Retraction notice to "Changes in regulators of the circulation in patients undergoing lung surgery" [Br J Anaesth 79 (1997) 733-9]

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief, Professor Hugh Hemmings, based on the recommendations of Justus-Liebig-University Giessen following an internal review of research conducted by Joachim Boldt at the University. This is further described in 'Further Retractions of Articles by Joachim Boldt', https://doi.org/10.1016/j.bja.2020.02.024.

Evaluating family-centred service in paediatric oncology with the measure of processes of care (MPOC-20)

BACKGROUND

In order to evaluate the family-centeredness of paediatric oncology services, a psychometrically sound measure of family-centred services is needed. We performed a comprehensive evaluation of the psychometric properties of the 20-item Measure of Processes of Care (MPOC-20) in parents of children undergoing treatment for cancer at five paediatric oncology centres in Canada.

METHODS

The sample included 411 parents (80% response rate). Exploratory factor analysis was used to determine the best way to group the items into scales. Psychometric tests were used to examine data quality, targeting, internal consistency reliability, within-scale construct validity and known-groups validity.

RESULTS

Exploratory factor analysis identified two factors: a summary measure of family-centred services and a scale measuring activities that meet parents' general informational needs. Scores spanned the entire scale range, floor and ceiling effects were low, and the sample distribution was not unduly skewed. Scales showed acceptable internal consistency reliability (Cronbach's alphas > or =0.93). Known-group hypotheses supported the scales' ability to differentiate between groups hypothesized to differ. Moderate effect sizes were found when MPOC-20 scale scores for parents and for children with good quality of life were compared with those with poor quality of life.

CONCLUSIONS

The MPOC-20 is the only evaluated instrument currently available to measure family-centred services in paediatric oncology. Paediatric cancer programmes can now use this tool to determine parental perception of the extent to which services are family-centred.

Comparison of the effects of gelatin and a modern hydroxyethyl starch solution on renal function and inflammatory response in elderly cardiac surgery patients

BACKGROUND

The effects of hydroxyethylstarch (HES) 130/0.4 6% and gelatin 4% on inflammation, endothelial integrity, and renal function after cardiac surgery were compared.

METHODS

Sixty patients aged >80 yr undergoing cardiac surgery were randomized to receive gelatin (n=30) or HES 130/0.4 (n=30). The colloid was used in the priming of the cardiopulmonary bypass circuit (500 ml) and for volume replacement until the second postoperative day (POD). Serum creatinine, creatinine clearance, IL-6, IL-10, intercellular adhesion molecule-1 (sICAM-1), urinary glutathione transferase-alpha, and neutrophil gelatinase-associated lipocalin (NGAL) were measured perioperatively. Serum creatinine was also reported approximately 60 days after discharge.

RESULTS

The mean(sd) volume of gelatin infused was 4180(440) ml, which was greater than the volume of HES infused 2910(330) ml (P=0.002). The mean(sd) volume of serum creatinine on the first POD was 151(24) micromol litre(-1) in the gelatin group and 126(13) micromol litre(-1) in the HES group (P=0.004). Values for the second POD were 161(0.26) and 133(16) micromol litre(-1), respectively (P=0.004). Creatinine clearance was lower in the gelatin group on the first POD [37(7) vs 46(8) ml min(-1) 1.73 m2 (P=0.004)] and the second POD [32(8) vs 45(10) ml min(-1) 1.73 m2 (P=0.002)]. Kidney function approximately 60 days after discharge did not differ between the groups. IL-6, IL-10, and sICAM-1 were significantly lower in the HES group than in the gelatin group on the first and second PODs. Urinary alpha-GST increased in both groups to a comparable extent. Urinary NGAL concentrations were higher in the gelatin than in the HES patients 5 h after surgery and on the first and second PODs.

CONCLUSIONS

In cardiac surgery patients aged >80 years, volume therapy with HES 130/0.4 6% was associated with less marked changes in kidney function and a less marked endothelial inflammatory response than gelatin 4%.

Infant serotonin transporter (SLC6A4) promoter genotype is associated with adverse neonatal outcomes after prenatal exposure to serotonin reuptake inhibitor medications

Reduced Apgar scores and birth weight, increased risk of respiratory distress, jitteriness and increased tone have been reported in up to 30% of neonates with prenatal exposure to serotonin reuptake inhibitor (SRI) antidepressant medications. In adults, effects of these medications may be related to the genotype for the serotonin transporter (SLC6A4) promoter. In this study we investigated whether SLC6A4 genotype influences the risk for adverse outcomes in neonates with prenatal SRI exposure. Neonatal outcomes including Apgar scores, birth weight, gestational age at birth, symptoms of poor neonatal adaptation and genotype for SLC6A4 were determined in 37 prenatally SRI exposed neonates and compared with 47 non-exposed neonates. Reduced 5 min Apgar scores were observed in exposed neonates and this was moderated by the ss genotype (P<0.001). Birth weight was lower in exposed ls neonates (P=0.008). Risk for respiratory symptoms (respiratory distress and rapid breathing) was higher in exposed neonates with the ll genotype compared to non-exposed neonates (P<0.05) and risk for neuromotor symptoms increased in exposed ss neonates (P<0.026). These relationships remained when controlling for maternal mood during pregnancy, length of gestational medication exposure and gestational age at birth and cesarean section rate. Prenatal SRI exposure was associated with adverse neonatal outcomes and these effects were moderated by infant SLC6A4 genotype. Relationships between polymorphisms and specific outcomes varied during the neonatal period, suggesting that beyond apparent gene-medication interactions, multiple mechanisms contribute to adverse neonatal outcomes following prenatal SRI exposure.

Nutrition support and treatment of motility disorders in critically ill patients - results of a survey on German intensive care units

BACKGROUND AND OBJECTIVE

To evaluate the current clinical attitude in enteral nutrition support and motility disorders in adult critically ill patients on German intensive care units.

METHODS

A total of 1493 questionnaires, including 25 items on the medical environment, treatment of motility disorders and enteral nutrition, were sent to German intensive care units in September 2005. Responses were collected during a 2-month period.

RESULTS

A total of 593 questionnaires were returned (response rate 41%). The intensive care units were mainly led by anaesthesiologists (63%) or internists (17%). Standard nutrition protocols were used in 44%. Feeding was mainly started as a combined enteral-parenteral regimen (70%). Early enteral nutrition was performed in 58% using a volume of 250-500 mL (66%) and increased by 200-400 mL day-1 (55%). It was mainly delivered by gastric tube (76%) via continuous pump systems (72%) with short interruption intervals of <4 h (86%). Enteral nutrition solutions were mainly standard polymeric formulae (86%). Modified solutions for diabetics and those with renal or liver failure were uncommonly used; immunonutrition did not play a role. Prokinetic agents, especially metoclopramide, laxatives and neostigmine, were routinely used (39%). Further therapeutic options in motility dysfunction included purgative enemas (96%), gastrografin (72%) and colon massage (39%).

CONCLUSIONS

The concept of early enteral nutrition has been well established and approved in German intensive care units, though the recommendations only meet level C criteria in the current ESPEN guidelines. The current survey may serve for further updates on practical nutrition support in intensive care medicine.

[Expensive modern therapy options in intensive care medicine in Germany-- are they being used? Results of a questionnaire]

BACKGROUND

The use of new, high-priced therapies in intensive care medicine should be assessed by a questionnaire.

METHODS

Questionnaires were sent to 849 intensive care units in Germany. The use of three new strategies were asked: treatment of methicilline resistant staphylococcus aureus (MRSA) patients (using linezolid), of severe bleeding (using rFVIIa), and of severe sepsis (using activated protein C [aPC]).

RESULTS

Approximately 39 % of the questionnaires were answered and analyzed. All three new strategies were only rarely or very rarely used in Germany even in universities and hospitals with more than 1000 beds. This appears to be very astonishing because all substances were subject to extensive marketing campaigns, received scientific prices (linezolid) or were strongly recommended by some scientific societies (aPC). One major concern to the use of the new approaches was based on the high pricing. Prices were assessed as excessive or very excessive. In spite of a mass of information about the substances, a lot of the intensivists reviewed the scientific basis as weak and not justifying the use of the costly substances.

CONCLUSIONS

Modern, costly pharmaceutical approaches in intensive care medicine are widely not accepted in Germany. Especially a tight financial corset hinders most intensivists to use these strategies that may be life-saving in some patients. A solution to this problem is urgently required that can be reached only in intensive exchange with all who are responsible for this dilemma.

[Dolasetron reduces pain on injection of propofol]

OBJECTIVE

Pain on injection is a well known side-effect of propofol. The present study was designed to assess the efficacy of dolasetron, a 5-HT 3 -antagonist, in prophylaxis of pain on injection of propofol compared with lidocaine and placebo.

METHODS

Prospective, randomised, double-blinded study including 150 patients randomly assigned to one of three groups: Group A received 12.5 mg dolasetron, group B 40 mg lidocaine and group C saline 0.9 % as placebo. After occluding the venous drainage the test medication was given. The occlusion was released after 1 min and 2.0 mg/kg Propofol was administered over a period of 30 sec. The patients were asked whether they felt any pain during the administration. Pain on injection was judged by using a four-point scale.

RESULTS

Incidence of pain on injection as well as the severity of pain was significantly reduced by lidocaine (62 % pain free) compared with placebo (28 %). Severity, but not incidence of pain on injection was significantly reduced by dolasetron (50 %) compared with placebo. There was no significant difference between dolasetron and lidocaine.

CONCLUSION

Dolasetron and lidocaine were effective in preventing pain of injection secondary to propofol.

Changes of the hemostatic network in critically ill patients--is there a difference between sepsis, trauma, and neurosurgery patients?

OBJECTIVE

To study the time course of coagulation data in intensive care patients.

DESIGN

Prospective, descriptive study.

SETTING

Clinical investigation on a surgical and neurosurgical intensive care unit of a university hospital.

PATIENTS

Fifteen patients with severe trauma (injury severity score, 15 to 25), 15 sepsis patients secondary to major surgery, and 15 neurosurgery patients (cancer surgery) were studied.

INTERVENTIONS

Standardized intensive care therapy.

MEASUREMENTS AND MAIN RESULTS

Standard coagulation data and molecular markers of coagulation activation and fibrinolytic activity (soluble thrombomodulin, protein C, free protein S, thrombin/antithrombin III complex, plasmin-alpha 2-antiplasmin complex, tissue plasminogen activator, platelet factor 4, beta-thromboglobulin were measured from arterial blood samples on the day of admission to the intensive care unit (trauma/neurosurgery patients) or on the day of diagnosis of sepsis (baseline value) and serially during the next 5 days. Antithrombin III, fibrinogen, and platelet counts were highest in neurosurgery patients but without significant differences between sepsis and trauma patients. Thrombin/antithrombin III complex increased in the sepsis patients (from 22.6+/-4.2 microg/L to 39.9+/-6.8 microg/L), but decreased in trauma (from 40.2+/-5.1 microg/L to 17.6+/-4.0 microg/L) and neurosurgery patients (from 28.2+/-4.2 microg/L to 16.2+/-3.8 microg/L). Tissue plasminogen activator increased in the sepsis patients (from 14.4+/-3.9 microg/L to 20.7+/-3.8 microg/mL) and remained almost unchanged in the other two groups. Soluble thrombomodulin plasma concentration increased significantly in the sepsis group (max, 131.8+/-22.5 ng/mL), while it remained elevated in the trauma (max, 75.5+/-5.9 ng/mL) and was almost normal in the neurosurgery patients. Protein C and free protein S remained decreased only in the sepsis group.

CONCLUSIONS

Alterations of the hemostatic network were seen in all three groups of critically ill patients. Hemostasis normalized in the neurosurgery patients and posttraumatic hypercoagulability recovered within the study period. By contrast, monitoring of molecular markers of the coagulation process demonstrated abnormal hemostasis in the sepsis patients during the entire study period indicating ongoing coagulation disorders and abnormalities in fibrinolysis in these patients.

Acute normovolaemic haemodilution vs controlled hypotension for reducing the use of allogeneic blood in patients undergoing radical prostatectomy

Blood loss in patients undergoing radical prostatectomy may be substantial. In a randomized, prospective study, we assessed two methods of reducing the need for allogeneic blood transfusion with regard to efficacy and costs. Sixty patients undergoing retropubic radical prostatectomy were allocated randomly to one of three groups. In group 1 (n = 20), acute normovolaemic haemodilution (ANH) was initiated after induction of anaesthesia; autologous blood 15 ml kg-1 was withdrawn and replaced by colloid solutions (gelatin) to maintain haemodynamic stability. In group 2 (n = 20), controlled hypotension was established using sodium nitroprusside (target mean arterial pressure (MAP) approximately 50 mm Hg). Group 3 (n = 20), without manipulations, served as a control group. Troponin T (TnT), a sensitive marker for myocardial ischaemia, and various coagulation variables were measured in the perioperative period. Packed red blood cells (PRBC) were given when haemoglobin concentration was less than 7 g dl-1. Cost calculations did not include hospital overhead costs or staff costs. In the ANH group, mean 1278 (SD 150) ml of autologous blood were withdrawn. Significantly more volume was infused in the ANH patients (gelatin 2450 (550) ml) than in the two other groups. Coagulation data (platelet count, activated partial thromboplastin time (aPTT), fibrinogen, antithrombin III (AT III), D-dimers) did not differ significantly between the three groups. The hypotension group had significantly lower blood loss (1260 (570) ml), whereas the ANH (1820 (680) ml) and control group (1920 (590) ml) did not differ significantly. Patients in the hypotension group needed significantly less PRBC (total 14 units; 75% of patients did not need PRBC) than the ANH (total 21 units; 55% of patients did not need PRBC) or control patients (total 28 units; 40% of patients did not need PRBC). Total costs were lowest in the hypotension group (41% less than in the control patients) (P < 0.05). We conclude that the use of hypotension during radical prostatectomy resulted in approximately 40% reduction in total transfusion costs. ANH was less effective and more costly than controlled hypotension.

Continuous heparinization and circulating adhesion molecules in the critically ill

Endothelial activation and damage are common endpoints of a complex process that may result in multiple organ dysfunction syndrome (MODS). The influence of continuous intravenous heparinization on plasma levels of circulating adhesion molecules was studied in 28 trauma patients (injury severity score between 15 and 25 points) and 28 sepsis patients secondary to abdominal surgery. According to a prospective, randomized sequence the patients received either unfractionated heparin (aim: activated partial thromboplastin time (aPTT) approximately 2 x normal) (trauma-heparin (n = 14); sepsis-heparin (n = 14)) or not (trauma (n = 14); sepsis (n = 14)). Plasma levels of circulating soluble endothelial leukocyte adhesion molecule-1 (sELAM-1), vascular cell adhesion molecule-1 (sVCAM-1), intercellular adhesion molecule-1 (slCAM-1), and granule membrane protein-140 (sGMP-140) were serially measured from arterial blood samples for 5 days. Approximately 600 U/h of heparin were given to increase aPTT to approximately 60 s. Plasma levels of all adhesion molecules increased in all groups. This increase was significantly (p < .05) highest in both sepsis groups (sepsis: sELAM-1: from 50+/-11 to 84+/-19 ng/mL; slCAM-1: 410+/-68 to 700+/-95 ng/mL), but did not differ significantly between the treated and nontreated patients (sepsis-heparin: sELAM-1: from 60+/-131 to 88+/-20 ng/mL; slCAM-1: from 398+/-99 to 686+/-119 ng/mL). Trauma patients showed a less pronounced increase in all adhesion molecules without differences between the two subgroups. Only sGMP-140 increased significantly (p < .05) more in the trauma (from 102+/-20 to 169+/-16 ng/mL) than in the trauma-heparin group (from 109+/-19 to 132+/-17 ng/mL). It is summarized that continuous heparinization with approximately 600 U/h did not attenuate the rise in circulating adhesion molecules in sepsis and trauma patients. The study findings suggest that heparin in this dose regimen may be unlikely to influence endothelial inflammation or endothelial function in critically ill patients.

Pain management in cardiac surgery patients: comparison between standard therapy and patient-controlled analgesia regimen

OBJECTIVE

To compare standard nurse-based pain therapy with a patient-controlled analgesia (PCA) regimen.

DESIGN

Prospective, randomized study.

SETTING

Single-institutional, clinical investigation in an urban, university-affiliated hospital.

PARTICIPANTS

Sixty patients undergoing elective first-time cardiac surgery were included.

INTERVENTIONS

In 30 patients, a standard analgesic regimen was used, and in 30 patients, a PCA regimen was used. The perioperative and postoperative management was similar for all patients.

MEASUREMENTS AND MAIN RESULTS

Degree of sedation, satisfaction, and pain (by visual analog scale [VAS]) was assessed within the first 3 postoperative days. Vital capacity (VC) and forced expiratory volume in 1 second (FEV1) were measured using a portable spirometry system. Cortisol and troponin T (TnT) plasma levels were also measured. The expectation of pain was similar in both groups, and the postoperative pain score was significantly lower in the PCA than in the standard group throughout the study period. Significantly more piritramid was used in the PCA (total, 75.6 +/- 33.4 mg) than in the standard group (total, 20.1 +/- 31.9 mg). VC and FEV1 were significantly lower in the standard group compared with the PCA patients. Cortisol and TnT plasma levels were similar in both groups. Frequency of side effects were similar for both groups.

CONCLUSION

Because of the beneficial effects with regard to degree of pain and satisfaction, pain management using PCA systems can be recommended for cardiac surgery patients. It appears to be superior to standard nurse-based pain therapy.

Influence of angiotensin-converting enzyme inhibitor enalaprilat on endothelial-derived substances in the critically ill

OBJECTIVE

To assess the effects of the angiotensin-converting enzyme inhibitor enalaprilat on endothelial cells in septic patients.

DESIGN

Prospective, randomized, placebo-controlled, blinded study.

SETTING

Clinical investigation on a surgical intensive care unit of a university hospital.

PATIENTS

Forty surgical septic patients (noncardiac/nonneurosurgical patients).

INTERVENTIONS

After inclusion in the study and after baseline data were obtained, either 0.25 mg/hr (enalaprilat group, n = 20) or saline solution as placebo (control group, n = 20) was continuously given and continued throughout the following 5 days.

MEASUREMENTS AND MAIN RESULTS

Extensive hemodynamic monitoring was carried out in all patients. Plasma concentrations of endothelin-1, angiotensin II, soluble thrombomodulin, and soluble adhesion molecules (endothelial leukocyte adhesion molecule-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and granule membrane protein-140) were measured from arterial blood samples. All measurements were carried out before the start of the infusion ("baseline" values) and daily during the following 5 days. All endothelial-derived substances (thrombomodulin, endothelin-1, and all soluble adhesion molecules) were similarly increased beyond normal in both group. Endothelin-1 increased only in the untreated control patients (from 6.9 +/- 0.7 to 14.3 +/- 1.4 mg/mL). Soluble thrombomodulin increased in the untreated control patients (from 58 +/- 9 to 79 +/- 14 ng/mL [p < .05]), but significantly decreased in the enalaprilat-treated patients. Soluble adhesion molecules increased in the untreated control group (endothelial leukocyte adhesion molecule from 92 +/- 14 to 192 +/- 29 ng/mL; intercellular adhesion molecule-1 from 480 +/- 110 to 850 +/- 119 ng/ mL) and returned almost to normal values in the enalaprilat patients. The survival rate did not differ significantly between the two groups. Control patients developed severe sepsis and septic shock more often than the enalaprilat-treated group.

CONCLUSIONS

The complex pathogenesis of endothelial function abnormalities in sepsis may offer a large number of pharmacologic interventions. Administration of the angiotensin-converting enzyme inhibitor enalaprilat resulted in a reduced release of soluble endothelial-derived substances into the circulating blood, which may indicate an improved endothelial function. The specific actions of enalaprilat on the endothelium have to be elucidated in further studies.

Retracted: Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

BACKGROUND

Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties.

METHODS

The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 micrograms.kg-1.min-1 of dopexamine (n = 15) or placebo (n = 15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day.

RESULTS

Cardiac index (CI) increased significantly in the dopexamine group (from 2.61 +/- 0.41 to 4.57 +/- 0.78 l.min-1.m-2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO2I) and oxygen consumption index (VO2I) were also significantly increased in the dopexamine group (DO2I: from 416 +/- 91 to 717 +/- 110 ml/m2.m2; VO2I: from 98 +/- 25 to 157 +/- 22 ml/m2.m2), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37 +/- 1.1 to 35.9 +/- 12.1 pg/ml; ET-1: from 2.88 +/- 0.91 to 6.91 +/- 1.20 pg/ml).

CONCLUSION

Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.

Are circulating adhesion molecules specifically changed in cardiac surgical patients?

BACKGROUND

Soluble adhesion molecules are considered to be markers of inflammation, endothelial activation, or damage. This study was designed to assess whether adhesion molecules are specifically altered in patients undergoing cardiac surgical procedures.

METHODS

Three groups of 20 patients each were prospectively studied: patients undergoing elective coronary artery bypass grafting; patients scheduled for a Whipple pancreatoduodenectomy; and patients undergoing elective pneumonectomy for lung cancer. Plasma levels of soluble adhesion molecules (endothelial leukocyte adhesion molecule-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and granule membrane protein 140) were measured from arterial blood samples after induction of anesthesia (baseline), at the end of the operation, 2 hours and 5 hours after operation, and on the morning of the first postoperative day.

RESULTS

Duration of operation was longest in the group having a Whipple operation (289 +/- 50 minutes) and did not differ between the other two groups. Plasma levels of all measured adhesion molecules at baseline were within normal ranges. After cardiopulmonary bypass, levels of adhesion molecules were significantly increased in the cardiac surgical patients (soluble endothelial leukocyte adhesion molecule-1, from 38 +/- 11 ng/mL at baseline to 68 +/- 12 ng/mL; soluble intercellular adhesion molecule-1, from 241 +/- 50 ng/mL to 498 +/- 78 ng/mL; and granule membrane protein 140, from 69 +/- 12 ng/mL to 150 +/- 25 ng/mL). On the morning of the first postoperative day, all levels had returned to baseline except that of soluble vascular cell adhesion molecule-1, which was still elevated (p < 0.05). In both the other groups, concentrations of adhesion molecules remained almost unchanged.

CONCLUSIONS

Cardiac operation was associated with increased plasma levels of soluble adhesion molecules, a finding indicating endothelial activation or dysfunction. In contrast, in patients undergoing complex, long-lasting abdominal or lung operations, soluble adhesion molecules remained unchanged. Activation of proinflammatory cascades, ischemia/reperfusion phenomenon, and microcirculatory dysfunction appear to be the most likely reasons for this difference between groups. Whether modulation of adhesion molecules may influence organ function after cardiopulmonary bypass remains to be elucidated in further studies.

Volume replacement strategies on intensive care units: results from a postal survey

OBJECTIVE

To assess volume replacement strategies on intensive care units (ICUs) in Germany.

DESIGN

A postal survey questionnaire of 18 questions was sent to 451 ICUs in Germany. The questionnaire was sent to general, surgical, anesthesiology, neurosurgery, cardiac surgery, and medical ICUs of hospital with more than 200 beds.

RESULTS

286 questionnaires (64%) were returned and analysed. Hydroxyethylstarch (HES) solution is the solution most often used for volume replacement (total: 193 ICUs, exclusively HES: 93 ICUs), crystalloids are next (crystalloids exclusively: 61 ICUs), and human albumin is used rarely as a first choice. Clinical experience is a very important argument for administering volume. Diagnostic tools, e.g. measurement of central venous pressure or pulmonary capillary wedge pressure, also play an important role. Albumin/total protein and colloid osmotic pressure (COP) are measured often on ICUs (albumin measured routinely: 173 ICUs; COP measured routinely: 33 ICUs). Critical values for albumin/total protein are defined in most ICUs. Reduced plasma levels of albumin/total protein was the indication most often cited for administering human albumin. Only 149 ICUs (52%) have a financial budget for their unit. Costs still do not play a major role in the choice of volume replacement on 30 ICUs (10%).

CONCLUSIONS

The kind of volume therapy differs widely among the different ICUs. This questionnaire supported the supposition that no standards exist for volume therapy in intensive care patients. New results concerning the abuse of albumin in the critically ill have not yet influenced strategies of volume replacement.

Volume therapy in the critically ill: is there a difference?

OBJECTIVE

There are still several concerns about the extensive and prolonged use of hydroxyethylstarch solution (HES) in critically ill patients. The effects of volume replacement with HES over 5 days on hemodynamics, laboratory data, and organ function were compared with volume therapy using human albumin (HA).

DESIGN

Prospective, randomized study.

SETTING

Clinical investigations on a surgical intensive care unit (ICU) of a university hospital.

PATIENTS

150 traumatized patients (injury severity score > 15) and 150 postoperative patients with sepsis were analyzed.

INTERVENTIONS

Either 10% low-molecular weight HES (HES-trauma, n = 75; HES-sepsis, n = 75) or 20% HA (HA-trauma, n = 75; HA-sepsis, n = 75) was given for 5 days to maintain the pulmonary capillary wedge pressure (PCWP) between 12 and 15 torr. The entire management of therapy of the patients was performed by physicians who were not involved in the study and blinded to the infusion regimen.

MEASUREMENTS AND RESULTS

In addition to extensive cardiorespiratory monitoring, several routine laboratory parameters for assessing pulmonary, renal, hepatic, and coagulation function were analyzed from arterial blood samples on the day of admission to the ICU and on the day of sepsis diagnosis, respectively ("baseline" value) and daily over the following 5 days. Mortality during and after the study did not differ significantly between the infusion groups. There were also no differences between the incidence of pulmonary, renal, or hepatic failure in the two subgroups. Mean arterial pressure, heart rate, and PCWP were similar in both subgroups, whereas cardiac index, oxygen delivery index, oxygen consumption index, and the ratio between the partial pressure of oxygen in arterial blood and fractional inspired oxygen were higher in the HES- than in the HA-treated groups. Standard coagulation parameters did not differ, albumin concentration increased significantly in both HA groups, and lactate concentrations decreased only in the HES-sepsis patients (from 2.8 +/- 0.5 to 1.5 +/- 0.4 mg/dl). Volume replacement using albumin was significantly (p < 0.001) more costly than therapy with HES.

CONCLUSIONS

Volume therapy with 10% HES for 5 days in the ICU patient showed no disadvantages compared with an infusion regimen using 20% albumin. Volume replacement using HES may even be associated with improved hemodynamics. HES appears to be a valuable and significantly cheaper alternative to albumin--even for prolonged volume therapy in the critically ill patient.

Changes in regulators of the circulation in patients undergoing lung surgery

Several vasoactive substances are responsible for control of the circulation. During lung surgery these substances may be influenced either by the technique of anaesthesia or by altered production and elimination. We have studied plasma concentrations of important regulators of the circulation in patients undergoing lobectomy using two different regimens: propofol-low-dose fentanyl-nitrous oxide-vecuronium, tracheal extubation immediately after surgery (group Ia (n = 15)); fentanyl-midazolam-pancuronium, delayed tracheal extubation in the intensive care unit (ICU) (group Ib (n = 15)). We also studied patients undergoing pneumonectomy using fentanyl-midazolam-pancuronium anaesthesia (group II (n = 15)). Plasma concentrations of endothelin-1 (ET-1), atrial natriuretic peptide (ANP), vasopressin, catecholamines (adrenaline, noradrenaline) and 6-keto-prostaglandin F1 alpha were measured. Extensive haemodynamic monitoring was performed using a pulmonary artery catheter. All measurements were carried out after induction of anaesthesia (baseline values), 30 min after one-lung ventilation (OLV) was induced, at the end of surgery, 2 h after surgery in the ICU and on the first day after operation. CVP, PAP and PCWP increased in all groups during OLV but remained increased only in patients undergoing pneumonectomy. CI decreased significantly in the pneumonectomy group but did not differ between both lobectomy groups. SVRI was lowest in the propofol-treated patients and remained highest in the pneumonectomy group. Plasma concentrations of adrenaline and noradrenaline did not change in group Ia, but increased significantly in groups Ib (noradrenaline: from 267 (67) to 496 (91) pg ml-1) and II (adrenaline: from 237 (59) to 681 (210) pg ml-1). Plasma concentrations of ET-1 remained almost unchanged in groups Ia and Ib, whereas they increased in pneumonectomy patients (from 2.63 (0.3) to 6.61 (1.01) pg ml-1). Vasopressin plasma concentrations increased during OLV in all groups; they were lowest in the propofol patients and highest in patients undergoing pneumonectomy (32.2 (10.2) pg ml-1). Plasma concentrations of ANP and 6-keto-prostaglandin F1 alpha increased in all groups during OLV and remained increased only in the pneumonectomy group.

Does age influence circulating adhesion molecules in the critically ill?

OBJECTIVE

Soluble adhesion molecules are regarded to be markers of inflammation, endothelial activation, or damage. The influence of age on plasma concentrations of circulating adhesion molecules should be serially studied in critically ill intensive care patients.

DESIGN

Prospective and descriptive study over 5 days.

SETTING

Clinical investigation in a surgical intensive care unit of a university hospital.

PATIENTS

Thirty critically ill patients (Acute Physiology and Chronic Health Evaluation [APACHE] II score of > 15 points), with sepsis secondary to postoperative complications, were included in this study. Fifteen consecutive patients aged < 50 yrs and 15 consecutive patients aged > 70 yrs were prospectively studied.

INTERVENTIONS

All patients were treated by the standard protocols of our intensive care unit, which did not differ between the groups. The patients received continuous analgesia-sedation and mechanical ventilation. Intensivists caring for the patients were not involved in the study and were blinded to data analysis.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic parameters were extensively monitored in all patients. From arterial blood samples, plasma concentrations of soluble adhesion molecules (endothelial leukocyte adhesion molecule-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, granule membrane protein-140) were measured on the day of admission (i.e., baseline values) and during the following 5 days. Three of the younger patients and six of the elderly patients died during the study period (p < .05). Oxygen delivery and consumption, and the other hemodynamic data, were without group differences throughout the study. Plasma concentrations of all adhesion molecules were beyond normal at baseline in both groups. These concentrations increased further during the first 2 to 3 days in both groups, with a significantly higher increase in the elderly patients (endothelial leukocyte adhesion molecule-1 to 179 +/- 32 ng/mL; intercellular adhesion molecule-1 to 1695 +/- 158 ng/mL; vascular cell adhesion molecule-1 to 1395 +/- 212 ng/mL; and granule membrane protein-140 to 888 +/- 119 ng/mL). In the younger patients, concentrations of soluble adhesion molecules decreased later in the study and almost reached baseline values on day 5. In the elderly patients, these concentrations remained significantly higher until the end of the study.

CONCLUSIONS

The higher plasma concentrations of the measured adhesion molecules in elderly critically ill patients indicate that elderly patients are more prone than younger patients to a more pronounced activation or even damage of the endothelium. Further work needs to be done to determine the prognostic importance and to define the role of soluble adhesion molecules, particularly in the elderly critically ill patient.

Influence of different volume therapy regimens on regulators of the circulation in the critically ill

Various vasoactive substances are involved in the regulation of the macro- and microcirculation. We have investigated if these regulators change during long-term volume therapy with human albumin (HA) or hydroxyethylstarch solution (HES) in trauma and sepsis patients. To maintain pulmonary capillary wedge pressure (PCWP) at 10-15 mm Hg, either 20% HA (HA-trauma, n = 14; HA-sepsis, n = 14) or 10% low-molecular weight HES solution (HES-trauma, n = 14; HES-sepsis, n = 14) were infused for 5 days, otherwise patient management did not differ between the two groups (trauma/sepsis). Mean arterial pressure (MAP), heart rate (HR), PCWP and cardiac index (CI) were monitored in all patients. Liver function was assessed using the monoethylglycinexylidide (MEGX) test, and gastric intramucosal pH (pHi) was monitored by tonometry to assess splanchnic perfusion. Plasma concentrations of vasopressin, endothelin-1, adrenaline, noradrenaline, atrial natriuretic peptide and 6-keto-prostaglandin F1 alpha were measured from arterial blood samples. All measurements were carried out on the day of admission to the intensive care unit (trauma patients) or on diagnosis of sepsis, and daily over the next 5 days at 12:00. MAP, HR and PCWP did not differ between the corresponding subgroups (trauma/sepsis). Cl increased significantly more in the HES than in the HA groups. pHi and MEGX plasma concentrations did not differ in the trauma patients throughout the study. Both were lower than normal in the sepsis groups and increased more markedly in the HES than in the albumin-treated patients (P < 0.05). In the trauma patients, concentrations of all vasoactive regulators were very similar in both groups. In both sepsis groups, vasopressors (vasopressin, endothelin-1, noradrenaline and adrenaline) were significantly increased above normal at baseline and decreased more markedly in HES than in HA patients. Concentrations of atrial natriuretic peptide increased only in the HA patients (from 159 (SD 31) to 215 (38) pg ml-1 on day 2). Plasma concentrations of 6-keto-prostaglandin F1 alpha decreased significantly only in the HES sepsis patients (from 112 (25) to 47 (15) pg ml-1).