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The effect of fluid bolus administration on cerebral tissue oxygenation in post-cardiac arrest patients. Resuscitation 2021; 168:1-5. [PMID: 34506875 DOI: 10.1016/j.resuscitation.2021.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 08/07/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Fluid boluses (FB) are often used in post-cardiac arrest (CA) patients with haemodynamic instability. Although FB may improve cardiac output (CO) and mean arterial pressure (MAP), FB may also increase central venous pressure (CVP), reduce arterial PaO2, dilute haemoglobin and cause interstitial oedema. The aim of the present study was to investigate the net effect of FB administration on cerebral tissue oxygenation saturation (SctO2) in post-CA patients. METHODS Pre-planned sub-study of the Neuroprotect post-CA trial (NCT02541591). Patients with anticipated fluid responsiveness based on stroke volume variation (SVV) or passive leg raising test were administered a FB of 500 ml plasma-lyte A (Baxter Healthcare) and underwent pre- and post-FB assessments of stroke volume, CO, MAP, CVP, haemoglobin, PaO2 and SctO2. RESULTS 52 patients (mean age 64 ± 12 years, 75% male) received a total of 115 FB. Although administration of a FB resulted in a significant increase of stroke volume (63 ± 22 vs 67 ± 23 mL, p = 0.001), CO (4,2 ± 1,6 vs 4,4 ± 1,7 L/min, p = 0.001) and MAP (74,8 ± 13,2 vs 79,2 ± 12,9 mmHg, p = 0.004), it did not improve SctO2 (68.54 ± 6.99 vs 68.70 ± 6.80%, p = 0.49). Fluid bolus administration also resulted in a significant increase of CVP (10,0 ± 4,5 vs 10,7 ± 4,9 mmHg, p = 0.02), but did not affect PaO2 (99 ± 31 vs 94 ± 31 mmHg, p = 0.15) or haemoglobin concentrations (12,9 ± 2,1 vs 12,8 ± 2,2 g/dL, p = 0.10). In a multivariate model, FB-induced changes in CO (beta 0,77; p = 0.004) and in CVP (beta -0,23; p = 0.02) but not in MAP (beta 0,02; p = 0.18) predicted post-FB ΔSctO2. CONCLUSIONS Despite improvements in CO and MAP, FB administration did not improve SctO2 in post-cardiac arrest patients.
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Internal jugular vein valves complicating central venous catheter placement: a case report. ACTA ANAESTHESIOLOGICA BELGICA 2021. [DOI: 10.56126/72.3.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Placement of central venous catheters in the internal jugular vein is a frequently performed procedure. We present the case of a patient with venous valves causing an unexpected anatomic hindrance in the placement of a central venous catheter in the internal jugular vein. Venous valves are common in the internal jugular vein and can hinder cannulation. Ultrasound can be of use in the proper placement of a central venous line in a patient where cannulation is complicated by venous valves.
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EJ-antisynthetase syndrome presenting as severe acute respiratory distress syndrome. Int J Tuberc Lung Dis 2021; 25:671-674. [PMID: 34330355 DOI: 10.5588/ijtld.21.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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4
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Monocyte-driven atypical cytokine storm and aberrant neutrophil activation as key mediators of COVID-19 disease severity. Nat Commun 2021; 12:4117. [PMID: 34226537 PMCID: PMC8257697 DOI: 10.1038/s41467-021-24360-w] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
Epidemiological and clinical reports indicate that SARS-CoV-2 virulence hinges upon the triggering of an aberrant host immune response, more so than on direct virus-induced cellular damage. To elucidate the immunopathology underlying COVID-19 severity, we perform cytokine and multiplex immune profiling in COVID-19 patients. We show that hypercytokinemia in COVID-19 differs from the interferon-gamma-driven cytokine storm in macrophage activation syndrome, and is more pronounced in critical versus mild-moderate COVID-19. Systems modelling of cytokine levels paired with deep-immune profiling shows that classical monocytes drive this hyper-inflammatory phenotype and that a reduction in T-lymphocytes correlates with disease severity, with CD8+ cells being disproportionately affected. Antigen presenting machinery expression is also reduced in critical disease. Furthermore, we report that neutrophils contribute to disease severity and local tissue damage by amplification of hypercytokinemia and the formation of neutrophil extracellular traps. Together our findings suggest a myeloid-driven immunopathology, in which hyperactivated neutrophils and an ineffective adaptive immune system act as mediators of COVID-19 disease severity.
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Correction to: A randomized, open-label, adaptive, proof-of-concept clinical trial of modulation of host thromboinflammatory response in patients with COVID-19: the DAWn-Antico study. Trials 2020; 21:1033. [PMID: 33375932 PMCID: PMC7770739 DOI: 10.1186/s13063-020-04991-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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A randomized, open-label, adaptive, proof-of-concept clinical trial of modulation of host thromboinflammatory response in patients with COVID-19: the DAWn-Antico study. Trials 2020; 21:1005. [PMID: 33298149 PMCID: PMC7724460 DOI: 10.1186/s13063-020-04878-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/06/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The peak of the global COVID-19 pandemic has not yet been reached, and many countries face the prospect of a second wave of infections before effective vaccinations will be available. After an initial phase of viral replication, some patients develop a second illness phase in which the host thrombotic and inflammatory responses seem to drive complications. Severe COVID-19 disease is linked to high mortality, hyperinflammation, and a remarkably high incidence of thrombotic events. We hypothesize a crucial pathophysiological role for the contact pathway of coagulation and the kallikrein-bradykinin pathway. Therefore, drugs that modulate this excessive thromboinflammatory response should be investigated in severe COVID-19. METHODS In this adaptive, open-label multicenter randomized clinical trial, we compare low molecular weight heparins at 50 IU anti-Xa/kg twice daily-or 75 IU anti-Xa twice daily for intensive care (ICU) patients-in combination with aprotinin to standard thromboprophylaxis in hospitalized COVID-19 patients. In the case of hyperinflammation, the interleukin-1 receptor antagonist anakinra will be added on top of the drugs in the interventional arm. In a pilot phase, the effect of the intervention on thrombotic markers (D-dimer) will be assessed. In the full trial, the primary outcome is defined as the effect of the interventional drugs on clinical status as defined by the WHO ordinal scale for clinical improvement. DISCUSSION In this trial, we target the thromboinflammatory response at multiple levels. We intensify the dose of low molecular weight heparins to reduce thrombotic complications. Aprotinin is a potent kallikrein pathway inhibitor that reduces fibrinolysis, activation of the contact pathway of coagulation, and local inflammatory response. Additionally, aprotinin has shown in vitro inhibitory effects on SARS-CoV-2 cellular entry. Because the excessive thromboinflammatory response is one of the most adverse prognostic factors in COVID-19, we will add anakinra, a recombinant interleukin-1 receptor antagonist, to the regimen in case of severely increased inflammatory parameters. This way, we hope to modulate the systemic response to SARS-CoV-2 and avoid disease progressions with a potentially fatal outcome. TRIAL REGISTRATION The EU Clinical Trials Register 2020-001739-28 . Registered on April 10, 2020.
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Invasive nocardiosis, disseminated varicella zoster reactivation, and pneumocystis jiroveci pneumonia associated with tofacitinib and concomitant systemic corticosteroid use in ulcerative colitis. J Gastroenterol Hepatol 2020; 35:2294-2297. [PMID: 32918841 DOI: 10.1111/jgh.15256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/30/2020] [Accepted: 09/07/2020] [Indexed: 12/22/2022]
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8
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Community-acquired bacterial meningitis in adults: emergency department management protocol. Acta Neurol Belg 2020; 120:1033-1043. [PMID: 32666505 DOI: 10.1007/s13760-020-01428-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
Acute bacterial meningitis (ABM) is a rare but disabling infectious condition that requires a performant multidisciplinary management approach. Between 70 and 90 adult patients are diagnosed with community-acquired ABM in Belgium annually, and reported case fatality rates range from 17 to 40%. The currently available guidelines provide evidence-based guidance on how to manage this disease. However, these guidelines do not translate the evidence to the daily practice at the emergency department in a Belgian healthcare context. We created a taskforce in University Hospitals Leuven consisting of experts with complementary expertise in managing this disease: neurology, neurosurgery, intensive care medicine, microbiology and infectious diseases. The taskforce agreed upon a flowchart containing seven management steps encompassing all relevant phases in emergency ABM management. In addition to the focus on timely and adequate initiation of antimicrobial treatment, the flowchart and protocol also provide guidance on practical hurdles such as how to assess the safety of performing a lumbar puncture and when to refer patients to the intensive care department. This protocol was implemented in University Hospitals Leuven and fosters inter-disciplinary coordination of ABM care.
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Validation of the German patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE™). Ann Oncol 2016; 27:2294-2299. [PMID: 27681863 DOI: 10.1093/annonc/mdw422] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 07/30/2016] [Accepted: 08/29/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Integrating the patient's perspective has become an increasingly important component of adverse event reporting. The National Cancer Institute has developed a Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™). This instrument has been translated into German and linguistically validated; however, its quantitative measurement properties have not been evaluated. PATIENTS AND METHODS A German language survey that included 31 PRO-CTCAE items, as well as the EORTC QLQ-C30 and the Oral Mucositis Daily Questionnaire (OMDQ), was distributed at 10 cancer treatment settings in Germany and Austria. Item quality was assessed by analysis of acceptability and comprehensibility. Reliability was evaluated by using Cronbach's' alpha and validity by principal components analysis (PCA), multitrait-multimethod matrix (MTMM) and known groups validity techniques. RESULTS Of 660 surveys distributed to the study centres, 271 were returned (return rate 41%), and data from 262 were available for analysis. Participants' median age was 59.7 years, and 69.5% of the patients were female. Analysis of item quality supported the comprehensibility of the 31 PRO-CTCAE items. Reliability was very good; Cronbach's' alpha correlation coefficients were >0.9 for almost all item clusters. Construct validity of the PRO-CTCAE core item set was shown by identifying 10 conceptually meaningful item clusters via PCA. Moreover, construct validity was confirmed by the MTMM: monotrait-heteromethod comparison showed 100% high correlation, whereas heterotrait-monomethod comparison indicated 0% high correlation. Known groups validity was supported; PRO-CTCAE scores were significantly lower for those with impaired versus preserved health-related quality of life. CONCLUSION A set of 31 items drawn from the German PRO-CTCAE item library demonstrated favourable measurement properties. These findings add to the body of evidence that PRO-CTCAE provides a rigorous method to capture patient self-reports of symptomatic toxicity for use in cancer clinical trials.
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Outcome of patients with systemic diseases admitted to the medical intensive care unit of a tertiary referral hospital: a single-centre retrospective study. Scand J Rheumatol 2015; 45:146-50. [DOI: 10.3109/03009742.2015.1067329] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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11
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Shigella flexneriserotype 1 infections in men who have sex with men in Vancouver, Canada. HIV Med 2015; 16:168-75. [DOI: 10.1111/hiv.12191] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2014] [Indexed: 11/29/2022]
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12
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Predictive value for weakness and 1-year mortality of screening electrophysiology tests in the ICU. Crit Care 2015. [PMCID: PMC4472684 DOI: 10.1186/cc14554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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13
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Acute liver failure secondary to khat (Catha edulis)-induced necrotic hepatitis requiring liver transplantation: case report. Transplant Proc 2014; 43:3493-5. [PMID: 22099826 DOI: 10.1016/j.transproceed.2011.09.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We describe the case of a 26-year-old man with acute liver failure secondary to ingestion of khat (Catha edulis) leaves. In fact, this is the first case of acute liver failure due to khat reported outside the United Kingdom. The combination of specific epidemiologic data (young man of East African origin) and clinical features (central nervous system stimulation, withdrawal reactions, toxic autoimmune-like hepatitis) led to the diagnosis. Mechanisms of action and potential side effects of khat are elaborated on.
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Abstract
INTRODUCTION Current treatment of the abdominal compartment syndrome (ACS) is based on consensus definitions but several questions regarding fluid regime or critical level of intra-abdominal hypertension (IAH)) remain unsolved. It is questionable whether these issues can be addressed in prospective randomized trials in the near future. This review aimed to summarize current animal models and to outline requirements for the best model. METHODS PubMed® data base was searched for articles describing animal models of ACS. RESULTS 25 articles were found. ACS in animals has not been defined yet. Investigations varied considerably regarding the experimental design. Animals were rats, rabbits, dogs and pigs with a bodyweight from 200g to 70 kg. IAP increase varied from 20 to 50 mmHg. The time period of IAH ranged between 30 min and 24h. The time between the IAH insult and organ dysfunction varied between 15 min and 18h. Investigations demonstrated that IAH is able to induce loss of intravascular volume, organ hypoperfusion, ischemic organ damage and multiple organ failure within 4 to 6h. CONCLUSION In contrast to IAH or pneumoperitoneum for surgical exposure, ACS in an animal may be stated if an artificially increased IAP leads to circulatory, respiratory and renal insufficiency. A next step in animal research would be the development of a "pathological" model in which haemorrhage or systemic inflammation together with resuscitation lead to abdominal fluid accumulation and increased intra-abdominal pressure.
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Abstract
INTRODUCTION Since the second World Congress on the Abdominal Compartment Syndrome (WCACS) in Noosa 2 years ago, interest and publications on intra-abdominal hypertension (IAH) and ACS have increased exponentially. This paper aimed to critically review recent publications and put this new data into the context of already acquired knowledge concerning IAH/ACS. METHODS A Medline and PubMed search was performed from January 2005 up to now using "intra-abdominal pressure (IAP)", "intra-abdominal hypertension (IAH)", "abdominal compartment syndrome (ACS)" and "decompressive laparotomy" as search items. RESULTS Although consensus definitions of IAH/ACS have been formulated recently, data on awareness are still disconcerting. Several groups refined current IAP measurement techniques and tested new direct IAP measurement devices for use in selected subpopulations. A series of recent publications identified specific patient subpopulations in IAH/ACS, like patients with burns or severe acute pancreatitis, with their specific pathophysiology and therapy. Although many studies already assessed the effect of elevated IAP on regional and micro-circulatory organ perfusion, a number of new publications attempted to unravel the link between elevated IAP and more "downstream" organ function or histology. Finally, therapy for IAH/ACS still reveals more questions than it answers. Global resuscitation does not necessarily equate with organ resuscitation. In fact, fluid-resuscitation may even induce IAH/ACS. CONCLUSIONS After publication of consensus guidelines on IAH/ACS, there is an urgent need for human intervention studies and, in parallel, clinically relevant animal models. Given moderately low incidence of ACS and the complex and interrelated pathologies of the critically ill patient with IAH/ACS, large animal models of pathology-induced IAH/ACS might create the opportunity to gain clinically relevant knowledge on the treatment of IAH/ACS.
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Acute and long-term outcomes of ICU-acquired weakness: a cohort study and propensity matched analysis. Crit Care 2014. [PMCID: PMC4070017 DOI: 10.1186/cc13656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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17
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Autopsy-detected diagnostic errors in critically ill patients with cirrhosis. Crit Care 2014. [PMCID: PMC4068390 DOI: 10.1186/cc13227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Polymerase chain reaction assay to detect Clostridium difficile tcdC variants is valuable in characterizing hospital epidemiology. J Hosp Infect 2013; 84:252-5. [DOI: 10.1016/j.jhin.2013.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 04/01/2013] [Indexed: 10/26/2022]
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20
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Withholding parenteral nutrition during the first week of critical illness increases plasma bilirubin but lowers the incidence of cholestasis and gallbladder sludge. Crit Care 2013. [PMCID: PMC3642572 DOI: 10.1186/cc12192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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21
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Upper gastrointestinal tract bleeding management: Belgian guidelines for adults and children. Acta Gastroenterol Belg 2011; 74:45-66. [PMID: 21563653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
UNLABELLED Upper gastrointestinal bleeding (UGIB) remains a common disease affecting 100 to 170 per 100 000 adults per year and causing thereby a significant burden to healthcare resources. Despite the improvements in the management of this disorder, the associated mortality ranges from 5 to 14%. Since the general management of UGIB is not uniform, the main objective of this work is to provide guidelines for the care of adults and children presenting with bleeding caused by gastro-duodenal ulcer or variceal rupture. METHODS In the absence of evidence-based recommendations, these guidelines were proposed after expert opinions reconciliation and graded accordingly. They are based on the published literature up to September 2010 and graded according to the class of evidence. RESULTS The current guidelines for the management of UGIB include recommendations for the diagnostic process, general supportive care, pharmacological therapy aiming at bleeding control, specific and endoscopic treatment of acute bleeding and follow-up for both gastro-duodenal ulcers and portal hypertension-induced bleeding.
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Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department. BMJ Qual Saf 2010; 19:371-5. [DOI: 10.1136/qshc.2009.035014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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A method for the estimation of functional brain connectivity from time-series data. Cogn Neurodyn 2010; 4:133-49. [PMID: 21629586 DOI: 10.1007/s11571-010-9107-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 02/05/2010] [Accepted: 02/11/2010] [Indexed: 11/25/2022] Open
Abstract
A central issue in cognitive neuroscience is which cortical areas are involved in managing information processing in a cognitive task and to understand their temporal interactions. Since the transfer of information in the form of electrical activity from one cortical region will in turn evoke electrical activity in other regions, the analysis of temporal synchronization provides a tool to understand neuronal information processing between cortical regions. We adopt a method for revealing time-dependent functional connectivity. We apply statistical analyses of phases to recover the information flow and the functional connectivity between cortical regions for high temporal resolution data. We further develop an evaluation method for these techniques based on two kinds of model networks. These networks consist of coupled Rössler attractors or of coupled stochastic Ornstein-Uhlenbeck systems. The implemented time-dependent coupling includes uni- and bi-directional connectivities as well as time delayed feedback. The synchronization dynamics of these networks are analyzed using the mean phase coherence, based on averaging over phase-differences, and the general synchronization index. The latter is based on the Shannon entropy. The combination of these with a parametric time delay forms the basis of a connectivity pattern, which includes the temporal and time lagged dynamics of the synchronization between two sources. We model and discuss potential artifacts. We find that the general phase measures are remarkably stable. They produce highly comparable results for stochastic and periodic systems. Moreover, the methods proves useful for identifying brief periods of phase coupling and delays. Therefore, we propose that the method is useful as a basis for generating potential functional connective models.
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Blood glucose amplitude variation: effects of intensive insulin therapy and relative association with mortality. Crit Care 2010. [PMCID: PMC2934260 DOI: 10.1186/cc8807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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25
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Abstract
We report a case of haemolytic due to the use of piperacillin-tazobactam in a 50-year-old woman. Since 2002 4 other cases were reported. Either the presence of piperacillin as tazobactam can induce haemolysis. In all cases discontinuating the drugs resolves the haemolysis. Although drug-induced haemolytic anaemia due to piperacillin-tazobactam is rare, the common use of this antibioticum in the critical care setting should alert the physician as a possible culprit in cases of haemolytic anaemia.
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Abstract
Fractionated Plasma Separation and Adsorption (FPSA) is a novel nonbiologic detoxification system for the removal of protein-bound solutes. FPSA is used to bridge patients during fulminant liver failure, either to functional recovery or to liver transplantation. Besides liver failure associated protein bound solutes, several important uremic retention solutes share important protein binding. We observed repeated occlusive thrombosis of the arterio-venous conduit during FPSA in hemodialysis (HD) patients, resulting in acute loss of function. A major reduction of several coagulation factors was demonstrated, exceeding 50% for factor II, factor X and protein C. Broad disturbances of the coagulation system were confirmed in FPSA treated liver failure patients. An ex vivo recirculation model demonstrated nonspecific adsorption of coagulation factors protein S and protein C on the anion exchange cartridge. Direct contact between fractionated plasma and the Prometh02 anion exchanger causes significant adsorption of procoagulant and anti-coagulant factors, associated with clinically relevant adverse events.
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Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a technology that can provide extracorporeal gas exchange to patients with severe pulmonary or cardiac dysfunction. We report on our clinical experience with ECMO in critically ill patients. METHODS We performed a retrospective analysis of 23 patients treated with ECMO in a medical intensive care unit in a tertiary referral academic centre. RESULTS 13 patients were considered immunocompetent and 10 were immunocompromised when extracorporeal membrane oxygenation was started. 16 patients presented with acute respiratory distress syndrome (ARDS), 2 patients had intractable cardiac failure, and 5 patients had combined respiratory and cardiac failure. In 16 patients, a veno-venous bypass was constructed; in 7 patients, the initial bypass was venoarterial. 11 patients survived. In 2 patients technical complications were fatal. CONCLUSIONS Our data indicate that patients with community-acquired pneumonia and no underlying disease will benefit most from this technique. However, long-term survival is possible in immunocompromised patients. Venoarterial bypass can carry a higher risk for technical complications. Increasing experience apparently also reduces the risk of technical complications.
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Abstract
Elevated intra-abdominal pressure (IAP) exerts effects not only on intra-abdominal organs, but also on organs distant to the abdominal compartment. Abdomino-thoracic interaction during intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) interferes with pulmonary, cardiovascular and cerebral function. In accordance with recent guidelines, IAH is defined as IAP above 12 mmHg and ACS as IAP more than 20 mmHg with one or more new organ failures. In this review we will first discuss the effects of elevated IAP on pulmonary dynamics and the relevance for interpreting airway pressures and adjusting ventilator settings. We will then discuss the interaction between abdomino-thoracic pressure transmission and global haemodynamics, the knowledge of which is necessary for correct assessment of cardiac preload and to optimize fluid therapy in the setting of IAH/ACS. A discussion on the relationship between increased IAP, increased intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP) will follow. Finally, we will review ventilator-induced thoracic pressure swings and their transmission to the abdominal compartment.
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Noosa, 2 years later... a critical analysis of recent literature. Acta Clin Belg 2007; 62 Suppl 1:33-43. [PMID: 17469700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Since the second World Congress on the Abdominal Compartment Syndrome (WCACS) in Noosa 2 years ago, interest and publications on intra-abdominal hypertension (IAH) and ACS have increased exponentially. This paper aimed to critically review recent publications and put this new data into the context of already acquired knowledge concerning IAH/ACS. METHODS A Medline and PubMed search was performed from January 2005 up to now using "intra-abdominal pressure (IAP)", "intra-abdominal hypertension (IAH)", "abdominal compartment syndrome (ACS)" and "decompressive laparotomy" as search items. RESULTS Although consensus definitions of IAH/ACS have been formulated recently, data on awareness are still disconcerting. Several groups refined current IAP measurement techniques and tested new direct IAP measurement devices for use in selected subpopulations. A series of recent publications identified specific patient subpopulations in IAH/ACS, like patients with burns or severe acute pancreatitis, with their specific pathophysiology and therapy. Although many studies already assessed the effect of elevated IAP on regional and micro-circulatory organ perfusion, a number of new publications attempted to unravel the link between elevated IAP and more "downstream" organ function or histology. Finally, therapy for IAH/ACS still reveals more questions than it answers. Global resuscitation does not necessarily equate with organ resuscitation. In fact, fluid-resuscitation may even induce IAH/ACS. CONCLUSIONS After publication of consensus guidelines on IAH/ACS, there is an urgent need for human intervention studies and, in parallel, clinically relevant animal models. Given moderately low incidence of ACS and the complex and interrelated pathologies of the critically ill patient with IAH/ACS, large animal models of pathology-induced IAH/ACS might create the opportunity to gain clinically relevant knowledge on the treatment of IAH/ACS.
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30
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Effect of intensive insulin therapy on coagulation and fibrinolysis of respiratory critically ill patients. Crit Care 2007. [PMCID: PMC4095180 DOI: 10.1186/cc5286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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31
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Hepatic mitochondrial dysfunction in fluid-resuscitated porcine septic shock. Crit Care 2007. [PMCID: PMC4095312 DOI: 10.1186/cc5419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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32
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Abdomino-thoracic transmission during ACS: facts and figures. Acta Clin Belg 2007; 62 Suppl 1:200-5. [PMID: 17469720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Elevated intra-abdominal pressure (IAP) exerts effects not only on intra-abdominal organs, but also on organs distant to the abdominal compartment. Abdomino-thoracic interaction during intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) interferes with pulmonary, cardiovascular and cerebral function. In accordance with recent guidelines, IAH is defined as IAP above 12 mmHg and ACS as IAP more than 20 mmHg with one or more new organ failures. In this review we will first discuss the effects of elevated IAP on pulmonary dynamics and the relevance for interpreting airway pressures and adjusting ventilator settings. We will then discuss the interaction between abdomino-thoracic pressure transmission and global haemodynamics, the knowledge of which is necessary for correct assessment of cardiac preload and to optimize fluid therapy in the setting of IAH/ACS. A discussion on the relationship between increased IAP, increased intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP) will follow. Finally, we will review ventilator-induced thoracic pressure swings and their transmission to the abdominal compartment.
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What is the best animal model for ACS? Acta Clin Belg 2007; 62 Suppl 1:225-32. [PMID: 17469725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Current treatment of the abdominal compartment syndrome (ACS) is based on consensus definitions but several questions regarding fluid regime or critical level of intra-abdominal hypertension (IAH)) remain unsolved. It is questionable whether these issues can be addressed in prospective randomized trials in the near future. This review aimed to summarize current animal models and to outline requirements for the best model. METHODS PubMed data base was searched for articles describing animal models of ACS. RESULTS 25 articles were found. ACS in animals has not been defined yet. Investigations varied considerably regarding the experimental design. Animals were rats, rabbits, dogs and pigs with a bodyweight from 200g to 70 kg. IAP increase varied from 20 to 50 mmHg.The time period of IAH ranged between 30 min and 24h. The time between the IAH insult and organ dysfunction varied between 15 min and 18h. Investigations demonstrated that IAH is able to induce loss of intravascular volume, organ hypoperfusion, ischemic organ damage and multiple organ failure within 4 to 6h. CONCLUSION In contrast to IAH or pneumoperitoneum for surgical exposure, ACS in an animal may be stated if an artificially increased IAP leads to circulatory, respiratory and renal insufficiency. A next step in animal research would be the development of a "pathological" model in which haemorrhage or systemic inflammation together with resuscitation lead to abdominal fluid accumulation and increased intra-abdominal pressure.
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Abstract
Liver failure, whether acute or acute-on-chronic, remains an important cause of morbidity and mortality. The lack of liver detoxification, metabolic and regulatory functions of the liver leads to life-threatening complications, such as renal failure, altered immune response, hepatic coma and systemic haemodynamic dysfunction, eventually culminating in multiorgan failure. Current medical therapy involves the management of the precipitating event and treatment of complications until the liver eventually recovers, leaving us with no other treatment options than transplantation if these attempts fail. However, the shortage in cadaveric organs and other transplant-related problems, have prompted the need for alternative methods to provide liver support. As liver failure is often potentially reversible, considerable effort has been invested in the development of liver support systems. Currently, most of the experience is available for non-biological support systems. They represent the focus of this review, which aims to define the goals of liver support, to describe the design of the different existing devices and to analyse the available data to determine their current status in the management of patients with liver failure.
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Acute intracardiac right-to-left shunt in a patient with acute respiratory distress syndrome and shock successfully treated with nitric oxide. Br J Anaesth 2006; 96:268-9. [PMID: 16415323 DOI: 10.1093/bja/aei636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wauters J, Claus P, Brosens N, Wilmer A. Crit Care 2006; 10:P306. [DOI: 10.1186/cc4653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
Rapidly fatal pulmonary tumour embolism is a rare complication of malignancy, and often presents as progressive dyspnea without obvious cause. We describe two cases presenting with a dramatic clinical picture of lactic acidosis and cardiopulmonary arrest soon after admission on ICU. The first patient was a 29-year old woman with a breast cancer seeming in remission who was admitted with rapidly increasing dyspnea since two weeks. The second patient was a 46-year old woman with HIV and no history of malignancy, who developed dyspnea and lactic acidosis over the course of a few days while she was investigated for an occipital brain lesion. Both patients died soon after admission and massive tumour emboli were found on autopsy. Breast cancer was the origin of the emboli in both cases. Symptoms were out of proportion to the initial physical cardiopulmonary findings and radiographic features. Clinical signs of pulmonary tumour embolism are non-specific and subacute. Prognosis is poor and definite diagnosis is usually made post-mortem. Solid malignancies such as breast cancer account for most of the cases. Pulmonary tumour embolism should be considered in critically ill patients with unexplained hypoxemia and lactic acidosis, mild or no radiological abnormalities and fast clinical deterioration. It may occur in young patients and in patients without history of malignancy.
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Wauters J, Claus P, Brosens N, Malbrain M, Wilmer A. Crit Care 2006; 10:P308. [DOI: 10.1186/cc4655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Influence of intra-abdominal hypertension on renal artery and vein flow in the porcine kidney. Crit Care 2006; 10. [PMCID: PMC4092678 DOI: 10.1186/cc4650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hermans G, Meersseman W, Wilmer A, Meyns B, Bobbaers H. Crit Care 2006; 10:P26. [DOI: 10.1186/cc4373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Pharmacokinetics of remifentanil and its major metabolite, remifentanil acid, in ICU patients with renal impairment †. Br J Anaesth 2004; 92:493-503. [PMID: 14766712 DOI: 10.1093/bja/aeh086] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The pharmacokinetics of remifentanil, an opioid analgesic metabolized by non-specific esterases, and its principal metabolite, remifentanil acid (RA), which is excreted via the kidneys, were assessed as part of an open-label safety study in intensive care unit (ICU) patients with varying degrees of renal impairment. METHODS Forty adult ICU patients with normal/mildly impaired renal function (creatinine clearance [CL(cr)] 62.9 (sd) 14.5 ml min(-1); n=10) or moderate/severe renal impairment (CL(cr) 14.7 (15.7) ml min(-1); n=30) were included. Remifentanil was infused for up to 72 h, at a starting rate of 6-9 microg kg(-1) h(-1) titrated to achieve a target sedation level, with additional propofol (0.5 mg kg(-1) h(-1)) if required. Intensive arterial sampling was performed for up to 72 h after infusion. Pharmacokinetic parameters obtained by simultaneous modelling of remifentanil and RA data were statistically compared between the two groups. RESULTS Remifentanil pharmacokinetics were not significantly affected by renal status. RA clearance in the moderate/severe group was reduced to about 25% that of the normal/mild group (41 (29) vs 176 (49) ml kg(-1) h(-1), P<0.0001). Metabolic ratio, a predictor of the ratio of RA to remifentanil concentrations at steady state, was approximately eight-fold higher in the moderate/severe group relative to the normal/mild group (116 (110) vs 15 (4), P<0.0001). Maximum RA levels approached 700 ng ml(-1) in the moderate/severe group. CONCLUSIONS Although RA accumulates in patients with moderate/severe renal impairment, pharmacokinetic modelling predicts that RA concentrations during a 9 microg kg(-1) h(-1) remifentanil infusion for up to 15 days would not exceed those reported in the present study, for which no associated prolongation of mu-opioid effects was observed.
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Chiumello D, Brienza N, Cohen J, Ranieri M, Wilmer A, Malbrain M. Crit Care 2004; 8:P168. [DOI: 10.1186/cc2635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Detoxifying Capacity and Kinetics of the Molecular Adsorbent Recycling System: Contribution of the Different Filters Inbuilt. Hemodial Int 2003. [DOI: 10.1046/j.1492-7535.2003.01212.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Specialist training in gastroenterology and hepatology is not standardised in different European countries. AIM The aim of this survey was to assess the different teaching and socioeconomic aspects of training programmes in Europe. METHODS Seventy questionnaires were distributed to last year trainees or newly graduated gastroenterologists. Forty two respondents (60%) from 34 major training centres in 10 different European countries replied. RESULTS Overall, the data revealed major diversity for all aspects analysed, between and within the different European countries. Both the duration of training (range 4-10.4 years) and workload (range 48.5-89.2 hours per week) differed markedly between countries. The average number of endoscopic procedures (gastroscopies, range 300-2600; colonoscopies, range 73-550; endoscopic retrograde cholangiopancreatographies, range 1-385) differed also. One third of last year trainees reported that they felt uncertain in some endoscopic procedure. The European trainee was on call for 5-6 nights a month on average (range 1-8). Monthly wages differed considerably between countries, ranging from 767 to 2180 Euro. CONCLUSION We found major differences in the professional aspects and socioeconomic conditions of gastroenterologist/hepatologist training in 10 different European countries, probably leading to differences in quality of training. In several countries or centres the average number of procedures was below the threshold issued by the European Board of Gastroenterology or the American Gastroenterological Association. Issuing a European diploma for gastroenterology is a valuable effort towards meeting this problem. Further studies are needed to re-evaluate the training programmes in Europe and to define threshold numbers and technical end points for assessment of endoscopic skills.
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Abstract
BACKGROUND Hypersensitivity to distension of the stomach is a frequent finding in functional dyspepsia. During gastric distension studies both wall tension and elongation are increased. AIM We wished to distinguish changes in wall tension from changes in elongation in the genesis of perception of mechanical stimuli originating from the proximal stomach in healthy subjects. SUBJECTS AND METHODS Twenty six volunteers were studied using gastric barostat and antroduodenal manometry. In 14 subjects, stepwise isobaric and isovolumetric distensions were performed before and during erythromycin infusion. In all volunteers, on a separate occasion, phasic contractions of the proximal stomach were detected as intraballoon pressure increases during fixed volume inflation. These contractions were matched with perception changes during two 10 minute periods, before and during administration of erythromycin. RESULTS Erythromycin significantly lowered the perception and discomfort thresholds during stepwise gastric distension. During fixed volume inflation, erythromycin increased the number and amplitude of fundic contractions and enhanced their perception from 51.1 (7.4)% to 64.0 (4.7)%. The proportion of perception score increases coinciding with fundic contractions increased from 47.3 (0.7)% to 81.5 (0.5)%. The amplitude of correctly identified isolated fundic pressure waves was higher compared with non-identified waves. CONCLUSIONS These results support the hypothesis that changes in gastric wall tension may be involved in the genesis of symptoms originating from the stomach.
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Molecular Adsorbent Recycling system (MARS) for acute on chronic alcoholic hepatitis: a case report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2001. [DOI: 10.1055/s-2001-919038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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