Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage

BACKGROUND: Aspiration of blood may cause significant morbidity during emergent endoscopy for severe upper GI bleeding. Endotracheal intubation is widely performed for airway protection in this setting, but there are few data regarding its efficacy. METHODS: Outcomes were compared for intensive care unit patients with upper GI bleeding for 1 year (1988) during which prophylactic endotracheal intubation was seldom performed before endoscopy, with outcomes during a subsequent year (1992) in which endotracheal intubation was routine for airway protection before or during EGD when there was hematemesis, altered mentation, unstable cardiopulmonary status, or large amounts of blood in the proximal GI tract, or before endoscopic treatment of lesions at high risk for bleeding. RESULTS: Background variables were similar for intensive care unit patients in 1988 (n = 101) and 1992 (n = 119) with respect to number of patients who had shock (respectively, 66.3% vs. 67.2%), cirrhosis (34.7% vs. 38.6%), variceal/portal hypertensive bleeding (22.8% vs. 33.6%), and endoscopic therapy (37.6% vs. 42.0%). Although use of endotracheal intubation specifically for EGD increased significantly between 1988 and 1992 (3.0% vs. 15.1%; p < 0.05), there were no significant changes in endotracheal intubation at any time during hospitalization (24.8% vs. 28.6%), in all EGD-related cardiopulmonary complications (5.0% vs. 3.4%), in new pulmonary infiltrates after EGD (12.9% vs. 15.1%), in mean number of intensive care unit days (7.1 vs. 6.4), or in mortality (15.9% vs. 11.8%). New infiltrates developed in 10 (48%) of 21 patients after EGD despite endotracheal intubation specifically for airway protection. However, in 1992 there were no fatal episodes of aspiration during EGD (2.0% vs. 0%; p = 0.21), no emergent post-EGD endotracheal intubation (6.0% vs. 0%; p < 0.05), and fewer in-hospital cardiopulmonary arrests (12.9% vs. 5.0%; p < 0.05). CONCLUSION: Frequent use of endotracheal intubation for airway protection during EGD for upper GI bleeding requiring intensive care unit admission did not significantly change the relatively high frequency of acquired pneumonia or cardiopulmonary events, but may have prevented the rare fatal episode of massive aspiration. Endotracheal intubation may benefit selected patients with upper GI bleeding, but its specific role remains unclear, and alternative methods of airway protection should be investigated.     

Endocrine evaluation of patients with critical illness.

Prolonged critical illness has a high morbidity and mortality. The acute and chronic phases of critical illness are associated with distinct endocrine alterations. The acute neuroendocrine response to critical illness involves an activated anterior pituitary function. In prolonged critical illness, however, a reduced pulsatile secretion of anterior pituitary hormones and the so-called "wasting syndrome" occur. The impaired pulsatile secretion of GH, thyrotropin and gonadotropin can be re-amplified by relevant combinations of releasing factors, which also substantially increase circulating levels of IGF-1, GH-dependent IGFBPs, thyroxin, tri-iodothyronine and testosterone. Anabolism is clearly re-initiated at the time GH secretagogues, thyrotropin-releasing hormone and gonadotropin-releasing hormone are coadministered but the effect on survival remains unknown. A lethal outcome of critical illness is predicted by a high serum concentration of IGFBP-1, pointing to impaired insulin effect rather than pituitary function, and survival was recently shown to be dramatically improved by strict normalization of glycemia with exogenous insulin. In addition to the illness-induced endocrine alterations, patients may have pre-existing central or peripheral endocrine diseases, either previously diagnosed or unknown. Hence, endocrine function testing in a critically ill patient represents a major challenge and the issue of treatment remains controversial. The recent progress in knowledge of the neuroendocrine response to critical illness and its interrelation with peripheral hormonal and metabolic alterations during stress, allows for potential new therapeutic perspectives to safely reverse the wasting syndrome and improve survival.     

Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation

BACKGROUND: Despite advances in endoscopic treatment methods for upper GI hemorrhage, hemostasis is often difficult to achieve. This study evaluated the usefulness of endoscopic band ligation for upper GI hemorrhage exclusive of hemorrhage from chronic gastroduodenal ulcer and varices. METHODS: This prospective study included 27 patients who underwent endoscopic band ligation and 31 patients in whom bipolar electrocoagulation was performed for upper GI hemorrhage. In both groups, the causes of hemorrhage included Dieulafoy's ulcer, Mallory-Weiss tear, gastric ulcer after polypectomy, and gastric angiodysplasia. Patients with esophageal varices and those with chronic gastroduodenal ulcer were excluded. RESULTS: Hemostasis was achieved in all 27 patients in the endoscopic band ligation group and in 26 of 31 patients (83.9%) in the bipolar electrocoagulation group. The median procedure time required for achieving hemostasis was 17.0 minutes (interquartile range: 11.5-23.5) in the endoscopic band ligation group versus 27.0 minutes (interquartile range: 20.5-40.0) in the electrocoagulation group. No major complications occurred in either group. CONCLUSION: Endoscopic band ligation is efficient, simple, and safe. Therefore, this technique should be considered as a treatment option for nonvariceal, nonchronic gastroduodenal ulcer upper GI hemorrhage.     

Challenges for the endocrine laboratory in critical illness

The endocrine laboratory must provide accurate and timely results for the critically ill patient. A number of pathophysiological factors affect assay systems for adrenal, thyroid and gonadal function tests. The effects are primarily on estimates of 'free hormone' concentration through abnormal binding protein concentrations and the effects of drugs and metabolites on hormone-protein binding. The limitations of the principal analytical techniques (immunoassay and chromatography-mass spectrometry) include drug effects, endogenous antibody interference and ion suppression. These effects are not always easily identified. Analytical specificity and standardisation result in differences in bias between assays and thus a requirement for assay specific decision limits and reference ranges. Good communication between clinician and laboratory is needed to minimise these effects. Developments in mass spectrometry should lead to greater sensitivity and wider applicability of the technique. International efforts to develop higher order reference materials and reference method procedures should lead to greater comparability of results.     

丘脑出血伴消化道出血患者血清胃液素的变化

目的探讨丘脑出血伴消化道出血与血清胃液素的关系．方法采用放射免疫方法检测丘脑出血患者２８例（男１６例，女１２例），分为急性期与恢复期及伴消化道出血１２例，伴或不伴消化道出血１３例的血清胃液素，并与３０例正常人对照．结果丘脑出血患者的胃液素水平为２０１０ｎｇ／Ｌ±７５１ｎｇ／Ｌ，较正常对照组（８１０ｎｇ／Ｌ±４７２ｎｇ／Ｌ）明显升高，其中急性期伴消化道出血（２２４０ｎｇ／Ｌ±６８８ｎｇ／Ｌ）或不伴消化道出血（１６４１ｎｇ／Ｌ±７１１ｎｇ／Ｌ）患者的胃液素水平与正常对照组之间也分别具有统计学差异．结论胃液素的改变与丘脑出血有关，尤其是急性期和伴消化道出血患者明显增高．     

Endocrine aspects of critical illness

Metabolic disorders and endocrine changes are common and relevant in critically ill patients. Thereby, endocrinopathies, electrolyte or metabolic derangements may either pre-exist or develop, and left unattended, may lead to significant morbidity and mortality. The homeostatic corrections which have emerged in the course of human evolution to cope with the catastrophic events during critical illness involve a complex multisystem endeavour, of which the endocrine contribution is an integral component. Although the repertoire of endocrine changes has been probed in some detail, discerning the vulnerabilities and failures of this system is far more challenging. The ensuing endocrine topics illustrate some of the current issues reflecting attempts to gain an improved insight and clinical outcome for critical illness. Disturbances in glucose and cortisol homeostasis during critical illness are two controversially debated topics in the current literature. The term "hormokine" encompasses the cytokine like behaviour of hormones during inflammation and infections. The concept is based on an ubiquitous expression of calcitonin peptides during sepsis. Adrenomedullin, another member of the calcitonin peptide superfamily, was shown to complement and improve the current prognostic assessment in lower respiratory tract infections. Procalcitonin is the protopye of "hormokine" mediators circulating procalcitonin levels increase several 10,000-fold during sepsis improve the clinical assessment especially of respiratory tract infections and sepsis safely and markedly reduces antibiotic usage in non-bacterial respiratory tract infections and meningitis. Adrenomedullin, another member of the calcitonin peptide superfamily, was shown to complement and improve the current prognostic assessment in lower respiratory tract infections. Hormokines are not only biomarkers of infection. Hormokines are also pivotal inflammatory mediators. Like all mediators, their role during systemic infections is basically beneficial, possibly to combat invading microbes. Yet, with increasing levels they can become harmful for their host. Multiple mechanisms of action were proposed. In several animal models the modulation and neutralization of hormokines during infection was shown to improve survival and thus might open new treatment options for severe infections, especially of the respiratory tract.     

Communication about chronic critical illness

BACKGROUND: Despite poor outcomes, life-sustaining treatments including mechanical ventilation are continued for a large and growing population of patients with chronic critical illness. This may be owing in part to a lack of understanding resulting from inadequate communication between clinicians and patients and families. Our objective was to investigate the informational needs of patients with chronic critical illness and their families and the extent to which these needs are met. METHODS: In this prospective observational study conducted at 5 adult intensive care units in a large, university-affiliated hospital in New York, New York, 100 patients with chronic critical illness (within 3-7 days of elective tracheotomy for prolonged mechanical ventilation) or surrogates for incapacitated patients were surveyed using an 18-item questionnaire addressing communication about chronic critical illness. Main outcome measures included ratings of importance and reports of whether information was received about questionnaire items. RESULTS: Among 125 consecutive, eligible patients, 100 (80%) were enrolled; questionnaire respondents included 2 patients and 98 surrogates. For all items, more than 78% of respondents rated the information as important for decision making (>98% for 16 of 18 items). Respondents reported receiving no information for a mean (SD) of 9.0 (3.3) of 18 items, with 95% of respondents reporting not receiving information for approximately one-quarter of the items. Of the subjects rating the item as important, 77 of 96 (80%) and 69 of 74 (93%) reported receiving no information about expected functional status at hospital discharge and prognosis for 1-year survival, respectively. CONCLUSIONS: Many patients and their families may lack important information for decision making about continuation of treatment in the chronic phase of critical illness. Strategies for effective communication in this clinical context should be investigated and implemented.     

Skeletal muscle in critical illness

Summary Skeletal muscle protein breakdown is a dominant feature of critical illness and is believed to be a useful biological response to injury. However the loss of muscle is accompanied by some major difficulties in medical management and complications for the patient. Protein turnover is difficult to study and the catabolic state is resistant to treatment, whether by nutritional or other strategies. This article provides an overview of the current physiological knowledge in this area, questions the usefulness of the catabolic response and highlights some new research worthy of further investigation. Received: 24 September 1998 Accepted: 20 April 1999     

Pituitary-thyroid axis in critical illness

Severe nonthyroidal illness has been claimed to cause secondary hypothyroidism. We reevaluated this concept measuring serum free T4 and free T3 by an ultrafiltration method and serum TSH by an ultrasensitive technique (detection limit, and serum TSH by an ultrasensitive technique (detection limit, 0.05 mU/L). Forty-five critically ill patients suffering from hepatic coma (n = 10), terminal cancer (n = 9), stroke (n = 8), and respiratory insufficiency not treated (n = 7) and treated (n = 11) with dopamine were studied. The mortality rate was 80%. No patients received glucocorticoids, and only patients in the last group received dopamine. Serum total as well as free thyroid hormone index values were grossly reduced in the majority of the patients. The 34 patients not receiving dopamine in general had normal values of serum free T4 (32 of 34) and free T3 (31 of 34), measurable TSH (33 of 34), and detectable TSH responses to iv TRH (33 of 34). In contrast, the dopamine-treated patients had reduced serum free T4 and TSH levels compared to normal subjects (P less than 0.05), as well as reduced TSH responses to TRH (P less than 0.01). Serum free T4 and free T3 were below the normal range in 3 patients and 1 patient, respectively, and serum TSH was below the detection limit in 2 patients. We conclude that critically ill patients with nonthyroidal illness not receiving dopamine have normal pituitary-thyroid function, whereas dopamine induces some degree of secondary hypothyroidism.     

Airway management in critical illness

Airway management in the ICU can be complicated due to many factors including the limited physiologic reserve of the patient. As a consequence, the likelihood of difficult mask ventilation and intubation increases. The incidence of failed airways and of cardiac arrest related to airway instrumentation in the ICU is much higher than that of elective intubations performed in the operating room. A thorough working knowledge of the devices available for the management of the difficult airway and recommended rescue strategies is paramount in avoiding bad patient outcomes. In this review, we will provide a conceptual framework for airway assessment, with an emphasis on assessment of the patient with limited cervical spine movement or injury and of morbidly obese patients. Furthermore, we will review the devices that are available for airway management in the ICU, and discuss controversies surrounding interventions like cricoid pressure and the use of muscle relaxants in the critically ill patient. Finally, strategies for the safe extubation of patients with known difficult airways will be provided.