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1.
BMC Infect Dis ; 20(1): 116, 2020 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-32041533

RESUMO

BACKGROUND: Yellow fever vaccine exists for over 80 years and is considered to be relatively safe. However, in rare cases it can produce serious neurotropic and viscerotropic complications. We report a case of a patient who presented both viscerotropic and neurological manifestations after yellow fever vaccination. CASE PRESENTATION: We describe the case of a 37 years old man who developed after the yellow fever vaccination a yellow fever vaccine-associated viscerotropic disease followed by acute uveitis. Prolonged detection of yellow fever RNA in blood and urine was consistent with yellow fever vaccine-associated adverse event. The final outcome was good, although with persistent fatigue over a few months. CONCLUSIONS: Even if the yellow fever vaccine is relatively safe, physicians should be aware of its possible serious adverse effects.

2.
Minerva Anestesiol ; 85(9): 943-950, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30871305

RESUMO

BACKGROUND: Although early identification of sepsis improves outcome, prompt and correct diagnostic remains often challenging. The expression of the high affinity immunoglobulin-Fc fragment receptor I CD64 on neutrophils is upregulated during acute inflammation. We here aimed at determining the usefulness of its rapid measurement in diagnosing sepsis. METHODS: Seventy-two consecutive patients were enrolled upon admission to Intensive Care Unit within a two-month period. Sequential determination of serum C-reactive protein (CRP) and procalcitonin (PCT) concentrations was obtained. The neutrophil CD64 index was measured using Accellix-CD64® device, an in vitro diagnosis system allowing for an automatic and standardized measure. RESULTS: Serum concentrations of CRP and PCT as well as the neutrophil CD64 index were higher in septic patients compared to all others (P<0.05 for the three markers). Only CD64 index was an independent predictor of sepsis, though with modest sensitivity and specificity (78% and 70%, respectively). Repeat determination of CD64 index at day 2 correctly classified 85% of patients. CONCLUSIONS: This prospective study demonstrates the moderate performance of the neutrophil CD64 index, assessed through the Accellix-CD64® device, in diagnosing sepsis in the critically ill patient. However, repeat measurements improve its accuracy and may help to predict ICU-acquired infections.

3.
Minerva Anestesiol ; 84(2): 196-203, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28726362

RESUMO

BACKGROUND: During septic shock, early development of hypertension after vasopressors weaning seems paradoxical. The aim of this study was to authenticate this empirical observation, identify associated factors and document its prognostic significance. METHODS: We conducted a descriptive, retrospective study in a medical ICU of a teaching hospital among adult patients with septic shock. RESULTS: From January 1st, 2013 to December 31st, 2014, 262 consecutive patients over 18 years of age were admitted because of septic shock; 195 of them were successfully weaned from vasopressors. Early hypertension within the 24 hours following vasopressors weaning occurred in 22% of patients (N.=43) who did not differ in terms of past history of hypertension or chronic renal insufficiency, severity scores, vasopressor doses or duration, volume resuscitation or fluid balance. In multivariate analysis, predictive factors for developing early hypertension were past history of ischemic heart disease (OR=4.25; 95% CI: 1.74-10.35, P=0.001) and invasive mechanical ventilation (OR=2.86; 95% CI: 1.26-6.51, P=0.01). Occurrence of early hypertension was independently associated with a better survival (OR=0.03; 95% CI: 0.001-0.73, P=0.03). CONCLUSIONS: Development of hypertension within 24 hours of vasopressor support cessation is a frequent event affecting almost a quarter of the patients who survived the initial phase of septic shock resuscitation and is independently associated with a better outcome.


Assuntos
Hipertensão/etiologia , Choque Séptico/tratamento farmacológico , Vasoconstritores/administração & dosagem , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Suspensão de Tratamento
4.
J Am Coll Cardiol ; 68(1): 40-9, 2016 07 05.
Artigo em Inglês | MEDLINE | ID: mdl-27364049

RESUMO

BACKGROUND: Preliminary data suggested a clinical benefit in treating out-of-hospital cardiac arrest (OHCA) patients with a high dose of erythropoietin (Epo) analogs. OBJECTIVES: The authors aimed to evaluate the efficacy of epoetin alfa treatment on the outcome of OHCA patients in a phase 3 trial. METHODS: The authors performed a multicenter, single-blind, randomized controlled trial. Patients still comatose after a witnessed OHCA of presumed cardiac origin were eligible. In the intervention group, patients received 5 intravenous injections spaced 12 h apart during the first 48 h (40,000 units each, resulting in a maximal dose of 200,000 total units), started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients in each group reaching level 1 on the Cerebral Performance Category (CPC) scale (survival with no or minor neurological sequelae) at day 60. Secondary endpoints included all-cause mortality rate, distribution of patients in CPC levels at different time points, and side effects. RESULTS: In total, 476 patients were included in the primary analysis. Baseline characteristics were similar in the 2 groups. At day 60, 32.4% of patients (76 of 234) in the intervention group reached a CPC 1 level, as compared with 32.1% of patients (78 of 242) in the control group (odds ratio: 1.01; 95% confidence interval: 0.68 to 1.48). The mortality rate and proportion of patients in each CPC level did not differ at any time points. Serious adverse events were more frequent in Epo-treated patients as compared with controls (22.6% vs. 14.9%; p = 0.03), particularly thrombotic complications (12.4% vs. 5.8%; p = 0.01). CONCLUSIONS: In patients resuscitated from an OHCA of presumed cardiac cause, early administration of erythropoietin plus standard therapy did not confer a benefit, and was associated with a higher complication rate. (High Dose of Erythropoietin Analogue After Cardiac Arrest [Epo-ACR-02]; NCT00999583).


Assuntos
Epoetina alfa/administração & dosagem , Hematínicos/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Idoso , Intervenção Médica Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego
6.
Circulation ; 132(3): 182-93, 2015 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-26092673

RESUMO

BACKGROUND: Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. METHODS AND RESULTS: Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1-2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93-2.16; P=0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96-2.35; P=0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group (P<0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group (P=0.009). CONCLUSION: Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00392639.


Assuntos
Temperatura Corporal , Gerenciamento Clínico , Procedimentos Endovasculares/métodos , Hipotermia Induzida/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Idoso , Procedimentos Endovasculares/mortalidade , Feminino , Seguimentos , Humanos , Hipotermia Induzida/mortalidade , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Estudos Prospectivos , Método Simples-Cego , Taxa de Sobrevida/tendências
7.
Crit Care ; 17(4): R140, 2013 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-23849321

RESUMO

INTRODUCTION: A rational use of antibiotics is of paramount importance in order to prevent the emergence of multidrug resistant bacteria that can lead to therapeutic impasse, especially in intensive care units (ICUs). A de-escalation strategy is therefore naturally advocated as part of better antibiotics usage. However, the clinical impact of such a strategy has not been widely studied. We aimed to assess the feasibility and the clinical impact of a de-escalation strategy in a medical ICU and to identify factors associated when de-escalation was possible. METHODS: We performed a retrospective study of patients hospitalized in a medical ICU over a period of six months. Independent factors associated with de-escalation and its clinical impact were assessed. RESULTS: Two hundred and twenty-nine patients were included in the study. Antibiotics were de-escalated in 117 patients (51%). The appropriateness of initial antibiotic therapy was the only independent factor associated with the performance of de-escalation (OR = 2.9, 95% CI, 1.5-5.7; P = 0.002). By contrast, inadequacy of initial antibiotic therapy (OR = 0.1, 0.0 to 0.1, P <0.001) and the presence of multidrug resistant bacteria (OR = 0.2, 0.1 to 0.7, P = 0.006) prevented from de-escalation. There were no differences in terms of short (ICU) or long-term (at 1 year) mortality rates or any secondary criteria such as ICU length of stay, duration of antibiotic therapy, mechanical ventilation, incidence of ICU-acquired infection, or multi-drug resistant bacteria emergence. CONCLUSIONS: De-escalation appears feasible in most cases without any obvious negative clinical impact in a medical ICU.


Assuntos
Antibacterianos/administração & dosagem , Infecções Bacterianas/prevenção & controle , Cuidados Críticos/métodos , Idoso , Antibacterianos/uso terapêutico , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque Séptico/tratamento farmacológico , Resultado do Tratamento , Suspensão de Tratamento
8.
Am J Respir Crit Care Med ; 186(1): 65-71, 2012 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-22538802

RESUMO

RATIONALE: Although the outcome of sepsis benefits from the prompt administration of appropriate antibiotics on correct diagnosis, the assessment of infection in critically ill patients is often a challenge for clinicians. In this setting, simple biomarkers, especially when used in combination, could prove useful. OBJECTIVES: To determine the usefulness of combination biomarkers to diagnose sepsis. METHODS: Three hundred consecutive patients were enrolled to construct a biologic score that was next validated in an independent prospective cohort of 79 critically ill patients from another center. MEASUREMENT AND MAIN RESULTS: Plasma concentrations of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and procalcitonin (PCT) were assayed, and the expression of the high-affinity immunoglobulin-Fc fragment receptor I (FcγRI) CD64 on neutrophils (polymorphonuclear [PMN] CD64 index) in flow cytometry was measured. A "bioscore" combining these biomarkers was constructed. Serum concentrations of PCT and sTREM-1 and the PMN CD64 index were higher in patients with sepsis compared with all others (P < 0.001 for the three markers). These biomarkers were all independent predictors of infection, the best receiver-operating characteristic curve being obtained for the PMN CD64 index. The performance of the bioscore, better than that of each individual biomarker, was externally confirmed in the validation cohort. CONCLUSIONS: This prospective study, including inceptive and validation cohorts of unselected intensive care unit patients, demonstrates the high performance of a bioscore combining the PMN CD64 index together with PCT and sTREM-1 serum levels in diagnosing sepsis in the critically ill patient.


Assuntos
Biomarcadores/sangue , Calcitonina/sangue , Glicoproteínas de Membrana/sangue , Precursores de Proteínas/sangue , Receptores Imunológicos/sangue , Sepse/diagnóstico , Peptídeo Relacionado com Gene de Calcitonina , Estado Terminal , Humanos , Modelos Logísticos , Células Mieloides/metabolismo , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Receptores de IgG/análise , Receptor Gatilho 1 Expresso em Células Mieloides
9.
Intensive Care Med ; 36(9): 1540-7, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20502866

RESUMO

PURPOSE: Probiotics have been shown to be able to restore a non-pathogenic digestive flora, to prevent digestive colonization by pathogenic bacteria, and to modulate immunity. The aim of this study was to assess the effects of prophylactic probiotic administration in patients ventilated for up to 2 days. METHODS: This study was performed as a double-blind, concealed randomized, placebo-controlled trial in a French medical intensive care unit (ICU). Adult patients mechanically ventilated for a period of more than 48 h received enterally administered probiotics (Ergyphilus, 2 x 10(10) lactic acid bacteria, mostly Lactobacillus rhamnosus GG, once a day) or placebo until successful weaning. RESULTS: A total of 167 patients were included. The two groups were comparable at baseline. The 28-day mortality rates were not different in the probiotic (25.3%) and placebo groups (23.7%). Mortality rates in ICU and at 90 days were also unaffected by the treatment. The incidence of ICU-acquired infections did not differ significantly except for that of catheter-related bloodstream infections that was lowered by probiotics. On a prespecified subgroup analysis, we found a reduction of the 28-day mortality among severe sepsis patients (total n = 101) treated with probiotics (n = 52) with an odds ratio (OR) for death at 0.38 (95% CI 0.16-0.93, p = 0.035). By contrast, probiotics were associated with a higher mortality rate in non-severe sepsis patients (OR 3.09, 95% CI 0.87-11.01, p = 0.08). CONCLUSIONS: Although numerous uncertainties remain (type and the number of strains to use, delay and length of administration), and despite an acceptable safety profile, the daily prophylactic administration of probiotics cannot be encouraged in the critically ill patient.


Assuntos
Cuidados Críticos/métodos , Estado Terminal , Lactobacillus rhamnosus , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Probióticos/administração & dosagem , Adulto , Idoso , Infecção Hospitalar/prevenção & controle , Método Duplo-Cego , Feminino , França , Humanos , Unidades de Terapia Intensiva/organização & administração , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Índice de Gravidade de Doença , Resultado do Tratamento
10.
Crit Care ; 12(6): R149, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-19036140

RESUMO

INTRODUCTION: Metformin-associated lactic acidosis (MALA) is a classic side effect of metformin and is known to be a severe disease with a high mortality rate. The treatment of MALA with dialysis is controversial and is the subject of many case reports in the literature. We aimed to assess the prevalence of MALA in a 16-bed, university-affiliated, intensive care unit (ICU), and the effect of dialysis on patient outcome. METHODS: Over a five-year period, we retrospectively identified all patients who were either admitted to the ICU with metformin as a usual medication, or who attempted suicide by metformin ingestion. Within this population, we selected patients presenting with lactic acidosis, thus defining MALA, and described their clinical and biological features. RESULTS: MALA accounted for 0.84% of all admissions during the study period (30 MALA admissions over five years) and was associated with a 30% mortality rate. The only factors associated with a fatal outcome were the reason for admission in the ICU and the initial prothrombin time. Although patients who went on to haemodialysis had higher illness severity scores, as compared with those who were not dialysed, the mortality rates were similar between the two groups (31.3% versus 28.6%). CONCLUSIONS: MALA can be encountered in the ICU several times a year and still remains a life-threatening condition. Treatment is restricted mostly to supportive measures, although haemodialysis may possess a protective effect.


Assuntos
Acidose Láctica/epidemiologia , Hipoglicemiantes/efeitos adversos , Unidades de Terapia Intensiva , Metformina/efeitos adversos , Acidose Láctica/induzido quimicamente , Acidose Láctica/mortalidade , Idoso , Feminino , França/epidemiologia , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Estudos Retrospectivos
11.
Scand J Infect Dis ; 39(6-7): 604-8, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17577825

RESUMO

This prospective, non-interventional study was conducted in a medical adult intensive care unit to determine the usefulness of procalcitonin (PCT) and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) determinations in the diagnosis of nosocomial sepsis. Serum PCT and bronchoalveolar lavage fluid sTREM-1 concentrations were measured in 50 critically ill patients suffering from nosocomial sepsis. Ventilator-associated pneumonia (VAP) was diagnosed in 31 patients and extrapulmonary sepsis in 19. Increase serum PCT concentration (>0.15 ng/ml) was found in 44 (88%) patients and was higher in those suffering from a non-pulmonary sepsis. The concomitant BAL sTREM-1 determination correctly classified pulmonary (VAP) versus non-pulmonary origin in 41 out of 44 cases (93%). Even when PCT concentration remained low, sTREM-1 assessment allowed for the detection of the sepsis (VAP) in 50% of cases. Both PCT and sTREM-1 concentrations were low in only 3 patients (6%) in whom sepsis could have been missed if only diagnosed by the measurement of these 2 biomarkers. We therefore concluded that the combined measurement of serum PCT and BAL sTREM-1 concentrations could be of interest in detecting the presence of a nosocomial sepsis and in discriminating VAP versus extrapulmonary infection.


Assuntos
Calcitonina/sangue , Infecção Hospitalar/diagnóstico , Glicoproteínas de Membrana/metabolismo , Precursores de Proteínas/sangue , Receptores Imunológicos/metabolismo , Sepse/diagnóstico , Adulto , Idoso , Biomarcadores/análise , Biomarcadores/sangue , Líquido da Lavagem Broncoalveolar/química , Peptídeo Relacionado com Gene de Calcitonina , Infecção Hospitalar/sangue , Infecção Hospitalar/microbiologia , Humanos , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/sangue , Pneumonia Associada à Ventilação Mecânica/diagnóstico , Pneumonia Associada à Ventilação Mecânica/microbiologia , Estudos Prospectivos , Sepse/sangue , Sepse/microbiologia , Receptor Gatilho 1 Expresso em Células Mieloides
12.
Intensive Care Med ; 33(8): 1347-53, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17525840

RESUMO

OBJECTIVE: To investigate plasma high-mobility group box 1 protein (HMGB1) concentration and its relationship with organ dysfunction and outcome in septic shock patients. DESIGN AND SETTING: Prospective, noninterventional study. Medical adult intensive care unit at a university hospital in France. PATIENTS: 42 critically ill patients with septic shock. METHODS: Arterial blood was drawn within 12 h of admission for the measurement of plasma HMGB1 concentration by ELISA. Repeated sampling was performed on days 3, 7, and 14. RESULTS: Median HMGB1 concentration was 4.4 ng/ml (IQR 1.2-12.5) at admission, with no difference between survivors and nonsurvivors. A positive correlation was observed between HMGB1 and SOFA score and lactate, and procalcitonin concentrations. There was a progressive but statistically nonsignificant decline in HMGB1 concentration among the survivors, while nonsurvivors showed an increase in HMGB1 level between days 1 and 3. SOFA score and lactate and procalcitonin concentrations did not vary significantly between days 1 and 3. When measured on day 3, HMGB1 discriminated survivors from nonsurvivors with 66% sensitivity and 67% specificity, and concentration greater than 4 ng/ml was associated with an odds ratio of death of 5.5 (95% CI 1.3-23.6).


Assuntos
Proteína HMGB1/análise , Choque Séptico/metabolismo , Idoso , Biomarcadores , Calcitonina/análise , Calcitonina/sangue , Calcitonina/metabolismo , Peptídeo Relacionado com Gene de Calcitonina , Ensaio de Imunoadsorção Enzimática , Feminino , França , Proteína HMGB1/sangue , Proteína HMGB1/metabolismo , Humanos , Inflamação/metabolismo , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/fisiopatologia , Estudos Prospectivos , Precursores de Proteínas/análise , Precursores de Proteínas/sangue , Precursores de Proteínas/metabolismo , Choque Séptico/fisiopatologia
13.
Presse Med ; 36(2 Pt 1): 211-6, 2007 Feb.
Artigo em Francês | MEDLINE | ID: mdl-17259029

RESUMO

OBJECTIVE: To analyze patients' assessment of quality of care in our intensive care unit. METHOD: We sent questionnaires to the homes of all patients admitted to intensive care from November 2002 through August 2003 who received mechanical ventilation for more than 24 hours. RESULTS: In all, we received 70 analyzable questionnaires. Patients' average age was 56.3 years and the mean duration of stay 13.6 days. Pain was mentioned by 47% of patients and was associated, in decreasing order of frequency, with endotracheal suctioning, placement of a urinary catheter, venipuncture, movement into a different position by staff and arterial punctures. Pain intensity evaluated by an analogic visual scale classified these procedures in the following order: endotracheal suctioning, urinary catheterization, position changing by staff, arterial punctures, venipunctures. 54% of the patients remembered mechanical ventilation. Overall, 17% reported feeling fear often or continuously. Aspects of the ICU environment that bothered them were, in order of decreasing frequency, communication difficulties, thirst, lack of sleep, staff discussions at the patient's bedside, noise and light. Finally, 34% no longer remembered the reason for their stay in the ICU and 19% reported they would have liked to be allowed more frequent visits from their relatives. CONCLUSION: Nearly half of the respondents underwent painful procedures, primarily endotracheal suctioning. One third did not know why they had been in the ICU. To improve the quality of intensive care, it is essential to make the nursing and medical teams aware of these findings.


Assuntos
Cuidados Críticos/psicologia , Unidades de Terapia Intensiva , Pacientes/psicologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Comunicação , Depressão/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
14.
Crit Care ; 11(1): R8, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17241453

RESUMO

INTRODUCTION: The product of growth arrest-specific gene 6 (Gas6) is a vitamin K dependent protein that is secreted by leucocytes and endothelial cells in response to injury and participates in cell survival, proliferation, migration and adhesion. Our purpose was to investigate plasma Gas6 concentration and its relation to organ dysfunction in patients with septic shock. METHODS: Forty-five patients with septic shock admitted to a medical adult intensive care unit were enrolled. Plasma Gas6 concentration was determined using enzyme-linked immunosorbent assay at days 1, 3, 7 and 14. RESULTS: The median (interquartile range) Gas6 concentration was 51 (5 to 95) pg/ml at admission. A positive correlation (Spearman rank-order coefficient [rs] = 0.37, P = 0.01) was found between Gas6 level and Sepsis-related Organ Failure Assessment score. Patients requiring renal support had higher Gas6 concentration that those without need for haemofiltration (76.5 [52 to 164] pg/ml versus 10.5 [1.5 to 80.5] pg/ml; P = 0.04). Moreover, there was a positive correlation between Gas6 and aspartate transaminase (rs = 0.42, P = 0.006) and between Gas6 and prothrombin time (rs = 0.45, P = 0.02). Although there was a progressive decline in Gas6 concentration in survivors (analysis of variance, P = 0.01), nonsurvivors exhibited persistently elevated Gas6. However, the two populations diverged only after day 7 (P = 0.04). CONCLUSION: Plasma concentrations of Gas6 correlate with disease severity, especially with renal and hepatic dysfunction, in septic shock.


Assuntos
Peptídeos e Proteínas de Sinalização Intercelular/sangue , Choque Séptico/sangue , Adulto , Idoso , Análise de Variância , Aspartato Aminotransferases/sangue , Feminino , Humanos , Nefropatias/sangue , Nefropatias/etiologia , Hepatopatias/sangue , Hepatopatias/etiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Índice de Gravidade de Doença , Choque Séptico/complicações , Choque Séptico/mortalidade
15.
Crit Care Med ; 33(4): 792-6, 2005 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15818107

RESUMO

OBJECTIVE: To describe the course of plasma sTREM (soluble triggering receptor expressed on myeloid cells)-1, procalcitonin (PCT), and C-reactive protein (CRP) concentrations during sepsis and their clinical informative value in predicting outcome. DESIGN: Prospective, noninterventional study. SETTING: Medical adult intensive care unit at a university hospital in France. PATIENTS: Sixty-three critically ill patients with sepsis, severe sepsis, or septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Soluble TREM-1 concentrations were significantly lower at admission in nonsurvivors (n = 21) than in survivors (n = 42) (94 [30-258] vs. 154 [52-435] pg/mL, p = .02), whereas PCT levels were higher among nonsurvivors (19.2 [0.3-179] vs. 2.4 (0-254) pg/mL, p = .001). CRP levels did not differ between the two groups of patients. Plasma PCT and CRP decreased during the 14-day period of study in both survivors and nonsurvivors. Conversely, sTREM-1 plasma concentrations remained stable or even increased in nonsurviving patients and decreased in survivors. An elevated baseline sTREM-1 level was found to be an independent protective factor with an odds of dying of 0.1 (95% confidence interval, 0.1-0.8). CONCLUSION: A progressive decline of plasma sTREM-1 concentration indicates a favorable clinical evolution during the recovery phase of sepsis. In addition, baseline sTREM-1 level may prove useful in predicting outcome of septic patients.


Assuntos
Proteína C-Reativa/metabolismo , Calcitonina/sangue , Glicoproteínas de Membrana/sangue , Precursores de Proteínas/sangue , Receptores Imunológicos/sangue , Sepse/sangue , Sepse/imunologia , Biomarcadores/sangue , Peptídeo Relacionado com Gene de Calcitonina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Análise de Sobrevida , Fatores de Tempo , Receptor Gatilho 1 Expresso em Células Mieloides
16.
Lancet ; 365(9462): 871-5, 2005.
Artigo em Inglês | MEDLINE | ID: mdl-15752531

RESUMO

BACKGROUND: Hyperlactataemia during septic shock is often viewed as evidence of tissue hypoxia. However, this blood disorder is not usually correlated with indicators of perfusion or diminished with increased oxygen delivery. Muscles can generate lactate under aerobic conditions in a process linking glycolytic ATP supply to stimulation of Na+K+ ATPase. Using in-vivo microdialysis, we tested whether inhibition of Na+K+ ATPase can reduce muscle lactate. METHODS: In 14 patients with septic shock, two microdialysis probes were inserted into the quadriceps muscles and infused with lactate-free Ringer's solution in the absence or presence of 10(-7) mol/L ouabain, a specific inhibitor of Na+K+ ATPase. We measured lactate and pyruvate concentrations in both the dialysate fluid and arterial blood samples. FINDINGS: All patients had increased blood lactate concentrations (mean 4.0 mmol/L; SD 2.1). Lactate and pyruvate concentrations were consistently higher in muscle than in arteries during the study period, with a mean positive gradient of 1.98 mmol/L (SD 0.2; p=0.001) and 230 micromol/L (30; p=0.01), respectively. Ouabain infusion stopped over production of muscle lactate and pyruvate (p=0.0001). Muscle lactate to pyruvate ratios remained unchanged during ouabain infusion with no differences between blood and muscle. INTERPRETATION: Skeletal muscle could be a leading source of lactate formation as a result of exaggerated aerobic glycolysis through Na+K+ ATPase stimulation during septic shock. Lactate clearance as an end-point of resuscitation could therefore prove useful. RELEVANCE TO CLINICAL PRACTICE: In patients with septic shock, a high lactate concentration should be interpreted as a marker of disease, portending a bad outcome. The presence of hyperlactataemia in resuscitated septic patients should not be taken as proof of oxygen debt needing increases in systemic or regional oxygen transport to supranormal values. Lactate, instead of being regarded only as a marker of hypoxia, might be an important metabolic signal.


Assuntos
Ácido Láctico/metabolismo , Músculo Esquelético/metabolismo , Choque Séptico/metabolismo , ATPase Trocadora de Sódio-Potássio/metabolismo , Aerobiose , Idoso , Inibidores Enzimáticos/farmacologia , Glicólise , Humanos , Ácido Láctico/sangue , Microdiálise , Músculo Esquelético/enzimologia , Ouabaína/farmacologia , Oxigênio/metabolismo , Pressão Parcial , Ácido Pirúvico/sangue , ATPase Trocadora de Sódio-Potássio/antagonistas & inibidores
17.
Intensive Care Med ; 31(3): 388-92, 2005 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-15703896

RESUMO

OBJECTIVE: To study the factors associated with relative adrenocortical deficiency in mechanically ventilated, critically ill patients. DESIGN AND SETTING: Prospective observational study in a multidisciplinary ICU of a university-affiliated teaching hospital. PATIENTS: Sixty-two consecutive, acutely ill patients needing mechanical ventilation for more than 24 h. MEASUREMENTS AND RESULTS: A high-dose short corticotropin test 24 h after endotracheal intubation. Relative adrenocortical deficiency ("nonresponder" group of patients) was defined by a rise in cortisol less than 90 microg/l after stimulation. Twenty-seven patients were classified as nonresponders and 35 as responders. On univariate analysis nonresponders were more often men, had lower mean arterial pressure, required vasoactive agents more often, had lower creatinine clearance, higher SAPS II, higher organ dysfunction scores, and received etomidate as a single bolus for endotracheal intubation more often than responders. On multivariate analysis, only etomidate administration was related to relative adrenocortical deficiency (OR 12.21; 95% CI 2.99-49.74) while female gender was protective (OR 0.13; 95% CI 0.03-0.57). CONCLUSIONS: A single bolus infusion of etomidate could be a major risk factor for the development of relative adrenocortical deficiency in ICU patients for at least 24 h after administration. Female gender is an independent protective factor.


Assuntos
Doença de Addison/epidemiologia , Cuidados Críticos/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Doença de Addison/sangue , Doença de Addison/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios/uso terapêutico , Pressão Sanguínea , Estudos de Coortes , Etomidato/uso terapêutico , Feminino , França/epidemiologia , Humanos , Hidrocortisona/sangue , Hidrocortisona/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Fatores de Risco , Distribuição por Sexo
18.
Ann Intern Med ; 141(1): 9-15, 2004 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-15238365

RESUMO

BACKGROUND: Previous experimental studies have suggested that the triggering receptor expressed on myeloid cells-1 (TREM-1) is specifically upregulated in the presence of microbial products. OBJECTIVE: To evaluate the diagnostic value of plasma levels of the soluble form of TREM-1 in patients admitted with clinical suspicion of infection. DESIGN: Prospective, noninterventional study conducted between July and September 2003. SETTING: Medical adult intensive care unit at a university hospital in France. PARTICIPANTS: 76 consecutive newly admitted patients who presented with clinically suspected infection and fulfilled at least 2 criteria of the systemic inflammatory response syndrome. MEASUREMENTS: Sensitivity and specificity of plasma soluble TREM-1 levels at admission for the diagnosis of infection. Two independent intensivists blinded to the results of soluble TREM-1 assays retrospectively classified patients as having the systemic inflammatory response syndrome, sepsis, severe sepsis, or septic shock. RESULTS: The systemic inflammatory response syndrome was diagnosed in 29 patients (38%), and sepsis, severe sepsis, or septic shock was diagnosed in the remaining 47 (62%). A plasma soluble TREM-1 level higher than 60 ng/mL was more accurate than any other clinical or laboratory finding for indicating infection (sensitivity, 96% [95% CI, 92% to 100%]; specificity, 89% [CI, 82% to 95%]; positive likelihood ratio, 8.6 [CI, 3.8 to 21.5]; negative likelihood ratio, 0.04 [CI, 0.01 to 0.2]). LIMITATIONS: The study did not enroll patients with mild infections not requiring intensive care unit hospitalization, patients older than 80 years of age, or patients who were immunocompromised. CONCLUSION: In newly admitted critically ill patients, measurement of plasma levels of soluble TREM-1 could help to rapidly identify those with infection.


Assuntos
Glicoproteínas de Membrana/sangue , Receptores Imunológicos/sangue , Sepse/diagnóstico , Western Blotting , Proteína C-Reativa/análise , Calcitonina/sangue , Estado Terminal , Diagnóstico Diferencial , Feminino , Humanos , Inflamação/diagnóstico , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Precursores de Proteínas/sangue , Receptor Gatilho 1 Expresso em Células Mieloides
19.
N Engl J Med ; 350(5): 451-8, 2004 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-14749453

RESUMO

BACKGROUND: The diagnosis and treatment of bacterial pneumonia in patients who are receiving mechanical ventilation remain a difficult challenge. The triggering receptor expressed on myeloid cells (TREM-1) is a member of the immunoglobulin superfamily, and its expression on phagocytes is specifically up-regulated by microbial products. The presence of soluble TREM-1 (sTREM-1) in bronchoalveolar-lavage fluid from patients receiving mechanical ventilation may be an indicator of pneumonia. METHODS: We conducted a prospective study of 148 patients receiving mechanical ventilation in whom infectious pneumonia was suspected. A rapid immunoblot technique was used to measure sTREM-1 in bronchoalveolar-lavage fluid. Two independent intensivists who were unaware of the results of the sTREM-1 assay determined whether community-acquired pneumonia and ventilator-associated pneumonia were present or absent. RESULTS: The final diagnosis was community-acquired pneumonia in 38 patients, ventilator-associated pneumonia in 46 patients, and no pneumonia in 64 patients. The presence of sTREM-1 by itself was more accurate than any clinical findings or laboratory values in identifying the presence of bacterial or fungal pneumonia (likelihood ratio, 10.38; sensitivity, 98 percent; specificity, 90 percent). In multiple logistic-regression analysis, the presence of sTREM-1 was the strongest independent predictor of pneumonia (odds ratio, 41.5). CONCLUSIONS: In patients receiving mechanical ventilation, rapid detection of sTREM-1 in bronchoalveolar-lavage fluid may be useful in establishing or excluding the diagnosis of bacterial or fungal pneumonia.


Assuntos
Líquido da Lavagem Broncoalveolar/química , Glicoproteínas de Membrana , Pneumonia Bacteriana/diagnóstico , Receptores Imunológicos/análise , Respiração Artificial , Idoso , Biomarcadores/análise , Líquido da Lavagem Broncoalveolar/imunologia , Infecções Comunitárias Adquiridas/diagnóstico , Citocinas/análise , Diagnóstico Diferencial , Feminino , Humanos , Modelos Logísticos , Pneumopatias Fúngicas/diagnóstico , Masculino , Pessoa de Meia-Idade , Células Mieloides , Pneumonia/diagnóstico , Pneumonia/etiologia , Pneumonia Bacteriana/imunologia , Pneumonia Bacteriana/terapia , Estudos Prospectivos , Curva ROC , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Receptor Gatilho 1 Expresso em Células Mieloides
20.
Clin Med Res ; 2(3): 181-7, 2004 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-15931355

RESUMO

Sepsis is a common cause of morbidity and mortality in intensive care units. Unfortunately, there is no gold standard for diagnosing sepsis as clinical and laboratory signs are neither sensitive enough nor specific enough, and microbiological studies often remain negative. Thus, there is a need for clinical or laboratory tools to distinguish between sepsis and non-infectious inflammatory disorders. Among the potentially useful markers of sepsis, procalcitonin has been suggested to be the most promising, although results are variable depending on the severity of illness and degree of infection in the patient population studied. The triggering receptor expressed on myeloid cells-1 (TREM-1) is a member of the immunoglobulin superfamily, of which expression is upregulated on phagocytic cells in the presence of bacteria or fungi. Here we report on the potential usefulness of assessing the soluble form of TREM-1 (sTREM-1) in biological fluids for the diagnosis of microbial infection.


Assuntos
Biomarcadores , Glicoproteínas de Membrana/metabolismo , Células Mieloides/metabolismo , Receptores Imunológicos/metabolismo , Sepse/diagnóstico , Sepse/imunologia , Humanos , Células Mieloides/imunologia , Pneumonia/diagnóstico , Pneumonia/imunologia , Solubilidade , Receptor Gatilho 1 Expresso em Células Mieloides
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