Michael Grounds

A randomised, controlled trial of the pulmonary artery catheter in critically ill patients.

Abstract.Objective: To compare the survival and clinical outcomes of critically ill patients treated with the use of a pulmonary artery catheter (PAC) to those treated without the use of a PAC. Design: Prospective, randomised, controlled, clinical trial from October 1997 to February 1999. Setting: Adult intensive care unit at a large teaching hospital. Patients: Two hundred one critically ill patients were randomised either to a PAC group (n=95) or the control group (n=106). One patient in the control group was withdrawn from the study and five patients in the PAC group did not receive a PAC. All participants were available for follow-up. Interventions: Participants were assigned to be managed either with the use of a PAC (PAC group) or without the use of a PAC (control group). Main outcome measures: Survival to 28xa0days, intensive care and hospital length of stay and organ dysfunction were compared on an intention-to-treat basis and also on a subgroup basis for those participants who successfully received a PAC. Results: There was no significant difference in mortality between the PAC group [46/95 (47.9%)] and the control group [50/106 (47.6)] (95% confidence intervals for the difference –13 to 14%, p>0.99). The mortality for participants who had management decisions based on information derived from a PAC was 41/91 (45%, 95% confidence intervals –11 to 16%, p=0.77). The PAC group had significantly more fluids in the first 24xa0h (4953 (3140, 7000) versus 4292 (2535, 6049)xa0ml) and an increased incidence of renal failure (35 versus 20% of patients at day 3 post randomisation p<0.05) and thrombocytopenia (p<0.03). Conclusions: These results suggest that the PAC is not associated with an increased mortality.

Clostridium difficile-Associated Disease Acquired in the Cardiothoracic Intensive Care Unit

OBJECTIVESnTo determine the prevalence, severity, and outcome associated with Clostridium difficile-associated disease (CDAD) acquired while in the cardiothoracic intensive care unit (CTICU).nnnDESIGNnA 5-year retrospective study.nnnSETTINGnThe CTICU.nnnPARTICIPANTSnAll CTICU patients with a positive C difficile stool toxin assay 48 hours after admission.nnnINTERVENTIONSnNone.nnnMEASUREMENTS AND MAIN RESULTSnThe results of all CTICU patients with a positive C difficile stool toxin assay were obtained from the Microbiology Department. Each patients medical notes and charts then were reviewed in turn. A total of 27 of 5,199 (0.5%) CTICU patients acquired CDAD. The median age was 74 years (IQR 68-77), and 17 (63%) patients were male. There were 21 (78%) surgical patients; 13 (62%) were elective admissions. The most frequent diagnosis on admission was valvular heart disease (10 [37%] patients). Sixteen (59%) patients underwent coronary artery bypass graft (CABG) surgery and/or valvular heart surgery. The median interval between CTICU admission and CDAD diagnosis was 10 days (IQR 5-18). Previously identified risk factors for ICU-acquired CDAD included age >65 years (23), antibiotic use (26), and medical device requirements (27). At the time of diagnosis, 14 (52%) patients had moderate CDAD. After treatment initiation, 8 (30%) patients developed worsening CDAD. The 30-day in-hospital mortality rate for CTICU-acquired CDAD was 26% (7 patients).nnnCONCLUSIONSnC difficile-associated disease rarely is acquired in the CTICU. Approximately one third of patients may experience disease progression, and just over a quarter may die within 30 days of diagnosis. The implementation of recommended severity definitions and treatment algorithms may reduce complication rates and merits prospective evaluation.

Idiopathic pulmonary fibrosis associated with pulmonary vein thrombosis: a case report.

BackgroundPulmonary vein thrombosis represents a potentially fatal disease. This syndrome may clinically mimic pulmonary embolism but has a different investigation strategy and prognosis. Pulmonary vein thrombosis is difficult to diagnose clinically and usually requires a combination of conventionally used diagnostic modalities.Case PresentationThe authors report a case of a 78-year-old previously healthy female presenting with collapse and shortness of breath. Serum biochemistry revealed acute kidney injury, positive D-dimmers and increased C reactive protein. Chest radiography demonstrated volume loss in the right lung. The patient was started on antibiotics and also therapeutic doses of low molecular weight heparin. The working diagnosis included community acquired pneumonia & pulmonary embolism. A computed tomography pulmonary angiogram was performed to confirm the clinical suspicions of pulmonary embolism. This demonstrated a thrombus in the pulmonary vein, with associated fibrosis and volume loss of the right lower lobe. A subsequent thrombophilia screen revealed a positive lupus anticoagulant antibody and rheumatoid factor and also decreased anti thrombin III and protein C levels. The urine protein/creatinine ratio was found to be 553 mg/mmol.ConclusionThe diagnosis of this patient was therefore of idiopathic pulmonary fibrosis associated with pulmonary vein thrombosis. Whether or not the pulmonary vein thrombosis was a primary cause of the fibrosis or a consequence of it was unclear. There are few data on the management of pulmonary vein thrombosis, but anticoagulation, antibiotics, and, in cases of large pulmonary vein thrombosis, thrombectomy or pulmonary resection have been used.

A study of muscle tissue oxygenation and peripheral microcirculatory dysfunction in cirrhosis using near infrared spectroscopy.

Background: The circulatory dysfunction associated with cirrhosis is well described. Reduced systemic vascular resistance and high cardiac output are the main features of the hyperdynamic state, but involvement of the peripheral microcirculation in this process is poorly understood. Near infrared spectroscopy (NIRS) has been used to assess muscle tissue oxygenation (StO2) in haemorrhagic and septic shock. Vascular occlusion testing (VOT) can produce dynamic changes in StO2 which represent tissue oxygen extraction, delivery, and hence, surrogate markers of microvascular function.

Hemodynamic optimization in severe trauma: a systematic review and meta-analysis.

Objective Severe trauma can be associated with significant hemorrhagic shock and impaired organ perfusion. We hypothesized that goal-directed therapy would confer morbidity and mortality benefits in major trauma. Methods The MedLine, Embase and Cochrane Controlled Clinical Trials Register databases were systematically searched for randomized, controlled trials of goal-directed therapy in severe trauma patients. Mortality was the primary outcome of this review. Secondary outcomes included complication rates, length of hospital and intensive care unit stay, and the volume of fluid and blood administered. Meta-analysis was performed using RevMan software, and the data presented are as odds ratios for dichotomous outcomes and as mean differences (MDs) and standard MDs for continuous outcomes. Results Four randomized, controlled trials including 419 patients were analyzed. Mortality risk was significantly reduced in goal-directed therapy-treated patients, compared to the control group (OR=0.56, 95%CI: 0.34-0.92). Intensive care (MD: 3.7 days 95%CI: 1.06-6.5) and hospital length of stay (MD: 3.5 days, 95%CI: 2.75-4.25) were significantly shorter in the protocol group patients. There were no differences in reported total fluid volume or blood transfusions administered. Heterogeneity in reporting among the studies prevented quantitative analysis of complications. Conclusion Following severe trauma, early goal-directed therapy was associated with lower mortality and shorter durations of intensive care unit and hospital stays. The findings of this analysis should be interpreted with caution due to the presence of significant heterogeneity and the small number of the randomized, controlled trials included.