A pre-printed medication chart in the ICU for patients admitted after coronary artery bypass graft surgery improves prescribing of secondary prevention at hospital discharge

Objective: To determine whether the introduction of a pre-printed Intensive Care Unit (ICU) drug chart after coronary artery bypass graft surgery (CABG) surgery was associated with an improvement in the rates of prescription of secondary prevention medicines at hospital discharge.
Design: Retrospective cohort study.
Setting: Tertiary cardiothoracic referral hospital in Wellington, New Zealand.
Patient and participants: Seven hundred forty-six CABG surgery patients. Three hundred seventy-one from the year before and 357 from the year after the introduction of the pre-printed ICU cardiac drug chart.
Interventions: A pre-printed ICU medication chart including aspirin, metoprolol, and atorvastatin used on all patients admitted to the ICU following CABG surgery.
Measurements: The primary outcome variable was the proportion of patients prescribed appropriate secondary prevention at hospital discharge. Secondary outcome variables included the proportion of patients receiving each of: aspirin, a beta-blocker, or a statin individually.
Results: Prescribing of appropriate secondary prevention increased from 81.1% to 92.7% following the introduction of the chart, adjusted OR 2.63 (1.53 to 4.50), p<0.001. The association between year of prescription and overall prescribing was mainly due to an increase in the prescription of beta-blockers. Conclusions: Introduction of a pre-printed ICU cardiac drug chart was associated with an increase in the rates of prescribing of secondary prevention on hospital discharge post-CABG surgery. A pre-printed medication chart in the ICU for patients admitted after coronary artery bypass graft surgery improves prescribing of secondary prevention at hospital discharge


The transpulmonary pressure as an indicator of lung stress in the disorder of chest wall mechanics in pediatric acute lung injury: Study in pig model

Objectives: To determine the role of the end-inspiratory transpulmonary pressure as an indicator of the lung stress in the disorder of chest wall mechanics, in pig model.
Design: Experimental study.
Setting: Department of Surgery and Radiology, Veterinary Medicine, Bogor Agricultural Institute.
Subjects: Nine healthy mixed breed domestic piglets were divided into 2 groups: intervention/splinted chest wall (n=5) and control (n=4).
Intervention: This study had approval from Animal Care and Use Committee. The care and handling animal were accorded with National Institute of Health guideline. All of animals were anesthetized, muscle paralyzed and bronchial lavage with warm saline, in supine position. Both group were mechanically ventilated and underwent lung recruitment using incremental-decremental technique. Chest wall splinting was conducted in intervention group while the control group did not.
Measurement and Main Results: Transpulmonary pressures calculated after measure the esophageal pressure using esophageal catheters. The transpulmonary pressure in intervention group prior to (1.80±2.28 cmH2O) and after (11.00±5.83 cmH2O) recruitment maneuver, increased significantly compared with control group prior to (1.25±3.68 cmH2O) and after (3.25±1.18 cmH2O), with p value 0.04. The difference of mean end-inspiratory transpulmonary pressure (Ptp plateau) between intervention and control group was significant (p=0.05). ∆Ptp plateau values have strong correlation with the increasing of chest wall elastance (Ecw) in the intervention group (p=0.001, R2=0.8) and control group (p=0.007, r=0.7), as well as the correlation of ∆Ptp plateau with decreasing the lung compliance (Cl) (p=0.05, r=0.8). The strong correlation between ∆Ptp plateau and ∆Paw (p=0.001, r=0.7) in the intervention group showed the potency of the transpulmonary pressure to reflect the real lung distending pressure and the lung stress.
Conclusions: The measurement of end-inspiratory transpulmonary pressure is reliable as an indicator of lung stress in disorder of chest wall mechanics.


Interleukin-10 polymorphisms and clinical risk factors in children with severe sepsis and septic shock


Background: Interleukin-10 (IL-10) is an important anti-inflammatory cytokine that play a key role in sepsis. It is a potent endogenous anti-inflammatory cytokine that decrease lung inflammation. Our aim was to identify clinical risk factors and IL-10 (592/1082) polymorphism in children with septic shock.

Methods: This is a prospective study. Children with severe sepsis and septic shock admitted to our PICU and healthy individuals were recruited into the study. The genotypes of polymorphisms-1082, -592 were determined by PCR restriction fragment length polymorphism. Clinical factors and PRISM III score were also recorded.

Results: In the period of our study, we enrolled 36 children with 8.3% (n=3) of severe sepsis and 91.7% (n=33) of septic shock. The mean age was 65.5±15.5 month. Their mortality was 19.4%, which significantly reduced from the past few years (40%, p=0.02). The mortality was significantly associated with high PRISM III score (16.7±5.7, 10.5±6.3, p=0.02) and delay resuscitation. The A allele of the SNP IL-10-592 polymorphism was more common in septic shock group compared to normal control (66.7% vs 56%, OR=1.94 [0.57-6.76], p=0.2) and A/A allele was also more common in septic shock group (44.4, 29.2 OR=1.94, 95% CI 0.57-6.76, p=0.2). The A/A allele of SNP IL-10-1082 polymorphism was more prevalent in sepsis but not significantly different between sepsis and control (32 [88.9%], 20 [83.3%] OR=1.1, 95% CI 0.21-5.92, p=0.9). In addition, there was a trend of A/A SNP-1082 genotype in the mortality group (100% vs 86.2%, p=0.1).

Conclusions: Our sepsis mortality was significantly associated with high PRISM III score and the delay in resuscitation. The AA allele of SNP IL-10-592/-1082 polymorphism had a trend to increase severity and susceptibility in children with sepsis.


Modeling comparative effectiveness studies: An example using a phase IV intravenous nicardipine versus labetalol in patients with uncontrolled hypertension trial


Background: Hypertension is a common acute presentation that requires effective medication for control. Few comparative effectiveness trials exist to guide which agents offer the most efficient response. Our objective was to perform a design simulation to determine if a future study comparing the effect of intravenous (IV) nicardipine or labetalol was warranted.

Methods: We created a predictive model using known clinical responses to currently recommended dosing of nicardipine and labetalol. For nicardipine, we used a three-compartment, weight-normalized pharmacokinetic nonlinear mixed-effects model. For labetalol, BP and HR changes were modeled as a function of time, group (pretreated or untreated within 24 hours), and total dose. Clinically relevant BP and HR changes were defined as >15% and >20% of baseline, respectively. At least 500 patients were simulated and results compared to known clinical data.

Results: Our models demonstrated that the rate of clinically relevant blood pressure drop within 30 minutes of initiation in the nicardipine group would be 61% versus 14-19%, without with a >20% HR decrease, for labetalol.

Conclusions: BP and HR models of antihypertensives can be designed to predict the published data reasonably well. In this fashion the need for comparative effectiveness trials can be assessed.


The effect of the antioxidant drug “U-74389G” on sodium levels during ischemia reperfusion injury in rats


Background: The aim of this experimental study was to examine the effect of the antioxidant drug “U-74389G” testing, on rat model and particularly in an ischemia reperfusion (IR) protocol. The beneficial effect or non-effectiveness of that molecule was studied biochemically using mean blood sodium levels.

Material and methods: 40 rats of mean weight 231.875 g were used in the study. Sodium levels were measured 60 min after reperfusion (groups A and C) and 120 min (groups B and D) after reperfusion with administration of the drug “U-74389G” in groups C and D.

Results: “U-74389G” administration non-significantly increased the sodium levels by 0.25 mmol/l (-1.479487 mmol/l-1.979487 mmol/l, p=0.7714). This finding was in accordance with the results of paired t-test (p=0.7714). Reperfusion time significantly decreased the sodium levels by 1.85 mmol/l (-3.471346 mmol/l-0.2286544 mmol/l, p=0.0264), also in accordance with paired t-test (p=0.0088). However, “U-74389G” administration and reperfusion time together non-significantly decreased the sodium levels by 0.4636364 mmol/l (-1.496569 mmol/l-0.5692967 mmol/l, p=0.3693).

Conclusions: “U-74389G” administrations as well its interaction with reperfusion time have non-significant alteration short-term effects on sodium. Perhaps, longer experiment times may reveal any possible significant effect of “U-74389G” on blood sodium levels.


Deep sedation contributes to high release of hypoxic pulmonary vasoconstriction in mechanically ventilated acute respiratory distress syndrome patients

Background: We report the cases of 2 patients with severe pneumonia who exhibited increased changes in hypoxic pulmonary vasoconstriction (HPV) during temporary increases in stroke volume and decreased stroke volume variation caused by in­creasing positive end-expiratory pressure (PEEP) under different sedation.

Cases: The first case was observed in a 79-year-old man with acute respiratory distress syndrome (ARDS) followed by pneumonia. The second case was observed in a 73-year-old woman on mechani­cal ventilation who suffered from ARDS following interstitial pneumonia.

The first patient was treated with 2 kinds of sedatives to improve oxygenation and protect the lungs. The second patient was treated with 3 kinds of sedatives. The first patient had a low P/F ratio (53.9/0.7=77) on mechanical ventilation. According to the recruit­ment maneuvers, an increasing PEEP leads to a slight temporary increase in stroke volume of about 2 mL. The patient died 3 days later due to multiple organ failure and disseminated intravascular co­agulation. The second patient had a low P/F ratio (38.5/0.7=55). As the PEEP increased, her stroke volume temporarily increased dramatically by about 8 mL. The patient recovered 56 days later.

Conclusions: HPV is an obstacle to oxygenation, prompting recruitment maneuvers for treating me­chanically ventilated ARDS patients; it is considered to be caused by physiological changes in the intracel­lular Ca2+ concentration in the pulmonary artery smooth muscle cells according to the sedation levels. The sedation level may contribute to decreased HPV in lung recruitment maneuvers.


Perioperative upper airway edema: Risk factors and management

Objectives: To study the risk factors and treatment of the postoperative patient who develops upper airway edema.
Design: Retrospective analysis.
Setting: Surgical Intensive Care Unit (SICU) of a tertiary care hospital.
Patients and participants: We performed a retrospective analysis over 24 months of SICU admissions of postoperative patients. Inclusion criteria were (1) failure to extubate after a surgical procedure, (2) a negative cuff leak test immediately postop (<110 mL of tidal volume loss with the cuff deflated), and (3) failure to extubate within 24 hours with suspected airway edema. Six patients met criteria for study. Interventions: Management of these patients included a multimodal strategy including a daily cuff leak test, use of corticosteroids, diuretics, and head of bed elevation. Measurements and results: All patients were female, with a mean age of 54.5-year-old. The majority had operations remote from the neck region. The mean body mass index (BMI) was 34.8, and the mean surgical time was 282 minutes. Two thirds of the patients were given blood products intraoperatively with a mean of 17.3 units transfused. The mean fluid balance intraoperatively was +5 L. Using our protocol, steroids were administered in the equivalence of 389 mg of hydrocortisone across a mean of 71 hours of mechanical ventilation. Simultaneously, they received a mean of 63 mg of furosemide to achieve a mean fluid balance of -2.8 L. All patients were extubated when the cuff leak became positive; none required reintubation. Conclusion: A multimodal strategy for the patient with postoperative upper airway edema is recommended.


Study of tracheostomized patients in Intensive Care Unit

Objectives: To describe the short-term and long-term outcomes of tracheostomized Intensive Care Unit (ICU) patients and to identify any predictors of complications during and after the tracheostomy procedure.
Design: A retrospective and prospective, observational case series performed in a general medical-surgical adult ICU in a regional hospital in Hong Kong.
Results: A total of 153 patients were recruited. The most common indication for tracheostomy was prolonged mechanical ventilation (72.6%), followed by failure of extubation (15%). Surgical tracheostomy was the predominant method used (73.9%). There were no statistically significant differences between surgical and percutaneous tracheostomy on the complication rate. Minor bleeding was the most common short-term complication (10.5%) and tracheal stenosis was the most common long-term complication (5.1%). Hypertension (adjusted odds ratio 5.28, 95% CI 1.05-26.51, p=0.044) and chronic renal failure (CRF) (adjusted odds ratio 17.56, 95% CI 2.87-107.42, p=0.002) were independent risk factors for minor bleeding; while the need to reintubate within 48 hours after extubation (adjusted odds ratio 10.5, 95% CI 1.30-84.88, p=0.027) was an independent risk factor for tracheal stenosis. CRF was independently associated with composite complications (minor bleeding and tracheal stenosis; adjusted odds ratio 13.63, 95% CI of 2.47-75.16, p=0.003). Mental health score at 1 year or more was generally better than physical health score in this cohort of patients.
Conclusion: This study described the outcome, complications with associated predictors in tracheostomized ICU patients in Chinese population. Further larger trials are required to confirm the findings.


Pulmonary coagulopathy in pediatric acute lung injury/acute respiratory distress syndrome

Background: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). Prior work has shown disorder of inflammation and coagulation in ALI/ARDS. Activated protein C (APC) is a potential critical endogenous regulator of coagulation and inflammation in ALI/ARDS.
Material and Methods: We prospectively studied children admitted with ALI/ARDS. We obtained clinical data, initial blood coagulation profiles including plasma protein C (PC) activity and free protein S antigen (PS Ag).
Results: 27 patients with ALI/ARDS were recruited in our study; their mean age was at 6.4±5.2 years. Fifteen were survivors (55%), 12 were non-survivors (45%). Initial plasma PC activity was 72.0±27.6% and plasma free PS Ag was 58.52±29.8%. Platelets, PT & PTT were significantly abnormal compared between survivors and non-survivors (p=0.01, 0.02, 0.01). There was a significantly negative correlation between plasma PC with initial systolic blood pressure (r=0.5, p=0.008) and PS Ag (r=0.41, p=0.02). There was also a trend of negative correlation between plasma PC with ventilator day (r2=0.0009, p=0.1) and length of stay in PICU (r2=0.1, p=0.09).
Conclusions: This study suggests that most of our pediatric ALI/ARDS had abnormal coagulogram. Coagulation dysfunction including initial plasma PC activity might be associated with the overall outcome.


High frequency oscillatory ventilation may not rescue ARDS patients: an observational study

HFOV is a rescue mode of ventilation. Our objective was to assess usage and mortality predictors of HFOV. Observational study of ARDS patients, with data extracted from an ICU database. Analysis was carried out using SPSS version 20.0. Of 136 ARDS patients, 29.4% (40) were placed on HFOV. Use of HFOV correlated with age (38.7±14.8 vs 49.7±19.4 years, p=0.002, 95% CI 4.2, 17.8) and pulmonary insults (Chi2 value 44.3, p<0.001). Earlier placement was associated with levels of support on conventional ventilation (PIP - 0.343, p=0.029, PEEP - 0.322, p=0.043, FiO2 - 0.404, p=0.010, tidal volumes - 0.4, p=0.009). ICU mortality was 58.8% (80) with 53% in patients on conventional ventilation and 72.5% (29) in patients on HFOV. Multivariate regression identified APACHE IV (score≤70 OR 0.97, 95% CI 0.96, 0.98, p<0.001) and use of HFOV (OR 2.4, 95% CI 1.05, 5.5, p=0.038) as independent predictors of mortality. Baseline PaO2/FiO2 ratio (p=0.006), concurrent iNO (p=0.001), tidal volumes on conventional ventilation (p=0.016) and improved oxygenation (p=0.001) correlated significantly with survival. HFOV is associated with increased ICU mortality in patients with ARDS.High frequency oscillatory ventilation may not rescue ARDS patients- an observational study


The effect of thrombocytopenia on outcome in critically ill children

Objective: Thrombocytopenia is common in pediatric intensive care unit. We aimed to investigate thrombocytopenia and risk factors associated with mortality in the pediatric intensive care unit.

Design: One year hospital records were investigated retrospectively.

Setting: Present study was performed in the pediatric intensive care unit in Çukurova University, Faculty of Medicine.

Patients and participants: A total of 94 patients, 50 (53.2 %) boys and 44 girls (46.8%), were included in this study. The median age was 24 months with a range from 1 to 240 months. Thrombocytopenia was defined as platelet counts <150x109/L. PRISM II score, mechanical ventilation (MV), use of central venous (CVC) or arterial catheters (AC), presence or absence of sepsis, coagulopathy, hemorrhage and receiving of transfusion were recorded at the time of admission. White blood cell count (WBC), aspartate aminotransferase (AST), alanin aminotransferase (ALT), total protein, albumin/globulin ratio, blood urea nitrogen (BUN), serum creatinine (Cr), total bilirubin, C reactive protein (CRP), procalcitonin (PCT) and lactate were recorded.

Measurements and results: The incidence of thrombocytopenia was 59.57%. MV, CVC, coagulopathy, hemorrhage and transfusion were found to be significant factors for thrombocytopenia. Leukocytosis and leucopenia were significant in thrombocytopenic patients (p=0.024). Increased ALT, AST, BUN, total bilirubin and decreased total protein levels significantly were related to thrombocytopenia. Hospital mortality rate was 37.2%. There was a significant association between mortality and the presence of MV, CVC and AC. Sepsis, coagulopathy, hemorrhage and transfusion had strong correlation with mortality. Increased ALT, AST, BUN, bilirubin, PCT, lactate and decreased total protein levels were related to the mortality.

Conclusions: The present study suggested that thrombocytopenia could be related to mortality and an indicator of poor prognosis in the pediatric intensive care unit. Therefore thrombocytopenia-associated risk factors should be closely followed up by physicians in critically ill children.The effect of thrombocytopenia on outcome in critically ill children