Impact of infection on the prognosis of critically ill cirrhotic patients: results from a large worldwide study.

BACKGROUND: Infections are a leading cause of death in patients with advanced cirrhosis, but there are relatively few data on the epidemiology of infection in intensive care unit (ICU) patients with cirrhosis. AIMS: We used data from the Extended Prevalence of Infection in Intensive Care (EPIC) II 1-day point-prevalence study to better define the characteristics of infection in these patients. METHODS: We compared characteristics, including occurrence and types of infections in non-cirrhotic and cirrhotic patients who had not undergone liver transplantation. RESULTS: The EPIC II database includes 13,796 adult patients from 1265 ICUs: 410 of the patients had cirrhosis. The prevalence of infection was higher in cirrhotic than in non-cirrhotic patients (59 vs. 51%, P < 0.01). The lungs were the most common site of infection in all patients, but abdominal infections were more common in cirrhotic than in non-cirrhotic patients (30 vs. 19%, P < 0.01). Infected cirrhotic patients more often had Gram-positive (56 vs. 47%, P < 0.05) isolates than did infected non-cirrhotic patients. Methicillin-resistant Staphylococcus aureus (MRSA) was more frequent in cirrhotic patients. The hospital mortality rate of cirrhotic patients was 42%, compared to 24% in the non-cirrhotic population (P < 0.001). Severe sepsis and septic shock were associated with higher in-hospital mortality rates in cirrhotic than in non-cirrhotic patients (41% and 71% vs. 30% and 49%, respectively, P < 0.05). CONCLUSIONS: Infection is more common in cirrhotic than in non-cirrhotic ICU patients and more commonly caused by Gram-positive organisms, including MRSA. Infection in patients with cirrhosis was associated with higher mortality rates than in non-cirrhotic patients.

Incidence and prognosis of dysnatraemia in critically ill patients: analysis of a large prevalence study.

BACKGROUND: The objective of this study is to assess the impact of dysnatraemia on mortality among intensive care unit (ICU) patients in a large, international cohort. MATERIAL AND METHODS: Analysis of the Extended Prevalence of Infection in Intensive Care (EPIC II) study, a 1-day (8 May 2007) worldwide multicenter, prospective point prevalence study. Hyponatraemia was categorized as mild (130-134 mM/L), moderate (125-129 mM/L) or severe (< 125 mM/L). Hypernatraemia was also categorized as mild (146-150 mM/L), moderate (151-155 mM/L) or severe (> 155 mM/L). Patients with normal serum sodium (135-145 mM/L) constituted the reference group. The main outcome was hospital mortality. Analysis was conducted separately for patients admitted on the study day (25.8%) and those already present on the ICU (74.2%). RESULTS: Serum sodium was measured in 13 276 of the 13 796 patients (96.2%). A total of 3815 patients (28.7%) had dysnatraemia: 12.9% with hyponatraemia and 15.8% with hypernatraemia. The prevalence of dysnatraemia was significantly greater in patients already present on the ICU prior to the study day than for those just admitted (13.1% vs. 12.3% for hyponatraemia and 17.1% vs. 12.1% for hypernatraemia, both P < 0.001). Hospital mortality rates were higher in patients with dysnatraemia than in those with normal sodium levels and were directly related to the severity of hypo- and hypernatraemia. This association between dysnatraemia and mortality was similar in infected and noninfected patients (P = 0.061). CONCLUSIONS: Dysnatraemia is more frequent during the ICU stay than on the day of admission. Dysnatraemia in the ICU - even mild - is an independent predictor of increased hospital mortality.

Evaluation of a single preoperative dose of etoricoxib for postoperative pain relief in therapeutic knee arthroscopy: a randomized trial.

UNLABELLED: BACKGROUND AND PURPOSE Analgesics can have undesirable effects. We assessed whether a single preoperative dose of 120 mg etoricoxib reduces the need for additional opioids after therapeutic arthroscopic knee surgery. METHODS A double-blind, placebo-controlled study was performed at a single center. 66 patients scheduled to undergo elective therapeutic knee arthroscopy were included. They were randomly selected to be given either 120 mg of etoricoxib (n = 33) or placebo (n = 33) 1 hour before induction of general anesthesia. A patient-controlled analgesia device was used postoperatively. We recorded total postoperative morphine consumption over 24 h, degree of pain as assessed with a visual analog scale, degree of satisfaction, and occurrence of adverse effects. RESULTS Mean total morphine consumption during the first 24 h was 24 (9-60) mg in the placebo group and 9 (0-34) mg in the etoricoxib group. In the etoricoxib group, pain intensity levels at rest were reduced and patient satisfaction with the analgesia provided was higher during the first postoperative day. There was no difference in the incidence of typical adverse effects of opioids in the 2 groups. INTERPRETATION: Etoricoxib is a suitable premedication to use before therapeutic arthroscopic knee surgery, as it reduced patients' morphine requirements.

Percutaneous lumbar discectomy using the Dekompressor system under CT-control.

In recent years, new minimally invasive therapies for the treatment of radicular pain associated with contained disc herniation have been introduced. These techniques have changed the field of interventional pain management. In a prospective, nonrandomized case study, we treated patients using the Dekompressor system guided by computed tomography instead of fluoroscopy. Pain scores, analgesic usage, and activities of daily living were assessed via structured telephone interviews 6 and 12 months after the procedure. Sixty-four patients were treated at 76 lumbar levels. Follow-up data after 12 months were obtained for all patients. The average reported pain level as measured by visual analog scale was 7.3 before the procedure and 2.1 after 12 months. Before the procedure, 61 patients (95%) used opioid or nonopioid analgesics regularly; after 1 year, a reduction in analgesic use was seen in 51 patients (80%). None of the patients reported procedure-related complications. When standardized patient selection criteria are used, treatment of patients with radicular pain associated with contained disc herniation using the Dekompressor can be a safe and efficient procedure.

Post-traumatic changes in energy expenditure and body composition in patients with acute spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To investigate the changes in resting energy expenditure and body composition over time in a cohort of patients with spinal cord injury during acute treatment, rehabilitation, and 2 years after the end of rehabilitation. METHODS: Adult patients admitted for acute treatment and rehabilitation after traumatic spinal cord injury were recruited. Measurements of resting energy expenditure and body composition were scheduled at 2, 6, 10 and 14 weeks after spinal cord injury, at the end of rehabilitation, and 2 years later. RESULTS: Patients' mean age was 38.8 years (standard deviation 14.0). Resting energy expenditure began to decrease up to the 10-week measurement (p = 0.02) and further decreased after the 130-week measurement (p< 0.001). Body weight was already decreased after the 6-week measurement (p< 0.01) and increased after the end of rehabilitation (p = 0.009). Percentage body fat mass showed similar changes. CONCLUSION: After an initial decrease in resting energy expenditure, body weight and percentage of body fat, these values levelled off during the rehabilitation period. After the end of the rehabilitation period, body weight and body fat mass increased again to the baseline levels, whereas resting energy expenditure decreased further. These results suggest that rehabilitation programmes should focus on adapting to these foreseeable changes.

Increased mortality in critically ill patients with mild or moderate hyperbilirubinemia.

PURPOSE: Increased bilirubin concentrations may be related to outcome, but this has not been well studied. We evaluated the relationship between total serum bilirubin levels and outcome in critically ill patients. MATERIALS AND METHODS: Data were analyzed from adult critically ill patients included in a 1-day international prevalence study after excluding those with an obvious underlying cause of hyperbilirubinemia. RESULTS: Serum bilirubin concentrations were >1 mg/dL in 2803 (31%) of 8973 patients, and these patients had higher mortality rates than patients with lower bilirubin concentrations (30% vs 21%, P<.01). For serum bilirubin values of 1.1-6 mg/dL, there was a linear increase in crude mortality (R2=0.96), with the highest hospital mortality (42%) in patients with bilirubin concentrations between 3.7 and 6.0 mg/dL. There was no further increase in the mortality rates for patients with bilirubin concentrations >6 mg/dL. A serum bilirubin concentration >1 mg/dL was an independent risk factor for mortality in multilevel analysis. CONCLUSIONS: Hyperbilirubinemia without a recognized cause was common and independently associated with increased mortality. There was a linear correlation of mortality with bilirubin concentration for values between 1 and 6 mg/dL but not for higher values.

The effects of local anesthetics on bile flow, potassium equilibrium and oxygen consumption in the perfused rat liver.

Amide local anesthetics mainly undergo hepatic metabolism. Specific applications, such as catheter application for long-term pain therapy, may result in large plasma concentrations. As it is unknown whether local anesthetics influence liver function, we examined the influence of lidocaine, bupivacaine, and ropivacaine in concentrations of 1 and 10 microg/mL on the metabolic activity of the perfused rat liver. At the large concentrations, all three local anesthetics caused an immediate increase of oxygen consumption. Bupivacaine and ropivacaine also transiently reduced potassium release. All drugs increased bile flow; this choleretic effect was also significant for bupivacaine and lidocaine in smaller concentrations. In the smaller concentration, only lidocaine significantly increased oxygen consumption. No significant changes in hepatic venous pH were observed. The results show that acute administration of all three local anesthetics results in significant changes of functional variables of the liver. The observed effects appear to result from mitochondrial uncoupling, uptake of the drugs, biliary secretion of their metabolites, and from inhibition of potassium channels. The data provide no evidence that these acute changes may result in enduring postoperative disturbances of liver function, such as cholestasis or jaundice.

Continuous blockade of both brachial plexus with ropivacaine in phantom pain: a case report.

A 39-year-old patient developed phantom pain after amputation of both upper arms following a burn injury. The pain did not respond to naproxen, morphine, carbamazepine, amitriptyline, calcitonin or transcutaneous electrical nerve stimulation (TENS). At the 39th post-operative day an axillary catheter was placed on the right side, as well as an interscalene catheter on the left. Ropivacaine 0.2% was infused, starting with a rate of 4 ml/h, that was increased to 6 ml/h during the subsequent 6 days. Within 20 min of catheter placement complete pain relief was achieved. The patient did not need any other analgesics and remained painfree for 7 months. Neither motor block, nor any other side effects occurred during the infusion of ropivacaine 0.2%. Thus, the patient not only received analgesia, but also got an effective treatment of established phantom pain. A similar approach with bupivacaine may not have been feasible, because of the possibility of toxic side effects. Ropivacaine is a long-acting local anaesthetic which is less toxic than bupivacaine and has the additional advantage of producing less motor-blockade in the concentration used, so the patient was able to move actively without experiencing any pain.

Changes in the use of the methylprednisolone protocol for traumatic spinal cord injury in Switzerland.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To examine the differences in the use of the methylprednisolone protocol for traumatic spinal cord injury before and after the publication of new guidelines in Switzerland. SUMMARY OF BACKGROUND DATA: The use of the methylprednisolone protocol for traumatic spinal cord injury changed after the publication of new guidelines. The rate of physicians prescribing high-dose methylprednisolone for patients with acute spinal cord injury was studied. Two intervals, each comprising 24 months before and after the publication of the consensus article in Switzerland, were compared. As a secondary parameter, the neurological development during the rehabilitation period was compared. METHODS: The charts of all adult patients who were referred for treatment of a spine or spinal cord injury during the periods from April 2001 to March 2003 and from April 2008 to March 2010 were retrospectively reviewed for demographic and medical details, the application of methylprednisolone within the first 48 hours after the injury, the diagnoses at the time of their referral, and the diagnosis at the time of hospital discharge. Classification of traumatic spinal cord injury was made according to the guidelines of the American Spinal Injury Association. Neurological improvement concerning the level of injury was defined as a change of this segment to a more caudal one or a complete normalization of sensory and motor function. RESULTS: During the 2 study periods, 110 patients (2001-2003) and 116 patients (2008-2010) were included. Between 2001 and 2003, 96% of patients with a neurological deficit after spinal cord injury were treated with high-dose methylprednisolone, whereas this rate dropped to 23% during the second time interval. In both treatment periods, neurological improvement during the rehabilitation period (mean: 6 mo) did not differ significantly. Pooled data of all patients with a neurological deficit in both study periods (n = 159) showed improved neurological levels in 32% of patients treated with methylprednisolone and 28% of patients without this therapy, without a statistical difference between the groups. CONCLUSION: In Switzerland, the acceptance of the guidelines for treating traumatic spinal cord injury with high-dose methylprednisolone has been extremely high in the past. The use of high-dose methylprednisolone has decreased to a much lower level in Switzerland after the publication of new guidelines, which is comparable to various other countries. Despite these changes, no differences in the neurological outcome were detected between the observed patient populations.

Increased mortality associated with methicillin-resistant Staphylococcus aureus (MRSA) infection in the intensive care unit: results from the EPIC II study.

Controversy continues regarding whether the presence of meticillin resistance increases mortality risk in Staphylococcus aureus infections. In this study, we assessed the role of meticillin resistance in survival of patients with S. aureus infection included in the EPIC II point-prevalence study of infection in critically ill patients performed on 8 May 2007. Demographic, physiological, bacteriological and therapeutic data were collected for 13796 adult patients in 1265 participating Intensive Care Units (ICUs) from 75 countries on the study day. ICU and hospital outcomes were recorded. Characteristics of patients with meticillin-sensitive S. aureus (MSSA) and meticillin-resistant S. aureus (MRSA) infections were compared. Co-morbidities, age, Simplified Acute Physiology Score (SAPS) II, site of infection, geographical region and MRSA/MSSA were entered into a multivariate model, and adjusted odds ratios (ORs) [95% confidence interval (CI)] for ICU and hospital mortality rates were calculated. On the study day, 7087 (51%) of the 13796 patients were classified as infected. There were 494 patients with MRSA infections and 505 patients with MSSA infections. There were no significant differences between the two groups in use of mechanical ventilation or haemofiltration/haemodialysis. Cancer and chronic renal failure were more prevalent in MRSA than in MSSA patients. ICU mortality rates were 29.1% and 20.5%, respectively (P<0.01) and corresponding hospital mortality rates were 36.4% and 27.0% (P<0.01). Multivariate analysis of hospital mortality for MRSA infection showed an adjusted OR of 1.46 (95% CI 1.03-2.06) (P=0.03). In ICU patients, MRSA infection is therefore independently associated with an almost 50% higher likelihood of hospital death compared with MSSA infection.

Anesthesia as therapy for persistent hiccups.

IMPLICATIONS: Chronic hiccups may be a serious therapeutic problem. Pharmacological treatment with increasing dosages of baclofen, carbamazepine, or gabapentin is not always successful. In this paper, the use of general anesthesia with positive-pressure ventilation and muscle relaxation for the termination of chronic hiccups is described.