22 Oct 08
Posted in ALI/ARDS at 10:50 by Laci
By T Mauri, A Coppadoro, G Bellani, M Bombino, N Patroniti, G Peri, A Mantovani, A Pesenti
Crit Care Med 2008;36:2302-2308
Pentraxin 3 is a fluid phase receptor involved in innate immunity. It belongs to the Pentraxins family, as C-reactive protein does. Pentraxin 3 is produced by a variety of tissue cells, whereas only the liver produces C-reactive protein. Pentraxin 3 plays a unique role in the regulation of inflammation. Acute lung injury and acute respiratory distress syndrome are characterized by an important inflammatory reaction. We investigated the role of pentraxin 3 as a marker of severity and outcome predictor of acute lung injury and acute respiratory distress syndrome.
Design
We measured circulating pentraxin 3 and C-reactive protein levels within 24 hrs from intubation (day 1), after 24 hrs from the first sample, then every 3 days for the first month and then once a week, until discharge from the intensive care unit. Pentraxin 3 was also measured in bronchoalveolar lavages, performed when clinically indicated.
Setting
One university medical center general intensive care unit.
Patients
The study included 21 patients affected by acute lung injury and acute respiratory distress syndrome (1994 Consensus Conference criteria).
Interventions
None.
Measurements and main results
Pentraxin 3 plasma levels were high with a peak on the first day (median 71.05 ng/mL, interquartile range 52.37-117.38 ng/mL, normal values <2 ng/mL), declining thereafter. C-reactive protein peaked later and remained at relatively high values. Out of several day 1 parameters, pentraxin 3 was the only significant difference between survivors and nonsurvivors. Pentraxin 3 levels were positively correlated with lung injury score values (p < 0.001) and number of organ failures (p < 0.001). Pentraxin 3 was present in bronchoalveolar lavages fluids (5.03 ng/mL, interquartile range 1.52-8.48 ng/mL) and bronchoalveolar lavages positive to bacterial culture were associated with significantly higher pentraxin 3 values (p < 0.05).
Conclusions
The results presented here show that pentraxin 3 is elevated in acute lung injury and acute respiratory distress syndrome and that its levels correlate with parameters of lung injury and systemic involvement. The clinical and pathophysiological significance of pentraxin 3 in acute lung injury and acute respiratory distress syndrome deserves further scrutiny.
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18 Oct 08
Posted in Obstructive sleep apnea at 13:50 by Laci
By F Chung, B Yegneswaran, P Liao, S Chung, S Vairavanathan, S Islam, A Khajehdehi, C Shapiro
Anesthesiology 2008;108:812-821
Obstructive sleep apnea (OSA) is a major risk factor for perioperative adverse events. However, no screening tool for OSA has been validated in surgical patients. This study was conducted to develop and validate a concise and easy-to-use questionnaire for OSA screening in surgical patients.
Methods
After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. After a factor analysis, reliability check, and pilot study; four yes/no questions were used to develop this screening tool. The four questions were respectively related to snoring, tiredness during daytime, observed apnea, and high blood pressure (STOP). For validation, the score from the STOP questionnaire was evaluated versus the apnea-hypopnea index from monitored polysomnography.
Results
The STOP questionnaire was given to 2,467 patients, 27.5% classified as being at high risk of OSA. Two hundred eleven patients underwent polysomnography, 34 for the pilot test and 177 for validation. In the validation group, the apnea-hypopnea index was 20 ± 6. The sensitivities of the STOP questionnaire with apnea-hypopnea index greater than 5, greater than 15, and greater than 30 as cutoffs were 65.6, 74.3, and 79.5%, respectively. When incorporating body mass index, age, neck circumference, and gender into the STOP questionnaire, sensitivities were increased to 83.6, 92.9, and 100% with the same apnea-hypopnea index cutoffs.
Conclusions
The STOP questionnaire is a concise and easy-to-use screening tool for OSA. It has been developed and validated in surgical patients at preoperative clinics. Combined with body mass index, age, neck size, and gender, it had a high sensitivity, especially for patients with moderate to severe OSA.
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10 Oct 08
Posted in Transfusion medicine, Trauma at 18:13 by Laci
By E A Gonzalez, J jastrow, J B Holcomb, L S Kao, F A Moore, R A Kozar
J Trauma 2008;64:247
We previously demonstrated that uncorrected coagulopathy in patients receiving massive transfusion was associated with increased mortality. Based on these findings we implemented early goal directed therapy beginning at the time of injury to approach an optimal plasma:PRBC ratio of 1:1. The aim of the current study was to evaluate mortality after implementation of this practice.
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Posted in Transfusion medicine, Trauma at 18:13 by Laci
By M A Borgman, P C Spinella, J G Perkins, K W Grathwohl, T Repine, A C Beekley, J Sebesta, D Jenkins et al
J Trauma 2007;63:805-813
Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units.
Methods
We performed a retrospective chart review of 246 patients at a US Army combat support hospital, each of who received a massive transfusion (>=10 units of RBCs in 24 hours). Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion. Mortality rates and the cause of death were compared among groups.
Results
For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range, 0:12–1:5), for the medium ratio group, 1:2.5 (interquartile range, 1:3.0–1:2.3), and for the high ratio group, 1:1.4 (interquartile range, 1:1.7–1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (interquartile range, 14–25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively, (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1–35.2).
Conclusions
In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.
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