Noninvasive ventilation for acute respiratory failure after lung resection: an observational study

Background  A single prospective randomized study found that, in selected patients with acute respiratory failure (ARF) following lung resection, noninvasive ventilation (NIV) decreases the need for endotracheal mechanical ventilation and improves clinical outcome. Method  We prospectively evaluated early NIV use for ARF after lung resection during a 4-year period in the setting of a medical and a surgical ICU of a university hospital. We documented demographics, initial clinical characteristics and clinical outcomes. NIV failure was defined as the need for tracheal intubation. Results  Among 690 patients at risk of severe complications following lung resection, 113 (16.3%) experienced ARF, which was initially supported by NIV in 89 (78.7%), including 59 with hypoxemic ARF (66.3%) and 30 with hypercapnic ARF (33.7%). The overall success rate of NIV was 85.3% (76/89). In-ICU mortality was 6.7% (6/89). The mortality rate following NIV failure was 46.1%. Predictive factors of NIV failure in univariate analysis were age (P = 0.046), previous cardiac comorbidities (P = 0.0075), postoperative pneumonia (P = 0.0016), admission in the surgical ICU (P = 0.034), no initial response to NIV (P < 0.0001) and occurrence of noninfectious complications (P = 0.037). Only two independent factors were significantly associated with NIV failure in multivariate analysis: cardiac comorbidities (odds ratio, 11.5; 95% confidence interval, 1.9–68.3; P = 0.007) and no initial response to NIV (odds ratio, 117.6; 95% confidence interval, 10.6–1305.8; P = 0.0001). Conclusion  This prospective survey confirms the feasibility and efficacy of NIV in ARF following lung resection. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. This work was presented during the September 2008 ESICM congress in Lisbon international meeting and published as an abstract.     

消痰通络外用中药制剂对腰神经根性痛大鼠神经根功能和组织学的作用

目的:观察消炎通络中药制剂外用后腰神经根性痛大鼠神经根功能和组织学的变化。方法:实验于2005-12/2006-01在中国科学院上海实验动物中心完成。健康雄性SD大鼠60只,体质量250～300g,随机数字法分为对照组、模型组、消痰通络中药组、扶他林组,每组15只。消痰通络中药全方由天南星、半夏、威灵仙等组成。建立大鼠自体髓核移植致腰神经根性痛模型,造模后第3天起给予不同药物干预。对照组、模型组、消痰通络中药组、扶他林组分别予生理盐水1mL、生理盐水1mL、消痰通络外用中药制剂1g、扶他林乳胶剂1g外涂于腰部伤口两侧,每日2次,连续用药4周。造模后第31天测大鼠后肢机械刺激缩爪阈值、马尾神经根感觉神经传导速度和运动神经传导速度。取移植髓核和右侧L5神经根作组织病理学观察。结果:60只SD大鼠全部进入结果分析。①造模后31d,模型组大鼠右后肢机械刺激缩爪阈值降低,与术前及对照组比较差异有显著性意义[(58.6±4.7),(90.8±6.5),(88.1±5.5)mmHg,P<0.01]。消痰通络中药组、扶他林组后肢机械刺激缩爪阈值比模型组显著增高[(82.4±6.0),(82.7±6.2),(58.6±4.7)mmHg,P<0.01]。②造模后31d,模型组大鼠感觉神经和运动神经传导速度明显减慢,与术前及对照组比较差异有显著性意义[(52.30±3.45),(63.87±4.81),(64.77±3.96)m/s,(46.48±2.47),(70.68±4.21),(69.85±3.34)m/s,P<0.01]。消痰通络中药组、扶他林组感觉神经传导速度比模型组显著增高[(59.61±4.27),(61.14±3.82),(52.30±3.45)m/s,P<0.05,P<0.01],运动神经传导速度比模型组显著增高[(62.01±3.44),(64.29±4.61),(46.48±2.47)m/s,P<0.01]。③消痰通络外用中药制剂能够减轻髓核和L5神经根病理损害程度。结论:消痰通络外用中药制剂具有减轻腰椎间盘突出症神经根性痛作用。     

Subcutaneous immunoglobulin in CIDP and MMN: a short-term nationwide study

This multi-center Italian prospective observational study reports the 4 months follow-up data of 87 patients affected by chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy (MMN) shifted from intravenous to subcutaneous immunoglobulin treatment. A therapeutic shift from intravenous to subcutaneous immunoglobulin was performed in 87 patients (66 CIDP; 21 MMN) affected by immune-mediated peripheral neuropathies with evidence of a sustained clinical response to intravenous immunoglobulin. Patients were evaluated by means of the Overall Neuropathy Limitation Scale, Medical Research Council Scale and Life Quality Index questionnaire, both at the time of therapeutic shift and after 4 months of subcutaneous immunoglobulin treatment. A sustained clinical efficacy was observed after the switch to subcutaneous immunoglobulin: the Overall Neuropathy Limitation Scale score improved in the group of 66 CIDP patients (P = 0.018), with only one subject reporting a worsening of 1 point, and remained stable in the group of 21 MMN patients (P = 0.841), with one subject reporting a worsening of two points. An improvement in the patient’s perception of therapeutic setting was reported in both groups. This large multi-center study confirms the short-term clinical equivalence of subcutaneous versus intravenous immunoglobulin and a possible improvement in the patient’s perception of therapeutic setting with the subcutaneous administration. However, further studies are required to extend the results to a longer observational period.     

Incidence of low central venous oxygen saturation during unplanned admissions in a multidisciplinary intensive care unit: an observational study

Introduction  

It has been shown that early central venous oxygen saturation (ScvO₂)-guided optimization of hemodynamics can improve outcome in septic patients. The early ScvO₂ profile of other patient groups is unknown. The aim of this study was to characterize unplanned admissions in a multidisciplinary intensive care unit (ICU) with respect to ScvO₂ and outcome.     

HMGB1 as a predictor of organ dysfunction and outcome in patients with severe sepsis

OBJECTIVE: To study the predictive value of high mobility group box-1 protein (HMGB1) and hospital mortality in adult patients with severe sepsis. STUDY DESIGN: Prospective observational cohort study in 24 ICUs in Finland. PATIENTS: Two hundred and forty-seven adult patients with severe sepsis. MEASUREMENTS AND MAIN RESULTS: Blood samples for HMGB1 analyses were drawn from 247 patients at baseline and from 210 patients 72 h later. The mean APACHE II and SAPS II scores were 24 (SD 9) and 44 (SD 17), respectively. The hospital mortality was 26%. The serum HMGB1 concentrations were measured first by semi-quantitative Western immunoblotting (WB) analysis. The median HMGB1 concentration on day 0 was 108% (IQR 98.5-119) and after 72 h 107% (IQR 98.8-120), which differed from healthy controls (97.5%, IQR 91.3-106.5; p=0.028 and 0.019, respectively). The samples were re-analysed by ELISA (in a subgroup of 170 patients) to confirm the results by WB. The median concentration in healthy controls was 0.65 ng/ml (IQR 0.51-1.0). This was lower than in patients with severe sepsis (3.6 ng/ml, IQR 1.9-6.5, p< 0.001). HMGB1 concentrations (WB and ELISA) did not differ between hospital survivors and non-survivors. In ROC analyses for HMGB1 levels (WB) on day 0 and 72 h with respect to hospital mortality, the areas under the curve were 0.51 and 0.56 (95% CI 0.40-0.61 and 0.47-0.65). CONCLUSIONS: Serum HMGB1 concentrations were elevated in patients with severe sepsis, but did not differ between survivors and non-survivors and did not predict hospital mortality.     

Herpes simplex virus load in bronchoalveolar lavage fluid is related to poor outcome in critically ill patients

Objective  To evaluate the relationship between the HSV-1 and -2 loads in BAL fluid (BALF) and clinical outcome. Design  Retrospective study. Setting  The general intensive care unit of the University Hospital Maastricht. Patients  Five hundred and twenty-one BALF samples from 462 patients were included. Patients were divided into three groups; (1) patients admitted to the hospital <48 h before lavage (Community), (2) patients admitted to the ICU >48 h before lavage (ICU) and (3) the remaining patients (non-ICU group). Interventions  No additional interventions were conducted. Measurements and results  HSV-1 and HSV-2 loads were determined by real-time polymerase chain reaction (PCR). HSV-1 DNA was detected in 4.3% (4/92) of samples in the community group, 15% (18/121) in the non-ICU group and in 32% (99/308) of the ICU group. In the age group <50 years HSV-1 DNA was less frequently isolated compared to the age group ≥50 years (16/129 (12%) versus 187/376 (25%), respectively, OR = 2.6; P < 0.001). HSV-1 loads of >10⁵ genome equivalents (ge)/ml were associated with an increased 14-day in-hospital mortality compared to patients with a HSV-1 load ≤10⁵ ge/ml in BALF (41 vs. 20%, respectively, P = 0.001). HSV-1 pneumonia was histologically proven in two patients with a HSV-1 load exceeding 10⁵ ge/ml. Conclusions  HSV-1 occurred more in critically ill patients and high loads in BALF were associated with an increased mortality. The higher mortality observed in patients with HSV-1 load >10⁵ ge/ml enforces its clinical relevance and necessitates to start randomized medical intervention studies. The abstract of this article was published in ESCV/SGM Conference, Birmingham, as an oral presentation.     

Distribution of Matrix Metalloproteinases in Human Atherosclerotic Carotid Plaques and Their Production by Smooth Muscle Cells and Macrophage Subsets

Purpose

In this study, the potential of matrix metalloproteinase (MMP) sense for detection of atherosclerotic plaque instability was explored. Secondly, expression of MMPs by macrophage subtypes and smooth muscle cells (SMCs) was investigated.

Procedures

Twenty-three consecutive plaques removed during carotid endarterectomy were incubated in MMPSense? 680 and imaged with IVIS® Spectrum. mRNA levels of MMPs, macrophage markers, and SMCs were determined in plaque specimens, and in in vitro differentiated M1 and M2 macrophages.

Results

There was a significant difference between autofluorescence signals and MMPSense signals, both on the intraluminal and extraluminal sides of plaques. MMP-9 and CD68 messenger RNA (mRNA) expression was higher in hot spots, whereas MMP-2 and αSMA expression was higher in cold spots. In vitro M2 macrophages had higher mRNA expression of MMP-1, MMP-9, MMP-12, and TIMP-1 compared to M1 macrophages.

Conclusion

MMP-9 is most dominantly MMP present in atherosclerotic plaques and is produced by M2 rather than M1 macrophages.

     

Influence of an acute increase in systemic vascular resistance on transpulmonary thermodilution-derived parameters in critically ill patients

Objective The transpulmonary thermodilution technique enables measurement of cardiac index (CI), intrathoracic blood volume (ITBV), global end-diastolic volume (GEDV), and extravascular lung water (EVLW). In this study, we analyzed the robustness of this technique during an acute increase in systemic vascular resistance (SVR). Design Prospective, clinical study. Setting Surgical intensive care unit in a university hospital. Patients and methods Twenty-four mechanically ventilated septic shock patients, who for clinical indications underwent extended hemodynamic monitoring by transpulmonary thermodilution and continuously received norepinephrine. Interventions and main results After baseline measurements, mean arterial pressure was increased briefly by increasing norepinephrine dosage and hemodynamic measurements were repeated before a control measurement was obtained. At each time point, 15 cc of 0.9% saline (< 8 °C) was administered by central venous injection in triplicate. Fluid status and respirator adjustments were kept constant. ANOVA with an all-pairwise comparison method was used for statistical analysis. Heart rate, central venous pressure, and EVLW remained constant throughout, while SVR significantly changed from 551 ± 106 to 746 ± 91 dyn*s*cm⁻⁵ and again to 566 ± 138 dyn*s*cm⁻⁵ (p < 0.05). However, CI and central blood volumes showed a reversible significant increase, i.e., ITBV went from 816 ± 203 to 867 ± 195 ml/m² and then to 821 ± 205 ml/m² and GEDV from 703 ± 178 to 747 ± 175 ml/m² and finally to 704 ± 170 ml/m², respectively. In eight patients, 2-D echocardiography was applied and revealed a reversible increase in left-ventricular end-diastolic area. Conclusion An acute increase in SVR by increasing norepinephrine dosage results in a reversible increase in central blood volumes (ITBV, GEDV) as measured by transpulmonary thermodilution and supported by echocardiography. This work was presented in part at the 19th annual meeting of the European Society of Intensive Care Medicine, 24–27 September 2006, Barcelona. Samir Sakka has received fees from Pulsion Medical Systems AG, Munich, Germany, for giving lectures.