Local Anaesthesia Suppressing Idiopathic Ventricular Tachycardia - A Cause of Non-inducible Arrhythmia During Electrophysiology Study

AbstractA 13year old boy having idiopathic ventricular tachycardia had non-inducible tachycardia twice on electrophysiology (EP) study due to suppression of arrhythmia by local anaesthetic agent, lignocaine. This case report demonstrates a cause of non-inducibility or arrhythmia during EP study and effect of lignocaine in suppression of idiopathic ventricular tachycardia

Cost-effectiveness in extracorporeal life support in critically ill adults in the Netherlands

Background: Extracorporeal life support (ECLS) is used to support the cardiorespiratory function in case of severe cardiac and/or respiratory failure in critically ill patients. According to the ELSO guidelines ECLS should be considered when estimated mortality risk approximates 80%. ECLS seems an efficient therapy in terms of survival benefit, but no undisputed evidence is delivered yet. The aim of the study is to assess the health-related quality of life after ECLS treatment and its cost effectiveness. Methods: We will perform a prospective observational cohort study. All adult patients who receive ECLS in the participating centers will be included. Exclusion criteria are patients in whom the ECLS is only used to bridge a procedure (like a high risk percutaneous coronary intervention or surgery) or the absence of informed consent. Data collection includes patient characteristics and data specific for ECLS treatment. Severity of illness and mortality risk is measured as precisely as possible using measurements for the appropriate age group and organ failure. For analyses on survival patients will act as their own control as we compare the actual survival with the estimated mortality on initiation of ECLS if conservative treatment would have been continued. Survivors are asked to complete validated questionnaires on health related quality of life (EQ5D-5 L) and on medical consumption and productivity losses (iMTA/iPCQ) at 6 and 12 months. Also the health related quality of life 1 month prior to ECLS initiation will be obtained by a questionnaire, if needed provided by relatives. With an estimated overall survival of 62% 210 patients need to be recruited to make a statement on cost effectiveness for all ECLS indications. Discussion: If our hypothesis that ECLS treatment is cost-effective is confirmed by this prospective study this could lead to an even broader use of ECLS treatment

Physiological definition for region of interest selection in electrical impedance tomography data:description and validation of a novel method

Objective:Geometrical region of interest (ROI) selection in electrical impedance tomography (EIT) monitoring may lack sensitivity to subtle changes in ventilation distribution. Therefore, we demonstrate a new physiological method for ROI definition. This is relevant when using ROIs to compute subsequent EIT-parameters, such as the ventral-to-dorsal ratio during a positive end-expiratory pressure (PEEP) trial.Approach:Our physiological approach divides an EIT image to ensure exactly 50% tidal impedance variation in the ventral and dorsal region. To demonstrate the effects of our new method, EIT measurements during a decremental PEEP trial in 49 mechanically ventilated ICU-patients were used. We compared the center of ventilation (CoV), a robust parameter for changes in ventro-dorsal ventilation distribution, to our physiological ROI selection method and different commonly used ROI selection methods. Moreover, we determined the impact of different ROI selection methods on the PEEP level corresponding to a ventral-to-dorsal ratio closest to 1.Main results:The division line separating the ventral and dorsal ROI was closer to the CoV for our new physiological method for ROI selection compared to geometrical ROI definition. Moreover, the PEEP level corresponding to a ventral-to-dorsal ratio of 1 is strongly influenced by the chosen ROI selection method, which could have a profound clinical impact; the within-subject range of PEEP level was 6.2 cmH2O depending on the chosen ROI selection method.Significance:Our novel physiological method for ROI definition is sensitive to subtle ventilation-induced changes in regional impedance (i.e. due to (de)recruitment) during mechanical ventilation, similar to the CoV.</p

Population pharmacokinetics of nadroparin for thromboprophylaxis in COVID-19 intensive care unit patients

Aims: Nadroparin is administered to COVID-19 intensive care unit (ICU) patients as thromboprophylaxis. Despite existing population pharmacokinetic (PK) models for nadroparin in literature, the population PK of nadroparin in COVID-19 ICU patients is unknown. Moreover, optimal dosing regimens achieving anti-Xa target levels (0.3–0.7 IU/mL) are unknown. Therefore, a population PK analysis was conducted to investigate different dosing regimens of nadroparin in COVID-19 ICU patients. Methods: Anti-Xa levels (n = 280) from COVID-19 ICU patients (n = 65) receiving twice daily (BID) 5700 IU of subcutaneous nadroparin were collected to perform a population PK analysis with NONMEM v7.4.1. Using Monte Carlo simulations (n = 1000), predefined dosing regimens were evaluated. Results: A 1-compartment model with an absorption compartment adequately described the measured anti-Xa levels with interindividual variability estimated for clearance (CL). Inflammation parameters C-reactive protein, D-dimer and estimated glomerular filtration rate based on the Chronic Kidney Disease Epidemiology Collaboration equation allowed to explain the interindividual variability of CL. Moreover, CL was decreased in patients receiving corticosteroids (22.5%) and vasopressors (25.1%). Monte Carlo simulations demonstrated that 5700 IU BID was the most optimal dosing regimen of the simulated regimens for achieving prespecified steady-state t = 4 h anti-Xa levels with 56.7% on target (0.3–0.7 IU/mL). Conclusion: In our study, clearance of nadroparin is associated with an increase in inflammation parameters, use of corticosteroids, vasopression and renal clearance in critically ill patients. Furthermore, of the simulated regimens, targeted anti-Xa levels were most adequately achieved with a dosing regimen of 5700 IU BID. Future studies are needed to elucidate the underlying mechanisms of found covariate relationships.</p