The diagnostic value of serum leptin monitoring and its correlation with tumor necrosis factor-α in critically ill patients: a prospective observational study

Introduction  

Severe infection and sepsis are common causes of morbidity and mortality. Early diagnosis in critically ill patients is important to reduce these complications. The present study was conducted to determine the role of serum leptin at early diagnosis and differentiation between patients with manifestations of systemic inflammatory response syndrome (SIRS) and those with sepsis in patients suffering from a broad range of diseases in the intensive care unit (ICU) and its correlation with other biomarkers, such as C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α).     

Evidence of altered cortisol metabolism in critically ill patients: a prospective study

Context Changes in cortisol metabolism due to altered activity of the enzyme 11β-hydroxysteroid dehydrogenase (11β-HSD) have been implicated in the pathogenesis of hypertension, obesity and the metabolic syndrome. No published data exist on the activity of this enzyme in critical illness. Objective To investigate cortisol metabolism in critically ill patients utilising plasma cortisol: cortisone ratio as an index of 11β-HSD activity. Setting Tertiary level intensive care unit. Patients Three cohorts of critically ill patients: sepsis (n = 13); multitrauma (n = 20); and burns (n = 19). Main outcome measures Serial plasma cortisol: cortisone ratios. Measurements and main results Plasma total cortisol cortisone ratios were determined serially after admission to the intensive care unit. As compared with controls, the plasma cortisol:cortisone ratio was significantly elevated in the sepsis and trauma cohorts on day 1 (22 ± 9, p = 0.01, and 23 ± 19, p = 0.0003, respectively) and remained elevated over the study period. Such a relationship was not demonstrable in burns. The ratio was significantly correlated with APACHE II (r = 0.77, p = 0.0008) and Simplified Acute Physiology Score (r = 0.7, p = 0.003) only on day 7 and only in the burns cohort. There were no significant correlations observed between total plasma cortisol or cortisone and sickness severity in the sepsis and trauma cohorts. Conclusions In critically ill patients, there is evidence of altered cortisol metabolism due to an increase in 11β-HSD activity as demonstrated by an elevation of plasma cortisol: cortisone ratios. Further studies with larger sample sizes specifically designed to examine altered tissue 11β-HSD activity and its clinical significance and correlation with outcome are warranted.     

Does ultrasonographic assessment of gastric antrum correlate with gastric residual volume in critically ill patients? A prospective observational study

Journal of Clinical Monitoring and Computing - This study aimed to evaluate the relationship between ultrasonographic gastric antral measurements and aspirated gastric residual volume (GRV) in...     

Is hyperlipasemia in critically ill patients of clinical importance? An observational CT study

Objective To assess morphological alterations of the pancreas by contrast-enhanced computed tomography (cCT) and subclinical cellular damage of the pancreas by measuring pancreatitis-associated protein (PAP) in critically ill patients without prior pancreatic disorder who presented with raised serum lipase levels. Design Prospective, observational study Setting Mixed surgical/neurosurgical intensive care unit of a German university hospital. Patients One hundred and thirty consecutive critically ill patients without prior damage or disease of the pancreas and an expected length of stay of more than 5 days. Interventions Daily serum lipase measurements and daily serum PAP measurements. Contrast-enhanced upper abdominal cCT study in patients with triple increase of serum lipase. Measurements and results Thirty-eight patients showed raised serum lipase levels and qualified for the cCT scan study. In 20 patients cCT scans were performed. Morphological alterations of the pancreas were found in 7 out these 20 patients while serum PAP levels were raised in all patients. Conclusion Hyperlipasemia is a common finding in critically ill patients without prior pancreatic disorder. While elevated serum PAP levels indicate pancreatic cellular stress morphological alterations of the pancreas are rare and of little clinical importance. C. Denz and L. Siegel contributed equally to this study. Results were presented in part and published as an abstract at the 18th ESICM Annual Congress, 25–28 September 2005, Amsterdam, Netherlands.     

Is hyperchloremia associated with mortality in critically ill patients? A prospective cohort study

Purpose

The aim of the study was to determine if acid-base variables are associated with hospital mortality.

Materials and Methods

This prospective cohort study took place in a university-affiliated hospital intensive care unit (ICU). One hundred seventy-five patients admitted to the ICU during the period of February to May 2007 were included in the study. We recorded clinical data and acid-base variables from all patients at ICU admission. A logistic regression model was constructed using Sepsis-related Organ Failure Assessment (SOFA) score, age, and the acid-base variables.

Results

Individually, none of the variables appear to be good predictors of hospital mortality. However, using the multivariate stepwise logistic regression, we had a model with good discrimination containing SOFA score, age, chloride, and albumin (area under receiver operating characteristic curve, 0.80; 95% confidence interval, 0.73-0.87).

Conclusions

Hypoalbuminemia and hyperchloremia were associated with mortality. This result involving chloride is something new and should be tested in future studies.     

Fiberoptic bronchoscopy–assisted percutaneous tracheostomy is safe in obese critically ill patients: A prospective and comparative study

Background

Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy.

Objective

The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients.

Patients and Method

A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m².

Results

The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 ± 9 kg/m² vs 22 ± 3 kg/m² for the nonobese patient group (P < .001). The obese patients required 18 ± 7 days of mechanical ventilation, on average, before PT vs 16 ± 7 days for the nonobese patients (P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively (P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients (P = .2).

Conclusion

Percutaneous tracheostomy using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.     

Nutrition-related outcomes and dietary intake in non–mechanically ventilated critically ill adult patients: A pilot observational descriptive study

BackgroundCritically ill patients who do not receive invasive mechanical ventilation (IMV) are a growing population, experiencing complex interventions that may impair dietary intake and nutrition-related outcomes.ObjectivesThe objectives of this study were to quantify intake and nutrition-related outcomes of non-IMV critically ill patients and to establish feasibility of methods to measure nutrition-related outcomes in this population.MethodsNon-IMV adult patients expected to remain in the intensive care unit (ICU) for ≥24 h were eligible. Nutrition-related outcomes were assessed at baseline by subjective global assessment (SGA); on alternate study days by mid-upper arm circumference (MUAC), calf circumference (CC), and ultrasound of quadriceps muscle layer thickness (QMLT); and daily by body weight and bioelectrical impedance analysis (BIA). Data were censored at day 5 or ICU discharge. Dietary intake from all sources, including oral intake via investigator-led weighed food records, was quantified on days 1–3. Feasibility was defined as data completion rate ≥70%. Data are expressed as mean (standard deviation) or median [interquartile range (IQR)].ResultsTwenty-three patients consented (50% male; 53 [42–64] y; ICU stay: 2.8 [1.9–4.0] d). Nutrition-related outcomes at baseline and ICU discharge were as follows: MUAC: 33.2 (8.6) cm (n = 18) and 29.3 (5.4) cm (n = 6); CC: 39.5 (7.4) cm (n = 16) and 37.5 (6.2) cm (n = 6); body weight: 95.3 (34.8) kg (n = 19) and 95.6 (41.0) kg (n = 10); and QMLT: 2.6 (0.8) cm (n = 15) and 2.5 (0.3) cm (n = 5), respectively. Oral intake provided 3155 [1942–5580] kJ and 32 [20–53] g protein, with poor appetite identified as a major barrier. MUAC, CC, QMLT, and SGA were feasible, while BIA and body weight were not.ConclusionsOral intake in critically ill patients not requiring IMV is below estimated requirements, largely because of poor appetite. The small sample and short study duration were not sufficient to quantify changes in nutrition-related outcomes. MUAC, CC, QMLT, and SGA are feasible methods to assess nutrition-related outcomes at a single time point in this population.     

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.     

Estimation of critically ill patients’ complaints by the nurse,the physician and the patient’s family: A prospective comparative study

ObjectivesTo evaluate the ability of the families of critically ill patients and of the intensive care team caring for the patient to communicate and accurately identify patients’ complaints.DesignThe complaints of critically ill patients were evaluated by a psychologist using a list of 12 items. The same day as the patient interview, the psychologist collected an estimation of the patient’s complaints from the family, the nurse and the physician.Setting20-bed Intensive Care Unit in a large University Hospital.Main Outcome MeasuresPatients’ complaints.Results51 patients were included. The most frequently reported complaints were insomnia, the inability to talk and presence of a tracheal tube. Patients reported a significantly higher prevalence of “misunderstanding” than that estimated by the nurses (55% vs 33%, p = 0.045). The reported prevalence of “inability to talk” as the main complaint was significantly higher among patients than estimated by nurses and physicians (16% vs 2%, p = 0.03 and 16% vs 2%, p = 0.03 respectively). For the analysis of the individual complaints, there was a poor agreement between the patients and the other respondents.ConclusionThis study found that the estimation of critically ill patients’ complaints by their families, nurses and physicians was largely suboptimal.     

Reporting the methodology of height and weight acquisition in studies of body mass index–based prognosis in critically ill patients

Purpose

Conflicting findings were reported on the body mass index (BMI)–based prognosis of critically patients. Errors in source weight and height data can confound BMI group allocation. The aim of the present work was to examine investigators' reporting on the methods of height and weight acquisition (HWA).

Materials and Methods

PubMed and Embase databases were searched for studies describing BMI group–based risk of death in critically ill patients. Eligible studies were examined for reporting on (1) the use of measured and/or estimated HWA, (2) details of measuring devices, (3) device accuracy, and (4) methods of adjustment for acute and chronic fluid-related weight changes.

Results

Thirty studies met the eligibility criteria, including 159?565 patients. No data were provided in 13 studies (52% of reported patients) on whether estimates or measurements were used for HWA. Measured HWA was used exclusively in 6 studies (3% of patients), and an unspecified combination of estimated and/or measured HWA was reported for the remainder. Only 1 study reported the specific devices used. None of the studies provided data on the bias and precision of measuring devices. Adjustment for chronic and/or acute fluid-related weight changes was addressed in 2 studies for each.

Conclusions

These findings demonstrate the prevalent risk for BMI group misallocation in the reviewed studies, which may confound BMI-based prognosis, raising concerns about the validity of reported BMI-related prognostic impact.     

The needs of patients with post–intensive care syndrome: A prospective,observational study

BackgroundThe needs of critical illness survivors and how best to address these are unclear.ObjectivesThe objective of this study was to identify critical illness survivors who had developed post–intensive care syndrome and to explore their use of community healthcare resources, the socioeconomic impact of their illness, and their self-reported unmet healthcare needs.MethodsPatients from two intensive care units (ICUs) in Western Australia who were mechanically ventilated for 5 days or more and/or had a prolonged ICU admission were included in this prospective, observational study. Questionnaires were used to assess participants' baseline health and function before admission, which were then repeated at 1 and 3 months after ICU discharge.ResultsFifty participants were enrolled. Mean Functional Activities Questionnaire scores increased from 1.8 out of 30 at baseline (95% confidence interval [CI]: 0–3.5) to 8.9 at 1 month after ICU discharge (95% CI: 6.5–11.4; P = <0.001) and 7.0 at 3 months after ICU discharge (95% CI: 4.9–9.1; P = < 0.001). Scores indicating functional dependence increased from 8% at baseline to 54% and 33% at 1 and 3 months after ICU discharge, respectively. Statistically significant declines in health-related quality of life were identified in the domains of Mobility, Personal Care, Usual Activities, and Pain/Discomfort at 1 month after ICU discharge and in Mobility, Personal Care, Usual Activities, and Anxiety/Depression at 3 months after ICU discharge. An increase in healthcare service use was identified after ICU discharge. Participants primarily identified mental health services as the service that they felt they would benefit from but were not accessing. Very low rates of return to work were observed, with 35% of respondents at 3 months, indicating they were experiencing financial difficulty as a result of their critical illness.ConclusionsStudy participants developed impairments consistent with post–intensive care syndrome, with associated negative socioeconomic ramifications, and identified mental health as an area they need more support in.     

Value of serum procalcitonin and B-type natriuretic peptide in diagnosis and predicting prognosis of hospital-acquired pneumonia in critically ill patients北大核心CSCD

Objective To examine the value of serum procalcitonin (PCT) and B-type natriuretic peptide (BNP) in diagnosis and prognosis evaluation of hospital-acquired pneumonia (HAP) in critically ill patients prospectively. Methods A total of 72 critically ill HAP patients were enrolled in intensive care unit (ICU). Another 30 patients surviving the perioperative period in ICU were taken as control. Serum levels of PCT and BNP were determined on days 1, 2, 3 and 7 after HAP diagnosis and compared with control group. The value of the two indicators for diagnosis of HAP was analyzed by the area under receiver operating characteristic (ROC) curve (AUC). The HAP patients were assigned to survivor group (n=53) or non-survivor group (n=19) based on 28-day survival state after diagnosis. Dynamic change of PCT and BNP levels (ΔPCT, ΔBNP) was compared between two groups to assess the value of PCT and BNP change in predicting the prognosis of HAP. Results The initial PCT and BNP levels in HAP group were significantly higher than those in control group (P < 0.05). The AUC of PCT and BNP were 0.627±0.059 (95% CI: 0.511-0.742, P=0.045), 0.894±0.030 (95% CI: 0.835-0.954, P=0.000), respectively. The sensitivity, specificity, positive predictive value and negative predictive value of PCT were 65.3%, 66.7%, 82.5% and 44.5%, respectively; and of BNP were 72.2%, 93.3%, 96.3% and 58.3%, respectively. During the first two days after diagnosis, no significant difference was found beween survivor group and non-survivor group in terms of serum PCT or BNP level, but significant difference was found on Days 3 and 7 (P<0.05). There was no significant correlation beween ΔPCT or ΔBNP and ICU stay (P>0.05). The AUC of ΔPCT and ΔBNP was 0.804±0.065 (95% CI: 0.605-0.861, P=0.003) and 0.733±0.065 (95% CI: 0.677-0.932, P=0.000), respectively. The sensitivity, specificity, positive predictive value and negative predictive value of ΔPCT were 77.4%, 78.9%, 56.8% and 90.7%, respectively; and of ΔBNP were 75.5%, 68.4%, 46.1% and 88.6%, respectively. Conclusions Monitoring of the dynamic change of serum PCT and BNP levels only provides limited utility in diagnosis and prognosis evaluation of HAP in critically ill patients. © by Editorial Department of Chinese Journal of Infection and Chemotherapy.     

Prognostication of critically ill patients with acute-on-chronic liver failure using the Chronic Liver Failure–Sequential Organ Failure Assessment: A Canadian retrospective study

PurposeWe evaluated the Chronic Liver Failure–Sequential Organ Failure Assessment (CLIF-SOFA) score to predict survival in a Canadian critically ill cohort with acute-on-chronic liver failure.MethodsWe retrospectively examined 274 acute-on-chronic liver failure patients admitted to a quaternary level intensive care unit (ICU) between April 1, 2000, and April 30, 2011. We evaluated severity of illness scores, including the Acute Physiology and Chronic Health Evaluation (APACHE) II, model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), SOFA, and CLIF-SOFA.ResultsOn ICU admission, patients had the following median (interquartile range): APACHE II, 23 (19-28); MELD, 26 (19-35); CTP, 12 (10-13); SOFA, 15 (11-18); and CLIF-SOFA, 17 (13-21). In-hospital survival was 40%. There were no significant differences in survival for cirrhosis etiology, reason, or year of admission. The CLIF-SOFA score had the greatest area under receiver operating curve of 0.865 (95% confidence interval, 0.820-0.909) and outperformed the CTP, MELD, SOFA, and APACHE II scores. Sequential Organ Failure Assessment score performance improved on the third day of ICU admission (area under receiver operating curve, 0.935; 95% confidence interval, 0.895-0.975).ConclusionsThe CLIF-SOFA and SOFA scores during the first 3 days of ICU admission appear to be highly predictive of in-hospital mortality.     

Association of prophylactic synbiotics with reduction in diarrhea and pneumonia in mechanically ventilated critically ill patients: A propensity score analysis

Introduction

The preventive association of synbiotics therapy has not been thoroughly clarified in mechanically ventilated patients. The purpose of this study was to evaluate whether synbiotics therapy has preventive association against septic complications in ventilated critically ill patients.

Implementation of a combo videolaryngoscope for intubation in critically ill patients: a before–after comparative study

Purpose

Airway management in intensive care unit (ICU) patients is challenging. The main objective of this study was to compare the incidence of difficult laryngoscopy and/or difficult intubation between a combo videolaryngoscope and the standard Macintosh laryngoscope in critically ill patients.

Methods

In the context of the implementation of a quality-improvement process for airway management, we performed a prospective interventional monocenter before–after study which evaluated a new combo videolaryngoscope. The primary outcome was the incidence of difficult laryngoscopy (defined by Cormack grade 3–4) and/or difficult intubation (more than two attempts). The secondary outcomes were the severe life-threatening complications related to intubation in ICU and the rate of difficult intubation in cases of predicted difficult intubation evaluated by a specific score (MACOCHA score ≥3).

Results

Two hundred and ten non-selected consecutive intubation procedures were included, 140 in the standard laryngoscope group and 70 in the combo videolaryngoscope group. The incidence of difficult laryngoscopy and/or difficult intubation was 16 % in the laryngoscope group vs. 4 % in the combo videolaryngoscope group (p = 0.01). The severe life-threatening complications related to intubation did not differ between groups (16 vs. 14 %, p = 0.79). Among the 32 patients with a MACOCHA score ≥3, there were significantly more patients with difficult intubation in the standard laryngoscope group in comparison to the combo videolaryngoscope group [12/23 (57 %) vs. 0/9 (0 %), p < 0.01].

Conclusions

The systematic use of a combo videolaryngoscope in ICU was associated with a decreased incidence of difficult laryngoscopy and/or difficult intubation.