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.


Authors:

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.


Authors:

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.


Authors:

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.


Authors:

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.


Authors:

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.


Authors:

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.


Authors:

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.


Authors:

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).


Authors:

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.


Authors:

Does the Direct Bilirubin/Total Bilirubin Ratio Reflect Prognosis in Acute Hepatic Failure?

The direct bilirubin/total bilirubin (D/T) ratio, which is not affected by such therapy as plasma exchange (PE), has been need for the determination of severity of acute hepatic failure. We studied 20 patients with acute hepatic failure who had received PE to examine whether the D/T ratio reflects prognosis, in association with tumor necrosis factor-alpha (TNF-a). Total bilirubin before the final PE was significantly higher than that before the initial PE (p=0.0064). No significant difference was observed between the D/T ratios before the initial PE and at the end of PE. No significant difference was observed between TNF-a before the initial PE and before the final PE. No significant correlation was observed among total bilirubin, D/T ratio, and TNF-a. No significant difference was observed between the survivor group and the nonsurvivor group in any factor. In the nonsurvivor group, total bilirubin before the final PE was significantly higher than that before the initial PE (p=0.0217). However, no significant difference was observed between the D/T ratios before the initial PE and before the final PE in the nonsurvivor group. In this study, the rise in total bilirubin reflected ineffectiveness of treatment. However, the D/T ratio failed to become an index of prognosis.


Authors:

Clinical Profile and Management of Heart Failure in a Cardiac Center.

Heart failure is a progressive and serious disease. In the future this syndrome is likely to become a major public health problem in a developing country like Indonesia because of an aging population and increasing frequency of some major coronary heart disease risk factors. At the moment there is no systematically collected information on the clinical profile and the pattern of management of heart failure in Indonesia. The present study sought to examine some important demographics and clinical characteristics of patients hospitalized for heart failure and the pattern of anti failure treatment as performed by cardiologist in a National Cardiac Center. All consequtive patients who were admitted because of heart failure in 2000 were included in this survey. Information was abstracted from medical records by trained personel using standardized froms. There were 397 patients (male 68%, mean age 58.14 ± 13.57 years) included in the present study. Heart failure was due to coronary artery disease in 47% of patients, hypertensive heart disease 27%, valvular heart disease 15%, cardiomyopathy 8% and others 3%. During hospitalization (mean length of stay 8.69 ± 6.61 days) 5% of the patients died, 8% complicated by stroke, and 2% developed thromboembolism. Recurrent admission rate was 39%. The results of this study showed that standard treatment for heart failure were not given equally well to all patients: ACE inhibitors 62%, beta blockers 31%, angiotensin II receptor blockers 10%, and digitalis 66%. Symptomatic treatment were given as follow: furosemid 80% HCT 6%, spirolactone 44% and nirate 66%. In summary, the present survey highlighted some important clinical characteristics patients of hospitalized for heart failure. Despite advances in the management of heart failure, patients currently hospitalized for this syndrome still have high mortality and morbidity and high readmission rate. There is still room for improvement of evidence-based therapy.


Authors:

Non-Equilibrium Method for the Non-Invasive Estimation of Arterial PCO2

Background: Under conditions of pulmonary ventilation/perfusion mismatch, end-tidal PCO2 (ETPCO2) may severely underestimate arterial PCO2 (PaCO2). Objective: We aimed to develop a method for the accurate non-invasive estimation of PaCO2 from ETPCO2. Methods/Patients: The fact that ETPCO2 is a mixture of PCO2 from both the ventilated and perfused alveoli, and the ventilated but unperfused ones (‘alveolar deadspace’), was brought into mathematical terms. Using the model, by inspiring two gases with different CO2 content and determining the corresponding ETPCO2 values, the PCO2 of the ventilated and perfused alveoli (truePCO2) may be calculated as an estimate of PaCO2. The model was applied on 12 ventilated patients aged 53 to 78 yrs. Estimates of PaCO2 were compared to the results of invasive determination. Results: Conventional ETPCO2 and PaCO2 differed on average by 22 percent (95% confidence interval, 18 to 26). Depending on the difference between the two inspiratory PCO2 levels used, the unsigned error of the model-based estimate typically was 5 percent (95% confidence interval, 3.5 to 7) or better. Conclusion: We provide a non-invasive method for the accurate estimation of PaCO2 and suggest its implementation into ventilators for the close monitoring of pulmonary treatment response.


Authors:

Effects of Permissive Hypercapnia on Pulmonary Mechanics and Hemodynamics during Mechanical Ventilation in Severe Acute Respirat

Objectives: To evaluate effects of permissive hypercapnia (PHC) on pulmonary mechanics and hemodynamics in patients with severe acute respiratory distress syndrome (ARDS). Methods: We observed the influence of different tidal volume (VT) on pulmonary mechanics and hemodynamics in 10 patients with severe ARDS. Results: PHC was induced by decreasing VT from 10 - 12 ml/kg (routine VT) to 6 - 8 ml/kg (small VT). Arterial oxygen pressure and saturation remained unchanged, but pulmonary venous admixture was increased (p < 0.05). Airway plateau pressure and mean pressure were also decreased markedly. C20/C, which reflects lung overdistention, was increased significantly. Mean arterial pressure, central venous pressure, pulmonary arterial pressure were not changed, while systemic vascular resistance index was decreased markedly (p < 0.05). Cardiac index (CI) and oxygen delivery (DO2) were increased (p < 0.05), while oxygen consumption remained unchanged. Conclusions: PHC, which was induced by small VT, might prevent lung overdistention and led to an increase in CI and DO2.


Authors:

A Prior Brain Microinjury Attenuates Hypermetabolism Induced by Brain Ischemia-Reperfusion in the Mouse

We have previously shown that a prior brain microinjury improves survival of mice following brain ischemia, though the precise mechanism remains to be determined. The purpose of the present study was to examine the modulatory effects of the brain microinjury on postischemic brain metabolism. Sixty-eight DDY mice were divided into four groups: sham-operated non-ischemia, sham-operated ischemia, brain-injured non-ischemia, and brain-injured ischemia groups. Brain microinjury was induced by vertically inserting a 25-gauge needle into the brain at selected four sites. Seven days after the injury or sham-operation, animals in two ischemia groups were subjected to brain ischemia (60 min occlusion of bilateral carotid arteries). Using 2-[14C] deoxyglucose method, relative metabolic activity of brain regions was measured seven days after brain microinjury or sham operation in two non-ischemia groups and seven days after brain ischemia in the other two ischemia groups. There were no significant differences in relative metabolic activity of any brain region measured when compared between sham-operated and brain-injured animals without ischemia. In mice with sham operation, metabolic activity after ischemia was significantly higher in 8 of 22 brain regions examined that that measured without ischemia (p < .05). In mice with brain microinjury, metabolic activity remained unchanged following brain ischemia in any brain region examined except in the mammilary complex. The minor brain injury it self did not affect regional brain metabolism but attenuated postischemic increase in metabolic activity, suggesting that the ability of an antecedent brain microtrauma to attenuate postischemic hypermetabolism is involved in protection from subsequent ischemic-reperfusion injury.


Authors: