Cumulative fluid intake minus output is not associated with ventilator weaning duration or extubation outcomes in children.

OBJECTIVE: The effect of fluid balance on respiratory outcomes for critically ill children has not been evaluated. The only indicator of fluid balance routinely recorded across our intensive care units was estimated fluid intake and output. We sought to determine whether cumulative intake minus output (I-O) at the start of weaning predicted weaning duration and whether cumulative I-O at extubation predicted extubation failure. DESIGN: Prospective observational study. SETTING: Ten pediatric intensive care units. PATIENTS: Cumulative I-O was recorded daily for 301 mechanically ventilated children (<18 yrs of age) from November 1999 through April 2001. INTERVENTIONS: Cumulative I-O was recorded during a study of weaning strategies and extubation failure in which mechanical ventilation of the majority of patients during weaning and extubation was managed according to a protocol that did not include fluid balance indicators. Outcomes were the time to successful removal of ventilatory support and the rate of initial extubation failure. MEASUREMENTS AND MAIN RESULTS: Relationships between cumulative I-O and outcomes were assessed by means of proportional hazards and logistic regression. The mean cumulative I-O per kilogram of ideal body weight at the start of weaning was 101 mL (sd, 180). Cumulative I-O at the time weaning was initiated did not predict duration of mechanical ventilator weaning. The mean cumulative I-O per kilogram of ideal body weight at extubation was 136 mL (sd, 237). Cumulative I-O at extubation did not predict extubation outcome. There was an association between cumulative I-O at extubation and the duration of weaning in cases not managed by a protocol. CONCLUSION: Although routinely recorded, cumulative fluid I-O does not appear to have clinical utility in cases managed according to a mechanical ventilator protocol in which tidal volume and oxygenation on minimal levels of ventilator support are systematically tested.     

Scintigraphy with Indium-labelled leukocytes in acute pancreatitis.

The authors assessed the clinical and prognostic value of abdominal (ASCI) and pulmonary (PSCI) scintiscans with 111Indium-labelled leukocytes in the early phase of acute pancreatitis. A grading scale was constructed for both ASCI (scored 0 to 3) and PSCI (scored 0 to 2) according to the intensity of isotope fixation versus adjacent structures. Results were compared in accordance to the presence or absence of a Ranson's score greater than or equal to 3, the presence or absence of respiratory failure and of late pancreatic complications. ASCI showed an important lack of specificity making its use uninteresting. PSCI revealed a very significant correlation with evaluation by Ranson's score and appears to have a high sensitivity and specificity to evaluate the patients who will develop ARDS or risk of ARDS. This demonstrates the pathophysiological role of leukocytes in the early phase of severe acute pancreatitis. The test might also be a reliable test for the assessment of therapeutic efficiency in acute pancreatitis.     

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose

Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.

Methods

In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.

Results

Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n?=?12, 18%) and poor (n?=?24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P?=?0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n?=?12, 18%) or without (n?=?20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.

Conclusion

Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

     

Antinociceptive and adverse effects of mu- and kappa-opioid receptor agonists: a comparison of morphine and U50488-H

Although mu-opioids such as morphine are undoubtedly effective in the treatment of acute and postoperative pain, kappa-opioids are of interest for the modulation of visceral pain. In the present study, we compared a kappa-opioid agonist (U50488-H; 0.63-40 mg/kg) with a mu-opioid agonist (morphine; 0.63-40 mg/kg) in different pain models (tail withdrawal, writhing, formalin and plantar test) to represent acute, peritoneovisceral and inflammatory pain states in rats. The effects of the respective receptor agonists on gastrointestinal motility, muscle rigidity and abuse liability were also studied in appropriate animal models (charcoal, castor oil, rotarod and drug discrimination learning). Morphine was highly efficacious in all the nociceptive models employed, but also elicited a potent inhibition of gastric motility, caused severe muscle rigidity and locomotor disturbances and displayed a potential for abuse liability at the higher doses tested (> or =10 mg/kg morphine). In contrast, U50488-H was inactive in the tail withdrawal test, but was more effective in visceral and inflammatory pain settings. Although U50488-H did not elicit any gastrointestinal inhibition, a loss of muscle tone following administration of the compound led to detrimental effects on rotarod performance. The findings presented here indicate that kappa-opioids possess antinociceptive efficacy in visceral and inflammatory pain settings, but their administration can lead to a loss of muscle tone. In contrast, mu-opioids are highly active as analgesics against a range of nociceptive stimuli, but also concomitantly elicit strongly adverse effects.