Endotracheal Cuff Pressures in Ventilated Patients in Intensive Care

There are well over 50,000 patients who receive ventilation via an endotracheal tube in the Intensive Care Units (ICUs) in Australia and New Zealand every year. Almost all episodes of invasive ventilation in adults are associated with inflation of endotracheal cuff. While monitoring of the cuff pressure has been recommended during anaesthesia this has not been reflected in any of the minimum standards documents. Endotracheal tubes placed in the Operating Theatre (OT) are usually in situ for a matter of hours, while endotracheal intubation in ICU is more prolonged, and thus the risk of time dependent sequelae is increased.
If the Pcuff is excessively elevated the cuff has the potential to herniate or to cause direct damage through ischemia of the tracheal mucosa.


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Sepsis: A Study of Physician’s Knowledge about the Surviving Sepsis Campaign in Puerto Rico

Sepsis is a clinical syndrome characterized by systemic inflammation and widespread tissue injury. It results from an excessive inflammatory host response to an infective agent which, when generalized, involves normal tissue not originally affected by the causative organism(s). There is massive release of inflammatory mediators, causing leukocytes to accumulate in organs distant from the initial infection, with further inflammation. Recent evidence recognizes the active role of a deregulated coagulation cascade in the pathophysiology of sepsis. These changes result in severe alterations of the microcirculation with the end result being tissue hypoperfusion.


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Natural History and Risk Factors of the “Cholestatic Post-cardiac Surgery Syndrome”

Jaundice following cardiac surgery, frequently referred to as “post-pump jaundice,” has been reported since the 1960’s with an incidence of between 3 to 40%. The incidence of jaundice following mitral valve replacement has been reported to be as high as 55%. Jaundice following cardiac surgery has been associated with prolonged mechanical ventilation, prolonged intensive care unit (ICU) stay, and a higher mortality. The causes of jaundice following cardiac surgery include acute cholecystitis, acute pancreatitis, shocked liver, and septic shock. However, a subset of patients develop hepatic dysfunction without an obvious cause. Hepatic dysfunction in these patients is characterized by hyperbilirubinemia with a mild elevation in hepatic transaminases and no evidence of biliary obstruction on imaging. This entity has been referred to as the “cholestatic post-cardiac surgery syndrome”.


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Berlin Questionnaire and Portable Monitoring Device for Diagnosing Obstructive Sleep Apnea: A Preliminary Study in Jakarta, Indo

Study objective: to evaluate patients who came with the history of snoring with Berlin Questionnaire and sleep study using portable monitoring device. Setting: Mitra International Hospital, Jakarta, Indonesia. Material and methods: This was a preliminary study in 15 patients who came to the Respiratory Clinic with the history of snoring and suspicion of having obstructive sleep apnea (OSA). They were intended to undergo a sleep study using a portable device (PM). All patients were screened with Berlin Questionnaire and continued with application of portable monitoring device for one night stay at the hospital. Parameters recorded during examination were body mass index (BMI), apnea/hypopnea index (AHI), oxygen saturation, oxygen desaturation during sleep and lowest oxygen desaturation during sleep. Results: There were 14 (93.3%) male and only 1 female (6.7%) joined the study; the mean age was 48.93 year old, with age ranged between 16-74 year old. Only 2 patients with BMI 18-23 and 13 others had BMI >23. Three patients were not assessed by Berlin Questionnaire, 1 patient was disconnected from oxygen accidentally during sleep. From 12 patients screened with Berlin Questionnaire, 9 patients (75%) had high risk and 3 patients (25%) had low risk. Based on AHI, there were 4 patients with AHI < 5, 3 patients with mild OSA (AHI 5-15), 3 patients with moderate OSA (AHI 15- 30), and 5 patients had severe OSA (AHI >30). Oxygen saturation recorded by pulse oxymeter (SpO2) ranged between 81.6% to 98.0%, while the lowest SpO2 during sleep ranged between 68.0% to 89.1%. Oxygen desaturation (OD) ranged between 4.40% to 9.40%. Only 4 patients (2 moderate OSA, 2 severe OSA) can be followed of using continuous positive airway pressure (CPAP) machine after the test. There was improvement in patient using CPAP. In patients with severe OSA, AHI improved to 5-15, while in moderate OSA AHI was improved to <5. Conclusion: Berlin Questionnaire is quite reliable to determine which patient need further evaluation of OSA and portable monitoring device may be used for diagnosing sleep apnea since in 4 patients with moderate (AHI 15-30) and severe OSA (AHI >30) were all improved with CPAP. Based on this preliminary study, portable monitoring device can be used in the situation where no sleep laboratory available or in patient refused to be assessed with attended full polysomnography.


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Predictor of Mortality and Rehospitalization of Acute Decompensated Heart Failure at Six Months Follow Up

Objective. To look for predictors of mortality and rehospitalization, we conducted a prospective study using fifty variables from history, physical examination, ECG, CXR, Echocardiography and blood test (N Terminal proBNP, hsCRP, and lactate level) that suspected as predictors in heart failure Design. Blinded prospective cohort study Setting. Emergency room of Harapan Kita National Heart Center, Jakarta-Indonesia as entry site, with ICCU, wards, and OPD for evaluation. Patients population for study. All consecutive patients with acute decompensated heart failure class III-IV that were hospitalized. Exclusion criteria were other concomitant severe diseases. Measurements and result. Of 97 patients enrolled, variables were measured using standard protocols. During follow up period of six months, 11 (11.3%) patients died of cardiac origin and 29 (29.9%) rehospitalized. Logistic regression analysis revealed BMI >30 kg/m2 with edema had OR 6.6 (95% CI: 1.33- 32.72, p=0,021), acute lung edema had OR 3,65 (CI 0,99-13,35, p=0,037), NYHA class IV had OR 5,42 (CI 95% : 1,11-26,59, p=0,037), left ventricle wall thickness >11 mm had OR 0,79 (CI 95 %: 0,63-1,00, p= 0,05), using beta-blocker had OR 0,09 ( CI 95%: 0,01- 0,74, p= 0,025), hemoglobin <12 g/dL had OR 4,53 (CI 95%: 1,24-16,56, p= 0,022), sodium <130 mmol/dL had OR 3,78( CI 95%: 1,02-14,03,p=0,047), NT proBNP >17,860 pg/mL on admission had OR 9,02 (CI 95%: 2.30-35.30, p=0,02) or NT proBNP > 8,499 pg/dL at discharge had OR 13,2 (CI 95%: 1,32-132,01, p=0,028) and served as predictors of mortality respectively. Using Cox Proportional Hazards and Kaplan Meier survival analysis and log rank test it were found that NT proBNP level >17.860 pg/ml on admission had a HR of 7.15 (95%CI 2.08-24.56, p=002) for mortality, while NT proBNP level >8.499 at discharged showed a HR of 9.55 (95%CI 1.06-85.77, p=0.044) for mortality. A decrease >35% of NT proBNP had a HR 0.13 (95%CI 0.02-1.19, p=0.071) for mortality, 0.38 (95%CI 0.14-1.00, p=0.049) for rehospitalization, and 0.42 (95%CI 0.12-0.76, p=0.010) for both. NT proBNP on admission >17.860 pg/dL together with EF <20 %, BMI >30 kg/m2 with edema and NYHA class IV were the most accurate predictor with AUC =0,94 (p=0.0001). Conclusion. Non decreased NT proBNP > 35 % during hospitalization was the predictor of mortality and rehospitalization. NT proBNP > 17,860 pg/mL at entry, NT proBNP > 8,499 pg/mL at discharged, NYHA class IV, BMI >30 kg/m2 with edema, EF <20%, acute pulmonary edema, Hb <12 g/dL, Na <130 mmol/ dL and not using beta-blocker were found as predictors for mortality of heart failure.


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Delayed neutrophil apoptosis in patients with multiple organ dysfunction syndrome

Aged neutrophils undergo spontaneous apoptosis and delayed apoptosis is associated with persistence of inflammatory disorders through release of toxic metabolites. We evaluated spontaneous apoptosis of neutrophils in patients with multiorgan dysfunction syndrome and neutrophil respiratory burst activity. Neutrophil apoptosis was assessed at study enrollment and after 24 hours incubation in culture medium by annexin-V assay, morphology and DNA fragmentation. Respiratory burst activity was measured using dihydrorhodamine. Twenty two patients with multiple organ dysfunction syndrome admitted to an intensive care unit and 22 healthy controls were studied. After 24 hours, a profound delay in spontaneous apoptosis in organ dysfunction patients was seen compared to controls for both annexin-V (26.9% versus 52.1%, p< 0.0001) and morphological assessment (25.0% versus 61.5%, p<0.0001). Respiratory burst activity was increased (86.3% versus 27.6%, p<0.001) suggesting that the delay in apoptosis was associated with prolongation of the functional activity of the cells. We conclude that in patient with multiple organ dysfunction syndrome there is a delay in spontaneous apoptosis together with a high functional activity of neutrophils.


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Relationship of uni-lung percentage of blood flow to uni-lung percentage of carbon dioxide production in normal and unilateral i

It is difficult clinically to measure relative blood flow to each lung. We hypothesized that uni-lung % blood flow is linearly related to % carbon dioxide excretion (VCO2). In a canine model of acute unilateral lung injury, we measured uni-lung flow with ultrasonic flow-probes, and uni-lung VCO2 with two separate metabolic monitors utilizing split lung ventilation following thoracotomy. Relative flow to the lungs was altered by inflating a pulmonary artery catheter balloon in one of the lungs under conditions of normal lung function and following induction of acute lung injury. There was a significant linear relationship between % blood flow and % VCO2 under all conditions (R = 0.83, p < 0.001, ANOVA). The slopes were identical for the injured lung and the contralateral control lung, although these slopes differed from their respective baseline values. We conclude that by measuring uni-lung % VCO2, one may trend changes in % flow to either lung in patients with split lung ventilation with or without unilateral lung disease.


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Analysis of post coronary bypass surgery risk factors and scoring system with study of immunogenetic epidemiology

Coronary heart disease patients with 308 polymorphism (particularly heterozygote G-A polymorphism) have a higher circulating TNF a concentration compared to CHD patients without polymorphism. The post surgical clinical manifestations were not proven to be influenced by circulating TNF á concentrations. It is thought that the increase was not enough to yield clinically manifestation.


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The use of levosimendan in shocked patients with compromised left ventricular function and requiring catecholamine support – A

Objective: Levosimendan is a calcium sensitizer that improves cardiac contractility without increasing intracellular calcium level, hence energy demand. Theoretically, it is safer to use levosimendan than catecholamine in shocked patients who require inotrope support. Studies on the use of levosimendan in shocked patients are, however, limited. In this case series, we describe the pre- and post-infusion effects of levosimendan in shocked patients with reduced cardiac function and requiring catecholamine inotrope support. Design: A case-series report. Setting: The intensive care unit of a teaching hospital. Patients: Fifteen shocked patients with reduced left ventricular ejection fraction and requiring catecholamine inotrope support were reviewed retrospectively. Intervention: 24 hour intravenous infusion of levosimendan with concomitant noradrenaline infusion. Results: In response to 24-h levosimendan infusion, the left ventricular ejection fraction increased from 25.7 ± 11.0% to 29.8 ± 8.6% (P = 0.0389), and the plasma B-type natriuretic peptide reduced from 993 ± 389 to 644 ± 408 pg/ml (P = 0.0015). The blood lactate also demonstrated a significant decrease. During infusion, the mean arterial blood pressure (MAP) was maintained above 65 mmHg by concomitant noradrenaline infusion. The noradrenaline dosages required to maintain the MAP were reduced at the end of infusion. No adverse event related to the drug was seen during the infusion. Conclusion: Levosimendan leads to an improvement in the hemodynamic status of the shocked patients with compromised left ventricular function. This improvement was reflected by an improvement in LVEF, the favorable changes in BNP and blood lactate levels. Levosimendan is safe to use and may present an alternative to catecholamine inotropes in the management of shocked patients with reduced cardiac function and requiring inotrope support.


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Cardiopulmonary resuscitation preferences among health professionals in Singapore

Introduction: Attitudes and preferences for cardiopulmonary resuscitation (CPR) among healthcare providers are varied among individuals and across countries. The purpose of this study was to determine these preferences amongst health practitioners attending the 3rd General Scientific Meeting of the Society of Intensive Care Medicine (Singapore) held in September 2003. Methods: The survey was conducted among physicians, nurses and other health care providers attending a lecture during the critical care meeting in Singapore. The 35-item questionnaire included information about age, gender, profession, and religion, but no other identifiers were used. There was no follow up of 3 non-responders out of the 125 health care practitioners surveyed. The results were analyzed using contingency tables. Results: 122 questionnaires were returned. Mean age was 33.5 ± 8.5 years and 9.8% were physicians, 74.5% were nurses. Physicians were significantly older (p<0.006) compared to nurses. 34.4% said they wanted “full code”, while 16.4% indicated they had not thought about code status. 53.7% of respondents would decline CPR if they are older than 65 years, with nurses significantly more likely to decline (p<0.006). 87.4% would decline CPR with end-stage renal disease, 92.6% with AIDS. The majority (58.5%) felt that future quality of life should be the most important factor in determining code status, following age. Respondents considered sepsis (25.8%) to carry the worst prognosis after CPR, following cancer (19.2%), SARS (14.2%), and myocardial infarction and AIDS (13.3%). Conclusions: Many health care providers in Singapore are often involved in CPR situations, but it is impressive how the majority of the respondents in our survey would not want full resuscitation efforts should they experience a cardiopulmonary arrest. It is also interesting that they would use age more than 65 years in their decision to decline CPR. Many of health practitioners are uncertain which medical conditions are the ones with worst prognosis after CPR.


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Surfactant protein-D and polymorphonuclear leukocyte elastase concentrations in patients with septic acute respiratory distress

Purpose: Inhibition of surfactant activities by the protein in pulmonary edematous fluid plays a role in the occurrence of respiratory failure in acute respiratory distress syndrome (ARDS). Polymorphonuclear (PMN) elastase may be involved in surfactant-mediated damage. Accordingly, the concentrations of surfactant protein-D (SP-D) and PMN elastase were determined in patients with sepsis, and the associations of these two factors with the occurrence of ARDS and prognosis were examined. Methods: Blood samples from 33 patients with sepsis and with or without ARDS were assayed. The SP-D and PMN elastase levels were determined using an enzyme-linked immunosorbent assay. Results: SP-D levels in groups with and without ARDS were 493.9 ± 373.3 ng/ml and 91.8 ± 30.1 ng/ml, respectively. The level in the ARDS group was significantly higher than that in the group without ARDS (P = .0002). The PMN elastase levels in the groups with and without ARDS were 845.1 ± 294.0 ng/ml and 424.9 ± 81.1 ng/ml, respectively. The level in the ARDS group was significantly higher than that in the group without ARDS (P < .0001). The SP-D level in patients who survived was 157.0 ± 127.4 ng/ml and that in those who died was 625.5 ± 433.2 ng/ml. The level in the latter group was significantly higher than that in the former (P < .0001). The PMN elastase level in patients who survived was 493.7 ± 145.8 ng/ml and that in those who died was 980.9 ± 300.9 ng/ml. The level in the latter group was significantly higher than that in the former (P < .0001). A significant correlation was observed between SP-D and the PMN elastase levels (r = 0.818, P < .0001). Conclusion: In the presence of ARDS, SP-D and PMN elastase served as good indicators of severity.


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The Psychological impact of SARS on health care providers

The Severe Acute Respiratory Syndrome (SARS) triggered a devastating and deadly outbreak in Singapore. The impact that this deadly disease caused was like no other; healthcare facilities were overwhelmed with patients, healthcare providers continuously fell victims of the disease, and the uncertainty of the natural history of the disease kept the world in a general state of panic.


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Laryngotracheobronchial stenoses in intensive care patients — four years’

Background: Most symptoms in laryngotracheobronchial malformations are non-specific thus leading to a delay in diagnosis and therapy. Objectives: We aimed to summarise our experience with cases of laryngotracheobronchial stenoses/obstructions admitted to PICU, discuss in the light of published evidence, and propose a rationale diagnostic and therapeutic approach.


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Respiratory sequelae after acute hypoxemic respiratory failure in children with meningococcal septic shock

In an observational follow-up study from 1999 to 2000, we assessed respiratory sequelae in the youngest survivors of meningococcal septic shock (MSS) with acute hypoxic respiratory failure (AHRF). We included children who survived from MSS and AHRF, with a maximum age of five at follow-up. AHRF was defined based on the first, second and fourth criteria of the American-European Consensus Conference (A-ECC) on the acute respiratory distress syndrome (ARDS).


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Child-Pugh class C liver cirrhosis is an independent prognostic factor in

The mortality rate of ARDS (acute respiratory distress syndrome) patients varies according to therapeutic modalities, the cause and severity of ARDS, and the presence of associated organ failure. The aim of this study was to determine the influence of liver cirrhosis on clinical outcome in ARDS patients. We retrospectively obtained the age, sex, and the underlying disease of 170 ARDS patients admitted to the medical intensive care unit. There were 3 groups of patients: the first group was ARDS patients with liver cirrhosis (LC, n=49), the second group was ARDS patients with other chronic diseases (n=72) and the third group was ARDS patients without any other logical, biochemical, metabolic, and inflammatory reactions. The liver plays a pivotal role not only in the defense mechanism of the host but also in many aspects of immunologic and metabolic processes [9]. It has been reported that liver failure is a poor prognostic factor in multiple-organ failure patients with sepsis [9,10] and ARDS patients [11,12]. The role of liver failure in promoting ARDS is partly evidenced by the fact that when patients had ARDS associated with end-stage liver failure, the pulmonary disease completely recovers with successful liver transplantation [13]. However, the clinical impact of liver cirrhosis on the outcome of ARDS patients has not been well addressed. There are several potential factors that badly influence the outcome of ARDS in patients with liver cirrhosis. Forty five percent patients with liver cirrhosis develope hypoxia [14]. The hypoxia is resulted from an intrapulmonary shunt, a portovenous shunt, decrease of diffusion capacity, or ventilation perfusion mismatching [15]. The ascites which is frequently associated with liver cirrhosis can influence the lung mechanism. Moreover, the liver may be a major source of inflammatory cytokines that are involved in the pathogenesis of acute lung injury From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. (Drs. Eun Kyung Kim, Tae Sun Shim, Chae Man Lim, Sang Do Lee, Woo Sung Kim, Dong Soon Kim, Won Dong Kim, And Younsuck Koh). Address requests for reprints to: Younsuck Koh, M.D., Division of Pulmonary and Critical Care Medicine. Department of Internal Medicine, Asan Medical Center, 388-1 Pungnap-dong, Songpa-ku, Seoul, 138-736, Korea Phone: 82-2-3010-3130. Fax: 82-2-3010-6968 E-mail: yskoh@amc.seoul.kr diseases(n=49). The overall mortality rate was 56.5%. The GOCA (Gas exchange, Organ failure, Cause, Associated diseases) score, mortality, the incidence of ARDS due to sepsis and the number of organ failures were higher in the LC group than in the other 2 groups. Serum albumin, sodium, the occurrence of other organ failure, GOCA score, SAPS II (Simplified Acute Physiology Score II) were independently associated with mortality. In univariate analysis, the presence of liver cirrhosis was found to be associated with a higher mortality, and Child- Pugh class C liver cirrhosis was an independent prognostic factor of ARDS.


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