Feasibility of endovascular and surface cooling strategies in acute stroke.

BACKGROUND: Therapeutic hypothermia (TH) is a promising treatment of stroke, but limited data are available regarding the safety and effectiveness of cooling methodology. We investigated the safety of TH and compared the cooling capacity of two widely used cooling strategies - endovascular and surface cooling. METHODS: COOLAID Oresund is a bicentre randomized trial in Copenhagen (Denmark) and Malmö (Sweden). Patients were randomized to either TH (33°C for 24 h) in a general intensive care unit (ICU) or standardized stroke unit care (control). Cooling was induced by a surface or endovascular-based strategy. RESULTS: Thirty-one patients were randomized. Seven were cooled using endovascular and 10 using surface-based cooling methods and 14 patients received standard care (controls). 14 (45%) patients received thrombolysis. Pneumonia was recorded in 6 (35%) TH patients and in 1 (7%) control. 4 TH patients and 1 control developed massive infarction. 1 TH patient and 2 control suffered asymptomatic haemorrhagic transformation. Mortality was comparable with 2 (12%) in the TH group and 1 (7%) among controls. Mean (SD) duration of hospital stay was 25.0 days (24, 9) in TH and 22.5 days (20.6) in control patients (P = 0.767). Mean (SD) induction period (cooling onset to target temperature) was 126.3 min (80.6) with endovascular cooling and 196.3 min (76.3) with surface cooling (P = 0.025). CONCLUSIONS: Therapeutic hypothermia with general anaesthesia is feasible in stroke patients. We noticed increased rates of pneumonia, while the length of hospital stay remained comparable. The endovascular cooling strategy provides a faster induction period than surface cooling.

Scandinavian glutamine trial: a pragmatic multi-centre randomised clinical trial of intensive care unit patients.

BACKGROUND: Low plasma glutamine concentration is an independent prognostic factor for an unfavourable outcome in the intensive care unit (ICU). Intravenous (i.v.) supplementation with glutamine is reported to improve outcome. In a multi-centric, double-blinded, controlled, randomised, pragmatic clinical trial of i.v. glutamine supplementation for ICU patients, we investigated outcomes regarding sequential organ failure assessment (SOFA) scores and mortality. The hypothesis was that the change in the SOFA score would be improved by glutamine supplementation. METHODS: Patients (n=413) given nutrition by an enteral and/or a parenteral route with the aim of providing full nutrition were included within 72 h after ICU admission. Glutamine was supplemented as i.v. l-alanyl-l-glutamine, 0.283 g glutamine/kg body weight/24 h for the entire ICU stay. Placebo was saline in identical bottles. All included patients were considered as intention-to-treat patients. Patients given supplementation for >3 days were considered as predetermined per protocol (PP) patients. RESULTS: There was a lower ICU mortality in the treatment arm as compared with the controls in the PP group, but not at 6 months. For change in the SOFA scores, no differences were seen, 1 (0,3) vs. 2 (0.4), P=0.792, for the glutamine group and the controls, respectively. CONCLUSION: In summary, a reduced ICU mortality was observed during i.v. glutamine supplementation in the PP group. The pragmatic design of the study makes the results representative for a broad range of ICU patients.

Decreases in myocardial glucose and increases in pyruvate but not ischaemia are observed during porcine endotoxaemia.

BACKGROUND: Myocardial dysfunction occurs commonly in septic shock. It is not known whether this is due to local ischaemia and metabolic disturbances. Our hypothesis was that endotoxaemic myocardial dysfunction may be associated with interstitial ischaemic and metabolic changes, measured using interstitial microdialysis (MD). METHODS: Eighteen pigs were randomized to control (n=6) or endotoxin infusion (n=12). MD catheters were inserted into the myocardium for measurement of interstitial glucose, pyruvate and lactate concentrations. Plasma glucose and lactate concentrations and systemic haemodynamic parameters were measured simultaneously. RESULTS: Compared with the control group, the endotoxaemic animals had significantly decreased left ventricular stroke work and venous oxygen saturation (SvO2), and increased mean pulmonary artery pressure and plasma lactate. In the endotoxaemic group, decreases in interstitial glucose were observed, occurring simultaneously with increases in interstitial pruvate. Interstitial lactate: pyruvate ratios decreased with time in all animals. CONCLUSIONS: Despite severe systemic and pulmonary haemodynamic changes, interstitial MD measurements revealed no evidence of anaerobic metabolism in the myocardium of endotoxaemic pigs. There were, however, changes in glucose and pyruvate concentrations, suggesting local energy metabolic disturbances.

Confusion assessment method for the intensive care unit (CAM-ICU): translation, retranslation and validation into Swedish intensive care settings.

BACKGROUND: Becoming critical ill or severely injured leads to a process of worry, anxiety and pain. Patients in intensive care sometimes have strange and frightening experiences and may show symptoms of acute confusion or delirium. CAM-ICU, the confusion assessment method for the intensive care unit, was based on the DSM IV, the Diagnostic and Statistic Manual of Mental Disorders IV, and today, healthcare professionals and researchers are increasingly accepting this concept of diagnosing ICU delirium. In Sweden, there is no commonly used, single instrument or method to test the development of ICU delirium. The aim of this study was to translate, retranslate and validate CAM-ICU for use in Swedish ICU settings. METHODS: The translation of the instrument was done according to the guidelines suggested by The Translation and Cultural Adaptation group which includes preparation, forward translation/reconciliation, back translation, back translation review, harmonization, cognitive debriefing and validation. In the validation process, the applicability of the Swedish version of the instruments was tested in a Swedish intensive care unit. RESULTS: Fourteen adult patients were included in the study, 40 paired tests were carried out, and 80 CAM-ICU instruments were completed. The participating patients were given CAM-ICU ratings using independent paired evaluations by two nurses, specialized in intensive care, at least twice during the patients' stay in the ICU. Interrater reliability was calculated using kappa statistics. In the 40 paired observations, interrater reliability was 'very good' (kappa statistics > 0.81). In our material, we recognized a delirium rate of 48%, which is in accordance with previous studies. CONCLUSION: The translation of the instrument CAM-ICU showed good correlation with the original version and could therefore be applicable in a Swedish ICU setting. In the 40 paired observations, interrater reliability was very good. Although there are limitations in using CAM-ICU, previous studies reveal a need for a homogeneous screening instrument making it possible to detect and determine ICU delirium; and from this basis are able to implement and make the necessary decisions required in medical and nursing care practice preventing ICU delirium.

Extrication of entrapped victims from motor vehicle accidents: the crew concept.

During the extrication process the trauma victim is at high risk for additional injuries or aggravation of existing lesions. Improper handling during extrication with poor concern and knowledge of the ongoing resuscitation process may increase the time spent at the scene and expose the patient to unnecessary risks. Earlier studies report a significant number of neurological injuries that appear to be a result of the extrication process, or of inadequate immobilization during transport. Recent work also underlines the need for appropriate and situation adapted Advanced Life Support (ALS) procedures to improve outcome after prehospital trauma resuscitation. In this paper we present a method for training advanced extrication of trauma victims and the results obtained after five consecutive courses. The training focuses on enhanced liaison between medical and technical team members to optimize synchronization of operations. The course consists of both theoretical lectures and practical training in different crash scenarios. The complexity of the scenarios increases throughout the course and different extrication techniques and strategies are practised. Both the times to extrication and on-scene times were reduced during the 3-day course. Therapeutic interventions and handling of the patient were also improved, in terms of early recognition of medical and technical risks and reduction of the time of no therapy.

Cytokine response after acute hyperbaric exposure in the rat.

Intravascular gas has earlier been shown to activate leukocytes and platelets, enhance cell adhesion, and promote secretion of vasoactive substances from platelets. Since decompression is known to release gas bubbles in the bloodstream, the present study was undertaken to investigate the effect of a standardized decompression trauma on inflammatory mediators. Two series of experiments were performed in which male Wistar rats were subjected to a sublethal decompression trauma using a dry pressure chamber. Postdive measurements of cytokine levels were performed to look for signs of an inflammatory reaction. All animals subjected to a decompression trauma showed postdive signs of mild to severe decompression illness (DCI) and measurements of interleukin-6 (IL-6) indicated a postdive increase in the majority of these animals. Our finding of a postdive increase in IL-6 suggests that an inflammatory response, probably created by a blood-gas interface, may be a factor in the process leading to DCI.

Complement system response to decompression.

A role for the activated complement system in the pathogenesis of decompression sickness has recently been suggested. In this study we aimed at evaluating the response of the complement system to decompression in 24 human volunteers. A significant reduction was observed in the levels of iC3, which is a conformationally changed form of the third complement component (C3), and C3A after decompression (P < 0.001). The levels of total C3 did not change during the experiment. A relatively mild decompression has thus led to a distinct change in the complement activation profile in human volunteers.