Pancreatic enzymes in chronic renal failure.

Serum was obtained from 55 patients, including 43 with stable chronic renal failure (CRF) (28 receiving chronic hemodialysis [CHD] and 15 receiving chronic ambulatory peritoneal dialysis [CAPD]), nine with peritonitis receiving CAPD, and three with pancreatitis receiving CAPD. Total serum amylase activity, lipase activity, isoamylase fractionation, and lipase concentration were used to measure pancreatic enzymes. Amylase activity was increased in 35 of 43 patients with CRF but was greater than threefold elevated in only three. Pancreatic isoamylase activity was greater than 80% in only one patient with CRF but was greater than 80% in all three patients with pancreatitis receiving CAPD. Lipase activity was increased in 26 patients and lipase concentration was elevated in 27. Peritoneal fluid from three patients with pancreatitis receiving CAPD contained high levels of amylase. Serum amylase and lipase are frequently elevated in patients with CRF in the absence of clinical pancreatitis. However, serum amylase activity greater than threefold elevated or the presence of pancreatic enzymes in the peritoneal fluid may suggest coexistent pancreatitis.

Renal failure from metastatic breast carcinoma reversed by radiotherapy and chemotherapy.

We treated a patient who had acute renal failure secondary to obstructive uropathy from metastatic breast carcinoma. Attempts at ureteral catheterization and nephrostomy failed. Bilateral ureteral irradiation was given, followed immediately by chemotherapy, with relief of obstruction and normalization of renal function. Nineteen months later, the patient died; at that time, her serum urea nitrogen and serum creatinine levels were normal.

Low fractional excretion of sodium. Occurrence with hemoglobinuric- and myoglobinuric-induced acute renal failure.

Ten patients with myoglobinuric and hemoglobinuric acute renal failure demonstrated low fractional excretion of sodium (FENa) values (less than 1%) during the oliguric phase of their course. Acute renal failure secondary to hemoglobinuria developed in five patients, and five demonstrated acute deterioration with myoglobinuria. The mean serum creatinine level increased from 1.1 mg/dL (range, 0.6 to 1.7 mg/dL) to a maximum of 6.9 mg/dL (range, 2 to 13.1 mg/dL). Although three patients required dialysis, all individuals eventually returned or were returning toward their baseline renal function at discharge. The importance of a low FENa in the setting of myoglobinuric and hemoglobinuric renal failure is reviewed. The findings in this report raise the possibility that a common mechanism may underlie the renal injury in both types of pigment toxicity.

Clinical correlates of eosinophiluria.

We assessed the clinical correlates of eosinophils in the urine in 65 patients. In 16% of 470 patients whose urine was specifically examined, eosinophils were noted in the urine sediment. Review of the 65 patients with eosinophiluria demonstrated that when eosinophils were expressed as a percentage of total urine white blood cells, 85% (55/65 patients) had less than 5% urine eosinophils and 45% (29/65 patients) had less than 1%. Infection of the upper and lower urinary tract accounted for 45% of the clinical conditions associated with eosinophiluria. In nine (14%) of the 65 patients a diagnosis of acute interstitial nephritis could be made by clinical criteria or from renal biopsy specimens. We conclude that the finding of urine eosinophils is associated with a variety of clinical conditions and may be most useful when expressed as a percentage of total white blood cells in the urine. At a low-percentage positive (less than 5%), it may not be a good predictor of acute interstitial nephritis, but at a higher level (greater than 5%) it may be a more valuable predictor.

Encephalopathy in chronic renal failure responsive to deferoxamine therapy. Another manifestation of aluminum neurotoxicity.

We describe a patient undergoing chronic hemodialysis who developed a neurologic syndrome consisting of seizures, progressive myoclonus, and mild dementia and who responded to chelation therapy with deferoxamine mesylate. Neither her serum nor bone aluminum concentrations indicated aluminum toxicity. However, the presence of a positive deferoxamine-infusion test was suggestive of an elevated body burden of aluminum. Treatment with deferoxamine resulted in marked clinical improvement in her neurologic status within two months. The utility of using the deferoxamine-infusion test rather than serum aluminum levels in evaluating aluminum toxicity in chronic renal failure is suggested.

Relationship of aluminum to neurocognitive dysfunction in chronic dialysis patients.

Aluminum has been proposed as the causative agent in dialysis encephalopathy syndrome. We prospectively assessed whether other, less severe, neuropsychologic abnormalities were also associated with aluminum. A total of 16 patients receiving chronic dialytic therapy were studied. The deferoxamine infusion test (DIT) was used to assess total body aluminum burden. Neurologic function was evaluated by quantitative measures of asterixis, myoclonus, motor strength, and sensation. Cognitive function was assessed by measures of dementia, memory, language, and depression. There were four patients with a positive DIT (greater than 125 micrograms/L increment in serum aluminum) that was associated with an increase in the number of neurologic abnormalities observed, as well as an increase in severity of myoclonus, asterixis, and lower extremity weakness. Patients with a positive DIT also showed significant impairment in memory; however, no differences were noted on tests of dementia, depression, or language. There was no significant correlation between sex, age, presence of diabetes, mode of dialysis, years of chronic renal failure, years of dialysis or years of aluminum ingestion and any neurologic or neurobehavioral measurement, serum aluminum level, or DIT. These changes may represent early aluminum-associated neurologic dysfunction.

Anemia in the critically ill: the role of erythropoietin.

Anemia is a common clinical problem in critically ill patients and is associated with substantial red blood cell (RBC) transfusion requirements. However, RBC transfusion has significant risks, including adverse effects on the immune system. Although a low hemoglobin concentration may be tolerable, it may not be optimal for the critically ill patient. Thus, alternative therapies that can increase hemoglobin and avoid complications of RBC transfusion are desirable. Critically ill patients appear to have anemia identical to the anemia of chronic inflammatory disease with blunted erythropoietin production. Results of a recent randomized controlled trial in critically ill patients demonstrated that recombinant human erythropoietin (r-HuEPO, epoetin alfa) significantly reduced (by approximately 50%) the number of RBC units transfused (P <.002) and significantly increased hematocrit (P <.01) compared with placebo. There was no increase in mortality or adverse clinical events with therapy. Epoetin alfa may be an effective therapeutic approach to anemia in critically ill patients, decreasing the need for transfusion and achieving higher hemoglobin concentrations than generally attained with transfusion.

RBC transfusion in the ICU. Is there a reason?

OBJECTIVE: To evaluate RBC transfusion practice in the ICU. DESIGN: Retrospective chart review. SETTING: Multidisciplinary ICU in a tertiary care center. PATIENTS: All patients admitted to the ICU with a length of stay of greater than 1 week. RESULTS: A total of 23% of all patients admitted to the ICU had a length of stay of greater than 1 week (19.6 +/- 1.6 days). Of these patients, 85% received blood transfusions (9.5 +/- 0.8 U per patient). These transfusions were not solely a function of acute blood loss. Patients were transfused a constant 2 to 3 U/wk. Patients receiving blood transfusions were phlebotomized on average 61 to 70 mL per day. Phlebotomy accounted for 49% of the variation in amount of RBCs transfused. No indication for blood transfusion was identified for 29% of transfusion events. A low hematocrit (< 25%) was the only identifiable indication in an additional 19% of events. Almost one third of all RBCs transfused were without a clear transfusion indication. CONCLUSION: The long-term ICU population receive a large number of blood transfusions. Phlebotomy contributes significantly to these transfusions. There is no clear indication for a large number of the blood transfusions given. Many blood transfusions appear to be administered because of an arbitrary "transfusion trigger" rather than a physiologic need for blood. Blood conservation and adherence to transfusion guidelines could significantly reduce RBC transfusion in the ICU.

Acute renal failure associated with cardiac operations. A case-control study.

We performed a case-control study to identify risk factors for the development of acute renal failure after cardiac operations. Forty-two cases of acute renal failure were identified in a total of 572 patients who underwent cardiac operations. They were matched with a control population of patients having cardiac operations without acute renal failure. Discriminant analysis performed with preoperative variables revealed preoperative serum creatinine values, concurrent valve and bypass surgery, and age to be significant variables for identifying patients at risk for acute renal failure. The use of these three variables in a discriminant model correctly classified 77% of patients. The addition of intraoperative variables did not significantly improve the ability of the model to correctly classify patients. Acute renal failure was associated with a significant increase in the number of postoperative complications, mortality, and length of hospitalization and intensive care unit stay.

The clinical significance of eosinophiluria.

Eosinophils are normally absent from the urine. Their presence has been associated with a variety of clinical conditions affecting the kidney or urinary tract. The authors examined the clinical significance and eosinophils, in particular, for acute interstitial nephritis.

Acute renal failure.

ARF is a common clinical problem associated with significant morbidity and mortality. Therefore, rapid and accurate diagnosis is imperative. Initial diagnostic strategies should be directed toward distinguishing among prerenal, renal, and postrenal causes of ARF. This can be done by the use of urinary diagnostic indices in concert with radiologic investigation, renal biopsy, and hemodynamic monitoring when appropriate. Treatment of established ARF should be directed toward maintaining fluid and electrolyte homeostasis and controlling complications resulting from retained nitrogenous waste products. This may necessitate the aggressive use of dialysis. As yet, there is no proven means to prevent ARF or alter the course of ARF once it is established.

Acute renal failure and dialysis in the chronically critically ill patient.

Acute renal failure is a common clinical problem in the intensive care unit (ICU) and is associated with significant morbidity and mortality. There is no "magic bullet" to prevent acute renal failure or to modify the clinical course of established renal failure. The approach to therapy is directed to the early initiation of dialysis therapy. Continuous dialysis therapy is becoming the preferred form of dialysis in the ICU.

Microscopic hematuria.

Microscopic hematuria is a common problem that may affect up to 13 per cent of the population. The number of RBCs identified in the urine sediment is dependent, in part, upon the technique used in performing the urinalysis. The exact number of RBCs normally excreted into the urine has been difficult to establish. However, three to eight RBCs per HPF would be accepted by most investigators as an acceptable dividing point between normal and abnormal hematuria. Although the prevalence of microscopic hematuria in the general population is high, the number of patients who have serious urologic disease is low. Many diagnostic algorithms are available for evaluating these patients, but at the present time there is still uncertainty regarding how extensive the evaluation should be for patients with asymptomatic microscopic hematuria.

Nutritional deficiencies and blunted erythropoietin response as causes of the anemia of critical illness.

PURPOSE: The purpose of this article was to determine the prevalence of iron, vitamin B12, and folate deficiency and to evaluate the erythropoietin (EPO) response to anemia in a cohort of long-term intensive care unit (ICU) patients. MATERIALS AND METHODS: All patients admitted to three academic medical center multidisciplinary ICUs were screened for eligibility into a randomized trial of EPO for the treatment of ICU anemia. On their second or third ICU day, patients enrolled in this trial had EPO levels drawn and were screened for iron, B12, and folate deficiency. Weekly EPO levels were obtained throughout patients' ICU stay. RESULTS: A total of 184 patients were screened for iron, B12, and folate deficiency. Sixteen patients (9%) were iron deficient by study criteria, 4 (2%) were B12 deficient, and 4 (2%) were folate deficient. Mean hemoglobin and reticulocyte percents of the remaining 160 patients were 10.3 +/- 1.2 g/dL and 1.66 +/- 1.09%, respectively. In most patients, serum iron and total iron binding capacity levels were very low, whereas ferritin levels were very high. Mean and median day 2 EPO levels were 35.2 +/- 35.6 mIU/mL and 22.7 mIU/mL, respectively (normal = 4.2-27.8). Serial EPO levels in most persistently anemic patients remained within the normal range. CONCLUSIONS: In this cohort, screening for iron, B12, and folate deficiency identified potentially correctable abnormalities in more than 13% of patients and should be considered in those who are anticipated to have long ICU stays. Even at an early point of critical illness, most patients had iron studies consistent with anemia of chronic disease (ACD), as well as a blunted EPO response that may contribute to this ACD-like anemia of critical illness.

The detection and interpretation of urinary eosinophils.

We determined the clinical diagnosis for 183 patients who had urine samples examined for the presence of eosinophils. Urine samples were examined with both Hansel's stain and Wright's stain. A total of 11% of these patients had eosinophils detected in the urine. A variety of clinical conditions were associated with eosinophiluria. Urinary tract infection and acute interstitial nephritis were most common, each accounting for 25% of the total patients with eosinophiluria. Eosinophiluria proved to be a good predictor of acute interstitial nephritis. Hansel's stain was superior to Wright's stain in detecting eosinophils in urine. In particular, Hansel's stain increased the sensitivity of eosinophiluria for acute interstitial nephritis (63% vs 25%) as well as its positive predictive value (50% vs 25%).

A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.

BACKGROUND: Few published data exist with respect to current implementation of interventions that increase patient safety in intensive care units (ICUs) Furthermore, even less published data exist that address implementation of outcome-related methodologies of patient safety interventions in ICUs. OBJECTIVE: The purpose of this study was threefold: (1) to increase implementation rates of known, evidence-based interventions in the Dartmouth Hitchcock Medical Center (DHMC) ICU that have been demonstrated to reduce morbidity and mortality in critically ill patients; (2) to develop a durable and reproducible intervention model that can be applied not only to various aspects of ICU medicine but to any healthcare microsystem that is process oriented; and (3) to design an "ICU-specific" value compass. DESIGN: Using a before/after study design, the interventions involved: (1) establishing a systematic approach to integrate the delivery of proven ICU safety measures; (2) using the design of the various tools to develop a method for team communication and team building; (3) incorporating prompts into a ICU progress note for the healthcare team to address three evidence-based measures on a daily basis; and (4) using a data wall to demonstrate progress and to provide "real-time" feedback for error correction. SETTING AND PARTICIPANTS: In the before and after study, two groups of 40 consecutive patients admitted to DHMC's Intensive Care Unit were evaluated. The first group of patients was admitted between April and May of 2003. The second group of 40 patients was admitted between May and June of 2004. To ensure process stability, control data were also collected on patients at an interval time point between these two groups. MAIN OUTCOME MEASURES: Three evidence-based interventions were identified that reduce the likelihood of adverse events resulting simply from an ICU stay: (1) prophylaxis against venous thrombo-embolic disease (venous thromboembolism or deep vein thrombosis); (2) prophylaxis against ventilator-associated pneumonia (VAP); and (3) prophylaxis against stress-ulcers (SU). Two data points were obtained per patient per day corresponding to the work shift schedule in the ICU. The unit of measure was patient-shift observation. A limited data set was collected before implementing the change package to ensure system stability. RESULTS: Both traditional statistical analysis and statistical process control (SPC) were used to evaluate the results. For each metric, it was possible to demonstrate an increase in the measure of the mean, reduced point-to-point variation as well as a substantial narrowing of the control limits indicating improved process control. LIMITATIONS: By virtue of the involvement of the researcher in the data collection for the control group, the potential existed for methodological bias by acting on the information collected. There was also the lack of a cohesive data structure from which to collect information (ie, the hospital computer speaks one language, the ventilator a second and the monitoring systems a third). CONCLUSIONS: A model for changing the ICU microsystem at DHMC was created that enabled successful implementation of evidence-based measures by maximising the natural flow of work and fostering a team-based culture to improve patient safety. Unique to this method and unlike currently available methods that define only the delivery of the appropriate intervention as success, system success was defined in terms of both true positives, namely delivering care when it is indicated, as well as true negatives, not delivering care when there is none indicated, to offer a more comprehensive system review. Additionally, the method of data collection allowed simplified defect analysis, thereby eliminating a resource-consuming audit of data after the fact. This approach, therefore, provides a basis for adapting and redesigning the PDSA cycle so as to specifically apply this type of "disciplinary" work.