Performance of influenza-specific triage tools in an H1N1-positive cohort: P/F ratio better predicts the need for mechanical ventilation and critical care admission.

BACKGROUND: Pandemic influenza presents a major threat to global health and socioeconomic well-being. Future demand for critical care may outstrip supply and force clinicians to triage patients for admission. We evaluated the Simple Triage Scoring System (STSS), Ontario Health Plan for an Influenza Epidemic (OHPIP) and PaO2 /FiO2  (P/F) ratio to determine utility in predicting need for mechanical ventilation. METHODS: We conducted a retrospective case note review of patients admitted to two centres, Royal Liverpool University Hospital and Countess of Chester Hospital, during the UK influenza pandemic of 2010-11. Demand for critical care during this period forced hospitals in Cheshire and Merseyside to implement escalation policies and increase capacity. Inclusion criteria were polymerase chain reaction-confirmed H1N1 influenza and age >18 years. Exclusion criteria were no evidence of treatment for influenza, patient not admitted to hospital or the inability to locate case notes. RESULTS: One hundred and one patients were included, 29 were admitted to critical care and 23 required mechanical ventilation. The P/F ratio predicted the need for mechanical ventilation with a receiver operating characteristic area under the curve (ROC AUC) of 0.885 (CI 0.817-0.952). Predictive ability was not reduced when the P/F ratio had to be estimated using the Pandharipande tool. The STSS score predicted the need for mechanical ventilation [ROC AUC 0.798 (CI 0.704-0.891)]. The reverse triage component of the OHPIP tool was a poor predictor of patient outcome. CONCLUSIONS: The P/F ratio was a better predictor of need for mechanical ventilation than STSS. The P/F ratio is a simple and accepted determinant of hypoxaemia and should be used if secondary triaging becomes necessary during future influenza pandemics.

Continuous S-(+)-ketamine administration during elective coronary artery bypass graft surgery attenuates pro-inflammatory cytokine response during and after cardiopulmonary bypass.

BACKGROUND: Coronary artery bypass surgery (CABG) with cardiopulmonary bypass (CPB) leads to elevated circulating plasma cytokines. In this prospective randomized study, the effect of an S-(+)-ketamine-based anaesthetic protocol on perioperative plasma cytokine levels was compared with standard anaesthesia with propofol and sufentanil during CPB. METHODS: Patients undergoing elective on-pump CABG were randomly allocated to anaesthesia with sufentanil-propofol-midazolam (Sufentanil) or S-(+)-ketamine-propofol-midazolam (Ketamine). Blood samples were obtained before induction of anaesthesia (baseline) and also at 1, 6, and 24 h after aortic unclamping. Plasma levels of the interleukins (IL)-6, IL-8, IL-10, and tumour necrosis factor (TNF)-alpha were determined by enzyme-linked immunosorbent assay. RESULTS: One hundred and twenty-eight patients were studied (Ketamine: n=60; Sufentanil: n=68). All measured cytokines increased during and after CPB. However, the increase in the pro-inflammatory cytokines IL-6 and IL-8 6 h after aortic unclamping was significantly lower in the Ketamine group compared with the Sufentanil group [mean (sd): IL-6 56.75 (46.28) pg ml⁻¹ (Ketamine) vs 172.64 (149.93) pg ml⁻¹ (Sufentanil), P<0.01; IL-8 7.74 (14.72) pg ml⁻¹ (Ketamine) vs 26.3 (47.12) pg ml⁻¹ (Sufentanil), P<0.01]. In contrast, the anti-inflammatory cytokine IL-10 showed higher levels 1 h after unclamping in the Ketamine group compared with the Sufentanil group [mean (sd): 69.59 (78.78) vs 24.63 (37.7) pg ml⁻¹, P<0.001]. CONCLUSION: Our data demonstrate that S-(+)-ketamine possesses anti-inflammatory potential. Anaesthesia with S-(+)-ketamine may have beneficial effects in attenuating the CPB-induced systemic inflammatory response.

Comparison of S-(+)-ketamine- with sufentanil-based anaesthesia for elective coronary artery bypass graft surgery: effect on troponin T levels.

BACKGROUND: S-(+)-ketamine anaesthesia carries potential benefits for the cardiovascularly compromised patient. However, the use of S-(+)-ketamine in ischaemic coronary artery disease is controversial. In a prospective, randomized, clinical trial, we have investigated whether an S-(+)-ketamine-based anaesthetic protocol leads to increased cardiac troponin T levels (cTnT) after coronary artery bypass grafting (CABG). METHODS: Two hundred and nine patients undergoing elective CABG were randomized to receive either i.v. anaesthesia with sufentanil-midazolam-propofol (SMP; n=108) or S-(+)-ketamine-midazolam-propofol (KMP; n=101). Haemodynamic variables were maintained within the normal range. Invasive haemodynamic monitoring was performed using a pulmonary artery catheter. Plasma cTnT levels were sampled before induction and 1, 6, and 24 h after aortic unclamping. Cardiovascular adverse events, such as electrocardiographic signs of ischaemia, perioperative myocardial infarction, and death, were recorded. RESULTS: Patient characteristics, cardiac profile, intraoperative management, and the incidence of cardiovascular adverse events were comparable between the groups. Plasma cTnT levels increased after operation in both groups. cTnT levels were significantly lower in the KMP group 6 h after aortic unclamping compared with the SMP group (P=0.004), but did not differ 24 h after aortic unclamping [median (range): SMP 0.4 (0.01-3.9) vs KMP 0.4 (0.07-6.6) microg litre(-1), P=0.338]. CONCLUSIONS: S-(+)-ketamine does not accentuate postoperative cTNT rises in haemodynamically stable elective CABG patients.

[Scoring systems for daily assessment in intensive care medicine. Overview, current possibilities and demands on new developments]. / Intensivmedizinische Scoringsysteme zur täglichen Anwendung. Ubersicht, aktuelle Möglichkeiten und Anforderungen an Neuentwicklungen.

Scoring systems are a fixed element of modern diagnostics and are integrated in the diagnosis-related groups (DRG) billing system as well as quality assurance projects. The ongoing developments require classification according to the terms of use in order to maintain an overview of the numerous systems available. In the area of intensive care medicine scoring systems can be divided into admission scores and progress scores, whereby the scores for daily assessment can be further subdivided into five categories, depending on the target criteria: objective description of the grade of organ dysfunction, progression in intensive care therapy, evaluation of the degree of nursing care, determination of outcome/mortality risk, and grouping of patient collectives for clinical trials. In future developments it will be necessary to generate new strategies to adequately describe the progress of a patient. Not only will mortality be challenged as a target criterion but also the handling of missing data and the simplification of reality by categorization practised so far that can be found in all established scoring systems as far as calculation of predictive values regarding a defined result.

[Morphine inhibits complement receptor expression, phagocytosis and oxidative burst by a nitric oxide dependent mechanism]. / Morphin hemmt die Expression von Komplementrezeptoren sowie Phagozytose und Oxidativen Burst in Monozyten über einen NO-abhängigen Mechanismus.

OBJECTIVE: Monocytes play a crucial role in the immune response by recognition, ingestion, and intracellular killing of microorganisms. We investigated whether morphine and fentanyl influence CD 11b and CD35 surface receptor expression, phagocytic activity and superoxide anion generation of monocytes in a whole blood flow cytometric assay. METHODS: Whole blood of 13 healthy volunteers was incubated with different morphine and fentanyl concentrations. Expression of surface receptors CD 11b and CD35 was determined by fluorochrome-labelled antibodies. Phagocytic activity was assessed by ingestion of fluorescent bacteria. Conversion of dihydrorhodamin served for oxidative burst measurements. RESULTS: Morphine inhibited monocyte function in a concentration and time dependent manner. Morphine-induced changes were abolished by preincubation with the NO synthase inhibitor N-nitro-l-arginine as well as naloxone. Fentanyl failed to inhibit receptor expression, phagocytosis and reactive oxygen production by monocytes in clinically relevant as well as supraclinical concentrations. CONCLUSION: Our results suggest that these monocyte functions are inhibited by a morphine-stimulated NO release mediated by a mu opiate receptor subtype expressed on the surface of monocytes. In contrast, fentanyl did not share morphine's inhibitory effects on monocyte activity.

[Case report: treatment of anti-basement membrane glomerulonephritis with immunoadsorption]. / Kasuistik: Therapie der antibasalmembranglomerulonephritis mittels Immunadsorption.

Immunoadsorption (IMAD) is a particle extracorporeal therapy in treatment of various autoimmune diseases which differs from plasmapheresis. In the case presented here IMAD was helpful in the therapy of an acute renal failure due to an antiglomerular basement membrane disease. IMAD resulted in a quick recovery and stabilisation of the renal function. In addition to IMAD, the patient was treated with steroids, an immunosuppressive therapy was started immediately after IMAD. Considering the course of this patient's disease, we are convicted that IMAD was a major factor in the therapeutic success. IMAD was well tolerated by the patient, no side effects were seen.

[High dose 7S-immunoglobulin therapy in collagenoses. Clinical observations and effects on the lymphocyte subsets and immunoglobulin production]. / Hochdosierte 7S-Immunglobulintherapie bei Kollagenosen. Klinische Beobachtungen und Effekte auf Lymphozytensubpopulationen und Immunglobulinproduktion.

Therapy with 7S-immunoglobulins in 8 patients with various connective tissue diseases led to a decrease of clinical disease activity. In vitro experiments showed that treatment induces change of B-cell function. Significant quantitative alteration of relative lymphocyte subpopulations did not occur. CRP, C3c, C4 and circulating immune complexes tended to normalization.