The effect of peer review on mortality rates.

OBJECTIVE: Lowering of mortality rates in hospitals with mortality rates higher than accepted reference values for acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia, stroke, mechanical ventilation (MV) and colorectal surgery by using an external peer review process that identifies areas requiring rectification and implements protocols directed at improving these areas. DESIGN: Retrospective, observational, quality management study using administrative data to compare in-hospital mortality rates (pre and post an external peer review process that included adoption of improvement protocols) with reference values. SETTING: German general hospitals of a large, private group. PARTICIPANTS: Hospitals with mortality rates higher than reference values. INTERVENTIONS: Peer review of medical records by experienced, outside physicians triggered by in-hospital mortality rates higher than expected. Inadequacies were identified, improvement protocols enforced and mortality rates subsequently re-examined. MAIN OUTCOME MEASURES: Mortality rates 1 year before and 1 year after peer review and protocol use. RESULTS: For AMI, CHF, pneumonia, stroke, MV and colorectal surgery, the mortality rates 1 year post-peer review were significantly decreased as compared to pre-peer review mortality rates. The standardized mortality ratio for all of the above diagnoses was 1.45, 1 year before peer review, and 0.97, 1 year after peer review. The absolute risk reduction of 7.3% translates into 710 deaths in this population which could have been prevented. CONCLUSIONS: Peer review triggered and conducted in the manner described here is associated with a significant lowering of in-hospital mortality rates in hospitals that previously had higher than expected mortality rates.

International registry on the use of the CytoSorb® adsorber in ICU patients : Study protocol and preliminary results.

INTRODUCTION: The aim of this clinical registry is to record the use of CytoSorb® adsorber device in critically ill patients under real-life conditions. METHODS: The registry records all relevant information in the course of product use, e. g., diagnosis, comorbidities, course of the condition, treatment, concomitant medication, clinical laboratory parameters, and outcome (ClinicalTrials.gov Identifier: NCT02312024). Primary endpoint is in-hospital mortality as compared to the mortality predicted by the APACHE II and SAPS II score, respectively. RESULTS: As of January 30, 2017, 130 centers from 22 countries were participating. Data available from the start of the registry on May 18, 2015 to November 24, 2016 (122 centers; 22 countries) were analyzed, of whom 20 centers from four countries provided data for a total of 198 patients (mean age 60.3 ± 15.1 years, 135 men [68.2%]). In all, 192 (97.0%) had 1 to 5 Cytosorb® adsorber applications. Sepsis was the most common indication for CytoSorb® treatment (135 patients). Mean APACHE II score in this group was 33.1 ± 8.4 [range 15-52] with a predicted risk of death of 78%, whereas the observed mortality was 65%. There were no significant decreases in the SOFA scores after treatment (17.2 ± 4.8 [3-24]). However interleukin-6 levels were markedly reduced after treatment (median 5000 pg/ml before and 289 pg/ml after treatment, respectively). CONCLUSIONS: This third interim report demonstrates the feasibility of the registry with excellent data quality and completeness from 20 study centers. The results must be interpreted with caution, since the numbers are still small; however the disease severity is remarkably high and suggests that adsorber treatment might be used as an ultimate treatment in life-threatening situations. There were no device-associated side effects.

Prostacyclin in septic shock.

OBJECTIVE: Investigation of the hypothesis that the infusion of 10 ng/kg/min prostacyclin (epoprostenol) (PGI2) improves O2 uptake in patients with hyperdynamic septic shock. DESIGN: Prospective, single cohort design. SETTING: ICU, university hospital. PATIENTS: Fifteen postoperative patients with septic shock. INTERVENTIONS: Infusion of 10 ng/kg/min of PGI2 for 60 min. MEASUREMENTS: Complete hemodynamic profile with O2 transport-related variables (simultaneous measurements of VO2 from the respiratory gases and by cardiovascular Fick) and blood lactate levels before start of the PGI2-infusion and 60 min thereafter. MAIN RESULTS: Oxygen delivery increased significantly (14 percent) from its already high value, 750 +/- 238 to 852 +/- 214 ml/min/m2. The O2 extraction ratio remained unchanged. When VO2 was measured from the respiratory gases, it was unchanged. When VO2 was measured by cardiovascular Fick, it increased slightly (p < 0.05). CONCLUSIONS: We conclude that in this O2 challenge test with PGI2 in patients with septic shock, an increase in O2 delivery was not matched by an increase in VO2. We believe that the adequate conventional support of these patients may have prevented the PGI2 from revealing a "covert" O2 debt. The PGI2 test did not predict mortality by O2 supply dependency. The small increase in VO2 as calculated indirectly suggests a degree of mathematical coupling of O2 delivery and uptake.

Dopexamine hydrochloride in septic shock.

OBJECTIVE: To test whether dopexamine hydrochloride, by its beta 2-adrenoreceptor and dopaminergic 1 (DA1) and dopaminergic 2 (DA2) agonistic properties, can improve oxygen consumption (VO2) in hyperdynamic patients with septic shock. DESIGN: Prospective, single-cohort study. SETTING: ICU, university hospital. PATIENTS: Twenty-nine postoperative, hemodynamically stabilized, hyperdynamic patients with septic shock. INTERVENTIONS: Short-term application (30 min) of dopexamine hydrochloride at a dose of 2 microgram/kg/min. MEASUREMENTS: Complete hemodynamic profile with O2 transport-related variables at baseline, 30 min after starting the dopexamine infusion, and 30 min after stopping the infusion. MAIN RESULTS: The dopexamine infusion resulted in significant increases in cardiac index (17%) (p<0.001) and O2 delivery (DO2) (16%) (p<0.001). VO2 increased slightly but significantly about 4% (p<0.001) by respiratory gas exchange measurements and 9% (p<0.001) by cardiovascular Fick calculations. The O2 extraction ratio decreased about 8% (0.001). CONCLUSIONS: The addition of dopexamine hydrochloride at a dose of 2 microgram/kg/min resulted in significant increases of DO2 and to a lesser extent VO2. Much of the global DO2 increase was not utilized, because O2 extraction ratio decreased. Direct calorigenic effects of dopexamine and an increase in myocardial VO2 likely account for a large portion of the increase in global VO2. Whether any of the VO2 increase reflects improvement in regions of jeopardized tissue oxygenation remains to be clarified before the definite value of this drug in septic shock can be established.

Comparison of invasive and noninvasive measurements of indocyanine green plasma disappearance rate in critically ill patients with mechanical ventilation and stable hemodynamics.

OBJECTIVES: We studied the correlation between invasive (aortic fiberoptic) and noninvasive (transcutaneous sensor) measurements of indocyanine green (ICG) plasma disappearance rate (PDR) in critically ill patients. DESIGN AND SETTING: Prospective clinical study in a surgical intensive care unit of a university hospital. PATIENTS: 16 critically ill patients with adult respiratory distress syndrome (n = 8), sepsis/septic shock (n = 6), subarachnoid hemorrhage (n = 1), or severe head injury (n = 1). MEASUREMENTS AND RESULTS: We analyzed 16 pairs of simultaneous ICG PDR measurements. All patients were deeply sedated and mechanically ventilated. Each patient received a 4-F aortic catheter with an integrated fiberoptic and thermistor connected to a computer system for automatic calculation of invasive ICG PDR (PDRINV). An ICG sensor was also attached to the nose wing and connected to a DDG2001 analyzer for noninvasive measurement (PDRNINV). Linear regression analysis revealed PDRNINV = 0.98 PDRINV +0.11%/min (r = 0.94, p < 0.0001) with a mean bias of 0.2 +/- 2.0%/min. CONCLUSION: Noninvasive measurements of ICG PDR are very highly correlated with values derived from an invasive fiberoptic-based reference technique.

Comparison of pulmonary artery and arterial thermodilution cardiac output in critically ill patients.

OBJECTIVE: We studied the agreement between cardiac output measurements via pulmonary artery thermodilution [CO(PA)], regarded as the current clinical gold standard, and aortic transpulmonary thermodilution [CO(AORTA)]. DESIGN: Prospective clinical study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: 37 patients with sepsis or septic shock (n = 34) and subarachnoid haemorrhage (n = 3). MEASUREMENTS AND RESULTS: We analysed 449 simultaneous cardiac output measurements. All patients were deeply sedated and mechanically ventilated in a pressure controlled mode. Each patient received a 7.5-F five-lumen pulmonary artery catheter and a 4-F aortic catheter with an integrated thermistor. The thermistors of the two different catheters were connected to one computer system (COLD-Z021, Pulsion Medical Systems, Munich, Germany). Linear regression analysis revealed: CO(AORTA) = 0.96. CO(PA) + 1.02 (l/min) (r = 0.97, p < 0.0001). CO(AORTA) was consistently higher than CO(PA) with a bias of 0.68 (l/min) and a standard deviation of 0.62 (l/min). CONCLUSION: Cardiac output derived from aortic transpulmonary thermodilution is suitable for measurement in the intensive care unit. Measurements of CO(AORTA) are consistent with, but slightly higher than, those obtained from pulmonary artery thermodilution.

Advantages of endoscopic therapy of gastrojejunal dissociation in critical care patients.

OBJECTIVE: To evaluate the advantages of a new three-lumen tube (Trelumina) and a percutaneous endoscopic gastrostomy (EntriStar) with a jejunal insertion tube (PEGJ) as a safe method of early enteral nutrition and simultaneous gastric decompression as well as fast reduction of the high gastric reflux in critical care patients. DESIGN: Retrospective, descriptive case series. SETTING: Two anaesthesiological and one surgical intensive care unit (ICU) in a university hospital. PATIENTS: Sixty-five consecutive critically ill patients with gastrojejunal dissociation. The mean Acute Physiology and Chronic Health Evaluation Score (APACHE II) was 19. INTERVENTIONS: Placement of 46 Trelumina and 19 PEGJ under endoscopic control. MEASUREMENTS AND MAIN RESULTS: None of the known percutaneous endoscopic gastrostomy (PEG) complications like wound infection, bleeding or organ perforation were seen. One secondary dislocation of the jejunal insertion tube and four dislocations of the jejunal part of the Trelumina were found. The average gastric reflux of the Trelumina and the PEGJ amounted to 1700 +/- 230 ml/day. Forty-three patients showed a clear decrease in the gastric reflux to 450 +/- 200 ml/day within the first 24 h of tube placement. The average time of reduction to normal gastric reflux volumes (0-200 ml/day) amounted to 4 -/+ 2 days. Forty-three (71 %) of the patients showed improved intestinal passage as expressed by regular peristalsis and defaecation. The price for 1 day enteral feeding via Trelumina or PEGJ was 10 times lower than 1 day total parenteral nutrition. CONCLUSIONS: Placement of the Trelumina and the PEGJ is a safe, successful and inexpensive means of early enteral nutrition and simultaneous gastric reflux reduction in critical care patients.

Variability of splanchnic blood flow in patients with sepsis.

OBJECTIVES: Previous studies on therapeutic interventions in sepsis have assumed stability of the measure of splanchnic blood flow throughout the study. We assessed the variability of splanchnic blood flow during stable global hemodynamics in eight patients with sepsis requiring treatment with dobutamine and/or norepinephrine. DESIGN AND SETTING: Prospective clinical study in an intensive care unit of a university hospital. MEASUREMENTS AND RESULTS: Global and regional hemodynamics were measured at baseline, 2 h later, and 4 h later. Cardiac output was measured by transpulmonary thermodilution, intrathoracic blood volume as an indicator of cardiac preload, and total blood volume by the double indicator (thermo-dye) dilution technique. Total body oxygen consumption was assessed by indirect calorimetry using a metabolic cart. Splanchnic blood flow was measured by the continuous indocyanine green method, and gastric mucosal CO2 tension by gas tonometry. Neither absolute nor fractional splanchnic blood flow (as ratio of cardiac output) revealed significant global tendencies during the study period. However, variance component analysis showed that splanchnic blood flow determinations varied considerably within patients, for repeated measurements at 5-min intervals (standard error 31.1%) as well as for average values at 2-h intervals (25.6%). CONCLUSION: Stable global hemodynamics during a 4-h period in septic patients does not exclude marked changes in splanchnic blood measured by a hepatic venous catheter technique.

The effects of low-dose dopamine on splanchnic blood flow and oxygen uptake in patients with septic shock.

OBJECTIVE: To assess the effects of low-dose dopamine on splanchnic blood flow and splanchnic oxygen uptake in patients with septic shock. DESIGN: Prospective, controlled trial. SETTING: University hospital intensive care unit. PATIENTS: 11 patients with septic shock, diagnosed according the criteria of the 1992 American College of Chest Physicians/Society of Critical Care Medicine consensus conference, who required treatment with norepinephrine. MEASUREMENTS AND MAIN RESULTS: Systemic and splanchnic hemodynamics and oxygen transport were measured before and during addition of low-dose dopamine (3 micrograms/kg per min). Low-dose dopamine and a marked effect on total body hemodynamics and oxygen transport. The fractional splanchnic flow at baseline ranged from 0.15 to 0.57. In 7 patients with a fractional splanchnic flow less than 0.30, low-dose dopamine increased splanchnic flow and splanchnic oxygen delivery and oxygen consumption. In 4 patients with a fractional splanchnic flow above 0.30, low-dose dopamine did not appear to change splanchnic blood flow. CONCLUSION: Low-dose dopamine has a potential beneficial effect on splanchnic blood flow and oxygen consumption in patients with septic shock, provided the fractional splanchnic flow is not already high before treatment.

A controlled study of leukocyte activation in septic patients.

OBJECTIVE: Qualitative and quantitative evaluation of leukocyte activation in septic patients in comparison to two control groups. DESIGN: A prospective clinical study in which the leukocyte oxidative output of whole blood was measured in three groups of patients. Two chemiluminescence markers (luminol or lucigenin), indicative of either total oxidant output or superoxide production, and three stimuli (opsonized zymosan, formyl-methionyl-leucyl-phenylalanine (fMLP), phorbol myristate acetate) (PMA), representing different pathways of leukocyte activation, were used. Tumor necrosis factor, interleukin-6 and C-reactive protein (TNF, IL-6, and CRP) were determined to evaluate the severity of the inflammatory process. SETTING: Intensive care and surgical units of a university hospital. PATIENTS: Seventy-four healthy patients, ten ICU patients without signs of sepsis or systemic inflammatory response syndrome and 19 septic patients were studied. MEASUREMENT AND MAIN RESULTS: With all three stimuli, whole blood total oxidative output and superoxide production were generally increased in septic patients. This was most likely due to the increased leukocyte numbers in these patients. When the chemiluminescence values were normalized per phagocyte (granulocytes and monocytes), the total oxidative output of septic phagocytes decreased with opsonin and fMLP but increased with PMA, while superoxide output decreased regardless of the stimuli used. TNF, IL-6 and CRP, although increased in septic patients as compared to ICU controls, correlated weakly with oxidant output. CONCLUSIONS: The oxidative output of whole blood was increased in septic patients compared to controls because of elevated leukocyte numbers. However, oxidant output normalized for phagocyte numbers generally decreases during sepsis for most stimuli. Cytokines and CRP do not appear to be associated with the extent of oxidant output during sepsis.

Splanchnic blood flow is greater in septic shock treated with norepinephrine than in severe sepsis.

OBJECTIVE: To assess global and splanchnic blood flow and oxygen transport in patients with sepsis with and without norepinephrine treatment. DESIGN: Prospective, clinical study. SETTING: University hospital intensive care unit. PATIENTS: A convenience sample of 15 septic shock patients treated with norepinephrine and 13 patients with severe sepsis who did not receive norepinephrine. MEASUREMENTS AND MAIN RESULTS: There were no differences between the two groups in global haemodynamics and oxygen transport. Splanchnic blood flow and oxygen delivery (splanchnic DO2 303 +/- 43 ml/min per m2) and consumption (splanchnic VO2 100 +/- 13 ml/min per m2) were much higher in the septic shock group compared with the severe sepsis group (splanchnic DO2 175 +/- 19 ml/min per m2, splanchnic VO2 61 +/- 6 ml/min per m2). Gastric mucosal pH was subnormal in both groups (septic shock 7.29 +/- 0.02, severe sepsis 7.25 +/- 0.02) with no significant difference. No significant differences between groups were detected in lactate values. CONCLUSION: These data confirm a redistribution of blood flow to the splanchnic region in sepsis that is even more pronounced in patients with septic shock requiring norepinephrine. However, subnormal gastric mucosal pH suggested inadequate oxygenation in parts of the splanchnic region due to factors other than splanchnic hypoperfusion. Progress in this area will depend on techniques that address not only total splanchnic blood flow, but also inter-organ flow distribution, intra-organ distribution, and other microcirculatory or metabolic malfunctions.

Effect of plasma and LPS on respiratory burst of neutrophils in septic patients.

OBJECTIVE: To compare the respiratory burst of neutrophils in sepsis and control patients using lipopolysaccharide (LPS), autologous plasma, and a combination of the two. DESIGN: Prospective, consecutive case study. SETTING: A 16-bed intensive care unit (ICU) in a university teaching hospital. INTERVENTIONS: None. PATIENTS: Plasma was obtained from 23 healthy patients scheduled for minor surgery immediately prior to induction of anesthesia (controls) and from 23 ICU patients within 24 h of diagnosis of sepsis or septic shock. MEASUREMENTS AND MAIN RESULTS: Respiratory burst was determined by lucigenin chemiluminescence expressed as mean +/- SEM of peak values of relative light units per neutrophil. There were no significant differences between neutrophils of septic patients and controls for the stimuli saline, phorbol myristate acetate, formyl-methionyl-leucyl-phenylalanine, and LPS alone. Septic patients showed a lower respiratory burst than controls (p < 0.05) under the following stimuli: plasma alone (5911 +/- 803 vs 15,397 +/- 3038) and LPS and plasma combined (13,857 +/- 1537 vs 23,026 +/- 2640). However, when stimulated with plasma after priming with LPS, septic patients elicited a higher value than control subjects (11,373 +/- 1758 vs 5987 +/- 1234, p < 0.05). CONCLUSIONS: (1) Some components of the plasma of septic patients may have a profound effect on neutrophil response; (2) plasma as a respiratory burst stimulus differentiates between sepsis and non-sepsis samples better than other common stimuli; (3) precautions must be taken when using plasma together with LPS because of the different response depending on whether LPS-priming precedes the plasma stimulus or both are introduced simultaneously and whether septic or nonseptic plasma is used.

Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution.

OBJECTIVE: Transpulmonary double-indicator dilution is a useful monitoring technique for measurement of intrathoracic blood volume (ITBV) and extravascular lung water (EVLW). In this study, we compared a simpler approach using single arterial thermodilution derived measurements of ITBV and EVLW with the double-indicator dilution technique. DESIGN: Prospective observational clinical study. SETTING: Surgical intensive care units of two university hospitals. PATIENTS AND METHODS: Global end-diastolic volume (GEDV) derived from single thermodilution was used for calculation of ITBV. Structural regression analysis of the first two thermo-dye dilution measurements in a derivation population of 57 critically ill patients (38 male, 19 female, 18-79 years, 56 +/- 15 years) revealed ITBV = (1.25 x GEDV)-28.4 (ml). This equation was then applied to all first measurements in a validation population of 209 critically ill patients (139 male, 70 female, 10-88 years, mean 53 +/- 19 years), and single-thermodilution ITBV (ITBV(ST)) and EVLW (EVLW(ST)) was calculated and compared to thermo-dye dilution derived values (ITBV(TD), EVLW(TD)). For inter-individual comparison, absolute values for ITBV and EVLW were normalised as indexed by body surface area (ITBVI) and body weight (EVLWI), respectively. MEASUREMENTS AND RESULTS: Linear regression analysis yielded a correlation of ITBVI(ST) = (1.05 x ITBVI(TD))-58.0 (ml/m2), r = 0.97, P < 0.0001. Bias between ITBVI(TD) and ITBVI(ST) was 7.6 (ml/m2) with a standard deviation of 57.4 (ml/m2). Single-thermodilution EVLWI (EVLWI(ST)) was calculated using ITBVI(ST) and revealed the correlation EVLWI(ST) = (0.83 x EVLWI(TD)) + 1.6 (ml/kg), r = 0.96, P < 0.0001. Bias between EVLWI(TD) and EVLWI(ST) was -0.2 (ml/kg) with a standard deviation of 1.4 (ml/kg). In detail, EVLWI(ST) systematically overestimated EVLWI(TD) at low-normal values for EVLWI and underestimated EVLWI at higher values (above 12 ml/kg). CONCLUSION: Determinations of ITBV and EVLW by single thermodilution agreed closely with the corresponding values from the double-indicator technique. Since transpulmonary single thermodilution is simple to apply, less invasive and cheaper, all these features make it a promising technique for the bedside. Nevertheless, further validation studies are needed in the future.

Comparison between intrathoracic blood volume and cardiac filling pressures in the early phase of hemodynamic instability of patients with sepsis or septic shock.

PURPOSE: The purpose of this study was to analyze three different variables of cardiac preload; central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), and intrathoracic blood volume index (ITBVI) that served as the best indicator of cardiac function, that is, cardiac index (C1) or stroke index (SI). MATERIALS AND METHODS: This was a prospective study in 57 critically ill patients with sepsis or septic shock in whom 581 hemodynamic profiles were analyzed. One patient was included a second time after a period of 6 weeks. All patients were sedated and mechanically ventilated. Each patient had a 7.5-Frfive-lumen pulmonary artery catheter (PAC) and a 4-Fr catheter with an integrated thermistor and fiberoptic that was advanced into the descending aorta via a femoral artery sheath. The study was performed in the surgical intensive care unit of a university hospital. RESULTS: Linear regression analysis of the first profile for each case (n = 58) revealed a significant correlation between ITBVI and SI (r = 0.66). For comparison, correlations for PAOP/SI (r = 0.06) and CVP/SI (r = 0.10) were poor. The analysis of all second profiles showed that only the change in ITBVI reflected the change in SI (r = 0.67), whereas PAOP (r = 0.07) and CVP (r = 0.05) failed. Furthermore, a positive change in SI (n = 265) was most often associated with an increase in ITBVI (n = 189, 71.3%), less for PAOP (n = 122, 46.0%) and CVP (n = 137, 51.7%). A reduction in SI (n = 256) was accompanied by a decrease in ITBVI (n = 176, 68.8%), PAOP (n = 119, 46.5%), and CVP (n = 118, 46.1%). An increase in ITBVI (n = 269) was accompanied by an increase in SI in 189 cases (70.3%). In these, PAOP increased only in 91 (48.1%) and CVP in 101 cases (53.4%), respectively. Accordingly, a positive change in PAOP (n = 218) was associated with an increase in SI in 122 cases (56.0%). ITBVI increased in 91 (74.6%) and CVP in 84 (68.9%) of these cases. A decrease in ITBVI (n = 250) was associated with a decrease in SI in 176 cases (70.4%). Decreases in PAOP (n = 89, 50.6%) and CVP (n = 91, 51.7%) did not reflect these changes. However, when PAOP (n = 229) and SI decreased (n = 119, 52.0%), ITBVI decreased in 89 (74.8%) and CVP in 73 cases (61.3%). CONCLUSIONS: In comparison with cardiac filling pressures, ITBVI seems to be the more reliable indicator of cardiac preload in patients with sepsis or septic shock.

The relevance of measuring O2 supply and O2 consumption for assessment of regional tissue oxygenation.

Septic shock and ARDS are associated with disturbed tissue oxygenation. It has been suggested to increase O2 supply (DO2) above the normal level (> 600 ml/min/m2) to compensate for the tissue hypoxia. The lack of a rise in O2 consumption (VO2) after increases of DO2 has been presumed to indicate adequate tissue oxygenation (negative O2 flux test). We were interested in whether a negative O2 flux test precludes an improvement of regional tissue oxygenation. The pH value of the gastric mucosa (pHi) is considered to be a sensitive marker for hypoxia in the splanchnic region. We measured pHi as well as DO2 and VO2 in 10 patients with hyperdynamic septic shock to assess the effect of volume substitution on tissue oxygenation. The initial therapeutic approach (volume substitution and catecholamines) led to a DO2 of 717 +/- 187 ml/min/m2. However, all patients had pHi values < 7.35 indicating regional tissue hypoxia. An additional increase of DO2 by colloidal volume substitution caused a significant rise of pHi from 7.20 +/- 0.05 to 7.25 +/- 0.05 but did not change VO2. We conclude that a negative O2 flux test does not rule out regional tissue hypoxia, and second, an increase in DO2 may improve tissue oxygenation without measurable changes in VO2. Furthermore, adequate volume substitution is an important step in the treatment of septic shock to increase total body blood flow and more specifically regional blood flow.

The relationship between mixed venous and hepatic venous O2 saturation in patients with septic shock.

It was the purpose of this study to measure the relationship between hepatic venous O2 saturation (ShvO2) and mixed venous O2 saturation (SvO2) in septic patients (n = 21) following treatment with various catecholamines (epinephrine, norepinephrine, dopamine, dopexamine). At baseline mean SvO2 was 74 +/- 5% while mean ShvO2 was 59 +/- 12%. Alpha-mimetic substances such as epinephrine and norepinephrine reduced ShvO2 and increased the difference between SvO2 and ShvO2.Beta2-mimetic and dopaminergic substances (dopexamine, dopamine) did not change the difference between SvO2 and ShvO2. These results show that SvO2 does not necessarily reflect all changes of ShvO2. Monitoring ShvO2 may be helpful in managing septic shock by adding information on adequacy of O2 supply/consumption ratio in the crucial splanchnic region.

[Effects of a mandatory guideline that prohibit hospital doctors from accepting any form of benefits in any form from the pharmaceutical industry]. / Der Einfluss einer krankenhausinternen Richtlinie auf die Einstellung von Arzten zur pharmazeutischen Industrie.

BACKGROUND AND OBJECTIVE: Several hospitals have issued their own guidelines that regulate the conduct of staff members toward the pharmaceutical industry. The effect of theses guidelines on the attitude of the doctors toward the pharmaceutical industry in Germany has so far been unknown. This study investigated whether hospital doctors with guidelines and those without guidelines differ in their attitude toward the pharmaceutical industry. METHODS: A retrospective analysis was undertaken to determine the influence of hospital guidelines on the attitude of doctors toward the pharmaceutical industry. In May 2008 all doctors in intensive care of a hospital with and one without guidelines were asked anonymously by a questionnaire about their dealings with the pharmaceutical industry. The response rate was 64.9 % (37/57) and 55.1 % (59/107) respectively. The cooperation rate in both groups was 100 %. RESULTS: In the hospital with guidelines every doctor was on average carrying 0.56 +/- 0.64 pharmaceutical advertising gifts with a company logo, while the average in the institution without guidelines was 1.2 +/- 0.61 advertising gifts (p = 0.026). Whereas 49 % of doctors with guidelines considered the acceptance of advertising gifts as not questionable, 81 % without guidelines did (p = 0.001; RRR = 0.65; 95 % CI = 0.48-0.91). Furthermore, 70 % of doctors in the institution with guidelines compared with 92 % of those doctors in the hospital without guidelines believed that the advertising practices of the pharmaceutical industry had no influence on their prescribing behaviour (p = 0.010; RRR = 3.6; 95 % CI = 1.36-9.52). Both groups of doctors are convinced that other doctors are more influenced by the pharmaceutical industry than they are themselves (51 % with and 37 % without guidelines, p = 0.207). 70 % and 90 %, respectively of all participants considered hospital guidelines setting standards of conduct toward the pharmaceutical industry and those not sponsored by industry to have a positive effect. Every other doctor additionally stated the advice by the pharmaceutical industry was not helpful for his work. CONCLUSIONS: Hospital guidelines on relations with the pharmaceutical industry appear to further a critical attitude by physicians regarding the pharmaceutical industry.