Urinary biomarker of oxidative stress correlating with outcome in critically septic patients

Objective To determine whether urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG), an in vivo parameter of oxidative stress, is correlated with the outcome of critically septic patients. Design and setting Clinical outcome study in an adult medical ICU. Patients Eighty-five consecutive septic patients: 59 men and 26 women. Measurements and results Urinary 8-OHdG was analyzed using isotope-dilution liquid chromatography with tandem mass spectrometry (LC/MS/MS). ICU mortality in these 85 septic patients was 25.9% (n = 22) and hospital mortality 38.8% (n = 33). APACHE II scores of survivors on day 1, on day 3, and the difference between them differed significantly from those of nonsurvivors (day 1, 21.0 ± 7.1 vs. 25.9 ± 8.0; day 3, 15.0 ± 5.8 vs. 23.2 ± 8.3; difference, 6.0 ± 5.5 vs. 1.7 ± 6.6). Urinary 8-OHdG was significantly lower in survivors than in nonsurvivors on day 1 (1.8 ± 2.4 vs. 3.0 ± 2.4). The area under receiver operating characteristic curve analysis for the association between day 1 urinary 8-OHdG and ICU mortality was 0.71. The comparison performed upon discharge from hospital revealed similar results. Conclusions This is a preliminary study. The excretion of the urinary 8-OHdG, as measured using isotope-dilution LC/MS/MS, as the APACHE II score, were correlated with the outcome of critically septic patients in medical ICU. An erratum to this article can be found at     

Terlipressin as a rescue therapy for catecholamine-resistant septic shock in children

Objective To evaluate the effect of terlipressin on oxygenation, PaO₂/FIO₂, heart rate, mean arterial pressure, and mortality in children with septic shock refractory to high doses of dopamine/dobutamine and adrenaline. Design and setting A randomized, nonblind study in the pediatric intensive care unit of a university hospital. Patients and measurements We studied 58 children with septic shock and refractory hypotension despite fluid loading and high doses of catecholamines, randomly enrolled to terlipressin (TP, n = 30) or control (n = 28). TP was administered as intravenous bolus doses of 20 μg/kg every 6 h for a maximum of 96 h. Hemodynamic changes, PaO₂/FIO₂ rates, length of stay, and mortality rate in PICU were recorded prospectively. Results Mean arterial pressure and PaO₂/FIO₂ significantly increased, and heart rate significantly decreased 30 min after each TP treatment, but mortality did not differ from control (67.3% vs. 71.4%). Mean stay in the PICU was shorter in the TP group (13.4 ± 7.9 vs. 20.2 ± 9.7 days and was longer among nonsurvivors of the TP group vs. control (10.4 ± 6.9 vs. 6.2 ± 3.4 days). Blood urea nitrogen, creatinine, AST, ALT, and urine output of patients in the TP group did not change after terlipressin. Conclusions Although terlipressin infusion had no effect on mortality, it significantly increases mean arterial pressure, PaO₂/FIO₂, and survival time in nonsurvivors. Terlipressin seems to cause no adverse effect but warrants further evaluation as a rescue therapy in refractory septic shock.     

Mean glucose level is not an independent risk factor for mortality in mixed ICU patients

Objective To find out if there is an association between hyperglycaemia and mortality in mixed ICU patients. Design and setting Retrospective cohort study over a 2-year period at the medical ICU of a university hospital. Measurements Admission glucose, maximum and mean glucose, length of stay, mortality, insulin therapy and Apache-II score. Results In 1085 consecutive patients, ICU- and hospital mortality were 20 and 25%, respectively. The total number of blood glucose measurements was 10.012. Admission glucose was 7.9 ± 4.5 mmol/l (mean ± SD), mean glucose 7.5 ± 2.9 and maximum glucose 10.0 ± 5.4 mmol/l. Median ICU length of stay (LOS) was 3.0 days (range 2.0–6.0 days, IQR), and hospital LOS was 16 days (range 7–32 days). In 28% of patients insulin treatment was started. Median Apache-II score was 13. 68% of patients were mechanically ventilated. Univariate analysis showed an association with ICU mortality for mean glucose (non-survivors 8.6 ± 4.3 vs 7.2 ± 2.4 survivors), maximum glucose (11.7 ± 5.9 vs 9.6 ± 5.2, non-survivors vs survivors, respectively), use of insulin (mortality 29 vs 17% in patients not using insulin) and age (61 vs 55.7 years). Gender and a history of diabetes mellitus were not associated with mortality. In a multivariate model, the Apache-II score was the only variable associated with mortality independent of other variables, including mean blood glucose. Conclusion In this retrospective study mean glucose level was not an independent risk factor for mortality in mixed ICU patients.     

Intensive care unit acquired infection and organ failure

Objective To assess the temporal relationship between ICU-acquired infection (IAI) and the prevalence and severity of organ dysfunction or failure (OD/F). Design and setting Observational, single center study in a mixed intensive care unit of a university hospital. Patients We analyzed 1,191 patients hospitalized for more than 2 days during a 2-year observation period: 845 did not acquire IAI, 306 of whom had infection on admission (IOA); 346 did acquire IAI, 125 of whom had IOA. Measurements and results The SOFA score was calculated daily, both SOFAmax, the sum of the worst OD/F during the ICU stay, and SOFApreinf, the sum of the worst OD/F existing before the occurrence of the first IAI. The SAPS II and SOFA score of the first 24 h were significantly higher in patients with than in those without IAI. SOFApreinf of IAI patients was also higher than the SOFAmax of patients without IAI both in patients with (12.1 ± 4.6 vs. 8.9 ± 4.7) and those without IOA (9.2 ± 4.0 vs. 6.7 ± 3.5). SOFApreinf represented 85.7% of the value of SOFAmax in patients with IAI. SOFApreinf increased significantly with the occurrence of sepsis, severe sepsis, or septic shock during ICU stay. Severe sepsis and septic shock during ICU stay as well as SOFApreinf were part of the factors associated with hospital mortality. Conclusions IAI is significantly associated with hospital mortality; however, its contribution to OD/F is minor. Moreover, severity of IAI seems to be related to previous health status. This article is discussed in the editorial available at: .     

Renal arterial resistance in septic shock: effects of increasing mean arterial pressure with norepinephrine on the renal resistive index assessed with Doppler ultrasonography

Objective To determine the effects of increasing mean arterial pressure (MAP) on renal resistances assessed by Doppler ultrasonography in septic shock. Design and setting Prospective, single-center, nonrandomized, open-label trial in the surgical intensive care unit in a university teaching hospital. Patients and participants 11 patients with septic shock who required fluid resuscitation and norepinephrine to increase and maintain MAP at or above 65 mmHg. Interventions Norepinephrine was titrated in 11 patients in septic shock during three consecutive not randomized periods of 2 h to achieve a MAP at successively 65, 75, and 85 mmHg. Measurements and results At the end of each period hemodynamic parameters and renal function variables (urinary output, creatinine, clearance) were measured, and Doppler ultrasonography was performed on interlobar arteries to assess the renal resistive index. When increasing MAP from 65 to 75 mmHg, urinary output increased significantly from 76 ± 64 to 93 ± 68 ml/h and the resistive index significantly decreased from 0.75 ± 0.07 to 0.71 ± 0.06. No difference was found between 75 and 85 mmHg. Conclusions Doppler ultrasonography and resistive index measurements may help determine in each patient the optimal MAP for renal blood flow and may be a relevant end-point to titrate the hemodynamic treatment in septic shock.     

Excess ICU mortality attributable to ventilator-associated pneumonia: The role of early vs late onset

Objective To determine the impact of ventilator-associated pneumonia (VAP) on ICU mortality, and whether it is related to time of onset of pneumonia. Design Prospective cohort study. Setting 16-bed medical-surgical ICU at a university-affiliated hospital. Patients and measurements From 2002 to 2003, we recorded patients receiving mechanical ventilation for > 72 h. Patients developing an infection other than VAP were excluded. Patients definitively diagnosed with VAP (n = 40) were cases and patients free of any infection acquired during ICU stay (n = 61) were controls. The VAP-attributed mortality was defined as the difference between observed mortality and predicted mortality (SAPS II) on admission. Results Mechanical ventilation was longer in VAP patients (25 ± 20 vs 11 ± 9 days; p < 0.001), as was ICU stay (33 ± 23 vs 14 ± 12 days; p < 0.001). In the non-VAP group, no difference was found between observed and predicted mortality (27.9 vs 27.4%; p > 0.2). In the VAP group, observed mortality was 45% and predicted mortality 26.5% (p < 0.001), with attributable mortality 18.5%, and relative risk (RR) 1.7 (95% CI 1.12–23.17). No difference was observed between observed and predicted mortality in early-onset VAP (27.3 vs 25.8%; p > 0.20); in late-onset VAP, observed mortality was higher (51.7 vs 26.7%; p < 0.01) with attributable mortality of 25% and an RR 1.9 (95% CI 1.26–2.63). Empiric antibiotic treatment was appropriate in 77.5% of episodes. No differences in mortality were related to treatment appropriateness. Conclusions In mechanically ventilated patients, VAP is associated with excess mortality, mostly restricted to late-onset VAP and despite appropriate antibiotic treatment.     

Renal blood flow and function during recovery from experimental septic acute kidney injury

Objective To measure renal blood flow (RBF) and renal function during recovery from experimental septic acute kidney injury (AKI). Design Controlled experimental study. Subjects Nine merino ewes. Setting University physiology laboratory. Intervention We recorded systemic and renal hemodynamics during a 96-h observation period (control) via implanted transit-time flow probes. We then compared this period with 96 h of septic AKI (48 h of Escherichia coli infusion) and subsequent recovery (48 h of observation after stopping E. coli). Measurements and results Compared with the control period, E. coli infusion induced hyperdynamic sepsis (increased cardiac output and decreased blood pressure) and septic AKI (serum creatinine 65.4 ± 8.7 vs. 139.9 ± 33.0 μmol/l; creatinine clearance 73.8 ± 12.2 vs. 40.2 ± 17.2 ml/min; p < 0.05) with a mortality of 22%. RBF increased (278.8 ± 33.9 vs. 547.9 ± 124.8 ml/min; p < 0.05) as did renal vascular conductance (RVC). During recovery, we observed a decrease in RVC and RBF with all values returning to control levels. Indices of tubular function [fractional excretion of sodium (FENa) and urea (FEUn) and urinary sodium concentration (UNa)], which had been affected by sepsis, returned to control values after 18 h of recovery, as did serum creatinine. Conclusions Infusion of E. coli induced a hyperdynamic circulatory state with hyperemic AKI. Recovery was associated with relative renal vasoconstriction and reduction in RBF and RVC back to control levels. Indices of tubular function normalized more rapidly than changes in RBF. This article is discussed in the editorial available at: .     

Adrenal response in patients with septic shock of abdominal origin: relationship to survival

Objective To evaluate the prognostic value of adrenocortical response to corticotropin in septic shock patients operated on exclusively for an intra-abdominal source of infection. Design and setting Prospective, observational, single-center study in a surgical intensive care unit of a university hospital Patients 118 consecutive septic shock patients undergoing laparotomy or drainage for intra-abdominal infection. Measurements and results Baseline cortisol (t ₀) and cortisol response to corticotropin test (Δ) were measured during the first 24 h following onset of shock. The relationship between adrenal function test results and survival was analyzed as well as the effect of etomidate anesthesia. Cortisol plasma level at t ₀ was higher in nonsurvivors than in survivors (33 ± 23 vs. 25 ± 14 μg/dl), but the response to corticotropin test did not differ between these two subgroups. ROC analysis showed threshold values for t ₀ (32 μg/dl) and Δ (8 μg/dl) that best discriminated survivorsfrom nonsurvivors in our population. We observed no difference in survival at the end of hospital stay using log rank test when patients were separated according to t ₀, Δ, or both. In addition, adrenal function testsand survival did not differ in patients who received etomidate anesthesia (n = 69) during the surgical treatment of their abdominal sepsis. Conclusions In this cohort of patients with abdominal septic shock baseline cortisol level and the response to corticotropin test did not discriminate survivors from nonsurvivors. No deleterious impact of etomidate anesthesia on adrenal function tests and survival was observed in these patients.     

Is myocardial adrenergic responsiveness depressed in human septic shock?

Objective To assess left ventricular (LV) contractile function and adrenergic responsiveness in septic patients. Methods We used echocardiographically defined fractional area of contraction (FAC), and LV area to end-systolic arterial pressure estimates of end-systolic elastance (E'es) and its change in response to dobutamine (5 μg/kg/min) in 10 subjects in septic shock admitted to an intensive care unit of an academic medical center. Subjects were studied on admission and again at both 5 days and 8–10 days after admission. Results Three of the 10 subjects died as a result of their acute process, while the others were discharged from hospital. Nine out of 10 subjects required intravenous vasopressor therapy on day 1, while only 1 of 9 subjects required vasopressor support at day 5. LV end-diastolic area (EDA) increased from day 1 to day 5 and days 8–10 (p < 0.05), but neither FAC nor E'es was altered by time (EDA 15.7 ± 5.8, 21.4 ± 5.1, and 19.4 ± 5.6 cm²; FAC 0.46 ± 0.19, 0.50 ± 0.20, and 0.48 ± 0.15%; E'es 21.6 ± 12.6, 23.2 ± 8.5, and 19.2 ± 6.3 mmHg/cm², mean ± SD, for days 1, 5 and 8–10 respectively). Although dobutamine did not alter E'es on day 1 or day 5, E'es increased in all of the 5 subjects studied on days 8–10 (p < 0.05). Conclusions Adrenergic hyporesponsiveness is present in septic shock and persists for at least 5 days into recovery, resolving by days 8–10 in survivors. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. Dr. Pinsky was a Professeur Associé at Cochin Hospital and Paris Descartes University.     

De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate

Objective To assess outcomes with de-escalation therapy in ventilator-associated pneumonia (VAP). Design Prospective observational study. Setting Multidisciplinary intensive care unit. Patients and participants VAP was diagnosed by positive quantitative cultures of both tracheal aspirate and bronchoalveolar lavage (BAL) and treated appropriately for all significant isolates of tracheal aspirate and BAL in 143 patients who were assigned to de-escalation therapy by BAL or tracheal aspirate. Interventions None. Measurements and results Antibiotic therapy was de-escalated in 58 patients (40.5%), who had decreased mortality at day 15 (5.1% vs. 31.7%) and day 28 (12% vs. 43.5%) and shorter intensive care unit (17.2 ± 1.2 vs. 22.7 ± 6.3 days) and hospital (23.7 ± 2.8 vs. 29.8 ± 11.1 days) stay (p < 0.05). Of the 81 patients assigned to tracheal aspirate, the 17 (21%) who achieved de-escalation of therapy had reduced 15-day mortality (5.8% vs. 34.3%), reduced 28-day mortality (11.6% vs. 45.3%), and shorter intensive care unit (17.2 ± 1.6 vs. 22.4 ± 6.4 days) and hospital (23.1 ± 4.4 vs. 29.9 ± 11.1 days) stay (p < 0.05). Of the 62 patients assigned to BAL, the 41 (66.1%) who achieved de-escalation of therapy had decreased 15-day mortality (4.8% vs. 23.8%), decreased 28-day mortality (12.1% vs. 38%), and shorter intensive care unit (17.2 ± 1.1 vs. 23.2 ± 6 days) and hospital (23.8 ± 2.4 vs. 29.8 ± 11.4 days) stay (p < 0.05). Conclusions For patients with VAP who have had appropriate treatment and shown a favorable clinical response, mortality and duration of stay can be further improved by de-escalation therapy.     

Incidence,risk factors and consequences of ICU delirium

Objective Delirium in the critically ill is reported in 11–80% of patients. We estimated the incidence of delirium using a validated scale in a large cohort of ICU patients and determined the associated risk factors and outcomes. Design and setting Prospective study in a 16-bed medical-surgical intensive care unit (ICU). Patients 820 consecutive patients admitted to ICU for more than 24 h. Interventions Tools used were: the Intensive Care Delirium Screening Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical Rating Scale for pain. Risk factors were evaluated with univariate and multivariate analysis, and factors influencing mortality were determined using Cox regression. Results Delirium occurred in 31.8% of 764 patients. Risk of delirium was independently associated with a history of hypertension (OR 1.88, 95% CI 1.3–2.6), alcoholism (2.03, 1.2–3.2), and severity of illness (1.25, 1.03–1.07 per 5-point increment in APACHE II score) but not with age or corticosteroid use. Sedatives and analgesics increased the risk of delirium when used to induce coma (OR 3.2, 95% CI 1.5–6.8), and not otherwise. Delirium was linked to longer ICU stay (11.5 ± 11.5 vs. 4.4 ± 3.9 days), longer hospital stay (18.2 ± 15.7 vs. 13.2 ± 19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital mortality (26.7% vs. 21.4%). Conclusion Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs. This article is discussed in the editorial available at:     

Effects of levosimendan and dobutamine in experimental acute endotoxemia: a preliminary controlled study

Objective To test the hypothesis that levosimendan increases systemic and intestinal oxygen delivery (DO₂) and prevents intramucosal acidosis in septic shock. Design Prospective, controlled experimental study. Setting University-based research laboratory. Subjects Nineteen anesthetized, mechanically ventilated sheep. Interventions Endotoxin-treated sheep were randomly assigned to three groups: control (n = 7), dobutamine (10 μg/kg/min, n = 6) and levosimendan (100 μg/kg over 10 min followed by 100 μg/kg/h, n = 6) and treated for 120 min. Measurements and main results After endotoxin administration, systemic and intestinal DO₂ decreased (24.6 ± 5.2 vs 15.3 ± 3.4 ml/kg/min and 105.0 ± 28.1 vs 55.8 ± 25.9 ml/kg/min, respectively; p < 0.05 for both). Arterial lactate and the intramucosal–arterial PCO₂ difference (ΔPCO₂) increased (1.4 ± 0.3 vs 3.1 ± 1.5 mmHg and 9 ± 6 vs 23 ± 6 mmHg mmol/l, respectively; p < 0.05). Systemic DO₂ was preserved in the dobutamine-treated group (22.3 ± 4.7 vs 26.8 ± 7.0 ml/min/kg, p = NS) but intestinal DO₂ decreased (98.9 ± 0.2 vs 68.0 ± 22.9 ml/min/kg, p < 0.05) and ΔPCO₂ increased (12 ± 5 vs 25 ± 11 mmHg, p < 0.05). The administration of levosimendan prevented declines in systemic and intestinal DO₂ (25.1 ± 3.0 vs 24.0 ± 6.3 ml/min/kg and 111.1 ± 18.0 vs 98.2 ± 23.1 ml/min/kg, p = NS for both) or increases in ΔPCO₂ (7 ± 7 vs 10 ± 8, p = NS). Arterial lactate increased in both the dobutamine and levosimendan groups (1.6 ± 0.3 vs 2.5 ± 0.7 and 1.4 ± 0.4 vs. 2.9 ± 1.1 mmol/l, p = NS between groups). Conclusions Compared with dobutamine, levosimendan increased intestinal blood flow and diminished intramucosal acidosis in this experimental model of sepsis. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. This study was solely funded by the Cátedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata. None of the authors have any financial interests to disclose. This article is discussed in the editorial available at: .     

Pituitary-adrenal responses to human corticotropin-releasing hormone in critically ill patients

Objective To investigate the pattern of pituitary-adrenal responses to human corticotropin-releasing hormone (hCRH) in critically ill patients and to examine the relation between responses and clinical outcome. Design and setting Prospective study in consecutive critically ill patients in a general intensive care unit in a teaching hospital. Patients The study included 37 critically ill, mechanically ventilated patients with diverse underlying diagnoses (28 men, 9 women; median age 56 years). Interventions A morning blood sample was obtained to measure baseline cortisol, corticotropin (ACTH), and cytokines. Patients were then injected with 100 μg hCRH, and plasma cortisol and ACTH were measured over a period of 2 h. Measurements and results In the overall patient population baseline and peak cortisol concentrations following hCRH were 16 ± 5 and 21 ± 5 μg/dl, respectively, and median baseline and peak ACTH levels 23 and 65 pg/ml, respectively. Higher ACTH levels and longer release of cortisol were noted in nonsurvivors (n = 18) than in survivors (n = 19). Furthermore, nonsurvivors had higher concentrations of interleukin 8 (115 vs. 38 pg/ml) and interleukin 6 (200 vs. 128 pg/ml) than survivors. Conclusions Critically ill patients demonstrate altered pituitary-adrenal axis responses to hCRH. This is particularly evident in the sickest patients with the highest degree of inflammatory profile who ultimately do not survive.     

Treatment of severe acute respiratory distress syndrome: role of extracorporeal gas exchange

Objective To evaluate the effect of extracorporeal gas exchange (ECMO) on mortality of patients referred with severe acute respiratory distress syndrome (ARDS).Design and setting Prospective observational study in a university hospital ICU.Patients 150 patients with severe ARDS.Interventions Multimodal treatment with and without ECMO.Measurements and main results We treated 118 patients (78.7%) conservatively and 32 patients with ECMO. Patients in the ECMO group presented with significantly more severe disease (lung injury score 3.8 ± 0.3 vs. 3.3 ± 0.4; SOFA score 52 ± 14 vs. 43 ± 12; and SAPS score 14 ± 3.3 vs. 10 ± 3.5). Mortality in ECMO-treated patients tended to be higher than that with conservative treatment (46.9% vs. 28.8%, p = 0.059). Multivariate logistic regression analyses with backward selection excluded ECMO as predictor of mortality (p = 0.79). Independent predictors of mortality were age (odds ratio 1.044, 95% confidence interval 1.014–1.075, p = 0.004), mean pulmonary artery pressure (1.082, 1.026–1.141, p = 0.036), sequential organ failure assessment score (1.148, 1.018–1.294, p = 0.024), and days of mechanical ventilation prior to referral (1.064, 1.008–1.123, p = 0.025).Conclusion ECMO treatment does not predict mortality in patients with most severe ARDS.     

Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients

Objective We examined whether guiding therapy by an algorithm based on optimizing the global end-diastolic volume index (GEDVI) reduces the need for vasopressor and inotropic support and helps to shorten ICU stay in cardiac surgery patients. Design and setting Single-center clinical study with a historical control group at an university hospital. Patients Forty cardiac bypass surgery patients were included prospectively and compared with a control group. Interventions In the goal-directed therapy (GDT) group hemodynamic management was guided by an algorithm based on GEDVI. Hemodynamic goals were: GEDVI above 640 ml/m², cardiac index above 2.5 l/min/m², and mean arterial pressure above 70 mmHg. The control group was treated at the discretion of the attending physician based on central venous pressure, mean arterial pressure, and clinical evaluation. Results In the GDT group duration of catecholamine and vasopressor dependence was shorter (187 ± 70 vs. 1458 ± 197 min), and fewer vasopressors (0.73 ± 0.32 vs. 6.67 ± 1.21 mg) and catecholamines (0.01 ± 0.01 vs. 0.83 ± 0.27 mg) were administered. They received more colloids (6918 ± 242 vs. 5514 ± 171 ml). Duration of mechanical ventilation (12.6 ± 3.6 vs. 15.4 ± 4.3 h) and time until achieving status of fit for ICU discharge (25 ± 13 vs. 33 ± 17 h) was shorter in the GDT group. Conclusions Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery. Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible for authorized users.     

Adrenal insufficiency in severe West Nile Virus infection

Objective To explore adrenal function in severe West Nile virus (WNV) infection.Design and setting Prospective interventional cohort study in a medical ICU of a teaching hospital.Patients Ten consecutive patients (seven men, mean age 64 ± 12 years, mean SAPS II 26 ± 6) with definite diagnosis of WNV related meningoencephalitis and variable proportion of organ/system failure. All patients had fever (mean body temperature 39 ± 1°C) and altered mental status (mean Glasgow Coma Score 11 ± 2). Mean SOFA score was 9 ± 2; eight patients had systemic inflammatory response syndrome, five septic shock, and six acute respiratory failure (usually from central origin) requiring mechanical ventilation.Interventions A short corticotropin test was performed in each patient to assess the adrenal function.Measurements and results Cortisol response was defined as the difference between baseline and corticotropin-stimulated peak. Absolute adrenal insufficiency was defined by a baseline cortisol level below 15 μg/dl (415 nmol/l). Relative insufficiency was defined by a cortisol response of 9 μg/dl (250 nmol/l) or less. Relative adrenal insufficiency, defined by a corticotropin response below 9 μg/dl, was observed in seven while the remaining three had normal cortisol response; six out of these seven died in the ICU. All patients with normal adrenal function survived.Conclusion Adrenal insufficiency is frequent in severe WNV infection and carries a poor outcome. In the absence of specific effective treatment, our data provide a rational to investigate a supplemental corticosteroid treatment in a controlled trial.     

Adult congenital heart disease: intensive care management and outcome prediction

Objective Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients. Design, setting and patients Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997–2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391 ± 130, moderate $13218 ± 261, complex $30074 ± 689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p = 0.0048), creatinine (p = 0.0032) and bilirubin (p = 0.0021) were highly predictive of mortality. Conclusions Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.     

Point of care management of heparin administration after heart surgery

Objectives Determination of activated partial thromboplastin time (aPTT) is used in coagulation management after heart surgery. Results from the central laboratory take long to be obtained. We sought to shorten the time to obtain coagulation results and the desired coagulation state and to reduce blood loss and transfusions using point of care (POC) aPTT determination.Design Randomized, controlled trial.Setting University-affiliated 20-bed surgical ICU.Patients and participants Forty-two patients planned for valve surgery (Valves) and 84 for coronary artery bypass grafting (CABG) with cardiopulmonary bypass.Interventions Valves and CABG were randomized to postoperative coagulation management monitored either by central laboratory aPTT (Lab group) or by POC aPTT (POC group). Heparin was administered according to guidelines.Measurements and results POC aPTT results were available earlier than Lab aPTT after venipuncture in Valves (3 ± 2 vs. 125 ± 68 min) and in CABG (3 ± 4 vs. 114 ± 62 min). Heparin was introduced earlier in the POC group in Valves (7 ± 23 vs. 13 ± 78 h, p = 0.01). Valves of the POC group bled significantly less than Valves in the Lab group (647 ± 362 ml vs. 992 ± 647ml, p < 0.04), especially during the first 8 h after ICU admission. There was no difference in bleeding in CABG (1074 ± 869 ml vs. 1102 ± 620, p = NS). In Valves, fewer patients in the POC group than in the Lab group needed blood transfusions (1/21 vs. 8/21; p = 0.03). No difference was detected in CABG.Conclusions In Valves in the POC group the time to the desired coagulation state was reduced, as was the thoracic blood loss, reducing the number of patients transfused. This improvement was not observed in CABG. Side effects were similar in the two groups.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.Presented in part at the annual congress of the European Society of Intensive Care Medicine (ESICM) in Amsterdam, 6–8 October 2003.     

Leptospirosis in Reunion Island (Indian Ocean): analysis of factors associated with severity in 147 confirmed cases

Objective Analysis of risk factors associated with severity in patients with confirmed leptospirosis. Design and setting Retrospective study in 147 leptospirosis-confirmed patients at two tertiary nonteaching hospital in Reunion Island. Patients 138 men and 9 women, aged 36 ± 14 years, 80 in the ICU and 67 in medical wards. Measurements and results We collected demographic, clinical, biological, and radiographic data and performed univariate and multivariate analysis to examine risk factors associated with admission in ICU and mortality. Pulmonary forms were more frequent (85%) than in previous reports, with 85 cases (65.3%) on abnormal chest radiography. Among the 38 patients who underwent bronchoalveolar lavage at admission 31 (81.5%) had alveolar hemorrhage. Independent factors related to ICU admission were: age over 46 years (OR 3.02), creatinine higher than 200 μmol/l (6.69), shock (13.87), and acute respiratory failure (20.69). Mortality was 12.9%. The only factor independently related to mortality was need for mechanical ventilation (OR 20.94). Icterohemorrhagiae serogroup was found in 62 cases (42.8%) but was not related to death. Conclusions Pulmonary involvement is a major feature in leptospirosis disease but is not associated with poor outcome. Identification of clinical and laboratory findings on admission may help to better characterize severe cases. Mailing address: Arnaud Bourdin is currently at the Service de Pneumologie, CHU Montpellier, France.     

Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective case control study

Objective To compare surgical and endovascular stent graft (ESG) treatment of blunt thoracic aortic injury (BAI) in the emergency setting.Design and setting Retrospective case control study in two surgical intensive care units of a university hospital.Patients 30 patients who presented with BAI between 1995 and 2005: 17 treated surgically and 13 by ESG. The two groups were comparable for the severity of trauma and mean delay before treatment; the mean age was higher in the ESG group (46 ± 18 vs. 35 ± 15 years).Results In the surgical group time spent in the operating theater was longer (310 ± 130 vs. 140 ± 48 min) and blood losses higher (2000 ± 1300 vs. no significant bleeding); aortic clamping time was 48 ± 20 min. The mortality rate was 15% with ESG (n = 2) and 23% with surgery (n = 4). Complications of the procedure were more frequent in the surgical group (1 vs. 7). In the ESG group there was one pulmonary embolism. In the surgical group there were three neurological complications, one acute aortic dissection, one perioperative rupture, one periprosthetic leak, and one septic shock. Two complications (postoperative aortic dissection and paraplegia) appeared in the same patient in the surgical group. Intensive care unit length of stay, duration of mechanical ventilation, and catecholamine support were similar in the two groups.Conclusions Stent graft for emergency treatment of BAI is efficient and is associated with fewer complications than surgical treatment.