Effect of "Touch Rugby" Training on the Cardiovascular Autonomic Control In Sedentary Subjects.

This study aimed to explore the effects of "touch-rugby" training on the cardiovascular autonomic control in sedentary subjects. 22 adults (30-64 years old) were included in this study. Before (pre-test) and after (post-test) the period of training, cardio-respiratory recordings were achieved at rest and during a graded maximal exercise on a treadmill. The Smoothed-Pseudo-Wigner-Ville Distribution provided instantaneous time frequency components of RR intervals and systolic blood pressure variability in low- and high-frequency bands. The baroreflex sensitivity was assessed in low-frequency and high-frequency bands. Between pre-test and post-test, resting heart rate (74±10 vs. 69±12 beats.min(-1), p<0.05) and systolic blood pressure (118±19 vs. 103±22 mm Hg, p<0.01) decreased. Root mean square of successive differences (34.6±30.1 vs. 47.6±34.8 ms, p<0.001), high-frequency RR variability (590±288 vs. 1262±767 ms², p<0.001) increased whereas low-frequency/high-frequency ratio decreased (3.5±3.4 vs. 1.5±0.9, p<0.05). The high-frequency baroreflex sensitivity increased (13.4±10.1 vs. 26.0±20.9 ms.mmHg(-1), p<0.05). Playing touch rugby with one session weekly over 3 months modified the cardiovascular autonomic control of sedentary subjects. A decrease in the sympathetic tone combined with both an increase in the vagal tone and a decrease in systolic blood pressure at rest were observed. Therefore, such training appears to be beneficial to cardiac health.

Early intensive care unit-acquired hypernatremia in severe sepsis patients receiving 0.9% saline fluid resuscitation.

BACKGROUND: Intensive care unit (ICU)-acquired hypernatremia is associated with increased mortality and ascribed to excessive sodium/insufficient free water intakes. We aimed to determine whether the volume of intravenous 0.9% saline fluid resuscitation was associated with hypernatremia in severe sepsis. METHODS: We retrospectively reviewed the charts of patients admitted to our medical ICU over 1 year with severe sepsis, and recorded all fluid intakes and plasma sodium levels (Nap ) for 5 days along with clinical data. ΔNap was defined as the difference between maximal Nap reached and initial Nap . Hypernatremia was defined as Nap > 145 mmoles/l. RESULTS: Among 95 patients with severe sepsis, 29 developed hypernatremia within 5 days (31%), reaching a maximum Nap of 149.1 ± 2.5 mmoles/l on average 3.8 ± 1.5 days after admission. For every 50-ml/kg increase in 0.9% saline intake for the first 48 h, the odds of hypernatremia were 1.61 times larger [confidence interval (CI): 0.98-2.62; P = 0.06] and the mean of ΔNap increased by 1.86 mmoles/l (CI: 0.86-2.86; P < 0.001). Compared with non-hypernatremic patients, hypernatremic patients received more 0.9% saline within the first 48 h (111 ± 50 ml/kg vs. 92 ± 42 ml/kg, P < 0.05) and more other fluids from 48 to 96 h (64 ± 38 ml/kg vs. 42 ± 24 ml/kg, P < 0.05). Patients developing hypernatremia had increased length of mechanical ventilation (12.0 ± 12.6 vs. 9.1 ± 7.2 days, P < 0.05) and ICU mortality (38.5% vs. 13%, P < 0.01). CONCLUSIONS: Early acquired hypernatremia is a frequent complication in severe sepsis patients and is associated with the volume of 0.9% saline received during the first 48 h of admission.

Echocardiographic features, mortality, and adrenal function in patients with cirrhosis and septic shock.

OBJECTIVES: Cirrhosis of the liver is associated with an increased susceptibility to bacterial infections capable of causing septic shock and with a basal hyperdynamic circulatory state. The primary objective of this study was to delineate the echocardiographic characteristics and outcomes of septic shock in patients with liver cirrhosis. The secondary objective was to determine whether adrenal insufficiency, which may contribute to hyperdynamic syndrome, was more marked in patients with cirrhosis than in other patients with septic shock. DESIGN: Prospective single-center cohort study. PATIENTS AND METHODS: Thirty-four patients admitted to the intensive care unit (ICU) for septic shocks were included, 14 with and 20 without liver cirrhosis. Echocardiography was performed within the first 24 h to measure the cardiac index (CI), systolic index (SI), and left ventricular ejection fraction (LVEF). A Synacthen test was performed. RESULTS: Patients with cirrhosis had higher values for the CI (3.69+/-1.0 vs. 2.86+/-0.8 l/min/m(2); P=0.02), SI (37.5+/-8 vs. 32.4+/-7 ml/m(2); P=0.04), and LVEF (67+/-7 vs. 55.9+/-12%; P=0.005). ICU mortality was 53% overall, 64% in patients with cirrhosis, and 45% in patients without cirrhosis (P=0.27). Serum cortisol levels under basal conditions (H0) and after stimulation (H1) showed no significant differences between patients with and without cirrhosis. The proportion of patients with no response to Synacthen was 77% among patients with cirrhosis and 50% among patients without cirrhosis (P=0.18). CONCLUSION: In a population with septic shock, left ventricular function was more hyperdynamic in the subset with cirrhosis. Relative adrenal insufficiency occurred in similar proportions of patients with and without cirrhosis.

[Interest of the brain natriuretic peptide as a marker of acute cor pulmonale in acute respiratory distress syndrome]. / Analyse du peptide natriurétique de type B comme marqueur du coeur pulmonaire aigu dans le syndrome de détresse respiratoire aiguë.

OBJECTIVE: The aim of this study was to evaluate the accuracy of the BNP as a marker of acute cor pulmonale in patients with ARDS. STUDY DESIGN: Prospective clinical trial. PATIENTS AND METHODS: At day 2 or 3 after the onset of the ARDS, an echocardiography was performed. Patients with left ventricular dysfunction were excluded. Right ventricular area (RVA) and RVA/LVA ratio were measured. ACP was defined as RVA/LVA > 0.6 associated with septal dyskinesia. Simultaneously, 5 ml of blood was collected for BNP measurement. RESULTS: 26 patients were studied. BNP levels were higher in 10 patients with ACP: 585.5 [189-4830] vs 145.5 [36.5-346] pg/ml (P=0.01) but in those with creatinine clearance < 90 ml/min: 602 [331-3530] vs 125 [39-189] pg/ml (P=0.007). BNP was correlated with RVA (r=0.5; p=0.01), RVA/LVA ratio (r=0.61; p=0.001), sPAP (r=0.58; p=0.002) and with age, cardiac index and creatinine clearance (r=0.61; p=0.001). In multivariate analysis, BNP was only correlated with creatinine clearance (p=0.03), and RVA (p=0.06). CONCLUSION: In ARDS patients without left ventricular dysfunction, BNP level is more elevated in patients with acute cor pulmonale than patients without cor pulmonale.

Accuracy of pulse oximetry in the intensive care unit.

OBJECTIVE: Pulse oximetry (SpO2) is a standard monitoring device in intensive care units (ICUs), currently used to guide therapeutic interventions. Few studies have evaluated the accuracy of SpO2 in critically ill patients. Our objective was to compare pulse oximetry with arterial oxygen saturation (SaO2) in such patients, and to examine the effect of several factors on this relationship. DESIGN: Observational prospective study. SETTING: A 26-bed medical ICU in a university hospital. PATIENTS: One hundred two consecutive patients admitted to the ICU in whom one or serial arterial blood gas analyses (ABGs) were performed and a reliable pulse oximeter signal was present. INTERVENTIONS: For each ABG, we collected SaO2, SpO2, the type of pulse oximeter, the mode of ventilation and requirement for vasoactive drugs. MEASUREMENTS AND RESULTS: Three hundred twenty-three data points were collected. The mean difference between SpO2 and SaO2 was -0.02% and standard deviation of the differences was 2.1%. From one sample to another, the fluctuations in SpO2 to arterial saturation difference indicated that SaO2 could not be reliably predicted from SpO2 after a single ABG. Subgroup analysis showed that the accuracy of SpO2 appeared to be influenced by the type of oximeter, the presence of hypoxemia and the requirement for vasoactive drugs. Finally, high SpO2 thresholds were necessary to detect significant hypoxemia with good sensitivity. CONCLUSION: Large SpO2 to SaO2 differences may occur in critically ill patients with poor reproducibility of SpO2. A SpO2 above 94% appears necessary to ensure a SaO2 of 90%.

Exhaled carbon monoxide in mechanically ventilated critically ill patients: influence of inspired oxygen fraction.

OBJECTIVE: To assess the feasibility of exhaled carbon monoxide (CO) measurements in mechanically ventilated critically ill adult patients and to determine the influence of inspired oxygen fraction on this measurement. DESIGN: Prospective physiologic study. SETTING: Medical ICU in a community hospital. PATIENTS: The study was performed on nine mechanically ventilated patients with varying diagnoses. MEASUREMENTS AND RESULTS: Carbon monoxide concentration was determined with an infrared CO analyzer on exhaled breath collected at the outlet of the ventilator. We assessed the stability of exhaled carbon monoxide concentration over a 4-hour period and determined its course during a 7-hour period after inspired oxygen fraction had been abruptly increased from baseline to 1. Carbon monoxide was detected in exhaled breath in each patient at a higher concentration than in inspired gas (0.64 +/- 0.1 ppm vs 0.25 ppm, approximately). Exhaled carbon monoxide did not vary during a 4-hour period in five hemodynamically stable patients. When inspired oxygen fraction was increased from baseline (0.52 +/- 0.04) to 1, exhaled carbon monoxide concentration increased abruptly from baseline (0.63 +/- 0.13 ppm) to a peak value of 1.54 +/- 0.16 ppm within 15 min and returned slowly to baseline values within 7 h. CONCLUSION: CO was easily detected in the exhaled breath of mechanically ventilated patients and CO lung excretion was markedly but transiently dependent on inspired oxygen fraction. Other studies are warranted in order to determine the different factors that might influence CO lung excretion in critically ill patients.

[Use of sevoflurane for surgery of pheochromocytoma]. / Utilisation du sévoflurane pour la chirurgie du phéochromocytome.

Resection of phaeochromocytoma is associated with sudden changes in arterial pressure. Pharmacodynamic and pharmacokinetic properties of sevoflurane are suitable for maintenance of haemodynamic stability. We report two cases of phaeochromocytoma resection using sevoflurane. Intraoperative hypotensive or hypertensive events have been rapidly controlled, most often only by adjustment of the end-expiratory fraction of sevoflurane.

[Color M-mode Doppler for postoperative estimation of pulmonary capillary wedge pressure]. / Estimation postopératoire de la pression artérielle pulmonaire d'occlusion par étude Doppler, en mode M couleur, du flux transmitral.

OBJECTIVE: The aim of this study was to evaluate the accuracy of the combined index E/Vp (peak E velocity combined with color M-mode color Doppler flow propagation) for estimating pulmonary capillary wedge pressure, in post cardiac surgery patients. STUDY DESIGN: Prospective clinical trial. PATIENTS AND METHODS: In post cardiac surgery patients (D1), we have measured with transthoracic echocardiography peak early E transmitral pulsed Doppler velocities and color M-mode Doppler flow propagation velocity (Vp). The E/Vp ratio was compared with pulmonary capillary wedge pressure (PAPO) obtained simultaneously. RESULTS: Thirty eight patients were studied. The coefficient of correlation between PAPO and E/Vp was r = 0.71 (p < 0.0001). The sensitivity and the specificity of E/Vp > 1.5 for prediction of PAPO > 15 mmHg were 79% and 79% respectively. CONCLUSION: In post cardiac surgery patients, PAPO can be reasonably estimated by measuring the ratio E/Vp obtained with Doppler echocardiography.

Hypocapnia-dependent facilitation of augmented breaths: observations in awake vs. anesthetized rats.

We investigated whether commonly used injectable laboratory anesthetics alter the regulation of augmented breaths (ABs) in different respiratory backgrounds. Male rats were studied on three separate experimental days, receiving one of three injections in randomized order: ethyl carbamate ('urethane'; 1.2mgkg(-1)), ketamine/xylazine (ket/xyl; 80/10mgkg(-1)), or normal saline. Following each of the three interventions, breathing was monitored during 15min exposures to normoxia (room air), hypoxia (10% O(2)) and hypoxia+CO(2) (10% O(2), 5% CO(2)). Urethane anesthesia completely eliminated ABs from the breathing rhythm in room air conditions (p<0.001), and decreased the hypocapnia-dependent component of this response (p<0.001). ket/xyl left the normal incidence of ABs in room air breathing intact but significantly suppressed the hypoxia-induced facilitation of ABs (p=0.0015). These results provide the first clear evidence that laboratory anesthesia can profoundly alter the regulation of ABs including the hypocapnia-dependent component of their facilitation.

[Colonic necrosis following a pancreatic pseudocyst embolization]. / Nécrose colique après embolisation d'un pseudo-anévrisme pancréatique.

A 43-year-old man with chronic alcohol pancreatitis was admitted in our intensive care unit for an haemorrhagic shock. An abdominal CT-scan performed on admission showed bleeding from a vessel in a pancreatic pseudocyst. Initial treatment included intravenous fluids, transfusion, mechanical ventilation and vasopressive support. Percutaneous arterial embolization (PAE) of a bleeding right superior colon artery was performed with an initial good result. Nevertheless after initial clinical improvement, hypotension refractory to fluid management occurred. An abdominal CT-scan disclosed pneumatosis in right colon. A right hemicolectomy was performed. Histologic analysis confirmed ischemic colitis. The patient recovered and was discharged from the intensive care unit. Colitis necrosis after PAE for pancreatic pseudoaneurysm had never been described before. It should be suspected when haemodynamic instability occurs following PAE.

B-type natriuretic peptide (BNP) and N-terminal-proBNP for heart failure diagnosis in shock or acute respiratory distress.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) assay is recommended as a diagnostic tool in emergency-room patients with acute dyspnea. In the intensive care unit (ICU), the utility of this peptide remains a matter of debate. The objectives of this study were to determine whether cut-off values for BNP and N-terminal-proBNP (NT-proBNP) reliably diagnosed right and/or left ventricular failure in patients with shock or acute respiratory distress, and whether non-cardiac factors led to an increase in these markers. METHODS: Plasma BNP and NT-proBNP levels and echocardiographic parameters of cardiac dysfunction were determined in 41 patients within 24 h of the onset of shock or acute respiratory distress. RESULTS: BNP and NT-proBNP levels were higher in the 25 patients with heart failure than in the other 16 patients: 491.7 +/- 418 pg/ml vs. 144.3 +/- 128 pg/ml and 2874.4 +/- 2929 pg/ml vs. 762.7 +/- 1128 pg/ml, respectively (P < 0.05). In the diagnosis of cardiac dysfunction, BNP > 221 pg/ml and NT-proBNP > 443 pg/ml had 68% and 84% sensitivity, respectively, and 88% and 75% specificity, respectively, but there was a substantial overlap of BNP and NT-proBNP values between patients with and without heart failure. BNP and NT-proBNP were elevated, but not significantly, in patients with isolated right ventricular dysfunction. Patients with renal dysfunction and normal heart function had significantly higher levels of BNP (258.6 +/- 144 pg/ml vs. 92.4 +/- 84 pg/ml) and NT-proBNP (2049 +/- 1320 pg/ml vs. 118 +/- 104 pg/ml) than patients without renal dysfunction. CONCLUSION: Both BNP and NT-proBNP can help in the diagnosis of cardiac dysfunction in ICU patients, but cannot replace echocardiography. An elevated BNP or NT-proBNP level merely indicates the presence of a 'cardiorenal distress' and should prompt further investigation.

Evaluation of basement membrane degradation during TNF-alpha-induced increase in epithelial permeability.

We evaluated whether tumor necrosis factor (TNF)-alpha induces an increase in permeability of an alveolar epithelial monolayer via gelatinase secretion and basement membrane degradation. Gelatinase secretion and epithelial permeability to radiolabeled albumin under unstimulated and TNF-alpha-stimulated conditions of an A549 human epithelial cell line were evaluated in vitro. TNF-alpha induced both upregulation of a 92-kDa gelatinolytic activity (pro form in cell supernatant and activated form in extracellular matrix) and an increase in the epithelial permeability coefficient compared with the unstimulated condition (control: 1.34 +/- 0.04 x 10(-6) cm/s; 1 microg/ml TNF-alpha: 1.47 +/- 0.05 x 10(-6) cm/s, P < 0.05). The permeability increase in the TNF-alpha-stimulated condition involved both paracellular permeability, with gap formation visualized by actin cytoskeleton staining, and basement membrane permeability, with an increase in the basement membrane permeability coefficient (determined after cell removal; control: 2.58 +/- 0.07 x 10(-6) cm/s; 1 microg/ml TNF-alpha: 2.82 +/- 0.02.10(-6) x cm/s, P < 0.05). Because addition of gelatinase inhibitors [tissue inhibitor of metalloproteinase (TIMP)-1 or BB-3103] to cell supernatants failed to inhibit the permeability increase, the gelatinase-inhibitor balance in the cellular microenvironment was further evaluated by cell culture on a radiolabeled collagen matrix. In the unstimulated condition, spontaneous collagenolytic activity inhibited by addition to the matrix of 1 microg/ml TIMP-1 or 10(-6) M BB-3103 was found. TNF-alpha failed to increase this collagenolytic activity because it was associated with dose-dependent upregulation of TIMP-1 secretion by alveolar epithelial cells. In conclusion, induction by TNF-alpha of upregulation of both the 92-kDa gelatinase and its inhibitor TIMP-1 results in maintenance of the gelatinase-inhibitor balance, indicating that basement membrane degradation does not mediate the TNF-alpha-induced increase in alveolar epithelial monolayer permeability.