In this edition of the series, Dr. Molinar provides an excellent review of the different types of hetastarches available along with associated pharmacokinetic and pharmacodynamic profiles.

CLICK HERE TO VIEW THE RECORDED JOURNAL CLUB WEBINAR

This is followed by Dr. Ahn’s review and discussion of the Schortgen et al. study in Lancet 2001. This was thew first “larger” study to evaluate hetastarch and its possible deleterious effect on the kidneys when compared to Gelatin in a multi-center randomized trial in France.

Finally, not until 2008 did we have a large multi-center German study called the VISEP trial published in NEJM which looked at severe sepsis and septic shock patients and compared Hetastarch to Lactated ringers (along with evaluation of intensive vs conventional glucose control). This too as a secondary endpoint ealuated the effects of therapy on renal failure and need for RRT. Although this trial was stopped prematurely because of severe hypoglycemic episodes in the intensive insulin therapy group, it is still the single largest multicenter trial to date looking at the outcomes of septic patients receiving Hetastarch.

These two trials really are the basis of what I have termed the “anti-hextend” movement in the critical care community however they are marked by a myriad of SIGNIFICANT design and statistical FLAWS which have also led to widespread criticism. This journal club webinar aims to dig deep into the analysis of these two trials and was a very engaging and though provoking session. Please FEEL free to comment below and let the discussion continue!!

In keeping with the spirit of ICU 2.0-3.0, I am proud to announce the introduction of the Critical Care Journal Club Series. The series will feature weekly or bi-weekly online, live, real time broadcasts of journal club conferences in the Surgical Intensive Care. The presenters will be residents and fellows rotating through the Surgical ICU and will be moderated by an attending physician. These discussions, much like the anesthesia ones are lively, educational and usually lead to animated conversations on controversial critical care topics facing us today.

Subscribe to the site via twitter or rss to get regular updates and find out how you can attend the next session LIVE online. In the mean time:

CLICK HERE

to get to the list of recordings of the sessions.  As always, comments, suggestions and lively discussion is heavily encouraged!!

Now featuring live online journal clubs on exciting topics in Anesthesia primarily focused on the ambulatory setting.  Follow the link to the Journal Club Series to explore the site and register for the next event. Theses live journal clubs are moderated, live events that lead to lively discussions and feature some of the experts in the field. After the event, you can find a link to the recording of the event where you can review the conference and continue the conversation online …. click on the link and enjoy …

iPad hands on review: Fits in your white coat and is fast enough for Medical point of care use [Healthcare Perspective]

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It really starts with you. As taboo as the topic may be, its a must for every individual to think about this and most importantly discuss it with the ones you love most. This is the most effective way to ensure that your wishes are truly upheld.

Here’s a great tool available online – The One Slide Project

Here is a link to the US Living Will Registry where you can find out more specific information. The link takes you directly to the state specific forms.

I apologize for the long delay between posts but I have been working on getting some updates into the website. As you can see, our theme is entirely different and starting today – We are iPhone friendly! now you can visit anytime and have the same ease of use that you do from the computer at home or work. Enjoy!

Several measures of ICU performance have been proposed in the past 30 years. It is intuitive, and correct, to assume that ICU mortality may be a useful marker of quality. However, crude mortality rates does not take into consideration the singular aspects of each specific patient population that is treated in a certain geographic region, hospital or ICU. Therefore approaches looking for standardized mortality ratios that are adjusted for disease severity, comorbidities and other clinical aspects are often sought. Severity of illness is usually evaluated by scoring systems that integrates clinical, physiologic and demographic variables. Scoring systems are interesting tools to describe ICU populations and explain their different outcomes. The most frequently used are the APACHE II, SAPS II and MPM. However, newer scores as APACHE IV and SAPS III have been recently introduced in clinical practice. More than only using scoring systems, one should search for a high rate of adherence to clinically effective interventions. Adherence to interventions as deep venous thrombosis prophylaxis, reduction of ICU-acquired infections, adequate sedation regimens and decreasing and reporting serious adverse events are essential and have been accepted as benchmarking of quality.

The complex task of collecting and analyzing data on performance measures are made easier when clinical information systems are available. Although several clinical information systems focus on important aspects as computerized physician order entry systems and individual patient tracking information, few have attempted to gather clinical information generating full reports that provide a panorama of the ICU performance and detailed data on several domains as mortality, length of stay, severity of illness, clinical scores, nosocomial infections, adverse events and adherence to good clinical practice. Through implementing quality initiatives, increasing the quality of care and patient safety are major and feasible goals. Such systems are available for clinical use and may facilitate the process of care on a daily basis and provide data for an in-depth analysis of ICU performance.

FDA’s anesthesiology and respiratory therapy devices advisory committee will meet May 28 in Gaithersburg, Md., to discuss Johnson & Johnson/Ethicon Endo-Surgery’s pre-market approval application for its Sedasys computer-assisted personalized sedation system, indicated for minimal to moderate sedation in adult patients undergoing colonoscopy and esophagogastroduodenoscopy procedures.

This is certainly going to spark some fireworks on both sides of the court. Can this really replace anesthesiologist presence in the GI suite? Lets see what the FDA has to say. In my opinion, we should certainly not jump to quick legislation and really put patient safety at the forefront! Just because it can be done DOESN’T mean it should be done.

Here is information about this controversial and potentially game changing technolology from JnJ.

Ethicon Endo-Surgery announced that the results from its pivotal trial demonstrated physician/nurse teams using the SEDASYS™ System reduced the risk of over sedation with propofol in patients undergoing screening and diagnostic procedures for colorectal cancer (colonoscopy), and disorders of the upper gastrointestinal tract (EGD). The study [...] included 1,000 subjects who underwent sedation for colonoscopy and EGD at eight sites and compared the SEDASYS™ System to the current standard of care for sedation (midazolam plus fentanyl or meperidine). Results were included in Ethicon Endo-Surgery’s PreMarket Application (PMA) for approval of the SEDASYS™ System, which is currently in review with the U.S. Food and Drug Administration.

“During the trial, the system made it possible for gastroenterologists to maintain minimal to moderate sedation with propofol, and helped prevent patients from entering deep sedation, which is traditionally associated with propofol,” said Daniel Pambianco, MD, F.A.C.G., medical director of Charlottesville (Va.) Medical Research and trial investigator. “The system offers a way to personalize the level of sedation appropriate for each patient because it combines propofol delivery with sophisticated monitoring to help us better control and predict the patient’s sedation level.”

Patients who received sedation with the SEDASYS™ System experienced fewer and less significant oxygen desaturation events, a clinical sign of over sedation, than patients sedated with current standard of care. The trial demonstrated this by achieving its primary endpoint of Area Under the Curve (AUC) of oxygen desaturation (SpO2 < 90%). AUC is an objective measure of a patient’s respiratory status that incorporates incidence, duration and depth of oxygen desaturation. Patients in the SEDASYS™ System group had an average AUC value of one-third less than the current standard of care patients. No device-related adverse events occurred in patients sedated with the SEDASYS™ System.

SEDASYS™ System patients were minimally-to-moderately sedated with propofol during the study. Sedation level was assessed every two minutes using a Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale of 0-5. Patients who are minimally sedated respond readily when called by name (MOAA/S=5), while moderately sedated patients may require mild tactile stimulus to respond (MOAA/S=2-4). More than 99 percent of SEDASYS™ System patient responses were a MOAA/S score of 2 – 5, indicating minimal to moderate sedation.

(excerpt from may 2008 taken from)
Johnson and Johnson
http://www.jnj.com

List of Useful Resources:

American Society of Anesthesiology:

• Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia – 2004
• Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, 2002
• Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals – 2006
• Granting Privileges to Non-Anesthesiologist Practitioners for Personally Administering Deep Sedation or Supervising Deep Sedation by Individuals Who Are Not Anesthesia Professionals, Statement on — 2006

Ohio Board of Nursing

• State of Ohio Board of Nursing: Guidelines for Administration of Medications, and Monitoring of Patients Receiving Intravenous Moderate Sedation for Medical/Surgical Procedures, July 20, 2007

ACG (American College of Gastroenterology) Practice Guidelines

• ACG Practice Guidelines

ASGE (American Society for Gastrointestinal Endoscopy) Practice Guidelines

• ASGE Practice Guidelines