Administration of recombinant activated factor VII (NovoSeven) in three cases of uncontrolled bleeding caused by disseminated intravascular coagulopathy.

Recombinant activated factor VII has been used successfully in many cases of traumatic and surgical bleeding complications that were unresponsive to standard treatment. However, because disseminated intravascular coagulation can develop from a thrombin burst as a side effect of recombinant activated factor VII, it is not yet established for bleeding complications induced by disseminated intravascular coagulation. This article presents 3 patients with severe sepsis and fulminant disseminated intravascular coagulation. Excessive microvascular bleeding persisted despite conventional therapy, and surgical intervention and radiologic embolization did not control bleeding. After administration of recombinant activated factor VII, bleeding ceased in all patients, and no overt thromboembolic events occurred. One patient survived to be discharged from the hospital. The other 2 patients died from refractory multiorgan failure and overall poor prognosis. Recombinant factor VIIa might be an option for the treatment of severe bleeding complications in the case of DIC refractory to the conventional therapy.

Alveolar granulocyte colony-stimulating factor and alpha-chemokines in relation to serum levels, pulmonary neutrophilia, and severity of lung injury in ARDS.

OBJECTIVES: To determine granulocyte colony-stimulating factor (G-CSF), epithelial neutrophil-activating peptide (ENA)-78, and interleukin (IL)-8 in BAL fluid (BALF), epithelial lining fluid (ELF), and serum for establishing the concentration gradient of G-CSF, ENA-78, and IL-8 between the blood and the alveolar space in ARDS and acute lung injury (ALI); and to evaluate the relationship of G-CSF, IL-8, and ENA-78 to pulmonary neutrophilia and severity of lung injury. DESIGN: Prospective study. SETTING: An adult trauma/surgical ICU. PATIENTS: Nineteen patients with ARDS and 10 patients with ALI. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: BAL and blood sampling simultaneously within 12 h and 24 h after onset of ARDS/ALI; G-CSF was detected in BALF in 18 of 19 patients with ARDS, in 7 of 10 patients with ALI, and in all serum samples. G-CSF in BALF and serum was significantly higher in ARDS than in ALI. ENA-78 was detected in BALF in 14 of 19 patients with ARDS, in 8 of 10 patients with ALI, and in serum of all patients. Levels in BALF and serum were not different between ARDS and ALI. IL-8 was detected in all patients; concentrations in BALF in ARDS were significantly higher than in ALI. Concentrations of G-CSF, ENA-78, and IL-8 in ELF were significantly higher than in serum. G-CSF in BALF and serum and IL-8 in BALF correlated positively with pulmonary neutrophilia. G-CSF in serum and IL-8 in BALF correlated negatively with PaO(2)/fraction of inspired oxygen (FIO(2)) ratio. However, ENA-78 did not show a correlation with neutrophil count or with PaO(2)/FIO(2) ratio. CONCLUSIONS: G-CSF may be pathophysiologically important for accumulation and activation of neutrophils in ARDS. Local G-CSF production is the likely driving force for neutrophils rather than elevation of circulating levels. In comparison to ENA-78, IL-8 seems to be the predominant neutrophil chemoattractant in the early phase of ARDS.

Effectiveness of direct-current cardioversion for treatment of supraventricular tachyarrhythmias, in particular atrial fibrillation, in surgical intensive care patients.

OBJECTIVE: To evaluate primary success rate and effectiveness of direct-current cardioversion in postoperative critically ill patients with new-onset supraventricular tachyarrhythmias. DESIGN: Prospective intervention study. SETTING: Twelve-bed surgical intensive care unit in a university teaching hospital. PATIENTS: Thirty-seven consecutive, adult surgical intensive care unit patients with new-onset supraventricular tachyarrhythmias without previous history of tachyarrhythmias. INTERVENTIONS: Direct-current cardioversion using a monophasic, damped sinus-wave defibrillator. Energy levels used were 50, 100, 200, and 300 J for regular supraventricular tachyarrhythmias (n = 6) and 100, 200, and 360 J for irregular supraventricular tachyarrhythmias (n = 31). MEASUREMENTS AND MAIN RESULTS: None of the patients was hypoxic, hypokalemic, or hypomagnesemic at onset of supraventricular tachyarrhythmia. Direct-current cardioversion restored sinus rhythm in 13 of 37 patients (35% primary responders). Most patients responded to the first or second direct-current cardioversion shock. Only one of 25 patients requiring more than two direct-current cardioversion shocks converted into sinus rhythm. Primary responders were significantly younger and demonstrated significant differences in arterial Po2 values at onset of supraventricular tachyarrhythmias compared with nonresponders. At 24 and 48 hrs, only six (16%) and five (13.5%) patients remained in sinus rhythm, respectively. CONCLUSIONS: In contrast to recent literature, direct-current cardioversion proved to be an ineffective method for treatment of new-onset supraventricular tachyarrhythmias and, in particular, atrial fibrillation with a rapid ventricular response in surgical intensive care unit patients.