C-type natriuretic peptide concentrations in the plasma and cerebrospinal fluid of patients with subarachnoid hemorrhage

Background

Cerebral vasospasm is a poor resulting outcome of a ruptured cerebral aneurysm; to clarify the mechanism of vasospasm it is important to improve this outcome. C-type natriuretic peptide (CNP) is present in the brain as a cerebral vasodilator; it is also an endothelium-derived relaxing factor produced via cGMP. We speculated that CNP might be an inhibitor of cerebral vasospasm after subarachnoid hemorrhage (SAH).

Methods

To clarify the role of CNP in cerebral vasospasm after SAH, we conducted 1 week monitoring of CNP concentrations in the plasma and cerebrospinal fluid (CSF) of 26 patients who had undergone clipping within 24 hours of the occurrence of SAH, and divided them into group A (positive for angiographic spasm) and group B (negative for angiographic spasm). We also examined CNP concentrations in the CSF of patients who were receiving spinal anesthesia for small orthopedic operations, as reference patients.

Results

The CNP concentration in the CSF on day 1 was higher than in the reference patients and decreased in both test groups, but we did not observe any significant difference between the groups. CNP concentrations in the plasma did not change in either group.

Conclusions

CNP concentrations in the CSF were high in the acute phase after SAH, whereas plasma CNP concentrations remained constant. However, our findings did not support our hypothesis because we did not find any relationship between vasospasm and changes in CNP concentrations in the CSF.     

Vasostatin-I, a chromogranin A-derived peptide, in non-selected critically ill patients: distribution, kinetics, and prognostic significance

Purpose

Chromogranin A (CGA) is released in the plasma during life-threatening illnesses. Its N-terminal 1–76 peptide, vasostatin-I (VS-I), has never been assessed in critically ill patients. Our aim was to examine whether the admission VS-I concentration has prognostic significance without having to specify a primary diagnosis.

Methods

VS-I concentrations were assessed with a new ELISA in 481 consecutive patients and 13 healthy controls. CGA and standard biological tests (including lactate) were performed; the simplified acute physiological score II (SAPS II) was calculated. Mortality was assessed at day 28. In a subgroup of 13 patients with shock, serial VS-I doses were given over 60?h.

Results

Critically ill patients had higher admission VS-I concentrations than controls [4.06 (2.78; 7.61) vs. 2.85 (2.47; 3.22)?ng/ml, p?p?p?p?p?Conclusions Significant amounts of VS-I are detected on admission in critically ill patients. A plasma VS-I concentration above 3.97?ng/ml is associated with poor outcome, and in routine practice simultaneous measurements of the three independent factors VS-I, lactate and age can affect the assessment of severity.     

The role of pentraxin 3 as diagnostic value in classification of patients with heart failure

Objective

Pentraxin 3 (PTX3) is a new inflammatory marker that is the prototype of the long pentraxin group, while C-reactive protein (CRP) is the short pentraxin group. The aim of the present study was to investigate the clinical significance of plasma PTX3 and CRP levels in heart failure (HF).

Materials and methods

The study included 22 male and 37 female patients with HF, and 23 healthy volunteers as the control group. Patients were divided into 4 groups (class I, II, III and IV) according to New York Heart Association functional class.

Results

Plasma PTX3 and CRP levels were significantly elevated in HF patients compared to healthy controls. Comparing PTX3 levels in patient groups, statistically significant difference was found between class-I and class-II, class-III and class-IV patients (p = 0.009, p = 0.001, p < 0.001, respectively). There was a positive correlation between PTX3 and CRP levels (r = 0.369, p = 0.004). In receiver-operating characteristic (ROC) curves, area under the curve (AUC) values for PTX3 and CRP were 0.928 (p = 0.001) and 0.834 (p = 0.001), respectively.

Conclusions

Plasma PTX3 levels are elevated in HF and might be used as diagnostic value in classification of patients with HF. It is still debated whether inflammation may be just a cause or a consequence of the disease. Therefore further work is needed to better understand in large populations of patients with HF.     

Transient decrease in PaCO2 and asymmetric chest wall dynamics in early progressing pneumothorax

Purpose

Diagnosis of pneumothorax (PTX) in newborn infants has been reported as late. To explore diagnostic indices for early detection of progressing PTX, and offer explanations for delayed diagnoses.

Methods

Progressing PTX was created in rabbits (2.3?±?0.5?kg, n?=?7) by injecting 1?ml/min of air into the pleural space. Hemodynamic parameters, tidal volume, EtCO₂, SpO₂, blood gas analyses and chest wall tidal displacements (TDi) on both sides of the chest were recorded.

Results

(Mean?±?SD): A decrease in SpO₂ below 90?% was detected only after 46.6?±?11.3?min in six experiments. In contrary to the expected gradual increase of CO₂, there was a prolonged transient decrease of 14.2?±?4.5?% in EtCO₂ (p?<?0.01), and a similar decrease in PaCO₂ (p?<?0.025). EtCO₂ returned back to baseline only after 55.2?±?24.7?min, and continued to rise thereafter. The decrease in CO₂ was a mirror image of the 14.6?±?5.3?% increase in tidal volume. The analysis of endotracheal flow and pressure dynamics revealed a paradoxical transient increase in the apparent compliance. Significant decrease in mean arterial blood pressure was observed after 46.2?±?40.1?min. TDi provided the most sensitive and earliest sign of PTX, decreasing on the PTX side after 16.1?±?7.2?min. The TDi progressively decreased faster and lower on the PTX side, thus enabling detection of asymmetric ventilation.

Conclusions

The counterintuitive transient prolonged decrease in CO₂ without changes in SpO₂ may explain the delay in diagnosis of PTX encountered in the clinical environment. An earlier indication of asymmetrically decreased ventilation on the affected side was achieved by monitoring the TDi.     

Perioperative amplitude-integrated EEG and neurodevelopment in infants with congenital heart disease

Purpose

Perioperative brain injury is common in young infants undergoing cardiac surgery. We aimed to determine the relationship between perioperative electrical seizures, the background pattern of amplitude-integrated electroencephalography (aEEG) and 2-year neurodevelopmental outcome in young infants undergoing surgery for congenital heart disease.

Methods

A total of 150 newborn infants undergoing cardiac surgery underwent aEEG monitoring prior to and during surgery, and for 72?h postoperatively. Two blinded assessors reviewed the aEEGs for seizure activity and background pattern. Survivors underwent neurodevelopmental outcome assessment using the Bayley Scales of Infant Development (3rd edn.) at 2?years.

Results

The median age at surgery was 7?days (IQR 4–11). Cardiopulmonary bypass was used in 83?%. Perioperative electrical seizures occurred in 30?%, of whom 1/4 had a clinical correlate, but were not associated with 2-year outcome. Recovery to a continuous background occurred at a median 6 (3–13)?h and sleep–wake cycling recovered at 21 (14–30)?h. Prolonged aEEG recovery was associated with increased mortality and worse neurodevelopmental outcome. Failure of the aEEG to recover to a continuous background by 48?postoperative hours was associated with impairment in all outcome domains (p?p?Conclusions Perioperative seizures were common in this cohort of infants but did not impact on 2-year neurodevelopmental outcome. Delayed recovery in aEEG background was associated with increased risk of early mortality and worse neurodevelopment. Ongoing monitoring of the survivors is essential to determine the longer-term significance of these findings.     

Prospective validation of the vasoactive-inotropic score and correlation to short-term outcomes in neonates and infants after cardiothoracic surgery

Purpose

Prospective validation of the vasoactive-inotropic score (VIS) and inotrope score (IS) in infants after cardiovascular surgery.

Methods

Prospective observational study of 70 infants (≤90?days of age) undergoing cardiothoracic surgery. VIS and IS were assessed at 24 (VIS24, IS24), 48 (VIS48, IS48), and 72 (VIS72, IS72)?h after surgery. Maximum VIS and IS scores in the first 48?h were also calculated (VIS48max and IS48max). The primary outcome was length of intubation. Additional outcomes included length of intensive care (ICU) stay and hospitalization, cardiac arrest, mortality, time to negative fluid balance, peak lactate, and change in creatinine.

Results

Based on receiver-operating characteristic (ROC) analysis, the area under the curve (AUC) was highest for VIS48 to identify prolonged intubation time. AUC for the primary outcome was higher for VIS than IS at all time points assessed. On multivariate analysis VIS48 was independently associated with prolonged intubation (OR 22.3, p?=?0.002), prolonged ICU stay (OR 8.1, p?=?0.017), and prolonged hospitalization (OR 11.3, p?=?0.011). VIS48max, IS48max, and IS48 were also associated with prolonged intubation, but not prolonged ICU or hospital stay. None of the scores were associated with time to negative fluid balance, peak lactate, or change in creatinine.

Conclusion

In neonates and infants, a higher VIS at 48?h after cardiothoracic surgery is strongly associated with increased length of ventilation, and prolonged ICU and total hospital stay. At all time points assessed, VIS is more predictive of poor short-term outcome than IS. VIS may be useful as an independent predictor of outcomes.     

Synthesis of a Novel l-Methyl-Methionine–ICG-Der-02 Fluorescent Probe for In Vivo Near Infrared Imaging of Tumors

Purpose

A novel near infrared fluorescent probe, l-methyl-methionine (Met)?CICG-Der-02, was synthesized and characterized for in vivo imaging of tumors and early diagnosis of cancers.

Method

Met was conjugated with ICG-Der-02 dye through the amide bond function by ethyl-3-(3-dimethyllaminopropyl) carbodiimide hydrochloride/N-hydroxysuccinimide catalysis chemistry. Met?CICG-Der-02 probe uptake was evaluated on PC3, MDA-MB-231, and human embryonic lung fibroblast cell lines. The dynamics of Met?CICG-Der-02 was investigated in athymic nude mice prior to evaluation of the probe targeting capability in prostate and breast cancer models.

Results

Met?CICG-Der-02 was successfully synthesized. Cell experiments demonstrated excellent cellular uptake of Met?CICG-Der-02 on cancer cell lines without cytotoxicity. Optical imaging showed a distinguishable fluorescence signal in the tumor area at 2?h while maximal tumor-to-normal tissue contrast ratio was at 12?h Met?CICG-Der-02 post-injection. Additionally, dynamic study of the probe indicated intestinal and liver?Ckidney clearance pathways.

Conclusion

Met?CICG-Der-02 probe is a promising optical imaging agent for tumor diagnosis, especially in their early stage.     

Persisting high levels of plasma pentraxin 3 over the first days after severe sepsis and septic shock onset are associated with mortality

Purpose

Pentraxin 3 (PTX3) is an inflammatory mediator produced by neutrophils, macrophages, myeloid dendritic and endothelial cells. During sepsis a massive inflammatory activation and coagulation/fibrinolysis dysfunction occur. PTX3, as a mediator of inflammation, may represent an early marker of severity and outcome in sepsis.

Methods

This study is based on a prospective trial regarding the impact of glycemic control on coagulation in sepsis. Ninety patients admitted to three general intensive care units were enrolled when severe sepsis or septic shock was diagnosed. At enrollment, we recorded sepsis signs, disease severity, coagulation activation [prothrombin fragments 1 + 2 (F₁₊₂)] and fibrinolysis inhibition [plasminogen activator inhibitor-1 (PAI-1)]. We measured plasma PTX3 levels at enrollment, everyday until day 7, then at days 9, 11, 13, 18, 23 and 28. Mortality was recorded at day 90.

Results

Although not different on day 1, PTX3 remained significantly higher in non-survivors than in survivors over the first 5 days (p = 0.002 by general linear model). On day 1, PTX3 levels were higher in septic shock than in severely septic patients (p = 0.029). Day 1 PTX3 was significantly correlated with platelet count (p < 0.001), SAPS II score (p = 0.006) and SOFA score (p < 0.001). Day 1 PTX3 was correlated with F₁₊₂ concentration and with PAI-1 activity and concentration (p < 0.05 for all).

Conclusions

Persisting high levels of circulating PTX3 over the first days from sepsis onset may be associated with mortality. PTX3 correlates with severity of sepsis and with sepsis-associated coagulation/fibrinolysis dysfunction.     

Vitamin?D status in critically ill children

Background

Hypovitaminosis?D is an independent risk factor for cardiovascular disease, muscle weakness, impaired metabolism, immune dysfunction, and compromised lung function. Hypovitaminosis?D is common in critically ill adults and has been associated with adverse outcomes. The prevalence of hypovitaminosis?D and its significance in critically ill children are unclear.

Methods

We performed a prospective study to determine the prevalence of hypovitaminosis?D in 316 critically ill children, and examined its association with physiological and biochemical variables, length of pediatric intensive care unit (PICU) stay, and hospital mortality.

Results

The prevalence of hypovitaminosis?D [25(OH)D₃ <50?nmol/L] was 34.5?%. Hypovitaminosis?D was more common in postoperative cardiac patients than in general medical ICU patients (40.5 versus 22.6?%, p?=?0.002), and the cardiac patients had a higher inotrope score [2.5 (1.9–3.3) versus 1.4 (1.1–1.9), p?=?0.006]. Additionally, ionized calcium within the first 24?h was lower in patients with 25(OH)D₃ <50?nmol/L [1.07 (0.99–1.14)?mmol/L] compared with patients with normal vitamin?D₃ [1.17 (1.14–1.19)?mmol/L, p?=?0.02]. Hypovitaminosis?D was not associated with longer PICU stay or increased hospital mortality.

Conclusions

Hypovitaminosis?D is common in critically ill children, and is associated with higher inotropes in the postoperative cardiac population, but not with PICU length of stay or hospital survival.     

Associations of markers of inflammation and coagulation with delirium during critical illness

Purpose

To assess the associations between a?priori-selected markers of inflammation and coagulation and delirium during critical illness.

Methods

In this prospective cohort study, we collected blood from mechanically ventilated medical intensive care unit (ICU) patients and measured nine plasma markers of inflammation and coagulation. We assessed patients daily for delirium using the Confusion Assessment Method for the ICU and used multivariable regression to analyze the associations between plasma markers and subsequent delirium, after adjusting for age, severity of illness, and sepsis.

Results

Among the 138 patients studied, with median age of 66?years and median Acute Physiology and Chronic Health Evaluation (APACHE)?II of 27, 107 (78?%) were delirious at some point during the study. Two markers of inflammation and one of coagulation were significantly associated with delirium. After adjusting for covariates, lower plasma concentrations of matrix metalloproteinase-9 (MMP-9) and protein?C were associated with increased probability of delirium (p?=?0.04 and 0.01, respectively), and higher concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1) were associated with increased probability of delirium (p?<?0.01). Concentrations of C-reactive protein (p?=?0.82), myeloperoxidase (p?=?0.11), neutrophil gelatinase-associated lipocalin (p?=?0.70), D-dimer (p?=?0.83), plasminogen activator inhibitor type?1 (p?=?0.98), and Von Willebrand factor antigen (p?=?0.65) were not associated with delirium.

Conclusions

In this study, MMP-9, protein?C, and sTNFR1 were independently associated with subsequent ICU delirium. These results suggest that specific aspects of inflammation and coagulation may play a role in the evolution of delirium during critical illness and that these markers should be examined in larger studies of ICU patients.     

Interventional closure of atrial septal defects without fluoroscopy in adult and pediatric patients

Background

Interventional closure of atrial septal defects (ASDs) with a transcatheter device is the preferred strategy in children and adults. This procedure has been proven in numerous studies, but X-ray and contrast agent exposure is still a major side effect. The aim of this study was to clarify whether the interventional closure of ASDs is possible and safe if it is guided by transesophageal echocardiography (TEE) alone.

Methods and results

We retrospectively selected and studied pediatric and adult patients with interventional closure of ASDs at the Deutsches Herzzentrum Berlin (DHZB) without fluoroscopy between 1999 and 2010. We included 330 out of 1,605 patients; 254 had an ASD II, 30 a PFO and 46 multiperforated atrial septum. Median age was 8.92 (0.96–76.3)?years and median body weight 32.6 (8.3–156)?kg. Median stretched defect size was 13 (5–29)?mm. Median procedure time was 50 (20–170)?min. Closure was performed in the majority of patients with the Amplatzer^? septal occluder or Amplatzer^? PFO occluder. The procedure succeeded in 98.2?% of cases and closure rate was 94.9?% after 48?h. Complication rate was low and procedure time was similar to that necessary with studies using fluoroscopy.

Conclusion

Interventional closure of ASDs is safe and effective if guided with TEE alone. The results can compete with those with the use of fluoroscopy. TEE-guided closure of ASD should be considered in more catheter laboratories to avoid unnecessary radiation exposure for the patient and the examiner.     

Taxane-induced peripheral neuropathy and health-related quality of life in postoperative breast cancer patients undergoing adjuvant chemotherapy: N-SAS BC 02, a randomized clinical trial

Purpose

To elucidate whether adjuvant taxane monotherapy is a feasible and tolerable for postoperative breast cancer patients, we evaluated the severity of chemotherapy-induced peripheral neuropathy (CIPN) and the relative tolerability of regimens by health-related quality of life (HRQOL) assessment in node-positive breast cancer patients treated with taxane-containing regimens.

Methods

We evaluated CIPN and HRQOL in the first 300 patients enrolled in a larger (1,060 total) multicenter phase III trial randomized to one of four adjuvant regimens: (1) anthracycline–cyclophosphamide followed by paclitaxel (ACP), (2) AC followed by docetaxel (ACD), (3) paclitaxel alone (PTX), or (4) docetaxel alone (DTX). CIPN was assessed by the Patient Neurotoxicity Questionnaire (PNQ) and the National Cancer Institute Common Toxicity Criteria, and HRQOL by Functional Assessment of Cancer Therapy-General (FACT-G). CIPN and HRQOL scores were compared between ACP and ACD vs. PTX and DTX, and ACP and PTX vs. ACD and DTX.

Results

PNQ sensory scores were significantly higher in patients treated with taxane monotherapy compared to treatment with AC followed by taxane (P?=?.003). No significant differences in PNQ sensory scores were observed between the ACP and PTX vs. ACD and DTX regimens (P?=?.669). Regardless of taxane regimen, PNQ severity scores for CIPN appear to be largely reversible within 1?year of adjuvant treatment. No significant difference in FACT-G scores was observed between any regimens during the study treatments.

Conclusions

Patient-reported CIPN was significantly more severe with single-agent adjuvant taxane compared to AC followed by taxane treatment; however, the HRQOL findings support that single-agent taxane treatment is tolerable.     

Causes and risk factors of death in patients with thrombotic microangiopathies

Purpose

Although plasma therapy of thrombotic micro-angiopathies (TMAs) has dramatically improved survival, the outcome remains fatal in up to 15?% of patients. We investigated the causes and risk factors of death in patients with TMA.

Methods

Retrospective matched case–control national-registry study of 57 patients who died within 180?days of TMA diagnosis and 48 survivors matched on age, gender, and baseline platelet count and creatinine level. The study period was 1995–2007. Factors associated with mortality were identified using a conditional logistic regression model.

Results

Median time from TMA symptom onset to death was 7 (5–14) days. The leading causes of death were nosocomial infections, myocardial infarction, stroke, and pulmonary embolism. Cases and controls did not differ significantly regarding haemolysis parameters, ADAMTS13 activity, or neurological or gastrointestinal involvement. TMA was more frequently related to HIV or cancer in patients who died. Compared to survivors, non-survivors more often had cardiac involvement at diagnosis (38 vs. 6?%, p?=?0.03) and less often received plasma exchange therapy (60 vs. 92?%, p?=?0.004). Only two factors were independently associated with mortality by multivariate analysis: cardiac involvement at diagnosis (odds ratio, 5.96; 95?% confidence interval, 1.06–33.4) and plasma exchange therapy (odds ratio, 0.25; 95?% confidence interval, 0.06–0.99).

Conclusion

Our data emphasise the adverse prognostic significance of cardiac abnormalities and support routine plasma exchange in patients with TMA. Given the high risk of cardiac and neurological complications, adequate monitoring should be proposed to these patients in appropriate hospital settings.     

End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test

Purpose

In stable ventilatory and metabolic conditions, changes in end-tidal carbon dioxide (EtCO₂) might reflect changes in cardiac index (CI). We tested whether EtCO₂ detects changes in CI induced by volume expansion and whether changes in EtCO₂ during passive leg raising (PLR) predict fluid responsiveness. We compared EtCO₂ and arterial pulse pressure for this purpose.

Methods

We included 65 patients [Simplified Acute Physiology Score (SAPS)?II?=?57?±?19, 37 males, under mechanical ventilation without spontaneous breathing, 15?% with chronic obstructive pulmonary disease, baseline CI?=?2.9?±?1.1?L/min/m²] in whom a fluid challenge was decided due to circulatory failure and who were monitored by an expiratory-CO₂ sensor and a PiCCO2 device. In all patients, we measured arterial pressure, EtCO₂, and CI before and after a fluid challenge. In 40 patients, PLR was performed before fluid administration. The PLR-induced changes in arterial pressure, EtCO₂, and CI were recorded.

Results

Considering the whole population, the fluid-induced changes in EtCO₂ and CI were correlated (r ²?=?0.45, p?=?0.0001). Considering the 40 patients in whom PLR was performed, volume expansion increased CI ??15?% in 21 ??volume responders.?? A PLR-induced increase in EtCO₂ ??5?% predicted a fluid-induced increase in CI ??15?% with sensitivity of 71?% (95?% confidence interval: 48?C89?%) and specificity of 100 (82?C100)?%. The prediction ability of the PLR-induced changes in CI was not different. The area under the receiver-operating characteristic (ROC) curve for the PLR-induced changes in pulse pressure was not significantly different from 0.5.

Conclusion

The changes in EtCO₂ induced by a PLR test predicted fluid responsiveness with reliability, while the changes in arterial pulse pressure did not.     

Haemodynamic and neuroendocrine effects of tezosentan in chronic experimental pulmonary hypertension

Purpose

Chronic pulmonary hypertension (PH) therapy is poorly investigated in intensive care. Our aim was to evaluate haemodynamic and neuroendocrine effects of the dual endothelin-1 (ET-1) blocker tezosentan in monocrotaline (MCT)-induced PH.

Methods

Male Wistar rats (180–200?g, n?=?194) randomly received 60?mg?kg^?1 MCT or vehicle, subcutaneously, and 2?days later, a subgroup of MCT-injected rats was gavaged with 300?mg?kg^?1?day^?1 bosentan (MCT BOS, n?=?46), while another (MCT, n?=?125) and control rats (Ctrl, n?=?23) received vehicle. At 25–30?days, 48?h after interrupting bosentan, rats randomly underwent either a dose–response evaluation (0.5–20?mg?kg^?1, n?=?7 each group) or a 4?h perfusion of tezosentan (20?mg?kg^?1 in 10?min?+?10?mg?g^?1?h^?1) or vehicle (n?=?8 per group, each). Haemodynamics, including blood gas analysis, were evaluated after thoracotomy under anaesthesia. After plasma, right ventricle (RV) and lung collection, plasma ET-1, cytokines, nitrate and 6-keto-PGF1α, and lung and right ventricular gene expression and cyclooxygenase (COX) and nitric oxide synthase (NOS) activities were quantified.

Results

Monocrotaline resulted in PH, RV dilation and decreased cardiac output (CO) that were attenuated in MCT BOS. Pulmonary hypertension was attenuated by tezosentan without systemic hypotension. Tezosentan increased CO without changing ventilation-perfusion matching. Both bosentan and tezosentan reduced ET-1 and cytokine plasma levels and tissue expression, and inducible NOS and COX-2 RV activities. Bosentan increased nitrate plasma levels and non inducible NOS activities whereas tezosentan decreased circulating 6-keto-PGF1α but increased lung COX-1 activity.

Conclusions

Tezosentan may be useful for haemodynamic handling and bosentan replacement in critically ill PH patients exerting important beneficial neuroendocrine and anti-inflammatory actions.     

Increase in use of non-invasive ventilation for infants with severe bronchiolitis is associated with decline in intubation rates over a decade

Purpose

To redress the paucity of studies evaluating non-invasive respiratory support in bronchiolitis patients.

Methods

Following ethics committee approval, the clinical database of a tertiary 23-bed paediatric intensive care unit (PICU) was reviewed for bronchiolitis admissions from January 2000 to December 2009. Length of stay (LOS), ventilatory requirements and risk factors, including prematurity, respiratory syncytial virus (RSV) status, chronic lung, neuromuscular, immune and congenital heart disease, were analysed.

Results

Of 8,288 admissions, 520 (6.27?%) had bronchiolitis with 343 (65.9?%) having RSV. Median (±SD) age and LOS were 2.78?months and 2.68 (±4.32)?days. One (0.2?%) patient died. Assisted ventilation was required for 399 (76.7?%) patients. A total of 114 (28.6?%) patients were intubated directly and 285 (71.4?%) had a trial of non-invasive ventilation (NIV). Significant increase in the use of NIV was seen (2.8?%/year) with decline in intubation rates (1.9?%/ year) (p?=?0.002). Of NIV patients, 237 (83.2?%) needed only NIV and 48 (16.8?%) failed and therefore needed intubation. The median LOS was shorter in those who succeeded NIV (2.38?±?2.43?days) compared to those with invasive ventilation (5.19?±?6.34?days) and those who failed NIV (8.41?±?3.44?days). Presence of a risk factor increased the chances of failing NIV from 6 to 10?%.

Conclusion

NIV was successful in the vast majority of patients, particularly in those without risk factors and halved the LOS in intensive care. Failure of NIV was associated with increased duration of invasive ventilation and PICU LOS. A prospective study comparing different techniques of NIV will be helpful in defining the risks of failure of NIV.     

The diagnostic value of serum pentraxin 3 levels in pulmonary contusion

Purpose

To investigate the difference in pentraxin 3 (PTX 3) levels between patients with pulmonary contusion and healthy volunteers.

Comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial

Purpose

To compare the effects of two arginine vasopressin (AVP) dose regimens on the hemodynamic response, catecholamine requirements, AVP plasma concentrations, organ function and adverse events in advanced vasodilatory shock.

Methods

In this prospective, controlled, open-label trial, patients with vasodilatory shock due to sepsis, systemic inflammatory response syndrome or after cardiac surgery requiring norepinephrine >0.6???g/kg/min were randomized to receive a supplementary AVP infusion either at 0.033?IU/min (n?=?25) or 0.067?IU/min (n?=?25). The hemodynamic response, catecholamine doses, laboratory and organ function variables as well as adverse events (decrease in cardiac index or platelet count, increase in liver enzymes or bilirubin) were recorded before, 1, 12, 24 and 48?h after randomization. A linear mixed effects model was used for statistical analysis in order to account for drop-outs during the observation period.

Results

Heart rate and norepinephrine requirements decreased while MAP increased in both groups. Patients receiving AVP at 0.067?IU/min required less norepinephrine (P?=?0.006) than those infused with AVP at 0.033?IU/min. Arterial lactate and base deficit decreased while arterial pH increased in both groups. During the observation period, AVP plasma levels increased in both groups (both P?<?0.001), but were higher in the 0.067?IU/min group (P?<?0.001) and in patients on concomitant hydrocortisone. The rate of adverse events and intensive care unit mortality was comparable between groups (0.033?IU/min, 52%; 0.067?IU/min, 52%; P?=?1).

Conclusions

A supplementary AVP infusion of 0.067?IU/min restores cardiovascular function in patients with advanced vasodilatory shock more effectively than AVP at 0.033?IU/min.     

Predictive value of bronchoscopy after infant cardiac surgery: a prospective study

Background and aims

Airway evaluation following infant cardiac surgery often reveals evidence of tracheobronchial narrowing. We studied the association between airway narrowing and extubation failure (EF) in this population.

Methods

Prospective cohort study of infants (age ≤6?months) from March–September 2009. Flexible bronchoscopy (FB) evaluations were obtained using a standardised protocol after operative intervention. The primary endpoint was the development of extubation failure (EF; defined as the need for invasive mechanical ventilation ≤48?h after primary extubation) and several secondary endpoints.

Results

Fifty-three patients were evaluated at a median age of 81 [interquartile range (IQR) 13–164] days and weight of 4.2 (IQR 3.2–6.0) kg; 13 (25?%) of the patients had single ventricle palliations and two subsequently underwent heart transplantation. Significant airway narrowing was noted in 15 of 30 [50 %, 95 % confidence interval (CI) 31–69?%] patients who underwent FB; ten of the 53 patients (19 %, 95 %CI 10–32?%) subsequently developed EF. Narrowed airway calibre on bronchoscopy had a sensitivity and specificity of 50 % (95 %CI 28–71 %) and 50 % (95 %CI 28–71 %), respectively, for EF. The single greatest predictor of EF by univariate analysis was the need for preoperative ventilation [odds ratio (OR)?6.5, 95 %CI 1.3–33.2, p?=?0.03]. Patients with EF had a greater likelihood of intensive care readmission (OR?4.8, 95 %CI 1.1–21, p?<?0.04) during the same hospital admission.

Conclusions

Airway narrowing on FB is noted frequently after infant cardiac surgery. Overall assessment and presence of narrowing on bronchoscopy had poor sensitivity and specificity for EF in our cohort. Expert assessment of tracheobronchial narrowing on FB has poor to moderate inter-rater reliability.     

Acute kidney injury in critically ill patients with 2009 influenza A (H1N1) viral pneumonia: an observational study

Objective

To describe the incidence, risk factors, and impact on mortality of acute kidney injury (AKI) in patients with 2009 influenza?A (H1N1) viral pneumonia requiring mechanical ventilation.

Design

Observational cohort study.

Patients and methods

AKI was defined as risk, injury or failure, according to the RIFLE classification. Early and late AKI were defined as AKI occurring on intensive care unit (ICU) day?2 or before, or after ICU day?2, respectively. Demographic data and information on organ dysfunction were collected daily.

Results

Of 84 patients, AKI developed in 43 patients (51%). Twenty (24%) needed renal replacement therapy. Early and late AKI were found in 28 (33%) and 15 (18%) patients, respectively. Patients with AKI, as compared with patients without AKI, had higher Acute Physiology and Chronic Health Evaluation (APACHE)?II score and ICU mortality (72% versus 39%, p?<?0.01) and presented on admission more marked cardiovascular, respiratory, and hematological dysfunction. Patients with early but not late AKI presented on admission higher APACHE?II score and more marked organ dysfunction, as compared with patients without AKI. ICU mortality was higher in late versus early AKI (93% versus 61%, p?<?0.001). On multivariate analysis, only APACHE?II score and late but not early AKI [odds ratio (OR) 1.1 (95% confidence interval 1.0?C1.1) and 15.1 (1.8?C130.7), respectively] were associated with mortality.

Conclusions

AKI is a frequent complication of 2009 influenza?A (H1N1) viral pneumonia. AKI developing after 2?days in ICU appears to be associated with different risk factors than early AKI, and is related to a higher mortality rate.