Intensive vs. conventional insulin therapy
[black small square] The role of intensive insulin therapy in medical/surgical intensive care patients remains unclear. This randomized controlled study examined the effect of intensive insulin therapy on mortality in a medical/surgical ICU at a tertiary care facility.
Patients in the study had admission blood glucose levels greater than 110 mg/dL (6.1 mmol/L). The 523 patients were randomly assigned to receive intensive insulin therapy (target blood glucose of 80 to 110 mg/dL [4.4 to 6.1 mmol/L]) or conventional insulin therapy (target blood glucose of 180 to 200 mg/dL [10 to 11.1 mmol/L]).
Researchers found no significant difference in ICU mortality between the intensive insulin therapy and conventional insulin therapy groups (13.5% versus 17.1%, p = 0.30). After adjusting for baseline characteristics, they found that intensive insulin therapy wasn't associated with mortality difference.
The researchers conclude that intensive insulin therapy isn't associated with improved survival among medical/surgical ICU patients and is associated with increased occurrence of hypoglycemia. Based on these results, they don't advocate universal application of intensive insulin therapy in ICU patients.
Source: Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, et al. Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008;36(12):3190-3197.
Which drug is best for ventilator-associated pneumonia caused by MRSA?
[black small square] Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of ventilator-associated pneumonia (VAP). This prospective, open-label, multicenter clinical trial compared the early microbiological efficacy of linezolid to vancomycin in patients with suspected MRSA VAP, based on baseline bronchoscopic bronchoalveolar lavage (BBAL) fluid cultures.
The 149 study patients were randomized to receive either 600 mg of linezolid or 1 gram of vancomycin every 12 hours, and a second BBAL fluid culture was performed 72 to 96 hours after the start of treatment.
A greater number of patients in the linezolid group achieved a microbiological cure compared with those in the vancomycin group (56.5% versus 47.4%, respectively; p = 0.757), but the difference wasn't statistically significant. Researchers also found no statistically significant differences between the two patient groups in clinical cure, survival rate, mean duration of ventilation, hospitalization, ICU stay, and time not receiving mechanical ventilation. The benefits of linezolid therapy may be due to factors other than increased bacterial clearance.
Source: Wunderink RG, Mendelson MH, Somero MS, Fabian TC, May AK, Bhattacharyya H, et al. Early microbiological response to linezolid vs. vancomycin in ventilator-associated pneumonia due to methicillin-resistant Staphylococcus aureus. Chest. 2008;134(6):1200-1207.
Aprotinin, tranexamic acid and reducing postcardiac surgery complications
[black small square] The aim of this study was to investigate postoperative complications and mortality after administration of aprotinin compared to tranexamic acid in an unselected, consecutive cohort.
Perioperative data from 1,188 consecutive cardiac surgery patients were prospectively collected between September 2005 and June 2006 in a university-affiliated clinic. During the first 5 months, 596 patients received aprotinin (Group A); in the next 5 months, 592 patients were treated with tranexamic acid (Group T). Except for antifibrinolytic therapy, the anesthetic and surgical protocols remained unchanged.
Pre- and intraoperative variables were comparable between the two groups. Postoperatively, Group T had a significantly higher incidence of seizures, persistent atrial fibrillation, and renal failure. Patients in Group A who'd had primary coronary artery bypass surgery had more acute myocardial infarctions and renal dysfunction. The 1-year mortality was significantly higher after aprotinin treatment in the high-risk surgery subgroup (17.7% versus 9.8%, p = 0.034).
The researchers concluded that both antifibrinolytic drugs bear the risk of adverse outcome depending on the type of cardiac surgery. Aprotinin shouldn't be administered to patients undergoing coronary artery bypass graft surgery and high-risk patients, and tranexamic acid isn't recommended in valve surgery.
Source: Martin K, Wiesner G, Breuer T, Lange R, Tassani P. The risks of aprotinin and tranexamic acid in cardiac surgery: a one-year follow-up of 1188 consecutive patients. Anesth Analg. 2008;107:1783-1790.