Is 10 min post heparin bolus ACT, alongside aPTT monitoring, predictive for CRRT filter survival?

OBJECTIVE: When using heparin anticoagulation for continuous renal replacement therapy (CRRT), the main challenge is to tailor the dosage to patient response. This study aimed to determine if the first activated thromboplastin time (aPTT) (measured after 3 hours post heparin bolus) can be a predictor for CRRT filter survival and if the first activated clotting time-low range (ACT-LR) (10 min post heparin bolus) can be predictive for subtherapeutic or therapeutic first aPTT. MATERIALS AND METHODS: An unfractionated heparin (UF) anticoagulation protocol was used in CRRT and heparin monitoring was performed by aPTT and ACT-LR. Extracorporeal therapy was analyzed and filter survival was assessed for general risk factors, especially coagulation tests. For statistical analysis, Logrank tests, ROC curve analysis, and the Kaplan-Meier chart for survival evaluations were utilized. RESULTS: Using the pLogrank test, the overall survival for the CRRT procedure was 47.8 hours (p=0.04), and no clotting events occurred during the first 12 hours for all examined therapies. Multivariate analysis for filter survival prediction to estimate 48 hours of CRRT revealed statistical relevance for Age (<60 years), BMI (<25.9), and INR (>1.3), with negative statistical significance for lipids, triglycerides, and fibrinogen. aPTT (180 min) values greater than 57 sec were shown to be predictive of 48-hour filter survival, and similar findings were obtained for aPTT measured at 6 hours. ACT-LR samples assessed 10 minutes after the initial heparin bolus was shown to be predictive of 48-hour filter survival (cutoff > 218 sec; p=0.04). When ACT prediction potential for therapeutic aPTT values was evaluated, ACT-LR 10 min (cut off > 200 sec.), ACT-LR 60 min (cut off > 186 sec.), and ACT-LR 180 min (cut off > 182 sec.) were found to be predictive. CONCLUSIONS: Based on this study and its sample size, ACT-LR can be a complimentary assessment to aPTT for monitoring anticoagulation with heparin on CRRT.

sTREM-1, sIL-2Rα, and IL-6, but not sCD163, might predict sepsis in polytrauma patients: a prospective cohort study.

BACKGROUND: To investigate whether sTREM-1, sIL-2Rα, sCD163, and IL-6 predict septic complications following polytrauma. Prospective observational study in a university hospital intensive care unit. METHODS: Blood samples were drawn on admission, 24 and 48 h after the injury from 64 adult polytrauma patients. The occurence of infectious complications was investigated. The sepsis-free rates for the multiple trauma patients were considered as end points in the Kaplan-Meier plot analysis. RESULTS: Upon admission, sIL-2Rα mean values were higher in the T group compared to the T&S patients (1789 ± 1027 pg/mL versus 1280 ± 605 pg/mL, p = 0.02). The initial mean values of sTREM-1, IL-6, and sCD163 did not discriminate between the T and T&S groups patients (p > 0.05). sTREM-1 cutoff was 62 pg/mL: the sepsis-free rates differed significantly between the patients with sTREM-1 concentrations lower and higher than the cutoff (80 versus 48 %, p < 0.01). From the patients with serum sIL-2Rα ≥1593 pg/mL, 86 % did not present sepsis; for sIL-2Rα values in the range 946-1593 pg/mL, the sepsis-free rate was 68 %, while from the patients with sIL-2Rα <945 pg/mL, only 40 % remained sepsis-free (p = 0.05). sCD163 cutoff of 1000 ng/mL did not discriminate between the patients (76 versus 64 %, p = 0.28). For IL-6, the sepsis-free rates differed significantly between the patients with concentrations lower and higher than 400 pg/mL (78 versus 38 %, p < 0.01). CONCLUSIONS: sTREM-1, sIL-2Rα, and IL-6, but not CD163, may be used as prognostic markers for the occurrence of sepsis in multiple trauma patients. LEVEL OF EVIDENCE: Level II-Diagnostic tests and criteria.

Maximum non-reactive concentration of midazolam and ketamine for skin testing study in non-allergic healthy volunteers.

The objective of our study was to determine the maximal non-reactive concentrations for midazolam and ketamine in healthy volunteers using both prick and intradermal skin tests. Twenty-one healthy Caucasian volunteers were tested for midazolam and ketamine using more clustered concentrations (identical for both prick and intradermal tests) than those resulting from decimal dilutions. The criteria for positivity were based on dilutions of drugs that cause wheal and flare reactions in subjects without history of allergy. For the prick method, the concentrations that did not produce wheal and flare were 1 mg/ml for midazolam and 10 mg/ml for ketamine. For intradermal tests, using serial dilutions, we found that the highest concentration for which the subjects did not pass the positivity criteria was 0.25 mg/ml for both drugs.

[Nutrition in infants with esophagocolonoplasty for esophageal atresia and tracheoesophageal fistula]. / Nutritia copilului mic cu esofagocoloplastie pentru atrezie esofagiana asociata cu fistula esotraheala.

The aim of this clinical prospective study was the follow up of a nutritional management protocol for children with esophageal atresia and tracheoesophageal fistula for whom the esophageal substitution was performed with left vascularized colon. In this study entered infants aged 3 months to 18 months old with a major nutritional deficit, due to respiratory infections complications, parastomal leaks and accelerated gastrointestinal transit. All infants were underweight, with a single exception, who had no preoperative complications. The patient was enterally fed postoperatively, all the other patients receiving combined enteral and parenteral nutrition for 5-6 days. The enteral nutrition was delivered early through a trans-anastomotic feeding tube. In the 5th-7th day, complete enteral nutrition was obtained. The parenteral nutrition followed our own recipe: a 10% amino-acid mixture, 50% glucose and Ringer plus electrolytes and vitamins. There was a critical transitional stage between the gastric tube feeding and the oral nutrition. These infants have the suction and the deglutition reflexes modified, followed by oral sensory and motor deficits. After the release from the hospital the patients have been surveyed, the oldest reaching now the age of 7. The earlier the reconstruction was performed, the less problems in oral nutrition were encountered.

Heterozygous protein C deficiency and coumarin necrosis of the skin.

An obese female patient aged 47 with a personal and familial history of recurrent venous thrombosis, who developed a coumarin-induced skin necrosis is presented. Laboratory investigations, performed three months after the acute event and in absence of coumarin therapy, emphasized a decreased anticoagulant activity of her plasma protein C (50% of the normal). These results as well as the high incidence of thrombotic disease in her relatives point to a familial heterozygous protein C deficiency. The antithrombotic role of the protein C system and the mechanism of coumarin induced necrosis of the skin are briefly discussed.