H Rueckoldt

Evaluation of noninvasive determinants for capillary leakage syndrome in septic shock patients

AbstractObjective: Capillary leakage syndrome (CLS) is a frequent complication in sepsis, characterized by loss of intravasal fluids leading to generalized edema and hemodynamic instability despite massive fluid therapy. In spite of its importance no standardized diagnostic criteria are available for CLS. Design: Prospective clinical study. Setting: 1800-bed university hospital Patients: Six septic shock patients with CLS were compared to six control patients. Measurements and results: CLS was clinically determined by generalized edema, positive fluid balance, and weight gain. Plasma volume was measured by indocyanine green, red blood cell volume by chromium-51 labeled erythrocytes, and colloid osmotic pressure before and 90 min after the administration of 300 ml 20% albumin. Extracellular water (ECW) was measured using the inulin distribution volume and bioelectrical impedance analysis. Red blood cells averaged 20.2±1.0 ml/kg body weight in CLS patients and 23.3±4.1 in controls. ECW was higher in CLS patients than in controls (40.0±6.9 vs. 21.7±3.7 l; p<0.05). ECW of inulin was correlated with that measured by bioelectrical impedance analysis (r=0.74, p<0.01). The increase in colloid osmotic pressure over the 90 min was less in CLS patients than in controls (1.1±0.3 vs. 2.8±1.3 mmHg; p<0.05). Conclusion: These results suggest that measurements of an increased ECW using bioelectrical impedance analysis combined with a different response of colloid osmotic pressure to administration of albumin can discriminate noninvasively between patients with and those without CLS.

C1-Inhibitor for treatment of acute vascular xenograft rejection in cynomolgus recipients of h-DAF transgenic porcine kidneys

Abstract: At present, the major barrier to successful discordant xenotransplantation of unmodified or complement regulator transgenic porcine xenografts is acute vascular xenograft rejection (AVR). AVR is associated with the intragraft deposition of induced recipient xenoreactive antibodies and subsequent complement activation. In a life‐supporting pig to primate kidney xenotransplantation setting using h‐DAF transgenic donor organs and postoperative immunosuppression, episodes of AVR were either treated with boluses of cyclophosphamide and steroids or with the same regimen supplemented by a three‐day course of C1‐Inhibitor, a multifunctional complement regulator. In 8 out of 10 animals stable initial graft function was achieved; in all animals one or more episodes of AVR were observed. When, in 4 animals, C1‐Inhibitor was added to the standard anti‐rejection treatment regimen, AVR was successfully reversed in 6 out of 7 episodes, while in another group of 4 animals receiving the standard anti‐rejection treatment 0 out of 4 episodes of AVR responded to treatment. Response to anti‐rejection treatment was associated with a significant increase in recipient survival time. We conclude that AVR of h‐DAF transgenic porcine kidneys can be successfully treated by additional short‐term fluid phase complement inhibition.

Predictors of respiratory function deterioration after transfer of critically ill patients

Objectives: Critically ill patients are often transferred due to the growing number of diagnostic procedures required to be performed outside the intensive care unit. These transfers have proved to be very critical. The aim of this study was to evaluate predictors for the deterioration of respiratory function in critically ill patients after transfer. Design: Prospective, clinical, observational study. Setting: 1800-bed university teaching hospital. Subjects: 98 mechanically ventilated patients were investigated during transfer. Measurement and main results: Before transfer, all patients were classified according to the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Therapeutic Intervention Scoring System (TISS). Haemodynamics and arterial blood gases were measured at 11 different times. Arterial oxgen tension (PaO2), fractional inspired oxygen (FIO2), PaO2/FIO2 ratio, lowest PaO2/FIO2 ratio, minimal PaO2 and maximal FIO2, APACHE II score, TISS before transfer, age and duration of transfer were analysed as potential predictors for deterioration of respiratory function after transfer. Variables were analysed using Classification and Regression Trees and Clustering by Response. In 54 transports (55 %) there was a decrease in the PaO2/FIO2 ratio, and a decrease of more than 20 % from baseline was noted in 23 of the transferred patients (24 %). Age > 43 years and FIO2 > 0.5 were identified as predictors for respiratory deterioration. Conclusions: Our predictors were able to indicate deterioration after transfer correctly in 20 of 22 patients (91 %), combined with a false-positive rate in 17 of 49 (35 %).

Compositional, structural, and functional alterations in pulmonary surfactant in surgical patients after the early onset of systemic inflammatory response syndrome or sepsis.

OBJECTIVES Sepsis is one of the most important predisposing factors for the development of the acute respiratory distress syndrome (ARDS). Alterations of pulmonary surfactant contribute in the pathogenesis of ARDS. However, little is known about surfactant in patients with less severe grades of lung injury related to sepsis or systemic inflammatory response syndrome (SIRS). Therefore, the purpose of this study was to characterize endogenous surfactant in surgical intensive care patients with sepsis or SIRS. DESIGN Prospective, observational study. SETTING University-affiliated, interdisciplinary intensive care unit. PATIENTS Eleven patients after major surgery with SIRS or sepsis included within 12 hrs of onset and 11 controls without infection or lung disease. INTERVENTIONS Operating room and standard intensive care unit management. MEASUREMENTS AND MAIN RESULTS Four serial bronchoalveolar lavage samples (BAL) were recovered over 7 days from the patients and single BAL samples were obtained from controls. BAL cells, total protein, surfactant-associated protein A (SP-A), surfactant alveolar transition forms, and surface activity were analyzed. Two of 11 patients met criteria for acute lung injury and six of the 11 patients met ARDS consensus conference criteria but acute lung injury or ARDS was not persistent. The mean Pao2/F(IO)2 for the patients over 7 days was 253.2+/-15.1 (SEM) and Murrays lung injury score was 1.12+/-0.12, indicating mild-to-moderate lung injury. BAL neutrophil counts were increased (p< .01), and the ratio of poorly functioning light aggregate surfactant to superiorly functioning heavy aggregate surfactant was increased compared with controls (0.32+/-0.06 vs. 0.09+/-0.01, p < .05). SP-A was decreased (1.9+/-0.4 vs. 3.5+/-0.6 microg/mL of BAL, p< .05) and there were increases in the ratios of phospholipid to SP-A (p < .05), protein to SP.A (p < .01), and protein to phospholipid (p < .05). The surface tension-lowering ability of purified heavy aggregate surfactant was significantly impaired (15.6+/-1.6 vs. 2.8+/-0.6 milliNewtons/m, p< .05). CONCLUSIONS These observations show that surgical patients with SIRS or sepsis who have mild-to-moderate lung injury develop surfactant dysfunction detectable within 7 days of onset. We propose, therefore, that therapeutic strategies to modulate these severe surfactant abnormalities should be considered, as these strategies may have the potential to reduce lung injury, which is associated with a high mortality in sepsis.

Septic shock after liver transplantation for Caroli's disease: clinical improvement after treatment with C1-esterase inhibitor.

Abstract The extent of complement and contact activation is related to outcome in sepsis. A low functional index of their main blocker C1-esterase inhibitor (C1-INH) is considered as a relative deficiency of C1-INH and might contribute to the development of fatal complications in the intensive care unit. The first results of therapeutic intervention with C1-INH concentrate in septic shock are promising. We report on our experience of C1-INH concentrate administration in a young woman with Carolis disease as ultimate rescue therapy for septic shock with capillary leakage syndrome after combined liver and kidney transplantation. No focus of infection was detectable and thus surgical intervention was not indicated. Antibiotic therapy at that time included vancomycin, tobramycin, meropenem and fluconazol. Hemodynamic stabilization occurred within hours after administration of C1-INH concentrate. Simultaneously a reduction in vasopressor medication was possible and negative fluid balance was achieved.

Cardiac output measurement by arterial thermodilution in piglets.

M easuring cardiac output (CO) in critically ill infants is often helpful after major cardiac surgery because surgical outcome may be improved by maintaining adequate CO (1). The measurement of CO by using a pulmonary artery catheter (PAC) in small infants, especially in those of ,10 kg, is rarely used because of technical difficulties of placement, invasiveness, and potential complications. The recent development of a small arterial thermistortipped catheter may overcome some of the technical problems associated with central cannulation and catheterization of the pulmonary artery. Insertion of such a catheter can be performed into the femoral or axillary artery through a 22-gauge cannula (2).The aim of this investigation was to evaluate the accuracy of CO measurements in piglets of 10.2 6 1.1 kg obtained by arterial trans-cardiopulmonary thermodilution (ATD) by using an arterial thermistor-tipped catheter compared with conventional pulmonary arterial thermodilution (PATD) by using a PAC.

Xenon inhalation increases airway pressure in ventilated patients.

Background: The inert gas xenon, known as an anaesthetic for nearly 50 years, is also used as a contrast agent during computerised tomography (CT)‐scanning. As xenon has a higher density and viscosity than air, xenon inhalation may increase airway resistance.

Low-dose dopexamine in patients undergoing hemihepatectomy: an evaluation of effects on reduction of hepatic dysfunction and ischaemic liver injury

Background: Hepatic dysfunction is a common problem in patients after hemihepatectomy. Treatment with low‐dose dopamine has been shown to be beneficial in hemihepatectomy patients. We hypothesized that dopexamine, a synthetic vasoactive catecholamine, due to its specific pharmocodynamic profile may be more effective in reducing hidden ischaemic episodes in the hepato‐splanchnic region during and after temporary total cross‐clamping of hepatic inflow in these patients.