25 Jul 08
Posted in Echocardiography, Heart failure/Cardiogenic shock, Sepsis at 16:47 by Laci
By A Vieillard-Baron, V Caille, C Charron, G Belliard, B Page, F Jardin
Crit Care Med 2008;36:1701-1706
To evaluate the actual incidence of global left ventricular hypokinesia in septic shock.
Method
All mechanically ventilated patients treated for an episode of septic shock in our unit were studied by transesophageal echocardiography, at least once a day, during the first 3 days of hemodynamic support. In patients who recovered, echocardiography was repeated after weaning from vasoactive agents. Main measurements were obtained from the software of the apparatus. Global left ventricular hypokinesia was defined as a left ventricular ejection fraction of <45%.
Measurements and Main Results
During a 3-yr period (January 2004 through December 2006), 67 patients free from previous cardiac disease, and who survived for >48 hrs, were repeatedly studied. Global left ventricular hypokinesia was observed in 26 of these 67 patients at admission (primary hypokinesia) and in 14 after 24 or 48 hrs of hemodynamic support by norepinephrine (secondary hypokinesia), leading to an overall hypokinesia rate of 60%. Left ventricular hypokinesia was partially corrected by dobutamine, added to a reduced dosage of norepinephrine, or by epinephrine. This reversible acute left ventricular dysfunction was not associated with a worse prognosis.
Conclusion
Global left ventricular hypokinesia is very frequent in adult septic shock and could be unmasked, in some patients, by norepinephrine treatment. Left ventricular hypokinesia is usually corrected by addition of an inotropic agent to the hemodynamic support.
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24 Jul 08
Posted in Inotropic support, Sepsis at 19:19 by Laci
By M Fries, C Ince, R Rossaint, C Bleilevens, J Bickenbach et al
Crit Care Med 2008;36:1886-1891
To determine the effects of norepinephrine and levosimendan on microvascular perfusion and oxygenation in a rat model of septic shock.
Design
Controlled laboratory animal study.
Setting
Research laboratory in a university hospital.
Subjects
Forty Sprague-Dawley rats.
Interventions
Sepsis was induced in 32 animals by cecal ligation and puncture. Eight animals served as sham controls. Animals were randomly assigned to five groups: 1) fluid resuscitation (25 ml.kg-1.h-1), 2) fluid resuscitation plus norepinephrine (0.5 ug.kg-1.min-1), 3) fluid resuscitation plus levosimendan (0.3 ug.kg-1.min-1), 4) no treatment and 5) sham control.
Measurements and Main Results
Microvascular perfusion was quantitated using sidestream darkfield imaging and microvascular oxygenation (uPO2) was assessed by oxygen-dependent quenching of phosphorescence. Measurements were obtained on the buccal mucosa at baseline and at hourly intervals thereafter. In parallel, cardiac output (CO) was recorded. After induction of sepsis microvascular perfusion and uPO2 were impaired early followed by significant decreases in CO. Although levosimendan and norepinephrine were equally effective in restoring CO, only treatment with levosimendan significantly improved uPO2 after 1 and 2 hours of treatment (9.7 +/- 2.0 vs. 15.1 +/- 2.6 and 16.0 +/- 3.7 mmHg; p < 0.05). Microvascular perfusion was not significantly influenced by any of the treatment strategies.
Conclusions
In this model, treatment with levosimendan and norepinephrine showed comparable effects in restoring CO and had no significant influence on microvascular perfusion. However, only levosimendan significantly improved uPO2, suggesting that a mechanism relatively independent of macrocirculatory hemodynamics and overall microvascular perfusion might account for these observations.
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23 Jul 08
Posted in Intra-abdominal pressure at 13:56 by Laci
By JC Ejike, K Bahjri, M Mathur
Crit Care Med 2008;36:2157-2162
The intravesical method has been validated and is considered the gold standard for indirect intra-abdominal pressure (IAP) measurements. In adults, a standard volume (25 mL) is instilled into the bladder to measure IAP. However, the optimal volume for accurate IAP measurements in children has not been well studied and using inappropriate volumes could give erroneous IAP readings.
Objective
To determine the normal IAP in critically ill children and the optimal volume for IAP measurement by the intravesical method in this population.
Design
Prospective observational study.
Setting
Tertiary pediatric intensive care unit.
Patients
Ninety-six mechanically ventilated children younger than 18 yrs of age with no clinical evidence of intra-abdominal hypertension.
Measurements and Results
Graduated volumes of normal saline in increments of 3-50 mL were instilled in the bladder via a urethral catheter. IAP was recorded by using the AbViser device (WolfeTory Medical, Inc., Salt Lake City, UT) with each instillation. A pressure-volume curve was generated for every patient, and the minimum and mean optimal volumes were determined from this curve. Data were analyzed by stratification of patients according to weights 0-10 kg, >10-20 kg, and >20-50 kg. Descriptive statistics was used for statistical analysis. Normal IAP for critically ill children was 7 +/- 3 and was similar in the different weight groups (p = .745). Although the mean optimal volume to measure accurate IAP was variable in the different weight groups, the minimum optimal volume was 3 mL irrespective of weight.
Conclusions
Mean IAP in critically ill children is 7 +/- 3 mm Hg. The minimum optimal volume needed to accurately measure IAP by the intravesical method in children is 3 mL. We recommend that 3 mL be the standard instillation volume for IAP measurement by the intravesical method in children. IAP >10 mm Hg should be considered elevated in children.
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Posted in Nutrition, Sepsis at 13:51 by Laci
By G Elke, D Schadler, C Engel, H Bogatsch, I Frerichs et al. for the German Competence Network Sepsis (SepNet)
Crit Care Med. 2008;36:1762-1767
To identify current clinical practice regarding nutrition and its association with morbidity and mortality in patients with severe sepsis or septic shock in Germany.
Design
Nationwide prospective, observational, cross-sectional, 1-day point-prevalence study.
Setting
The study included 454 intensive care units from a representative sample of 310 hospitals stratified by size.
Patients
Participants were 415 patients with severe sepsis or septic shock (according to criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference).
Interventions
None.
Measurements and Main Results
Data were collected by on-site audits of trained external study physicians during randomly scheduled visits during 1 yr. Valid data on nutrition were available for 399 of 415 patients. The data showed that 20.1% of patients received exclusively enteral nutrition, 35.1% exclusively parenteral nutrition, and 34.6% mixed nutrition (parenteral and enteral); 10.3% were not fed at all. Patients with gastrointestinal/intra-abdominal infection, pancreatitis or neoplasm of the gastrointestinal tract, mechanical ventilation, or septic shock were less likely to receive exclusively enteral nutrition. Median Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment scores were significantly different among the nutrition groups. Overall hospital mortality was 55.2%. Hospital mortality was significantly higher in patients receiving exclusively parenteral (62.3%) or mixed nutrition (57.1%) than in patients with exclusively enteral nutrition (38.9%) (p = .005). After adjustment for patient morbidity (Acute Physiology and Chronic Health Evaluation II score, presence of septic shock) and treatment factors (mechanical ventilation), multivariate analysis revealed that the presence of parenteral nutrition was significantly predictive of mortality (odds ratio, 2.09; 95% confidence interval, 1.29-3.37).
Conclusions
Patients with severe sepsis or septic shock in German intensive care units received preferentially parenteral or mixed nutrition. The use of parenteral nutrition was associated with an increased risk of death.
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