Year in Review 2006: The Critically Ill Patient in the Pediatric ICU

The care of the critically ill patient in the pediatric intensive care unit (PICU) has remained an important topic for those health care providers dealing with children. The purpose of this article is to introduce to the reader a summary of selected papers which we consider relevant to the care of the pediatric critically ill patient and that were published in the year 2006. These articles were selected on the basis of application to the PICU, overall importance and are not to be solely considered authoritative in their field. There are many other useful articles. We have attempted to choose those articles with scientific merit and rigorous methodology that we believe present interesting data in the field.


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Effectiveness Study of rHuEPO in the ICU

Purpose: To evaluate the clinical outcomes and resource use in ICU patients receiving rHuEPO in a naturalistic setting. Methods: A retrospective, case-matched (1:2 ratio) study compared patients receiving rHuEPO to a control group. Patients admitted between January 2000 and July 2002 with an ICU length of stay (LOS) ¡Ý3 days were identifi ed by an electronic data repository. Patients, who received rHuEPO prior to ICU admission, had chronic renal failure or were <18 years of age were excluded. Patients were matched by age (¡À5 years), sex, admission year and ICU type. Collected data included patient demographics, admission date, ICU and hospital mortality and LOS, mechanical ventilation days, serum creatinine concentration, hemoglobin concentration, number of blood transfusions, and ICU resource use. Results: rHuEPO-treated patients (n=391) were matched with 782 controls. Patients receiving rHuEPO had higher Simplifi ed Acute Physiology Scores II (46.2 vs 38.8; p <0.001) and received signifi cantly more blood transfusions than control patients (19 vs 6; p <0.001). After adjusting for severity of illness in a linear regression model, rHuEPO was signifi cantly associated with increased blood transfusions and higher mortality risk. Patients receiving rHuEPO had signifi cantly longer hospital and ICU LOS, mechanical ventilation duration, and higher hospital and ICU mortality rate and hospital resource use (p <0.001). Conclusions: In this real-world retrospective analysis, critically ill patients treated with rHuEPO did not experience clinical benefi ts; however, patients were sicker and received rHuEPO late in their ICU stay. Monitoring prescribing patterns and patient selection of rHuEPO treatment in critically ill patients in clinical practice is recommended to optimize rHuEPO use and outcomes.


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Critical Care of the Liver Transplant ICU Patients: A Pittsburgh “Point of View”

The purpose of this review is to summarize the advances in critical care management of the liver transplant ICU patients (patients with end stage liver disease, before and after orthotopic liver transplant). The review is based on search of Medline literature, with a focus on liver failure patients and critical care issues around liver transplantation. Starzl Transplantation Institute at the University of Pittsburgh Medical Center is one of the global leaders in the treatment of end stage liver disease (ESLD). This review is in part based on our work in the 28-bed liver transplant ICU at Montefi ore Hospital, University of Pittsburgh Medical Center, in Pittsburgh, PA. Over the past few years, our understanding of the several important pathophysiologic markers of end stage liver disease has been signifi cantly improved. For example, we do now much better understand hyperdynamic circulation of liver failure, hepatorenal syndrome and its consequences, the role of TIPSS (transjugular intrahepatic portosystemic shunt) and adrenal insuffi ciency in liver failure patients. The management and prophylaxis of variceal bleeding and subacute bacterial peritonitis (SBP), has been successfully standardized. These and other advances in understanding of ESLD pathophysiology and its clinical results, have certainly contributed to more promising outcomes in the ICU management of these complex patients.


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Abdominal Sarcoidosis

Abdominal sarcoidosis is an uncommon form of sarcoidosis. The clinical presentation of esophageal, gastric, small bowel, colon, appendicular, spleen, pancreas, and abdominal aortic sarcoidosis are discussed in this review. The differential diagnosis of abdominal sarcoidosis is extensive. Other granulomatous diseases including tuberculosis, fungal infections, parasitic diseases, infl ammatory bowel disease, and Whipple’s disease should be excluded before making the diagnosis of gastrointestinal sarcoidosis. Corticosteroid therapy is the mainstay of medical therapy in abdominal sarcoidosis. Second line agents such as methotrexate are also discussed. Surgical intervention may be necessary in patients with bowel obstruction, perforation, or massive hemorrhage. The authors also provide their experience regarding preoperative pulmonary evaluation of patients with pulmonary sarcoidosis undergoing surgery.


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Severe Complications of Herbal Medicines

Herbal medicines are being increasingly used for treatment of variety of disorders. Herbal medicines are generally thought to lack severe side effects. Despite of the general belief, herbal medicines are known to cause serious side effects and toxicities. On the other hand, physicians’ knowledge of herbal medicines and their potential toxicities are generally limited. Neurotoxicity, cardiac toxicity, pulmonary toxicity, hepatotoxicity, and nephrotoxicity are potential severe complications of herbal medicines.


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Sublingual Capnometry: A Non-invasive Measure of Microcirculatory Dysfunction in Sepsis

Sepsis is among the most common reason for admission to intensive care units throughout the world. Sepsis is characterized by a generalized microcirculatory injury, which results in tissue dysoxia. Tissue dysoxia is believed to be the causation of multiorgan dysfunction syndrome (MODS) which commonly complicates the course of sepsis. The expedient detection and correction of tissue dysoxia may limit the development of MODS. The standard oxygenation and hemodynamic variables (blood pressure, arterial oxygenation, cardiac output) which are monitored in critically ill patients are “upstream” markers and provide little information as to the adequacy of tissue oxygenation. Global “downstream” markers of tissue dysoxia such as mixed venous oxygen saturation and blood lactate are insensitive indicators of the extent of the microcirculatory injury in patients with sepsis. Sublingual/buccal mucosal PCO2 is a regional marker of microvascular perfusion and tissue dysoxia that holds great promise for the risk stratifi cation and endpoint of goal-directed resuscitation in patients with sepsis.


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Cardiopulmonary Emergencies in Sarcoidosis

Sarcoidosis is a systemic disease that commonly involves the lungs and the heart. Although rare, lifethreatening cardiopulmonary emergencies can occur. Acute respiratory failure, massive hemoptysis, and cardiac emergencies are described in sarcoidosis. These clinical manifestations can be the first clinical presentation of sarcoidosis. The subject of cardiopulmonary sarcoidosis is reviewed.


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Clevidipine: A Unique Agent for the Critical Care Practitioner

Clevidipine is a new third generation intravenous dihydropyridine calcium channel blocker. It is a specific arterial vasodilator developed for the acute reduction and control of arterial blood pressure in the perioperative period. This drug has an extremely short half life and is rapidly metabolized by tissue and plasma esterases. Clevidipine is a potent arterial vasodilator with very little or no effect of the myocardial contractility and venous capacitance and also minimal side effects. Clevidipine can also theoretically help to protect against organ reperfusion injury. Theoretically, this effect resides in the capacity of this agent to debilitate oxygen free radical-mediated toxicity, cell calcium overload and augment endothelial nitric oxide bioavailability through antioxidative actions. As a result it may diminish the severity of low flow myocardial ischemia and preserve the coronary endothelial function thereby reducing the infarct size. Due to all the characteristics of this parenteral agent it promises to be the drug of choice for the critical care practitioner for the strict control of blood pressure in different clinical scenarios.


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Cardiac troponin I elevation in subarachnoid hemorrhage: Should we worry?

Troponin I can be used as a marker not only for cardiac outcome in patients with SAH; but also as predictive for complications such as DCI, hypotension and pulmonary edema. More over it can be used as a prognostic factor in terms of functionality.


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Hyperglycemia after trauma: Physiologic and tolerable or a possible threat that needs to be corrected?

Admission hyperglycemia is associated with an increased morbidity and mortality in the critically ill trauma population studied by Sung and coworkers. There are a variety of mechanisms involved and attempts to control the glycemic index should become routine in the management of these patients.


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IABP deployment in critical care

The Intra Aortic Balloon Pump (IABP) is an established support in addition to pharmacologic treatment of the failing heart after myocardial infarction, unstable angina, cardiac surgery and percutaneous coronary intervention (PCI). The indication for IABP in acute myocardial infarction expanded to include support of severely ill patient during acute cardiac catheterization and myocardial revascularization both percutaneous and surgical. An international randomized trial, SHould we emergently revascularized Occluded Coronaries for cardiogenic shocK? (SHOCK) reported that cardiogenic shock patients treated with the combination of IABP support followed by early angiography and myocardial revascularization, and/ or thrombolytic therapy had the lowest observed inhospital mortality. The Benchmark Registry revealed plausible IABP economic benefits in total hospital costs; whereas, the potential benefits of careful use of IABP therapy are unlikely to be offset by vascular and hemorrhagic complications. The inference, whether IABP can be appropriate initial therapy at hospitals without revascularization facilities, if followed by prompt transfer to tertiary centers in the developing world, requires careful assessment.


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Lactate is the ultimate oxidative energy substrate in brain and elsewhere

Now-a-days, the focus on lactate is due to its being an oxidative substrate for energy metabolism in brain (and other tissues), rather than a useless end product of anaerobic glycolysis. Mounting evidence indicates that lactate does play a major role in aerobic energy metabolism in the brain, the heart, skeletal muscle and possibly in any other tissue and organ. Nevertheless, this evidence has challenged the old concept of lactate being an anaerobic waste product and ignited a fierce debate between the supporters of glucose as the major oxidative energy substrate and those who support lactate as a possible alternative to glucose under certain conditions. While researchers working on energy metabolism in skeletal muscle have taken great strides toward bridging between these two extreme positions, accepting lactate role as an oxidative energy substrate, neuroscientists appear to be somewhat more emotional about their differences and less agreeable. In this paper I have employed findings from research on skeletal muscle along with the existing old and new data on cerebral energy metabolism, to postulate that lactate is the only major product of cerebral (and other tissues) glycolysis, whether aerobic or anaerobic, neuronal or astrocytic, under rest or during activation. Accordingly, lactate is a major, if not the only, substrate used by the mitochondrial tricarboxylic acid cycle. If proven true, this hypothesis should provide a better understanding of the biochemistry and physiology of (cerebral) energy metabolism and hold important implications where neuroimaging is concerned.


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