Effects on the left ventricular diastolic dysfunction of a cardiac rehabilitation program in chronic heart failure patients

Funding Acknowledgements

Type of funding sources: None.

PURPOSE

The aim of the present study is to evaluate the impact of a cardiac rehabilitation program on the diastolic dysfunction, the ejection fraction (EF) of left ventricular and the volume index of the left atrium comparing 2 groups: those with restricted EF (<40%) and those with intermediate and preserved EF (≥ 40%).

METHODS

In the present study 41 stable CHF patients (N = 41; 56 ±10 years [mean ± SD], 34 males and 7 females) with diastolic dysfunction, participated in an exercise rehabilitation program (3 sessions a week). Only 38 of them completed the rehabilitation program in the form of circuit-interval aerobic training, adjusted according to 70–80% of heart rate reserve, for a period of 3 months. A detailed echocardiogram was performed before and immediately after the rehabilitation program, focusing on the diastolic dysfunction assessment of the left ventricular.

RESULTS

At the end of the three months rehabilitation program, the diastolic dysfunction stage was significantly decreased (from 1.45+/- 0.72 to 1.08 +/-0.67, p = .000). The LV ejection fraction was significantly increased (from 34.97+/-10.66 to 36.68 +/-10.52, p = .002). In addition, there was a significant decrease in E/E" and RVSP (from 9.37+/-3.54 to 8.47+/-3.34 and from 28.44+/-6.86mmHg to 27.38+/-5.87 mmHg, p =.033 and p =.030, respectively). Finally, the left atrial volume and the average e" had no significant decrease.

CONCLUSIONS

Circuit training improved both diastolic and systolic dysfunction but had no significant repercussion on the left atrium volume. From this study it was concluded that a rehabilitation cardiac program can have an impact in the improvement in the diastolic dysfunction, especially in the restricted EF group, a mechanism that is essential in the pathophysiology of the CHF.

Table 1 PairedDifferences t df Sig. (2-tailed) Mean Std. Deviation Std. ErrorMean 95% Confidence Interval of the Difference Lower Upper Diast.stage b-a 0.368 .589 .096 .175 .562 3.855 37 .000 A b - A a ( m/sec) -.03816 .21084 .03420 -.10746 .03114 -1.116 37 .272 Ε/Α b - Ε/Α a .11039 .44705 .07252 -.03655 .25734 1.522 37 .136 mean e" b - a(cm/sec) .19395 2.56304 .41578 -.64850 1.03640 .466 37 .644 Ε/e "b - Ε/e "a .90026 2.50613 .40655 .07652 1.72401 2.214 37 .033 DTeb -DTe a (msec) 8.500 44.324 7.190 -6.069 23.069 1.182 37 .245 T-Test for the measured diastolic parameters (diastolic stage, E, A, E/A, mean e", E/E", DTe) for all groups (b = before, a = after).

Abstract Figure. Linear scatter plot for EF

A cardiac rehabilitation program increases the acute respond of endothelial progenitor cells after maximum exercise in patients with chronic heart failure

Background

Chronic heart failure (CHF) remains a leading cause of morbidity and mortality and it is characterized by vascular endothelial dysfunction. During the last decades, endothelial progenitor cells (EPCs) are being used as an index of the endothelium restoration potential, therefore reflecting the vascular endothelial function. Exercise training has been shown to stimulate the mobilization of EPCs at rest in CHF patients. However, the effect of exercise training on the acute respond of EPCs after maximum exercise in CHF patients remains unknown.

Purpose

The purpose of the study was to assess the effect of a cardiac rehabilitation (CR) program on the acute respond of EPCs after maximum exercise in patients with CHF.

Methods

Forty-four consecutive patients (35 males) with stable CHF [mean±SD, Age (years): 56±10, BMI (kg/m2): 28.7±5.2, EF (%): 33±8, Peak VO2 (ml/kg/min): 18.4±4.4, Peak work rate (watts): 101±39] enrolled a 36-session CR program based on high-intensity interval exercise training. All patients underwent an initial symptom limited maximal cardiopulmonary exercise testing (CPET) on an ergometer before the CR program and a final maximal CPET after the CR program. Venous blood was drawn before and after each CPET. Five circulating endothelial populations were identified and quantified by flow cytometry; CD34+/CD45-/CD133+, CD34+/CD45-/CD133+/VEGFR2, CD34+/CD133+/VEGFR2, CD34+/CD45-/CD133- and CD34+/CD45-/CD133-/VEGFR2. EPCs values are expressed as cells/million enucleated cells in medians (25th-75th percentiles).

Results

The acute mobilization of EPCs after the final CPET was higher than after the initial CPET in 4 out of 5 circulating endothelial populations. Most specifically, difference of the acute mobilization of CD34+/CD45-/CD133+ cells [initial CPET: 25 (15–46) vs final CPET: 49 (26–71), p=0.002], CD34+/CD45-/CD133+/VEGFR2 cells [initial CPET: 3 (2–5) vs final CPET: 8 (5–12), p<0.001], CD34+/CD45-/CD133- cells [initial CPET: 129 (52–338) vs final CPET: 250 (129–518), p=0.03] and CD34+/CD45-/CD133-/VEGFR2 cells [initial CPET: 2 (1–4) vs final CPET: 6 (3–9), p<0.001] increased after the final CPET. The acute mobilization of CD34+/CD133+/VEGFR2 cells [initial CPET: 3 (−1–7) vs final CPET: 5 (0–15), p=0.441] did not differ between the 2 CPETS.

Conclusion

A 36-session cardiac rehabilitation program increases the acute respond of endothelial progenitor cells after maximum cardiopulmonary exercise training in patients with chronic heart failure, therefore indicating the beneficial effect of exercise training on the vascular endothelial function.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme “Human Resources Development, Education and Lifelong Learning” in the context of the project

The comparison between two different exercise training programs on the mobilization of endothelial progenitor cells in patients with chronic heart failure

Background

Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure (CHF). Endothelial progenitor cells (EPCs) are being used as an index of vascular endothelial function. Cardiac rehabilitation (CR) programs have been shown to stimulate the mobilization of EPCs in CHF patients. However, the effect of different exercise training programs on the EPCs in CHF patients has not been investigated.

Purpose

The purpose of the study was to assess the effect of 2 different exercise training programs on the mobilization of EPCs in patients with CHF and investigate if there were differences between them.

Methods

Forty-four consecutive patients (35 males) with stable CHF [mean±SD, Age (years): 56±10, EF (%): 33±8, Peak VO2 (ml/kg/min): 18.4±4.4] enrolled a 36-session CR program and they were randomized in one exercise training protocol; either high-intensity interval training (HIIT) or HIIT combined with muscle strength (COM). Venous blood was drawn at rest before and after the CR program. Five circulating endothelial populations were identified and quantified by flow cytometry (Table 1). EPCs values are expressed as cells/million enucleated cells in medians (25th-75th percentiles).

Results

In both HIIT and COM groups, the mobilization of all circulating endothelial populations increased after the CR program (p<0.05, Table 1). However, there was no difference in the mobilization of EPCs between HIIT and COM groups (p>0.05, Table 1).

Conclusion

A 36-session cardiac rehabilitation program increases the mobilization of endothelial progenitor cells in patients with chronic heart failure. High-intensity interval exercise training and HIIT combined with muscle strength have similar beneficial effect on endothelial progenitor cells, and therefore on vascular endothelial function.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme “Human Resources Development, Education and Lifelong Learning” in the context of the project

P753Exercise has similar beneficial effect in the mobilization of endothelial progenitor cells in patients with chronic heart failure of different severity

Introduction

Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure (CHF). Exercise has been shown to stimulate the mobilization of endothelial progenitor cells (EPC) in healthy populations. EPC contribute to the regeneration of the inflammatory endothelium and promote neovascularization.

Purpose

The purpose of the present study was to investigate the mobilization of EPC between CHF patients with different severity after a 36-session exercise training program.

Methods

Thirty eight consecutive patients (32 ♂, 6 ♀) with stable CHF [mean±SD, age (years): 56±10, EF (%): 32±9, peak VO2 (ml/kg/min): 18.1±4.1] enrolled a 36-session exercise training program. All patients underwent a symptom limited maximal cardiopulmonary exercise testing (CPET) on a cycle ergometer before and after the training program. Venous blood was sampled before and after each CPET. Five endothelial circulating populations were quantified by flow cytometry (Table 1). Patients were divided in severity groups according to the median values of peak VO2, predicted peak VO2, VE/VCO2 slope and EF. EPC values are expressed as “cells/million enucleated cells” in medians (25th, 75th percentiles).

Results

In all patients, rehabilitation showed a statistical significant effect as well as a significant acute effect in all endothelial circulating populations (p<0.001). Although there was statistical significant mobilization of endothelial circulating populations within each severity group (groups separated by peak VO2), no differences were observed between groups (p>0.05, Table 1). Similar results were also shown for the rest of CPET parameters and EF.

Cellular populations in severity groups Endothelial cellular populations Peak VO2 <18 ml/kg/min Peak VO2 ≥18 ml/kg/min Before rehabilitation After rehabilitation Before rehabilitation After rehabilitation Before CPET After CPET Before CPET After CPET Before CPET After CPET Before CPET After CPET CD34+/CD45–/CD133+ 54 (24–74) 90 (40–104)* 96 (54–120) 154 (100–169)* 37 (16–66) 60 (33–93)* 79 (46–106) 122 (96–159)* CD34+/CD45–/CD133+/VEGFR2 1 (1–3) 3 (2–8)* 8 (4–9) 14 (10–19)* 2 (1–3) 4 (3–8)* 5 (4–7) 13 (9–16)* CD34+/CD133+/VEGFR2 13 (8–18) 13 (9–25) 22 (16–31) 27 (14–38) 10 (7–19) 14 (9–20)** 16 (13–37) 22 (15–62)** CD34+/CD45–/CD133– 186 (131–368) 494 (202–640)* 431 (301–564) 738 (590–921)* 214 (150–270) 306 (233–575)* 434 (277–835) 740 (524–1588)* CD34+/CD45–/CD133–/VEGFR2 2 (1–2) 3 (2–5)* 4 (3–5) 10 (9–14)* 1 (1–1) 3 (2–5)* 4 (2–8) 9 (7–12)* Differences within groups *p<0.001, **p<0.05.

Conclusion

A 36-session training program stimulates the long term mobilization of EPC in CHF patients. This mobilization seems to be similar in all patients irrespective of their severity. The clinical relevance of these findings and the potential mechanisms need further investigation.

Acknowledgement/Funding

Greece and the European Union (European Social Fund-ESF) through the Operational Programme “Human Resources Development, Education, Lifelong Learning”

Clinical factors affecting costs in patients receiving systemic antifungal therapy in intensive care units in Greece: Results from the ESTIMATOR study

Invasive fungal infections are common in intensive care units (ICUs) but there is a great variability in factors affecting costs of different antifungal treatment strategies in clinical practice. To determine factors affecting treatment cost in adult ICU patients with or without documented invasive fungal infection receiving systemic antifungal therapy (SAT) we have performed a prospective, multicentre, observational study enrolling patients receiving SAT in participating ICUs in Greece. During the study period, 155 patients received SAT at 14 participating ICUs: 37 (23.9%) for proven fungal infection before treatment began, 10 (6.5%) prophylactically, 77 (49.7%) empirically and 31 (20.0%) pre-emptively; 66 patients receiving early SAT (55.9%) were subsequently confirmed to have proven infection with Candida spp. (eight while on treatment). The most frequently used antifungal drugs were echinocandins (89/155; 57.4%), fluconazole (31/155; 20%) and itraconazole (20/155; 12.9%). Mean total cost per patient by SAT strategy was €20 458 (proven), €15 054 (prophylaxis), €23 594 (empiric) and €22 184 (pre-emptive). Factors associated with significantly increased cost were initial treatment failure, length of stay (LOS) in ICU before starting SAT (i.e. from admission until treatment start), fever and proven candidaemia (all P≤.05).

CONCLUSION

Early administration of antifungal drugs was not a substantial component of total hospital costs. However, there was a significant adverse impact on costs with increasing LOS in febrile patients in ICU for whom diagnosis of fungaemia was delayed before starting SAT, and with initial treatment failure. Awareness of potential candidaemia and initiation of pre-emptive or empirical strategy as early appropriate treatment may improve ICU patient outcomes while reducing direct medical costs.

Left Ventricular Diastolic Dysfunction—An Independent Risk Factor for Weaning Failure from Mechanical Ventilation

The objective of this study was to investigate the contribution of left ventricular (LV) diastolic dysfunction to weaning failure, along with the levels of the currently used cardiac biomarkers. Forty-two mechanically ventilated patients, who fulfilled criteria for weaning from mechanical ventilation (MV), underwent a two-hour spontaneous breathing trial (SBT). Transthoracic echocardiography (TTE) was performed before the start of the SBT. The grade of LV diastolic dysfunction was assessed by pulsed-wave Doppler and tissue Doppler imaging at the level of the mitral valve. Haemodynamic and respiratory parameters were recorded. Blood levels of B-type natriuretic peptide (BNP), troponin I, creatine kinase–MB, and myoglobin were measured on MV and at the end of the SBT. Weaning success was defined as the patient's ability to tolerate spontaneous breathing for more than 48 hours. Fifteen patients failed to wean. LV diastolic dysfunction was significantly associated with weaning failure ( P <0.001). The grade of diastolic dysfunction was significantly correlated with BNP levels both on MV and at the end of the SBT ( P <0.001, r = 0.703 and P <0.001, r = 0.709, respectively). BNP levels on MV were lower in patients who successfully weaned compared to those who did not (361 ± 523 ng/l versus 643 ± 382 ng/l respectively, P=0.008). The presence of diastolic dysfunction was independently associated with weaning failure (odds ratio [OR] 11.23, confidence interval [CI] 1.16–109.1, P=0.037) followed by respiratory frequency/tidal volume (OR 1.05, CI 1.00–1.10, P=0.048). Therefore, assessment of LV diastolic function before the start of weaning could be useful to identify patients at risk of weaning failure.

Changes in thenar muscle tissue oxygen saturation assessed by near-infrared spectroscopy during weaning from mechanical ventilation

BACKGROUND

Tissue oxygen saturation (StO₂) measured by near-infrared spectroscopy (NIRS) has been used to provide information on local tissue oxygenation in different clinical settings. This study aims to determine the effect of weaning from mechanical ventilation on thenar muscle StO₂.

METHODS

In consecutive critically ill mechanically ventilated patients, StO₂ at the thenar eminence, along with a vascular occlusion test (VOT), were measured by NIRS, on mechanical ventilation and during a 2-hour T-piece spontaneous breathing trial (SBT). Hemodynamic, gas exchange and respiratory variables were recorded.

RESULTS

Forty-four patients were included in this study, 25 tolerated the SBT and 19 failed. On mechanical ventilation, no differences in any measured variable were observed between patients who succeeded or failed. Two minutes after SBT start, StO₂ was decreased in patients who failed whereas it did not change in patients who succeeded (P<0.001). For all data, 2 minutes after the start of SBT, StO₂ significantly correlated with SaO₂ (r=0.32, P=0.037) and with the respiratory frequency/tidal volume (f/VT) index (r=-0.34, P=0.023). VOT-derived StO₂ downslope and StO2 upslope did not change significantly along the SBT test. The maximum StO₂ value, its ratio to minimum StO2, and the post-VOT StO₂ value decreased significantly in patients who failed whereas no change was found in those who succeeded the SBT (P=0.003, P=0.025 and P<0.001 respectively). StO₂ and f/VT at the second minute of SBT yielded a receiver operator characteristics curve area value of 0.77 and 0.80, P=0.002, respectively, in detecting the SBT outcome.

CONCLUSION

SBT failure was associated with a significant impairment of thenar muscle StO₂. A decrease of StO₂ at 2 minutes after disconnection from the ventilator was associated with SBT failure. Further validation is warranted.

Carbapenem-resistant versus carbapenem-susceptible Acinetobacter baumannii bacteremia in a Greek intensive care unit: risk factors, clinical features and outcomes

BACKGROUND

There has been an increasing incidence of carbapenem-resistant Acinetobacter baumannii (CRAB) infections in recent years. The objective of this study was to determine specific risk factors for and outcome of bacteremia due to CRAB isolates among our ICU patients with A. baumannii bacteremia.

PATIENTS AND METHODS

Among 96 patients with ICU-acquired A. baumannii bacteremia, 30 patients with CRAB were compared with the remaining 66 with carbapenem-susceptible A. baumannii (CSAB) isolates.

RESULTS

Recent ventilator-associated pneumonia (VAP) due to CRAB (OR 16.74, 95% CI 3.16-88.79, p = 0.001) and a greater number of intravascular devices (OR 3.93, 95% CI 1.9-13.0, p = 0.025) were independently associated with CRAB bacteremia acquisition. Patients with CRAB bacteremia had a lower severity of illness on admission than those with CSAB. Although, by univariate analysis, patients with CRAB were more likely to have had exposure to colistin, carbapenems and linezolid, multivariate analysis did not revealed any significant association. The mortality was not different between patients with CRAB and CSAB bacteremia (43.3 vs. 46.9%, p = 0.740). Severity of organ failure (OR 1.42, 95% CI 1.20-1.67, p = 0.001), and increased white blood cell (WBC) count (OR 1.09, 95% CI 1.01-1.19, p = 0.036), at bacteremia onset were independently associated with mortality.

CONCLUSION

VAP due to CRAB and excess use of intravascular devices are the most important risk factors for CRAB bacteremia in our ICU. Severity of organ failure and WBC count at A. baumannii bacteremia onset are independently associated with mortality.

Non-invasive Assessment of the Microcirculation in Critically Ill Patients

Sepsis is associated with abnormalities of muscle tissue oxygenation and of microvascular function. We investigated whether the technique of near-infrared spectroscopy can evaluate such abnormalities in critically ill patients and compared near-infrared spectroscopy-derived indices of critically ill patients with those of healthy volunteers.

We studied 41 patients (mean age 58±22 years) and 15 healthy volunteers (mean age 49±13 years). Patients were classified into one of three groups: systemic inflammatory response syndrome (SIRS) (n=21), severe sepsis (n=8) and septic shock (n=12). Near-infrared spectroscopy was used to continuously measure thenar muscle oxygen saturation before, during and after a three-minute occlusion of the brachial artery via pneumatic cuff.

Oxygen saturation was significantly lower in patients with SIRS, severe sepsis or septic shock than in healthy volunteers. Oxygen consumption rate during stagnant ischaemia was significantly lower in patients with SIRS (23.9±7.7%/minute, P <0.001), severe sepsis (16.9±3.4%/minute, P <0.001) or septic shock (14.8±6%/minute, P <0.001) than in healthy volunteers (35.5±10.6%/minute). Furthermore, oxygen consumption rate was significantly lower in patients with septic shock than patients with SIRS. Reperfusion rate was significantly lower in patients with SIRS (336±141%/minute, P <0.001), severe sepsis (257±150%/minute, P <0.001) or septic shock (146±101%/minute, P <0.001) than in healthy volunteers (713±223%/minute) and significantly lower in the septic shock than in the SIRS group.

Near-infrared spectroscopy can detect tissue oxygenation deficits and impaired microvascular reactivity in critically ill patients, as well as discriminate among groups with different disease severity.

Impaired oxygen kinetics in beta-thalassaemia major patients

AIM

Beta-thalassaemia major (TM) affects oxygen flow and utilization and reduces patients' exercise capacity. The aim of this study was to assess phase I and phase II oxygen kinetics during submaximal exercise test in thalassaemics and make possible considerations about the pathophysiology of the energy-producing mechanisms and their expected exercise limitation.

METHODS

Twelve TM patients with no clinical evidence of cardiac or respiratory disease and 10 healthy subjects performed incremental, symptom-limited cardiopulmonary exercise testing (CPET) and submaximal, constant workload CPET. Oxygen uptake (VO2), carbon dioxide output and ventilation were measured breath-by-breath.

RESULTS

Peak VO2 was reduced in TM patients (22.3 +/- 7.4 vs. 28.8 +/- 4.8 mL kg(-1) min(-1), P < 0.05) as was anaerobic threshold (13.1 +/- 2.7 vs. 17.4 +/- 2.6 mL kg(-1) min(-1), P = 0.002). There was no difference in oxygen cost of work at peak exercise (11.7 +/- 1.9 vs. 12.6 +/- 1.9 mL min(-1) W(-1) for patients and controls respectively, P = ns). Phase I duration was similar in TM patients and controls (24.6 +/- 7.3 vs. 23.3 +/- 6.6 s respectively, P = ns) whereas phase II time constant in patients was significantly prolonged (42.8 +/- 12.0 vs. 32.0 +/- 9.8 s, P < 0.05).

CONCLUSION

TM patients present prolonged phase II on-transient oxygen kinetics during submaximal, constant workload exercise, compared with healthy controls, possibly suggesting a slower rate of high energy phosphate production and utilization and reduced oxidative capacity of myocytes; the latter could also account for their significantly limited exercise tolerance.

New insights into the exercise intolerance of beta-thalassemia major patients

The purpose of our study was assessment of the relative contribution of the systems involved in blood gas exchange to the limited exercise capacity in patients with beta-thalassemia major (TM) using integrative cardiopulmonary exercise testing (CPET) with estimation of oxygen kinetics. The study consisted of 15 consecutive TM patients and 15 matched controls who performed spirometric evaluation, measurement of maximum inspiratory pressure (Pimax) and an incremental symptom-limited CPET on a cycle ergometer. Exercise capacity was markedly reduced in TM patients as assessed by peak oxygen uptake (pVO(2), mL/kg/min: 22.1+/-6.6 vs 33.8+/-8.3; P<0.001) and anaerobic threshold (mL/kg/min: 13.0+/-3.0 vs 18.7+/-4.6; P<0.001) compared with controls. No ventilatory limitation to exercise was noted in TM patients (VE/VCO(2) slope: 23.4+/-3.2 vs 27.8+/-2.6; P<0.001 and breathing reserve, %: 42.9+/-17.0 vs 29.5+/-12.0; P<0.005) and no difference in oxygen cost of work (peak VO(2)/WR, mL/min W: 12.2+/-1.7 vs 12.2+/-1.5; P=NS). Delayed recovery oxygen kinetics after exercise was observed in TM patients (VO(2)/t slope, mL/kg/min(2): 0.67+/-0.27 vs 0.93+/-0.23; P<0.05) that was significantly correlated with Pimax at rest (r: 0.81; P<0.001). The latter was also significantly correlated to pVO(2) (r: 0.84; P<0.001) and inversely correlated to ferritin levels (r: -0.6; P<0.02). Exercise capacity is markedly reduced in TM patients and this reduction is highly associated with the limited functional status of peripheral muscles.

Predisposing factors for critical illness polyneuromyopathy in a multidisciplinary intensive care unit

OBJECTIVE

To investigate risk factors of critical illness polyneuromyopathy (CIPM) in a general multidisciplinary intensive care unit (ICU).

PATIENTS AND METHODS

Prospective observational study in a 28-bed university multidisciplinary ICU. Four hundred and seventy-four (323 M/151 F, age 55 +/- 19) consecutive patients were prospectively evaluated. All patients were assigned admission Acute Physiology and Chronic Health Evaluation (APACHE II; 15 +/- 7) and Sequential Organ Failure Assessment (SOFA; 6 +/- 3) scores and were subsequently evaluated for newly developed neuromuscular weakness. Other potential causes of new-onset weakness after ICU admission were excluded before CIPM was diagnosed.

RESULTS

Forty-four (23.8%) of 185 patients developed generalized weakness that met the criteria for CIPM. Patients with CIPM had higher APACHE II (18.9 +/- 6.6 vs 15.6 +/- 6.4, P = 0.004) and SOFA scores (8.4 +/- 2.9 vs 7.1 +/- 2.9, P = 0.013). According to multivariate logistic regression analysis, the following risk factors were independently associated with the development of CIPM: severity of illness at the time of ICU admission, administration of aminoglycoside antibiotics and high blood glucose levels. Analysis according to severity of illness stratification revealed the emergence of Gram (-) bacteremia as the most important independent predisposing factor for CIPM development in less severely ill patients.

CONCLUSIONS

CIPM has a high incidence in the ICU setting. Our study revealed the association of aminoglycosides, hyperglycemia and illness severity with CIPM development, as well as the association between Gram (-) bacteremia and development of CIPM in less severely ill patient population.

Propofol-induced hyperamylasaemia in a general intensive care unit

This study examined the incidence of hyperamylasaemia, in the absence of other plausible causes of pancreatic dysfunction, in intensive care unit (ICU) patients who received propofol. One-hundred-and-seventy-two consecutive patients of a general ICU who stayed for more than 24 hours were studied. Patients with a diagnosis consistent with elevated serum amylase levels at admission were excluded from the study, as were patients who had received medications known to raise serum amylase levels. Forty-four patients 53 +/- 20 years of age and median duration of ICU stay of five days (range two to 55) were eligible. Thirty of those, aged 54 +/- 21 years and median duration of ICU stay of five days (range two to 27) received continuous infusion of propofol for sedation (maximum dose 45 microg/kg/min). Of the 30 patients who received propofol, 16 (53%) developed hyperamylasaemia (125 to 466 IU/l) after two to nine days of continuous infusion. Liver and kidney function remained normal throughout the observation period. Of the 14 patients who did not receive propofol (aged 51 +/- 18 years), only two (14%) developed hyperamylasaemia, a significantly lower incidence (P = 0.021). Propofol infusion is associated with biochemical evidence of pancreatic injury. Amylase levels monitoring of propofol-sedated patients is warranted.

A multidisciplinary overview of cardiogenic shock

Cardiogenic shock complicating acute myocardial infarction (AMI) is reviewed from multidisciplinary viewpoints encompassing both basic and clinical aspects. Insights into the absolute obligate aerobic nature of the heart which possesses neither facultative capability nor functional collateral channels, together with O2 diffusion gradients, mitochondrial O2 sensing and anaerobic ATP deficiencies, are described in some detail. Myocardial adaptive responses against energy crisis, termed the Pasteur Effect, and hypoxia inducible factor (HIF)-1 alpha are implicated for cardiomyocyte viability. Oncosis and/or lysosomal autophagy cause such overwhelming numbers (several billions) of cardiomyocyte death, virtually simultaneously following coronary thrombotic occlusion. Apoptosis is briefly described and cardiogenic shock is discussed in terms of the diagnostic criteria by MIRU, unique hemodynamic manifestations, infarct sizes and border zone extension, and potentially jeopardized myocardium in the remote areas. Reperfusion injury, i.e., reactive oxygen species (ROS), is noted as a double-edged sword. The importance of early revascularization by means of PCI, CABG, and IABP support is emphasized according to current guidelines. For innovative promise in the future, de novo development of collateral channels by growth factors and trials of stem cell implantation aimed at myocardial regeneration are introduced.