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Critical Care - Latest Articles
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The latest research articles published by Critical Care
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ROTEM-guided coagulation factor concentrate therapy in trauma - 2-year experience in Venice, Italy
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Elevated plasma levels of heparin-binding protein in intensive care unit patients with severe sepsis and septic shock
IntroductionRapid detection of and optimized treatment for severe sepsis and septic shock is crucial for successful outcome. Heparin-binding protein (HBP), a potent inducer of increased vascular permeability, is a potentially useful biomarker for predicting outcome in patients with severe infections. Our aim was to study the systemic release and dynamics of HBP in plasma of patients with severe sepsis and septic shock in the intensive care unit (ICU).
Methods:
A prospective study of two patient cohorts treated in the ICU at Karolinska University Hospital Huddinge in Sweden. 179 patients were included, of whom 151 had sepsis (126 with septic shock and 25 patients with severe sepsis) and 28 a non-septic critical condition. Blood samples were collected at five time points during six days after admission.
Results:
HBP levels were significantly higher in the sepsis group as compared to the control group. At admission to the ICU, a plasma HBP concentration of [greater than or equal to]15 ng/mL and/or a HBP (ng/mL) / White blood cell count (109/L) ratio of >2 was found in 87.2% and 50.0% of critically ill patients with sepsis and non-septic illness, respectively. A lactate level of >2.5 mmol/L was detected in 64.9% and 56.0% of the same patient groups. Both in the sepsis group (n=151) and in the whole group (n=179), plasma HBP concentrations at admission and in the last measured sample within the 144 hour study period were significantly higher among 28-day non-survivors as compared to survivors, and in the sepsis group, an elevated HBP-level at baseline was associated with an increased case-fatality rate at 28 days.
Conclusions:
Plasma HBP levels were significantly higher in patients with severe sepsis or septic shock compared to patients with non-septic illness in the ICU. HBP was associated with severity of disease, and an elevated HBP at admission was associated with an increased risk of death. HBP that rises over time may identify patients with a deteriorating prognosis.Thus, repeated HBP measurement in the ICU may help monitor treatment and predict outcome in patients with severe infections.
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New strategies to manage complicated pleural effusions
Background:
More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is the key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial therapy (Multicenter Intrapleural Sepsis Trial [MIST1]).
Methods:
Objective: To evaluate the efficacy and safety of intrapleural DNase alone, alteplase alone, or the combination of both, to improve pleural drainage.DesignMulticenter, double-blind, double-dummy, 2x2 factorial randomized trial.Setting: Eleven centers in the United Kingdom (UK).Subjects: Adult patients (mean age 59 y, 72% men), who had clinical evidence of infection, and pleural fluid that had macroscopic purulence, a positive culture or Gram stain for bacteria, or a pH < 7.2.Intervention: Patients were assigned to 1 of the 4 study interventions for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo.Outcomes: The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events.
Results:
The mean (+/-SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (29.5+/-23.3% vs. 17.2+/-19.6%; difference, 7.9%; 95% confidence interval [CI], 13.4 to 2.4; P = 0.005). The change observed with t-PA alone and with DNase alone (17.2+/-24.3 and 14.7+/-16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87;P = 0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P = 0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, 6.7 days; 95% CI, 12.0 to 1.9; P = 0.006). Hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups.
Conclusions:
Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of hospital stay. Treatment with DNase alone or t-PA alone was ineffective.CitationRahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, Peckham D, Davies CW, Ali N, Kinnear W, Bentley A, Kahan BC, Wrightson JM, Davies HE, Hooper CE, Lee YC, Hedley EL, Crosthwaite N, Choo L, Helm EJ, Gleeson FV, Nunn AJ, Davies RJ.N Engl J Med. 2011 Aug 11; 365(6):518-26.PMID: 21830966, available on www.pubmed.gov
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Red cell distribution width improves the simplified acute physiology score for risk prediction in unselected critically ill patients
IntroductionRecently, red cell distribution width (RDW), a measure of erythrocytes' size variability, has been shown to be a prognostic marker in critical illness. The aim of this study was to investigate whether adding RDW has the potential to improve the prognostic performance of the simplified acute physiology score (SAPS) to predict short and long term mortality in an independent, large and unselected population of intensive care unit (ICU) patients.
Methods:
This observational cohort study includes 17,922 ICU patients with available RDW measurements from different types of ICUs. We modeled the association between RDW and mortality using multivariable logistic regression, adjusting for demographic factors, comorbidities, hematocrit, and severity of illness using the SAPS.
Results:
ICU-, inhospital- and 1-year mortality rates in the 17,922 included patients were 7.6% (95%CI 7.2 to 8.0), 11.2% (95%CI 10.8 to 11.7) and 25.4% (95%CI 24.8 to 26.1). RDW was significantly associated with in-hospital mortality (OR per 1% increase in RDW [95%CI]) (1.14 (1.08, 1.19), P<0.0001), ICU mortality (1.10 (1.06, 1.15), P<0.0001), and 1-year mortality (1.20 (95%CI 1.14, 1.26), P<0.001). Adding RDW to SAPS significantly improved the AUC from 0.746 to 0.774 (P<0.001) for in-hospital mortality and 0.793 to 0.805 (P<0.001) for ICU mortality. Significant improvements in classification of SAPS were confirmed in reclassification analyses. Subgroups demonstrated robust results for gender, age categories, SAPS categories, anemia, hematocrit categories and renal failure.
Conclusions:
RDW is a promising independent short- and long-term prognostic marker in ICU patients and significantly improves risk stratification of SAPS. Further research is needed to better understand the pathophysiology underlying these effects.
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Combining intermediate levels of the endotoxin activity assay (EAA)
with other biomarkers in the assessment of patients with sepsis: results of an observational study
IntroductionThe Endotoxin Activity Assay (EAA) is a useful test to risk stratify patients with severe sepsis and assess for Gram negative infection. However, the significance of intermediate levels of EAA (0.4-0.59) at the bedside has not been well elucidated. The purpose of this study was to interpret intermediate EAA levels in clinical practice.
Methods:
This retrospective observational study included all adult patients with suspected sepsis admitted to our medico-surgical intensive care unit (ICU) in whom EAA was measured from July 2008 to September 2011. Data collected included EAA, white blood cell (WBC) count and differential, C-reactive protein (CRP), procalcitonin (PCT) and bacterial cultures. Data were analyzed by comparative statistics.
Results:
Two hundred and ten patients were studied. Ninety two (43 %) patients had culture documented gram negative infection. Patients with Gram-negative organisms in cultures had significantly higher EAA levels (0.47, IQR 0.27) than those without any Gram-negative organisms in cultures (0.34, IQR 0.22) (p < 0.0001). For patients with intermediate EAA levels (0.40 to 0.59), PCT levels and presence of left shift of WBC significantly differed between patients with Gram negative organisms in their blood oar other cultures and those who no organisms in any of the cultures (4.9 vs. 1.7 ng/mL, p < 0.05; 57.9 vs. 18.9 %, p < 0.0004, respectively).
Conclusions:
We confirm that high levels of EAA in our cohort of patients with suspected sepsis is strongly associated with gram negative infection. In those patients with intermediate elevation in EAA levels, use of PCT and WBC differential can provide additional diagnostic value to clinicians at the bedside.
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