A prospective randomized trial evaluating colloid versus crystalloid resuscitation in the treatment of the vascular leak syndrome associated with interleukin-2 therapy

Interleukin-2 (IL-2)-based therapy induces a vascular leak syndrome (VLS), manifested by hypotension, tachycardia, and oliguria, as is also seen with septic shock. The optimal method for treating such VLS is not known. A prospective randomized trial was undertaken to compare crystalloid and colloid fluid resuscitation for patients receiving bolus IL-2-based therapy for metastatic cancer. All patients received maintenance crystalloid fluid administration and were randomized to receive crystalloid (0.9% normal saline) or colloid (5% human serum albumin) fluid boluses to maintain acceptable vital signs and urine output. Patients refractory to fluid boluses were given dopamine for oliguria and/or phenylephrine for hypotension. Of 107 patients who completed one cycle of therapy on study, 76 completed a full treatment course (two cycles) on study. The total number of saline and albumin fluid boluses given were 9.5 +/- 0.9 versus 7.7 +/- 0.7 (p = 0.36, n = 107) for the first cycle and 19.2 +/- 1.8 versus 16.1 +/- 1.6 (p = 0.33, n = 76) for a complete course, respectively. Although patients receiving saline boluses had significantly more oliguria during a course of therapy, weight gain, number of IL-2 doses, tachycardia, hypotension, vasopressor use, hospital stay, and clinical response rates did not significantly differ between arms. Changes in hematocrit, hemoglobin, protein, albumin, blood urea nitrogen (BUN), and creatinine were analyzed, and patients receiving crystalloid showed greater decreases in albumin (p < 0.0001) and total protein (p < 0.05) as expected. A 40-fold greater cost associated with albumin suggested that crystalloid resuscitation be used to treat the VLS associated with IL-2 therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Uptake of glucose during continuous arteriovenous hemofiltration

OBJECTIVE

To quantify glucose balance related to continuous arteriovenous hemofiltration (CAVH) when a glucose-rich replacement fluid is used for the plasma ultrafiltrate removed.

DESIGN

Prospective, nonintervention study.

SETTING

Medical/surgical and cardiac surgical intensive care units of a university hospital.

PATIENTS

Critically ill patients (n = 20) with acute oliguric renal failure undergoing CAVH.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Timed collections of CAVH effluent were analyzed and other observations were made. Serum creatinine and blood urea nitrogen concentrations decreased substantially during CAVH in each patient. The mean measured glucose concentration of the replacement fluid (Dianeal 1.5%) was 1.40 +/- 0.11 (SD) g/dL (77 +/- 6 mmol/L) and rate of infusion was 1.39 +/- 0.43 L/hr. Effluent volume was 1.51 +/- 0.49 L/hr and glucose was 0.47 +/- 0.10 g/dL (26 +/- 5 mmol/L). The glucose content of the replacement fluid infused was consistently and substantially greater than that value of the effluent removed during the same period. Thus, the average net glucose uptake in relation to the CAVH circuit was 11.9 +/- 3.1 g/hr (range 4.3 to 17.6). Serum glucose concentrations increased in each patient with initiation of CAVH (from 135 +/- 44 to 278 +/- 80 mg/dL [7.4 +/- 2.4 to 15.3 +/- 4.4 mmol/L]; p < .001). Negative fluid balance achieved during CAVH was approximately 100 mL/hr.

CONCLUSIONS

CAVH using predilution with replacement fluid is effective in managing uremia and fluid overload in critically ill patients. The use of a glucose-rich replacement fluid is accompanied by the net uptake of large amounts of glucose, approaching 300 g/day on average in our patients and representing a major exogenous calorie source. This finding has important implications for the metabolic management of critically ill patients during CAVH and should be taken into account in prescribing their nutritional support.

Dose-related cardiovascular effects of spironolactone

The aim of this study was to assess the short-term hemodynamic effects of increasing doses of spironolactone (25, 50, and 75 mg/day) on oliguric patients (5 men, mean age 47 +/- 12 years) undergoing hemodialysis for chronic renal impairment. Parameters of interest included heart rate (HR), cardiac output, systemic vascular resistance (SVR), arterial pressure, right atrial pressure, and pulmonary capillary wedge pressure (PCWP). The study also evaluated how spironolactone modified the effects on arterial and right atrial pressures and PCWP of infusion of increasing doses of norepinephrine (20, 40, and 100 ng/kg/min) and angiotensin II (2, 4, and 10 ng/kg/min). Compared with placebo, the lowest dose of spironolactone (25 mg/day) produced statistically significant (p < 0.05) modifications in systemic arterial pressures without a compensatory increase in cardiac output. The modifications were more pronounced at 50 and 75 mg/day, and the latter had a significant dose-dependent effect. Moreover, doses of 50 and 75 mg/day produced significant (p < 0.05) decreases in right atrial pressure and PCWP. Spironolactone administration caused the curve expressing the relation between an infused norepinephrine or angiotensin II dose and the blood pressure response to shift significantly (p < 0.05 to < 0.01) to the right, and the pressor doses of norepinephrine or angiotensin II showed a significant (p < 0.05 to < 0.01) dose-related increase, suggesting that treatment with spironolactone inhibited cardiovascular reactivity. This effect was observed on both the capacitance (i.e., low-pressure) and resistance (i.e., high pressure) vessels.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemofiltration as treatment for patients with refractory heart failure

Hemofiltration was performed in 15 patients with refractory congestive heart failure. All of these patients had oliguria, although intensive treatment with diuretics, digitalis, vasodilators, and catecholamines was prescribed. Hemofiltration was performed under hemodynamic monitoring in 14 patients. The water removal by hemofiltration decreased pulmonary arterial pressure, pulmonary capillary wedge pressure and right atrial pressure. Despite these hemodynamic improvements, nine patients (60%) died within one month after the start of hemofiltration; the causes were fatal arrhythmia in three, renal failure in two, sepsis in one and irreversible cardiogenic shock in three. Oliguria for over 15 h or a serum creatinine concentration of more than 4.0 mg/dl at the start of hemofiltration related to poor prognosis. In view of these results, hemofiltration for refractory heart failure should be started earlier and performed carefully in order to avoid arrhythmia, cardiogenic shock, and other complications.

Obstetric critical care issues in prematurity

Typically, obstetric critical care issues focus on the management of the patients whose pregnancies are complicated by severe preeclampsia and oliguria. Here, the focus is on the expectant management of the preterm pregnancy complicated by severe preeclampsia, HELLP syndrome, or eclampsia. Then, the emphasis shifts to tocolytic and severe preeclampsia-related pulmonary edema and its clinical management.

Combined ascitic--fluid and furosemide infusion: a therapeutic option for massive diuretic-resistant ascites and severe oliguria of hepatic cirrhosis

We describe the successful use of combined ascitic-fluid and furosemide infusion as a therapeutic option in the management of massive diuretic-resistant ascites and severe oliguria of hepatic cirrhosis in a 30-year-old Nigerian male farmer. It is simple, safe, convenient and effective treatment modality. The mechanics of this procedure seen against the backgroup of the pathogenesis of sodium retention and renal dysfunction in hepatic cirrhosis is discussed.

Hypotension and disseminated intravascular coagulation following intralesional bacillus Calmette-Guérin therapy for locally metastatic melanoma

Four patients developed serious hypotension and signs of disseminated intravascular coagulation shortly after a second round of Tice bacillus Calmette-Guérin (BCG) injections into locally recurrent cutaneous melanoma satellite nodules. Each of these patients survived following intensive therapy with isoniazid, pyridoxine, steroids, pressors, antibiotics, and cardio-renal support including, in one case, three acute hemodialyses. Plasma specimens from two of the four patients caused gelation of lysate from the amebocytes of Limulus polyphemus, indicating the presence of endotoxin or an endotoxin-like substance. In vitro studies on the BCG preparations led us to conclude that this endotoxin activity in the plasma is not the result of direct injection of endotoxin with the BCG preparation, but rather from release of endotoxin from endogenous sources, such as the intestinal tract during a period of relative hypotension following an allergic reaction. Prior immunity appeared to be the consistent factor in the toxic reactions reported herein. Finally, we present recommendations for serial monitoring of these patients and discuss the use of an alternative agent for intralesional therapy.

[The effect of hemodialysis on the vasopressin level and on the renin-aldosterone system in patients with hemorrhagic fever with renal syndrome]

A total of 29 patients with severe hemorrhagic fever associated with the renal syndrome were studied for impact of extracorporeal hemodialysis on the activity of the renin-aldosterone system (RAS), plasma vasopressin and osmolality and the levels of the major osmotically active agents, as well as the circadian urine output and blood pressures. In patients with oliguria there was a significant activation of RAS, an increase in plasma vasopressin ad osmolality due to the increment of the urea in presence of hyponatremia. Hemodialysis led to a temporary normalization of plasma aldosterone and vasopressin levels and a decrease in blood pressure. No significant changes were documented in the activity of the plasma renin and circadian urinary output. A direct correlation was established between the plasma osmolality and the levels of vasopressin. In patients with polyuria developed in presence of hypernatremic hyperosmia plasma vasopressin elevated and aldosterone dropped.

Early changes in intracranial pressure during haemofiltration treatment in patients with grade 4 hepatic encephalopathy and acute oliguric renal failure

We measured the intracranial pressure (ICP), using a subdural catheter in nine patients admitted with grade 4 hepatic encephalopathy due to fulminant hepatic failure complicated by oliguric renal failure. Six patients received daily machine haemofiltration and four patients were treated with continuous arteriovenous haemofiltration (CAVHF). The mean ICP increased during the first hour of machine haemofiltration from 9 +/- 1.4 mmHg to 13 +/- 1.8 mmHg (P less than 0.05), and there was a reduction in the mean arterial pressure from 92.4 +/- 2.7 mmHg to 81 +/- 3.2 mmHg (P less than 0.05) resulting in a reduction in cerebral perfusion pressure of up to 30%. The group treated by CAVHF, although having a greater mean ICP prior to treatment (19 +/- 4.8 mmHg) and a lower mean arterial pressure (66 +/- 3.6 mmHg) and consequently a lower cerebral perfusion pressure, did not show any increase in ICP or reduction in mean arterial or cerebral perfusion pressure. There was a significant reduction in serum osmolality during the first hour of treatment in the machine haemofiltration group (314 +/- 4 mOsm/kg to 309 +/- 4 mOsm/kg, P less than 0.05), whereas there was no corresponding change in the CAVHF group. This suggests that CAVHF is to be preferred for the treatment of acute renal failure in such patients who are at considerable risk of developing cerebral oedema.

Ultrasonographic guidance for central venous access during pregnancy

Real-time ultrasonographic imaging of vascular and anatomic neck structures allows easy visualization of the right internal jugular vein and carotid artery. Application of this technology during pregnancy may reduce potential complications encountered with central venous monitoring and will be especially useful in cases of difficult anatomy.

Changes in intracranial pressure during haemofiltration in oliguric patients with grade IV hepatic encephalopathy

Seven consecutive patients with grade IV hepatic encephalopathy, due to fulminant hepatic failure complicated by oliguric renal failure were allocated at random to treatment with daily machine haemofiltration (MHF) or continuous arteriovenous haemofiltration (CAVHF). Intracranial pressure (ICP) was continuously monitored using a subdural catheter. Four patients received 17 treatments by MHF, and ICP increased from 8.4 +/- 1.5 mm Hg (mean + SEM) prior to treatment to 12.6 +/- 1.8 mm Hg on completion (p less than 0.05). Active intervention was required on twenty occasions to treat sustained increases in ICP (greater than 25 mm Hg maintained for 5 min or longer). A total of 12 haemofilters were used in the treatment of 3 patients by CAVHF. The ICP showed greater stability during CAVHF therapy, the mean pressure prior to treatment was 15.6 +/- 5.2 mm Hg and fell to 11.7 +/- 2.3 mm Hg at 4 h. Sustained increases in ICP occurred in only 1 patient as a preterminal event. These findings suggest that CAVHF is the preferred method of treatment in patients with fulminant hepatic failure complicated by oliguric renal failure who are at risk of developing cerebral oedema.

Clinical experience of pumped arteriovenous haemofiltration in the management of patients in oliguric renal failure following cardiothoracic surgery

Pumped continuous arteriovenous haemofiltration offers a means of managing oliguric renal failure. We report our experience with the use of this technique in the management of patients with oliguric renal failure complicating cardiothoracic surgery, and conclude that it allows management of this complication without transfer to a renal unit.

Monitoring renal function

Acute renal failure is a common cause of morbidity and mortality in critically ill patients. The prompt, effective management of acute oliguria, frequently the presenting sign of renal deterioration, remains difficult because of the lack of suitable monitors. No monitor presently in common use is sufficiently specific, sensitive, or rapidly available to satisfy clinical needs.

Clinical indications for pulmonary artery catheterization in the patient with severe preeclampsia

The obstetric literature reflects an increased interest in invasive hemodynamic monitoring during the past decade. While much of this interest has focused on research applications, the patient with severe preeclampsia may benefit clinically from pulmonary artery catheterization under several circumstances. These conditions include severe hypertension unresponsive to conventional antihypertensive therapy, pulmonary edema, persistent oliguria unresponsive to fluid challenge, and in induction of conduction anesthesia in select patients. Theoretical and clinical evidence to support this contention is presented.

Treatment of a potentially lethal dose isoniazid ingestion

A seven-year-old boy ingested 3,000 mg (125 mg/kg) of isoniazid. Initial blood levels of isoniazid were 250 micrograms/mL approximately six hours after ingestion. Despite IV treatment in the emergency department with 3,000 mg pyridoxine and a repeat of the same antidote one hour later in the intensive care unit, the high isoniazid blood levels and persistent metabolic acidosis and coma prompted a decision to increase drug clearance by hemodialysis. Clearance data confirmed the effectiveness of hemodialysis in removing the poison, and the clinical response was dramatic.

[Use of continuous arteriovenous hemofiltration in diuretic-resistant hypervolemia and electrolyte disorders]

CAVH was carried out in 10 olig/anuric children with diuretic resistant hypervolemia. In addition, three children had hypercalcemia and one child hypernatremia. All but one needed artificial ventilation for pulmonary edema and positive inotropic cardiac support. Mean duration of CAVH for correction of fluid- and electrolyte imbalance was 51.5 hours (range 20-144 hours). The mean fluid removal of 1715 +/- 1479 (SD) ml decreased mean body weight from 21.4 +/- 18.9 (SD) kg to 19.2 +/- 17.0 (SD) kg. The electrolyte disorders were corrected within 18-24 hours. After correction of fluid overload and electrolyte imbalance 7 children could be extubated and cardiac support could be stopped. Two children died because of multiple organ system failure. CAVH was well tolerated by all children, no hemofiltration related complications occurred. CAVH is an effective and safe extracorporal renal replacement therapy system to correct fluid- and electrolyte imbalances in critically ill children. It can be installed easily and quickly, can be performed in every pediatric intensive care unit and is well tolerated even by small children.

Urgent hemosorption in leptospirosis

Resistant oliguria with increasing serum creatine phosphokinase (CPK) level are the most important early signs of the development of acute renal failure in leptospirosis. This symptomocomplex must be considered as indication for urgent hemosorption. Diuresis and normalisation of creatine phosphokinase level are the criteria for accessing the efficiency of hemosorptions.