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Intensive Care Medicine

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Measurement of end-expiratory lung volume by oxygen washin – washout in controlled and assisted mechanically ventilated patients

Abstract

Objective Assessing limits of agreement with helium dilution and repeatability of a new system (lung funcution, LUFU) that measures end-expiratory lung volume (EELV) in mechanically ventilated patients using the O₂ washin (EELV_Win) and washout (EELV_Wout) technique. LUFU consists of an Evita 4 ventilator, a side-stream oxygen analyzer, and a dedicated PC software.

Design and setting Prospective human study in a general ICU of a University hospital.

Patients Thirty-six mechanically ventilated patients.

Interventions We obtained 36 couples of both EELV_Win and EELV_Wout measurements in each patient (5 with healthy lungs, 9 with ALI, 22 with ARDS). Measurements were obtained with patients ventilated either by assisted (ASB, 16 measurements) or controlled (CMV, 20 measurements) ventilation. In 19 of 20 cases in CMV, we obtained helium dilution measurements (EELV_He).

Measurements and results Bias for agreement with EELV_He was -16 ± 156 and 8 ± 161 ml, respectively, for EELV_Win and EELV_Wout. Bias for agreement between EELV_Win and EELV_Wout was 28 ± 78 and 23 ± 168 ml, respectively, for CMV and ASB. During CMV bias for repeatability were 8 ± 92 and 23 ± 165 ml, respectively, for EELV_Win and EELV_Wout. During ASB bias for repeatability were 32 ± 160 and -15 ± 147 ml, respectively, for EELV_Win and EELV_Wout.

Conclusions The LUFU method showed good agreement with helium, and good repeatability during partial and controlled mechanical ventilation. The technique is simple and safe.

Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1218-1Authors N. Patroniti, University of Milano-Bicocca, Ospedale San Gerardo Nuovo dei Tintori Department of Experimental Medicine via Donizetti 106 20052 Monza Milan ItalyM. Saini, University of Milano-Bicocca, Ospedale San Gerardo Nuovo dei Tintori Department of Experimental Medicine via Donizetti 106 20052 Monza Milan ItalyA. Zanella, University of Milano-Bicocca, Ospedale San Gerardo Nuovo dei Tintori Department of Experimental Medicine via Donizetti 106 20052 Monza Milan ItalyD. Weismann, Draegerwerk AG Luebeck GermanyS. Isgrò, University of Milano-Bicocca, Ospedale San Gerardo Nuovo dei Tintori Department of Experimental Medicine via Donizetti 106 20052 Monza Milan ItalyG. Bellani, University of Milano-Bicocca, Ospedale San Gerardo Nuovo dei Tintori Department of Experimental Medicine via Donizetti 106 20052 Monza Milan ItalyG. Foti, Ospedale San Gerardo Nuovo dei Tintori Dipartimento di Medicina perioperatoria via Cadore 48 20052 Monza Milan ItalyA. Pesenti, University of Milano-Bicocca, Ospedale San Gerardo Nuovo dei Tintori Department of Experimental Medicine via Donizetti 106 20052 Monza Milan Italy Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642

Nontuberculous mycobacteria pulmonary infection in medical intensive care unit: the incidence, patient characteristics, and clinical significance

Abstract

Background The clinical significance of nontuberculous mycobacteria (NTM) pulmonary infection in medical intensive care unit (ICU) is still unclear.

Materials and methods We conducted a retrospective study in the medical ICUs of a medical center in Taiwan from January 1999 to June 2007. Patients with NTM isolated from respiratory specimens within 1 month before or during the ICU course were identified. Those who fulfilled the diagnostic criteria of NTM pulmonary infection were identified and compared with patients with NTM colonization and control subjects who were culture-negative for mycobacteria.

Results Among the 5,378 patients admitted to medical ICUs, 2,866 (53.3%) had received mycobacterial culture for respiratory specimens. NTM were isolated from 169 (5.8%) patients. Of them, 47 (27.8%) were considered NTM pulmonary infection. M. avium complex and M. abscessus were the most common pathogens. Within 100 days after ICU admission, significantly more patients with NTM infection died than those with NTM colonization and control subjects (47 vs. 8 vs. 14%, P < 0.001). Twenty-one (49%) patients with NTM pulmonary infection received anti-NTM treatment, with four experiencing adverse effects. Although statistically insignificant, anti-NTM treatment was associated with prolonged survival for those who died in the ICU and shorter ICU stay for those who survived the ICU course.

Conclusion Our findings suggest that NTM pulmonary infection seems to associate with higher mortality in medical ICUs. Anti-NTM treatment is probably associated with a better outcome. Therefore, keeping a high suspicion when NTM is isolated and using careful consideration when starting anti-NTM treatment should be emphasized.

Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1221-6Authors Chin-Chung Shu, National Taiwan University Hospital Department of Internal Medicine Yun-Lin Branch Yun Lin TaiwanChih-Hsin Lee, Buddhist Tzu Chi General Hospital Department of Internal Medicine Taipei Branch Taipei TaiwanJann-Yuan Wang, National Taiwan University Hospital Department of Internal Medicine # 7, Chung-Shan South Road Taipei 100 TaiwanJih-Shuin Jerng, National Taiwan University Hospital Department of Internal Medicine Taipei TaiwanChong-Jen Yu, National Taiwan University Hospital Department of Internal Medicine Taipei TaiwanPo-Ren Hsueh, National Taiwan University Hospital Department of Laboratory Medicine Taipei TaiwanLi-Na Lee, National Taiwan University Hospital Department of Laboratory Medicine Taipei TaiwanPan-Chyr Yang, National Taiwan University Hospital Department of Internal Medicine Taipei Taiwanthe TAMI group Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642

Secretory phospholipase A2 and neonatal respiratory distress: pilot study on broncho-alveolar lavage

Abstract

Purposes Secretory phospholipase A2 hydrolyzes phosphoglycerides and it has been shown to be involved in alveolar inflammation and surfactant degradation. It plays an important role in acute lung injury but it has never been studied in newborn infants. We were aimed to investigate the phospholipase A2 activity in neonatal lung injury and its relationship with ventilatory findings.

Setting Third level university hospital NICU.

Methods We measured phospholipase activity in broncho-alveolar lavage fluid of 21 neonates with hyaline membrane disease, 10 with pneumonia or sepsis and 10 controls, ventilated for extrapulmonary reasons. Fluid was obtained before surfactant administration on the first day of life and phospholipase activity was measured using an ultrasensitive enzymatic method. Before lavage, lung mechanics in pressure controlled synchronized intermittent mandatory ventilation was analyzed.

Results Phospholipase A2 was higher in babies ventilated for sepsis/pneumonia compared to hyaline membrane disease and to control babies. Phospholipase correlated negatively with dynamic compliance, positively with inspired oxygen fraction, mean airway pressure and oxygenation index. These correlations still remained significant after multivariate analysis, adjusting for possible confounding factors. Phospholipase was not correlated with blood and alveolar pH, gestational age, birth weight, blood gases, Apgar score, tidal volume, surfactant need and ventilation time.

Conclusions These are the first data about phospholipase A2 in neonates. The enzyme plays a role in neonatal lung injury, especially in infection related respiratory failure. It is associated with lung stiffness, higher mean airway pressure and need for oxygen.

Content Type: Journal ArticleCategory Pediatric OriginalDOI 10.1007/s00134-008-1224-3Authors Daniele De Luca, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Neonatal Intensive Care Unit, Department of Pediatrics L.go A. Gemelli 8 00168 Rome ItalySilvia Baroni, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Institute of Clinical Biochemistry Rome ItalyGiovanni Vento, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Neonatal Intensive Care Unit, Department of Pediatrics L.go A. Gemelli 8 00168 Rome ItalyMarco Piastra, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Pediatric Intensive Care Unit, Department of Anaesthesiology and Intensive Care Rome ItalyDomenico Pietrini, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Pediatric Intensive Care Unit, Department of Anaesthesiology and Intensive Care Rome ItalyFederica Romitelli, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Institute of Clinical Biochemistry Rome ItalyEttore Capoluongo, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Institute of Clinical Biochemistry Rome ItalyCostantino Romagnoli, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Neonatal Intensive Care Unit, Department of Pediatrics L.go A. Gemelli 8 00168 Rome ItalyGiorgio Conti, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Pediatric Intensive Care Unit, Department of Anaesthesiology and Intensive Care Rome ItalyEnrico Zecca, University Hospital 'A. Gemelli', Catholic University of the Sacred Heart Neonatal Intensive Care Unit, Department of Pediatrics L.go A. Gemelli 8 00168 Rome Italy Intensive Care MedicineOnline ISSN: 1432-1238Print ISSN: 0342-4642

Comment on 'Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with haematological malignancies' by Vandijck et al.

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/s00134-008-1222-5Authors 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.

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/s00134-008-1223-4Authors 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

Airway pressure release ventilation and biphasic positive airway pressure: a systematic review of definitional criteria

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 H₂O 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 H₂O. 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/s00134-008-1216-3Authors 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

Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure

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/s00134-008-1208-3Authors 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

Protein C concentrate in adult septic patients Content Type: Journal ArticleCategory CorrespondenceDOI 10.1007/s00134-008-1211-8Authors 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?

NAVA: brain over machine? Content Type: Journal ArticleCategory EditorialDOI 10.1007/s00134-008-1215-4Authors 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

Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support

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-yAuthors 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

Immunonutrition in critically ill patients: a systematic review and analysis of the literature

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/s00134-008-1213-6Authors 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

Hypercapnic acidosis minimizes endotoxin-induced gut mucosal injury in rabbits

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_ICO₂ 5% under mechanical ventilation to achieve hypercapnia throughout the study periods, whereas the former with F_ICO₂ 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/s00134-008-1212-7Authors 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

Natriuretic peptides in acute pulmonary embolism: a systematic review

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/s00134-008-1214-5Authors 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

Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study

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.

Interventions None.

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/s00134-008-1204-7Authors 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

Safety and efficacy of ultrasound assistance during internal jugular vein cannulation in neurosurgical infants

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/s00134-008-1210-9Authors 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

'Host tissue damage' signal ATP impairs IL-12 and IFN? secretion in LPS stimulated whole human blood Content Type: Journal ArticleCategory ErratumDOI 10.1007/s00134-008-1196-3Authors 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

Response to hypercapnic challenge is associated with successful weaning from prolonged mechanical ventilation due to brain stem lesions

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 CO₂ concentrations were initiated and P0.1, respiratory rate, minute ventilation (V _e), tidal volume (V _t) and end tidal CO₂ 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 cmH₂O, 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 cmH₂O, 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 cmH₂O 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/s00134-008-1197-2Authors 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

Effects of mannitol alone and mannitol plus furosemide on renal oxygen consumption, blood flow and glomerular filtration after cardiac surgery

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 (RVO₂)_, 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%), RVO₂ (19%) and renal oxygen extraction (21%). When combined with mannitol, furosemide normalised sodium reabsorption, RVO₂, 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 RVO₂ 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/s00134-008-1206-5Authors 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

Acute decompensation of isovaleric acidemia induced by Graves' disease Content Type: Journal ArticleCategory CorrespondenceDOI 10.1007/s00134-008-1192-7Authors 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

Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock?

Abstract

Objective To test the hypothesis that, in resuscitated septic shock patients, central venous-to-arterial carbon dioxide difference [P(cv-a)CO₂] may serve as a global index of tissue perfusion when the central venous oxygen saturation (ScvO₂) 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 ScvO₂ > 70% were included immediately after their admission into the ICU (T0). Patients were separated in Low P(cv-a)CO₂ group (Low gap; n = 26) and High P(cv-a)CO₂ 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 ScvO₂ 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)CO₂ values were inversely correlated (P < 0.0001).

Conclusion In ICU-resuscitated patients, targeting only ScvO₂ may not be sufficient to guide therapy. When the 70% ScvO₂ goal-value is reached, the presence of a P(cv-a)CO₂ larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.

Content Type: Journal ArticleCategory OriginalDOI 10.1007/s00134-008-1199-0Authors 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