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Anaesthetic management of patients with

severe sepsis

Article in BJA British Journal of Anaesthesia March 2011

DOI: 10.1093/bja/aer015 Source: PubMed

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Bethan Gibson Chris Terblanche

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British Journal of Anaesthesia 106 (3): 41623 (2011)
CORRESPONDENCE
Etomidate for induction of the
septic patient
EditorWe commend Eissa and colleagues1 review article;
however, we wish to draw attention to the selection of induc-
tion agent for septic patients. The ideal haemodynamic prop-
erties of etomidate use in this population are countered by
lingering concerns about subsequent impaired adrenal ster-
oidogenesis with its attendant consequencesa situation
described as an ultimate Faustian bargain.2 Two recent sys-
tematic reviews have examined effects of single-dose etomi-
date in critically ill patients,3 and those with suspected
sepsis.4 They both conclude that single-dose etomidate is
associated with transient suppression of the adrenal axis.
However, neither study reported a significant effect of etomi-
date on mortality. In fact, no prospective randomized trials to
date have reported that etomidate has a significant adverse
effect on mortality in patients with sepsis.5 We feel that
while uncertainty remains, consideration should be given to
using alternative induction agents, such as ketamine, in the
patient with severe sepsis.
Conflict of interest
None declared.
N. M. Dooney*
A. Dagal
Seattle, USA
*E-mail: neilmd1@uw.edu
1 Eissa D, Carton EG, Buggy DJ. Anaesthetic management of
patients with severe sepsis. Br J Anaesth 2010; 105: 734 43
2 Hofer J, Nunnally M. Taking the septic patient to the operating
room. Anesthesiol Clin 2010; 28: 13 24
3 Hohl CM, Kelly-Smith CH, Yeung TC, et al. The effect of a bolus dose
of etomidate on cortisol levels, mortality, and health services util-
ization: a systematic review. Ann Emerg Med 2010; 56: 10513
4 Edwin SB, Walker PL. Controversies surrounding the use of etomi-
date for rapid sequence intubation in patients with suspected
sepsis. Ann Pharmacother 2010; 44: 130713
5 Jones A. The etomidate debate. Ann Emerg Med 2010; 56: 490 1
doi:10.1093/bja/aer013
Reply from the authors
EditorI appreciate the authors comments on our review
article.1 The articles they cite support the case for etomidate
use, on the grounds that there is little evidence of any detri-
mental effect other than transient adrenocortical suppression.
Ketamine is also indicated in the induction of the haemodyna-
mically compromised septic patient. However, I fear that
formal comparison of these two agents in a randomized
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
controlled trial with mortality or even major system dysfunc-
tion as an outcome measure would be extremely difficult to
achieve.
Conflict of interest
None declared.
D. J. Buggy*
Dublin, Ireland
*E-mail: donal.buggy@nbsp.ie
1 Eissa D, Carton EG, Buggy DJ. Anaesthetic management of
patients with severe sepsis. Br J Anaesth 2010; 105: 734 43
Downloaded from http://bja.oxfordjournals.org/ by guest on July 2, 2012
doi:10.1093/bja/aer011
Anaesthetic management of patients with
severe sepsis
EditorWe read with interest the review article on the
anaesthetic management of patients with severe sepsis.1
While informative, we were disappointed that no reference
was made to the use of activated protein C (APC). This
would be particularly relevant to the consideration of neurax-
ial blocks. The only real benefit we can see with epidural
catheters in septic patients taken to critical care postop is
to aid with weaning. However, epidurals on a background
of sepsis is not only high risk but may preclude the use of
APC which might be potentially life saving at a later stage.
Although initial enthusiasm for APC has waned, the Surviving
Sepsis Guidelines 2008 still recommends that adult patients
with sepsis-induced organ dysfunction associated with a
clinical assessment of high risk of death receive APC if
there are no contraindications.2 We hope that the results of
the two current randomized controlled trials underway (one
funded by the French government3 due to be completed in
March 2012 the PROWESS-SHOCK trial)4 will address the
issue of APC and severe sepsis. Until this time, we believe
that the placement of epidural catheters in patients with
severe sepsis should be discussed with the on-call intensivist
before insertion.
B. Gibson*
C. Terblanche
Swansea, UK
*E-mail: bethangibson@doctors.org.uk
1 Eissa D, Carton EG, Buggy DJ. Anaesthetic management of
patients with severe sepsis. Br J Anaesth 2010; 105: 734 43
2 Dellinger RP, Levy MM, Carlet J, et al. Surviving sepsis campaign:
international guidelines for management of severe sepsis and
septic shock. Intensive Care Med 2008; 34: 17 60
Correspondence
3 University of Versailles. Activated protein C and corticosteroids for
human septic shock (APROCCHS). Available from http://clinicaltrials
.gov/ct2/show/NCT00625209 (updated February 17, 2009)
4 Finfer S, Ranieri VM, Thompson BT, et al. Design, conduct, analysis
and reporting of a multi-national placebo controlled trial of acti-
vated protein C for persistent septic shock. Intensive Care Med
2008; 34: 1935 47
doi:10.1093/bja/aer015
Reply from the authors
EditorI thank Dr Gibson and Dr Terblanche for their interest
in our article.1 I disagree that weaning is the only benefit of
epidurals in these patients, as attenuation of the surgical
stress response, optimum analgesia, avoidance of high-dose
opioids, reduction in thromboembolic phenomena, etc. are
among the many potential benefits of an epidural when indi-
cated after an individual risk benefit analysis. Denying the
septic patient an epidural in this scenario on the currently
remote possibility of a subsequent theoretical indication to
use activated protein C in these patients seems unjustified.
I am more confident that the anaesthetist looking after the
patient in theatre is better placed to decide on the merits
of an epidural after an individual risk benefit analysis than
an intensive care-based colleague, possibly liaising by tele-
phone, who may or may not be familiar with the patient.
Conflict of interest
None declared.
D. J. Buggy*
Dublin, Ireland
*E-mail: donal.buggy@nbsp.ie
1 Eissa D, Carton EG, Buggy DJ. Anaesthetic management of
patients with severe sepsis. Br J Anaesth 2010; 105: 734 43
doi:10.1093/bja/aer012
Some old truths are still true . . .
succinylcholine in spinal cord injury
EditorI was perturbed by the study by Yoo and colleagues1
on the cardiovascular responses to tracheal intubation in
patients after spinal cord injury (SCI). While I agree with
their conclusion that patients with cervical cord injuries are
commonly hypotensive after induction, I have serious con-
cerns about the anaesthetic techniques used in this study.
Since the early 1970s, there have been reports of hyperka-
laemia and life-threatening arrhythmias in SCI after succinyl-
choline administration. The mechanisms responsible for
hyperkalaemia are described in the 2006 review referenced
by Yoo and colleagues in their paper.2 In fact, the review
states that Quadriplegics and paraplegics with persistent
paralysis, therefore, could have the potential for succinylcho-
line hyperkalaemia throughout life. Despite this, Yoo and col-
leagues administered succinylcholine to 214 SCI patients at
View publication stats
BJA
various stages after SCI. The indication for rapid sequence
induction seems particularly unclear: only 50 of the 214
were acute, defined as within 4 weeks of injury. In previous
similar studies,3 4 the authors used vecuronium: there is no
explanation for the change to succinylcholine in this study.
In my own experience, rapid sequence induction is rarely
indicated in this group, and I would question whether the
use of this technique simply to fit a study protocol is
ethical. At the very least, serial plasma potassium concen-
trations should have been provided by the authors.
Most anaesthetists regard avoidance of cardiovascular
instability at induction as a laudable aim, and routinely admin-
ister opioids to help achieve this. This is particularly important
in neuroanaesthesia. I am confused as to why Yoo and col-
leagues chose to use an opioid-free technique which not sur-
prisingly produced the massive swings in heart rate and
arterial pressure they report. I would not be proud of an anaes-
thetic chart showing that systolic arterial pressure and heart
rate had increased by up to 60 mm Hg and 60 beats min21,
Downloaded from http://bja.oxfordjournals.org/ by guest on July 2, 2012
respectively, when I intubated the patient. They have pre-
viously demonstrated3 4 that patients with tetraplegia have
a blunted cardiovascular response to laryngoscopy and intu-
bation, but conversely, they found that patients with paraple-
gia had at least a similar, and in some cases enhanced,
response. Even in the (uninjured) control group, two in 20
patients had transient ventricular arrhythmias: the incidence
in the injured patients reached up to 20% in some groups.
Such cardiovascular instability is particularly undesirable in
patients with chronic paraplegia who may be increased risk
of cardiac disease: the authors acknowledge this in their dis-
cussion but made no attempt to avoid this very instability
when actually looking after the patients!
Intubation was peformed 60 s after the administration of
succinylcholine using direct laryngoscopy and manual inline
stabilization of the head. The text states that Patients in
whom intubation took more than 15 s were excluded from
analysis, that is, 105 s after giving thiopental. I wonder
how many patients were excluded from the study for this
reason and how they were eventually intubated. In the
context of spinal instability attempting laryngoscopy if both
muscle relaxation and anaesthesia are beginning to wear
off is likely to put the spinal cord at risk of further injury.
I believe that this risk is increased by the anaesthetic
technique used in this study.
Overall I believe that the techniques described in this
study put patients at increased risk of life-threatening com-
plications. I am surprised that it received ethical approval
in the first place and in particular that the BJA agreed to
publish it.
Conflict of interest
None declared.
P. Edgar*
Glasgow, UK
*E-mail: paul.edgar@ggc.scot.nhs.uk
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