Hypoalbuminemia in critically sick children

Context:

There is a paucity of data evaluating serum albumin levels and outcome of critically ill-children admitted to intensive care unit (ICU).

Aims:

The aim was to study frequency of hypoalbuminemia and examine association between hypoalbuminemia and outcome in critically ill-children.

Settings and Design:

Retrospective review of medical records of 435 patients admitted to 12 bedded pediatric ICU (PICU).

Materials and Methods:

Patients with hypoalbuminemia on admission or any time during PICU stay were compared with normoalbuminemic patients for demographic and clinical profile. Effect of albumin infusion was also examined. Odds ratio and 95% confidence interval were calculated using SPSS 16.

Results:

Hypoalbuminemia was present on admission in 21% (92 of 435) patients that increased to 34% at the end of 1^st week and to 37% (164 of 435) during rest of the stay in PICU. Hypoalbuminemic patients had higher Pediatric Risk of Mortality scores (12.9 vs. 7.5, P < 0.001) and prolonged PICU stay (13.8 vs. 6.7 days, P < 0.001); higher likelihood of respiratory failure requiring mechanical ventilaton (84.8% vs. 28.8%, P < 0.001), prolonged ventilatory support, progression to multiorgan dysfunction syndrome (87.8% vs. 16.2%) and risk of mortality (25.6% vs. 17.7%). Though, the survivors among recipients of albumin infusion had significantly higher increase in serum albumin level (0.76 g/dL, standard deviation [SD] 0.54) compared with nonsurvivors (0.46 g/dL, SD 0.44; P = 0.016), albumin infusion did not reduce the risk of mortality.

Conclusions:

Hypoalbuminemia is a significant indicator of mortality and morbidity in critically sick children. More studies are needed to define role of albumin infusion in treatment of such patients.     

Tracheostomy in the management of patients with thermal injuries

Objective:

To assess the use and clinical impact of tracheostomy in burn patients.

Summary Background Data:

The role of tracheostomy in the management of burn patients is controversial, with only a few recent studies conducted in this population.

Methods:

Retrospective study of all adult burn patients who underwent a tracheostomy in a Burns Unit between 1995 and 2013. These were compared with a control group (1:1) who underwent orotracheal intubation. Hospital records were reviewed to obtain demographic and clinical information, including those related to respiratory support and tracheostomy. The McNemar''s Chi-square and Signed-Rank Tests were used to study differences in morbimortality between both groups.

Results:

A total of n = 20 patients underwent tracheostomy (0.9% of admissions, 56.0 ± 19.5 years, 60.0% women). The most common indication was long-term ventilation (75%), 24.6 ± 19.7 days after admission. Thirteen patients were successfully decannulated with a fatal complication observed in one case. Patients in the tracheostomy group were found to require longer-term mechanical ventilation (43.2 vs. 20.4 days; P = 0.004), with no differences in respiratory infection rates (30.0% vs. 31.6%; P = 0.687) or mortality (30.0% vs. 42.1%; P = 0.500). Ventilator weaning times (15.7 vs. 3.3 days; P = 0.001) and hospital stays (99.1 vs. 53.1 days; P = 0.030) were longer in the tracheostomy group, with no differences in duration of sedation.

Conclusions:

Tracheostomy may be a safe procedure in burn patients and is not associated with higher rates of mortality or respiratory infection. Tracheostomy patients showed longer mechanical ventilation times and higher morbidity, probably not attributable to tracheostomy.     

Hyperglycemia in critically ill children

Objectives:

To determine the incidence and study association of hyperglycemia with outcome of critically ill children.

Setting and Design:

This was a prospective observational study conducted in eight bedded pediatric intensive care unit (PICU) of a tertiary care hospital.

Materials and Methods:

One hundred and one critically ill non-diabetic children between ages of 1 month to 16 years were studied from the day of admission till discharge or death. Serial blood sugars were determined first at admission, thereafter every 12 hourly in all children. Blood glucose level above 126 mg/dl (>7 mmol/dl) was considered as hyperglycemia. Children with hyperglycemia were followed 6 hourly till blood glucose fell below 126 mg/dl. Hyper and non-hyperglycemic children were compared with respect to length of stay, mechanical ventilation, use of inotrops and final outcome. Survivors and non-survivors were compared in relation to admission blood glucose, peak blood glucose level and duration of hyperglycemia.

Results:

Seventy (69.3%) children had hyperglycemia. Requirement of ventilation [(23) 32.9% vs.(3) 9.7%], requirement of inotropic support [(27) 38.6% vs.(5) 16.1%], Mean length of stay in PICU (7.91 ± 5.01 vs. 5.58 ± 1.95 days) and mortality (28.6% vs. 3.2%) among hyperglycemic children was significantly higher (P < 0.05) than that of non-hyperglycemic. Logistic regression analysis showed Peak blood glucose level and duration of hyperglycemia has independent association with increased risk of death.

Conclusion:

Incidence of hyperglycemia is high in critically ill children and it is associated with high morbidity and mortality.     

Prehospital transport practices prevalent among patients presenting to the pediatric emergency of a tertiary care hospital

Background and Objectives:

Prehospital transport practices prevalent among children presenting to the emergency are under-reported. Our objectives were to evaluate the prehospital transport practices prevalent among children presenting to the pediatric emergency and their subsequent clinical course and outcome.

Methods:

In this prospective observational study we enrolled all children ≤17 years of age presenting to the pediatric emergency (from January to June 2013) and recorded their demographic data and variables pertaining to prehospital transport practices. Data was entered into Microsoft Excel and analyzed using Stata 11 (StataCorp, College Station, TX, USA).

Results:

A total of 319 patients presented to the emergency during the study period. Acute gastroenteritis, respiratory tract infection and fever were the most common reasons for presentation to the emergency. Seventy-three (23%) children required admission. Most commonly used public transport was auto-rickshaw (138, 43.5%) and median time taken to reach hospital was 22 min (interquartile range: 5, 720). Twenty-six patients were referred from another health facility. Of these, 25 were transported in ambulance unaccompanied. About 8% (25) of parents reported having difficulties in transporting their child to the hospital and 57% (181) of parents felt fellow passengers and drivers were unhelpful. On post-hoc analysis, only time taken to reach the hospital (30 vs. 20 min; relative risk [95% confidence interval]: 1.02 [1.007, 1.03], P = 0.003) and the illness nature were significant (45% vs. 2.6%; 0.58 [0.50, 0.67], P ≤ 0.0001) on multivariate analysis.

Conclusions:

In relation to prehospital transport among pediatric patients we observed that one-quarter of children presenting to the emergency required admission, the auto-rickshaw was the commonest mode of transport and that there is a lack of prior communication before referring patients for further management.     

Can integrative weaning index be a routine predictor for weaning success?

Objective:

To assess the effectiveness of integrative weaning index (IWI) as a predictor of weaning success.

Materials and Methods:

This is a prospective randomized controlled observer-blinded study and carried out on 120 patients of both sexes; patients who received mechanical ventilation for more than 24 h and met defined criteria for a weaning trial, underwent a 2-h spontaneous breathing trial with either IWI plus routine criteria of weaning (Group I n = 60) or routine criteria of weaning alone (control group) (Group C n = 60), in Group C the IWI was measured retrospective as it is not used in weaning decision. Those tolerated the trial would be immediately extubated. The primary outcome measure was the ability to maintain spontaneous, unassisted breathing for more than 48 h after extubation. Secondary outcome measures were the duration of mechanical ventilation, length of Intensive Care Unit (ICU) stay, and length of hospital stay.

Results:

The mean duration (hours) of mechanical ventilation and length of ICU stay (days) were significantly shorter in the Group I where the IWI was used (83.6 ± 34.3 vs. 97.49 ± 47.2 h, P = 0.002 and 5.5 ± 1.6 vs. 7.12 ± 2.3 days, P = 0.03, respectively). Weaning success rate was significantly higher in the Group I (53 vs. 34, P = 0.0001) while weaning failure rate was significantly lower in the Group I C (7 vs. 26, P = 0.0001).

Conclusion:

IWI is a strong predictor of both successful and failed weaning.     

Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting?

Context:

Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended.

Aims:

The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting.

Settings and Design:

retrospective and observational cohort study at tertiary hospital.

Subjects and Methods:

All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT.

Results:

A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively).

Conclusions:

Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.     

Comparison of anxiety, depression, and post-traumatic stress symptoms in relatives of ICU patients in an American and an Indian public hospital

Context:

An intensive care unit (ICU) admission of a patient causes considerable stress among relatives. Whether this impact differs among populations with differing sociocultural factors is unknown.

Aims:

The aim was to compare the psychological impact of an ICU admission on relatives of patients in an American and Indian public hospital.

Settings and Design:

A cross-sectional study was carried out in ICUs of two tertiary care hospitals, one each in major metropolitan cities in the USA and India.

Materials and Methods:

A total of 90 relatives visiting patients were verbally administered a questionnaire between 48 hours and 72 hours of ICU admission that included the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II (BDI-II) and Impact of Events Scale-Revised (IES-R) for post-traumatic stress response.

Statistical Analysis:

Statistical analysis was done using the Mann-Whitney and chi-square tests.

Results:

Relatives in the Indian ICU had more anxiety symptoms (median HADS-A score 11 [inter-quartile range 9-13] vs. 4 [1.5-6] in the American cohort; P<0.0001), more depression symptoms (BDI-II score 14 [8.5-19] vs. 6 [1.5-10.5], P<0.0001) but a comparable post-traumatic stress response (IES-R score>30). 55% of all relatives had an incongruous perception regarding “change in the patient''s condition” compared to the objective change in severity of illness. “Change in worry” was incongruous compared to the perception of improvement of the patient''s condition in 78% of relatives.

Conclusions:

Relatives of patients in the Indian ICU had greater anxiety and depression symptoms compared to those in the American cohort, and had significant differences in factors that may be associated with this psychological impact. Both groups showed substantial discordance between the perceived and objective change in severity of illness.     

Clinical effects of sevoflurane anesthesia induction with a portable inhalational anesthetic circuit in pediatric patients

Introduction

Pediatric anesthesia induction with sevoflurane usually needs a special vaporizer and gas source, which limits its use to the operating room (OR). Many children feel anxious and cry when entering the OR because of being separated from their parents, which impairs anesthesia safety and their physical and mental health. In this study, we used a portable circuit to perform sevoflurane anesthesia induction outside the OR, assessed its effects and compared them with those of ketamine anesthesia in pediatric patients.

Material and methods

One hundred children had anesthesia induced with either sevoflurane (sevoflurane group) through the portable inhalational anesthetic circuit, or ketamine by intramuscular injection (ketamine group), then were transferred to the OR. Peak inspired concentration (Cp) and steady state concentration (Cs) of sevoflurane were measured. Heart rate (HR) and saturation of peripheral oxygen (SpO₂) were monitored. Time for anesthesia induction, awakening, leaving the OR and duration of the operation were recorded. The patients’ reaction during anesthesia was also analyzed.

Results

The Cp and Cs of sevoflurane were correlated with bodyweight. Compared with the ketamine group, the sevoflurane group showed shorter time for anesthesia induction (28 ±7 s vs. 195 ±34 s, p < 0.0001), awakening (11.2 ±3.6 s vs. 63.5 ±6.7 s, p < 0.0001) and leaving the OR (20.5 ±5.6 s vs. 43.4 ±10.6, p < 0.0001), less noncooperation during anesthesia induction (10% vs. 80%, p < 0.0001), lower HR (130 ±16 beats/min vs. 143 ±19 beats/min, p = 0.0004) and higher SpO₂ (98.9 ±0.9% vs. 96.1 ±2.5%, p < 0.0001) on arrival at the OR.

Conclusions

Pediatric anesthesia induction by sevoflurane with the portable inhalational anesthetic circuit is convenient, safe and effective outside the OR.     

Economic analysis of costs associated with a Respiratory Intensive Care Unit in a tertiary care teaching hospital in Northern India

Background:

There is a paucity of cost analytical studies from resource constrained developing countries defining intensive care costs and their containment.

Objective:

Economic analysis of costs in a Respiratory Intensive Care Unit (RICU) of a tertiary care teaching hospital in northern India.

Materials and Methods:

A prospective study was conducted in 74 patients admitted in the RICU. Costs were segregated into fixed and variable costs. Total and categorized costs averaged per day and costs incurred on the first day of the RICU stay were calculated. Correlation of the costs was performed with the length of stay, length of mechanical ventilation, survival, and therapeutic intervention scoring system-28 (TISS-28).

Results:

The total cost per day was Indian rupees (INR) 10,364 (US $ 222). 46.4% of the total cost was borne by hospital and rest by patients. The mean cost represented 36.8% of the total cost and 69.8% of the variable cost. Expenditure on personnel salary constituted 37% of the total costs and 86% of the fixed cost. Length of stay in RICU was significantly higher in nonsurvivors (14.73 ± 13.6 days) vs. survivors (8.3 ± 7.8 days) (P < 0.05). The TISS-28 score points in survivors was 30.6 vs. nonsurvivors 69.2 per nurse (P < 0.05) correlating strongly with the total cost (r = 0.91).

Conclusion:

Although considerably less expensive than in economically developed countries, intensive care in India remains expensive relative to the cost of living. The cost block methodology provides a framework for cost estimation, aids resource allocation and allows international comparisons of economic models.     

Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial

Introduction:

Our aim was to evaluate the impact of hyperproteic hypocaloric enteral feeding on clinical outcomes in critically ill patients, particularly on severity of organic failure measured with the Sequential Organ Failure Assessment (SOFA).

Materials and Methods:

In a double blind clinical trial, 80 critically ill adult patients were randomized to hyperproteic hypocaloric or to isocaloric enteral nutrition; all patients completed follow-up of at least 4 days. Prescribed caloric intake was: Hyperproteic hypocaloric enteral nutrition (15 kcal/kg with 1.7 g/kg of protein) or isocaloric enteral nutrition (25 kcal/kg with 20% of the calories as protein). The main outcome was the differences in delta SOFA at 48 h. Secondary outcomes were intensive care unit (ICU) length of stay, days on ventilator, hyperglycemic events, and insulin requirements.

Results:

There were no differences in SOFA score at baseline (7.5 (standard deviation (SD) 2.9) vs 6.7 (SD 2.5) P = 0.17). The total amount of calories delivered was similarly low in both groups (12 kcal/kg in intervention group vs 14 kcal/kg in controls), but proteic delivery was significantly different (1.4 vs 0.76 g/kg, respectively P ≤ 0.0001). The intervention group showed an improvement in SOFA score at 48 h (delta SOFA 1.7 (SD 1.9) vs 0.7 (SD 2.8) P = 0.04) and less hyperglycemic episodes per day (1.0 (SD 1.3) vs 1.7 (SD 2.5) P = 0.017).

Discussion:

Enteral hyperproteic hypocaloric nutrition therapy could be associated with a decrease in multiple organ failure measured with SOFA score. We also found decreased hyperglycemia and a trend towards less mechanical ventilation days and ICU length of stay.     

Disturbances in apoptosis of lamina propria lymphocytes in Crohn's disease

Introduction

The aim of this study was to assess the potential mechanisms providing resistance to apoptosis of lamina propria lymphocytes (LPL) directlyin intestinal tissues from patients with Crohn''s disease (CD).

Material and methods

Fifty CD patients were enrolled in the study. The control group consisted of healthy patients who underwent surveillance colonoscopy after endoscopic polypectomy. Each CD patient underwent colonoscopy with tissue sampling from inflamed areas of the colon with the assessment of immunohistochemical expression of active caspase 3, Fas, tumour necrosis factor receptor 1 (TNFR1), Bcl-2, Bax, CD4 and CD8. This was compared with healthy intestinal mucosa.

Results

The expression of active caspase 3 was significantly lower in LPL in CD (0.4 ±0.3 vs. 2.8 ±1.5; p = 0.0002). A statistically significant increase of CD4 and CD8 positive cells was noted in CD (2.3 ±0.5 vs. 1.2 ±0.2, p < 0.0001; 2.1 ±0.3 vs. 1.1 ±0.3, p < 0.0001, respectively). It was associated with a significant increase of the Bcl-2 (6.7 ±2.7 vs. 2.9 ±0.8; p < 0.0001) and a decrease of the Bax protein expression (3.4 ±2.1 vs. 5.5 ±1.8; p < 0.0001) in CD. The expression of Fas and TNFR1 did not differ between the study groups.

Conclusions

LPL in CD are resistant to apoptosis when compared with physiological conditions. This is probably due to an imbalance in Bcl-2 family proteins. TNFR1-related pathway is probably not involved in disturbances of LPL apoptosis in CD.     

Assessment of accuracy of Cockcroft-Gault and MDRD formulae in critically ill Indian patients

Background:

Cockroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) formulae have not been validated in critically ill Indian patients. We sought to quantify the discrepancy, if any, in Glomerular Filteration Rate (GFR) estimated by CG and MDRD formulae with 24 hrs urine Creatinine Clearance (Cr Cl).

Materials and Methods:

Prospective cohort study in 50 adult patients in a mixed medical-surgical intensive care unit. Inclusion criteria: Intensive Therapy Unit (ITU) stay >48 hrs and indwelling urinary catheter. Exclusion criteria: Age <18 years, pregnancy, dialysis, urine output <400 ml/day and patients receiving ranitidine, cefoxitin, trimethoprim or diuretics. We estimated Creatinine Clearance by CG and MDRD formula and measured GFR by 24 hrs urine creatinine clearance. Bland Altman plot was used to find the difference between the paired observations. The association between the methods was measured by the product moment correlation coefficient.

Result:

The mean GFR as calculated by Creatinine Clearance was 79.76 ml/min/1.73 m² [95% Confidence Interval (CI) 65.79 to 93.72], that by CG formula was 90.05 ml/min/1.73 m² [95% CI: 74.50 to 105.60], by MDRD was 85.92 ml/min/1.73 m² [95% CI: 71.25 to 100.59]. The Bias and Precision between CG and Cr Cl were −4.5 and 140.24 respectively, between MDRD and Cr Cl was −6.1 and 122.52. The Correlation coefficient of CG formula as a measure of GFR was 0.65 (P < 0.0001), that of MDRD was 0.70 (P < 0.0001).

Conclusion:

We conclude that CG and MDRD formulae have a strong correlation with measured GFR but are not a reliable measure and overestimate GFR in critically ill Indian patients.     

Aortic valve calcification in 499 consecutive patients referred for computed tomography

Introduction

Aortic valve calcification (AVC) is the most common cause of aortic stenosis. The aim of the study was to assess the prevalence of aortic valve, coronary artery and aortic calcifications and to evaluate the correlation between calcification of the aortic valve, coronary arteries and aorta.

Material and methods

The study included 499 patients aged 60 years and over who underwent coronary computed tomography because of chest pain. Beside coronary artery calcium score (CAC), we evaluated AVC and ascending aorta calcifications (AAC).

Results

Aortic valve calcification was found in 144 subjects (28.9% of the whole study population). Prevalence of CAC and AAC was higher than AVC and amounted to 73.8% and 54.0%. Prevalence of AVC, CAC and AAC was significantly lower in the group of patients ≤ 70 years than in the group of patients > 70 years of age (p = 0.0002, p < 0.0001, p < 0.0001). Aortic valve calcification was more often observed in men than women (34.7% vs. 25.4%, p = 0.02). Degree of aortic valve calcification was also significantly higher among men than women (median score 4 vs. 0, p = 0.01). Similar observations were true for CAC and AAC, where both prevalence and degree of calcification was higher among men than women. In the whole study population no correlation was noted between AVC and CAC or AAC (p = 0.34, p = 0.85). There was a significant correlation between AAC and CAC (p < 0.0001).

Conclusions

Despite some similarities in pathological mechanism and risk factors, a degenerative defect of the aortic valve could be independent of atheromatous lesions in the coronary arteries and aorta.     

Critical illness associated with 2013-2014 influenza A (H1N1): Postpandemic characteristics,presentation and outcomes

Introduction:

The United States experienced a postpandemic outbreak of H1N1 influenza in 2013–2014. Unlike the pandemic in 2009 clinical course and outcomes associated with critical illness in this postpandemic outbreak has been only sparsely described.

Methods:

We conducted a retrospective analysis of all patients admitted to the Medical Intensive Care Unit with H1N1 influenza infection in 2009–2010 (pandemic) and 2013–2014 (postpandemic).

Results:

Patients admitted in the postpandemic period were older (55 ± 13 vs. 45 ± 12, P = 0.002), and had a higher incidence of underlying pulmonary (17 vs. 7, P = 0.0007) and cardiac (16 vs. 8, P = 0.005) disease. Mechanical ventilation was initiated in most patients in both groups (27 vs. 21, P = 1.00). The PaO₂/FiO₂ ratio was significantly higher in the pandemic group on days 1 (216 vs. 81, P = 0.0009), 3 (202 ± 99 vs. 100 ± 46, P = 0.002) and 7 (199 ± 103 vs. 113 ± 44, P = 0.019) but by day 14 no difference was seen between the groups. Rescue therapies were used in more patients in the postpandemic period (48% vs. 20%, P = 0.028), including more frequent use of prone ventilation (10 vs. 3, P = 0.015), inhaled vasodilator therapy (11 vs. 4, P = 0.015) and extracorporeal membrane oxygenation (ECMO) (4 vs. 2, P = NS). No significant differences in mortality were seen between the two cohorts.

Conclusions:

Compared to the 2009–2010 pandemic, the 2013–2014 H1N1 strain affected older patients with more underlying co-morbid cardio-pulmonary diseases. The patients had worse oxygenation indices and rescue modalities such as prone ventilation, inhaled epoprostenol and ECMO, were used more consistently as compared to the 2009 pandemic.     

Exercise capacity as an independent risk factor for adverse cardiovascular outcomes among nondiabetic and diabetic patients

Introduction

To investigate if decreased exercise capacity is an independent risk factor for major adverse cardiovascular events (MACE) in diabetics and nondiabetics.

Material and methods

The association of decreased exercise capacity (EC) during a treadmill exercise sestamibi stress test with MACE was investigated in 490 nondiabetics and 404 diabetics. Mean follow-up was 53 months.

Results

Nondiabetics with a predicted EC < 85% had a higher prevalence of myocardial ischemia (34% vs. 19%, p = 0.0002), 2- or 3-vessel obstructive coronary artery disease (CAD) (31% vs. 13%, p = 0.016), myocardial infarction (MI) (17% vs. 7%, p = 0.0005), stroke (8% vs. 2%, p = 0.002), death (11% vs. 3%, p = 0.0002), and MI or stroke or death at follow-up (32% vs. 11%, p < 0.001) compared to nondiabetics with a predicted EC ≥ 85%. Diabetics with a predicted EC < 85% had a higher prevalence of myocardial ischemia (48% vs. 32%, p = 0.0009), 2- or 3-vessel obstructive CAD (54% vs. 28%, p = 0.001), MI (32% vs. 14%, p < 0.001), stroke (22% vs. 6%, p < 0.001), death (17% vs. 9%, p = 0.031), and MI or stroke or death at follow-up (65% vs. 27%, p < 0.001). Stepwise Cox regression analysis showed decreased EC was an independent and significant risk factor for MACE among nondiabetics (hazard ratio 3.3, p < 0.0001) and diabetics (hazard ratio 2.7, p < 0.0001).

Conclusions

Diabetics and nondiabetics with decreased EC were at increased risk for MACE with nondiabetics and decreased EC at similar risk as diabetics with normal EC.     

Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP

Background and Objective:

The surviving sepsis campaign treatment guideline (SSC) implementation is associated with improved outcome in adults with severe sepsis. The effect on outcome of pediatric sepsis is less clear.

Purpose:

To determine the clinical outcomes of SSC implementation and to investigate the prognostic value of initial plasma NT-proBNP and procalcitonin in children.

Materials and Methods:

Infants and children (aged 1month/0-15 years with severe sepsis or septic shock) were prospectively enrolled and treated according to the guidelines. Initial blood drawn was saved for NT-pro-BNP, procalcitonin measurements and clinical data were also recorded.

Results:

A total of 47 subjects were recruited. Since the application of the SSC, our mortality rate had significantly decreased from 42-19% (P = 0.003) as compared to the data in the previous 3 years. Clinical factors that significantly increased the mortality rate were: Initial central venous oxygen saturation < 7 0% after fluid resuscitation [odds ratio (OR) = 23.3; 95% confidence interval (CI) 3.7-143; P = 0.001], and initial albumin level (≤ 3 g/dl, OR = 6.7; 95% CI 1.2-37.5, P = 0.03). There was asignificant difference between the initial NT-proBNP levels between survivors and non survivors, (6280.3 ± 9597 ng/L, P < 0.001), but not for procalcitonin (12.7 ± 24.8, 29.3 ± 46 μg/L, P = 0.1), respectively. An initial NT-proBNP level of more than 11,200 pg/ml predicted Pediatric Intensive Care Unit (PICU) mortality with a sensitivity of 85.7% and a specificity of 90%.

Conclusions:

A modified SSC for severe sepsis and septic shock significantly reduced the mortality rate in our PICU. High initial NT-ProBNP level was associated with mortality.     

The impact of packed red blood cell transfusion on clinical outcomes in patients with septic shock treated with early goal directed therapy

Background:

The optimal hemoglobin level and transfusion threshold in patients with septic shock treated with an early, goal oriented approach to resuscitation remains unknown.

Aims:

To assess the impact of packed red blood cell (PRBC) transfusion on clinically relevant outcomes in patients with septic shock treated with early goal directed therapy (EGDT).

Settings and Design:

Retrospective cohort study of 93 patients who presented with septic shock, to a single center academic intensive care unit and received EGDT.

Materials and Methods:

Data were collected on patients identified via the Surviving Sepsis Campaign Chart Review database and linked to Project IMPACT database. The PRBC group and no PRBC group were compared by the Pearson chi-square and Fisher’s exact test to analyze statistical significance.

Results:

The PRBC group had a mortality of 41.2% vs. 33.9% in the no PRBC transfusion group (P = NS). The PRBC group also had more mechanical ventilation days (11.2 days vs. 5.0 days, (P ≤ 0.05), longer hospital length of stay (25.9 days vs. 12.5 days, (P ≤ 0.05), and longer intensive care unit length of stay (11.4 days vs. 3.8 days, (P ≤ 0.05).

Conclusions:

In this retrospective cohort study, transfusion of PRBCs was associated with worsened clinical outcomes in patients with septic shock treated with EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with PRBC transfusion.     

Safety and Efficacy of Oral Transmucosal Fentanyl Citrate Compared to Morphine Sulphate Immediate Release Tablet in Management of Breakthrough Cancer Pain

Aim:

To compare the efficacy and safety of oral transmucosal fentanyl citrate (OTFC) and oral morphine in Indian patients with breakthrough episodes of cancer pain.

Materials and Methods:

In this randomized, open label, active controlled, clinical study, total 186 patients who regularly experienced 1-4 episodes of breakthrough cancer pain (BTCP) daily, over the persistent pain controlled by taking oral morphine 60 mg/day or its equivalent were randomized to receive either OTFC 200 mcg or oral morphine 10 mg for the treatment of BTCP for 3 days. Improvement in pain as determined by numerical rating scale (NRS) at 5, 15, 30, and 60 minutes of drug administration and percentage of BTCP episodes showing reduction in pain intensity by >33% at 15 minutes were primary efficacy endpoints. Secondary efficacy endpoints were requirement for rescue analgesia and global assessment by physician and patient. Data of both treatment groups were analysed by appropriate statistical test using software, STATISTICA, version 11.

Results:

Patients treated with OTFC experienced significantly greater improvement in pain intensity of breakthrough episodes compared to those treated with oral morphine at all assessment time points (P < 0.0001). 56% of breakthrough pain episodes treated with OTFC showed a greater than 33% reduction in pain intensity from baseline at 15 minutes compared to 39% episodes treated with oral morphine (P < 0.0001). Patient''s and physician''s global assessment favoured OTFC than oral morphine (P < 0.0001). Requirement of rescue analgesia in both the study groups was similar (P > 0.05). Both study drugs were well tolerated.

Conclusions:

OTFC was found to provide faster onset of analgesic effect than immediate release oral morphine in management of breakthrough cancer pain.     

CYP17 T27C polymorphism and prostate cancer risk: a meta-analysis based on 31 studies

Objective

The cytochrome P450 17α-hydroxylase (CYP17) plays a vital role in androgen biosynthesis. A T-to-C polymorphism in the 5′ promoter region of CYP17 has been implicated as a risk factor for prostate cancer, but the results of individual studies are inconclusive or controversial. To derive a more precise estimation of the relationship, we performed an updated meta-analysis from 31 studies based on 27 publications.

Methods

A comprehensive search was conducted to examine all the eligible studies of CYP17 polymorphism and prostate cancer risk. We used odds ratios (ORs) with 95% confidence intervals (CIs) to assess the strength of the association.

Results

Overall, individuals with CC/CT genotype were not associated with prostate cancer risk (CC vs. TT: OR = 1.03, 95% CI = 0.86-1.24, P = 0.72, P_{heterogeneity} < 0.0001; CT vs. TT: OR = 0.99, 95% CI = 0.87-1.12, P = 0.88, P_{heterogeneity} = 0.0006). In the stratified analysis by ethnicity, there was a significantly increased risk of prostate cancer among individuals of African descent under the recessive model (OR = 1.56, 95% CI = 1.01-2.39, P = 0.04, P_{heterogeneity} = 0.65).

Conclusion

This meta-analysis suggested that CYP17 polymorphism might be associated with prostate cancer risk among individuals of African descent.     

Hyponatremia in critically ill patients

Context:

Hyponatremia is a common electrolyte disturbance in critically ill hence understanding its implications is important.

Aims:

This study was carried out to ascertain frequency, predisposing conditions and outcome in critically ill patients with hyponatremia on intensive care unit (ICU) admission.

Settings and Design:

This was an observational, prospective study of a series of ICU patients during a 12-month period.

Materials and Methods:

The patients were divided into two groups: Hyponatremic (serum sodium < 135 mmol/L) and Eunatremic groups (135-145 mmol/L). Clinical examination included volume status and drug history, biochemistries, clinical diagnosis and cause of hyponatremia.

Statistical Analysis Used:

Fisher''s exact test, unpaired t-tests Wilcoxon ranksum tests, profile-likelihood method, log-rank test and Kaplan—Meier curves were used. P < 0.05 were considered to be statistically significant.

Results:

In the hyponatremic group, the frequency of hyponatremia on ICU admission was 34.3%, most were euvolumic, 58.96%. Females comprised of 36.5%. The mean age was 60.4 ± 17.2. The Syndrome of inappropriate Antidiuretic Hormone (SIADH) criteria was met in ninety-one patients (36.25%), peumonia being the leading cause of SIADH. Patients with severe sepsis, elective surgery patients, renal failure and heart failure, cirrhosis of liver and subarachnoid hemorrhage were other more likely etiologic causes (P < 0.05). The hyponatremic group spent a longer time in the ICU (P = 0.02), had longer mechanical ventilator days (P < 0.05) and had an increased mortality rate (P = 0.01).

Conclusions:

Hyponatremia present on admission to the ICU is independent risk factors for poor prognosis.