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Introduction: A severe course of COVID-19 is characterized by a hyperinflammatory state resulting in acute respiratory distress syndrome or even multi-organ failure along a derailed sympatho-vagal balance. Methods: In this prospective, randomized study, we evaluate the hypothesis that percutaneous minimally invasive auricular vagus nerve stimulation (aVNS) is a safe procedure and might reduce the rate of clinical complications in patients with severe course of COVID-19. In our study, patients with SARS-CoV-2 infection admitted to the intensive care unit with moderate-to-severe acute respiratory distress syndrome, however without invasive ventilation yet, were included and following randomization assigned to a group receiving aVNS four times per 24 h for 3 h and a group receiving standard of care (SOC). Results: A total of 12 patients were included (six in the aVNS and six in the SOC group). No side effects in aVNS were reported, especially no significant pain at device placement or during stimulation at the stimulation site or significant headache or bleeding after or during device placement or lasting skin irritation. There was no significant difference in the aVNS and SOC groups between the length of stay in the intensive care unit and at the hospital, bradycardia, delirium, or 90-day mortality. In the SOC group, five of six patients required invasive mechanical ventilation during their stay at hospital and 60% of them venovenous extracorporeal membrane oxygenation, compared to three of six patients and 0% in the aVNS group (p = 0.545 and p = 0.061). Discussion: Vagus nerve stimulation in patients with severe COVID-19 is a safe and feasible method. Our data showed a trend to a reduction of progression to the need of invasive ventilation and venovenous extracorporeal membrane oxygenation which encourages further research with larger patient samples.
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Covid-19 is an infectious disease associated with cytokine storms and derailed sympatho-vagal balance leading to respiratory distress, hypoxemia and cardiovascular damage. We applied the auricular vagus nerve stimulation to modulate the parasympathetic nervous system, activate the associated anti-inflammatory pathways, and reestablish the abnormal sympatho-vagal balance. aVNS is performed percutaneously using miniature needle electrodes in ear regions innervated by the auricular vagus nerve. In terms of a randomized prospective study, chronic aVNS is started in critical, but not yet ventilated Covid-19 patients during their stay at the intensive care unit. The results show decreased pro-inflammatory parameters, e.g. a reduction of CRP levels by 32% after 1 day of aVNS and 80% over 7 days (from the mean 151.9 mg/dl to 31.5 mg/dl) or similarly a reduction of TNFalpha levels by 58.1% over 7 days (from a mean 19.3 pg/ml to 8.1 pg/ml) and coagulation parameters, e.g. reduction of DDIMER levels by 66% over 7 days (from a mean 4.5 µg/ml to 1.5 µg/ml) and increased anti-inflammatory parameters, e.g. an increase of IL-10 levels by 66% over 7 days (from the mean 2.7 pg/ml to 7 pg/ml) over the aVNS duration without collateral effects. aVNS proved to be a safe clinical procedure and could effectively supplement treatment of critical Covid-19 patients while preventing devastating over-inflammation.
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BACKGROUND: In addition to respiratory symptoms, many patients with coronavirus disease 2019 (COVID-19) present with neurological complications. Several case reports and small case series described myoclonus in five patients suffering from the disease. The purpose of this article is to report on five critically ill patients with COVID-19-associated myoclonus. MATERIAL AND METHODS: The clinical courses and test results of patients treated in the study center ICU and those of partner hospitals are described. Imaging, laboratory tests and electrophysiological test results are reviewed and discussed. RESULTS: In severe cases of COVID-19 myoclonus can manifest about 3 weeks after initial onset of symptoms. Sedation is sometimes effective for symptom control but impedes respiratory weaning. No viral particles or structural lesions explaining this phenomenon were found in this cohort. CONCLUSION: Myoclonus in patients with severe COVID-19 may be due to an inflammatory process, hypoxia or GABAergic impairment. Most patients received treatment with antiepileptic or anti-inflammatory agents and improved clinically.
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COVID-19 , Mioclonía , Enfermedad Crítica , Humanos , Unidades de Cuidados Intensivos , Mioclonía/inducido químicamente , Mioclonía/diagnóstico , Mioclonía/tratamiento farmacológico , SARS-CoV-2RESUMEN
BACKGROUND: Convalescent plasma (CP) containing antibodies derived from coronavirus disease 2019 (COVID-19) survivors has been proposed as a promising therapeutic option for severe COVID-19. METHODS: In our intensive care unit (ICU), 55 patients (46 male, median age 61 years) with PCR-confirmed COVID-19 (35 = 63.6% on mechanical ventilation, 7 = 14.5% on high-flow nasal oxygen, 12 = 20% on non-invasive ventilation, 1 = 1.8% without respiratory support) were treated with high-titre CP (200 mL per dose, range 1-6 doses, median 3 doses per patient, minimum titre > 1:100, Wantai test). 139 COVID-19 patients treated in the same ICU who did not receive CP served as control group. In 27 patients, the effect of CP on the individual levels of SARS-CoV-2 IgG antibodies was assessed by ELISA in serum sample pairs collected before and after CP transfusion. RESULTS: The first CP dose was administered at a median of 8 days after symptom onset. 13 patients in the plasma cohort died (28-day mortality 24.1%), compared to 42 (30.2%) in the cohort who did not receive CP (p = 0.5, Pearson Chi-squared test). Out of the 27 individuals investigated for the presence of IgG antibodies, 8 did not have detectable IgG levels before the first CP transfusion. In this subpopulation, 3 patients (37.5%) died. Not a single confirmed adverse reaction to CP was noted. CONCLUSIONS: While adjunctive treatment with CP for severe and life-threatening COVID-19 was a very safe intervention, we did not observe any effect on mortality.
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COVID-19 , Enfermedad Crítica , COVID-19/terapia , Estudios de Cohortes , Humanos , Inmunización Pasiva , Masculino , Persona de Mediana Edad , SARS-CoV-2 , Sueroterapia para COVID-19RESUMEN
BACKGROUND: A significant portion of critically ill patients with coronavirus disease 2019 (COVID-19) are at high risk of developing intensive care unit (ICU)-acquired swallowing dysfunction (neurogenic dysphagia) as a consequence of requiring prolonged mechanical ventilation. Pharyngeal electrical stimulation (PES) is a simple and safe treatment for neurogenic dysphagia. It has been shown that PES can restore safe swallowing in orally intubated or tracheotomized ICU patients with neurogenic dysphagia following severe stroke. We report the case of a patient with severe neurogenic post-extubation dysphagia (PED) due to prolonged intubation and severe general muscle weakness related to COVID-19, which was successfully treated using PES. CASE PRESENTATION: A 71-year-old Caucasian female patient with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection developed neurogenic dysphagia following prolonged intubation in the ICU. To avoid aerosol-generating procedures, her swallowing function was evaluated non-instrumentally as recommended by recently published international guidelines in response to the COVID-19 pandemic. Her swallowing function was markedly impaired and PES therapy was recommended. PES led to a rapid improvement of the PED, as evaluated by bedside swallowing assessments using the Gugging Swallowing Screen (GUSS) and Dysphagia Severity Rating Scale (DSRS), and diet screening using the Functional Oral Intake Scale (FOIS). The improved swallowing, as reflected by these measures, allowed this patient to transfer from the ICU to a non-intensive medical department 5 days after completing PES treatment. CONCLUSIONS: PES treatment contributed to the restoration of a safe swallowing function in this critically ill patient with COVID-19 and ICU-acquired swallowing dysfunction. Early clinical bedside swallowing assessment and dysphagia intervention in COVID-19 patients is crucial to optimize their full recovery. PES may contribute to a safe and earlier ICU discharge of patients with ICU-acquired swallowing dysfunction. Earlier ICU discharge and reduced rates of re-intubation following PES can help alleviate some of the pressure on ICU bed capacity, which is critical in times of a health emergency such as the ongoing COVID-19 pandemic.
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COVID-19/terapia , Trastornos de Deglución/terapia , Terapia por Estimulación Eléctrica/métodos , Intubación Intratraqueal/efectos adversos , Faringe , Recuperación de la Función , Anciano , Trastornos de Deglución/etiología , Trastornos de Deglución/fisiopatología , Femenino , Humanos , Respiración Artificial , SARS-CoV-2 , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
While coronavirus disease 2019 (COVID-19), caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), has often been perceived as a predominantly respiratory condition, it is characterized by complications in multiple organ systems. Especially the involvement of the cardiovascular system, along with the possibly severe pulmonary injury, is crucial for prognosis. We identified three COVID-19 patients with takotsubo (TT) cardiomyopathy at our infectious diseases treatment center and present their clinical, laboratory, echocardiographic, electrocardiographic, and angiographic features. All patients were female (median age, 67 years); disease severity regarding COVID-19 ranged from asymptomatic to ARDS (adult respiratory syndrome) necessitating mechanical ventilation for 22 days. Angiography revealed normal coronary arteries in patient 1, severe three-vessel coronary artery disease (CAD) in patient 2, and insignificant bystander CAD in patient 3. All patients showed classic apical hypokinesia with basal hyperkinesia. In patient 3, TT cardiomyopathy resulted in transient cardiogenic shock. Twenty-eight-day mortality was 0% in this case series. In conclusion, takotsubo cardiomyopathy may be yet another clinical entity associated with SARS-CoV-2 infection.
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OBJECTIVE: Mortality on medical intensive care units (ICU) is approximately 25%. It is associated with age, severity of illness, and comorbidities. Preexisting depression is a risk factor for worse outcome in many diseases. The impact of depression on outcome of ICU patients has not been investigated. We assessed a possible association between mortality and preexisting depressive mood at the time of ICU admission. The primary end point was 28-day mortality. METHODS: This single-center cohort study was conducted in a tertiary medical ICU. Two hundred patients were evaluated for preexisting depressive mood at ICU admission, determined by Hospital Anxiety and Depression Scale (HADS) score ≥8 in the depression dimension in patients with appropriate cognitive function. Patients with insufficient cognitive function were assessed using observer rating by next of kin by Hammond scale (cutoff ≥4) and/or a modified version of the Hospital Anxiety and Depression Scale for observer rating (cutoff ≥10). RESULTS: In total, 66 (33%) of 200 patients were classified with preexisting depressive mood. Forty-nine (24.5%) of 200 patients had died by day 28. Of these, 23 (47%) had preexisting depressive mood as compared with 43 of 151 (29%) 28-day survivors (p = .017). Multiple logistic regression analysis revealed that preexisting depressive mood at the time of ICU admission is an independent risk factor for 28-day (odds ratio = 2.2, 95% confidence interval = 1.08-4.5, p = .030) and in-hospital mortality (median time till death = 20.5 [2-186] days, odds ratio = 2.58, 95% confidence interval = 1.31-5.1, p = .006). CONCLUSION: Preexisting depressive mood might be an independent risk factor for 28-day mortality in medical ICU patients. This could have diagnostic and therapeutic implications for critically ill patients.
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Enfermedad Crítica/mortalidad , Depresión/mortalidad , Antidepresivos/uso terapéutico , Estudios de Cohortes , Enfermedad Crítica/psicología , Depresión/complicaciones , Depresión/tratamiento farmacológico , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Escalas de Valoración Psiquiátrica , Factores de RiesgoRESUMEN
Ganciclovir is an antiviral agent that is frequently used in critically ill patients with cytomegalovirus (CMV) infections. Continuous venovenous hemodiafiltration (CVVHDF) is a common extracorporeal renal replacement therapy in intensive care unit patients. The aim of this study was to investigate the pharmacokinetics of ganciclovir in anuric patients undergoing CVVHDF. Population pharmacokinetic analysis was performed for nine critically ill patients with proven or suspected CMV infection who were undergoing CVVHDF. All patients received a single dose of ganciclovir at 5 mg/kg of body weight intravenously. Serum and ultradiafiltrate concentrations were assessed by high-performance liquid chromatography, and these data were used for pharmacokinetic analysis. Mean peak and trough prefilter ganciclovir concentrations were 11.8 ± 3.5 mg/liter and 2.4 ± 0.7 mg/liter, respectively. The pharmacokinetic parameters elimination half-life (24.2 ± 7.6 h), volume of distribution (81.2 ± 38.3 liters), sieving coefficient (0.76 ± 0.1), total clearance (2.7 ± 1.2 liters/h), and clearance of CVVHDF (1.5 ± 0.2 liters/h) were determined. Based on population pharmacokinetic simulations with respect to a target area under the curve (AUC) of 50 mg · h/liter and a trough level of 2 mg/liter, a ganciclovir dose of 2.5 mg/kg once daily seems to be adequate for anuric critically ill patients during CVVHDF.
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Antivirales/sangre , Antivirales/farmacocinética , Enfermedad Crítica , Ganciclovir/sangre , Ganciclovir/farmacocinética , Hemodiafiltración , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Método de MontecarloRESUMEN
INTRODUCTION: Critical illness polyneuropathy and/or myopathy (CIPNM) is a severe complication of critical illness. Retrospective data suggest that early application of IgM-enriched intravenous immunoglobulin (IVIG) may prevent or mitigate CIPNM. Therefore, the primary objective was to assess the effect of early IgM-enriched IVIG versus placebo to mitigate CIPNM in a prospective setting. METHODS: In this prospective, randomized, double-blinded and placebo-controlled trial, 38 critically ill patients with multiple organ failure (MOF), systemic inflammatory response syndrome (SIRS)/sepsis, and early clinical signs of CIPNM were included. Patients were randomly assigned to be treated either with IgM-enriched IVIG or placebo over a period of three days. CIPNM was measured by the CIPNM severity sum score based on electrophysiological stimulation of the median, ulnar, and tibial nerves on days 0, 4, 7, 14 and on the histological evaluation of muscle biopsies on days 0 and 14 and ranged from 0 (no CIPNM) to 8 (very severe CIPNM). RESULTS: A total of 38 critically ill patients were included and randomized to receive either IgM-enriched IVIG (n = 19) or placebo (n = 19). Baseline characteristics were similar between the two groups. CIPNM could not be improved by IVIG treatment, represented by similar CIPNM severity sum scores on day 14 (IVIG vs. placebo: 4.8 ± 2.0 vs. 4.5 ± 1.8; P = 0.70). CIPNM severity sum score significantly increased from baseline to day 14 (3.5 ± 1.6 vs. 4.6 ± 1.9; P = 0.002). After an interim analysis the study was terminated early due to futility in reaching the primary endpoint. CONCLUSIONS: Early treatment with IVIG did not mitigate CIPNM in critically ill patients with MOF and SIRS/sepsis. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01867645.
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Inmunoglobulina M/uso terapéutico , Inmunoglobulinas Intravenosas/uso terapéutico , Insuficiencia Multiorgánica/complicaciones , Enfermedades Musculares/tratamiento farmacológico , Polineuropatías/tratamiento farmacológico , Síndrome de Respuesta Inflamatoria Sistémica/complicaciones , Adulto , Anciano , Austria , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Musculares/etiología , Placebos , Polineuropatías/etiología , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Continuous glucose monitoring has been proposed to optimize glucose control in critically ill patients. To achieve strict glucose regulation, accurate and reliable continuous glucose-monitoring systems are essential. OBJECTIVE: Evaluation of a subcutaneous continuous glucose-monitoring system for use in critically ill patients. DESIGN: Pooled-data analysis of two prospective, randomized, controlled trials. SETTING: An eight-bed medical intensive care unit of a university hospital. PATIENTS: A total of 174 critically ill patients on intensive insulin therapy. INTERVENTIONS: Subcutaneous continuous glucose monitoring. MEASUREMENTS: Two thousand forty-five continuous glucose-monitoring system sensor glucose values were compared with arterial reference blood glucose levels, determined by a blood gas analyzer. Continuous glucose monitoring data were recorded continuously for up to 72 hrs by using a subcutaneous continuous glucose-monitoring sensor. The correlation of both methods and differences between continuous glucose-monitoring systems and reference values were calculated, as well as the conformity of continuous glucose-monitoring values with the International Organization for Standardization criteria (<0.83 mmol/L [15 mg/dL] difference for glucose values ≤ 4.12 mmol/L [≤ 75 mg/dL] and <20% difference for glucose values >4.12 mmol/L [>75 mg/dL]). RESULTS: The Pearson correlation coefficient was 0.92, showing strong correlation between the two methods. The intraclass correlation coefficient was 0.92, indicating that 92% of the variability is due to subjects and measurement occasions. Mean difference between continuous glucose-monitoring system and reference values was -0.10 mmol/L (confidence interval: -0.13 to -0.07) (-2 mg/dL [confidence interval: -2 to -1]) (continuous glucose-monitoring system minus reference) and absolute difference 0.44 mmol/L (confidence interval: 0.41-0.47) (8 mg/dL [confidence interval: 7-8]). According to the insulin titration error grid analysis, 99.1% of continuous glucose-monitoring system values were in the acceptable treatment zone. No continuous glucose-monitoring system measurements were found in the life-threatening zone, and 92.9% of the continuous glucose-monitoring system glucose values met the International Organization for Standardization criteria. CONCLUSION: The subcutaneous continuous glucose-monitoring system is reliable for use in critically ill patients and showed glucose values with a strong correlation to arterial reference blood glucose levels, determined by a blood gas analyzer.
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Glucemia/análisis , Cuidados Críticos/métodos , Monitoreo de Radiación/métodos , Análisis de los Gases de la Sangre , Enfermedad Crítica , Humanos , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
OBJECTIVE: Head-to-head comparison of the success rate of jejunal placement of a new electromagnetically visualized jejunal tube with that of the endoscopic technique in critically ill patients. DESIGN: : Prospective, randomized clinical trial. SETTING: Two intensive care units at a university hospital. PATIENTS: : A total of 66 critically ill patients not tolerating intragastric nutrition. INTERVENTIONS: Patients were randomly assigned (2:1 ratio) to receive an electromagnetically visualized jejunal feeding tube or an endoscopically placed jejunal tube. The success rate of correct jejunal placement after 24 hrs was the main outcome parameter. MEASUREMENTS AND MAIN RESULTS: The correct jejunal tube position was reached in 21 of 22 patients using the endoscopic technique and in 40 of 44 patients using the electromagnetically visualized jejunal tube (95% vs. 91%; relative risk 0.9524, confidence interval 0.804-1.127, p = .571). In the remaining four patients, successful endoscopic jejunal tube placement was performed subsequently. The implantation times, times in the right position, and occurrences of nose bleeding were not different between the two groups. The electromagnetically visualized technique resulted in the correct jejunal position more often at the first attempt. Factors associated with successful placement at the first attempt of the electromagnetically visualized jejunal tube seem to be a higher body mass index and absence of emesis. This trial is registered at ClinicalTrials.gov, number NCT00500851. CONCLUSIONS: In a head-to-head comparison correct jejunal tube placement using the new electromagnetically visualized method was as fast, safe, and successful as the endoscopic method in a comparative intensive care unit patient population.
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Enfermedad Crítica/terapia , Fenómenos Electromagnéticos , Endoscopía Gastrointestinal/métodos , Nutrición Enteral/métodos , Yeyuno , Adulto , Anciano , Intervalos de Confianza , Nutrición Enteral/instrumentación , Femenino , Humanos , Unidades de Cuidados Intensivos , Intubación Gastrointestinal/instrumentación , Intubación Gastrointestinal/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Valores de Referencia , Medición de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE To evaluate the impact of real-time continuous glucose monitoring (CGM) on glycemic control and risk of hypoglycemia in critically ill patients. RESEARCH DESIGN AND METHODS A total 124 patients receiving mechanical ventilation were randomly assigned to the real-time CGM group (n = 63; glucose values given every 5 min) or to the control group (n = 61; selective arterial glucose measurements according to an algorithm; simultaneously blinded CGM) for 72 h. Insulin infusion rates were guided according to the same algorithm in both groups. The primary end point was percentage of time at a glucose level <110 mg/dl. Secondary end points were mean glucose levels and rate of severe hypoglycemia (<40 mg/dl). RESULTS Percentage of time at a glucose level <110 mg/dl (59.0 +/- 20 vs. 55.0 +/- 18% in the control group, P = 0.245) and the mean glucose level (106 +/- 18 vs. 111 +/- 10 mg/dl in the control group, P = 0.076) could not be improved using real-time CGM. The rate of severe hypoglycemia was lower in the real-time CGM group (1.6 vs. 11.5% in the control group, P = 0.031). CGM reduced the absolute risk of severe hypoglycemia by 9.9% (95% CI 1.2-18.6) with a number needed to treat of 10.1 (95% CI 5.4-83.3). CONCLUSIONS In critically ill patients, real-time CGM reduces hypoglycemic events but does not improve glycemic control compared with intensive insulin therapy guided by an algorithm.
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Glucemia/análisis , Sistemas de Computación , Enfermedad Crítica/terapia , Monitoreo Fisiológico/métodos , Adulto , Anciano , Algoritmos , Glucemia/metabolismo , Femenino , Humanos , Hipoglucemia/etiología , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/instrumentación , Respiración Artificial , RiesgoRESUMEN
PURPOSE: Hypoxic hepatitis (HH) is a frequent cause of acute hepatocellular damage at the intensive care unit. Although mortality is reported to be high, risk factors for mortality in this population are unknown. METHODS: One-hundred and seventeen consecutive patients with HH were studied prospectively at three medical intensive care units of a university hospital. RESULTS: The main causes of hypoxic hepatitis were low cardiac output and septic shock, and most patients (74%) had more than one underlying factor. Peak aspartate transaminase (P = 0.02), lactate dehydrogenase (P = 0.03), INR (P < 0.001) and lactate (P < 0.01) were higher in non-survivors. Prolonged duration of HH caused higher overall mortality rate (P = 0.03). INR > 2 (P = 0.02), septic shock (P = 0.01) and SOFA score >10 (P = 0.04) were risk factors of mortality in the regression model. CONCLUSIONS: Hypoxic hepatitis is the consequence of multiorgan injury. Outcome is influenced by the severity of liver impairment and the etiology and severity of the basic disease.
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Hepatitis/mortalidad , Hipoxia/mortalidad , Anciano , Austria/epidemiología , Enfermedad Crítica/mortalidad , Femenino , Hepatitis/etiología , Hepatitis/fisiopatología , Hospitales Universitarios , Humanos , Hipoglucemia , Hipoxia/etiología , Hipoxia/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Choque SépticoRESUMEN
OBJECTIVE: To compare the success rate of correct jejunal placement of a new self-advancing jejunal tube with the gold standard, the endoscopic guided technique, in a comparative intensive care unit (ICU) patient population. DESIGN: Prospective, randomized study. SETTING: Two medical ICUs at a university hospital. PATIENTS: Forty-two mechanically ventilated patients with persisting intolerance of intragastric enteral nutrition despite prokinetic therapy. METHODS: Patients were randomly assigned to receive an unguided self-advancing jejunal feeding tube (Tiger Tube) or an endoscopic guided jejunal tube (Freka Trelumina). Primary outcome measure was the success rate of correct jejunal placement after 24 h. RESULTS: Correct jejunal tube placement was reached in all 21 patients using the endoscopic guided technique whereas the unguided self-advancing jejunal tube could be placed successfully in 14 out of 21 patients (100% versus 67%; P = 0.0086). In the remaining seven patients, successful endoscopic jejunal tube placement was performed subsequently. Duration of tube placement was longer in the unguided self-advancing tube group (20 +/- 12 min versus 597 +/- 260 min; P < 0.0001). Secondary outcome parameters (complication rate, number of attempts, days in correct position with accurate functional capability, days with high gastric residual volume, length of ICU stay, ICU mortality) were not statistically different between the two groups. No potentially relevant parameter predicting the failure of correct jejunal placement of the self-advancing tube could be identified. CONCLUSIONS: Success rate of correct jejunal placement of the new unguided self-advancing tube was significantly lower than the success rate of the endoscopic guided technique.
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Endoscopía/normas , Nutrición Enteral/instrumentación , Yeyuno , Anciano , Endoscopía/métodos , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Respiración ArtificialRESUMEN
BACKGROUND & AIMS: Ionized ammonia (NH(3)) and partial pressure of the gaseous ammonia (pNH(3)) are associated with hepatic encephalopathy and intracranial hypertension in patients with acute liver failure; NH(3) is also believed to contribute to extrahepatic organ failure. We investigated whether the severity of organ failure was associated with intracranial hypertension and evaluated the correlation between NH(3) and pNH(3) and grade of hepatic encephalopathy. METHODS: In 87 patients with acute liver failure admitted to the intensive care unit, we simultaneously evaluated arterial ammonia, pNH(3), clinical grade of hepatic encephalopathy, the sequential organ failure assessment score (SOFA score), and evidence of intracranial hypertension. RESULTS: In comparing patients with intracranial hypertension (n = 37) with patients without intracranial hypertension (n = 50), the highest NH(3) and pNH(3) levels and SOFA scores before onset of intracranial hypertension were independent predictors of intracranial hypertension (P < .001). Among patients with NH(3) levels less than 146 mumol/L, those with intracranial hypertension had a higher SOFA score than those without intracranial hypertension (median, 10 vs 5.5; P = .004), despite the patients' similar levels of NH(3). NH(3) (r = 0.68, P < .0001) and pNH(3) (r = 0.78, P < .0001) both correlated with grade of hepatic encephalopathy. However, in multiple regression analysis, only pNH(3) (P < .0001) was shown to be a significant independent parameter for predicting grade of hepatic encephalopathy (P = .27). CONCLUSIONS: SOFA score and ammonia levels are independent predictors of intracranial hypertension. In patients with acute liver failure admitted to the intensive care unit, pNH(3) level is a better predictor of clinical grade of hepatic encephalopathy than arterial NH(3) level.
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Amoníaco/sangre , Encefalopatía Hepática/fisiopatología , Hipertensión Intracraneal/fisiopatología , Fallo Hepático Agudo/complicaciones , Insuficiencia Multiorgánica/fisiopatología , APACHE , Adulto , Amoníaco/toxicidad , Femenino , Encefalopatía Hepática/sangre , Encefalopatía Hepática/etiología , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Hipertensión Intracraneal/sangre , Hipertensión Intracraneal/etiología , Fallo Hepático Agudo/sangre , Fallo Hepático Agudo/fisiopatología , Masculino , Persona de Mediana Edad , Presión Parcial , Valor Predictivo de las Pruebas , Factores de Riesgo , Índice de Severidad de la Enfermedad , Adulto JovenRESUMEN
OBJECTIVE: To evaluate the impact of circulatory shock requiring norepinephrine therapy on the accuracy and reliability of a subcutaneous continuous glucose monitoring system (CGMS) in critically ill patients. DESIGN AND SETTING: A prospective, validation study of a medical intensive care unit at a university hospital was carried out. METHODS: Continuous glucose monitoring was performed subcutaneously in 50 consecutive patients on intensive insulin therapy (IIT), who were assessed according to the a priori strata of circulatory shock requiring norepinephrine therapy or not. RESULTS: A total of 736 pairs of sensor glucose (SG)/blood glucose (BG) values were analysed (502 without and 234 with norepinephrine therapy). For all values, repeated measures Bland-Altman analysis showed a mean difference of 0.08 mmol/l (limits of agreement: -1.26 and 1.43 mmol/l). Circulatory shock requiring norepinephrine therapy did not influence the relation of arterial BG with SG in a multivariable random effects linear regression analysis. The covariates norepinephrine dose, body mass index (BMI), glucose level and severity of illness also had no influence. Insulin titration grid analysis showed that 98.6% of the data points were in the acceptable treatment zone. No data were in the life-threatening zone. CONCLUSIONS: Circulatory shock requiring norepinephrine therapy, as well as other covariates, had no influence on the accuracy and reliability of the CGMS in critically ill patients.
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Glucemia/análisis , Sistemas de Infusión de Insulina , Norepinefrina/uso terapéutico , Choque/tratamiento farmacológico , Vasoconstrictores/uso terapéutico , Anciano , Anciano de 80 o más Años , Índice de Masa Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Choque/fisiopatologíaAsunto(s)
Fibrilación Atrial/mortalidad , Hiperglucemia/mortalidad , Infarto del Miocardio/mortalidad , Estrés Fisiológico/fisiología , Fibrilación Atrial/etiología , Mortalidad Hospitalaria , Humanos , Hiperglucemia/tratamiento farmacológico , Hiperglucemia/etiología , Insulina/uso terapéutico , Factores de RiesgoRESUMEN
BACKGROUND: Strict glycemic control in critically ill patients is challenging for both physicians and nurses. OBJECTIVES: To determine the effect of focused education of intensive care staff followed by implementation of a glucose control protocol. METHODS: A prospective observational study in a medical intensive care unit in a university hospital. After intensive education of nurses and physicians, a glucose control protocol with a nurse-managed insulin therapy algorithm was developed and implemented. Every measured blood glucose value and insulin dose per hour and per day were documented in 36 patients before and 44 patients after implementation of the protocol. RESULTS: Median blood glucose levels decreased after implementation of the protocol (133 vs 110 mg/dL; P < .001). The amounts of time when patients' blood glucose levels were less than 110 mg/dL and less than 150 mg/dL increased after implementation of the protocol (8% vs 44%; 75% vs 96%; P<.001). The median use of insulin increased after implementation of the protocol (28 vs 35 IU/day; P=.002). Diabetic patients had higher median blood glucose levels than did nondiabetic patients both before (138 vs 131 mg/dL) and after (115 vs 108 mg/dL; P<.001) implementation, although median insulin use also increased (before implementation, 33 vs 26 IU/day; P=.04; after implementation, 46 vs 30 IU/day; P < .001). CONCLUSIONS: Use of a collaboratively developed glucose control protocol led to decreased median blood glucose levels and to longer periods of normoglycemia. Despite increased insulin use, glucose control was worse in diabetic patients.
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Protocolos Clínicos , Enfermedad Crítica , Hiperglucemia/prevención & control , Capacitación en Servicio , Insulina/uso terapéutico , Anciano , Algoritmos , Austria , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Cuerpo Médico de Hospitales/educación , Persona de Mediana Edad , Relaciones Enfermero-Paciente , Personal de Enfermería en Hospital/educación , Estudios ProspectivosRESUMEN
OBJECTIVES: Voriconazole is a new triazole antifungal agent that is frequently used in intensive care patients with severe fungal infections. Continuous venovenous haemodiafiltration (CVVHDF) is an important extracorporal renal replacement therapy in critically ill patients suffering from severe infections and multiple organ failure. This study investigates the pharmacokinetics of voriconazole in anuric patients undergoing CVVHDF. PATIENTS AND METHODS: Pharmacokinetic analysis was performed in nine intensive care patients-one of them with liver cirrhosis-with suspected or proven fungal infection and acute renal failure undergoing CVVHDF who received voriconazole intravenously. The concentration of voriconazole in serum and ultradiafiltrate was determined by HPLC. RESULTS: Mean peak pre-filter voriconazole concentration in eight patients without cirrhosis was 5.9 +/- 2.9 mg/L and mean pre-filter trough level was 1.1 +/- 0.3 mg/L. Mean elimination half-life, mean volume of distribution, mean AUC(0-12) and mean sieving coefficient were 14.7 +/- 6.5 h, 228 +/- 42 L, 22.4 +/- 3.7 mg.h/L and 0.56 +/- 0.16, respectively. The total clearance was 12.9 +/- 6.7 L/h and the clearance via CVVHDF was 1.1 +/- 0.3 L/h. In the patient with liver cirrhosis, elimination half-life, volume of distribution, AUC(0-12) and sieving coefficient were 52 h, 301 L, 19.8 mg.h/L and 0.31, respectively. CONCLUSIONS: Voriconazole should be given without a dosage adaptation in critically ill patients without liver cirrhosis undergoing CVVHDF. However, according to results in one patient, reduction of the maintenance dosing regimen of voriconazole seems to be meaningful in patients with liver cirrhosis.
Asunto(s)
Antifúngicos/farmacocinética , Hemodiafiltración , Pirimidinas/farmacocinética , Triazoles/farmacocinética , Lesión Renal Aguda , Adulto , Anciano , Antifúngicos/sangre , Área Bajo la Curva , Enfermedad Crítica , Femenino , Semivida , Humanos , Masculino , Persona de Mediana Edad , Micosis/prevención & control , Pirimidinas/sangre , Triazoles/sangre , VoriconazolRESUMEN
BACKGROUND & AIMS: The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, arterial deoxygenation, and widespread pulmonary vasodilatation. Hypoxic hepatitis, also known as ischemic hepatitis, is the leading cause of acute liver impairment in hospitals. It is unknown whether HPS occurs in hypoxic hepatitis. We assessed the prevalence and clinical consequences of HPS in patients with hypoxic hepatitis. METHODS: Forty-four patients with hypoxic hepatitis were screened prospectively for HPS using established criteria: (1) presence of hepatic disease, (2) increased alveolar-arterial difference for the partial pressure of oxygen greater than the age-related threshold, and (3) intrapulmonary vasodilatation detected via contrast-enhanced echocardiography. Sixty-two critically ill patients with different cardiopulmonary diseases but without hepatic disease were screened for prevalence of intrapulmonary vasodilatation as a control group. RESULTS: Criteria of HPS were fulfilled in 18 patients with hypoxic hepatitis. HPS-positive patients had a significantly decreased partial pressure of arterial oxygen (P = .001) and partial pressure of arterial oxygen/fraction of inspired oxygen ratio (P = .034) at the time of diagnosis of HPS, a significant decreased area under the curve of the partial pressure of arterial oxygen/fraction of inspired oxygen ratio during the first 48 hours after diagnosis of hypoxic hepatitis (P = .009), and a significantly increased peak serum aspartate transaminase level (P = .028), compared with patients without HPS. Complete resolution of intrapulmonary vasodilatation was observed during follow-up evaluation. Contrast-enhanced echocardiography was negative for intrapulmonary vasodilatation in all 62 control patients. CONCLUSIONS: Intrapulmonary vasodilatation indicating HPS frequently occurs in patients with hypoxic hepatitis. It is reversible after normalization of the hepatic dysfunction. Clinicians should consider intrapulmonary vasodilatation and HPS in patients with hypoxic hepatitis.