RESUMO
Intensive-care-unit (ICU) patients exhibit disturbed sleeping patterns, often attributed to environmental noise, although the relative contribution of noise compared to other potentially disrupting factors is often debated. We therefore systematically reviewed studies of the effects of ICU noise on the quality of sleep to determine to what extent noise explains the observed sleep disruption, using the Cochrane Collaboration method for non-randomized studies. Searches in Scopus, PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library were conducted until May 2017. Twenty papers from 18 studies assessing sleep of adult patients and healthy volunteers in the ICU environment, whilst recording sound levels, were included and independently reviewed by two reviewers. We found that the numbers of arousals between the baseline and the ICU noise condition in healthy subjects differed significantly (mean difference 9.59; 95% confidence interval 2.48-16.70). However, there was considerable heterogeneity between studies (I2 94%, P < 0.00001), and all studies suffered from a considerable risk of bias. The meta-analysis of results was hampered by widely varying definitions of sound parameters between studies and a general lack of detailed description of methods used. It is, therefore, currently impossible to quantify the extent to which noise contributes to sleep disruption among ICU patients, and thus, the potential benefit from noise reduction remains unclear. Regardless, the majority of the observed sleep disturbances remain unexplained. Future studies should, therefore, also focus on more intrinsic sleep-disrupting factors in the ICU environment.
Assuntos
Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Ruído/efeitos adversos , Privação do Sono/etiologia , Estado Terminal , Humanos , Valores de Referência , SonoRESUMO
Hypoxic hepatitis secondary to heart failure is a known and treatable cause of liver failure. The diagnosis may be difficult, especially when symptoms of heart failure are absent. We present two patients who were transferred to our hospital with the diagnosis of acute liver failure to be screened for a liver transplantation. Both patients had increased serum levels ofaminotransferases, lactic acidosis, coagulation disorders, and non-specific clinical symptoms. Echocardiography revealed right ventricular dysfunction. Treatment with inotropes resulted in a fast normalization of liver enzymes, acidosis and coagulation, confirming the diagnosis hypoxic hepatitis. In conclusion, when the cause of acute liver dysfunction is unclear, hypoxic hepatitis due to heart failure should be considered and echocardiography should be performed, even when symptoms are non-specific for heart failure.
Assuntos
Insuficiência Cardíaca/complicações , Hepatite/etiologia , Hipóxia/complicações , Falência Hepática/etiologia , Doença Aguda , Diagnóstico Diferencial , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Hepatite/diagnóstico , Humanos , L-Lactato Desidrogenase/sangue , Fígado/enzimologia , Falência Hepática/diagnóstico , Pessoa de Meia-Idade , Transaminases/sangue , Ultrassonografia , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico por imagemRESUMO
Background. Duchenne muscular dystrophy (DMD) patients used to die mainly from pulmonary problems. However, as advances in respiratory care increase life expectancy, mortality due to cardiomyopathy rises. Echocardiography remains the standard diagnostic modality for cardiomyopathy in DMD patients, but is hampered by scoliosis and poor echocardiographic acoustic windows in adult DMD patients. Multigated cardiac radionuclide ventriculography (MUGA) does not suffer from these limitations. N-terminal proBNP (NTproBNP) has shown to be a diagnostic factor for heart failure. We present our initial experience with plasma NT-proBNP measurement in the routine screening and diagnosis of cardiomyopathy in adult mechanically ventilated DMD patients.Methods. Retrospective study, 13 patients. Echocardiography classified left ventricular (LV) function as preserved or depressed. NT-proBNP was determined using immunoassay. LV ejection fraction (LVEF) was determined using MUGA.Results. Median (range) NT-proBNP was 73 (25 to 463) ng/l. Six patients had an NT-proBNP >125 ng/l. Seven patients showed an LVEF <45% on MUGA. DMD patients with depressed LV function (n=4) as assessed by echocardiography had significantly higher median NT-proBNP than those (n=9) with preserved LV function: 346 (266 to 463) ng/l versus 69 (25 to 257) ng/l (p=0.003). NT-proBNP significantly correlated with depressed LV function on echocardiogram and with LVEF determined by MUGA.Conclusion. Although image quality of MUGA is superior to echocardiography, the combination of echocardiography and NT-proBNP achieves similar results in the evaluation of left ventricular function and is less time consuming and burdensome for our patients. We advise to add NT-proBNP to echocardiography in the routine cardiac assessment of DMD patients. (Neth Heart J 2009;17:232-7.).
RESUMO
PURPOSE: To evaluate the clinical pharmacology of exogenous alkaline phosphatase (AP). METHODS: Randomized, double-blind, placebo-controlled sequential protocols of (1) ascending doses and infusion duration (volunteers) and (2) fixed dose and duration (patients) were conducted at clinical pharmacology and intensive care units. A total of 103 subjects (67 male volunteers and 36 patients with severe sepsis) were administered exogenous, 10-min IV infusions (three ascending doses) or 24-72 h continuous (132.5-200 U kg(-1) 24 h(-1)) IV infusion with/without preceding loading dose and experimental endotoxemia for evaluations of pharmacokinetics, pharmacodynamics, safety parameters, antigenicity, inflammatory markers, and outcomes. RESULTS: Linearity and dose-proportionality were shown during 10-min infusions. The relatively short elimination half-life necessitated a loading dose to achieve stable enzyme levels. Pharmacokinetic parameters in volunteers and patients were similar. Innate immunity response was not significantly influenced by AP, while renal function significantly improved in sepsis patients. CONCLUSIONS: The pharmacokinetics of exogenous AP is linear, dose-proportional, exhibit a short half-life, and are not influenced by renal impairment or dialysis.
Assuntos
Fosfatase Alcalina/administração & dosagem , Fosfatase Alcalina/farmacologia , Endotoxemia/tratamento farmacológico , Adulto , Idoso , Fosfatase Alcalina/efeitos adversos , Fosfatase Alcalina/sangue , Fosfatase Alcalina/farmacocinética , Método Duplo-Cego , Feminino , Meia-Vida , Humanos , Infusões Intravenosas , Interleucinas/sangue , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Fator de Necrose Tumoral alfa/sangueRESUMO
Self-poisoning with organophosphate pesticides is a major health problem world-wide. Through the inhibition of acetylcholinesterase, organophosphorus poisoning is characterised by the clinical picture of acute cholinergic crisis. Other manifestations are the intermediate neurotoxic syndrome and delayed polyneuropathy. In the Western world, the occurrence of organophosphorus poisoning is less prevalent due to the declining availability of organophosphate pesticides, which could render the recognition of this particular type of intoxication and its specific treatment more difficult. In this article we discuss some recent developments and treatment dilemmas, illustrated by cases from our clinic, followed by a review of the current recommendations in the treatment of organophosphate poisoning.
Assuntos
Intoxicação por Organofosfatos , Praguicidas/intoxicação , Tentativa de Suicídio , Suicídio , Adulto , Diagnóstico Diferencial , Humanos , Inseticidas/intoxicação , Masculino , Oximas/uso terapêutico , Paration/intoxicação , Intoxicação/diagnóstico , Intoxicação/fisiopatologia , Intoxicação/terapiaRESUMO
A 37-year-old woman was admitted to the emergency room because of an autointoxication with hydroxychloroquine, leading to haemodynamic instability. Treatment consisted of the rapid administration of intravenous diazepam, after which the hypotension recovered rapidly even though no vasoactive medication was given. Treatment with diazepam has been advised in the Netherlands for many years in case of severe hydroxychloroquine intoxication, despite the fact that convincing evidence for its use is lacking. On the basis of the experience with the relevant cases, the administration of diazepam, 2 mg/kg initially followed by 2 mg/kg/24 hours as a continuous infusion, should certainly be considered for supportive treatment in the ICU in case of severe haemodynamic instability.
Assuntos
Diazepam/uso terapêutico , Hidroxicloroquina/intoxicação , Hipotensão/induzido quimicamente , Adulto , Overdose de Drogas , Feminino , Humanos , Hipotensão/complicações , Resultado do TratamentoRESUMO
The last revision of the Dutch resuscitation guidelines, a translation of the European Resuscitation Council Guidelines 2005, is based on the recommendations of the International Liaison Committee on Resuscitation (ILCOR). The previous Dutch guidelines were issued in 2002. Most changes are based on laboratory studies and retrospective analyses. The most important changes are: recognizing circulatory arrest on unresponsiveness and abnormal breathing; a new ratio of chest compressions to ventilations i.e. 30:2 instead of 15:2; and following the procedure of checking the airway (A), taking over the circulation (C) and breathing (B). Furthermore in the event of ventricular fibrillation or ventricular tachycardia with no pulsations then one defibrillator shock only is to be given; this is in contrast with the previous application of cycles of 3 shocks. The work and costs of implementation involved in the revision of resuscitation guidelines are tremendous, especially in view of the huge number of laypersons who need to be retrained. Also, frequent changes of guidelines may cause confusion and have a negative effect on the quality of resuscitation. Therefore, it is not evident that the benefits of this revision justify its costs. It would be good to prospectively evaluate the effectiveness and costs of this revision. In the future, these data might help to decide when altered international recommendations should be translated into new Dutch resuscitation guidelines. Alternative strategies should be considered, for example only changing the guidelines for advanced life support.
Assuntos
Reanimação Cardiopulmonar/economia , Reanimação Cardiopulmonar/normas , Serviços Médicos de Emergência/normas , Parada Cardíaca/terapia , Guias de Prática Clínica como Assunto , Análise Custo-Benefício , Serviços Médicos de Emergência/métodos , Primeiros Socorros/métodos , Primeiros Socorros/normas , HumanosRESUMO
We describe two patients with a severe Cushing's syndrome due to ectopic production of ACTH. Both patients developed a life-threatening Pneumocystis jiroveci pneumonia (PCP) shortly after treatment of the hypercortisolism was started by means of inhibition of production of glucocorticoids and glucocorticoid receptor blockade. We presume that the restored immune response elicited the clinical symptoms of the opportunistic, previously subclinical Pneumocystis jiroveci infection. The immunocompromised state and the delicate glucocorticoid balance in patients with a severe Cushing's syndrome necessitate a specific diagnostic and therapeutic approach.
Assuntos
Síndrome de Cushing/complicações , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/diagnóstico , Progressão da Doença , Evolução Fatal , Feminino , Humanos , Cetoconazol/uso terapêutico , Pessoa de Meia-Idade , Mifepristona/uso terapêutico , Infecções Oportunistas/etiologia , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/etiologia , Fatores de Risco , Espironolactona/uso terapêuticoRESUMO
Venomous snakebites are a rarity in the Netherlands. In this report we describe the case of a 26-year-old male amateur snakekeeper who was bitten in his left index finger by a Western bush viper (Atheris chlorechis). His clinical condition deteriorated rapidly with acute renal failure and considerable blood loss due to coagulopathy. Antidote was not readily available and was finally supplied by a zoo in Antwerp, Belgium. One day after admission the blood loss diminished.
Assuntos
Antivenenos/uso terapêutico , Venenos de Crotalídeos/intoxicação , Mordeduras de Serpentes/complicações , Viperidae , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/terapia , Adulto , Animais , Dedos/fisiopatologia , Hemorragia/induzido quimicamente , Hemorragia/terapia , Humanos , Masculino , Países Baixos , Mordeduras de Serpentes/tratamento farmacológico , Mordeduras de Serpentes/cirurgia , Fatores de TempoRESUMO
Cardiac troponin I (cTnI) and cardiac troponin T (cTnT) are valuable heart markers in patients presenting with symptoms of ischaemic heart disease. A number of categories of patients frequently have raised concentrations of cardiac troponin (cTn) without having ischaemic heart disease. These include patients with heart diseases such as heart failure, myocarditis and valvular disease but also those with lung emboli, renal failure and sepsis. Possible underlying mechanisms are diffuse necrosis, cTn proteolysis or leakage of cytoplasmatic cTn with no irreversible damage to the contraction complex of heart-muscle cells. It is possible that cTn-measurement in patients with non-cardiac conditions is of prognostic value but so far this has only been demonstrated in dialysis patients and patients with pulmonary embolism.
Assuntos
Miocárdio/química , Embolia Pulmonar/sangue , Diálise Renal , Troponina/sangue , Doença Aguda , Biomarcadores/sangue , Humanos , Falência Renal Crônica/sangue , Isquemia Miocárdica/sangue , Embolia Pulmonar/diagnóstico , Troponina I/sangue , Troponina T/sangueRESUMO
Newer, more selective, antidepressant agents are increasingly being used as first-line treatment. However, clinical experience in patients after a deliberate overdose is limited. We present a case of venlafaxine intoxication complicated by a late rise in creatine kinase, seizures and serotonin syndrome. Rhabdomyolysis prolonged the hospital stay in our patient but had no other serious consequences. Physicians should be aware of this late phenomenon in patients with venlafaxine poisoning.
Assuntos
Antidepressivos de Segunda Geração/efeitos adversos , Cicloexanóis/efeitos adversos , Rabdomiólise/induzido quimicamente , Inibidores Seletivos de Recaptação de Serotonina/efeitos adversos , Síndrome da Serotonina/induzido quimicamente , Adulto , Antidepressivos de Segunda Geração/administração & dosagem , Creatina Quinase/sangue , Cicloexanóis/administração & dosagem , Preparações de Ação Retardada , Overdose de Drogas , Feminino , Humanos , Inibidores Seletivos de Recaptação de Serotonina/administração & dosagem , Cloridrato de VenlafaxinaRESUMO
The decision to move from curative treatment to palliative care in the intensive-care situation is less related to morals and ethics than it is to the assessment of medical issues, professionalism, communication and orchestration. Treatment should be considered medically pointless if, in the view of the treating physicians, it does not offer realistic chance to return to a meaningful life. Continuing futile care can be seen as disrespectful, both to the patient, his partner and the family, as well as to the members of the ICU team. Intensivists are responsible for withholding or withdrawing life support to patients in whom further life support is considered futile and who are unable to express their wishes due to critical illness and sedation. The intensivist typically makes this type of decision after a period in which medical and other information has been collected and after intensive discussions with other medical professionals as well as the partner and family. This is based on the trust that is built up through their skill, attitude and behaviour and that is perpetuated in a continuing process of intensive communication. Conflicts should be prevented, or at least recognised early and discussed. Ifa conflict is ongoing then it should be tackled by planning a number of consecutive consultations.
Assuntos
Família/psicologia , Cuidados Paliativos , Relações Profissional-Família , Assistência Terminal/normas , Tomada de Decisões , Eutanásia Passiva , Humanos , Unidades de Terapia Intensiva , Cuidados Paliativos/psicologia , Cuidados Paliativos/normas , Assistência Terminal/métodos , Assistência Terminal/psicologiaAssuntos
Estado Terminal , Intubação Intratraqueal , Respiração Artificial , Traqueotomia , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/efeitos adversos , Pneumonia/etiologia , Respiração Artificial/efeitos adversos , Fatores de Tempo , Traqueotomia/efeitos adversos , Traqueotomia/métodosRESUMO
A 23-year-old woman presented with renal failure resulting from polycystic kidney disease (PKD) aggravated by tubulo-interstitial nephritis. Emergency haemodialysis was planned, and cannulation of the right subclavian vein was attempted, but failed. During this procedure, inadvertent arterial puncture occurred. Transient mild ischaemia of the right arm, and a transient Horner's syndrome were noted. Seven weeks later she presented with severe stridor with impending respiratory failure necessitating emergency intubation; the right-sided Horner's syndrome had recurred. CT imaging showed a large pseudo-aneurysm of the brachiocephalic artery resulting in severe compression of the trachea. Using a prosthetic graft, the operation for the pseudo-aneurysm was successful; there were mild neurological sequelae. Although her family history was negative, autosomal dominant PKD should be considered, and we discuss the possible role of a pre-existing PKD-associated aneurysm.