Pulmonary edema associated with electrical injury.

The occurrence of cardiogenic pulmonary edema following alternating current electrical injury has not been reported. A patient developing severe pulmonary edema immediately following an electrical injury-induced episode of ventricular fibrillation is described. Evidence that the etiology of the pulmonary edema was cardiogenic is derived from both hemodynamic data and the calculation of the pulmonary edema fluid to serum colloid osmotic pressure ratio.

Trace element homeostasis during continuous sedation with propofol containing EDTA versus other sedatives in critically ill patients.

OBJECTIVE: To evaluate changes in serum and urinary zinc, cobalt, copper, iron, and calcium concentrations in critically ill patients receiving propofol containing disodium edetate (disodium ethylenediaminetetraacetic acid [EDTA]) versus sedative agents without EDTA. DESIGN: This was a randomised, open-label, parallel-group study with randomisation stratified by baseline Acute Physiology and Chronic Health Evaluation (APACHE II) scores. SETTING: Intensive care units (ICU) in 23 medical centres. PATIENTS: Medical, surgical, or trauma ICU patients 17 years of age or older who required mechanical ventilator support and sedation. INTERVENTIONS: A total of 106 patients received propofol containing 0.005 % EDTA (propofol EDTA), and 104 received other sedative agents without EDTA (non-EDTA). Only the first 108 patients were assessed for urinary trace metal excretion. Twenty-four-hour urine samples were collected on days 2, 3, and 7 and every 7 days thereafter for determination of zinc, cobalt, copper, iron, and calcium excretion; EDTA levels; urine osmolality; albumin levels; and glucose levels. The first 143 patients were assessed for serum concentration of zinc, cobalt, copper, iron, and calcium; creatinine; blood urea nitrogen; and albumin at baseline and once during each 24-hour urine collection. MEASUREMENTS AND RESULTS: For the assessment of trace metals, patients receiving propofol EDTA demonstrated increased mean urinary excretion of zinc, copper, and iron compared with the normal range. All patients receiving sedatives demonstrated increased urinary excretion of zinc and copper above normal reference values. Compared with the non-EDTA sedative group, the propofol EDTA group demonstrated increased urinary excretion of zinc and iron. Mean serum concentrations of zinc and total calcium were decreased in both patient groups. Serum zinc concentrations increased from baseline to day 3 in the non-EDTA sedative group but not in the propofol EDTA group. Renal function, measured by blood urea nitrogen, serum creatinine, and creatinine clearance, did not deteriorate during ICU sedation with either regimen. CONCLUSION: This study showed that critical illness is associated with increased urinary losses of zinc, copper, and iron. Propofol EDTA-treated patients had greater urinary losses of zinc and iron and lower serum zinc concentrations compared with the non-EDTA sedative group. No adverse events indicative of trace metal deficiency were observed in either group. The clinical significance of trace metal losses during critical illness is unclear and requires further study.

A randomized study of the efficacy and safety of intravenous acetaminophen vs. intravenous placebo for the treatment of fever.

This randomized, double-blind, placebo-controlled study evaluated the antipyretic effect and safety of intravenous (i.v.) acetaminophen using an endotoxin-induced fever model. Subjects exhibiting sufficient fever response following administration of reference standard endotoxin (RSE) were randomly assigned to receive i.v. acetaminophen 1,000 mg (n = 31) or matching placebo (n = 29). The primary efficacy end point was the weighted sum of temperature differences from baseline through 6 h. Relative to placebo, i.v. acetaminophen administration produced a rapid decrease in temperature that persisted throughout the 6-h study period. The primary end point favored i.v. acetaminophen over placebo (P < 0.001). Temperature differences from baseline reached statistical significance at T30 min after endotoxin administration (15 min after completing the study medication infusion). Acetaminophen administered i.v. was well tolerated, and the frequency of adverse events was comparable to that after administration of i.v. placebo. This study shows that i.v. acetaminophen in a single 1,000-mg dose is safe and effective in reducing fever.

Effects of exogenous lipids on blood gas measurements.

OBJECTIVE: Numerous reports have appeared describing the effects of intravenous lipid administration on the pulmonary function of the critically ill patient. Our study was undertaken to determine whether the lipid content of an arterial blood gas specimen affects the measurement of arterial pH, PaO2, PaCO2, or arterial oxygen saturation. DESIGN: Prospective, in vitro controlled study. SETTING: Medical and cardiac intensive care units. PATIENTS: Critically ill patients undergoing clinically-directed blood gas sampling via indwelling arterial catheters. INTERVENTIONS: None. MEASUREMENTS: Arterial blood gas specimens were modified in vitro by dividing the sample and adding a known amount of lipid emulsion to half of the sample, resulting in a difference between the plasma triglyceride concentrations of the two halves. Two series of experiments were run: one series was run with a predicted plasma triglyceride difference of 400 mg/dL (4.5 mmol/L) between the two samples; the other series was run with a predicted plasma triglyceride difference of 800 mg/dL (9.0 mmol/L) between the two samples. Blood gas measurements were performed on each half of a sample, and the results were compared. Because some studies have only noted changes in patients with the adult respiratory distress syndrome (ARDS), samples from these patients were also analyzed as a separate group. RESULTS: No significant changes were found in arterial pH, PaO2, PaCO2, or arterial oxygen saturation between the two halves of the sample. With 95% confidence, differences as small as 1.5 torr (0.2 kPa) for PaO2 and PaCO2, 0.5% for arterial oxygen saturation, and 0.005 for pH, would have been detected. No differences were found in the ARDS subgroup. CONCLUSIONS: The addition of clinically relevant amounts of lipid to blood samples does not affect blood gas measurements. Any observed changes in blood gas values after lipid feeding are presumably due to products of lipid metabolism or alterations in pulmonary function.

Magnitude and duration of the effect of sepsis on survival. Department of Veterans Affairs Systemic Sepsis Cooperative Studies Group.

OBJECTIVE: To determine the magnitude and duration of the effects of sepsis on survival. DESIGN: Cohort study. SETTING: The 10 Department of Veterans Affairs Medical Centers of the Systemic Sepsis Cooperative Studies Group, which from 1983 to 1986 conducted the Department of Veterans Affairs Cooperative Study of Corticosteroids in Systemic Sepsis. PATIENTS: The septic population consisted of 1505 patients with evaluable data from the screening log of the Cooperative Study of Corticosteroids in Systemic Sepsis. All 91830 nonpsychiatric, noninfected patients discharged from the participating medical centers between October 1, 1984, and September 30, 1985, were included in the control population. MAIN OUTCOME MEASURE: Death through 8 years after the index hospitalization. RESULTS: On the basis of a proportional hazards model constructed from the demographic and illness characteristics of the control population, the septic population was at significant risk of dying of nonseptic causes (26% predicted 1-year mortality). In the septic population, the daily risk of dying exceeded predictions from this model for 5 years, and the hazard rate rose with increasing severity of the septic episode throughout the first year (P<.05). Among 30-day survivors, sepsis reduced the remaining mean life span from a predicted 8.03 years to 4.08 years. CONCLUSIONS: Sepsis not only causes deaths acutely, but also increases the risk of death for up to 5 years after the septic episode even after comorbidities are accounted for. The risk of late death during the first year is associated with the severity of the septic episode.

Prior healthcare utilization as a predictor of survival for medical intensive care unit patients.

OBJECTIVE: To determine whether measures of inpatient care utilization from the year preceding admission to a medical intensive care unit (MICU) improve physiology-based predictions of hospital and 1-yr survival. DESIGN: Inception cohort study with a validation cohort. SETTING: The MICU in university-affiliated Department of Veterans Affairs Medical Center. PATIENTS: A total of 1,200 consecutive patients admitted to the MICU. MEASUREMENTS AND MAIN RESULTS: Increased use of inpatient health care before MICU admission was associated with increased mortality. However, inpatient utilization data failed to improve physiology-based logistic models for hospital and 1-yr survival (p > .15 for improvement in the area under the receiver operating characteristic curve for both end points in the validation cohort), whereas physiologic data improved models derived from measures of inpatient care (p < .001 for both end points). Empirically derived inpatient care models used only information from the few days preceding MICU admission, despite the availability of a full year of data. CONCLUSIONS: Chronic illness, as gauged by a need for frequent inpatient care in the year before MICU admission, is not independently predictive of poor short- or long-term survival. Clinicians should not attempt to predict survival of prospective MICU patients by the extent of previous inpatient care.

Recurrent portopulmonary hypertension after liver transplantation: management with epoprostenol and resolution after retransplantation.

We report a case of portopulmonary hypertension in which the pulmonary hypertension resolved after initial orthotopic liver transplantation. Portopulmonary hypertension recurred when the transplanted liver failed and again resolved after a second liver transplantation. Intravenous epoprostenol was administered perioperatively to control the pulmonary hypertension in both instances.

Incidence and susceptibility of pathogenic bacteria vary between intensive care units within a single hospital: implications for empiric antibiotic strategies.

BACKGROUND: The purpose of this study was to determine whether the incidence of recovery and patterns of antibiotic susceptibility of pathogenic bacteria vary between intensive care units (ICUs) in a single teaching hospital. METHODS: Culture and susceptibility results were collected prospectively for a 3-month period (April through June 1999) in each of the surgical, trauma, and medical ICUs. The number of unique isolates and susceptibility patterns were determined. Susceptibility of isolates among ICUs was compared with chi2. RESULTS: Statistically significant differences between ICUs in susceptibility to various antibiotics were found for Staphylococcus aureus, Enterococcus sp, Acinetobacter sp, Enterobacter sp, Klebsiella sp, and Pseudomonas sp. Notably, vancomycin-resistant Enterococcus was not seen in the medical ICU, whereas it was seen in both the surgical and trauma ICUs. Klebsiella spp resistant to ceftazidime were seen only in the trauma ICU. The aminoglycosides and quinolones had attenuated activity against Pseudomonas sp in the surgical ICU, whereas they remained highly effective in the trauma ICU. Cefazolin had no activity against the Enterobacter sp in either of the surgical ICUs, but was highly effective in the medical ICU. CONCLUSION: Although the microbiologic results of this study should not be extrapolated to other institutions, the principle is of value. There is variability between ICUs in a single large teaching hospital in susceptibility of bacterial pathogens to various antibiotics. This may have implications in the design of empiric antibiotic strategies and the planning of the hospital formulary. Hospital wide or composite ICU antibiograms are inadequate for planning empiric therapy in the ICU.

An evaluation of the hemodynamic effects of HA-1A human monoclonal antibody.

OBJECTIVES: We sought to determine whether there might be acute changes in hemodynamics attributable to HA-1A, a monoclonal antibody to endotoxin, in patients with presumed Gram-negative sepsis. DESIGN: Post hoc analysis of a multicenter, randomized, double-blind, placebo-controlled study. PATIENTS: A total of 543 patients with severe sepsis presumed to be caused by Gram-negative bacteria who were enrolled in a clinical trial to evaluate the efficacy and safety of HA-1A human monoclonal antibody. INTERVENTIONS: Patients were randomly assigned to receive either 100 mg of HA-1A or placebo. MEASUREMENT AND MAIN RESULTS: Patients were grouped by the study drug, HA-1A, or placebo, and the presence or absence of Gram-negative bacteremia. Hemodynamic variables were monitored from before, until 72 hrs after infusion of the study drug. For the entire study population (n = 543), no changes over time attributable to study drug were noted in the mean arterial pressure (p > .19), heart rate (p > .53) or the need for vasopressor administration (p > .62). One hundred ninety-seven patients underwent pulmonary artery catheterization and had hemodynamic data available from before the infusion of HA-1A or placebo until at least 12 hrs after infusion. Evaluating all 197 patients on an intent to treat basis demonstrated no significant differences over time in cardiac index (p > .15), oxygen delivery index (p > .43), or left ventricular stroke work index (p > .48) between patients who received HA-1A and those patients receiving placebo. Grouping patients by the presence of Gram-negative bacteremia and study drug received also failed to demonstrate any significant difference attributable to HA-1A in mean arterial pressure (p > .54), heart rate (p > .84), cardiac index (p > .13), oxygen delivery index (p > .05), or left ventricular stroke work index (p > .48) between populations. CONCLUSION: There is no apparent relationship between the administration of HA-1A, the presence of Gram-negative bacteremia, and hemodynamic profiles over the 72-hr study period.