Jan Rulisek

Czech mass methanol outbreak 2012: Epidemiology, challenges and clinical features

Abstract Objectives. Methanol poisonings occur frequently globally, but reports of larger outbreaks where complete clinical and laboratory data are reported remain scarce. The objective of the present study was to report the data from the mass methanol poisoning in the Czech Republic in 2012 addressing the general epidemiology, treatment, and outcomes, and to present a protocol for the use of fomepizole ensuring that the antidote was provided to the most severely poisoned patients in the critical phase. Methods. A combined prospective and retrospective case series study of 121 patients with confirmed methanol poisoning. Results. From a total of 121 intoxicated subjects, 20 died outside the hospital and 101 were hospitalized. Among them, 60 survived without, and 20 with visual/CNS sequelae, whereas 21 patients died. The total and hospital mortality rates were 34% and 21%, respectively. Multivariate regression analysis found pH < 7.0 (OR 0.04 (0.01–0.16), p < 0.001), negative serum ethanol (OR 0.08 (0.02–0.37), p < 0.001), and coma on admission (OR 29.4 (10.2–84.6), p < 0.001) to be the only independent parameters predicting death. Continuous hemodialysis was used more often than intermittent hemodialysis, but there was no significant difference in mortality rate between the two [29% (n = 45) vs 17% (n = 30), p = 0.23]. Due to limited stockpiles of fomepizole, ethanol was administered more often; no difference in mortality rate was found between the two [16% (n = 70) vs. 24% (n = 21), p = 0.39]. The effect of folate administration both on the mortality rate and on the probability of visual sequelae was not significant (both p > 0.05). Conclusions. Severity of metabolic acidosis, state of consciousness, and serum ethanol on admission were the only significant parameters associated with mortality. The type of dialysis or antidote did not appear to affect mortality. Recommendations that were issued for hospital triage of fomepizole administration allowed conservation of valuable antidote in this massive poisoning outbreak for those patients most in need.

Perioperative Tight Glucose Control Reduces Postoperative Adverse Events in Nondiabetic Cardiac Surgery Patients

CONTEXTnTight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date.nnnOBJECTIVEnThe purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients.nnnDESIGNnThis was a single center, single-blind, parallel-group, randomized controlled trial.nnnSETTINGSnThe setting was an academic tertiary hospital.nnnPARTICIPANTSnParticipants were 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative intensive care unit treatment for at least 2 consecutive days.nnnINTERVENTIONnIntensive insulin therapy was initiated perioperatively or postoperatively with a target glucose range of 4.4 to 6.1 mmol/L.nnnMAIN OUTCOME MEASURESnAdverse events from any cause during postoperative hospital stay were compared.nnnRESULTSnIn the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2% vs 34.1%, 95% confidence interval [CI], 0.60-0.78) despite only minimal improvement in glucose control (blood glucose, 6.6 ± 0.7 vs 6.7 ± 0.8 mmol/L, P < .001; time in target range, 39.3% ± 13.7% vs 37.3% ± 13.8%, P < .001). The positive effects of TGC on postoperative complications were driven by nondiabetic subjects (21.3% vs 33.7%, 95% CI, 0.54-0.74; blood glucose 6.5 ± 0.6 vs 6.6 ± 0.8 mmol/L, not significant; time in target range, 40.8% ± 13.6% vs 39.7% ± 13.8%, not significant), whereas no significant effect was seen in diabetic patients (29.4% vs 35.1%, 95% CI, 0.66-1.06) despite significantly better glucose control in the perioperative group (blood glucose, 6.9 ± 1.0 vs 7.1 ± 0.8 mmol/L, P < .001; time in target range, 34.3% ± 12.7% vs 30.8% ± 11.5%, P < .001).nnnCONCLUSIONSnPerioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.

Efficiency of acidemia correction on intermittent versus continuous hemodialysis in acute methanol poisoning.

Abstract Context: Acidemia is a marker of prognosis in methanol poisoning, as well as compounding formate-induced cytotoxicity. Prompt correction of acidemia is a key treatment of methanol toxicity and methods to optimize this are poorly defined. Objective: We studied the efficiency of acidemia correction by intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) in a mass outbreak of methanol poisoning. Methods: The study was designed as observational cohort study. The mean time for an increase of 1u2009mmol/L HCO3–, 0.01 unit arterial blood pH, and the total time for correction of HCO3– were determined in IHD- and CRRT-treated patients. Results: Data were obtained from 18 patients treated with IHD and 13 patients treated with CRRT. At baseline, CRRT group was more acidemic than IHD group (mean arterial pH 6.79u2009±u20090.10 versus 7.05u2009±u20090.10; pu2009=u20090.001). No association was found between the rate of acidemia correction and age, weight, serum methanol, lactate, formate, and glucose on admission. The time to HCO3– correction correlated with arterial blood pH (r=u2009−0.511; pu2009=u20090.003) and creatinine (ru2009=u20090.415; pu2009=u20090.020). There was association between the time to HCO3– correction and dialysate/effluent and blood flow rates (r=u2009−0.738; pu2009<u20090.001 and r=u2009−0.602; pu2009<u20090.001, correspondingly). The mean time for HCO3– to increase by 1u2009mmol/L was 12u2009±u20092u2009min for IHD versus 34u2009±u20098u2009min for CRRT (pu2009<u20090.001), and the mean time for arterial blood pH to increase 0.01 was 7u2009±u20091 mins for IHD versus 11u2009±u20094u2009min for CRRT (pu2009=u20090.024). The mean increase in HCO3– was 5.67u2009±u20090.90u2009mmol/L/h for IHD versus 2.17u2009±u20090.74u2009mmol/L/h for CRRT (pu2009<u20090.001). Conclusions: Our study supports the superiority of IHD over CRRT in terms of the rate of acidemia correction.

Extracorporeal membrane oxygenation used in a massive lung bleeding following pulmonary endarterectomy.

The authors present a case of massive lung bleeding following pulmonary endarterectomy (PEA) that was treated with peripheral veno-venous extracorporeal membrane oxygenation (VV ECMO). The patient repeatedly underwent bronchoscopy for airway blood clot obstruction and finally was successfully weaned off the support. The authors discuss the indications for ECMO in treatment of the most serious complications following PEA, and emphasize the importance of echocardiographic evaluation of the right ventricular function in relation to the indicated type of extracorporeal support. Anticoagulation strategy for patients shortly after the major surgery connected to ECMO is also discussed.

The effect of adjusting tracheal tube cuff pressure during deep hypothermic circulatory arrest: a randomised trial.

BACKGROUND Regular endotracheal tube cuff monitoring may prevent silent aspiration. OBJECTIVES We hypothesised that active management of the cuff of the tracheal tube during deep hypothermic cardiac arrest would reduce silent subglottic aspiration. We also determined to study its effect on postoperative mechanical ventilation and the incidence of postoperative positive tracheal cultures. DESIGN A randomised clinical trial. SETTING The study was conducted in a University Teaching Hospital from September 2008 to November 2009. PATIENTS Twenty-four patients undergoing elective pulmonary endarterectomy were included in the study. INTERVENTION After induction of general anaesthesia and tracheal intubation, the cuff of the tracheal tube was inflated to 25u200acmH2O. Following this, 1u200aml of methylene blue dye diluted in 2u200aml of physiological saline was injected into the hypopharynx. Patients were randomly assigned to active cuff management during cooling and warming (where cuff pressure was monitored and the cuff was reinflated if it dropped below 20u200acmH2O, or deflated if pressure exceeded 30u200acmH2O) or passive monitoring (where cuff pressure was monitored but volume was not altered). Before weaning from cardiopulmonary bypass, fibreoptic bronchoscopy was performed. Silent aspiration was then diagnosed if blue dye was seen in the trachea below the cuff of the tube. MAIN OUTCOME MEASURES The primary aim of this study was to determine the incidence of silent aspiration. Secondary outcomes included duration of postoperative mechanical ventilation of the lungs and incidence of positive culture of tracheal aspirate. RESULTS Active cuff management patients were younger than controls (51.2u200a±u200a11.6 vs. 63.2u200a±u200a9 years, Pu200a=u200a0.028), but otherwise the two groups were similar. The primary endpoint was reached because we showed that silent aspiration was significantly less frequent in the study group (0/12 vs. 8/12 patients, Pu200a=u200a0.001). Significantly lower intracuff pressures were measured in the control group patients at several timepoints during cooling, just before hypothermic arrest and at all timepoints during rewarming. CONCLUSION We recommend that the cuff of the tracheal tube should be checked regularly during surgery under deep hypothermia, and the cuff pressure adjusted as required.

Intermittent versus continuous renal replacement therapy in acute methanol poisoning: comparison of clinical effectiveness in mass poisoning outbreaks

BackgroundIntermittent hemodialysis (IHD) is the modality of choice in the extracorporeal treatment (ECTR) of acute methanol poisoning. However, the comparative clinical effectiveness of intermittent versus continuous modalities (CRRT) is unknown. During an outbreak of mass methanol poisoning, we therefore studied the effect of IHD versus CRRT on mortality and the prevalence of visual/central nervous system (CNS) sequelae in survivors.MethodsThe study was designed as prospective observational cohort study. Patients hospitalized with a diagnosis of acute methanol poisoning were identified for the study. Exploratory factor analysis and multivariate logistic regression were applied to determine the effect of ECTR modality on the outcome.ResultsData were obtained from 41 patients treated with IHD and 40 patients with CRRT. The follow-up time in survivors was two years. Both groups of patients were comparable by age, time to presentation, laboratory data, clinical features, and other treatment applied. The CRRT group was more acidemic (arterial blood pH 6.96xa0±xa00.08 vs. 7.17xa0±xa00.07; pxa0<xa00.001) and more severely poisoned (25/40 vs. 9/41 patients with Glasgow Coma Scale (GCS)xa0≤xa08; pxa0<xa00.001). The median intensive care unit length of stay (4 (range 1–16) days vs. 4 (1–22) days; pxa0=xa00.703) and the number of patients with complications during the treatment (11/41 vs. 13/40 patients; pxa0=xa00.576) did not differ between the groups. The mortality was higher in the CRRT group (15/40 vs. 5/41; pxa0=xa00.008). The number of survivors without sequelae of poisoning was higher in the IHD group (23/41 vs. 10/40; pxa0=xa00.004). There was a significant association of ECTR modality with both mortality and the number of survivors with visual and CNS sequelae of poisoning, but this association was not present after adjustment for arterial blood pH and GCS on admission (all pxa0>xa00.05).ConclusionsIn spite of the faster correction of the acidosis and the quicker removal of the toxic metabolite in intermittent dialysis, we did not find significant differences in the treatment outcomes between the two groups after adjusting for the degree of acidemia and the severity of poisoning on admission. These findings support the strategy of “use what you have” in situations with large outbreaks and limited dialysis capacity.

A randomised controlled trial of roller versus centrifugal cardiopulmonary bypass pumps in patients undergoing pulmonary endarterectomy.

Objectives: There is some controversy as to whether there is a benefit from the use of a centrifugal pump compared with a roller pump during cardiopulmonary bypass to facilitate cardiac surgery. We compared the two pumps, with the primary aim of determining any difference in the effects on inflammation after pulmonary endarterectomy surgery which required prolonged cardiopulmonary bypass and deep hypothermic circulatory arrest. Methods: Between September 2010 and July 2013, 58 elective patients undergoing pulmonary endarterectomy were included in this prospective, randomised, controlled study; 30 patients were randomly allocated to the control group, which used a roller pump, and 28 patients to the treatment group, which used a centrifugal pump. Interleukin-6, procalcitonin, C-reactive protein, thromboelastographic parameters, P-selectin, international normalised ratio, activated prothrombin time, free haemoglobin, haematocrit, red blood cell count, white blood cell count, platelet count and protein S100β were recorded during and after the procedure. We also recorded the length of intensive care unit stay, blood loss and transfusion, neurological outcomes and respiratory and renal failure. Results: There was a significant difference in the primary outcome measure: Interleukin-6 was significantly higher in the roller pump group (587±38 ng·l-1 vs. 327±37 ng·l-1; p<0.001) 24 hours after surgery, which we interpreted as an increased inflammatory response. This was confirmed by a significant rise in the procalcitonin level in the roller pump group 48 hours following surgery (0.79 (0.08-25.25) ng·ml-1 vs. 0.36 (0.02-5.83) ng·ml-1; p<0.05). There were, however, no significant differences in clinical outcome data. Conclusions: We have shown that the use of a centrifugal pump during prolonged cardiopulmonary bypass and deep hypothermic circulatory arrest is associated with a reduced inflammatory response compared to the standard roller pump. Larger multi-centre trials in this area of practice are required.

A rationale for early extracorporeal membrane oxygenation in patients with postinfarction ventricular septal rupture complicated by cardiogenic shock: ECMO in patients with ventricular septal rupture

Ventricular septal rupture (VSR) became a rare mechanical complication of myocardial infarction in the era of percutaneous coronary interventions but is associated with extreme mortality in patients who present with cardiogenic shock (CS). Promising outcomes have been reported with the use of circulatory support allowing haemodynamic stabilization, followed by delayed repair. Therefore, we analysed our experience with an early use of Veno‐Arterial Extracorporeal Membrane Oxygenation (V‐A ECMO) for postinfarction VSR.

Successful use of extra-corporeal membrane oxygenation in a patient with streptococcal sepsis: a case report and review of literature.

A young patient with streptococcal sepsis due to the phlegmon of his left thigh was admitted to the general intensive care unit. He developed a multi-organ failure and septic cardiomyopathy with subsequent cardiogenic shock. This resulted in hemodynamic instability unresponsive to conservative medical treatment. We report a successful application of veno-arterial extra-corporeal membrane oxygenation, which was used to overcome the period of critically low cardiac output caused by severe septic myocardial dysfunction.

The effects of a novel calcium-free lactate buffered dialysis and substitution fluid for regional citrate anticoagulation--prospective feasibility study.

Background: Testing metabolic effects of a novel calcium-free, magnesium, phosphate and lactate containing solution (Lactocitrate) in combination with citrate anticoagulation. Methods: Patients on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min, trisodium citrate (4% TSC)) with arterial lactate <3 mmol/l were included. At start, bicarbonate-buffered fluid was changed to Lactocitrate and the substitution of magnesium and phosphorus ceased. At 9 h the Qb was increased to 150 ml/min. At 18 h the CRRT dosage was increased to 3,000 ml/h. Results: In 22 CVVHDF patients and another 23 on CVVH the pH, aHCO3 and Na (all p > 0.05) showed no significant changes regardless of the increased dosage of 4% TSC at 9 h (p < 0.001). Mgtot and phosphorus stabilised within normal range. Arterial lactate increased to 1.9 (1.6-2.6) mmol/l at 3,000 ml/h, p < 0.001). Citrate- and lactate-related energetic gains were up to 74 (61-86) kJ/h. Conclusions: The fluid performed well within ordinary CRRT dosage and Qb up to 150 ml/min. Lactate levels mildly increased and no magnesium and phosphorus replenishments were necessary.