Septic shock and the use of norepinephrine in an intermediate care unit: Mortality and adverse events.

BACKGROUND: Septic shock is associated with high mortality. Aged and multimorbid patients are not always eligible for intensive care units. Norepinephrine is an accepted treatment for hypotension in septic shock. It is unknown whether norepinephrine has a place in treatment outside an intensive care unit and when given peripherally. OBJECTIVES: To describe mortality, Acute Physiology And Chronic Health Evaluation (APACHE-II), time to mean arterial pressure >65 mmHg, and adverse events in patients with septic shock receiving norepinephrine peripherally in an intermediate care unit. METHODS: From a retrospective chart review of 91 patients with septic shock treated with norepinephrine for hypotension, ward mortality, 30-, 60- and 90-day mortality, standardized mortality ratio (SMR) and adverse events (necrosis and arrhythmia) were analysed. Administration route via peripheral venous catheter or central venous catheter was registered. RESULTS: Median age was 81 (43-96) years and median APACHE-II score was 26 (12-42). Observed ward mortality was 27.5% (SMR 0.443, 95% CI: 0.287-0.654), and 30-day and 90-day mortality were 47.2% and 58.2%, respectively. CONCLUSIONS: Elderly patients with septic shock treated with norepinephrine displayed a better survival in the ward and at 30 days than expected. Our retrospective study did not indicate frequent complications when administering norepinephrine via a peripheral venous catheter.

[Hypernatremia - common condition in critical illness associated with high mortality. But the treatment arsenal is inadequate]. / Hypernatremi ­ vanligt tillstånd vid kritisk sjukdom associerat med hög mortalitet - Men behandlingsarsenalen är otillräcklig.

Hypernatremia in ICU is common, both as a preexisting condition and acquired during intensive care. Hypernatremia increases mortality and morbidity as an increased length of a stay and increased risk of complications. Current treatment options of manifest hypernatremia are limited, but there are opportunities for prevention that should not be overlooked.

Lactate clearance predicts outcome after major trauma

Introduction:To determine a correlation between lactate clearance within 48h and survival in trauma patients at a Level I trauma centre in a developing country and compare to previous international lactate clearance studies.Methods:We conducted a retrospective study of a prospectively collected database at a Level I trauma centre from March 2007 to November 2010. Patients of all ages were included. Metabolic parameters from initial arterial blood gas were measured in all patients; an abnormal lactate beindefined as 2.5mmol/L. A subgroup analysis of blunt versus penetrating injury was performed. Results:Of the 657 patients in the database; 493 had complete lactate data. The survival rate of patients with lactate values 2.5mmol/L was 88. Of the patients with high lactate levels that cleared within 24 and 48h the survival rates were 81 and 71; respectively. The survival rate amongst patients not achieving a normal lactate within 48h was 46 but was higher in those with penetrating as opposed to blunt injury (67 versus 38). The overall survival was 81.Conclusion:The present results confirm previous studies showing that prolonged lactate clearance predicts increased mortality in severely injured trauma patients. Thus; the measurements of arterial serum lactate trends are simple and effective predictors of outcome

Hypoventilation does not explain the impaired quality of sleep in postpolio patients ventilated noninvasively vs. invasively.

In a previous study, it was found that patients treated with noninvasive ventilation (NIV) reported larger dysfunctions in sleep-related parameters as assessed with the Sickness Impact Profile (SIP) and Health Index questionnaires than those treated with tracheostomy. The aim of the current study was to further evaluate these sleep limitations and relate these limitations to blood gas analyses in the groups to investigate, if the differences could be related to differences in the efficacy of ventilation. We compared postpolio patients treated with tracheostomy (PPT, n = 17), NIV (PPN, n = 14) and patients with neuromuscular disorders treated with NIV (NMN, n = 15). Significantly fewer patients in the PPT group scored large dysfunctions in the SIP sleep (SIP score >10 points) compared with the PPN and NMN patients. The PPT patients scored significantly higher regarding quality of sleep and less sense of tiredness than the PPN and NMN patients. No differences were found between the groups regarding blood gas parameters neither before nor during or after the study period. In conclusion, postpolio patients treated with invasive home mechanical ventilation seem to experience better sleep and less sense of tiredness than patients on NIV. These differences cannot be explained by differences in alveolar ventilation as assessed with blood gas analyses.

Synthesis rates of total liver protein and albumin are both increased in patients with an acute inflammatory response.

The general perception that catabolism and inflammation are associated with a high synthesis rate of total liver protein and a low albumin synthesis rate has been challenged in recent years by several studies in man, indicating that the synthesis rate of albumin in response to a catabolic insult is increased rather than decreased. Thus changes in liver protein synthesis rates in conjunction with catabolism and acute inflammation in man need to be characterized better. The aim of the present study was to measure protein synthesis rates of total liver protein and albumin during a state of acute inflammation. Patients (n = 10) undergoing acute laparoscopic cholecystectomy due to acute cholecystitis were investigated. FSRs (fractional synthesis rates) of total liver protein (liver biopsy specimens) and albumin (plasma samples) were investigated as early as possible during the surgical procedure, using a flooding dose of L-[2H5]phenylalanine. The results were compared with a reference group of patients without cholecystitis undergoing elective laparoscopic cholecystectomy (n = 17). FSR of total liver protein was 60% higher (P < 0.001) and the FSR of albumin was 45% higher (P < 0.01) in the cholecystitis patients compared with the control group. In conclusion, the synthesis rates of total liver protein and albumin are both increased in patients with an acute general inflammatory reaction undergoing laparoscopic cholecystectomy.

The synthesis rate of albumin decreases during laparoscopic surgery.

In previous studies, a decline in total liver protein synthesis during elective laparoscopic surgery has been observed. However, when albumin synthesis was measured in parallel no apparent influence of the procedure was detected. The aim of the present study was to specifically investigate the effect of a laparoscopic procedure on albumin synthesis. Female (n = 9) patients scheduled for elective laparoscopic cholecystectomy as a consequence of cholecystolithiasis were investigated. The fractional synthesis rate (FSR) of albumin was investigated twice in each patient, before and during surgery (2-3 h apart), employing L-[2H5]phenylalanine and gas chromatography mass spectrometry. The FSR of albumin decreased from 7.3 +/- 1.2% per day before surgery to 6.2 +/- 1.4% per day during the procedure (P<0.01), whereas the corresponding absolute synthesis rates of albumin decreased from 114 +/- 24 to 86 +/- 16 mg kg(-1) day(-1), respectively (P<0.001). In conclusion, the synthesis rate of albumin decreased during a laparoscopic surgery procedure. However, the characteristics for this decrease differ from those previously observed for total liver protein synthesis.

Albumin synthesis in humans increases immediately following the administration of endotoxin.

In order to investigate the immediate (i.e. within 3 h) response of albumin synthesis to the administration of endotoxin, as a model of a moderate and well controlled catabolic insult, two measurements employing L-[(2)H(5)]phenylalanine were performed in 16 volunteers. One group ( n =8) received an intravenous injection of endotoxin (4 ng/kg; lot EC-6) immediately after the first measurement of albumin synthesis, whereas the other group received saline. A second measurement was initiated 1 h later. In the endotoxin group, the fractional synthesis rate of albumin was 6.9+/-0.6%/day (mean+/-S.D.) in the first measurement. In the second measurement, a significant increase was observed (9.6+/-1.2%/day; P <0.001). The corresponding values in the control group were were 6.6+/-0.6%/day and 7.0+/-0.6%/day respectively (not significant compared with first measurement and P <0.001 compared with the second measurement in the endotoxin group). The absolute synthesis rates of albumin were 148+/-35 and 201+/-49 mg x kg(-1) x day(-1) before and after endotoxin ( P <0.01). In the control group, the corresponding values were 131+/-21 and 132+/-20 mg x kg(-1) x day(-1) (not significant compared with the first measurement and P <0.01 compared with the second measurement in the endotoxin group). In conclusion, these results indicate that albumin synthesis increases in the very early phase after a catabolic insult, as represented by the administration of endotoxin.