Author Archives: E. Lawson

Splenic artery aneurysms: Comparing open and endovascular surgical modalities

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Barrionuevo P, Malas MB, Nejim B, et al. A systematic review and meta-analysis of the management of visceral artery aneurysms. J Vasc Surg. 2019;70(5):1694–1699.

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“We included 33 case series of 523 splenic artery aneurysms treated with an endovascular approach and 22 series of 252 splenic artery aneurysms treated with open surgery. Short-term and long-term mortality rates were very low and not significantly different between the two interventions. Mortality was high for ruptured aneurysms treated with an open approach, with an event rate of 0.29 (95% CI, 0.04-0.71). End-organ infarction and gastrointestinal complications rates were not significantly different between the two approaches. The need for reintervention was lower for open surgery 0.00 (95% CI, 0.00-0.11) than for the endovascular approach 0.07 (95% CI, 0.01-0.17). The risk of access site complications for the endovascular approach was low at 0.02 (95% CI, 0.00-0.09). Rates of PES and coil migration were 0.38 (95% CI, 0.04-0.79) and 0.08 (95% CI, 0.00-0.24), respectively. Data were insufficient to identify a difference in mortality based on aneurysm size.”

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Article of interest: Retrospective Analysis of the Incidence of Epidural Haematoma in Patients With Epidural Catheters and Abnormal Coagulation Parameters

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Gulur P, et al. Retrospective analysis of the incidence of epidural haematoma in patients with epidural catheters and abnormal coagulation parameters. Br J Anaesth. 015;114(5): 808–811.

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“Results: During the study period, 11 600 epidural catheters were placed. In the setting of abnormal coagulation parameters, 278 (2.4%) epidural catheters were placed and 351 (3%) were removed. Two epidural haematomas occurred; both patients had epidural catheters and spinal drains placed for vascular procedures with abnormal coagulation parameters after operatation. The haematomas occurred after removal of the catheters. Based on our study, the incidence of epidural haematoma in patients with abnormal coagulation parameters is 1 in 315 patients, with the lower limit of the 95% confidence interval at 87 and the upper limit at 2597.”

See also: Lee LO, Bateman BT, Kheterpal S, et al. Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group. Anesthesiology. 2017;126(6):1053–1063.

The utility of Trendelenburg position on subclavian port placement

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Kwon MY, Lee EK, Kang HJ, et al. The effects of the Trendelenburg position and intrathoracic pressure on the subclavian cross-sectional area and distance from the subclavian vein to pleura in anesthetized patients. Anesth Analg. 2013;117(1):114–118.

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“We evaluated the effects of increased intrathoracic pressure (20 cm H2O) or Trendelenburg position on the CSA and DSCV-pleura during SCV catheterization and general anesthesia, and determined whether their changes were clinically relevant (defined as [DELTA]CSA and [DELTA]DSCV-pleura >=15% vs S-0). Applying positive intrathoracic pressure alone or Trendelenburg position alone provided a statistically increased CSA of the SCV, but this increase did not meet our defined threshold for a relevant degree ([DELTA]CSA of >=15%). Only the combined application of these 2 maneuvers yielded a relevant increase in the CSA ([DELTA]CSA 23.2% vs S-0). No maneuvers provided a relevant change of DSCV-pleura ([DELTA]DSCV-pleura >=15%) despite their statistically significant changes in some conditions.” (Kwon, 2013, p. 116)

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Article of interest: ECMO for Severe ARDS

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Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018;378(21):1965–1975.

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Results: At 60 days, 44 of 124 patients (35%) in the ECMO group and 57 of 125 (46%) in the control group had died (relative risk, 0.76; 95% confidence interval [CI], 0.55 to 1.04; P=0.09). Crossover to ECMO occurred a mean (±SD) of 6.5±9.7 days after randomization in 35 patients (28%) in the control group, with 20 of these patients (57%) dying. The frequency of complications did not differ significantly between groups, except that there were more bleeding events leading to transfusion in the ECMO group than in the control group (in 46% vs. 28% of patients; absolute risk difference, 18 percentage points; 95% CI, 6 to 30) as well as more cases of severe thrombocytopenia (in 27% vs. 16%; absolute risk difference, 11 percentage points; 95% CI, 0 to 21) and fewer cases of ischemic stroke (in no patients vs. 5%; absolute risk difference, -5 percentage points; 95% CI, -10 to -2).

Extracorporeal liver support systems

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One of the topics of discussion this week was the utilization of Molecular Adsorbent Recirculating System™ (MARS) in patients with acute liver failure.

Saliba F, Camus C, Durand F, et al. Albumin dialysis with a noncell artificial liver support device in patients with acute liver failure: a randomized, controlled trial. Ann Intern Med. 2013;159(8):522–531.

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Results: 102 patients (mean age, 40.4 years [SD, 13]) were in the modified intention-to-treat (mITT) population. The per-protocol analysis (49 conventional, 39 MARS) included patients with at least 1 session of MARS of 5 hours or more. Six-month survival was 75.5% (95% CI, 60.8% to 86.2%) with conventional treatment and 84.9% (CI, 71.9% to 92.8%) with MARS (P = 0.28) in the mITT population and 75.5% (CI, 60.8% to 86.2%) with conventional treatment and 82.9% (CI, 65.9% to 91.9%) with MARS (P = 0.50) in the per-protocol population. In patients with paracetamol-related ALF, the 6-month survival rate was 68.4% (CI, 43.5% to 86.4%) with conventional treatment and 85.0% (CI, 61.1% to 96.0%) with MARS (P = 0.46) in the mITT population. Sixty-six of 102 patients had transplantation (41.0% among paracetamol-induced ALF; 79.4% among non-paracetamol-induced ALF) (P < 0.001). Adverse events did not significantly differ between groups.

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NEJM Perspective: Learning from the Dead

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De Cock KM, Zielinski-Gutiérrez E, Lucas SB. Learning from the Dead. N Engl J Med. 2019 Nov 14;381(20):1889-1891.

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“Obstacles to exploiting the rich database that the world’s decedents represent include not only the decline in autopsy rates but also a failure to prioritize broader innovative and culturally acceptable research and surveillance. Even information from medicolegal autopsies is not widely shared for auditing or educational purposes. A commitment among the medical and scientific communities to increase research and evaluation involving the dead, including assessments of postmortem investigations short of complete autopsies, could have great public health benefit.” (De Cock, 2019, pgs. 1889-1890)

Risk of Acute Kidney Injury After IV Contrast Media Administration

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Hinson JS, Ehmann MR, Fine DM, et al. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med. 2017 May;69(5):577-586.e4.

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Results: “Rates of acute kidney injury were similar among all groups. Contrast administration was not associated with increased incidence of acute kidney injury (contrast-induced nephropathy criteria odds ratio=0.96, 95% confidence interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes criteria odds ratio=1.00, 95% confidence interval 0.87 to 1.16). This was true in all subgroup analyses regardless of baseline renal function and whether comparisons were made directly or after propensity matching. Contrast administration was not associated with increased incidence of chronic kidney disease, dialysis, or renal transplant at 6 months. Clinicians were less likely to prescribe contrast to patients with decreased renal function and more likely to prescribe intravenous fluids if contrast was administered.”