Charles Weissman

Diastolic dysfunction and mortality in severe sepsis and septic shock

AIMSnSystolic dysfunction in septic shock is well recognized and, paradoxically, predicts better outcome. In contrast, diastolic dysfunction is often ignored and its role in determining early mortality from sepsis has not been adequately investigated.nnnMETHODS AND RESULTSnA cohort of 262 intensive care unit patients with severe sepsis or septic shock underwent two echocardiography examinations early in the course of their disease. All clinical, laboratory, and survival data were prospectively collected. Ninety-five (36%) patients died in the hospital. Reduced mitral annular e-wave was the strongest predictor of mortality, even after adjusting for the APACHE-II score, low urine output, low left ventricular stroke volume index, and lowest oxygen saturation, the other independent predictors of mortality (Coxs proportional hazards: Wald = 21.5, 16.3, 9.91, 7.0 and 6.6, P< 0.0001, <0.0001, 0.002, 0.008, and 0.010, respectively). Patients with systolic dysfunction only (left ventricular ejection fraction ≤50%), diastolic dysfunction only (e-wave <8 cm/s), or combined systolic and diastolic dysfunction (9.1, 40.4, and 14.1% of the patients, respectively) had higher mortality than those with no diastolic or systolic dysfunction (hazard ratio = 2.9, 6.0, 6.2, P= 0.035, <0.0001, <0.0001, respectively) and had significantly higher serum levels of high-sensitivity troponin-T and N-terminal pro-B-type natriuretic peptide (NT-proBNP). High-sensitivity troponin-T was only minimally elevated, whereas serum levels of NT-proBNP were markedly elevated [median (inter-quartile range): 0.07 (0.02-0.17) ng/mL and 5762 (1001-15 962) pg/mL, respectively], though both predicted mortality even after adjusting for highest creatinine levels (Wald = 5.8, 21.4 and 2.3, P= 0.015, <0.001 and 0.13).nnnCONCLUSIONnDiastolic dysfunction is common and is a major predictor of mortality in severe sepsis and septic shock.

In-Hospital Resource Utilization During Multiple Casualty Incidents

Objective:To suggest guidelines for hospital organization during terror-related multiple casualty incidents (MCIs) based on the experience of 6 level I trauma centers. Summary Background Data:Most terror-related MCIs are bombings. The sporadic nature of these events complicates in-hospital preparation. Methods:Data were collected at all level I Trauma centers during/after MCIs for the Israel National Trauma registry. Patients were included if they were admitted or died in hospital following injury in suicide bombings (October 1, 2000 to June 30, 2003), which fulfilled Ministry of Health suggested criteria for MCIs (number of admissions, severity of injury). Results:Included were 325 casualties from 32 events, 34% of which had an Injury Severity Score >16. A third of the admissions arrived within 10 minutes and 65% within 30 minutes. Forty percent of the patients underwent CT scans directly from the ED. Operative procedures were performed on 60% of patients and 36% were transferred directly from the ED to the OR. Initiation of surgical procedures peaked at 1 to 1.5 hours, mainly multidisciplinary abdominal, thoracic, and vascular surgery. Orthopedic and plastic surgery predominated later. A third of the patients were admitted to ICUs, often (31%) directly from the ED. Conclusions:High staffing demands for ED, OR, and ICU overlap. Anesthesiologists, general, thoracic, and vascular surgeons are in immediate demand. ICU admissions occur simultaneously with ongoing patient arrival to the ED. Most patients operated within the first 2 hours require multidisciplinary surgical teams. Demand for orthopedic and plastic surgery and anesthesiology services continues for >24 hours.

Clinical review: The Israeli experience: conventional terrorism and critical care

Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospitals response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical centers trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients.

Nutrition in the intensive care unit.

Nutritional support has become a routine part of the care of the critically ill patient. It is an adjunctive therapy, the main goal of which is to attenuate the development of malnutrition, yet the effectiveness of nutritional support is often thwarted by an underlying hostile metabolic milieu. This requires that these metabolic changes be taken into consideration when designing nutritional regimens for such patients. There is also a need to conduct large, multi-center studies to acquire more knowledge of the cost-benefit and cost effectiveness of nutritional support in the critically ill.

Randomized controlled trial of external cephalic version in term multiparae with or without spinal analgesia

BACKGROUNDnNeuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia.nnnMETHODSnProspective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests.nnnRESULTSnAmong 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia (P=0.009; 95% CI of difference: 0.075-0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (sd) 1.7 (2.4) vs 5.5 (2.9) without (P<0.0001). Maternal hypotension was seen after spinal analgesia in 10 of 31 (32%) (P=0.0003) and easily treated without adverse outcome. No complications were noted after the ECV.nnnCONCLUSIONSnAdministration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort. The trial was registered at the National Institute of Health Trials Registry, NCT00119184, www.clinicaltrials.gov.

Myocardial Dysfunction in Severe Sepsis and Septic Shock: No Correlation With Inflammatory Cytokines in Real-life Clinical Setting.

BACKGROUNDnIn vitro studies suggested that circulating inflammatory cytokines cause septic myocardial dysfunction. However, no in vivo clinical study has investigated whether serum inflammatory cytokine concentrations correlate with septic myocardial dysfunction.nnnMETHODSnRepeated echocardiograms and concurrent serum inflammatory cytokines (IL-1β, IL-6, IL-8, IL-10, IL-18, tumor necrosis factor-α, and monocyte chemoattractant protein-1) and cardiac biomarkers (high-sensitivity [hs] troponin-T and N-terminal pro-B-type natriuretic peptide [NT-proBNP]) were examined in 105 patients with severe sepsis and septic shock. Cytokines and biomarkers were tested for correlations with systolic and diastolic dysfunction, sepsis severity, and mortality.nnnRESULTSnSystolic dysfunction defined as reduced left ventricular ejection fraction (LVEF) < 50% or < 55% and diastolic dysfunction defined as e-wave < 8 cm/s on tissue-Doppler imaging (TDI) or E/e-ratio were found in 13 (12%), 24 (23%), 53 (50%), and 26 (25%) patients, respectively. Forty-four patients (42%) died in-hospital. All cytokines, except IL-1, correlated with Sequential Organ Failure Assessment and APACHE (Acute Physiology and Chronic Health Evaluation) II scores, and all cytokines predicted mortality. IL-10 and IL-18 independently predicted mortality among cytokines (OR = 3.1 and 28.3, P = .006 and < 0.0001). However, none of the cytokines correlated with LVEF, end-diastolic volume index (EDVI), stroke-volume index (SVI), or s-wave and e-wave velocities on TDI (Pearson linear and Spearman rank [ρ] nonlinear correlations). Similarly, no differences were found in cytokine concentrations between patients dichotomized to high vs low LVEF, EDVI, SVI, s-wave, or e-wave (Mann-Whitney U tests). In contrast, NT-proBNP strongly correlated with both reduced LVEF and reduced e-wave velocity, and hs-troponin-T correlated mainly with reduced e-wave.nnnCONCLUSIONSnUnlike cardiac biomarkers, none of the measured inflammatory cytokines correlates with systolic or diastolic myocardial dysfunction in severe sepsis or septic shock.

Obesity, Metabolic Syndrome, and the Surgical Patient

Contemporary life, with its sedentary lifestyles, fast foods, processed foodstuff, and desk-bound service employment, is beset by an epidemic of overweight and obese individuals. The World Health Organization reported that worldwide a billion adults are overweight and at least 30% of them are obese. Moreover, increasing numbers of children are obese. In the United States, 2 National Health and Nutrition Examination Surveys of adults aged 20 to 74 years showed that the prevalence of obesity increased from 15% in the 1976 to 1980 survey to 34% in the 2003 to 2004 survey. Obesity and the metabolic syndrome are unfortunately becoming increasingly common perioperative issues. The ultimate aim of caring for such patients is to find ways to minimize the untoward effects of surgery in patients who are obese or have metabolic syndrome.

The importance of differentiating between elective and emergency postoperative critical care patients

PURPOSEnThe purpose of the study is to demonstrate the importance of separately analyzing data on elective and emergency surgery patients admitted postoperatively to intensive and intermediate care units.nnnMATERIALS AND METHODSnA prospective observational study was performed in a tertiary care university hospital to assess the demographic and clinical differences between emergency and elective surgical patients (>14 years old). Group 1 included patients transferred to a floor bed or the ambulatory surgery unit for discharge home after a short stay (<12 hours) in the postanesthesia care unit. Group 2 patients were admitted to the cardiothoracic intensive care unit (ICU), neurosurgical ICU, general ICU, or for an extended intermediate care postanesthesia care unit stay (>12 hours).nnnRESULTSnIn groups 1 (n = 1059), there were significant differences between the elective and emergency patients. Emergency, as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting illnesses (ie, had higher American Society of Anesthesiology classifications), underwent different and shorter operations, required prolonged postoperative mechanical ventilation, required longer ICU stays, and had higher mortality.nnnCONCLUSIONSnSubstantial differences between elective and emergency surgery patients have important implications when conducting and reporting research on the nature, extent, and outcome of postoperative ICU care.

Medical specialty considerations by medical students early in their clinical experience

BackgroundSpecialty selection by medical students determines the future composition of the physician workforce. Selection of career specialties begins in earnest during the clinical rotations with exposure to the clinical and intellectual environments of various specialties. Career specialty selection is followed by choosing a residency program. This is the period where insight into the decision process might help healthcare leaders ascertain whether, when, and how to intervene and attempt to influence students decisions. The criteria students consider important in selecting a specialty and a residency program during the early phases of their clinical rotations were examined.MethodsQuestionnaires distributed to fifth-year medical students at two Israeli medical schools.Results229 of 275 (83%) questionnaires were returned. 80% of the students had considered specialties; 62% considered one specialty, 25% two, the remainder 3-5 specialties. Students took a long-range view; 55% considered working conditions after residency more important than those during residency, another 42% considered both equally important. More than two-thirds wanted an interesting and challenging bedside specialty affording control over lifestyle and providing a reasonable relationship between salary and lifestyle. Men were more interested in well-remunerated procedure-oriented specialties that allowed for private practice. Most students rated as important selecting a challenging and interesting residency program characterized by good relationships between staff members, with positive treatment by the institution, and that provided much teaching. More women wanted short residencies with few on-calls and limited hours. More men rated as important residencies affording much responsibility for making clinical decisions and providing research opportunities. More than 50% of the students considered it important that their residency be in a leading department, and in a large university medical center. Only 5% considered it important to do their residency in the countrys peripheral areas, while 30% reported interest in a residency in the countrys center.ConclusionsThe fifth year of a six-year medical school is an opportune time to provide students with information and guidance on the various specialties and selecting a residency program as they begin to solidify their perceptions and ideas about the various specialties. This study serves as an impetus to medical educators and healthcare leaders to become interested in students career selection.

Characteristics of patients receiving vasopressors

BACKGROUNDnPatients receiving intensive care frequently need pharmacologic support of their blood pressure because of shock. In some patients, shock is so severe that extremely high doses of vasopressors are needed to elevate their blood pressure.nnnOBJECTIVEnWe sought to ascertain the maximal dose of vasopressors administered to patients, and to describe the population of patients receiving vasopressors in one intensive care unit.nnnMETHODSnAll adult patients admitted in 2001 to a 10-bed surgical unit in a university hospital, and receiving a vasopressor agent for 1 hour or more, underwent recordings of their demographic data, diagnoses upon admission, Acute Physiological and Chronic Health Evaluation (APACHE) II scores, vasopressors (including type, initial dose, dose increases, and maximal dose), number of days administered, complications, and mortality.nnnRESULTSnOf 689 patients whose charts were reviewed, 72 received vasopressors. The mean age was 65 ± 21.4 years, and 66% were male. The mean APACHE II scores were 24 ± 6.2. The administration of .5 μg/kg/minute of norepinephrine or epinephrine resulted in 96% sensitivity and a specificity of 76% for the likelihood of mortality. Using Kaplan-Meyer curves, those patients receiving less than .5 μg/kg/minute demonstrated an 80% 6-year survival. All 17 patients receiving more than 3.8 μg/kg/minute of norepinephrine, and all 5 patients receiving more than 9.6 μg/kg/minute of epinephrine, died. The length of time during which patients received less than their maximal dose of vasopressors had no influence on survival (P = .4). The elderly (aged ≥ 75 years) and the young (aged <75 years) had the same intensive care unit survival rates when receiving vasopressors.nnnCONCLUSIONnIn this study, little likelihood of intensive care unit survival was evident when patients received more than .5 μg/kg/minute of norepinephrine or epinephrine.