Protein and micronutrient deficiencies in patients with radiation cystitis and outcome after hyperbaric oxygen therapy.

BACKGROUND & AIMS: Haemorrhagic radiation cystitis (HRC) is a late complication of pelvic radiotherapy. Severe cases are difficult to treat due to persistent or recurrent bleeding, despite urological and hyperbaric oxygen therapy (HBOT). However, wound healing requires a good nutritional status. In this respect, we aimed at analysing the nutritional status of patients with HRC prior to the onset of HBOT and at highlighting predictive nutritional factors of outcome. METHODS: Data were retrospectively collected from a cohort of 179 patients with HRC (between 2011 and 2015). Haematuria was graded according to the Subjective, Objective, Management, Analytic scale (SOMA): grade-4 (n = 46) was compared with grade-3 (n = 56), and with grades 1 and 2 (n = 77). S-albumin, prealbumin, vitamins C, D and B6, zinc, selenium, and essential fatty acids were evaluated before HBOT. HBOT response was measured at 3 months according to the haematuria SOMA grade. The Mann-Whitney test, Fisher's exact test and principal-component analysis were used to compare groups. RESULTS: Patients with higher haematuria grades (3 and 4) harboured significant deficiencies in S-albumin, prealbumin, vitamins C, D and B6, zinc, selenium and essential fatty acids. Moreover, grade-4 patients without improvement after 3 months of HBOT had significant lower initial levels of S-albumin, vitamin C, selenium and linoleic acid. Vitamin C levels <2.5 mg/L were strongly associated with HBOT non-response (OR 23.14, 95% CI 3.73-143.69, p = 0.002). CONCLUSIONS: Our analyses show serious nutritional deficiencies associated with higher grades of HRC and worse prognoses. Patients with haemorrhagic cystitis might benefit from an adequate dietary supplementation to support healing of their bladder mucosa.

Causes and Characteristics of Death in Intensive Care Units: A Prospective Multicenter Study.

BACKGROUND: Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts. METHODS: An observational multicenter cohort study was performed in 96 intensive care units. During 1 yr, each intensive care unit was randomized to participate during a 1-month period. Demographic data, characteristics of organ failures (Sequential Organ Failure Assessment subscore greater than or equal to 3), and organ supports were collected on all patients who died in the intensive care unit. Modes of death were defined as anticipated (after withdrawal or withholding of treatment or brain death) or unexpected (despite engagement of full-level care or sudden refractory cardiac arrest). RESULTS: A total of 698 patients were included during the study period. At the time of death, 84% had one or more organ failures (mainly hemodynamic) and 89% required at least one organ support (mainly mechanical ventilation). Deaths were considered unexpected and anticipated in 225 and 473 cases, respectively. Compared to its anticipated counterpart, unexpected death occurred earlier (1 day vs. 5 days; P< 0.001) and had fewer organ failures (1 [1 to 2] vs. 1 [1 to 3]; P< 0.01) and more organ supports (2 [2 to 3] vs. 1 [1 to 2]; P< 0.01). Withdrawal or withholding of treatments accounted for half of the deaths. CONCLUSIONS: In a general intensive care unit population, the majority of patients present with at least one organ failure at the time of death. Anticipated and unexpected deaths represent two different modes of dying and exhibit profiles reflecting the different pathophysiologic underlying mechanisms.

Predicting preload responsiveness using simultaneous recordings of inferior and superior vena cavae diameters.

INTRODUCTION: Echocardiographic indices based on respiratory variations of superior and inferior vena cavae diameters (ΔSVC and ΔIVC, respectively) have been proposed as predictors of fluid responsiveness in mechanically ventilated patients, but they have never been compared simultaneously in the same patient sample. The aim of this study was to compare the predictive value of these echocardiographic indices when concomitantly recorded in mechanically ventilated septic patients. METHODS: Septic shock patients requiring hemodynamic monitoring were prospectively enrolled over a 1-year period in a mixed medical surgical ICU of a university teaching hospital (Toulouse, France). All patients were mechanically ventilated. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax - Dmin)/Dmax for ΔSVC and (Dmax - Dmin)/Dmin for ΔIVC, where Dmax and Dmin are the maximal and minimal diameters of SVC and IVC. Measurements were performed at baseline and after a 7-ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in cardiac index ≥15%) and nonresponders (increase in cardiac index <15%). RESULTS: Among 44 included patients, 26 (59%) patients were responders (R). ΔSVC was significantly more accurate than ΔIVC in predicting fluid responsiveness. The areas under the receiver operating characteristic curves for ΔSVC and ΔIVC regarding assessment of fluid responsiveness were significantly different (0.74 (95% confidence interval (CI): 0.59 to 0.88) and 0.43 (95% CI: 0.25 to 0.61), respectively (P = 0.012)). No significant correlation between ΔSVC and ΔIVC was found (r = 0.005, P = 0.98). The best threshold values for discriminating R from NR was 29% for ΔSVC, with 54% sensitivity and 89% specificity, and 21% for ΔIVC, with 38% sensitivity and 61% specificity. CONCLUSIONS: ΔSVC was better than ΔIVC in predicting fluid responsiveness in our cohort. It is worth noting that the sensitivity and specificity values of ΔSVC and ΔIVC for predicting fluid responsiveness were lower than those reported in the literature, highlighting the limits of using these indices in a heterogeneous sample of medical and surgical septic patients.

Integrated use of bedside lung ultrasound and echocardiography in acute respiratory failure: a prospective observational study in ICU.

BACKGROUND: It has been suggested that the complementary use of echocardiography could improve the diagnostic accuracy of lung ultrasonography (LUS) in patients with acute respiratory failure (ARF). Nevertheless, the additional diagnostic value of echocardiographic data when coupled with LUS is still debated in this setting. The aim of the current study was to compare the diagnostic accuracy of LUS and an integrative cardiopulmonary ultrasound approach (thoracic ultrasonography [TUS]) in patients with ARF. METHODS: We prospectively recruited patients consecutively admitted for ARF to the ICU of a university teaching hospital over a 12-month period. Inclusion criteria were age ≥ 18 years and the presence of criteria for severe ARF justifying ICU admission. We compared both LUS and TUS approaches and the final diagnosis determined by a panel of experts using machine learning methods to improve the accuracy of the final diagnostic classifiers. RESULTS: One hundred thirty-six patients were included (age, 68 ± 15 years; sex ratio, 1). A three-dimensional partial least squares and multinomial logistic regression model was developed and subsequently tested in an independent sample of patients. Overall, the diagnostic accuracy of TUS was significantly greater than LUS (P < .05, learning and test sample). Comparisons between receiver operating characteristic curves showed that TUS significantly improves the diagnosis of cardiogenic edema (P < .001, learning and test samples), pneumonia (P < .001, learning and test samples), and pulmonary embolism (P < .001, learning sample). CONCLUSIONS: This study demonstrated for the first time to our knowledge a significantly better performance of TUS than LUS in the diagnosis of ARF. The value of the TUS approach was particularly important to disambiguate cases of hemodynamic pulmonary edema and pneumonia. We suggest that the bedside use of artificial intelligence methods in this setting could pave the way for the development of new clinically relevant integrative diagnostic models.

Neuropsychological outcome after carbon monoxide exposure following a storm: a case-control study.

BACKGROUND: The cognitive consequences of carbon monoxide (CO) poisoning are well described. However, most studies have been carried out without an ad-hoc group of control subjects. The main aim of this study was to evaluate cognitive and psychiatric outcome after CO exposure during the storm Klaus in the South West of France (January 2009) in a homogeneous group of patients compared to a group of 1:1 paired controls. METHODS: Patients and controls were asked to fill out questionnaires about quality of life and cognitive complaints. They then underwent a cognitive assessment derived from the Carbon Monoxide Neuropsychological Screening Battery. Psychiatric assessment was performed using subtests of the Mini International Neuropsychiatric Interview. RESULTS: 38 patients and 38 paired controls were included (mean age 38.8 years) and evaluated 51 days after the poisoning. No difference was found between groups on the cognitive complaint questionnaire but patients had a lower quality of life than controls. Patients showed significantly lower cognitive performance than controls on processing speed, mental flexibility, inhibition and working and verbal episodic memories. Patients were more depressed than controls, and suffered more from post-traumatic stress disorder. CONCLUSIONS: We report the first study investigating cognitive and psychiatric outcome in consecutive patients after CO poisoning during a natural disaster, using a group comparison method. CO poisoning during storms needs to be dealt with adequately and clinicians should be aware of its possible consequences.

Oxygen challenge test in septic shock patients: prognostic value and influence of respiratory status.

Transcutaneous oxygen pressure (PtcO2) value in response to an increase of FiO2 or oxygen challenge test (OCT) in ventilated patients has been reported to be related to peripheral perfusion and outcome during septic shock. However, patients with sepsis-related acute respiratory distress syndrome could demonstrate compromised arterial oxygenation with OCT impairment decoupled to circulatory failure. The aims of this study were to confirm the prognostic value of OCT and to explore the influence of respiratory status on OCT results. This was a prospective study set in an intensive care unit of a tertiary teaching hospital. Fifty-six mechanically ventilated patients with septic shock criteria were studied. Transcutaneous oxygen pressure was measured at baseline and after OCT, at intensive care unit admittance (T0), and 24 h later (T24). Survival at day 28 and hemodynamic and respiratory parameters were analyzed and compared according to outcome and respiratory status. Central hemodynamic parameters or static transcutaneous data did not differ between survivors and nonsurvivors at enrollment. The OCT was statistically different at T24 according to outcome (P < 0.001), but sensitivity was low (53%). Moreover, patients with low OCT results at T24 exhibited more severe respiratory failure (P < 0.01). The OCT at T24 is related to outcome but is influenced by the severity of respiratory failure. Our results suggest considering with caution hemodynamic management based on OCT in septic shock patients with altered pulmonary function.

Guidewire localization by transthoracic echocardiography during central venous catheter insertion: a periprocedural method to evaluate catheter placement.

PURPOSE: To evaluate the feasibility of guidewire detection in right cardiac cavities by transthoracic echocardiography (TTE) in order to detect catheter misplacement and to optimize central venous catheter (CVC) positioning. Ultrasonic control for catheter tip positioning was compared to that by chest X-ray (CXR). METHODS: We conducted a monocentric prospective observational study (January-November 2010). All consecutive patients undergoing CVC insertion were included. The puncture was performed using the landmark method or ultrasound guidance. TTE was performed during the procedure to follow the arrival of the guidewire in the right cardiac cavities. Catheter misplacement was defined as an aberrant position on the postprocedural CXR (catheter positioning in ipsilateral or contralateral veins). The primary endpoint was the prediction of catheter misplacement by guidewire detection in the cardiac cavities. The secondary endpoint was the optimization of the catheter tip placement in the superior vena cava. RESULTS: A total of 98 patients received 101 CVC. The guidewire was visualized in 92 cases. In five cases, the guidewire was not seen in the right cardiac cavities and CXR showed catheter misplacement. In four cases, poor echogenicity led to the ultrasound examination being abandoned. Catheter misplacement was detected by TTE with a sensitivity of 96% (CI 90-98%), a specificity of 83% (CI 44-97%), a positive predictive value of 98%, and a negative predictive value of 55%. Likelihood ratios were LR+ 5.7 (CI 0.96-34.4) and LR- 0.05 (CI 0.02-0.14). Guidewire removal under TTE avoided an excessively distal position of the catheter tip in all cases. CONCLUSION: TTE is a reliable tool to detect catheter misplacement and to optimize catheter tip positioning during the procedure of CVC insertion.

Alteration of plasma phospholipid fatty acid profile in patients with septic shock.

In septic shock patients, alterations of plasma phospholipid fatty acid profile have never been described. The purpose of this monocentric, non-interventional, observational prospective study was to describe this fatty acid profile in the early phase of septic shock in intensive care unit. Thirty-seven adult patients with septic shock were included after the first day of stay in intensive care unit, before any form of artificial nutritional support. Plasma phospholipid fatty acid composition was determined by gas chromatography. All biological data from patients with septic shock were compared with laboratory reference values. Patients presented hypocholesterolemia and hypertriglyceridemia. They had low concentrations of phospholipid fatty acids specifically n-6 and n-3 polyunsaturated fatty acids (PUFAs) with a high n-6/n-3 ratio. Plasma phospholipid PUFA concentrations were strongly correlated with cholesterolemia. PUFAs/SFAs (saturated fatty acids) and PUFAs/MUFAs (monounsaturated fatty acids) ratios were low because of low percentage of n-6 and n-3 PUFAs and high percentage of SFAs and MUFAs. Low levels of plasma long chain PUFAs (≥20 carbons) were significantly associated with mortality at 28th day. In conclusion, plasma phospholipid FA profile of septic patients is very characteristic, close to that of acute respiratory distress syndrome and mortality is associated with long chain PUFA decrease. This profile could be explained by numerous non-exclusive physio-pathological processes 1) an activation of hepatic de novo lipogenesis that could contribute to hepatic steatosis, 2) an elevated adipose tissue lipolysis, 3) an increased free radical attack of FA by oxidative stress, 4) an over-production of inflammatory lipid mediators.

Usefulness of cardiothoracic chest ultrasound in the management of acute respiratory failure in critical care practice.

BACKGROUND: This study investigated the clinical relevance of early general chest ultrasonography (ie, heart and lung recordings) in patients in the ICU with acute respiratory failure (ARF). METHODS: We prospectively compared this diagnostic approach (ultrasound) to a routine evaluation established from clinical, radiologic, and biologic data (standard). Subjects were patients consecutively admitted to the ICU of a university teaching hospital during a 1-year period. Inclusion criteria were age ≥ 18 years and the presence of severe ARF criteria to justify ICU admission. We compared the diagnostic approaches and the final diagnosis determined by a panel of experts. RESULTS: Seventy-eight patients were included (age, 70 ± 18 years; sex ratio, 1). Three patients given two or more simultaneous diagnoses were subsequently excluded. The ultrasound approach was more accurate than the standard approach (83% vs 63%, respectively; P < .02). Receiver operating characteristic curve analysis showed greater diagnostic performance of ultrasound in cases of pneumonia (standard, 0.74 ± 0.12; ultrasound, 0.87 ± 0.14; P < .02), acute hemodynamic pulmonary edema (standard, 0.79 ± 0.11; ultrasound, 0.93 ± 0.08; P < .007), decompensated COPD (standard, 0.8 ± 0.09; ultrasound, 0.92 ± 0.15; P < .05), and pulmonary embolism (standard, 0.65 ± 0.12; ultrasound, 0.81 ± 0.17; P < .04). Furthermore, we found that the use of ultrasound data could have significantly improved the initial treatment. CONCLUSIONS: The use of cardiothoracic ultrasound appears to be an attractive complementary diagnostic tool and seems able to contribute to an early therapeutic decision based on reproducible physiopathologic data.

The 90% effective dose of a sufentanil bolus for the management of painful positioning in intubated patients in the ICU.

CONTEXT: Pain and discomfort arising from the routine care of intubated patients in the ICU is managed by continuous infusion of narcotic and sedative drugs. There is benefit in keeping infusion rates low because lightening sedation improves clinical outcome, but this risks breakthrough pain. Management of this discomfort by bolus administration could permit lower background infusion rates, but the lowest effective bolus dose of sufentanil to achieve this is unknown. OBJECTIVE: The aim of this study was to determine the effective analgesic dose in 90% of intubated patients (ED90) in the ICU given bolus sufentanil. Pain was assessed using a Behavioural Pain Scale (BPS) requiring a score of 3-4 during moving to the lateral decubitus position. DESIGN: Prospective, dose response study. SETTING: A 16-bed multidisciplinary ICU in a French university hospital. Study period was from January to June 2010. PATIENTS: Intubated and ventilated patients were eligible for the study once they had reached a BPS of 3 or 4 and Ramsay score of 3-5 within 48 h of admission to the ICU. INTERVENTION: The analgesic efficacy of a sufentanil bolus was measured during successive lateral decubitus positioning over a 72-h study period, using the BPS scale. The dose was increased with each subsequent turn to lateral decubitus until a BPS score of 3-4 was obtained (dose escalation, starting at zero). MAIN OUTCOME MEASURES: BPS, Ramsay score, heart rate and mean arterial pressure were collected before and during each procedure. RESULTS: A total of 25 patients were enrolled over 6 months. The ED90 bolus for sufentanil was 0.15 µg kg, but 40% of the patients subsequently demonstrated increased BPS with this dose. CONCLUSION: The effective dose in 90% was 0.15 µg kg during the first 5 days of sedation. There were no adverse effects. A pre-emptive sufentanil bolus can be used to treat anticipated pain in the ICU. Regular and frequent assessments of acute pain and sedation are essential for adjusting the dose, on a case-by-case basis. This strategy may help clinicians to keep background infusions of sedatives and narcotics as low as possible and may improve clinical outcome. TRIAL REGISTRATION: ClinicalTrials.gov NCT01356732.

Predictive value of abdominal obesity vs. body mass index for determining risk of intensive care unit mortality.

OBJECTIVE: To explore whether sagittal abdominal diameter as a marker of abdominal obesity is a risk factor for death and morbidity in patients in the intensive care unit and a better outcome determinant for obese patients than body mass index. DESIGN: Prospective, observational study from April 2008 to January 2009. SETTING: Two general intensive care units, both in Toulouse University Hospitals, France. PARTICIPANTS: All adult patients admitted in the two intensive care units except those routinely discharged within 48 hrs or those having conditions with possible effect on anthropometric indices. INTERVENTIONS: Measurement of the sagittal abdominal diameter at admission allowed us to divide the studied population into abdominally obese, underweight, and control groups. MEASUREMENTS AND RESULTS: The primary outcome measure was mortality in the intensive care unit until day 60 after admission. Secondary outcomes were morbidity and length of stay in the intensive care unit. Among 503 patients admitted, 403 were included. At admission, age, diabetes, dyslipidemia, hypertension, Simplified Acute Physiology Score II, and McCabe scores were higher in the abdominally obese group (n = 109) than in the control group (n = 277). The rate of death was higher in the abdominally obese group compared to control (44% vs. 25.3%; p < .01). After adjustment for age, simplified acute physiology score, II and McCabe score, a multivariate analysis showed an increased risk of death in the abdominally obese group (adjusted odds ratio, 2.12; 95% confidence interval, 1.25-3.60). A body mass index >30 kg/m2 was not an independent risk factor for death. During the stay in the intensive care unit, incidence of acute renal failure and abdominal compartment syndrome were higher in the abdominally obese group. CONCLUSION: A high sagittal abdominal diameter, and not a high body mass index, is an independent risk factor of death in critically ill patients.

Intra-abdominal pressure measurement method via the urinary-tube: bedside validation of a biomechanical model integrating urine column height and bladder urinary volume.

BACKGROUND: The objective of this work was to demonstrate the possibility of accurately measuring intra-abdominal pressure (IAP) by using a common urine drainage bag (U-Tube) as a hydrostatic column of measurement. This has been done by integrating urine column height (h) and bladder urinary volume (BUV) in the IAP measurement method. METHOD: Seventy-eight newly admitted patients in a 22 bed university hospital intensive care unit (ICU) were studied. Two U-Tube IAP measurement methods were compared with the "Gold-standard" closed-system repeated measurement technique with bladder pressure transducer: U-Tube method I, where h (in cm) alone assesses IAP (in cm H2O) and U-Tube method II, integrating BUV according to a basic biomechanical model of bladder wall compliance to give a more accurate IAP estimation. RESULTS: Correlation rate using linear regression analysis was better between the Gold standard method and method II than method I with R = 0.901, P < 0.0001 and R = 0.682, P < 0.0001, respectively. For method II, Bland-Altman analysis showed a mean bias of -1.0 +/- 0.1 mm Hg (limits of agreement -3.4-1.4, percentage error +/-7.7%). Area under the receiver operator characteristics curves to screen intra-abdominal hypertension (IAP >or=12 mm Hg) was significantly greater with method II than with method I: 0.99 versus 0.93, P < 0.05; sensitivity and specificity of method II were 95% and 98%, respectively. CONCLUSION: By integrating urine column height and BUV in the measurement method, it may be conceivable to screen IAH at the bedside via a U-Tube in ICU; bladder wall compliance should be estimated to avoid the emergence of false-positive subjects due to the possible occurrence of bladder wall compliance alteration before or during the ICU stay.

Pulse pressure variations adjusted by alveolar driving pressure to assess fluid responsiveness.

OBJECTIVE: To evaluate the ability of DeltaPP/DeltaP [pulse pressure variations (DeltaPP) adjusted by alveolar pressure variations (DeltaP = Pplat-PEEPtot)] in predicting fluid responsiveness, to compare its accuracy to that of DeltaPP used alone and to evaluate the influence of tidal volume (Vt) on these two indices. DESIGN: Prospective study. SETTING: A 22-bed general intensive care unit (ICU). PATIENTS: Eighty-four surgical or medical ventilated patients requiring fluid challenge. INTERVENTION: A 6 ml/kg colloid fluid challenge in 30 min. MEASUREMENTS AND RESULTS: Hemodynamic measurements taken before and after fluid challenge. Patients separated into responders and nonresponders according to a 15% increase in their cardiac output. Thirty-nine patients found to be responders and 45 nonresponders. DeltaPP/DeltaP and DeltaPP were both higher in responders than in nonresponders. DeltaPP/DeltaP was a better predictor of fluid responsiveness than PP, especially for patients ventilated with Vt > or = 8 ml/kg [area under the curve (AUC) 0.88 (0.77-0.98) versus 0.75 (0.60-0.89), P < 0.01)]. In this population DeltaPP/DeltaP higher than 0.9 predicted fluid response with positive predictive value of 87% and negative predictive value of 78%. Overall DeltaPP and DeltaPP/DeltaP reliability was poor for patients ventilated with Vt < 8 ml/kg [AUC 0.63 (0.45-0.81) and 0.72 (0.55-0.88), respectively]. CONCLUSION: In this mixed ICU population PP adjusted by P is a simple index which outperforms DeltaPP for patients ventilated with Vt > or = 8 ml/kg. However, correcting DeltaPP by DeltaP still fails to predict fluid response reliably in patients ventilated with low tidal volume.

Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock?

OBJECTIVE: To test the hypothesis that, in resuscitated septic shock patients, central venous-to-arterial carbon dioxide difference [P(cv-a)CO(2)] may serve as a global index of tissue perfusion when the central venous oxygen saturation (ScvO(2)) goal value has already been reached. DESIGN: Prospective observational study. SETTING: A 22-bed intensive care unit (ICU). PATIENTS: After early resuscitation in the emergency unit, 50 consecutive septic shock patients with ScvO(2) > 70% were included immediately after their admission into the ICU (T0). Patients were separated in Low P(cv-a)CO(2) group (Low gap; n = 26) and High P(cv-a)CO(2) group (High gap; n = 24) according to a threshold of 6 mmHg at T0. MEASUREMENTS: Measurements were performed every 6 h over 12 h (T0, T6, T12). RESULTS: At T0, there was a significant difference between Low gap patients and High gap patients for cardiac index (CI) (4.3 +/- 1.6 vs. 2.7 +/- 0.8 l/min/m(2), P < 0.0001) but not for ScvO(2) values (78 +/- 5 vs. 75 +/- 5%, P = 0.07). From T0 to T12, the clearance of lactate was significantly larger for the Low gap group than for the High gap group (P < 0.05) as well as the decrease of SOFA score at T24 (P < 0.01). At T0, T6 and T12, CI and P(cv-a)CO(2) values were inversely correlated (P < 0.0001). CONCLUSION: In ICU-resuscitated patients, targeting only ScvO(2) may not be sufficient to guide therapy. When the 70% ScvO(2) goal-value is reached, the presence of a P(cv-a)CO(2) larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.

The hemodynamic "target": a visual tool of goal-directed therapy for septic patients.

OBJECTIVE: To improve understanding of the hemodynamic status of patients with sepsis by nursing teams through the attainment of hemodynamic parameters using a pentaxial "target" diagram as a clinical tool. Parameters include cardiac index (CI), arterial oxygen saturation (SaO2), mean arterial pressure (MAP), arterial blood lactate, and central venous oxygen saturation (ScvO2). DESIGN: Prospective descriptive study. SETTING: The intensive care unit of a university hospital. PATIENTS: During a 6-month period, 38 intubated septic shock patients were included in the study. Survivors and nonsurvivors were compared. INTERVENTIONS: MAP, CI, SaO2, ScvO2 and lactate were measured at 0, 6, 12, 24, 36, and 48 h. Measurements were recorded on the target diagram along with the norepinephrine infusion rate and the hemoglobin (Hb) level. The number of lactate and ScvO2 measurements achieved during the target period were compared to a 6-month retrospective control period just before starting the protocol. We assessed the nurse knowledge status prior to the introduction of target diagram. We then performed a post-test after implementing the new recording technique. MEASUREMENTS AND RESULTS: The nursing team expressed a positive attitude toward the target concept. The mean number of lactate and ScvO2 measurements performed for each patient during the control period was significantly lower than during the target period, and those values were rarely used as goal values before the introduction of the target diagram. At 24 hours, 46% of the survivors had achieved all the goal parameter values of the target diagram, compared to only 10% of nonsurvivors (P = .01). CONCLUSION: The target diagram is a visual multiparametric tool involving all the medical and nursing team that helps achieve goal-directed therapy for septic patients. The number of goal values reached at each time point during the first 48 hours was closely linked to mortality.

The hemodynamic "target": a visual tool of goal-directed therapy for septic patients

OBJECTIVE: To improve understanding of the hemodynamic status of patients with sepsis by nursing teams through the attainment of hemodynamic parameters using a pentaxial "target" diagram as a clinical tool. Parameters include cardiac index (CI), arterial oxygen saturation (SaO2), mean arterial pressure (MAP), arterial blood lactate, and central venous oxygen saturation (ScvO2). METHODS: Design: Prospective descriptive study. Setting: The intensive care unit of a university hospital. Patients: During a 6-month period, 38 intubated septic shock patients were included in the study. Survivors and nonsurvivors were compared. Interventions: MAP, CI, SaO2, ScvO2 and lactate were measured at 0, 6, 12, 24, 36, and 48 h. Measurements were recorded on the target diagram along with the norepinephrine infusion rate and the hemoglobin (Hb) level. The number of lactate and ScvO2 measurements achieved during the target period were compared to a 6-month retrospective control period just before starting the protocol. We assessed the nurse knowledge status prior to the introduction of target diagram. We then performed a post-test after implementing the new recording technique. MEASUREMENTS AND RESULTS: The nursing team expressed a positive attitude toward the target concept. The mean number of lactate and ScvO2 measurements performed for each patient during the control period was significantly lower than during the target period, and those values were rarely used as goal values before the introduction of the target diagram. At 24 hours, 46 percent of the survivors had achieved all the goal parameter values of the target diagram, compared to only 10 percent of nonsurvivors (P = .01). CONCLUSION: The target diagram is a visual multiparametric tool involving all the medical and nursing team that helps achieve goal-directed therapy for septic patients. The number of goal values reached at each time point during the first 48 hours was closely linked to mortality.

OBJETIVO: Melhorar a compreensão do "status" hemodinâmico de pacientes em sepse pelas equipes de enfermagem através da obtenção de parâmetros hemodinâmicos usando um diagrama-alvo pentaxial como ferramenta clínica. Os parâmetros usados foram índice cardíaco, saturação arterial de oxigênio, pressão arterial media, lactato sangüíneo arterial e saturação venosa central de oxigênio. MÉTODOS: Estudo descritivo prospectivo, realizado na Unidade de Terapia Intensiva de um Hospital Universitário. Pacientes: Durante um período de 6 meses, 38 pacientes intubados em choque séptico foram incluídos no estudo. Foram comparados sobreviventes vs. não sobreviventes. Intervenções: Os cinco parâmetros referidos foram medidos nas horas 0, 6, 12, 24, 36 e 48. As medidas foram registradas no diagrama alvo, juntamente com a velocidade de infusão de norepinefrina e nível de hemoglobina. O número de medidas de lactato e saturação venosa central de oxigênio realizado durante o período de estudo foi comparado com um período retrospectivo de 6 meses imediatamente precedendo a introdução do protocolo. Avaliamos o nível de conhecimento das equipes de enfermagem antes da introdução do diagrama-alvo. Após a realização do protocolo realizamos uma nova avaliação. MEDIDAS E RESULTADOS: A equipe de enfermagem exprimiu uma atitude positiva em relação ao conceito de diagrama alvo. O número de medidas de lactato e saturação venosa central de oxigênio foi significativamente menor durante o período controle anterior ao protocolo. E os valores medidos raramente foram empregados como valores meta antes da introdução do diagrama-alvo. Na medida de 24 horas, 46 por cento dos sobreviventes haviam atingido todas as metas do diagrama-alvo, contra apenas 10 por cento dos não sobreviventes (P = 0,01). CONCLUSÃO. O diagrama-alvo é uma ferramenta visual multiparamétrica envolvendo, as equipes médicas e de enfermagem, que auxilia a obtenção de uma estratégia terapêutica para pacientes...

Stroke output variations calculated by esophageal Doppler is a reliable predictor of fluid response.

OBJECTIVE: Esophageal Doppler allows continuous monitoring of stroke volume index (SVI) and corrected flow time (FTc). We hypothesized that variations in stroke output index SOI (SVI/FTc) during volume expansion can predict the hemodynamic response to subsequent fluid loading better than the static values. DESIGN AND SETTING: Prospective study in the intensive care unit of a university hospital. PATIENTS: Fifty-one patients with circulatory failure were monitored by esophageal Doppler. INTERVENTIONS: Patients who responded to a first fluid challenge received a second one. Patients who responded to both were classified as responders-responders, and those who did not respond to the second as responders-nonresponders. In these two groups we compared DeltaSVI, DeltaFTc, and DeltaSOI during each fluid challenge and also static values at the end of each fluid challenge. MEASUREMENTS AND RESULTS: After the first fluid challenge DeltaSOI and DeltaSVI were significantly higher in patients who responded to subsequent volume expansion than in patients who no longer responded. ROC curves showed that DeltaSOI was a better predictor of fluid responsiveness than DeltaSVI. During volume expansion a DeltaSOI value of 11% discriminated between responders and nonresponders to subsequent volume expansion with a sensitivity of 91% and a specificity of 97%. There was no significant difference between the two groups for FTc value at the end of first fluid challenge. CONCLUSIONS: Analysis of DeltaSOI during fluid challenge predicts response to subsequent fluid challenge and FTc is not a reliable indicator of cardiac preload.

Effect of treatment on maxillary sinus and nasal nitric oxide concentrations in patients with nosocomial maxillary sinusitis.

STUDY OBJECTIVES: In maxillary nosocomial sinusitis (MNS) related to severe sepsis, nitric oxide (NO) concentration in the maxillary sinuses is drastically reduced secondarily to a downregulation of type-2 NO synthase. NO plays a major role in nonspecific immune defense of sinuses. We therefore aimed to study maxillary NO concentration during the treatment of MNS with drainage, daily lavage, and removal of any nasally introduced tube. PATIENTS AND METHODS: Nine patients were studied during the first 4 days of treatment of MNS. We measured the concentration of NO gas in the maxillary sinus and in the nasal cavity, and the NO metabolite levels (nitrites/nitrates [NOx]) in the sinus lavages. MEASUREMENTS AND RESULTS: Maxillary NO concentration (median [25 to 75 percentile]) increased from 70 parts per billion (ppb) [40 to 100 ppb] to 2,050 ppb (1,700 to 3,000 ppb) after 4 days of treatment of MNS (p < 0.0001). In the meantime, nasal NO increased from a median of 100 ppb (98 to 148 ppb) to 180 ppb (180 to 188 ppb) [p < 0.001]. At any time, there was a correlation between maxillary NO (logarithmic value) and nasal NO (r2 = 0.57, p < 0.0001). NOx levels remained stable in the lavages. CONCLUSIONS: We conclude that the treatment of the sinusitis with drainage, daily lavage, and removal of the gastric tube lead to a spectacular increase of maxillary and nasal NO concentrations.

Regional citrate anticoagulation in continuous venovenous haemodiafiltration using commercial solutions.

BACKGROUND: Treatment with trisodium citrate provides an effective means of regional anticoagulation during continuous renal replacement therapy (CRRT). We evaluated the efficacy, safety and cost of a regional citrate anticoagulation protocol using commercial solutions in 17 critically ill patients treated with continuous venovenous haemodiafiltration (CVVHDF). We performed a total of 22 sessions. METHODS: We delivered an A.C.D-A(541(R)) solution containing 112.9 mmol/l disodium citrate (3.22%) at a median rate of 260 (190-280) ml/h via the pre-filter port of a COBE PRISMA with an AN-69 dialyser, while adjusting the rate to maintain post-filtered ionized calcium (iCa(2+)) between 0.25 and 0.4 mmol/l. Plasma iCa(2+) was maintained at >1.1 mmol/l by infusion of calcium chloride at a median rate of 1.70 (1.36-2.27) mmol/h. The dialysate was easily modified according to the acid-base status of each patient. Both replacement and dialysate solutions were delivered at 1200 ml/h. Each session was scheduled for 48 h and biological parameters were assessed every 6 h. RESULTS: The mean dialyser survival was 39 +/- 11 h (median 41.5 h; range 13-48 h). We observed dialyser clotting in four cases (18%). There were no bleeding events or modifications of coagulation parameters. The citrate solution, replacement solution and dialysate were obtained as commercial products. Both the replacement and dialysate solutions contained calcium. The extra cost of this technique was 25 euro;/day as compared to anticoagulation with heparin. CONCLUSIONS: We designed an efficient method of regional citrate anticoagulation for CVVHDF by using commercial solutions. The monitoring of patients was as intensive as during heparin anticoagulation for CRRT. Because of the higher cost of this method, it should be proposed only for patients with high bleeding risk.