Norbert Mutz

The effects of vasopressin on systemic hemodynamics in catecholamine-resistant septic and postcardiotomy shock: A retrospective analysis

We retrospectively investigated the effects of continuous arginine vasopressin (AVP) infusion on systemic hemodynamics, acid/base status, and laboratory variables in patients (mean age [mean ± sd]= 66.3 ± 10.1 yr) with catecholamine-resistant septic (n = 35) or postcardiotomy shock (n = 25). Hemodynamic and acid/base data were obtained before; 30 min after; and 1, 4, 12, 24, 48, and 72 h after the start of AVP infusion. Laboratory examinations were recorded before and 24, 48, and 72 h after the start of AVP infusion. For statistical analysis, a mixed-effects model was used. The overall intensive care unit mortality was 66.7%. AVP administration caused a significant increase in mean arterial pressure (+29%) and systemic vascular resistance (+56%), accompanied by a significant decrease in heart rate (−24%) and mean pulmonary arterial pressure (−11%) without any change in stroke volume index. Norepinephrine requirements could be reduced by 72% within 72 h. During AVP infusion, a significant increase in liver enzymes and total bilirubin concentration and a significant decrease in platelet count occurred. Arginine vasopressin was effective in reversing systemic hypotension. However, adverse effects on gastrointestinal perfusion and coagulation cannot be excluded.

Blunted erythropoietic response to anemia in multiply traumatized patients.

ObjectivesTo assess the relations between anemia, serum erythropoietin (EPO), iron status, and inflammatory mediators in multiply traumatized patients. DesignProspective observational study. SettingIntensive care unit. PatientsTwenty-three patients suffering from severe trauma (injury severity score ≥30). InterventionsNone. Measurements and Main Results Blood samples were collected within 12 hrs after the accident (day 1) and in the morning on days 2, 4, 6, and 9 to determine blood cell status, serum EPO, tumor necrosis factor-&agr; (TNF-&agr;), soluble tumor necrosis factor-receptor I (sTNF-rI), interleukin-1 receptor antagonist (IL1-ra), interleukin-6 (IL-6), neopterin, and iron status, respectively. Hemoglobin concentration was low at admission (mean, 10.0 g/dL; range, 6.8–12.9 g/dL) and did not increase during the observation time. Serum EPO concentration was 49.8 U/L (mean value) on day 1 and did not show significant increases thereafter. No correlation was found between EPO and hemoglobin concentrations. TNF-&agr; remained within the normal range. sTNF-rI was high at admission and increased further. IL1-ra was above the normal range. IL-6 was very high at admission and did not decrease thereafter. The initial neopterin concentration was normal, but increased until day 9. Serum iron was significantly decreased on day 2 posttrauma and remained low during the study. Serum ferritin increased steadily from day 2, reaching its maximum on day 9. In contrast, concentrations of transferrin were low from admission onward. ConclusionsMultiply traumatized patients exhibit an inadequate EPO response to low hemoglobin concentrations. Thus, anemia in severe trauma is the result of a complex network of bleeding, blunted EPO response to low hemoglobin concentrations, inflammatory mediators, and a hypoferremic state.

Tachyarrhythmias in a surgical intensive care unit: a case-controlled epidemiologic study.

Objective: Incidence, types, and factors associated with new onset tachyarrhythmias (TA) in surgical intensive care patients.¶Design: Pairwise-matched case-controlled study. Setting: Surgical intensive care unit (ICU) with nine intensive care beds. Patients: During a 1-year period, all TA patients (n = 89) were included in the study. Control patients (n = 82) without TA were matched according to age, sex, and surgical region. Methods: TA workup included: 12-lead ECG, arterial blood gas, serum electrolyte (K+, Mg2+), and serum CK/CKMB isoenzyme analysis. Pre-existing cardiovascular and pulmonary disease, cardiovascular risk factors, preoperative regular medication, and admission SAPS were recorded in all patients. A multiple organ dysfunction syndrome (MODS) score, the presence or absence of SIRS or sepsis, and hemodynamics (MAP and CVP) before onset of TA were evaluated in TA patients, while in control patients highest MODSscore, the presence or absence of SIRS or sepsis, mean hemodynamic and laboratory values calculated from highest and lowest readings during ICU stay were used for statistical comparison. Logistic regression analysis was performed to identify variables multivariately associated with TA. Results: Eighty-nine (14.8 %) of 596 patients developed TA. Atrial fibrillation was most frequent (60.7 %). Presence of SIRS or sepsis (adj. OR = 36.45; 95 % CI: 11.5–115.5), high admission SAPS (adj. OR = 1.25/point; 95 % CI: 1.08–1.44), high CVP (adj. OR = 1.27/mmHg; 95 % CI: 1.09–1.48), and low arterial oxygen tension (adj. OR = 0.97/mmHg); 95 % CI: 0.95–0.99) were found to be significant predictors for development of TA. Conclusions: In surgical patients hypoxia, high cardiac filling pressures, a greater degree of physiologic derangement at admission, and the presence of SIRS and sepsis are independent risk factors for the development of TA.

Selective intestinal decontamination in multiple trauma patients : Prospective, controlled trial

BACKGROUND Reduction of potential pathogens by selective intestinal decontamination has been proposed to improve intensive care. Despite large scientific interest in this method, little is known about its benefit in homogeneous trauma populations. METHODS In a prospective, controlled study, we enrolled non-infected trauma patients (age over 18 years, mechanical ventilation > or = 48 hours, intensive care for more than 3 days) who primarily were admitted to our university medical center. We randomized patients to be treated with two different topical regimens (polymyxin, tobramycin, and amphotericin (PTA) or polymyxin, ciprofloxin, amphotericin (PCA)) or the carrier only (placebo), administered four times daily both to the oropharynx and to the gastrointestinal tract. All patients received intravenous ciprofloxacin (200 mg, bd) for 4 days. FINDINGS Of 357 enrolled patients, 310 (age 38.0 +/- 16.5 years, Injury Severity Score 35.2 +/- 12.7) met all inclusion criteria. Selective decontamination successfully reduced intestinal bacterial colonization. However, we did not identify significant differences between groups regarding pneumonia (PTA 47.5%, PCA 39.0%, placebo 45.3%), sepsis (PTA 47.5%, PCA 37.8%, placebo 42.6%), multiple organ failure (PTA 56.3%; PCA 52.4%, placebo 58.1%), and death (PTA 11.3%, PCA 12.2%, placebo 10.8%). Total costs per patient were highest with the PTA regimen. CONCLUSIONS We found no benefit of selective decontamination in trauma patients. Apparently, bacterial overgrowth in the intestinal tract is not the sole link between trauma, sepsis, and organ failure.

Effectiveness of direct-current cardioversion for treatment of supraventricular tachyarrhythmias, in particular atrial fibrillation, in surgical intensive care patients.

ObjectiveTo evaluate primary success rate and effectiveness of direct-current cardioversion in postoperative critically ill patients with new-onset supraventricular tachyarrhythmias. DesignProspective intervention study. SettingTwelve-bed surgical intensive care unit in a university teaching hospital. PatientsThirty-seven consecutive, adult surgical intensive care unit patients with new-onset supraventricular tachyarrhythmias without previous history of tachyarrhythmias. InterventionsDirect-current cardioversion using a monophasic, damped sinus-wave defibrillator. Energy levels used were 50, 100, 200, and 300 J for regular supraventricular tachyarrhythmias (n = 6) and 100, 200, and 360 J for irregular supraventricular tachyarrhythmias (n = 31). Measurements and Main ResultsNone of the patients was hypoxic, hypokalemic, or hypomagnesemic at onset of supraventricular tachyarrhythmia. Direct-current cardioversion restored sinus rhythm in 13 of 37 patients (35% primary responders). Most patients responded to the first or second direct-current cardioversion shock. Only one of 25 patients requiring more than two direct-current cardioversion shocks converted into sinus rhythm. Primary responders were significantly younger and demonstrated significant differences in arterial Po2 values at onset of supraventricular tachyarrhythmias compared with nonresponders. At 24 and 48 hrs, only six (16%) and five (13.5%) patients remained in sinus rhythm, respectively. ConclusionsIn contrast to recent literature, direct-current cardioversion proved to be an ineffective method for treatment of new-onset supraventricular tachyarrhythmias and, in particular, atrial fibrillation with a rapid ventricular response in surgical intensive care unit patients.

LONG-TERM ADMINISTRATION OF PANCURONIUM AND PIPECURONIUM IN THE INTENSIVE-CARE UNIT

This study was performed to determine the optimum dose of pancuronium (n = 30) and pipecuronium (n = 30) under continuous sedation and analgesia in the intensive care unit (ICU). This was an open clinical investigation in 60 critically ill patients with head injury, multiple trauma (in some complicated with sepsis and multi-organ failure), requiring neuromuscular block for ventilation for at least 48 h. Emphasis was placed on the neuromuscular monitoring with a peripheral nerve stimulator and adequate sedation and analgesia. Satisfactory block was achieved in all cases with an average dose of 3 mg/h with either compound. None of the patients experienced prolonged paralysis, muscle weakness, or other neuromuscular dysfunctions in the postventilatory period. We suggest that adequate use of sedative hypnotics and opioids plus neuromuscular monitoring allowed us to optimize the dose of muscle relaxants according to the need of individual patients.

Acute respiratory failure associated with catastrophic antiphospholipid syndrome.

Abstract. Wiedermann FJ, Mayr A, Schobersberger W, Knotzer H, Sepp N, Rieger M, Hasibeder W, Mutz N (The Leopold‐Franzens‐University of Innsbruck, Innsbruck, Austria). Acute respiratory failure associated with catastrophic antiphospholipid syndrome (Case Report). J Intern Med 2000; 247: 723–730.

Effects of epinephrine on intestinal oxygen supply and mucosal tissue oxygen tension in pigs

ObjectiveTo study the effects of increasing dosages of epinephrine given intravenously on intestinal oxygen supply and, in particular, mucosal tissue oxygen tension in an autoperfused, innervated jejunal segment. DesignProspective, randomized experimental study. SettingAnimal research laboratory. SubjectsDomestic pigs. InterventionsSixteen pigs were anesthetized, paralyzed, and normoventilated. A small segment of the jejunal mucosa was exposed by midline laparotomy and antimesenteric incision. Mucosal oxygen tension was measured by using Clark-type surface oxygen electrodes. Microvascular hemoglobin oxygen saturation and microvascular blood flow (perfusion units) were determined by tissue reflectance spectrophotometry and laser-Doppler velocimetry. Systemic hemodynamics, mesenteric-venous acid-base and blood gas variables, and systemic acid-base and blood gas variables were recorded. Measurements were performed after a resting period and at 20-min intervals during infusion of increasing dosages of epinephrine (n = 8; 0.01, 0.05, 0.1, 0.5, 1, and 2 &mgr;g·kg−1·min−1) or without treatment (n = 8). In addition, arterial and mesenteric-venous lactate concentrations were measured at baseline and at 60 and 120 mins. Measurements and Main Results Epinephrine infusion led to significant tachycardia; an increase in cardiac output, systemic oxygen delivery, and oxygen consumption; and development of lactic acidosis. Epinephrine significantly increased jejunal microvascular blood flow (baseline, 267 ± 39 perfusion units; maximum value, 443 ± 35 perfusion units) and mucosal oxygen tension (baseline, 36 ± 2.0 torr [4.79 ± 0.27 kPa]; maximum value, 48 ± 2.8 torr [6.39 ± 0.37 kPa]) and increased hemoglobin oxygen saturation above baseline. Epinephrine increased mesenteric venous lactate concentration (baseline, 2.9 ± 0.6 mmol·L−1; maximum value, 5.5 ± 0.2 mmol·L−1) without development of an arterial-mesenteric venous lactate concentration gradient. ConclusionsEpinephrine increased jejunal microvascular blood flow and mucosal tissue oxygen supply at moderate to high dosages. Lactic acidosis that develops during infusion of increasing dosages of epinephrine is not related to development of gastrointestinal hypoxia.

Angiotropic large B-cell lymphoma misdiagnosed as urosepsis with multiple organ dysfunction syndrome.

A 53‐year‐old woman with a history of cervical carcinoma 14 years ago, treated with hysterectomy and radiation therapy, was admitted to the intensive care unit with severe SIRS (systemic inflammatory response syndrome) progressing to shock, multiple organ failure and death within 5 d. Bilateral hydronephrosis diagnosed by sonography and an enlarged left kidney with suspected abscesses verified in a CT‐scan suggested the diagnosis of urosepsis. However, multiple microbiological examinations remained sterile. Despite surgical treatment and aggressive intensive care, she died in unresponsive shock. Pathohistologically, an angiotropic large B‐cell lymphoma, a rare diffuse intravascular neoplasm of lymphoid origin, was diagnosed. The patient’s history of abdominal radiation therapy 14 years earlier as well as multiple negative microbiological specimens in a patient with suspected urosepsis should have initiated the search for a non‐infectious cause of the disease.

Gamma scintigraphic imaging of lung microvascular permeability in adult respiratory distress syndrome

The sequence of lung microvascular permeability (LMVP) changes in early direct posttraumatic and late indirect pancreatitis-induced adult respiratory distress syndrome (ARDS) was studied and compared with that of a control group, as well as non-ARDS ICU patients. A computerized large field of view gamma camera was used to measure LMVP simultaneously over both lungs by In 113m-labeled transferrin and Tc 99m-labeled erythrocytes. The LMVP index (LMVPI) (%/h) was used to quantify LMVP in the dynamic scintigraphic measurement. In the control group the LMVPI was 2.6 +/- 2.8%/h for the right and 2.0 +/- 2.8%/h for the left lung. Similar values were found in mechanically ventilated ICU patients without ARDS (group A) on admission (right LMVPI 3.2 +/- 2.6, left LMVPI 2.6 +/- 2.7%/h) and 4 days later (right LMVPI 3.9 +/- 2.6, left LMVPI 2.3 +/- 1.8%/h). Interestingly, the initial evaluation of patients with direct early posttraumatic ARDS (lung contusion) (group B) showed significantly (p less than .01) elevated LMVP for the contused side (LMVPI 10.8 +/- 5.1%/h), but normal values for the nontraumatized lung (LMVPI 3.9 +/- 3.4%/h), whereas 4 days later the LMVP increased significantly (p less than .05) on the primarily healthy side (LMVPI 8.0 +/- 5.0%/h) while remaining elevated for the traumatized lung (LMVPI 10.9 +/- 6.0%/h).(ABSTRACT TRUNCATED AT 250 WORDS)