Assessment of procalcitonin to predict outcome in hypothermia-treated patients after cardiac arrest.

Objective. Determine the potential of procalcitonin (PCT) to predict neurological outcome after hypothermia treatment following cardiac arrest. Methods. Retrospective analysis of patient data over a 2-year period. Mortality and neurological outcome of survivors were determined 6 months after cardiac arrest using the Cerebral Performance Category (CPC) score. Results. Data from 53 consecutive patients were analyzed. Median age was 63 (54-71) and 79% were male. Twenty-seven patients had good outcome (CPC ≤ 2) whereas 26 had severe neurological sequelae or died (CPC 3-5). At 48 h, after regaining normothermia, PCT was significantly higher in patients with bad outcome compared to those with good outcome: 3.38 (1.10-24.48) versus 0.28 (0-0.75) ng/mL (P < 0.001). PCT values correlated with bad neurological outcome (r = 0.54, P = 0.00004) and predicted outcome with an area under the curve of 0.84 (95% CI 0.73-0.96). A cutoff point of 1 ng/mL provided a sensitivity of 85% and a specificity of 81%. Above a PCT level of 16 ng/mL, no patient regained consciousness. PCT provided an additive value over simplified acute physiology score II. Conclusions. PCT might be an ancillary marker for outcome prediction after cardiac arrest treated by induced hypothermia.

Internet suicide guidelines: report of a life-threatening poisoning using tobacco extract.

BACKGROUND: Severe nicotine intoxication occurred in a patient after ingestion of a tobacco extract made from a recipe found on a freely available Internet site. OBJECTIVES: To determine the levels of nicotine and cotinine in the plasma of a patient who tried to commit suicide by drinking a highly concentrated tobacco extract. CASE REPORT: A 67-year-old man tried to commit suicide by following guidelines found on an Internet site. He soaked 300 grams of tobacco for 3 days in water, evaporated most of the extract, and drank the rest of it. He felt sick immediately, with the following signs: respiratory depression, hypothermia, hypersalivation, bradycardia, and myoclonic jerks. Soon after the ingestion he vomited most of the extract. Toxicological analysis revealed potentially life-threatening nicotine and cotinine serum concentrations. Surprisingly, nicotine peak levels (322 microg/L) and cotinine peak levels (9092 microg/L) were reached more than 3 h after ingestion of the extract. Estimated nicotine and cotinine half-lives were 200 min and 1185 min, respectively. Treatment consisted of gastric lavage, ventilation, and monitoring of vital functions. The patient recovered and was discharged from the Emergency Department 4 days later without sequelae. CONCLUSION: Nicotinergic intoxication is not always easy to recognize, and without clues from the patient and the toxicologic analysis, might well have been missed in the present case.

Bispectral index (BIS) helps predicting bad neurological outcome in comatose survivors after cardiac arrest and induced therapeutic hypothermia.

AIM OF THE STUDY: Determine the use of bispectral index (BIS) as prognostic tool in therapeutic hypothermia (TH) treated comatose survivors after cardiac arrest (CA), regardless of initial rhythm, location or cause. METHODS: Prospective, single-centre, unblinded, observational cohort study in an 18 bed general ICU in a tertiary teaching hospital. 45 consecutive comatose patients admitted after CA and treated with TH were included. All patients were sedated with a standardised protocol including neuromuscular blockade. Induced TH was started as soon as possible after arrival in the hospital and continued for 24h before slow rewarming. Sedation was stopped after reaching normothermia (36 degrees C). All patients benefited from maximal supportive intensive care and no therapeutic withdrawal or withholding was done unless bad neurological status was confirmed. Continuous BIS monitoring was performed over 72h in all patients. RESULTS: 14 patients presented BIS values of zero (0) during their ICU stay. At 6 months 11 patients were dead, 1 remained comatose and 2 had severe neurological sequelae (CPC3). No patient of this group had good neurological outcome or improved his neurological outcome between ICU and 6-month follow-up. 31 patients had BIS values higher than 0. At 6 months of those, 11 died, none remained comatose, 3 had bad neurological outcome (CPC3) and 17 had no or minor neurological sequelae (CPC1-2). Thus no correlation between good outcome and BIS values higher than 0 is possible. CONCLUSIONS: BIS values of 0 help predict bad neurological outcome after CA and induced hypothermia.