Evidence for the need of bedside accuracy of pulse oximetry in an intensive care unit

OBJECTIVE: To compare pulse oximetry saturation (Spo2 with arterial blood gas saturation (SaO2) obtained during clinical routine to determine the optimal lowest reliable value of SpO2 in ventilator-dependent patients before setting up a nurse-directed protocol of FIO2 titration. DESIGN: Prospective clinical study. SETTING: Surgical intensive care unit in a university hospital. PATIENTS: Thirty-three patients with a pulse oximeter probe in whom arterial blood gas was measured with a radial artery line. INTERVENTIONS: SPO2 was recorded by the nurses and compared with SaO2 obtained by blood gas analysis with a co-oximeter. Two sensors currently used in our surgical intensive care unit and connected to a monitor (HP OmniCare M1165/66A; Hewett Packard, Andover, MA) were tested. In group I, the Durensor DS 100A (Nellcor Puritan Bennett, Pleasanton, CA), a reusable sensor, was used. In group II, the Oxisensor D25L (Nellcor Puritan Bennett), a nonreusable sensor, was used. MEASUREMENTS AND MAIN RESULTS: In group 1, 64 data pairs were obtained. In this group, SaO2 ranged from 87 to 98% and SpO2 ranged from 92 to 100%. The bias was -1.90% and the limits of agreement ranged from -5.56 to 1.76%. In group 11, 47 data pairs were obtained. In this group, SaO2 ranged from 87 to 99% and SpO2 ranged from 92 to 100%. The bias was -2.49% and the limits of agreement ranged from -6.62 to 1.64%. CONCLUSIONS: In the range of SaO2 tested, regardless of the sensor used, SpO2 overestimated SaO2. Large limits of agreement were found. Based on this result, the authors concluded that before defining a nurse-directed protocol of FIO2 titration with SpO2, the material used daily must be evaluated. A minimum threshold SpO2 value of 96% in both groups I and II is more reliable to ensure SaO2 > or = 90%.     

kT‐points: Short three‐dimensional tailored RF pulses for flip‐angle homogenization over an extended volume

With Transmit SENSE, we demonstrate the feasibility of uniformly exciting a volume such as the human brain at 7T through the use of an original minimalist transmit k‐space coverage, referred to as “k_T‐points.” Radio‐frequency energy is deposited only at a limited number of k‐space locations in the vicinity of the center to counteract transmit sensitivity inhomogeneities. The resulting nonselective pulses are short and need little energy compared to adiabatic or other B‐robust pulses available in the literature, making them good candidates for short‐repetition time 3D sequences at high field. Experimental verification was performed on three human volunteers at 7T by means of an 8‐channel transmit array system. On average, whereas the standard circularly polarized excitation resulted in a 33%‐flip angle spread (standard deviation over mean) throughout the brain, and a static radio‐frequency shim showed flip angle variations of 17% and up, application of k_T‐point‐based excitations demonstrated excellent flip angle uniformity (8%) for a small target flip angle and with sub‐millisecond durations. Magn Reson Med, 2011. © 2011 Wiley‐Liss, Inc.     

Erythropoietin and renin as biological markers in critically ill patients

Introduction

During sepsis the endocrine, immune and nervous systems elaborate a multitude of biological responses. Little is known regarding the mechanisms responsible for the final circulating erythropoietin (EPO) and renin levels in septic shock. The aim of the present study was to assess the role of EPO and renin as biological markers in patients with septic shock.

Methods

A total of 44 critically ill patients with septic shock were evaluated.

Results

Nonsurvivors had significantly higher serum EPO levels than did survivors on admission (median [minimum–maximum]; 61 [10–602] versus 20 [5–369]). A negative relationship between serum EPO and blood haemoglobin concentrations was observed in the survivor group (r = -0.61; P < 0.001). In contrast, in the nonsurvivors the serum EPO concentration was independent of the blood haemoglobin concentration. Furthermore, we observed significant relationships between EPO concentration and lactate (r = 0.5; P < 0.001), arterial oxygen tension/fractional inspired oxygen ratio (r = -0.41; P < 0.005), arterial pH (r = -0.58; P < 0.001) and renin concentration (r = 0.42; P < 0.005). With regard to renin concentration, significant correlations with lactate (r = 0.52; P < 0.001) and arterial pH (r = -0.33; P < 0.05) were observed.

Conclusion

Our findings show that EPO and renin concentrations increased in patients admitted to the intensive care unit with septic shock. Renin may be a significant mediator of EPO upregulation in patients with septic shock. Further studies regarding the regulation of EPO expression are clearly warranted.

     

The effect of cigarette smoking on lymphocyte subsets and progression to AIDS in a cohort of homosexual men.

We investigated the effect of cigarette smoking on the percentage of CD4 and CD8 cells (CD4%, CD8%) within a prospective study of homosexual men in Vancouver, Canada and compared progression rates to AIDS among seroincident smokers and non-smokers. Serial measurements of CD4% and CD8% obtained from four annual visits were available for 299 men and were compared with respect to smoking status and serologic group. CD4% was significantly elevated (p less than 0.025) and CD8% was significantly lower (p less than 0.002) in seronegative smokers compared to non-smokers. However, no effect of smoking was observed in the seropositive group for either of these variables. In a prospective analysis of 122 seroincident subjects, we failed to find a significant association between smoking and progression to AIDS (p = 0.829) or Pneumocystis carinii pneumonia (p = 0.894). At 72 months, cumulative AIDS progression was 29.1% in seroincident smokers compared to 25.2% in seroincident non-smokers. These data suggest that in the absence of HIV, smoking is associated with higher CD4% and lower CD8% but these effects are not present in seropositive subjects with longer durations of infection. Cigarette smoking does not appear to be associated with an altered rate of progression to AIDS.     

3-N Enzymatic Acetylation of Gentamicin, Tobramycin, and Kanamycin by Escherichia coli Carrying an R Factor

A new R factor-mediated gentamicin acetyltransferase obtained from a clinical isolate of gentamicin-, tobramycin-, and kanamycin-resistant Klebsiella was characterized. R factor R 176 was transferred to Escherichia coli K-12 LA 290 from a Klebsiella. Resistance transfer, minimal inhibitory concentrations of various aminoglycoside antibiotics, enzymatic inactivation, and the isoelectric point of the enzyme obtained were determined. We found that R factor R 176 could govern the enzymatic 3-N acetylation of gentamicin, tobramycin, and kanamycin, and isoelectric point determinations suggested that the enzymes governed by R 176 and R 135 are different. The genes responsible for resistance to gentamicin, tobramycin, and kanamycin govern the synthesis of an isoenzyme of AAC(3)I, which we propose to call AAC(3)II.