14 Apr 08
Posted in Anesthesia, BNP, Echocardiography, Heart failure/Cardiogenic shock at 13:28 by Laci
By P B Messer, R Singh, F T McAuley, G Handley, B Peaston and C P Snowden
Anaesthesia 2008;63:482-487
Heart failure is a major risk factor for adverse postoperative events following non-cardiac surgery. The use of transthoracic echocardiogram as a pre-operative investigation to assess cardiac dysfunction has limitations in this setting. The N-Terminal fragment of B-Type natriuretic peptide (NT proBNP) has been used in screening for heart failure. We have investigated the use of NT proBNP as a screening tool for left ventricular systolic dysfunction to reduce the requirement for pre-operative echocardiograms. Ninety-eight pre-operative non-cardiac surgical patients scheduled to undergo echocardiography were assessed clinically and with an NT proBNP measurement. Echocardiogram was used to define two groups of patients depending on the presence or absence of abnormal left ventricular function and the NT proBNP level was compared between the groups using non-parametric and receiver-operator-characteristic (ROC) curve analysis. In terms of pre-operative screening, a NT proBNP of <38.2 pmol.l−1 had a 100% negative predictive value in predicting patients with normal left ventricular systolic function and would have prevented the requirement for echocardiogram in 43% of pre-operative patients. NT proBNP was superior to electrocardiological and clinical criteria for detection of a normal echocardiogram. This may have significant impact in the pre-operative assessment of patients undergoing non-cardiac surgery.
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01 Apr 08
Posted in Infection, Steroid at 19:29 by Laci
By J de Gans, D van de Beek for the European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators
NEJM 2002;347:1549-1556
Mortality and morbidity rates are high among adults with acute bacterial meningitis, especially those with pneumococcal meningitis. In studies of bacterial meningitis in animals, adjuvant treatment with corticosteroids has beneficial effects.
Methods
We conducted a prospective, randomized, double-blind, multicenter trial of adjuvant treatment with dexamethasone, as compared with placebo, in adults with acute bacterial meningitis. Dexamethasone (10 mg) or placebo was administered 15 to 20 minutes before or with the first dose of antibiotic and was given every 6 hours for four days. The primary outcome measure was the score on the Glasgow Outcome Scale at eight weeks (a score of 5, indicating a favorable outcome, vs. a score of 1 to 4, indicating an unfavorable outcome). A subgroup analysis according to the causative organism was performed. Analyses were performed on an intention-to-treat basis.
Results
A total of 301 patients were randomly assigned to a treatment group: 157 to the dexamethasone group and 144 to the placebo group. The base-line characteristics of the two groups were similar. Treatment with dexamethasone was associated with a reduction in the risk of an unfavorable outcome (relative risk, 0.59; 95 percent confidence interval, 0.37 to 0.94; P=0.03). Treatment with dexamethasone was also associated with a reduction in mortality (relative risk of death, 0.48; 95 percent confidence interval, 0.24 to 0.96; P=0.04). Among the patients with pneumococcal meningitis, there were unfavorable outcomes in 26 percent of the dexamethasone group, as compared with 52 percent of the placebo group (relative risk, 0.50; 95 percent confidence interval, 0.30 to 0.83; P=0.006). Gastrointestinal bleeding occurred in two patients in the dexamethasone group and in five patients in the placebo group.
Conclusions
Early treatment with dexamethasone improves the outcome in adults with acute bacterial meningitis and does not increase the risk of gastrointestinal bleeding.
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Posted in Inotropic support, Sepsis at 19:26 by Laci
By A Kumar, E Schupp, E Bunnell, A Ali, B Milcarek and J E Parrillo
Critical Care 2008, 12:R35
During septic shock, resistance to the hemodynamic effects of catecholamine vasopressors/inotropes is a well-recognized marker of mortality risk. However, the specific cardiovascular/metabolic response elements that are most closely associated with outcome have not been well defined. The objective of this study was to assess cardiovascular/metabolic responses to dobutamine as correlates of outcome in patients with severe sepsis/septic shock.
Methods
A prospective, non-randomized, non-blinded interventional study of graded dobutamine challenge (0, 5, 10, and 15 ug/kg/min) in adult patients who had undergone pulmonary artery catheterization within 48 hours of onset of severe sepsis or septic shock (8 survivors/15 non-survivors) was performed. Radionuclide cineangiography during graded infusion was used to determine biventricular ejection fractions at each increment of dobutamine.
Results
In univariate analysis, a variety of cardiovascular/hemodynamic and oxygen transport/metabolic variables (at the point of maximum cardiac index response for a given subject) were associated with survival including increased stroke volume index (p=0.0003), right ventricular end-diastolic volume index (p=0.0047), left ventricular stroke work index (p=0.0054), oxygen delivery index (p=0.0084), cardiac index (p=0.0093), systolic blood pressure/left ventricular end-systolic volume index ratio (sbp/lvesvi) (p=0.0188), left ventricular ejection fraction (p=0.0160), venous oxygen content (p=0.0208), mixed venous oxygen saturation (p=0.0234) and pulse pressure (p=0.0403); and decreased pulmonary artery diastolic pressure (p=0.0133), systemic vascular resistance index (p=0.0154), extraction ratio (p=0.0160) and pulmonary vascular resistance index (p=0.0390). Increases of SVI of greater than or less than 8.5 ml/m2 were concordant with survival or death in 21 of 23 cases. Multivariate profile construction showed stroke volume index as the dominant discriminating variable for survival with the sBP/LVESVI ratio alone among all other variables significantly improving the model.
Conclusions
Survivors maintain cardiac responsiveness to catecholamine stimulation during septic shock. Survival from severe sepsis/septic shock is associated with increased cardiac performance and contractility indices during dobutamine infusion. Further studies are required to determine whether these parameters are predictive of outcome in a larger severe sepsis/septic shock population.
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Posted in Admission to ICU, ScvO2, Sepsis at 19:23 by Laci
By PA van Beest, JJ Hofstra, MJ Schultz, EC Boerma, PE Spronk and MA Kuiper
Critical Care 2008, 12:R33
Low mixed or central venous saturation (S(c)vO2) can reveal global tissue hypoxia and therefore can predict poor prognosis in critically ill patients. Early goal directed therapy (EGDT), aiming at an ScvO2 ≥ 70%, has been shown to be a valuable strategy in patients with sepsis or septic shock and is incorporated in the Surviving Sepsis Campaign guidelines.
Methods
In this prospective observational multi-center study, we determined central venous pressure (CVP), hematocrit, pH, lactate and ScvO2 or SvO2 in a heterogeneous group of critically ill patients early after admission to the intensive care units (ICUs) in three Dutch hospitals.
Results
Data of 340 acutely admitted critically ill patients were collected. The mean SvO2 value was > 65% and the mean ScvO2 value was > 70%. With mean CVP of 10.3 ± 5.5 mmHg, lactate plasma levels of 3.6 ± 3.6 and acute physiology, age and chronic health evaluation (APACHE II) scores of 21.5 ± 8.3, the in-hospital mortality of the total heterogeneous population was 32.0%. A subgroup of septic patients (n = 125) showed a CVP of 9.8 ± 5.4 mmHg, mean ScvO2 values of 74.0 ± 10.2%, where only 1% in this subgroup revealed a ScvO2 value < 50%, and lactate plasma levels of 2.7 ± 2.2 mmol/l with APACHE II scores 20.9 ± 7.3. Hospital mortality of this subgroup was 26%.
Conclusion
The incidence of low ScvO2 values for acutely admitted critically ill patients is low in Dutch ICUs. This is especially true for patients with sepsis/septic shock.
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