Intensive care physicians' insufficient knowledge of right-heart catheterization at the bedside: time to act?

OBJECTIVE

To evaluate French, Swiss, and Belgian intensive care physicians' knowledge about the pulmonary artery catheter.

DESIGN

Survey study by questionnaire.

SETTING

Eighty-six European university and nonuniversity intensive care units (ICUs).

SUBJECTS

One hundred thirty-four ICUs identified from the directories of two European intensive care medicine societies were asked to participate. Five hundred thirty-five critical care physicians working in 86 ICUs participated.

INTERVENTIONS

In any particular ICU, all physicians were to complete--simultaneously, anonymously and without prior notice--a multiple choice questionnaire consisting of 31 questions regarding all aspects of bedside pulmonary artery catheterization. This questionnaire was the same one already used and extensively validated in a similar study conducted several years earlier in the United States and Canada.

MEASUREMENTS AND MAIN RESULTS

The percentage of correct answers per participant (score) was tabulated. Sixty-eight percent of respondents still in training (n = 232) believed that their knowledge of the pulmonary artery catheter was less than adequate; 36% of those who had completed their postgraduate training (n = 294) also believed their knowledge to be inadequate. The mean score of all respondents was 72.2 +/- 14.4%, significantly lower (p <.0001) in case of uncompleted postgraduate training (67.3 +/- 14.7%, lower quartile 56.7%, median 70.0%, upper quartile 76.7%), as compared with completed postgraduate training (76.1 +/- 13.0%, lower quartile 70.0%, median 80.0%, upper quartile 86.7%). When using multivariate analysis, the location of the ICU in a university hospital, the belief of respondent that his/her knowledge of the pulmonary artery catheter was adequate, and the responsibility for supervising catheter insertion were the only independent predictors of good performance on the questionnaire (p < .001 for all three variables). It was impossible to identify any subcategory of physicians with a uniformly good knowledge of the pulmonary artery catheter. The proportion of incorrect answers to some basic items was disturbingly high. For instance, approximately 50% of the respondents, whether trained or in training, did not correctly identify pulmonary artery occlusion pressure from a clear chart recording.

CONCLUSIONS

Knowledge of right-heart pulmonary artery catheterization is not uniformly good among ICU physicians. Accreditation policies and teaching practices concerning this technique need urgent revision.

Selective iNOS inhibition is superior to norepinephrine in the treatment of rat endotoxic shock

S-methyl-isothiourea (SMT) is a potent inhibitor of NO synthase (NOS) with relative selectivity towards the inducible isoform (iNOS). We compared SMT and norepinephrine for the treatment of experimental endotoxic shock. Anesthetized rats challenged intravenously with lipopolysaccharide (LPS), 10 mg/kg, were treated after 1 h with a 4-h infusion of norepinephrine (titrated to maintain blood pressure within baseline values), SMT at low dose (0.1 mg x kg-1 x h-1), or at high dose (1 mg x kg-1 x h-1), or an equivalent volume of saline (2 ml x kg-1 x h-1). In saline-treated animals, LPS increased plasma nitrate and produced hypotension, low cardiac output (CO), lactic acidosis, and signs of liver and kidney dysfunction. Norepinephrine maintained blood pressure (BP) and reduced the fall in CO, without affecting lactic acidosis, organ dysfunction, and nitrate accumulation. The latter was dose-dependently blunted by SMT. Treatment with this agent prevented hypotension, through systemic vasoconstriction with the high dose and a maintained CO with the low dose. Low, but not high, dose SMT blunted lactic acidosis. Both doses reduced the signs of renal, but not liver, dysfunction. In additional studies, we obtained evidence that, in contrast with the high dose, SMT at low dose did not interfere with the function of constitutive NOS. These findings suggest a potential advantage of selective iNOS inhibition over standard adrenergic support in the therapy of septic shock.

Effect of L-lysine on nitric oxide overproduction in endotoxic shock

1. An enhanced production of nitric oxide (NO) from L-arginine, related to the diffuse expression of an inducible NO synthase (iNOS), contributes to the pathogenesis of endotoxic shock. Since iNOS activity depends on extracellular L-arginine, we hypothesized that limiting cellular L-arginine uptake would reduce NO production in endotoxic shock. We investigated the effects of L-lysine, an inhibitor of L-arginine uptake through system y+, on NO production, multiple organ dysfunction and lactate levels, in normal and endotoxaemic rats. 2. Anaesthetized rats challenged with intravenous lipopolysaccharide (LPS, 10 mg kg[-1]) received a 5 h infusion of either L-lysine (500 micromol kg(-1) h(-1), n = 12) or isotonic saline (2 ml kg(-1) h(-1), n = 11). In rats treated with saline, LPS produced a large increase in plasma nitrate and L-citrulline concentrations at 5 h, both markers of enhanced NO production. LPS also caused severe hypotension, low cardiac output and marked hyperlactataemia. All these changes were significantly reduced by L-lysine administration. 3. Endotoxaemia also caused a significant rise in the plasma levels of alanine aminotransferase (ALAT), lipase, urea and creatinine, and hence, liver, pancreatic and renal dysfunction. These changes tended to be less pronounced in rats treated with L-lysine, although the differences did not reach statistical significance. 4. Similar experiments were conducted in 10 rats challenged with LPS vehicle in place of LPS and then treated with L-lysine (500 micromol kg(-1) h(-1), n = 5) or saline (2 ml kg(-1) h(-1), n = 5) for 5 h. In these animals, all the haemodynamic and metabolic variables remained stable and not statistically different between both treatment groups, except for a slight rise in ALAT, which was comparable in L-lysine and saline-treated rats. 5. In conclusion, L-lysine, an inhibitor of cellular L-arginine uptake, reduces NO production and exerts beneficial haemodynamic effects in endotoxaemic rats. L-lysine also reduces hyperlactataemia and tends to blunt the development of organ injury in these animals. Contrastingly, L-lysine has no effects in the absence of endotoxin and thus appears to act as a selective modulator of iNOS activity.

Hypoxic contraction of small pulmonary arteries from normal and endotoxemic rats: fundamental role of NO

The present study was aimed at examining the role of nitric oxide (NO) in the hypoxic contraction of isolated small pulmonary arteries (SPA) in the rat. Animals were treated with either saline (sham experiments) or Escherichia coli lipolysaccharide [LPS, to obtain expression of the inducible NO synthase (iNOS) in the lung] and killed 4 h later. SPA (300- to 600-micrometer outer diameter) were mounted as rings in organ chambers for the recording of isometric tension, precontracted with PGF2alpha, and exposed to either severe (bath PO2 8 +/- 3 mmHg) or milder (21 +/- 3 mmHg) hypoxia. In SPA from sham-treated rats, contractions elicited by severe hypoxia were completely suppressed by either endothelium removal or preincubation with an NOS inhibitor [NG-nitro-L-arginine methyl ester (L-NAME), 10(-3) M]. In SPA from LPS-treated rats, contractions elicited by severe hypoxia occurred irrespective of the presence or absence of endothelium and were largely suppressed by L-NAME. The milder hypoxia elicited no increase in vascular tone. These results indicate an essential role of NO in the hypoxic contractions of precontracted rat SPA. The endothelium independence of HPV in arteries from LPS-treated animals appears related to the extraendothelial expression of iNOS. The severe degree of hypoxia required to elicit any contraction is consistent with a mechanism of reduced NO production caused by a limited availability of O2 as a substrate for NOS.

Moderate hypercapnia exerts beneficial effects on splanchnic energy metabolism during endotoxemia

PURPOSE

Low tidal volume ventilation and permissive hypercapnia are required in patients with sepsis complicated by ARDS. The effects of hypercapnia on tissue oxidative metabolism in this setting are unknown. We therefore determined the effects of moderate hypercapnia on markers of systemic and splanchnic oxidative metabolism in an animal model of endotoxemia.

METHODS

Anesthetized rats maintained at a PaCO(2) of 30, 40 or 60 mmHg were challenged with endotoxin. A control group (PaCO(2) 40 mmHg) received isotonic saline. Hemodynamic variables, arterial lactate, pyruvate, and ketone bodies were measured at baseline and after 4 h. Tissue adenosine triphosphate (ATP) and lactate were measured in the small intestine and the liver after 4 h.

RESULTS

Endotoxin resulted in low cardiac output, increased lactate/pyruvate ratio and decreased ketone body ratio. These changes were not influenced by hypercapnia, but were more severe with hypocapnia. In the liver, ATP decreased and lactate increased independently from PaCO(2) after endotoxin. In contrast, the drop of ATP and the rise in lactate triggered by endotoxin in the intestine were prevented by hypercapnia.

CONCLUSIONS

During endotoxemia in rats, moderate hypercapnia prevents the deterioration of tissue energetics in the intestine.