07 Oct 06
By Cr Bouch, G Williams
Critical Care 2006, 10:167
Pneumonia (hospital-acquired and community-acquired) is commonly encountered in intensive care. Several papers recently published on this subject have shed more light on different aspects of this important topic. Hypothermia has been shown to improve post-arrest outcome, but how often do we use it? And finally, several papers have recently appeared in the journals related to the admission of the elderly to the critical care area and their outcome.
28 Mar 06
By S Gaïni, OG Koldkjær, C Pedersen and SS Pedersen
Critical Care 2006, 10:R53 http://ccforum.com/content/10/2/R53
Clinicians are in need of better diagnostic markers in diagnosing infections and sepsis. We studied the ability of procalcitonin, lipopolysaccharide-binding protein, IL-6 and C-reactive protein to identify patients with infection and sepsis.
Plasma and serum samples were obtained on admission from patients with suspected community-acquired infections and sepsis. Procalcitonin was measured with a time-resolved amplified cryptate emission technology assay. Lipopolysaccharide-binding protein and IL-6 were measured with a chemiluminescent immunometric assay.
Of 194 included patients, 106 had either infection without systemic inflammatory response syndrome or sepsis. Infected patients had significantly elevated levels of procalcitonin, lipopolysaccharide-binding protein, C-reactive protein and IL-6 compared with noninfected patients (P < 0.001). In a receiver-operating characteristic curve analysis, C-reactive protein and IL-6 performed best in distinguishing between noninfected and infected patients, with an area under the curve larger than 0.82 (P < 0.05). IL-6, lipopolysaccharide-binding protein and C-reactive protein performed best in distinguishing between systemic inflammatory response syndrome and sepsis, with an area under the curve larger than 0.84 (P < 0.01). Procalcitonin performed best in distinguishing between sepsis and severe sepsis, with an area under the curve of 0.74 (P < 0.01).
C-reactive protein, IL-6 and lipopolysaccharide-binding protein appear to be superior to procalcitonin as diagnostic markers for infection and sepsis in patients admitted to a Department of Internal Medicine. Procalcitonin appears to be superior as a severity marker.
10 Jan 06
By Murugan Raghavan and John A Kellum
Hydrocortisone infusion in severe community-acquired pneumonia (CAP) attenuates systemic inflammation and leads to earlier resolution of pneumonia and a reduction in sepsis-related complications.
Prospective, randomized, double-blind, placebo-controlled multi-center clinical trial.
Intensive care units and respiratory intermediate units of six hospitals in Italy between July 2000 and March 2003.
Forty-six patients admitted to the intensive care unit with clinical and radiographic evidence of pneumonia and either two minor or one major 1993 American Thoracic Society criterion for severe pneumonia. Patients with nosocomial pneumonia, immunosuppression, acute burn injury, pregnancy, life expectancy less than 3 months, and conditions requiring more than 0.5 mg/kg/day of prednisone equivalent (such as acute asthma and COPD) were excluded.
Subjects were randomly assigned to receive hydrocortisone infusion or placebo in addition to protocol guided antimicrobial therapy. Hydrocortisone was given as an intravenous 200 mg bolus followed by infusion at a rate of 10 mg/hour for 7 days.
The primary end-points of the study were improvement in PaO2:FiO2 (PaO2:FiO2 >300 or =100 increase from study entry) and multiple organ dysfunction syndrome (MODS) score by Study Day 8, and development of delayed septic shock. The secondary end-points were duration of mechanical ventilation, length of ICU and hospital stay, and survival to hospital discharge and to 60 days.
The hydrocortisone group had lower PaO2:FiO2, higher chest radiograph score and C-reactive protein (CRP) level at study entry. However by study day 8, treated patients had, compared with control subjects, a significant improvement in PaO2:FiO2 (p = 0.002) and chest radiograph score (p < 0.0001), and a significant reduction in CRP levels (p = 0.01), MODS score (p = 0.003), and delayed septic shock (p = 0.001). Hydrocortisone treatment was associated with a significant reduction in length of hospital stay (p = 0.03) and mortality (p = 0.009). There were seven deaths in the control group, whereas none in the hydrocortisone group.
A seven-day course of low-dose hydrocortisone infusion in patients with severe community-acquired pneumonia was associated with a significant reduction in duration of mechanical ventilation, hospital length of stay, and hospital mortality.