Cristina Santonocito

Soluble urokinase-type plasminogen activator receptor as a prognostic biomarker in critically ill patients.

PURPOSE The aim of this study was to assess the role of blood soluble urokinase-type plasminogen activator receptor (suPAR) levels in the diagnosis and prognostication of sepsis in critically ill patients. METHODS Serum suPAR levels were measured prospectively in adult intensive care unit (ICU) patients on admission and then daily until ICU discharge (maximum of 14 days) using an enzyme-linked immunosorbent assay kit. Normal levels were established in 31 healthy controls. RESULTS We included 258 patients (161 men); median admission Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 17 (9-23) and 6 (3-9), respectively. The mortality rate was 13.6%. Sepsis was diagnosed on admission in 94 patients (36%), of whom 23 had severe sepsis and 49 had septic shock. On admission, septic patients had higher suPAR levels than did nonseptic patients (8.9 [5.9-12.7] vs 3.7 [2.7-5.4] ng/mL), but the predictive value of suPAR for diagnosing sepsis was weaker than that of C-reactive protein. During the week after ICU admission, serum suPAR concentrations correlated with Sequential Organ Failure Assessment scores over time. High suPAR levels on admission were a strong independent predictor for ICU and 28-day mortality. In the global population, a suPAR level higher than 6.15 ng/mL had 66% sensitivity and 64% specificity for prediction of ICU mortality, with a receiver operating characteristic area under the curve of 0.726 (95% confidence interval, 0.645-0.808). CONCLUSIONS In ICU patients, serum suPAR concentrations have limited use for identifying sepsis, but their time course correlated with the degree of organ dysfunction, and they have prognostic value in septic and nonseptic populations.

Do-not-resuscitate order: a view throughout the world

Resuscitation has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort, and consume resources. The do-not-resuscitate (DNR) order and advance directives are still a debated issue in critical care. This review will focus on several aspects, regarding withholding and/or withdrawing therapies and advance directives in different continents. It is widely known that there is a great diversity of cultural and religious beliefs in society, and therefore, some critical ethical and legal issues have still to be solved. To achieve a consensus, we believe in the priority of continuing education and training programs for health care professionals. It is our opinion that a serious reflection on ethical values and principles would be useful to understand the definition of medical professionalism to make it possible to undertake the best way to avoid futile and aggressive care. There is evidence of the lack of DNR order policy worldwide. Therefore, it appears clear that there is a need for standardization. To improve the attitude about the DNR order, it is necessary to achieve several goals such as: increased communication, consensus on law, increased trust among patients and health care systems, and improved standards and quality of care to respect the patients will and the familys role.

Biomarkers as predictors of outcome after cardiac arrest

Cardiac arrest (CA) is a major health and economic problem. Management of patients resuscitated from CA is challenging for clinicians, and the mortality rate of those who achieve return of spontaneous circulation remains high. Hypoxic brain injury, cardiovascular abnormalities and systemic ischemia/reperfusion response characterize the so-called ‘postcardiac arrest syndrome’, which could lead to multiple organ failure and poor outcome after CA. The magnitude of these disorders differs in individual patients, mainly based on the cause and duration of CA and on the severity of the ischemic episode. Prognostication of outcome after CA is of importance because it could help physicians on triage decisions and readdress the overall management. A number of factors are thought to influence the prognosis of patients after CA, but due to the heterogeneity of CA population and scenarios no single factor has been identified as a reliable predictor of outcome and the timing and optimal approach to prognostication is still controversial. Biomarkers represent a growing area of interest in this field, as they may provide clinicians with early information on the severity of organ dysfunction to make a decision on clinical strategies and prognosticate outcome. In this article, the authors will focus on cardiac, neurological and inflammatory biomarkers as potential predictors of outcome after CA.

C-reactive protein kinetics after major surgery.

BACKGROUND:Diagnosis of sepsis in the postoperative period is a challenge. Measurements of inflammatory markers, such as C-reactive protein (CRP), have been proposed in medical patients, but the interpretation of these values in surgical patients is more difficult. We evaluated the changes in blood CRP levels and white blood cell count in postoperative patients with and without infection. METHODS:All patients admitted to our 34-bed Department of Intensive Care after major (elective or emergency) cardiac, neuro-, vascular, thoracic, or abdominal surgery during a 4-month period were prospectively included. Patients were screened daily and characterized as infected or noninfected. CRP levels and white blood cell counts were recorded daily in all patients for up to 7 days after the surgical intervention. RESULTS:Of the 151 patients enrolled, 115 underwent elective surgery and 36 emergency surgery; cardiac surgery was performed in 49 patients, neurosurgery in 65, abdominal surgery in 25, vascular surgery in 7, and thoracic surgery in 5. In noninfected patients (n = 117), mean CRP values increased from baseline to postoperative day (POD) 3 (P < 0.0001, estimated mean difference [EMD] = 99.7 mg/L [95% confidence interval, 85.6–113.8]) and then decreased until POD 7 but remained higher than the level at baseline (P < 0.0001, EMD = 49.2 mg/L [95% confidence interval, 27.1–71.2]). Postoperative infection occurred in 20 patients (13.2%). In these patients, CRP values were already higher on POD 1 than in noninfected patients (P = 0.0054). CONCLUSIONS:CRP levels increase in the first week after major surgery but to a much larger extent in infected than in noninfected patients. Persistently high CRP levels after POD 4, especially when >100 mg/L, suggest the presence of a postoperative infection.

Professionalismo. Punto di vista anestesiologico

Un acceso dibattito si sta svolgendo sul migliore modello di sistema sanitario realizzabile per rispondere alle aspettative dei pazienti. L’opinione pubblica manifesta dubbi sulla capacita dei medici di preservare il loro ruolo attuale al servizio dei pazienti.