hospital stays, frequent readmissions, prolonged use of antibiotics and higher postoperative rehabilitation periods. © Springer-Verlag London 2015

Management strategies for infected total hip arthroplasty. A critical appreciation of problems and techniques

Infection is a devastating complication of total hip arthroplasty (THA). Risk factors have been recognised and prevention is possible. The nature of the disease is heterogeneous and for satisfactory management one has to weigh factors related to pathogen, host, local soft tissue, bone stock, surgeon experience and financial resources. Available data in the current literature is of poor quality and there is a lack of data comparing different techniques. Referral of patients to dedicated departments with the appropriate facilities may be more appropriate

Total hip arthroplasty: Survival and modes of failure

Total hip arthroplasty (THA) is a very satisfactory surgical procedure for end-stage hip disorders. Implant modifications, such as large femoral heads to improve stability, porous metals to enhance fixation and alternative bearings to improve wear, have been introduced over the last decade in order to decrease the rate of early and late failures. There is a changing pattern of THA failure modes. The relationship between failure modes and patientrelated factors, and the time and type of revision are important for understanding and preventing short and late failure of implants. The early adoption of innovations in either technique or implant design may lead to an increased risk of early failure. ©2018 The author(s)

Differences between CT and MR imaging in acute closed head injuries

AbstractThe authors sought to compare the early MRI and CT findings in patients suffering closed head injury and to investigate the impact of imaging discrepancies on treatment management. A group of 62 patients with closed head injury and discrepancy between the apparently normal or with minor findings CT scan, and their neurological statuses were prospectively studied with MRI. Both CT and MRI were performed within the first 6 days after injury. According to the Glasgow Coma Scale (GCS), 46 patients suffered severe head injury (GCS≤8) and 16 patients moderate head injury (GCS 9–12). Four MRI sequences in various planes were applied using a 1T MR scanner. CT findings were present in 19 out of 62 patients and MRI findings in 61. Extra-axial lesions were found in 52 patients with MRI and in 16 with CT. Subarachnoid hemorrhage (SAH) was observed in 40 patients with MRI and in 12 with CT. Intraventricular hemorrhage was observed in 15 patients with MRI and in 6 with CT. Intraaxial lesions were demonstrated in 54 patients with MRI and in 17 patients with CT. MRI demonstrated diffuse axonal injuries (DAI) type I in 27 patients, type II in 32 and type III in 9 as opposed to 2, 1 and 0 patients with CT respectively. Subcortical gray matter injuries were shown in 12 patients with MRI and 4 with CT. Primary brainstem injuries were shown in 6 patients with MRI and 1 with CT. The FLAIR sequence alone, revealed 89% of the findings demonstrated by all 4 MRI sequences. No statistically significant difference on GCS versus the hemorrhagic and non-hemorrhagic nature of the lesions was found (p>0.05). In conclusion, in closed head injury patients with minor or absent CT findings and severe or moderate injury, MRI findings are almost always present and include particularly DAI lesions and SAH. These differences in favor of MRI do not alter the treatment management