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Comment on 'Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with haematological malignancies' by Vandijck et al.
Content Type: Journal ArticleCategory CorrespondenceDOI 10.1007/s00134-008-1222-5
Authors
Sascha Meyer, University Hospital of Saarland Department of Paediatrics and Paediatric Intensive Care Medicine 66421 Homburg GermanyLudwig Gortner, University Hospital of Saarland Department of Paediatrics and Paediatric Intensive Care Medicine 66421 Homburg GermanySven Gottschling, University Hospital of Saarland Department of Paediatric Hematology and Oncology Homburg Germany
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with haematological malignancies: reply to letter by Meyer et al.
Content Type: Journal ArticleCategory CorrespondenceDOI 10.1007/s00134-008-1223-4
Authors
Dominique M. Vandijck, Ghent University, Ghent University Hospital Department of Intensive Care Medicine, Faculty of Medicine and Health Sciences De Pintelaan 185 9000 Ghent BelgiumDominique D. Benoit, Ghent University, Ghent University Hospital Department of Intensive Care Medicine, Faculty of Medicine and Health Sciences De Pintelaan 185 9000 Ghent Belgium
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective The objective of this study was to identify the definitional criteria for the pressure-limited and time-cycled modes: airway
pressure release ventilation (APRV) and biphasic positive airway pressure (BIPAP) available in the published literature.
Design Systematic review.
Methods Medline, PubMed, Cochrane, and CINAHL databases (1982 – 2006) were searched using the following terms: APRV, BIPAP, Bilevel
and lung protective strategy, individually and in combination. Two independent reviewers determined the paper eligibility
and abstracted data from 50 studies and 18 discussion articles.
Measurements and results Of the 50 studies, 39 (78%) described APRV, and 11 (22%) described BIPAP. Various study designs, populations, or outcome measures
were investigated. Compared to BIPAP, APRV was described more frequently as extreme inverse inspiratory:expiratory ratio [18/39
(46%) vs. 0/11 (0%),
P = 0.004] and used rarely as a noninverse ratio [2/39 (5%) vs. 3/11 (27%),
P = 0.06]. One (9%) BIPAP and eight (21%) APRV studies used mild inverse ratio (>1:1 to =2:1) (
P = 0.7), plus there was increased use of 1:1 ratio [7 (64%) vs. 12 (31%),
P = 0.08] with BIPAP. In adult studies, the mean reported set inspiratory pressure (PHigh) was 6 cm H
2O greater with APRV when compared to reports of BIPAP (
P = 0.3). For both modes, the mean reported positive end expiratory pressure (PLow) was 5.5 cm H
2O. Thematic review identified inconsistency of mode descriptions.
Conclusions Ambiguity exists in the criteria that distinguish APRV and BIPAP. Commercial ventilator branding may further add to confusion.
Generic naming of modes and consistent definitional parameters may improve consistency of patient response for a given mode
and assist with clinical implementation.
Content Type: Journal ArticleCategory ReviewDOI 10.1007/s00134-008-1216-3
Authors
Louise Rose, University of Toronto Lawrence S. Bloomberg Faculty of Nursing 155 College Street, Room 276 Toronto ON M5T 1P8 CanadaMartyn Hawkins, Stirling Royal Infirmary Intensive Care Unit Stirling Scotland, UK
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective Neurally adjusted ventilatory assist (NAVA) is a new mode wherein the assistance is provided in proportion to diaphragm electrical
activity (EAdi). We assessed the physiologic response to varying levels of NAVA and pressure support ventilation (PSV).
Setting ICU of a University Hospital.
Patients Fourteen intubated and mechanically ventilated patients.
Design and protocol Cross-over, prospective, randomized controlled trial. PSV was set to obtain a
V
t/kg of 6 – 8 ml/kg with an active inspiration. NAVA was matched with a dedicated software. The assistance was decreased and
increased by 50% with both modes. The six assist levels were randomly applied.
Measurements Arterial blood gases (ABGs), tidal volume (
V
t/kg), peak EAdi, airway pressure (Paw), neural and flow-based timing. Asynchrony was calculated using the asynchrony index
(AI).
Results There was no difference in ABGs regardless of mode and assist level. The differences in breathing pattern, ventilator assistance,
and respiratory drive and timing between PSV and NAVA were overall small at the two lower assist levels. At the highest assist
level, however, we found greater
V
t/kg (9.1 ± 2.2 vs. 7.1 ± 2 ml/kg,
P < 0.001), and lower breathing frequency (12 ± 6 vs. 18 ± 8.2,
P < 0.001) and peak EAdi (8.6 ± 10.5 vs. 12.3 ± 9.0,
P < 0.002) in PSV than in NAVA; we found mismatch between neural and flow-based timing in PSV, but not in NAVA. AI exceeded
10% in five (36%) and no (0%) patients with PSV and NAVA, respectively (
P < 0.05).
Conclusions Compared to PSV, NAVA averted the risk of over-assistance, avoided patient – ventilator asynchrony, and improved patient – ventilator
interaction.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1208-3
Authors
Davide Colombo, Università degli Studi del Piemonte Orientale 'A. Avogadro', SCDU Anestesia, Terapia Intensiva e Rianimazione Generale, Azienda Ospedaliera Universitaria 'Maggiore della Carità' C.so Mazzini 18 28100 Novara ItalyGianmaria Cammarota, Università degli Studi del Piemonte Orientale 'A. Avogadro', SCDU Anestesia, Terapia Intensiva e Rianimazione Generale, Azienda Ospedaliera Universitaria 'Maggiore della Carità' C.so Mazzini 18 28100 Novara ItalyValentina Bergamaschi, Università degli Studi del Piemonte Orientale 'A. Avogadro', SCDU Anestesia, Terapia Intensiva e Rianimazione Generale, Azienda Ospedaliera Universitaria 'Maggiore della Carità' C.so Mazzini 18 28100 Novara ItalyMarta De Lucia, Università degli Studi del Piemonte Orientale 'A. Avogadro', SCDU Anestesia, Terapia Intensiva e Rianimazione Generale, Azienda Ospedaliera Universitaria 'Maggiore della Carità' C.so Mazzini 18 28100 Novara ItalyFrancesco Della Corte, Università degli Studi del Piemonte Orientale 'A. Avogadro', SCDU Anestesia, Terapia Intensiva e Rianimazione Generale, Azienda Ospedaliera Universitaria 'Maggiore della Carità' C.so Mazzini 18 28100 Novara ItalyPaolo Navalesi, Università degli Studi del Piemonte Orientale 'A. Avogadro', SCDU Anestesia, Terapia Intensiva e Rianimazione Generale, Azienda Ospedaliera Universitaria 'Maggiore della Carità' C.so Mazzini 18 28100 Novara Italy
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Protein C concentrate in adult septic patients
Content Type: Journal ArticleCategory CorrespondenceDOI 10.1007/s00134-008-1211-8
Authors
Alex P. Betrosian, Athens University Evgenidion Hospital, 3rd Department of Critical Care 20, Papadiamantopoulou Str Athens 11528 GreeceNikolaos Memos, Athens University Hippokration General Hospital, 1st Department of Propedeutic Surgery Athens GreeceGeorge Theoddossiades, Hippokration General Hospital, First Regional Transfusion and Haemophilia Centre Athens GreeceEmmanuel E. Douzinas, Athens University Evgenidion Hospital, 3rd Department of Critical Care 20, Papadiamantopoulou Str Athens 11528 Greece
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
NAVA: brain over machine?
Content Type: Journal ArticleCategory EditorialDOI 10.1007/s00134-008-1215-4
Authors
Franco Laghi, Edward Hines Jr. VA Hospital and Loyola University Medical Center, Pulmonary and Critical Care Medicine 5th Ave and Roosevelt Rd Mail Route 111N Hines IL 60141 USA
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Background/purpose Children receiving extracorporeal membrane oxygenation (ECMO) for respiratory failure can have significant fluid overload
and renal insufficiency. Addition of inline continuous venovenous hemofiltration (CVVH) could provide additional benefits
in fluid management compared to use of standard medical therapies with ECMO.
Methods Patients with pediatric respiratory failure receiving ECMO with CVVH were case-matched to similar patients receiving ECMO
without CVVH to compare fluid balance, medication use, and clinical outcomes.
Results Twenty-six of eighty-six patients with pediatric respiratory failure on ECMO (30%) received CVVH for >24 h (median 7.5 days
on CVVH). Survival was not significantly different between patients receiving CVVH and those who did not receive CVVH (
P = 0.51). For ECMO survivors receiving CVVH, overall fluid balance was less than that in non-CVVH survivors (median 25.1 ml kg
-1 day
-1; range -40.2 to 71.2 vs. 40.2, 1.1 to 134.9;
P = 0.028). Time to desired caloric intake was faster in patients receiving CVVH (1 day, 1 – 5) than in patients who did not
receive CVVH (5 days; 1 – 11;
P < 0.001). Patients receiving CVVH – ECMO also received less furosemide (0.67 vs. 2.11 mg kg
-1 day
-1;
P = 0.009).
Conclusions Use of CVVH in ECMO was associated with improved fluid balance and caloric intake and less diuretics than in case-matched
ECMO controls.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1200-y
Authors
Nancy G. Hoover, Walter Reed Army Medical Center Department of Pediatrics Washington DC USAMichael Heard, Children's Healthcare of Atlanta at Egleston Division of ECMO and Advanced Technologies Atlanta GA USAChristopher Reid, Children's Healthcare of Atlanta at Egleston Division of ECMO and Advanced Technologies Atlanta GA USAScott Wagoner, Children's Healthcare of Atlanta at Egleston Division of ECMO and Advanced Technologies Atlanta GA USAKristine Rogers, Children's Healthcare of Atlanta at Egleston Division of Clinical Research Atlanta GA USAJason Foland, Nemours Children's Clinic Pediatric Critical Care Pensacola FL USAMatthew L. Paden, Emory University School of Medicine Department of Pediatrics Atlanta GA USAJames D. Fortenberry, Emory University School of Medicine Department of Pediatrics Atlanta GA USA
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Background The role of immuno-modulating diets (IMDs) in critically ill patients is controversial.
Objective The goal of this meta-analysis was to determine the impact of IMD's on hospital mortality, nosocomial infections and length
of stay (LOS) in critically ill patients. Outcome was stratified according to type of IMD and patient setting.
Data sources MEDLINE, Embase, Cochrane Register of Controlled Trials.
Study selection RCT's that compared the outcome of critically ill patients randomized to an IMD or a control diet.
Data synthesis Twenty-four studies (with a total of 3013 patients) were included in the meta-analysis; 12 studies included ICU patients,
5 burn patients and 7 trauma patients. Four of the studies used formulas supplemented with arginine, two with arginine and
glutamine, nine with arginine and fish oil (FO), two with arginine, glutamine and FO, six with glutamine alone and three studies
used a formula supplemented with FO alone. Overall IMD's had no effect on mortality or LOS, but reduced the number of infections
(OR 0.63; 95% CI 0.47 – 0.86,
P = 0.004,
I
2 = 49%). Mortality, infections and LOS were significantly lower only in the ICU patients receiving the FO IMD (OR 0.42, 95%
CI 0.26 – 0.68; OR 0.45, 95% CI 0.25 – 0.79 and WMD -6.28 days, 95% CI -9.92 to -2.64, respectively).
Conclusions An IMD supplemented with FO improved the outcome of medical ICU patients (with SIRS/sepsis/ARDS). IMDs supplemented with arginine
with/without additional glutamine or FO do not appear to offer an advantage over standard enteral formulas in ICU, trauma
and burn patients.
Content Type: Journal ArticleCategory ReviewDOI 10.1007/s00134-008-1213-6
Authors
Paul E. Marik, Thomas Jefferson University Division of Pulmonary and Critical Care Medicine 834 Walnut Street, Suite 650 Philadelphia PA 19107 USAGary P. Zaloga, Baxter Healthcare Deerfield IL USA
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective Recent evidence demonstrated that hypercapnic acidosis due to lung protective strategy was not only permissive but also even
therapeutic for injured lung. Since the effects of hypercapnic acidosis on extra-pulmonary organs remain to be clarified,
we tested the hypothesis that hypercapnic acidosis protects gut mucosal barrier function by modulating inflammation in a rabbit
model of endotoxemia.
Design Prospective randomized animal study.
Setting University research laboratory.
Subjects Male New Zealand white rabbits.
Interventions Thirty-two animals were randomly allocated into two groups: normocapnia (
n = 17) and hypercapnia (
n = 15). The latter group received F
ICO
2 5% under mechanical ventilation to achieve hypercapnia throughout the study periods, whereas the former with F
ICO
2 0%.
Measurements and results Arterial blood gas, intramucosal pH (pHi) and portal blood flow were assessed at baseline, 2-h and 4-h infusion of lipopolysaccharide.
At 4 h, ileal myeloperoxidase (MPO) activity and intestinal permeability were measured. The animals in the hypercapnia group
showed apparent hypercapnic acidosis and progressive intramucosal acidosis at 4 h, accompanied by significantly lower intestinal
permeability versus normocapnia group. Ileal MPO activity was comparable between the study groups.
Conclusions Hypercapnic acidosis attenuates endotoxin-induced gut barrier dysfunction possibly through neutrophil-independent mechanisms.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1212-7
Authors
Hiroshi Morisaki, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 JapanSatoshi Yajima, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 JapanYoko Watanabe, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 JapanTakeshi Suzuki, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 JapanMichiko Yamamoto, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 JapanNobuyuki Katori, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 JapanSaori Hashiguchi, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 JapanJunzo Takeda, Keio University School of Medicine Department of Anesthesiology 35 Shinanomachi, Shinjuku-ku Tokyo 160-8582 Japan
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Background Patients with pulmonary embolism (PE) have a high risk of death, and it is important to recognize factors associated with
higher mortality. Recently, several biomarkers have been studied for risk stratification in patients with PE.
Objectives Evaluate the available evidence on (a) the accuracy of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic
peptide (NT-proBNP) for the diagnosis of right ventricular dysfunction and (b) their value as a prognostic factor of all-cause
in-hospital or short-term mortality in patients with PE.
Data sources MEDLINE, Embase, and citation review of relevant primary and review articles.
Selection criteria We selected studies evaluating the accuracy of BNP or NT-proBNP for the diagnosis of right ventricular dysfunction. We also
selected studies that reported data on BNP or NT-proBNP as a predictor of short-term mortality in patients with PE.
Results Sixteen studies met our inclusion criteria. The pooled diagnostic odds ratio for the diagnosis of right ventricular dysfunction
in pulmonary embolism was 39.45 (95% CI; 15.54 – 100.12) and 24.73 (95% CI 2.02 – 302.37) for BNP and NT-proBNP, respectively.
The pooled odds ratio for all-cause in-hospital or short-term mortality was 6 (95% CI 1.31 – 27.43; p: 0.021) and 16.12 (95%
CI 3.1 – 83.68; p: 0.001) for BNP (cutoff: 100 pg/ml) and NT-proBNP (cutoff: 600 ng/L), respectively.
Conclusion The results of this meta-analysis indicate that BNP and NT-proBNP are associated with the diagnosis of right ventricular dysfunction
(RVD) in patients with an acute PE and are significant predictors of all-cause in-hospital or short-term mortality in these
patients.
Content Type: Journal ArticleCategory ReviewDOI 10.1007/s00134-008-1214-5
Authors
Rodrigo Cavallazzi, Thomas Jefferson University Division of Pulmonary and Critical Care Medicine 834 Walnut Street, Suite 650 Philadelphia PA 19107 USAAbhilash Nair, Thomas Jefferson University Division of Pulmonary and Critical Care Medicine 834 Walnut Street, Suite 650 Philadelphia PA 19107 USATajender Vasu, Thomas Jefferson University Division of Pulmonary and Critical Care Medicine 834 Walnut Street, Suite 650 Philadelphia PA 19107 USAPaul E. Marik, Thomas Jefferson University Division of Pulmonary and Critical Care Medicine 834 Walnut Street, Suite 650 Philadelphia PA 19107 USA
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective To assess the risk factors associated with CR-BSI development in critically ill patients with non-tunneled, non-cuffed central
venous catheters (CVC) and the prognosis of the episodes of CR-BSI. Design and setting; prospective, observational, multicenter
study in nine Spanish Hospitals.
Patients All subjects admitted to the participating ICUs from October 2004 to June 2005 with a CVC.
Measurement and results Overall, 1,366 patients were enrolled and 2,101 catheters were analyzed. Sixty-six episodes of CR-BSI were diagnosed. The
incidence of CR-BSI was significantly higher in CVC compared with peripherically inserted central venous catheters (PICVC)
without significant differences among the three locations of CVC. In the multivariate analysis, duration of catheterization
and change over a guidewire were the independent variables associated with the development of CR-BSI whereas the use of a
PICVC was a protective factor. Excluding PICVC, 1,598 conventional CVC were analyzed. In this subset, duration of catheterization,
tracheostomy and change over a guidewire were independent risk factors for CR-BSI. A multivariate analysis of predictors for
mortality among 66 patients with CRSI showed that early removal of the catheter was a protective factor and APACHE II score
at the admission was a strong determinant of in-hospital mortality.
Conclusions Peripherically inserted central venous catheters is associated with a lower incidence of CR-BSI in critically ill patients.
Exchange over a guidewire of CVC and duration of catheterization are strong contributors to CR-BSI. Our results reinforce
the importance of early catheter removal in critically ill patients with CR-BSI.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1204-7
Authors
Jose Garnacho-Montero, Hospital Virgen del Rocio Intensive Care Unit Sevilla SpainTeresa Aldabó-Pallás, Hospital Virgen del Rocio Intensive Care Unit Sevilla SpainMercedes Palomar-Martínez, Hospital de la Vall d'Hebron Intensive Care Unit Barcelona SpainJordi Vallés, Hospital Hospital Parc Tauli Intensive Care Unit Sabadell (Barcelona) SpainBenito Almirante, Hospital de la Vall d'Hebron Infectious Diseases Service Barcelona SpainRafael Garcés, Hospital de la Ribera Intensive Care Unit Alcira (Valencia) SpainFabrio Grill, Hospital Ramon y Cajal Microbiology Service Madrid SpainMiquel Pujol, Hospital de Bellvitge Infectious Diseases Service Barcelona SpainCristina Arenas-Giménez, Hospital Gregorio Marañon Microbiology Service Madrid SpainEduard Mesalles, Hospital Germans Trias y Pujol Intensive Care Unit Badalona (Barcelona) SpainAna Escoresca-Ortega, Hospital Virgen del Rocio Intensive Care Unit Sevilla SpainMarina de Cueto, Hospital Virgen Macarena Microbiology Service Sevilla SpainCarlos Ortiz-Leyba, Hospital Virgen del Rocio Intensive Care Unit Sevilla Spain
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective Ultrasound guidance (USG) for internal jugular cannulation is the best solution in difficult settings where paediatric patients
are involved. This is an outcome study on efficacy and complications of the USG for the internal jugular vein (IJV) cannulation
in neurosurgical infants as well as an ultrasound study of anatomical findings of the IJVs in infants.
Design and settings A prospective study conducted in two Academic Neurosurgical hospitals.
Participants In 191 babies (body weight <15 kg), anatomical findings were studied. We performed CVC echo guided placement in 135/191 infants
(weighting <10 kg).
Results After a brief training period, both institutions adopted a common protocol and USG device. We obtained successful cannulation
in all patients. Carotid puncture (1.5%) was the only main complication registered and minor complications were poor. Time
required for cannulation was 12.5 ± 5.7 min. Anatomical findings (in 191 patients) were IJV laterality in 34.6% cases, IJV
antero-lateral in 59.7% and anterior in 5.7%. A linear relation was found between weight and internal jugular vein diameter
even if
R
2 = 0.43 and the model cannot be used to predict the exact size of the vein. In 62/135 babies weighting <10 kg, anatomical
measurements were done in supine and Trendelemburg position. Trendelemburg position increases significantly (
P < 0.001) IJV diameter, but not IJV depth.
Conclusions We considered ultrasound guidance as the first choice in infants because it can enhance IJV cannulation success, safety, and
allows one to measure relationships and diameter of the IJV and optimise the central line positioning.
Content Type: Journal ArticleCategory Pediatric OriginalDOI 10.1007/s00134-008-1210-9
Authors
M. Lamperti, National Neurological Institute 'C. Besta' Department of Neuroanaesthesiology Via Celoria 11 20133 Milan ItalyD. Caldiroli, National Neurological Institute 'C. Besta' Department of Neuroanaesthesiology Via Celoria 11 20133 Milan ItalyP. Cortellazzi, National Neurological Institute 'C. Besta' Department of Neuroanaesthesiology Via Celoria 11 20133 Milan ItalyD. Vailati, National Neurological Institute 'C. Besta' Department of Neuroanaesthesiology Via Celoria 11 20133 Milan ItalyA. Pedicelli, Catholic University Medical School Department of Bioimaging and Radiological Sciences Rome ItalyF. Tosi, Catholic University Medical School Paediatric Intensive Care Unit Rome ItalyM. Piastra, Catholic University Medical School Paediatric Intensive Care Unit Rome ItalyD. Pietrini, Catholic University Medical School Paediatric Intensive Care Unit Rome Italy
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
'Host tissue damage' signal ATP impairs IL-12 and IFN? secretion in LPS stimulated whole human blood
Content Type: Journal ArticleCategory ErratumDOI 10.1007/s00134-008-1196-3
Authors
Marek Nalos, University of Sydney Department of Intensive Care, Nepean Hospital P.O. Box 63 Penrith NSW 2750 AustraliaStephen Huang, University of Sydney Department of Intensive Care, Nepean Hospital P.O. Box 63 Penrith NSW 2750 AustraliaRonald Sluyter, University of Sydney Department of Medicine, Nepean Clinical School P.O. Box 63 Penrith NSW 2750 AustraliaAlamgir Khan, Macquarie University Australian Proteome Analysis Facility (APAF) Level 4, Building F7B, Research Park Drive Sydney NSW 2109 AustraliaBrigitte Santner-Nanan, University of Sydney Department of Paediatrics, Nepean Clinical School P.O. Box 63 Penrith NSW 2750 AustraliaRalph Nanan, University of Sydney Department of Pediatrics, Nepean Hospital P.O. Box 63 Penrith NSW 2750 AustraliaAnthony S. McLean, University of Sydney Department of Intensive Care, Nepean Hospital P.O. Box 63 Penrith NSW 2750 Australia
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective We propose that higher airway occlusion pressure (P0.1) responses to hypercapnic challenge (HC) indicate less severe injury.
The study aim was to determine whether P0.1 responses to HC were associated with successful weaning after prolonged mechanical
ventilation (PMV) in patients with brainstem lesions and to determine a reference value for clinical use.
Design and setting Forty-two patients with brainstem lesions on PMV were recruited. Breathing parameters and P0.1 were measured before HC. Three-minute
HC challenges with increasing CO
2 concentrations were initiated and P0.1, respiratory rate, minute ventilation (
V
e), tidal volume (
V
t) and end tidal CO
2 were measured.
Measurements and results Patients were classified into high (group I) and low (group II) response groups on the basis of P0.1 responses to HC. Increases
in
V
e and
V
t after HC were significantly greater in group I patients (12.22 ± 8.22 vs. 3.08 ± 4.84 L/min,
P < 0.001 and 399.11 ± 278.18 vs. 110.54 ± 18.275 ml,
P < 0.001). P0.1 levels were significantly higher in group I compared to group II before HC (2.69 ± 1.81 vs. 1.28 ± 1.04 cmH
2O,
P = 0.003). The increase in P0.1 following HC was significantly greater in group I compared to group II patients (11.05 ± 4.06
vs. 2.90 ± 2.53 cmH
2O,
P < 0.001). Weaning success was significantly higher in group I compared to group II patients (72.2% vs. 33.3%,
P = 0.02). A P0.1 increase of >6 cmH
2O following HC was significantly associated with successful weaning.
Conclusions Assessing the P.01 response to serial increases in the level of HC may be a safe means to ascertain whether patients with
brainstem lesions are ready for ventilator weaning.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1197-2
Authors
Yao-Kuang Wu, Buddhist Tzu Chi General Hospital Division of Pulmonary and Critical Care Medicine Taipei TaiwanChih-Hsin Lee, Buddhist Tzu Chi General Hospital Division of Pulmonary and Critical Care Medicine Taipei TaiwanBen-Chang Shia, Fu Jen Catholic University Department of Statistics and Information Science Taipei TaiwanYing-Huang Tsai, Chang Gung Memorial Hospital Division of Pulmonary and Critical Care Medicine Taoyuan TaiwanThomas C. Y. Tsao, Chung Shan University Hospital and Chung Shan Medical University Division of Thoracic Medicine 110 Sec. 1 Chien-Kuo N. Road Taichung 402 Taiwan
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective Imbalance of the renal medullary oxygen supply/demand relationship can cause hypoxic medullary damage and ischaemic acute
renal failure (ARF). The use of mannitol for prophylaxis/treatment of clinical ischaemic ARF is controversial and the effect
of mannitol on renal oxygenation in man has not yet been investigated. We evaluated the effects of mannitol on renal oxygen
consumption (RVO
2)
, renal blood flow (RBF) and glomerular filtration rate (GFR) in postoperative patients.
Design Prospective interventional study.
Setting University hospital cardiothoracic ICU.
Patients Ten uncomplicated mechanically ventilated and sedated postcardiac surgery patients with preoperatively normal renal function.
Interventions Mannitol infusion (225 mg/kg + 75 mg/kg/h) and combined mannitol and furosemide infusion (0.25 mg/kg + 0.25 mg/kg/h).
Measurements and results Systemic haemodynamics were evaluated by a pulmonary artery catheter. RBF and GFR were measured by the renal vein thermodilution
technique and by renal extraction of
51Cr – EDTA, respectively. Mannitol increased urine flow (60%), GFR (20%) and filtration fraction (FF) (20%) with no change in
RBF. This was accompanied by an increase in renal sodium reabsorption (18%), RVO
2 (19%) and renal oxygen extraction (21%). When combined with mannitol, furosemide normalised sodium reabsorption, RVO
2, renal oxygen extraction with no change in RBF, while GFR and FF were still elevated compared to control.
Conclusions In patients with normal renal function, mannitol increases GFR, which increases tubular sodium load, sodium reabsorption and
RVO
2 after cardiac surgery. The lack of effect on RBF, indicates that mannitol impairs the renal oxygen supply/demand relationship.
Furosemide normalised renal oxygenation when combined with mannitol.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1206-5
Authors
Bengt Redfors, Sahlgrenska University Hospital Department of Cardiothoracic Anaesthesia and Intensive Care 41345 Göteborg SwedenKristina Swärd, Sahlgrenska University Hospital Department of Cardiothoracic Anaesthesia and Intensive Care 41345 Göteborg SwedenJohan Sellgren, Sahlgrenska University Hospital Department of Cardiothoracic Anaesthesia and Intensive Care 41345 Göteborg SwedenSven-Erik Ricksten, Sahlgrenska University Hospital Department of Cardiothoracic Anaesthesia and Intensive Care 41345 Göteborg Sweden
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Acute decompensation of isovaleric acidemia induced by Graves' disease
Content Type: Journal ArticleCategory CorrespondenceDOI 10.1007/s00134-008-1192-7
Authors
Antoine Kimmoun, INSERM U 724 Hôpital Brabois, CHU de Nancy Children's Hospital, Centre de référence des maladies héréditaires du métabolisme 54500 Vandoeuvre les Nancy FranceGeorges Abboud, Hôpital Bel-Air Service de Réanimation Polyvalente Thionville FranceJean Strazeck, INSERM U 724 Hôpital Brabois, CHU de Nancy Children's Hospital, Centre de référence des maladies héréditaires du métabolisme 54500 Vandoeuvre les Nancy FranceMarc Merten, INSERM U 724 Hôpital Brabois, CHU de Nancy Children's Hospital, Centre de référence des maladies héréditaires du métabolisme 54500 Vandoeuvre les Nancy FranceJean-Louis Guéant, INSERM U 724 Hôpital Brabois, CHU de Nancy Children's Hospital, Centre de référence des maladies héréditaires du métabolisme 54500 Vandoeuvre les Nancy FranceFrançois Feillet, INSERM U 724 Hôpital Brabois, CHU de Nancy Children's Hospital, Centre de référence des maladies héréditaires du métabolisme 54500 Vandoeuvre les Nancy France
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective To test the hypothesis that, in resuscitated septic shock patients, central venous-to-arterial carbon dioxide difference [P(cv-a)CO
2] may serve as a global index of tissue perfusion when the central venous oxygen saturation (ScvO
2) goal value has already been reached.
Design Prospective observational study.
Setting A 22-bed intensive care unit (ICU).
Patients After early resuscitation in the emergency unit, 50 consecutive septic shock patients with ScvO
2 > 70% were included immediately after their admission into the ICU (T0). Patients were separated in Low P(cv-a)CO
2 group (Low gap;
n = 26) and High P(cv-a)CO
2 group (High gap;
n = 24) according to a threshold of 6 mmHg at T0.
Measurements Measurements were performed every 6 h over 12 h (T0, T6, T12).
Results At T0, there was a significant difference between Low gap patients and High gap patients for cardiac index (CI) (4.3 ± 1.6
vs. 2.7 ± 0.8 l/min/m²,
P < 0.0001) but not for ScvO
2 values (78 ± 5 vs. 75 ± 5%,
P = 0.07). From T0 to T12, the clearance of lactate was significantly larger for the Low gap group than for the High gap group
(
P < 0.05) as well as the decrease of SOFA score at T24 (
P < 0.01). At T0, T6 and T12, CI and P(cv-a)CO
2 values were inversely correlated (
P < 0.0001).
Conclusion In ICU-resuscitated patients, targeting only ScvO
2 may not be sufficient to guide therapy. When the 70% ScvO
2 goal-value is reached, the presence of a P(cv-a)CO
2 larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1199-0
Authors
Fabrice Vallée, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse FranceBenoit Vallet, Université Lille II Pôle d'Anesthésie et Réanimation, Hôpital Huriez CHU de Lille FranceOlivier Mathe, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse FranceJacqueline Parraguette, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse FranceArnaud Mari, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse FranceStein Silva, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse FranceKamran Samii, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse FranceOlivier Fourcade, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse FranceMichèle Genestal, Université Paul Sabatier Pôle d'Anesthésie et Réanimation, Unité de Réanimation Polyvalente de Purpan, GRCB 48 CHU de Toulouse France
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Purpura fulminans
due to imported falciparum malaria
Content Type: Journal ArticleCategory CorrespondenceDOI 10.1007/s00134-008-1188-3
Authors
Philippe Corne, Université de Montpellier 1 Service de Réanimation Médicale, Hôpital Gui de Chauliac, Centre Hospitalier Universitaire de Montpellier 80 avenue Augustin Fliche 34295 Montpellier Cedex 5 FranceFabrice Bruneel, Hôpital André Mignot, Centre Hospitalier de Versailles Service de Réanimation Médico-Chirurgicale 177, rue de Versailles 78150 Le Chesnay FranceChristine Biron-Andreani, Centre Hospitalier Universitaire de Montpellier Laboratoire d'Hématologie, Hôpital Saint-Eloi 80 avenue Augustin Fliche 34295 Montpellier Cedex 5 FranceOlivier Jonquet, Université de Montpellier 1 Service de Réanimation Médicale, Hôpital Gui de Chauliac, Centre Hospitalier Universitaire de Montpellier 80 avenue Augustin Fliche 34295 Montpellier Cedex 5 France
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objectives It is not known if proportional assist ventilation with load-adjustable gain factors (PAV+) may be used as a mode of support
in critically ill patients. The aim of this study was to examine the effectiveness of sustained use of PAV+ in critically
ill patients and compare it with pressure support ventilation (PS).
Design and setting Randomized study in the intensive care unit of a university hospital.
Methods A total of 208 critically ill patients mechanically ventilated on controlled modes for at least 36 h and meeting certain criteria
were randomized to receive either PS (
n = 100) or PAV+ (
n = 108). Specific written algorithms were used to adjust the ventilator settings in each mode. PAV+ or PS was continued for
48 h unless the patients met pre-defined criteria either for switching to controlled modes (failure criteria) or for breathing
without ventilator assistance.
Results Failure rate was significantly lower in PAV+ than that in PS (11.1 vs. 22.0%,
P = 0.040, OR 0.443, 95% CI 0.206 – 0.952). The proportion of patients exhibiting major patient – ventilator dyssynchronies at
least during one occasion and after adjusting the initial ventilator settings, was significantly lower in PAV+ than in PS
(5.6 vs. 29.0%,
P < 0.001, OR 0.1, 95% CI 0.06 – 0.4). The proportion of patients meeting criteria for unassisted breathing did not differ between
modes.
Conclusions PAV+ may be used as a useful mode of support in critically ill patients. Compared to PS, PAV+ increases the probability of
remaining on spontaneous breathing, while it considerably reduces the incidence of patient – ventilator asynchronies.
Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1209-2
Authors
Nektaria Xirouchaki, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceEumorfia Kondili, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceKaterina Vaporidi, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceGeorge Xirouchakis, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceMaria Klimathianaki, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceGeorge Gavriilidis, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceEvi Alexandopoulou, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceMaria Plataki, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceChristina Alexopoulou, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete GreeceDimitris Georgopoulos, University of Crete Intensive Care Medicine Department, University Hospital of Heraklion, Medical School Heraklion Crete Greece
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
Abstract
Objective To compare the lithium-thermal double indicator dilution (Li-thermal), indocyanine green-thermal double indicator dilution
(ICG-thermal), single thermal indicator dilution (single-thermal) and gravimetric techniques of extravascular lung water volume
(EVLW) measurement in porcine models of acute lung injury.
Design Two animal models designed to invoke a systemic inflammatory response.
Setting Laboratory study.
Subjects A total of 12 immature Deutsches Landschwein pigs.
Interventions Extravascular lung water volume was measured at four time points using Li-thermal, ICG-thermal and single-thermal techniques.
Measurements were performed using existing technology according to manufacturer's instructions. Post-mortem gravimetric EVLW
measurements were performed by measuring wet and dry mass of lung tissue. Measurements were compared using the Bland – Altman
method. Data are presented as mean (SD).
Measurements and main results Data were collected in 12 animals and comparison between all 4 techniques was possible in 10 animals. EVLW measured by gravimetry
was 9.2 (±3.0)ml kg
-1. When compared to gravimetry, both Li-thermal and ICG-thermal techniques showed minimal bias but wide limits of agreement
(LOA) [Li-thermal: bias -1.8 ml kg
-1 (LOA ± 13.1); ICG-thermal bias -1.0 ml kg
-1 (LOA ± 6.6)]. Comparison between the single-thermal and gravimetric methods identified both considerable bias and wide LOA
[+8.5 ml kg
-1 (LOA ± 14.5)].
Conclusion Clinically significant differences between EVLW measurements obtained with the gravimetric method and three in vivo indicator
dilution techniques were identified. While none of the techniques could be considered ideal, the ICG-thermal method appeared
more reliable than either the Li-thermal or single thermal techniques. Further research is required to determine whether the
accuracy of the prototype Li-thermal technique can be improved.
Content Type: Journal ArticleCategory Brief ReportDOI 10.1007/s00134-008-1207-4
Authors
Benjamin Maddison, Barts and The London School of Medicine and Dentistry, Queen Mary University of London Intensive Care Unit, Royal London Hospital Whitechapel London E1 1BB UKRiccardo Giudici, Polo Universitario San Paolo, University of Milan Institute of Anaesthesiology and Intensive Care Medicine Milan ItalyEnrico Calzia, Universitätsklinikum Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung Ulm GermanyChristopher Wolff, Barts and The London School of Medicine and Dentistry, Queen Mary University of London Intensive Care Unit, Royal London Hospital Whitechapel London E1 1BB UKCharles Hinds, Barts and The London School of Medicine and Dentistry, Queen Mary University of London Intensive Care Unit, Royal London Hospital Whitechapel London E1 1BB UKPeter Radermacher, Universitätsklinikum Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung Ulm GermanyRupert M. Pearse, Barts and The London School of Medicine and Dentistry, Queen Mary University of London Intensive Care Unit, Royal London Hospital Whitechapel London E1 1BB UK
Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642
