951
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Torjman MC, Goldberg ME, Littman JJ, Hirsh RA, Dellinger RP. Pilot evaluation of a prototype critical care blood glucose monitor in normal volunteers. J Diabetes Sci Technol 2009; 3:1233-41. [PMID: 20144376 PMCID: PMC2787022 DOI: 10.1177/193229680900300602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Availability of a highly accurate in-hospital automated blood glucose (BG) monitor could facilitate implementation of intensive insulin therapy protocols through effective titration of insulin therapy, improved BG control, and avoidance of hypoglycemia. We evaluated a functional prototype BG monitor designed to perform frequent automated blood sampling for glucose monitoring. METHODS Sixteen healthy adult volunteer subjects had intravenous catheter insertions in a forearm or hand vein and were studied for 8 hours. The prototype monitor consisted of an autosampling unit with a precise computer-controlled reversible syringe pump and a glucose analytical section. BG was referenced against a Yellow Springs Instrument (YSI) laboratory analyzer. Sampling errors for automated blood draws were assessed by calculating the percent of failed draws, and BG data were analyzed using the Bland and Altman technique. RESULTS Out of 498 total sample draws, unsuccessful draws were categorized as follow: 11 (2.2%) were due to autosampler technical problems, 21 (4.2%) were due to catheter-related failures, and 37 (7.4%) were BG meter errors confirmed by a glucometer-generated error code. Blood draw difficulties or failures related to the catheter site (e.g., catheter occlusion or vein collapse) occurred in 6/15 (40%) subjects. Mean BG bias versus YSI was 0.20 +/- 12.6 mg/dl, and mean absolute relative difference was 10.4%. CONCLUSIONS Automated phlebotomy can be performed in healthy subjects using this prototype BG monitor. The BG measurement technology had suboptimal accuracy based on a YSI reference. A more accurate BG point-of-care testing meter and strip technology have been incorporated into the future version of this monitor. Development of such a monitor could alleviate the burden of frequent BG testing and reduce the risk of hypoglycemia in patients on insulin therapy.
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Affiliation(s)
- Marc C Torjman
- Division of Research, Department of Anesthesiology, Cooper University Hospital, The Robert Wood Johnson Medical School-UMDNJ, Camden, New Jersey 08103, USA.
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952
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Abstract
Acute hyperglycemia is common in critically ill patients. Strict control of blood glucose (BG) concentration has been considered important because hyperglycemia is associated independently with increased intensive care unit mortality. After intensive insulin therapy was reported to reduce mortality in selected surgical critically ill patients, lowering of BG levels was recommended as a means of improving patient outcomes. However, a large multicenter multination study has found that intensive insulin therapy increased mortality significantly. A difference in variability of BG control may be one possible explanation why the effect of intensive insulin therapy varied from beneficial to harmful. Several studies have confirmed significant associations between variability of BG levels and patient outcomes. Decreasing the variability of the BG concentration may be an important dimension of glucose management. If reducing swings in the BG concentration is a major biologic mechanism behind the putative benefits of glucose control, it may not be necessary to pursue lower glucose levels with their attendant risk of hypoglycemia.
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Affiliation(s)
- Moritoki Egi
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata, Okayama, Japan.
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953
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954
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955
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Hoekstra M, Vogelzang M, Verbitskiy E, Nijsten MWN. Health technology assessment review: Computerized glucose regulation in the intensive care unit--how to create artificial control. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:223. [PMID: 19849827 PMCID: PMC2784347 DOI: 10.1186/cc8023] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Current care guidelines recommend glucose control (GC) in critically ill patients. To achieve GC, many ICUs have implemented a (nurse-based) protocol on paper. However, such protocols are often complex, time-consuming, and can cause iatrogenic hypoglycemia. Computerized glucose regulation protocols may improve patient safety, efficiency, and nurse compliance. Such computerized clinical decision support systems (Cuss) use more complex logic to provide an insulin infusion rate based on previous blood glucose levels and other parameters. A computerized CDSS for glucose control has the potential to reduce overall workload, reduce the chance of human cognitive failure, and improve glucose control. Several computer-assisted glucose regulation programs have been published recently. In order of increasing complexity, the three main types of algorithms used are computerized flowcharts, Proportional-Integral-Derivative (PID), and Model Predictive Control (MPC). PID is essentially a closed-loop feedback system, whereas MPC models the behavior of glucose and insulin in ICU patients. Although the best approach has not yet been determined, it should be noted that PID controllers are generally thought to be more robust than MPC systems. The computerized Cuss that are most likely to emerge are those that are fully a part of the routine workflow, use patient-specific characteristics and apply variable sampling intervals.
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Affiliation(s)
- Miriam Hoekstra
- Departments of Anesthesiology and Cardiology, University Medical Center Groningen, 9700 RB Groningen, the Netherlands.
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956
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957
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Leone M. Terlipressin or europressin? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:192. [PMID: 19832999 PMCID: PMC2784359 DOI: 10.1186/cc8035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Use of terlipressin in septic shock relies on a series of European studies resulting in a better knowledge of this vasopressive agent. Additional studies demonstrate that this agent appears to have attractive properties when administered properly. In comparison to prior reports, continuous infusion of low-dose terlipressin seems superior when administered to septic animals. For the first time in humans, Morelli and colleagues compared this mode of administration with other vasopressors.
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Affiliation(s)
- Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Chemin des Bourrely, 13915 Marseille cedex 20 France.
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958
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Vandijck DM, Blot SI, Vogelaers DP. Implementation of an evidence-based sepsis program in the intensive care unit: evident or not? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:193. [PMID: 19833007 PMCID: PMC2784379 DOI: 10.1186/cc8056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Severe sepsis and septic shock are among the most serious health conditions and are associated with unwelcome clinical, social, and economic outcomes. With the introduction of the Surviving Sepsis Campaign guidelines, the campaign leaders aimed to reduce mortality from severe sepsis by at least one quarter by 2009 by means of a six-point action plan, namely, building awareness among health care professionals, improving early and accurate disease recognition and diagnosis, increasing the use of appropriate treatments and interventions, education, getting better post-intensive care unit access, and developing standard processes of care. However, adherence to these recommendations is a first but crucial step in obtaining these goals. A comprehensive evaluation of both, adherence to a sepsis program and whether this results in better outcomes for patients, is therefore essential to guide informed decision-making regarding the implementation of such an evidence-based protocol.
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Affiliation(s)
- Dominique M Vandijck
- Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
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959
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Abstract
Shock is a clinical disorder that challenges caregivers in the neonatal intensive care unit. Critically ill neonates may develop shock due to a variety of causes but the predominant cause of shock in neonates is sepsis. This article provides the neonatal nurse with basic knowledge of the pathophysiology and the types of shock seen in the critically ill neonate. Treatment and supportive care of the neonate in shock is determined by the underlying cause of shock with the ultimate goal of treatment being adequate perfusion of tissues to deliver oxygen to the cells and remove metabolic waste products.
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960
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Fischerova D. Urgent care in gynaecology: Resuscitation and management of sepsis and acute blood loss. Best Pract Res Clin Obstet Gynaecol 2009; 23:679-90. [DOI: 10.1016/j.bpobgyn.2009.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 06/02/2009] [Indexed: 12/18/2022]
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961
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Silvani P, Facchini A, Bignami E, Capodanno P, Pappalardo F, Gerli C, Landoni G. Which protein C after cardiac surgery? J Cardiothorac Vasc Anesth 2009; 24:738-9. [PMID: 19783161 DOI: 10.1053/j.jvca.2009.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Indexed: 11/11/2022]
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962
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Severe cutaneous adverse reactions: emergency approach to non-burn epidermolytic syndromes. Intensive Care Med 2009; 36:22-32. [PMID: 19787334 DOI: 10.1007/s00134-009-1659-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 07/29/2009] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Although severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome and toxic epidermal necrolysis, are rare, they are associated with considerable morbidity and mortality. METHODS The current knowledge regarding background, differential diagnoses, critical care and implications for inter-hospital emergency medical service (EMS) transport of these patients is discussed. CONCLUSION SCAR patients will substantially benefit from early interdisciplinary care and thorough consideration of complications during EMS transport and intensive care treatment.
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963
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Differential proteomics of the plasma of individuals with sepsis caused by Acinetobacter baumannii. J Proteomics 2009; 73:267-78. [PMID: 19782774 DOI: 10.1016/j.jprot.2009.09.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/23/2009] [Accepted: 09/15/2009] [Indexed: 12/23/2022]
Abstract
This study examines alterations in the plasma proteome in ten adults affected by sepsis caused by Acinetobacter baumannii as compared to paired healthy controls. 2-DE profiles of plasma from patients and paired healthy donors, depleted of the six most abundant proteins, were analysed by the DIGE technique. Protein spot detection and quantification were performed with the Differential In-gel Analysis and Biological Variation Analysis modules of the DeCyder() software. Differentially expressed proteins were identified by mass spectrometry (MALDI-TOF/TOF) after colloidal Coomassie blue staining. Almost 900 spots were detected on a unique 2-D gel by the DIGE technique. A total of 269 protein spots of differential abundance were shown to be statistically significant (2.5-fold) with p values of p< or =0.01 (135 spots) and p< or =0.05 (134 spots) as determined by the t test. Seventy-one spots were submitted to mass spectrometry and about 30% could be successfully identified. This multiplex approach significantly reduced experimental variability, allowing for the confident detection of small differences in protein levels. Results include differentially expressed lipoproteins as well as proteins belonging to inflammatory/coagulation pathways and the kallikrein-kinin system. These data improves the knowledge for future developments in sepsis diagnosis, staging and therapy.
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964
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Abstract
Patients with burn injuries to more than 10% of the body surface area (BSA) are in potential danger of traumatic hypovolemic shock and from 20% BSA a generalized burn edema can occur. In the preclinical setting an increased infusion therapy is generally unnecessary. Clinical circulation therapy is goal-directed taking hemoglobin concentration, hematocrit, MAP, diuresis, CVP and central venous sO(2 )into consideration. For initial volume replacement, balanced crystalloids with the addition of acetate and possibly malate are infused. Colloids should be given with great caution. Additional gelatine solution is only to be used in patients with impending hypotension and catecholamines should also be avoided if possible. If necessary, dobutamine is used to increase cardiac inotropy and cardiac output. Norepinephrine is only indicated in patients with significantly reduced SVR. Extended hemodynamic monitoring is necessary in all patients with prolonged catecholamine therapy.
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965
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Briegel J, Sprung CL, Annane D, Singer M, Keh D, Moreno R, Möhnle P, Weiss Y, Avidan A, Brunkhorst FM, Fiedler F, Vogeser M. Multicenter comparison of cortisol as measured by different methods in samples of patients with septic shock. Intensive Care Med 2009; 35:2151-6. [DOI: 10.1007/s00134-009-1627-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 08/24/2009] [Accepted: 08/24/2009] [Indexed: 01/12/2023]
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966
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Torgersen C, Dünser MW, Wenzel V, Jochberger S, Mayr V, Schmittinger CA, Lorenz I, Schmid S, Westphal M, Grander W, Luckner G. Comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial. Intensive Care Med 2009; 36:57-65. [PMID: 19756505 DOI: 10.1007/s00134-009-1630-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 08/19/2009] [Accepted: 08/19/2009] [Indexed: 01/30/2023]
Abstract
PURPOSE To compare the effects of two arginine vasopressin (AVP) dose regimens on the hemodynamic response, catecholamine requirements, AVP plasma concentrations, organ function and adverse events in advanced vasodilatory shock. METHODS In this prospective, controlled, open-label trial, patients with vasodilatory shock due to sepsis, systemic inflammatory response syndrome or after cardiac surgery requiring norepinephrine >0.6 microg/kg/min were randomized to receive a supplementary AVP infusion either at 0.033 IU/min (n = 25) or 0.067 IU/min (n = 25). The hemodynamic response, catecholamine doses, laboratory and organ function variables as well as adverse events (decrease in cardiac index or platelet count, increase in liver enzymes or bilirubin) were recorded before, 1, 12, 24 and 48 h after randomization. A linear mixed effects model was used for statistical analysis in order to account for drop-outs during the observation period. RESULTS Heart rate and norepinephrine requirements decreased while MAP increased in both groups. Patients receiving AVP at 0.067 IU/min required less norepinephrine (P = 0.006) than those infused with AVP at 0.033 IU/min. Arterial lactate and base deficit decreased while arterial pH increased in both groups. During the observation period, AVP plasma levels increased in both groups (both P < 0.001), but were higher in the 0.067 IU/min group (P < 0.001) and in patients on concomitant hydrocortisone. The rate of adverse events and intensive care unit mortality was comparable between groups (0.033 IU/min, 52%; 0.067 IU/min, 52%; P = 1). CONCLUSIONS A supplementary AVP infusion of 0.067 IU/min restores cardiovascular function in patients with advanced vasodilatory shock more effectively than AVP at 0.033 IU/min.
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Affiliation(s)
- Christian Torgersen
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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967
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Sabatier C, Ferrer R, Vallés J. Treatment strategies for central venous catheter infections. Expert Opin Pharmacother 2009; 10:2231-43. [DOI: 10.1517/14656560903133819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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968
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Infections with VIM-1 metallo-{beta}-lactamase-producing enterobacter cloacae and their correlation with clinical outcome. J Clin Microbiol 2009; 47:3514-9. [PMID: 19741074 DOI: 10.1128/jcm.01193-09] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The aim of this study was to ascertain the incidence and clinical significance of metallo-beta-lactamases among Enterobacter strains isolated from patients with nosocomial infections. We prospectively collected data on patients with Enterobacter infection during a 13-month period. All of the strains were investigated for antibiotic susceptibility, the presence and expression of metallo-beta-lactamases, and clonality. Of 29 infections (11 involving the urinary tract, 7 pneumonias, 3 skin/soft tissue infections, 3 intra-abdominal infections, 3 bacteremias, and 2 other infections), 7 (24%) were caused by Enterobacter cloacae strains harboring a bla(VIM-1) gene associated or not with a bla(SHV12) gene. Infections caused by VIM-1-producing strains were more frequently associated with a recent prior hospitalization (P = 0.006), cirrhosis (P = 0.03), relapse of infection (P < 0.001), and more prolonged duration of antibiotic therapy (P = 0.01) than were other infections. All of the isolates were susceptible to imipenem and meropenem and had bla(VIM-1) preceded by a weak P1 promoter and inactivated P2 promoters. Most VIM-1-producing Enterobacter isolates belonged to a main clone, but four different clones were found. Multiclonal VIM-1-producing E. cloacae infections are difficult to diagnose due to an apparent susceptibility to various beta-lactams, including carbapenems, and are associated with a high relapse rate and a more prolonged duration of antibiotic therapy.
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969
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Preston P. Commentary: centralized assessment in graduate medical education: how can it help us reinvent training? J Grad Med Educ 2009; 1:28-9. [PMID: 21975703 PMCID: PMC2931177 DOI: 10.4300/01.01.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Paul Preston
- Corresponding author: Paul Preston, MD, Department of Anesthesia, San Francisco Medical Center, 2425 Geary Boulevard, San Francisco, CA 94115, 415.833.4526,
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970
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971
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Erbüyün K, Vatansever S, Tok D, Ok G, Türköz E, Aydede H, Erhan Y, Tekin I. Effects of levosimendan and dobutamine on experimental acute lung injury in rats. Acta Histochem 2009; 111:404-14. [PMID: 19027145 DOI: 10.1016/j.acthis.2008.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 09/19/2008] [Accepted: 09/25/2008] [Indexed: 11/30/2022]
Abstract
The effects of levosimendan on acute lung injury induced by peritonitis and abdominal hypertension in the early stages of sepsis in rats were investigated. Twenty-four adult male Wistar rats were randomized into: (1) sham, (2) subjected to abdominal hypertension and peritonitis induced lung injury using cecal ligation and puncture, then treated by dobutamine, (3) subjected to abdominal hypertension and peritonitis induced lung injury using cecal ligation and puncture, then treated by levosimendan, and (4) controls subjected to abdominal hypertension and peritonitis induced lung injury using cecal ligation and puncture with no treatment. In the control and levosimendan groups, cecal ligation and puncture resulted in moderate IL-1beta immunolabelling in lung tissue; marked IL-1beta immunolabelling was demonstrated in the dobutamine group. TNF-alpha immunolabelling was negative in both the sham and levosimendan groups, but moderate and weak immunoreactivities were observed in the dobutamine and control groups, respectively. There were almost no TUNEL positive cells in the sham, but they were prominent in the control. TUNEL positive cells were significantly less in the levosimendan treated lungs when compared to control and dobutamine groups. Immunoreactivity of eNOS was stronger in the dobutamine group when compared with the levosimendan group. In addition, iNOS immunoreactivity was strongly detected in the control group; this immunoreactivity was less in the levosimendan group than the dobutamine group. In this experimental sepsis model, treatment with levosimendan had a marked effect on attenuating or decreasing apoptosis and inflammation in the lung.
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Affiliation(s)
- Koray Erbüyün
- Department of Anesthesiology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey.
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972
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Severe community-acquired pneumonia and PIRO: A new paradigm of management. Curr Infect Dis Rep 2009; 11:343-8. [DOI: 10.1007/s11908-009-0049-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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973
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974
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Human protein C zymogen concentrate in patients with severe sepsis and multiple organ failure after adult cardiac surgery. Intensive Care Med 2009; 35:1959-63. [DOI: 10.1007/s00134-009-1584-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 07/09/2009] [Indexed: 10/20/2022]
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975
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Lakhal K, Ehrmann S, Runge I, Legras A, Dequin PF, Mercier E, Wolff M, Régnier B, Boulain T. Tracking hypotension and dynamic changes in arterial blood pressure with brachial cuff measurements. Anesth Analg 2009; 109:494-501. [PMID: 19608825 DOI: 10.1213/ane.0b013e3181a8d83a] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Arterial cannulation is strongly recommended during shock. Nevertheless, this procedure is associated with significant risks and may delay other emergent procedures. We assessed the discriminative power of brachial cuff oscillometric noninvasive blood pressure (NIBP) for identifying patients with an invasive mean arterial blood pressure (MAP) below 65 mm Hg or increasing their invasive MAP after cardiovascular interventions. METHODS This prospective study, conducted in three intensive care units, included adults in circulatory failure who underwent 45 degrees passive leg raising, 300 mL fluid loading, and additional 200 mL fluid loading. The collected data were four invasive and noninvasive MAP measurements at each study phase. RESULTS Among 111 patients (50 septic, 15 cardiogenic, and 46 other source of shock), when averaging measurements of each study phase, NIBP measurements accurately predicted an invasive MAP lower than 65 mm Hg: area under the receiver operating characteristic curve 0.90 (95% CI: 0.71-1), positive and negative likelihood ratios 7.7 (95% CI: 5.4-11) and 0.31 (95% CI: 0.22-0.44) (cutoff 65 mm Hg). For identifying patients increasing their invasive MAP by more than 10%, the area under the receiver operating characteristic curve was 0.95 (95% CI: 0.92-0.96); positive and negative likelihood ratios (cutoff 10%) were 25.7 (95% CI: 10.8-61.4) and 0.26 (95% CI: 0.2-0.34). CONCLUSIONS NIBP measurements have a good discriminative power for identifying hypotensive patients and performed even better in tracking MAP changes, provided that one averages four NIBP measurements.
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Affiliation(s)
- Karim Lakhal
- Service de Réanimation Médicale, Hôpital de La Source, Centre Hospitalier Régional, Assistance Publique des Hôpitaux de Paris, F45067 Orléans cedex 1, France
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976
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Costalonga EC, Melo NCV, Rodrigues CE, Sette LHBC, Ianhez LE. The potential role of C-reactive protein in distinguishing cytomegalovirus from tuberculosis and bacterial infections in renal transplant recipients. Clin Transplant 2009; 23:710-5. [PMID: 19594772 DOI: 10.1111/j.1399-0012.2009.01030.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The delay in the diagnosis of infections can be deleterious in renal transplant recipients. Thus, laboratory tests leading to an earlier diagnosis are very useful for these patients. PURPOSE To assess the behavior of C-reactive protein (CRP) in renal transplant recipients with a diagnosis of cytomegalovirus (CMV) infection, tuberculosis (TB) and bacterial infection (BI). METHODS A retrospective analysis of 129 patients admitted at our hospital, from 2006 to 2008 because of CMV, TB or BI, was carried out. Appropriate statistical analysis was done and values were expressed as medians, range. RESULTS When CRP levels were compared among the groups with CMV disease, TB or BI, the group with CMV disease presented lower levels of CRP (18.4 mg/L, 0.28-44 mg/L) than the TB and BI (p < 0.05) groups. The area under the receiver-operating characteristics curve, distinguishing CMV disease from TB/BI, was 0.96 (p < 0.0001), resulting in 100% sensitivity and 90.63% specificity to detect CMV disease when CRP < 44.5 mg/L. The subgroup analysis of CMV infection showed increasing levels of CRP (0.28, 16 and 29.5 mg/L) in the asymptomatic, symptomatic and invasive disease subgroups, respectively (p < 0.05). CONCLUSION The measurement of CRP levels may be a useful tool for differentiating CMV infection from the other types (bacterial or TB) of infection in kidney transplant recipients.
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Affiliation(s)
- Elerson C Costalonga
- Renal Transplant Unit, Urological Division, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
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977
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Hoo WES, Muehlberg K, Ferraro RG, Jumaoas MC. Successes and Lessons Learned Implementing the Sepsis Bundle. J Healthc Qual 2009; 31:9-14; quiz 14-5. [DOI: 10.1111/j.1945-1474.2009.00032.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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978
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979
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Morita Y, Oda S, Sadahiro T, Nakamura M, Oshima T, Otani S, Hirasawa H. The effects of body temperature control on cytokine production in a rat model of ventilator-induced lung injury. Cytokine 2009; 47:48-55. [DOI: 10.1016/j.cyto.2009.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 03/18/2009] [Accepted: 04/09/2009] [Indexed: 11/24/2022]
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980
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Martin G, Brunkhorst FM, Janes JM, Reinhart K, Sundin DP, Garnett K, Beale R. The international PROGRESS registry of patients with severe sepsis: drotrecogin alfa (activated) use and patient outcomes. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R103. [PMID: 19566927 PMCID: PMC2717475 DOI: 10.1186/cc7936] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 03/06/2009] [Accepted: 06/30/2009] [Indexed: 12/22/2022]
Abstract
Introduction Since the launch of drotrecogin alfa activated (DrotAA), institutions and individual countries have published data on its use in clinical practice, based on audit or registry data. These studies were limited in size and geographic locale and included patients with greater disease severity and higher mortality than those in clinical trials. The purpose of this study was to compare baseline characteristics and clinical outcomes (using appropriate statistical adjustments) of patients treated or not treated with DrotAA from the international PROGRESS (Promoting Global Research Excellence in Severe Sepsis) cohort study of severe sepsis. Methods PROGRESS was a global, non-interventional, multi-center, prospective, observational study of patients having a diagnosis of severe sepsis treated in intensive care units at a participating institution. All treatment modalities were as per standard of care at the participating institutions. Baseline characteristics and hospital mortality were analyzed and regression techniques used to develop propensity and outcome models adjusted for baseline imbalances between groups. Results Overall, 14,543 patients from 37 countries were enrolled and 12,492 had complete data for analysis. Germany was the highest enrolling country (1,810; 14.5%) and the US had the most DrotAA patients (206, 23.3%); 882 (7%) overall received DrotAA therapy. DrotAA-treated patients were younger (median age 58 vs. 61 years), had greater organ dysfunction (cardiovascular: 90% vs. 74%; respiratory: 90% vs. 81%; renal: 60% vs. 45%; metabolic: 63% versus 42%; 3 or more organ dysfunctions: 84% vs. 67%) and had a higher median APACHE II score (26 vs. 23, all with P < 0.001). Although in-hospital mortality was similar for DrotAA and non-DrotAA-treated patients (49.6% vs. 49.7%, respectively), after adjusting for imbalances, patients receiving DrotAA had a 28% (0.60 to 0.86, 95% Confidence Intervals) reduction in the odds of death and a relative risk reduction of 17% (P = 0.0003). Conclusions In the PROGRESS registry, DrotAA-treated patients were younger, more severely ill, and had fewer co-morbidities than patients not treated with DrotAA. After adjustment for group differences, a significant reduction in the odds of death was observed for patients that received DrotAA compared with those that did not.
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Affiliation(s)
- Greg Martin
- Division of Pulmonary, Allergy, and Critical Care, Emory University, Atlanta, Georgia 30322, USA.
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981
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Piagnerelli M, Van Nuffelen M, Maetens Y, Lheureux P, Vincent JL. A 'shock room' for early management of the acutely ill. Anaesth Intensive Care 2009; 37:426-31. [PMID: 19499862 DOI: 10.1177/0310057x0903700307] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Our 850-bed, academic, tertiary care hospital uses a four-bed dedicated 'shock room' situated between the Departments of Emergency Medicine and Intensive Care to stabilise all acutely ill patients from outside or inside the hospital before transfer to the intensive care unit or other department. Admitted patients stay a maximum of four hours in the shock room. In this article we describe our experiences using this shock room by detailing the demographic data, including time and source of admission, diagnosis and outcome, for the 2514 patients admitted to the shock room in 2006. The most common reasons for admission were cardiac (33%) and neurological (21%) diagnoses. After diagnosis and initial treatment, 54% of patients were transferred to an intensive care unit or a coronary care unit; 2.5% of patients died in the shock room. The shock room provides a useful area of collaboration between emergency department and intensive care unit staff and enables acutely ill patients to be assessed and treated rapidly to optimise outcomes.
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Affiliation(s)
- M Piagnerelli
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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982
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Hydroxyethyl starch 130/0.4 inhibits production of plasma proinflammatory cytokines and attenuates nuclear factor-kappaB activation and Toll-like receptors expression in monocytes during sepsis. J Surg Res 2009; 160:133-8. [PMID: 19766237 DOI: 10.1016/j.jss.2009.05.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Revised: 05/21/2009] [Accepted: 05/28/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hydroxyethyl starch (HES) is one of the most frequently used plasma substitutes, and could modulate inflammatory response in sepsis. Our aim of this study was to investigate the mechanism of the effect of HES 130/0.4 by studying plasma levels of inflammatory cytokines, nuclear factor-kappaB (NF-kappaB) activation, and Toll-like receptors (TLRs) expression in peripheral monocytes during polymicrobial sepsis. MATERIALS AND METHODS Rats with sepsis induced by cecal ligation and puncture (CLP) were treated with HES130/0.4 (7.5, 15, or 30 mL/kg, intravenously); then, rat plasma and monocytes were isolated from blood 5 h later. The plasma level of cytokines (tumor necrosis factor [TNF]-alpha and interleukin [IL]-6), NF-kappaB activity, and mRNA and protein levels of TLRs (TLR2 and TLR4) in peripheral blood monocytes were determined by enzyme-linked immunosorbent assay, electrophoretic mobility shift assay, reverse transcription-polymerase chain reaction, and Western blotting, respectively. RESULTS HES130/0.4 dose-dependently reduced the plasma level of TNF-alpha and IL-6 in rats with sepsis. HES130/0.4 also significantly inhibited NF-kappaB activation, and TLRs mRNA and protein levels in peripheral monocytes. CONCLUSION During sepsis, HES130/0.4 can down-regulate the inflammatory response, possibly through inhibition of the TLRs/NF-kappaB signaling pathway, and could be one more appropriate plasma substitute in sepsis.
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983
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Riché FC, Dray X, Laisné MJ, Matéo J, Raskine L, Sanson-Le Pors MJ, Payen D, Valleur P, Cholley BP. Factors associated with septic shock and mortality in generalized peritonitis: comparison between community-acquired and postoperative peritonitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R99. [PMID: 19552799 PMCID: PMC2717471 DOI: 10.1186/cc7931] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Accepted: 06/24/2009] [Indexed: 12/31/2022]
Abstract
Introduction The risk factors associated with poor outcome in generalized peritonitis are still debated. Our aim was to analyze clinical and bacteriological factors associated with the occurrence of shock and mortality in patients with secondary generalized peritonitis. Methods This was a prospective observational study involving 180 consecutive patients with secondary generalized peritonitis (community-acquired and postoperative) at a single center. We recorded peri-operative occurrence of septic shock and 30-day survival rate and analyzed their associations with patients characteristics (age, gender, SAPS II, liver cirrhosis, cancer, origin of peritonitis), and microbiological/mycological data (peritoneal fluid, blood cultures). Results Frequency of septic shock was 41% and overall mortality rate was 19% in our cohort. Patients with septic shock had a mortality rate of 35%, versus 8% for patients without shock. Septic shock occurrence and mortality rate were not different between community-acquired and postoperative peritonitis. Age over 65, two or more microorganisms, or anaerobes in peritoneal fluid culture were independent risk factors of shock. In the subgroup of peritonitis with septic shock, biliary origin was independently associated with increased mortality. In addition, intraperitoneal yeasts and Enterococci were associated with septic shock in community-acquired peritonitis. Yeasts in the peritoneal fluid of postoperative peritonitis were also an independent risk factor of death in patients with septic shock. Conclusions Unlike previous studies, we observed no difference in incidence of shock and prognosis between community-acquired and postoperative peritonitis. Our findings support the deleterious role of Enterococcus species and yeasts in peritoneal fluid, reinforcing the need for prospective trials evaluating systematic treatment against these microorganisms in patients with secondary peritonitis.
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Affiliation(s)
- Florence C Riché
- Department of Anesthesiology and Intensive Care, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris 75010, France.
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984
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Pea F, Viale P. Bench-to-bedside review: Appropriate antibiotic therapy in severe sepsis and septic shock--does the dose matter? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:214. [PMID: 19519961 PMCID: PMC2717408 DOI: 10.1186/cc7774] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Appropriate antibiotic therapy in patients with severe sepsis and septic shock should mean prompt achievement and maintenance of optimal exposure at the infection site with broad-spectrum antimicrobial agents administered in a timely manner. Once the causative pathogens have been identified and tested for in vitro susceptibility, subsequent de-escalation of antimicrobial therapy should be applied whenever feasible. The goal of appropriate antibiotic therapy must be pursued resolutely and with continuity, in view of the ongoing explosion of antibiotic-resistant infections that plague the intensive care unit setting and of the continued decrease in new antibiotics emerging. This article provides some principles for the correct handling of antimicrobial dosing regimens in patients with severe sepsis and septic shock, in whom various pathophysiological conditions may significantly alter the pharmacokinetic behaviour of drugs.
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Affiliation(s)
- Federico Pea
- Department of Experimental and Clinical Pathology, Institute of Clinical Pharmacology & Toxicology, Medical School, University of Udine, 33100 Udine, Italy.
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985
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Tyagi A, Sethi AK, Girotra G, Mohta M. The microcirculation in sepsis. Indian J Anaesth 2009; 53:281-93. [PMID: 20640135 PMCID: PMC2900118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2009] [Indexed: 11/14/2022] Open
Abstract
SUMMARY Sepsis is a leading cause of mortality in critically ill patients. The pathophysiology of sepsis involves a highly complex and integrated response, including the activation of various cell types, inflammatory mediators, and the haemostatic system. Recent evidence suggests an emerging role of the microcirculation in sepsis, necessitating a shift in our locus away Irom the macrohaemodynamics to ill icrohaemodynanmics in a septic patient. This review article provides a brief overview of the microcirculation, its assessment techniques, and specific therapies to resuscitate the microhaemodynamics.
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Affiliation(s)
- Asha Tyagi
- Reader, Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, Shahadra, Delhi-110095, India
| | - Ashok Kumar Sethi
- Professor & Head, Reader, Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, Shahadra, Delhi-110095, India
| | - Gautam Girotra
- Senior Resident, Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, Shahadra, Delhi-110095, India
| | - Medha Mohta
- Reader, Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, Shahadra, Delhi-110095, India
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986
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Update on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation--clinical application. Curr Opin Anaesthesiol 2009; 22:23-30. [PMID: 19295290 DOI: 10.1097/aco.0b013e32831d7b41] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine the evidence for and the clinical use of continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP) for the management of one-lung ventilation during thoracic surgery. CPAP and PEEP use are important as we are increasingly challenged with patients with less respiratory reserve and greater comorbidity leading to the need for greater clinical management and more interventions during one-lung ventilation for thoracic surgery to prevent perioperative complications. RECENT FINDINGS The focus of this article is on the most recent literature with selected classic articles. First, the supportive literature and rationale for application of PEEP, CPAP or both during thoracic surgery are reviewed, relative to the threats of hypoxemia, hyperoxia and mechanical lung injury. The second part of the article focuses on the clinical use of PEEP and CPAP. Algorithms for the application of CPAP and PEEP to patients both at risk and not at risk of acute lung injury are presented. SUMMARY CPAP and PEEP are useful not only to treat hypoxia and atelectasis as the consequence of one-lung ventilation, perhaps more importantly, also as part of a protective lung-ventilation strategy to ameliorate mechanical stress and prevent acute lung injury.
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987
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Abstract
Immunotherapy in the critically ill is an appealing notion because of the apparent abnormal immune and inflammatory responses seen in so many patients. The administration of a medication that could alter immune responses and decrease mortality in patients with sepsis could represent a ‘magic bullet’. Various approaches have been tried over the last 20 yr: steroids; anti-endotoxin or anti-cytokine antibodies; cytokine receptor antagonists; and other agents with immune-modulating side-effects. However, in some respects, research along these lines has been unsuccessful or disappointing at best. The current state of knowledge is summarized with particular reference to sepsis and the acute respiratory distress syndrome.
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Affiliation(s)
- N R Webster
- Anaesthesia and Intensive Care, Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
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988
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Miyauchi T, Tsuruta R, Kutsuna S, Nakahara T, Fujita M, Kasaoka S, Maekawa T. Successful treatment with hydrocortisone for heat stroke with critical illness-related corticosteroid insufficiency: transitional changes in serum cytokine and cortisol concentrations. J Anesth 2009; 23:266-9. [PMID: 19444568 DOI: 10.1007/s00540-008-0725-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 11/22/2008] [Indexed: 12/14/2022]
Abstract
A 37-year-old man was transferred to our emergency center because of heat stroke with circulatory shock. Despite aggressive body cooling, massive intravenous transfusion, and supply of inotropic agents, shock was persistent. To evaluate adrenal function, an adrenocorticotropic hormone stimulation test was conducted and the results indicated that he had critical illness-related corticosteroid insufficiency (CIRCI) as a result of adrenal insufficiency. Continuous hydorocortisone administration was started and he recovered from shock within a few hours. He was discharged on the thirty-seventh hospital day. Serum cortisol and cytokine concentrations were initially high and the cytokines decreased subsequent to hydrocortisone administration. It is speculated that CIRCI is an exacerbating factor in heat stroke, and hydrocortisone may be a potential therapeutic approach in such patients.
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Affiliation(s)
- Takashi Miyauchi
- Advanced Medical Emergency And Critical Care Center, Yamaguchi University Hospital, 1-1-1 Minami-Kogushi, Ube, 755-8505, Japan
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989
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Alterations in rat serum proteome and metabolome as putative disease markers in sepsis. ACTA ACUST UNITED AC 2009; 66:1065-75. [PMID: 19359916 DOI: 10.1097/ta.0b013e3181958ad7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Despite a decreased mortality from sepsis, the absolute number of sepsis-related deaths has actually increased during the last years. At present, there are no biological markers available that can reliably assist early clinical diagnosis and the prompt initiation of therapy. This study investigated the changes in serum protein expression in a coecal ligature and puncture model of rat sepsis at 12, 24, and 48 hours after the induction of sepsis using differential proteomics. METHODS Sixty-two male Wistar rats were randomly assigned to a sepsis group (coecal ligature and puncture; n = 46) or a sham group (n = 16). Surviving rats were killed 12 hour (n = 6), 24 hour (n = 9), or 48 hour (n = 4) after operation, and their serum lysates were subjected to two-dimensional gel electrophoresis and peptide mass fingerprinting. A systematic functional network mapping and molecular pathway analysis were performed using Ingenuity Pathways Analysis. RESULTS Septic mortality was 58.7%, but no rat of the sham group was lost. Per gel, an average of 1,082 +/- 10 spots could be discriminated, of which 40 different protein spots were differentially expressed (p < 0.01). From the total of 40, the number of regulated protein spots was 13 (12 hour group) versus 10 (24 hour group) versus 18 (48 hour group). Ingenuity pathways analysis identified 10 of the differential proteins and allocated them to a pathway of tissue inflammation. CONCLUSIONS The present study quantitatively detected several proteins differentially expressed in acute sepsis. Since a longer time-period was investigated and compared with previous studies, the results may offer new insights into septic organ dysfunction and altered protein pathways. The horizontal analysis of protein expression arrays and systematic biochemical pathways may represent an important new tool for the clinical assessment of septic conditions and support the development of early sepsis markers.
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990
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Molina JM, Córdoba J, Ramírez P, Gobernado M. [Automatic detection of bacterial and fungal infections in blood]. Enferm Infecc Microbiol Clin 2009; 26 Suppl 9:75-80. [PMID: 19195450 PMCID: PMC7130238 DOI: 10.1016/s0213-005x(08)76544-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
La sepsis es una de las principales causas de mortalidad y morbilidad en los hospitales. La detección temprana de los patógenos mediante técnicas basadas en ácidos nucleicos puede facilitar el diagnóstico rápido de la bacteriemia y/o fungemia, la rápida adecuación del tratamiento antibiótico, reducir el uso de antibióticos innecesarios y disminuir la mortalidad. Se describen 2 técnicas disponibles comercialmente que ayudan, en un tiempo reducido, a identificar distintas bacterias y hongos productores de sepsis: LightCycler® SeptiFast Test Mgrade (Roche Diagnostic SL) y GenoType Blood Culture (Hain Lifescience). De estas 2 técnicas, mostramos los resultados de un estudio inicial propio con el LightCycler® SeptiFast Test Mgrade. El estudio se realizó con 50 muestras correspondientes a 28 pacientes (1-3 muestras por paciente) con síndrome séptico ingresados en la unidad de cuidados intensivos, comparando la nueva técnica con el hemocultivo convencional. La concordancia entre los resultados del hemocultivo y el SeptiFast fue buena, 79% en el primer ensayo, y 89% en el segundo, después de corregir defectos técnicos. Inicialmente se observó inhibición importante de los controles internos para los bacilos gramnegativos, por la presencia de heparina en la sangre empleada y un exceso de ácido desoxirribonucleico (ADN) debido al número de leucocitos. Con la finalidad de disminuir las inhibiciones, en otro estudio posterior se trabajó con 24 muestras a la mitad de volumen original, llevando el ácido nucleico extraído a dilución 1:4. Con estas modificaciones, se apreciaron reducciones importantes de las inhibiciones. En comparación con el hemocultivo, el SeptiFast diferencia mejor las contaminaciones por estafilococos coagulasa-negativa y especies de estreptococos.
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991
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Hernandez G, Peña H, Cornejo R, Rovegno M, Retamal J, Navarro JL, Aranguiz I, Castro R, Bruhn A. Impact of emergency intubation on central venous oxygen saturation in critically ill patients: a multicenter observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R63. [PMID: 19413905 PMCID: PMC2717418 DOI: 10.1186/cc7802] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 04/17/2009] [Accepted: 05/04/2009] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Central venous oxygen saturation (ScvO2) has emerged as an important resuscitation goal for critically ill patients. Nevertheless, growing concerns about its limitations as a perfusion parameter have been expressed recently, including the uncommon finding of low ScvO2 values in patients in the intensive care unit (ICU). Emergency intubation may induce strong and eventually divergent effects on the physiologic determinants of oxygen transport (DO2) and oxygen consumption (VO2) and, thus, on ScvO2. Therefore, we conducted a study to determine the impact of emergency intubation on ScvO2. METHODS In this prospective multicenter observational study, we included 103 septic and non-septic patients with a central venous catheter in place and in whom emergency intubation was required. A common intubation protocol was used and we evaluated several parameters including ScvO2 before and 15 minutes after emergency intubation. Statistical analysis included chi-square test and t test. RESULTS ScvO2 increased from 61.8 +/- 12.6% to 68.9 +/- 12.2%, with no difference between septic and non-septic patients. ScvO2 increased in 84 patients (81.6%) without correlation to changes in arterial oxygen saturation (SaO2). Seventy eight (75.7%) patients were intubated with ScvO2 less than 70% and 21 (26.9%) normalized the parameter after the intervention. Only patients with pre-intubation ScvO2 more than 70% failed to increase the parameter after intubation. CONCLUSIONS ScvO2 increases significantly in response to emergency intubation in the majority of septic and non-septic patients. When interpreting ScvO2 during early resuscitation, it is crucial to consider whether the patient has been recently intubated or is spontaneously breathing.
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Affiliation(s)
- Glenn Hernandez
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile.
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992
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Utilité de la C-reactive protein dans le suivi thérapeutique des patients infectés. Med Mal Infect 2009; 39:319-24. [DOI: 10.1016/j.medmal.2009.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 12/31/2008] [Accepted: 03/04/2009] [Indexed: 11/19/2022]
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993
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Promoting Global Research Excellence in Severe Sepsis (PROGRESS): Lessons from an International Sepsis Registry. Infection 2009; 37:222-32. [DOI: 10.1007/s15010-008-8203-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 10/06/2008] [Indexed: 01/31/2023]
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994
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Vascular dysfunction in septic shock--any ROCKing news? Crit Care Med 2009; 37:1820-1. [PMID: 19373062 DOI: 10.1097/ccm.0b013e3181a09408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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995
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Scheiermann P, Ahluwalia D, Hoegl S, Dolfen A, Revermann M, Zwissler B, Muhl H, Boost KA, Hofstetter C. Effects of intravenous and inhaled levosimendan in severe rodent sepsis. Intensive Care Med 2009; 35:1412-9. [DOI: 10.1007/s00134-009-1481-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 02/13/2009] [Indexed: 11/30/2022]
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996
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Rehberg S, Ertmer C, Köhler G, Spiegel HU, Morelli A, Lange M, Moll K, Schlack K, Van Aken H, Su F, Vincent JL, Westphal M. Role of arginine vasopressin and terlipressin as first-line vasopressor agents in fulminant ovine septic shock. Intensive Care Med 2009; 35:1286-96. [PMID: 19360396 DOI: 10.1007/s00134-009-1470-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 03/15/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the effects of first-line therapy with low-dose arginine vasopressin (AVP) or terlipressin (TP) on mesenteric blood flow, plasma AVP levels, organ function and mortality in ovine septic shock. METHODS Twenty-four adult ewes were anesthetized and instrumented for chronic hemodynamic monitoring. A flow-probe was placed around the superior mesenteric artery, and feces were extracted from the cecum. Following baseline measurements, feces were injected into the peritoneal cavity. When mean arterial pressure (MAP) decreased to less than 60 mmHg, animals were randomly assigned to receive AVP (0.5 mU kg(-1) min(-1)), TP (1 microg kg(-1) h(-1)) or saline (n = 8 each). A norepinephrine infusion was titrated to maintain MAP at 70 +/- 5 mmHg in all groups. RESULTS Cardiovascular pressures, cardiac output, mesenteric blood flow, and lung tissue concentrations of 3-nitrotyrosine and hemoxygenase-1 were similar among groups throughout the study period. TP infusion resulted in lower plasma AVP concentrations, reduced positive net fluid balance, increased central venous oxygen saturation and slightly prolonged survival compared to control and AVP-treated animals. However, TP treatment was associated with higher liver transaminases and lactate dehydrogenase versus control animals after 12 h. CONCLUSIONS This study provides evidence that the effects of low-dose TP differ from those of AVP, not only as TP has a longer half life, but also because of different mechanisms of action. Although low-dose TP infusion may be superior to sole norepinephrine or AVP therapy in septic shock, the safety of this therapeutic approach should be determined in more detail.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Str. 33, 48149, Muenster, Germany.
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997
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Egi M, Bellomo R, Reade MC. Is reducing variability of blood glucose the real but hidden target of intensive insulin therapy? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:302. [PMID: 19435472 PMCID: PMC2689479 DOI: 10.1186/cc7755] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Since the first report that intensive insulin therapy reduced mortality in selected surgical critically ill patients, lowering of blood glucose levels has been recommended as a means of improving patient outcomes. In this initial Leuven trial, blood glucose control by protocol using insulin was applied to 98.7% of patients in the intensive group but to only 39.2% (P < 0.0001) of patients in the control group. If appropriately applied, such protocols should decrease both the mean blood glucose concentration and its variability (variation of blood glucose concentration). Thus, it is logically possible that the benefit of intensive insulin therapy in the first Leuven trial was due to a decrease in mean glucose levels, a decrease in their variability, or both. Several recent studies have confirmed significant associations between variability of blood glucose levels and patient outcomes. Decreasing the variability of blood glucose levels might be an important dimension of glucose management, a possible mechanism by which an intensive insulin protocol exerts its putative beneficial effects, and an important goal of glucose management in the intensive care unit. Clinicians need to be aware of this controversy when considering the application of intensive insulin therapy and interpreting future trials.
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Affiliation(s)
- Moritoki Egi
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata City, Japan 700-8558
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998
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999
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Affiliation(s)
- Luke S Howard
- Department of Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London.
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1000
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Dalchow S, Binning A. Changes in Management of Septic Shock in Scottish Intensive Care Units after the Publication of the Surviving Sepsis Campaign Guidelines 2008. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The 2004 guidelines of the Surviving Sepsis Campaign (SSC)1 for the management of severe sepsis and septic shock included recommendations about glucose control, the use of recombinant human activated protein C (rhAPC) and intravenous steroid replacement, based on original trials by van den Berghe and Annane in 2001 and Bernard (PROWESS) in 2002. In 2008, the SSC revised the international guidelines2 to reflect the results of recent trials (VISEP, CORTICUS, ADDRESS, RESOLVE). Some of these studies completely or partially contradicted results of the earlier trials. We conducted a questionnaire survey of all intensive care units (ICUs) in Scotland six months after publication of the 2008 SSC guidelines to assess current practice.
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Affiliation(s)
- Stephan Dalchow
- Specialist Registrar in Anaesthetics and Intensive Care Medicine
| | - Alexander Binning
- Consultant in Anaesthetics and Intensive Care Medicine, Anaesthetic Department, Gartnavel General Hospital, Glasgow
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