J. J. M. Ligtenberg

Hormones in the critically ill patient: to intervene or not to intervene?

Abstract. Critically ill patients show a variety of hormonal changes that appear to differ considerably in acute and prolonged critical illness. Whether these endocrine alterations serve as physiological adaptation or contribute to further deterioration remains an intriguing question. We review the recent literature and discuss whether measuring circulating hormone concentrations, performing stimulation tests, and intervening with hormone substitution could contribute to the recovery of critically ill patients.

Prevention of hypotension after induction of anesthesia after preoperative tune-up - A preliminary report of the Groningen tune-up study

OBJECTIVE To investigate whether the frequently occurring hypotension after induction of anesthesia can be prevented by preoperative treatment at the ICU guided by hemodynamic data obtained from a pulmonary artery (PA) catheter. DESIGN Prospective controlled open randomized single center study. SETTING University tertiary referral hospital. PATIENTS Thirty-one patients undergoing major vascular- or abdominal surgery. INTERVENTIONS Patients were randomized to either the control group or the ICU group. Patients allocated for the ICU group were admitted to the ICU the day before the operation and treatment was started aimed at a CI > or = 4.0 l/min/m2. No special treatment was given to the control group the day before the operation. Anesthesia was induced with etomidate, rocuronium and sufentanil. MEASUREMENTS AND MAIN RESULTS Seventeen patients were allocated for the control group and 14 for the ICU-group. Mean ages were 65 +/- 2.5 and 66 +/- 2.5 years, respectively. Both groups were comparable regarding age, sex, blood pressure and type of operation. Filling pressures at admission on the ICU were: central venous pressure 3 +/- 2 mm Hg and pulmonary capillary wedge pressure 8 +/- 3 mm Hg while CI was 3.2 +/- 0.8 l/min/m2. The hemodynamic goal was achieved in all 14 patients of the ICU-group preoperatively with a background infusion of three l/24 h crystalloids, after a mean infusion of 1623 +/- 552 ml colloids, and in seven patients a median dose of 3 micrograms/kg/min (range 2-6) dopamine. Blood pressure before induction was comparable in both groups. The fall in systolic BP 10 min after induction of anesthesia was 22 +/- 18 in the ICU-group versus 41 +/- 17 mm Hg in the control group (p = 0.004). The fall in diastolic BP was 11 +/- 6 mm Hg in the ICU group versus 25 +/- 11 mm Hg in the control group (p = 0.0003). No differences between the groups in changes of heart rate were observed: a decrease of 13 +/- 7 bpm (95% confidence intervals 8.5 to 17.0) in the ICU group versus 15 +/- 14 (95% confidence intervals 7.6 to 21.9) bpm in the control group (p = 0.6). CONCLUSIONS Hypotension after induction of anesthesia is significantly attenuated by preoperative treatment aiming at a CI > or = 4.0 l/min/m2 in high risk patients planned for major vascular- or abdominal surgery.

Lessons from an unusual case: malignancy associated hypercalcemia, pancreatitis and respiratory failure due to ARDS

A 37-year old woman, presenting with severe hypercalcaemia-associated pancreatitis with pseudocyst formation, was admitted to intensive care because she developed ARDS with respiratory failure. Skeletal metastasis from non-small cell bronchial carcinoma were subsequently diagnosed. After she developed arterial occlusion in the lower limb, supportive treatment was withdrawn. Severe pancreatitis is an exceedingly unusual presentation of non-small cell bronchial carcinoma. Concepts of diagnostic and therapeutic strategies in the context of suspected unusual pathology, and the concept of futility are briefly discussed.

A Systematic Review of the Effects of Hyperoxia in Acutely Ill Patients: Should We Aim for Less?

Introduction Despite widespread and liberal use of oxygen supplementation, guidelines about rational use of oxygen are scarce. Recent data demonstrates that current protocols lead to hyperoxemia in the majority of the patients and most health care professionals are not aware of the negative effects of hyperoxemia. Method To investigate the effects of hyperoxemia in acutely ill patients on clinically relevant outcomes, such as neurological and functional status as well as mortality, we performed a literature review using Medline (PubMed) and Embase. We used the following terms: hyperoxemia OR hyperoxemia OR [“oxygen inhalation therapy” AND (mortality OR death OR outcome OR survival)] OR [oxygen AND (mortality OR death OR outcome OR survival)]. Original studies about the clinical effects of hyperoxemia in adult patients suffering from acute or emergency illnesses were included. Results 37 articles were included, of which 31 could be divided into four large groups: cardiac arrest, traumatic brain injury (TBI), stroke, and sepsis. Although a single study demonstrated a transient protective effect of hyperoxemia after TBI, other studies revealed higher mortality rates after cardiac arrest, stroke, and TBI treated with oxygen supplementation leading to hyperoxemia. Approximately half of the studies showed no association between hyperoxemia and clinically relevant outcomes. Conclusion Liberal oxygen therapy leads to hyperoxemia in a majority of patients and hyperoxemia may negatively affect survival after acute illness. As a clinical consequence, aiming for normoxemia may limit negative effects of hyperoxemia in patients with acute illness.

Post mortem examination in the intensive care unit: still useful?

cardial infarction, pulmonary embolus, and mesenteric thrombosis may be epiphenomena of the dying process. It is not easy to imagine how we can adapt our diagnostic process to prevent missing these diagnoses. We must also bear in mind that only diagnoses with a macroor microscopic substrate can be detected by PME. It is often disappointing how little substrate is found in patients who died of multiorgan failure or septic shock. The difficulty of translating PME findings in clinical practice and the lack of an answer to important questions are probably the most important reasons for the decline in PME rates. As a result the other important goals of PME, the educational and training aspects, can no longer be met. It is, important, for instance, for ICU personnel to see and feel an ARDS lung or a lung with emphysema. It improves the understanding of the ventilation problems during the ICU stay. It is also important in a training process that the person sees with his own eyes (autopsy) that the diagnosis was correct. In our view the emphasis must be on the educational aspects of PME instead of on finding the cause of death and searching for missed diagnoses. Otherwise we lose an educational tool due to the often disappointing answers it gives to other questions. It is therefore of ultimate importance that physicians in training attend the PME of the patients whom they treated.