24 Oct 06
Posted in Venous thromboembolism at 18:05 by Laci
By JA Kline, J Hernandez-Nino, GA Rose, H James Norton, CA Camargo
Critical Care Medicine 2006;34:2773-2780
Although echocardiography has proven utility in risk stratifying normotensive patients with pulmonary embolism, echocardiography is not always available.
Objective
Test if a novel panel consisting of pulse oximetry, 12-lead electrocardiography, and serum troponin T would have prognostic equivalence to echocardiography and to examine the prognostic performance of age, previous cardiopulmonary disease, D-dimer, brain natriuretic peptide, and percentage of pulmonary vascular occlusion on chest computed tomography.
Design
Prospective cohort study.
Patients and Setting
Normotensive (systolic blood pressure of >100 mm Hg) emergency department and hospital inpatients with diagnosed pulmonary embolism who underwent cardiologist-interpreted echocardiography and other measurements within 15 hrs of anticoagulation.
Measurements and Main Results
End points were in-hospital circulatory shock or intubation, or death, recurrent pulmonary embolism, or severe cardiopulmonary disability (defined as echocardiographic evidence of severe right ventricular dysfunction with New York Heart Association class III dyspnea or 6-min walk test of <330 m) at 6-month follow-up. The two-one-sided test tested the hypothesis of equivalence with one-tailed a = 0.05 and ? = 5%. Of 200 patients enrolled, data were complete for 181 (88%); 51 of 181 patients (28%) had an adverse outcome, including in-hospital complication (n = 18), death (n = 11), recurrent pulmonary embolism (n = 2), or cardiopulmonary disability (n = 20). Right ventricular dysfunction on initial echocardiogram was 61% sensitive (95% confidence interval, 46-74%) and 57% specific (48-66%). The panel was 71% sensitive (56-83%) and 62% specific (53-71%). The two-one-sided procedure demonstrated superiority of the panel to echocardiography for both sensitivity and noninferiority for specificity. No other biomarker demonstrated equivalence, noninferiority, or superiority for sensitivity and specificity.
Conclusion
Normotensive patients with pulmonary embolism have a high rate of severe adverse outcomes during 6-month follow-up. A panel of three widely available tests can be used to risk stratify patients with pulmonary embolism when formal echocardiography is not available.
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Posted in Infection at 18:04 by Laci
By M Auburtin, Ml Wolff, J Charpentier, E Varon, Y Le Tulzo, C Girault, I Mohammedi et al
Critical Care Medicine 2006;34:2758-2765
To identify factors associated with mortality and morbidity among adults admitted to intensive care units (ICUs) for pneumococcal meningitis, particularly the impact of delayed antibiotic administration.
Design
We conducted a prospective, multicenter, observational study of 156 consecutive adults hospitalized for pneumococcal meningitis. We analyzed parameters associated with 3-month survival.
Setting
Fifty-six medical and medical-surgical ICUs in France.
Results
Of the 148 strains isolated, 56 (38%) were nonsusceptible to penicillin G. At 3 months after ICU admission, the mortality rate was 33% (51/156), and 34% of survivors (36/105) had neurologic sequelae. Multivariate analysis identified three variables as independently associated with 3-month mortality: Simplified Acute Physiology Score II (odds ration [OR], 1.12; 95% confidence interval [CI], 1.072-1.153; p = .002); isolation of a nonsusceptible strain (OR, 6.83; 95% CI, 2.94-20.8; p < 10-4), and an interval of >3 hrs between hospital admission and administration of antibiotics (OR, 14.12; 95% CI, 3.93-50.9; p < 10-4). In contrast, a cerebrospinal fluid leukocyte count >103 cells/µL had a protective effect (OR, 0.30; 95% CI, 0.10-0.944; p = 0.04).
Conclusions
Independent of severity at the time of ICU admission, isolation of penicillin-nonsusceptible strains and a delay in antibiotic treatment following admission were predictors of mortality among patients with pneumococcal meningitis.
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Posted in Sepsis at 18:03 by Laci
By AC Kalil, JE Sevransky, DE Myers, C Esposito, RW Vandivier, P Eichacker, G Susla et al
Critical Care Medicine 2006;34:2719-2728
l-arginine supplementation in sepsis is controversial. Septic shock has been alternatively viewed as an l-arginine-deficient state or as a syndrome caused by excess nitric oxide, an end-product of l-arginine metabolism.
Design
Randomized, placebo-controlled, and double-blinded (investigators, veterinarians, and pharmacists).
Setting
Laboratory.
Subjects
Purpose-bred, 1- to 2-yr-old, 10- to 12-kg beagles.
Interventions
The effects of parenteral l-arginine alone or in combination with N-acetylcysteine were compared with vehicle alone in a well-characterized canine model of Escherichia coli peritonitis. Two doses were studied that delivered approximately 1.5-fold (10 mg·kg-1·hr-1) and 15-fold (100 mg·kg-1·hr-1) the l-arginine dose typically administered with standard total parenteral nutrition. Animals in the low- and high-dose l-arginine arms were further randomized to receive vehicle alone or N-acetylcysteine (20 mg·kg-1·hr-1) as an antioxidant to prevent peroxynitrite formation.
Measurements and Main Results
The main measurements were hemodynamics, plasma arginine and ornithine, serum nitrate/nitrite, laboratory studies for organ injury, and survival. Both doses of l-arginine similarly increased mortality (p = .02), and worsened shock (p = .001 for reduced mean arterial pressure). These effects were associated with significant increases in plasma arginine (p = .0013) and ornithine (p = .0021). In addition, serum nitrate/nitrite (p = .02), liver enzymes (p = .08), and blood urea nitrogen/creatinine ratios (p = .001) rose, whereas arterial pH (p = .001) and bicarbonate levels (p = .001) fell. N-acetylcysteine did not significantly decrease any of the harmful effects of l-arginine. Thus, parenteral l-arginine monotherapy was markedly harmful in animals with septic shock.
Conclusions
These findings suggest that supplemental parenteral l-arginine, at doses above standard dietary practices, should be avoided in critically ill patients with septic shock.
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Posted in Sepsis at 18:01 by Laci
By ST Micek, N Roubinian, T Heuring, M Bode, J Williams et al
Critical Care Medicine 2006;34:2707-2713
To evaluate a standardized hospital order set for the management of septic shock in the emergency department.
Design
Before-after study design with prospective consecutive data collection.
Setting
Emergency department of a 1,200-bed academic medical center.
Patients
A total of 120 patients with septic shock.
Interventions
Implementation of a standardized hospital order set for the management of septic shock.
Measurements and Main Results
A total of 120 consecutive patients with septic shock were identified. Sixty patients (50.0%) were managed before the implementation of the standardized order set, constituting the before group, and 60 (50.0%) were evaluated after the implementation of the standardized order set, making up the after group. Demographic variables and severity of illness measured by the Acute Physiology and Chronic Health Evaluation II were similar for both groups. Patients in the after group received statistically more intravenous fluids while in the emergency department (2825 ± 1624 mL vs. 3789 ± 1730 mL, p = .002), were more likely to receive intravenous fluids of >20 mL/kg body weight before vasopressor administration (58.3% vs. 88.3%, p < .001), and were more likely to be treated with an appropriate initial antimicrobial regimen (71.7% vs. 86.7%, p = .043) compared with patients in the before group. Patients in the after group were less likely to require vasopressor administration at the time of transfer to the intensive care unit (100.0% vs. 71.7%, p < .001), had a shorter hospital length of stay (12.1 ± 9.2 days vs. 8.9 ± 7.2 days, p = .038), and a lower risk for 28-day mortality (48.3% vs. 30.0%, p = .040).
Conclusions
Our study found that the implementation of a standardized order set for the management of septic shock in the emergency department was associated with statistically more rigorous fluid resuscitation of patients, greater administration of appropriate initial antibiotic treatment, and a lower 28-day mortality. These data suggest that the use of standardized order sets for the management of septic shock should be routinely employed.
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