L. Huyghens

Measuring the effect of interprofessional problem-based learning on the attitudes of undergraduate health care students

Objectivesu2002 This study aimed to measure the improvement in attitudes towards interprofessional collaboration of undergraduate health care students who have a single module of interprofessional problem‐based learning (PBL) using real patients as triggers integrated into their curricula.

Effects of N-acetylcysteine on Microalbuminuria and Organ Failure in Acute Severe Sepsis : Results of a Pilot Study

STUDY OBJECTIVEnThe level of microalbuminuria is thought to reflect the severity of inflammation-induced systemic vascular permeability and may have prognostic value with regard to organ dysfunction and survival. N-acetylcysteine (NAC) has been shown to decrease capillary leakage in experimental sepsis. The present study investigated the effect of early treatment with NAC on microalbuminuria and organ dysfunction in severe clinical sepsis.nnnDESIGNnProspective, randomized, placebo-controlled study.nnnSETTINGnA 24-bed multidisciplinary ICU in a university teaching hospital.nnnPATIENTSnThirty-five patients included within 4 h of fulfilling consensus criteria of severe sepsis.nnnINTERVENTIONSnPatients were randomly assigned to receive either NAC (continuous infusion starting with 50 mg/kg/4 h followed by 100 mg/kg/24 h for 44 h; n = 18) or placebo (n = 17) in addition to standard therapy.nnnMEASUREMENTS AND RESULTSnUrine samples for measurement of microalbuminuria/creatinine ratio (MACR) were collected on inclusion and after 4 h, 24 h, and 48 h. Severity of illness and degree of organ failure were determined by using, respectively, the APACHE (acute physiology and chronic health evaluation) II score and the sequential organ failure assessment (SOFA) score. The MACR did not differ over time between the placebo- and the NAC-treated groups. SOFA scores were comparable between both treatment groups at baseline (6.2 +/- 3.9 vs 6.5 +/- 2.7, NAC vs placebo; p = 0.6) and increased during treatment in the NAC-treated patients but not in the placebo group (7.9 +/- 3.7 vs 5.9 +/- 2.5, p = 0.09 and 7.7 +/- 3.8 vs 5.1 +/- 2.1, p < 0.05; NAC vs placebo, respectively, at 24 h and at 48 h). The cardiovascular SOFA score progressively increased during NAC treatment, reaching higher values as compared to time-matched scores in the placebo group.nnnCONCLUSIONSnEarly NAC administration does not influence the course of MACR in severe clinical sepsis, suggesting that NAC might not attenuate endothelial damage in this condition. NAC treatment even aggravated sepsis-induced organ failure, in particular cardiovascular failure.

The effect of mild hypothermia and induced hypertension on long term survival rate and neurological outcome after asphyxial cardiac arrest in rats

STUDY OBJECTIVEnwe studied the long-term effect of a combined treatment with resuscitative mild hypothermia and induced hypertension on survival rate and neurological outcome after asphyxial cardiac arrest (CA) in rats.nnnMETHODSn36 male Wistar rats, were randomised into three groups: Group I (n=10): anaesthetised with halothane and N(2)O/O(2) (70/30%) had vessel cannulation but no asphyxial CA; mechanical ventilation was continued to 1 h. Group II (n=13): under the same anaesthetic conditions and vessel cannulation, was subjected to asphyxial CA of 8 min, reversed by brief external heart massage and followed by mechanical ventilation to 1 h post restoration of spontaneous circulation (ROSC). Group III (n=13): received the same insult and resuscitation as described in group II, but in contrast to the previous group, a combination treatment of hypothermia (34 degrees C) and induced hypertension was started immediately after ROSC and maintained for 60 min ROSC. Survival rate and neurological deficit (ND) scores were determined before arrest, at 2 and 24 h, and each 24-h up to 4 weeks after ROSC.nnnRESULTSnBaseline variables were the same in the three groups. Comparison of the asphyxial CA groups (groups II and III), showed an increased, although not statistically significant, survival rate at 72 h after ROSC in group III, and it became highly significant at 4 weeks after ROSC. The ND scores were the same in both asphyxial CA groups (groups II and III).nnnCONCLUSIONSnResuscitative mild hypothermia and induced hypertension after asphyxial CA in rats is associated with a better survival rate. This beneficial effect persisted for 4 weeks after ROSC.

Drotrecogin alfa (activated) may attenuate severe sepsis-associated encephalopathy in clinical septic shock

IntroductionSepsis-associated encephalopathy (SAE) is a diffuse cerebral dysfunction induced by the immuno-inflammatory response to infection. Elevated levels of the brain-specific S100B protein are present in many septic patients and reflect the severity of SAE. Adjunctive treatment with drotrecogin alfa (activated) (DrotAA), the human recombinant form of activated protein C, has been shown to improve mortality in patients with severe sepsis-induced organ failure. We studied the effect of DrotAA on S100B levels in patients with acute septic shock who presented with increased baseline values of this biomarker.MethodsAll patients received standard goal-directed resuscitation treatment. Patients with pre-existing or acute neurological disorders were excluded. Based on the Glasgow coma scale (GCS), patients were classified into two groups: GCS ≥ 13 and GCS <13. DrotAA was given as a continuous infusion of 24 μg/kg/h for 96 h. S100B was measured before sedation and the start of DrotAA (0 h) and at 32 h, 64 h and 96 h and at corresponding time points in patients not treated with DrotAA. The lower limit of normal was < 0.5 μg/L.ResultsFifty-four patients completed the study. S100B was increased in 29 (54%) patients. Twenty-four patients (9 with GCS ≥ 13 and 15 with GCS <13) received DrotAA. S100B levels in DrotAA-treated patients with a GCS <13, though higher at baseline than in untreated subjects (1.21 ± 0.22 μg/L vs. 0.95 ± 0.12 μg/L; P = 0.07), progressively and significantly decreased during infusion (0.96 ± 0.22 μg/L at 32 h, P = 0.3; 0.73 ± 0.12 μg/L at 64 h, P < 0.05; and 0.70 ± 0.13 μg/L at 96 h, P < 0.05 vs. baseline). This patient group had also significantly lower S100B values at 64 h and at 96 h than their untreated counterparts. In the patients with a GCS ≥ 13, S100B levels were not influenced by DrotAA treatment.ConclusionsS100B-positivity is present in more than half of the patients with septic shock. When increased S100B levels are used as a surrogate for SAE, adjunctive DrotAA treatment seems to beneficially affect the evolution of severe SAE as discriminated by an admission GCS <13.

DIAGNOSTIC MARKERS OF SEPSIS IN THE EMERGENCY DEPARTMENT

Abstract Sepsis is defined as the systemic inflammatory response to infection. However, changes in body temperature, heart and respiratory rate and white cell count (the “SIRS” criteria) are not specific enough to identify infected patients in the emergency department. Among many biological parameters, measurement of lactate, central venous oxygen saturation (ScvO2), C-reactive protein (CRP) and procalcitonin (PCT) are of particular interest. Early (within 6h) and goal-directed (ScvO2 > 70%) resuscitation increases survival in severe sepsis and septic shock, particularly in patients with high lactate clearances. CRP and PCT are both useful markers of sepsis but PCT increases earlier, better differentiates infective from non-infective causes of inflammation, more closely correlates with sepsis severity in terms of shock and organ dysfunction and better predicts outcome when followed in time. However, PCT measurement is more costly, time-consuming, and not widespread available. New markers for rapid diagnosis of sepsis (e.g. TREM-1) are under investigation.

Introducing a new generation indirect calorimeter for estimating energy requirements in adult intensive care unit patients: Feasibility, practical considerations, and comparison with a mathematical equation ☆

PURPOSEnIndirect calorimetry (IC) is increasingly advocated for individualizing nutritional therapy in critically ill adult patients, but questions remain regarding its practical implementation.nnnMATERIALS AND METHODSnDuring 12 weeks, we prospectively assessed utility and practical aspects of IC use. Adult medico-surgical intensive care unit (ICU) patients were daily screened for malnutrition. Indirect calorimetry was planned in subjects considered unable to meet energy requirements on day 3 after admission. Measured energy expenditure (MEE) was compared with calculated (resting/total) energy expenditure.nnnRESULTSnA total of 940 evaluations were performed in 266 patients (age, 63±16 years; 59% males; Acute Physiology and Chronic Health Evaluation II score, 14±8). A total of 230 patients (86.5%) were at risk for malnutrition, and in 118 of them, IC was indicated. Practical considerations precluded measurements in 72 cases (61%). Forty-six calorimetric evaluations revealed an MEE of 1649±544 kcal per 24 hours that poorly correlated with calculated resting energy expenditure (r2=0.19) and calculated total energy expenditure (r2=0.20). Indirect calorimetry measurements were not time-consuming.nnnCONCLUSIONSnIndirect calorimetry was indicated in half but effectively performed in only 20% of a representative intensive care unit population at risk for malnutrition. Correlation between MEE and CEE was poor.nnnCLINICAL RELEVANCY STATEMENTnIndirect calorimetry is increasingly advocated for individualizing nutritional therapy in critically ill adult patients. Practical feasibility is tested in this study. Large differences between measured and calculated energy expenditure are observed. Together with patients characteristics, feasibility results can guide clinicians or institutes in using IC in their daily clinical practice.

Liver perfusion and hepatocellular inflammatory response in sepsis.

Sepsis is characterized by disturbances in liver perfusion and alterations in intrahepatic cellular functions and interactions. This provokes structural and functional liver damage as well as hepatocellular activation that is believed to perpetuate the immuno-inflammatory response. Changes in hepatic perfusion during sepsis are still poorly understood due to the heterogeneity of septic animal models and the difficult accessibility of the hepatic circulation in humans. Sinusoidal blood flow is severely compromised during sepsis due to a decline in perfused sinusoidal area in association with a decrease in sinusoidal flow velocity. Imbalances in the production of nitric oxide may account for these (micro) circulatory disorders. Interactions between liver macrophages, activated endothelial cells and hepatocytes determine the intensity of inflammation and contribute to initial liver damage. Hepatocellular injury is then enhanced by attracted and invading neutrophils. The management of hepatic dysfunction during sepsis is largely supportive and based on prevention and vigorous resuscitation including early nutritional support and adequate oxygenation. Interestingly, experimental studies suggest that pharmacological interventions with significant hemodynamic effects, such as dobutamine and nitric oxide synthase inhibitors, may adversely affect the liver during the septic process.

Measuring resting energy expenditure during extracorporeal membrane oxygenation: preliminary clinical experience with a proposed theoretical model.

Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with severe respiratory failure. Indirect calorimetry (IC) is a safe and non‐invasive method for measuring resting energy expenditure (REE). No data exist on the use of IC in ECMO‐treated patients as oxygen uptake and carbon dioxide elimination are divided between mechanical ventilation and the artificial lung. We report our preliminary clinical experience with a theoretical model that derives REE from IC measurements obtained separately on the ventilator and on the artificial lung.

Reversible “locked-in” syndromes

Two young patients are described who made good recoveries from a “locked-in” syndrome presumed to be due to ventral pontine ischemia. The first patient recovered completely from quadriplegia and mutism. In the second patient the only permanent sequellae were slight dysarthria and mild spasticity. Since patients may recover nearly completely from a “locked-in” syndrome, aggressive supportive therapy seems justified during the initial weeks or months.

Meprobamate poisoning, hypotension and the swan-ganz catheter

A case is described in which voluntary ingestion of 72 g meprobamate (mpb) was complicated by shock ascribed to cardiac failure and vasodilation, documented by hemodynamic monitoring. Forced diuresis and cardiac inotropic support were added to the therapy. We recommend Swan-Ganz monitoring in any case of mpb overdosage associated with hypotension and suggest that forced diuresis is not contraindicated if appropriate assessment of the patients hemodynamic condition is performed.