Ilkka Parviainen

Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study

IntroductionPositive fluid balance has been associated with an increased risk for mortality in critically ill patients with acute kidney injury with or without renal replacement therapy (RRT). Data on fluid accumulation prior to RRT initiation and mortality are limited. We aimed to study the association between fluid accumulation at RRT initiation and 90-day mortality.MethodsWe conducted a prospective, multicenter, observational cohort study in 17 Finnish intensive care units (ICUs) during a five-month period. We collected data on patient characteristics, RRT timing, and parameters at RRT initiation. We studied the association of parameters at RRT initiation, including fluid overload (defined as cumulative fluid accumulation > 10% of baseline weight) with 90-day mortality.ResultsWe included 296 RRT-treated critically ill patients. Of 283 patients with complete data on fluid balance, 76 (26.9%) patients had fluid overload. The median (interquartile range) time from ICU admission to RRT initiation was 14 (3.3 to 41.5) hours. The 90-day mortality rate of the whole cohort was 116 of 296 (39.2%; 95% confidence interval 38.6 to 39.8%). The crude 90-day mortality of patients with or without fluid overload was 45 of 76 (59.2%) vs. 65 of 207 (31.4%), P < 0.001. In logistic regression, fluid overload was associated with an increased risk for 90-day mortality (odds ratio 2.6) after adjusting for disease severity, time of RRT initiation, initial RRT modality, and sepsis. Of the 168 survivors with data on RRT use at 90 days, 34 (18.9%, 95% CI 13.2 to 24.6%) were still dependent on RRT.ConclusionsPatients with fluid overload at RRT initiation had twice as high crude 90-day mortality compared to those without. Fluid overload was associated with increased risk for 90-day mortality even after adjustments.

SALINE PCO2 IS AN IMPORTANT SOURCE OF ERROR IN THE ASSESSMENT OF GASTRIC INTRAMUCOSAL PH

Objective: To determine whether the measurement error of saline Pco2, using blood gas analyzers, is relevant for the interpretation and clinical use of the gastric intramucosal pH measurement. Design: A comparison of four different blood gas analyzers (ABL‐520, Ciba Corning, IL‐1302, and Nova), using tonometered saline as the reference. Setting: Clinical laboratory of a university hospital intensive care unit. Interventions: None. Measurements and Main Results: The bias and the precision of each blood gas analyzer was determined for measurements of Pco2 in saline samples. These samples had been balanced to Pco2 levels of 30, 45, and 68 torr (4, 6, and 9 kPa, respectively). In addition, the effect of buffering the saline was evaluated. The bias of the Pco2 measurement increased (p < .001) at the higher Pco2 levels. The bias ranged from ‐5.2 to ‐25.9 torr (‐0.69 to ‐3.45 kPa) at a Pco2 of 45 torr (6 kPa) and from ‐5.2 to ‐33.1 torr (‐0.69 to ‐4.41 kPa) at a Pco2 of 68 torr (9 kPa), and there was a significant ( p < .001) analyzer‐Pco2 level interaction. The type of the analyzer also influenced the bias ( p < .001). The Nova analyzer underestimated the Pco2 by 50% to 60%. The other analyzers underestimated the Pco2 by 5% to 19%. The use of the buffer reduced the bias of all analyzers ( p < .001). Based on the precision of the saline Pco2 measurement, a difference in gastric intramucosal pH of 0.06 pH units can be reliably detected at a Pco2 of 45 torr (6 kPa) by all analyzers, with the exception of the Nova analyzer. Conclusions: Measurement of saline Pco2 is an important source of error in the assessment of gastric intramucosal pH, and the error depends on both the analyzer used and the actual Pco2 level. Direct comparison of pH values obtained by different analyzers is not valid. Changes in gastric intramucosal pH of 0.06 pH units can be detected by most analyzers in the clinically relevant Pco2 level. (Crit Care Med 1994; 22:1877–1879)

High-dose thiopental in the treatment of refractory status epilepticus in intensive care unit

The authors studied prospectively the effects of thiopental anesthesia on seizure control, hemodynamics, and the course of intensive care in 10 patients with refractory status epilepticus. Clinical and electrophysiological seizures were terminated in every patient. Hemodynamically, thiopental was well tolerated, but slow recovery from anesthesia prolonged the need for intensive care.

Refractory generalised convulsive status epilepticus : a guide to treatment.

The patient with status epilepticus has continuous or rapidly repeating seizures. Generalised convulsive status epilepticus (GCSE) is the most common form of the disorder and is a life-threatening condition that requires prompt medical management. Status epilepticus that does not respond to first-line benzodiazepines (lorazepam or diazepam) or to second-line antiepileptic drugs (phenytoin/fosphenytoin, phenobarbital or valproate) is usually considered refractory and requires more aggressive treatment.The optimal treatment of refractory GCSE has not been defined, but patients should be treated in an intensive care unit, as artificial ventilation and haemodynamic support are required. Invasive haemodynamic monitoring is often necessary and EEG monitoring is essential.The drug treatment of refractory GCSE involves general anaesthesia with continuous intravenous anaesthetics given in doses that abolish all clinical and electrographic epileptic activity, often requiring sedation to the point of burst suppression on the EEG. Barbiturate anaesthetics, pentobarbital in the US and thiopental sodium in Europe and Australia, are the most frequently used agents and are highly effective for refractory GCSE both in children and adults. Indeed, they remain the only way to stop seizure activity with certainty in severely refractory cases. Other options are midazolam for adults and children and propofol for adults only.Regardless of the drug selected, intravenous fluids and vasopressors are usually required to treat hypotension. Once seizures have been controlled for 12–24 hours, continuous intravenous therapy should be gradually tapered off if the drug being administered is midazolam or propofol. Gradual tapering is probably not necessary with pentobarbital or thiopental sodium. Continuous EEG monitoring is required during high-dose treatment and while therapy is gradually withdrawn. During withdrawal of anaesthetic therapy, intravenous phenytoin/fosphenytoin or valproate should be continued (these agents having been administered during earlier phases of GCSE) to ensure an adequate baseline of antiepileptic medication so as to prevent the recurrence of status epilepticus. If additional medication is needed, the most appropriate antiepileptic drugs are gabapentin for focal seizures and levetiracetam and topiramate for all seizure types, as these drugs can be started at high doses with a low risk of idiosyncratic reactions.Even with current best practice, mortality in patients who experience refractory GCSE is about 50% and only the minority return to their premorbid functional baseline. Therefore, new treatment options are urgently needed. The ideal new drug for refractory GCSE would be one that has the ability to stop seizures more effectively and safely than current drugs, and that has neuroprotective properties to prevent the brain damage and neurological morbidity caused by GCSE.

Effect of mode of hydrocortisone administration on glycemic control in patients with septic shock: a prospective randomized trial

AbstractIntroductionLow-dose hydrocortisone treatment is widely accepted therapy for the treatment of vasopressor-dependent septic shock. The question of whether corticosteroids should be given to septic shock patients by continuous or by bolus infusion is still unanswered. Hydrocortisone induces hyperglycemia and it is possible that continuous hydrocortisone infusion would reduce the fluctuations in blood glucose levels and that tight blood glucose control could be better achieved with this approach.MethodsIn this prospective randomized study, we compared the blood glucose profiles, insulin requirements, amount of nursing workload needed, and shock reversal in 48 septic shock patients who received hydrocortisone treatment either by bolus or by continuous infusion with equivalent dose (200 mg/day). Duration of hydrocortisone treatment was five days.ResultsThe mean blood glucose levels were similar in the two groups, but the number of hyperglycemic episodes was significantly higher in those patients who received bolus therapy (15.7 ± 8.5 versus 10.5 ± 8.6 episodes per patient, p = 0.039). Also, more changes in insulin infusion rate were needed to maintain strict normoglycemia in the bolus group (4.7 ± 2.2 versus 3.4 ± 1.9 adjustments per patient per day, p = 0.038). Hypoglycemic episodes were rare in both groups. No difference was seen in shock reversal.ConclusionStrict normoglycemia is more easily achieved if the hydrocortisone therapy is given to septic shock patients by continuous infusion. This approach also reduces nursing workload needed to maintain tight blood glucose control. Trial Registration Number ISRCTN98820688

Early non-invasive cardiac output monitoring in hemodynamically unstable intensive care patients: A multi-center randomized controlled trial

IntroductionAcute hemodynamic instability increases morbidity and mortality. We investigated whether early non-invasive cardiac output monitoring enhances hemodynamic stabilization and improves outcome.MethodsA multicenter, randomized controlled trial was conducted in three European university hospital intensive care units in 2006 and 2007. A total of 388 hemodynamically unstable patients identified during their first six hours in the intensive care unit (ICU) were randomized to receive either non-invasive cardiac output monitoring for 24 hrs (minimally invasive cardiac output/MICO group; n = 201) or usual care (control group; n = 187). The main outcome measure was the proportion of patients achieving hemodynamic stability within six hours of starting the study.ResultsThe number of hemodynamic instability criteria at baseline (MICO group mean 2.0 (SD 1.0), control group 1.8 (1.0); P = .06) and severity of illness (SAPS II score; MICO group 48 (18), control group 48 (15); P = .86)) were similar. At 6 hrs, 45 patients (22%) in the MICO group and 52 patients (28%) in the control group were hemodynamically stable (mean difference 5%; 95% confidence interval of the difference -3 to 14%; P = .24). Hemodynamic support with fluids and vasoactive drugs, and pulmonary artery catheter use (MICO group: 19%, control group: 26%; P = .11) were similar in the two groups. The median length of ICU stay was 2.0 (interquartile range 1.2 to 4.6) days in the MICO group and 2.5 (1.1 to 5.0) days in the control group (P = .38). The hospital mortality was 26% in the MICO group and 21% in the control group (P = .34).ConclusionsMinimally-invasive cardiac output monitoring added to usual care does not facilitate early hemodynamic stabilization in the ICU, nor does it alter the hemodynamic support or outcome. Our results emphasize the need to evaluate technologies used to measure stroke volume and cardiac output--especially their impact on the process of care--before any large-scale outcome studies are attempted.Trial RegistrationThe study was registered at ClinicalTrials.gov (Clinical Trials identifier NCT00354211)

Effect of nasogastric suction and ranitidine on the calculated gastric intramucosal pH

ObjectiveTo study the effect of nasogastric suction and ranitidine on the determination of gastric intramucosal pH (pHi).DesignProspective study.SettingClinical research unit at a university hospital intensive care department.Subjects12 healthy volunteers.InterventionsAfter a 2-h measurement control period a tonometer was connected to nasogastric suction for 2 h, and thereafter ranitidine was given intravenously and gastric pHi measured.Measurements and resultsDuring each 2-h measurement period gastric PCO2, gastric pHi, and pH gap were determined every 30 min. Luminal pH was measured after insertion of tonometer and at the end of each study period. Neither nasogastric suction nor ranitidine had an effect on the coefficient of variation for either gastric PCO2 or pHi. Compared to control and nasogastric suction periods, after ranitidine mean gastric pHi was higher (control 7.22±0.08; nasogastric suction 7.23±0.07; after ranitidine 7.31±0.06,p<0.001) mean gastric PCO2 lower (control 6.4±1.3; nasogastric suction 6.5±1.3; after ranitidine 5.3±0.9,p<0.001) and pH gap lower (control 0.18±0.08; nasogastric suction 0.17±0.05; after ranitidine 0.09±0.06,p<0.01). Luminal pH increased after ranitidine in each subject.ConclusionsH2 blockers have no effect on the reproducibility of gastric pHi measurements, but the use of H2 blockers modifies the normal values for gastric pHi in healthy subjects.

Myocardial function and haemodynamics in extensive burn trauma: evaluation by clinical signs, invasive monitoring, echocardiography and cytokine concentrations. A prospective clinical study

Background:  The objectives of this study were to (1) describe the haemodynamic profile of patients with extensive burns during the early fluid resuscitation phase, (2) evaluate myocardial performance by invasive monitoring and echocardiography and (3) analyze the relations between serum cytokine (IL‐6, IL‐8, TNF) and natriuretic peptide (ANP, BNP) concentrations and myocardial function in these patients.

Propofol and barbiturates for the anesthesia of refractory convulsive status epilepticus: pros and cons

Abstract Objective: To discuss mainly the use of propofol and barbiturates in the anesthesia of refractory status epilepticus (RSE). Methods: Review of literature. Results: There are no prospective, randomized works comparing the effects of anesthetics in the treatment of RSE. Recently, the use of propofol has increased in the treatment of RSE. Propofol terminates both clinical and electric seizures quickly, but the maintenance of burst-suppression EEG pattern requires repetitive titration of doses. Relapses of seizures have occurred in 19–33% of patients, especially when tapering of dose. The advantages of barbiturates are lower frequency of short-term treatment failures, breakthrough seizures and changes to a different anesthetic agent. On the other hand, prolonged recovery leads to prolonged duration of mechanical ventilation, intensive care and hospital stay. Discussion: The use of propofol, barbiturates or midazolam in the anesthesia of RSE can be justified. When using propofol, the duration of high doses should be limited to 48 hours and the risk of propofol infusion syndrome should be kept in mind. High doses of barbiturates terminate effectively seizures but recovery from anesthesia prolongs ventilator treatment and intensive care.

The proportion of intensive care unit admissions related to alcohol use: a prospective cohort study

Background:  Alcohol abuse is a risk factor for serious illnesses, and a history of chronic alcohol abuse adversely affects the outcome of critically ill patients. It is not known what proportion of intensive care unit (ICU) admissions is related to alcohol use. Therefore, we investigated the proportion of emergency admissions related to alcohol.