Patterns and early evolution of organ failure in the intensive care unit and their relation to outcome

Introduction

Recognition of patterns of organ failure may be useful in characterizing the clinical course of critically ill patients. We investigated the patterns of early changes in organ dysfunction/failure in intensive care unit (ICU) patients and their relation to outcome.

Methods

Using the database from a large prospective European study, we studied 2,933 patients who had stayed more than 48 hours in the ICU and described patterns of organ failure and their relation to outcome. Patients were divided into three groups: patients without sepsis, patients in whom sepsis was diagnosed within the first 48 hours after ICU admission, and patients in whom sepsis developed more than 48 hours after admission. Organ dysfunction was assessed by using the sequential organ failure assessment (SOFA) score.

Results

A total of 2,110 patients (72% of the study population) had organ failure at some point during their ICU stay. Patients who exhibited an improvement in organ function in the first 24 hours after admission to the ICU had lower ICU and hospital mortality rates compared with those who had unchanged or increased SOFA scores (12.4 and 18.4% versus 19.6 and 24.5%, P < 0.05, pairwise). As expected, organ failure was more common in sepsis than in nonsepsis patients. In patients with single-organ failure, in-hospital mortality was greater in sepsis than in nonsepsis patients. However, in patients with multiorgan failure, mortality rates were similar regardless of the presence of sepsis. Irrespective of the presence of sepsis, delta SOFA scores over the first 4 days in the ICU were higher in nonsurvivors than in survivors and decreased significantly over time in survivors.

Conclusions

Early changes in organ function are strongly related to outcome. In patients with single-organ failure, in-hospital mortality was higher in sepsis than in nonsepsis patients. However, in multiorgan failure, mortality rates were not influenced by the presence of sepsis.     

Fatal Evans' syndrome after matched unrelated donor transplantation for hyper-IgM syndrome

A 3 and 1/2-yr-old boy underwent matched unrelated stem cell transplantation (SCT) for hyper-IgM syndrome. He developed acute and chronic skin graft-vs.-host disease (GVHD). Ten months following SCT he presented with severe hemolytic anemia and thrombocytopenia (Evans' syndrome). Treatment included high-dose steroids, intravenous immunoglobulins, cyclosporine, mycophenolate mofetil, chemotherapeutic agents (cyclophosphamide, vincristine, VP-16), immunoadsorption, and anti-CD20 and anti-CD52 monoclonal antibodies without response. The patient died 16 months after SCT.     

Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate

BACKGROUND: The treatment of pancreatic fistula can be difficult. A novel endoscopic approach to sealing pancreatic fistulas by using N-butyl-2-cyanoacrylate is described. METHODS: Twelve patients with pancreatic fistulas underwent endoscopic injection of N-butyl-2-cyanoacrylate into the fistulous tract, in addition to endoscopic drainage. RESULTS: Fistulas were closed successfully in 8 of 12 patients. A single treatment session was successful in 7 patients; a second session was required in one patient. In two patients, closure was temporary, and, in one patient, the treatment failed. One patient died 24 hours after treatment. He developed a pulmonary thromboembolism from a left popliteal vein thrombosis and died from complications of surgical thromboembolectomy. At autopsy, a pulmonary embolus was found, but there was no evidence of N-butyl-2-cyanoacrylate in the lungs. No procedure-related complication occurred over a median follow-up of 20.7 months (range 9-51 months). CONCLUSIONS: In this preliminary study, occlusion of pancreatic fistulas by using N-butyl-2-cyanoacrylate glue was safe and effective, and obviated the need for surgery in a substantial proportion of patients. Further studies of the use of N-butyl-2-cyanoacrylate for closure of pancreatic fistula are warranted.     

Fusion imaging: Combined visualization of 3D reconstructed coronary artery tree and 3D myocardial scintigraphic image in coronary artery disease

Background: In patients with coronary artery disease, coronary angiography is performed for assessment of epicardial coronary artery stenoses. In addition, myocardial scintigraphy is commonly used to evaluate regional myocardial perfusion. These two-dimensional (2D) imaging modalities are typically reviewed through a subjective, visual observation by a physician. Even though on the analysis of 2D display scintigraphic myocardial perfusion segments are arbitrarily assigned to three major coronary artery systems, the standard myocardial distribution territories of the coronary tree correspond only in 50–60% of patients. On the other hand, the mental integration of both 2D images of coronary angiography and myocardial scintigraphy does not allow an accurate assignment of particular myocardial perfusion regions to the corresponding vessels. To achieve an objective assignment of each vessel segment of the coronary artery tree to the corresponding myocardial regions, we have developed a 3D ‘fusion image’ technique and applied it to patients with coronary artery disease. The morphological data (coronary angiography) and perfusion data (myocardial scintigraphy) are displayed in a 3D format, and these two 3D data sets are merged into one 3D image. Results: Seventy-eight patients with coronary artery disease were studied with this new 3D fusion technique. Of 162 significant coronary lesions, 120 (74%) showed good coincidence with regional myocardial perfusion abnormality on 3D fusion image. No regional myocardial perfusion abnormality was found in 44 (26%) lesions. Furthermore, the 3D fusion image revealed 24 ischemic myocardial regions that could not be related to angiographically significant coronary artery lesions. Conclusion: The results of this study demonstrate that our newly developed 3D fusion technique is useful for an accurate assignment of coronary vessel segments to the corresponding myocardial perfusion regions, and suggest that it may be helpful to improve the interpretative and decision-making process in the treatment of patients with coronary artery disease.

     

Spontaneous, bifocal rupture of the limbus in secondary angle closure glaucoma after open globe injury

PURPOSE: To report on a case of bifocal rupture of the limbus that developed in a young male with secondary angle closure glaucoma 7 months after penetrating eye injury. CASE REPORT: A 20-year old male suffered from severe polytrauma due to a car accident. Examination revealed an open globe injury of the left eye due to corneal penetration by a foreign body (glass). After primary wound closure a pars plana vitrectomy with lens extraction and removal of the foreign body was performed. Five months later IOP increased markedly and could neither be controlled by antiglaucomatous medication nor by cyclophotocoagulation. Seven months after the injury a bifocal, closed rupture of the upper nasal and temporal corneoscleral limbus occurred. IOP of the eye was elevated despite the rupture. The limbal dehiscence was readapted and IOP increased again. A new limbal rupture occurred and a tectonic keratoplasty was performed. Because a marked thinning of the transplanted cornea occurred accompanied by strong evidence of advanced epithelial ingrowth the eye was enucleated. Histologic examination of the excised tissue and enucleated eye showed diffuse epithelial ingrowth. CONCLUSION: This is first reported case of delayed, spontaneous, bifocal rupture of the corneoscleral limbus after primary open globe injury. It may be speculated that severe contusion of the eye with structural damage of the corneoscleral limbus preceded the penetrating injury and that the later limbal rupture was caused by a marked elevated IOP due to epithelial ingrowth.     

Anticoagulant and/or antiplatelet treatment in patients with atrial fibrillation after percutaneous coronary intervention. A single-center experience

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia sustained and frequently occurs in patients with coronary heart disease. Thus, a large number of patients requiring percutaneous coronary intervention (PCI) also suffer from AF. An anticoagulant regimen has not been standardized for patients with AF after coronary stent implantation. PATIENTS AND METHODS: The authors investigated data from 159 patients with AF who underwent PCI in their department. Baseline variables and incidence of a combined endpoint (stroke, myocardial infarction, cardiovascular death, severe bleeding) were compared in patients receiving clopidogrel and acetylsalicylic acid (ASA; group 1) versus patients receiving the combination of clopidogrel and ASA with low-molecular-weight heparin (LMWH; group 2) versus patients receiving the combination of clopidogrel and ASA with oral anticoagulation (OAC; group 3) at discharge. RESULTS: Patients discharged with triple therapy including OAC seemed to be at higher risk: patients in group 3 had decreased left ventricular ejection fraction and increased inflammatory state as measured by plasma fibrinogen and C-reactive protein. Moreover, previous OAC treatment and strokes were found more often in this subgroup of patients. In a median follow-up of 1.4 years, two severe bleeding events (both in group 1), four myocardial infarctions (all in group 1), 13 strokes (nine in group 1, four in group 2), and nine cardiovascular deaths (three in group 1, five in group 2, one in group 3) occurred. CONCLUSION: In this analysis, no treatment regimen seemed to be clearly superior. It underlines the importance of prospective, randomized trials to investigate the optimal antithrombotic/antiplatelet treatment for patients with AF after PCI.