Philippe Gottignies

Comparison of Dopamine and Norepinephrine in the Treatment of Shock

BACKGROUND Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other. METHODS In this multicenter, randomized trial, we assigned patients with shock to receive either dopamine or norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. When blood pressure could not be maintained with a dose of 20 microg per kilogram of body weight per minute for dopamine or a dose of 0.19 microg per kilogram per minute for norepinephrine, open-label norepinephrine, epinephrine, or vasopressin could be added. The primary outcome was the rate of death at 28 days after randomization; secondary end points included the number of days without need for organ support and the occurrence of adverse events. RESULTS The trial included 1679 patients, of whom 858 were assigned to dopamine and 821 to norepinephrine. The baseline characteristics of the groups were similar. There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001). A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock (P=0.03 for cardiogenic shock, P=0.19 for septic shock, and P=0.84 for hypovolemic shock, in Kaplan-Meier analyses). CONCLUSIONS Although there was no significant difference in the rate of death between patients with shock who were treated with dopamine as the first-line vasopressor agent and those who were treated with norepinephrine, the use of dopamine was associated with a greater number of adverse events. (ClinicalTrials.gov number, NCT00314704.)

Torsade de pointes in Kearns–Sayre syndrome

A 47-year-old woman with Kearns–Sayre syndrome (KSS) and an implanted pacemaker for complete heart block was admitted to the intensive care unit following a cardiac arrest due to ventricular tachycardia (torsade de pointes) in the setting of QT prolongation. Complete heart blocks and ventricular tachycardia are implicated as mechanisms of sudden deaths in KSS; such patients may require pacemaker implantation and implantation of an automatic implantable cardioverter–defibrillator.

Late onset of Aspergillus aortitis presenting as femoral artery embolism following coronary artery bypass graft surgery.

Aspergillus sp. are ubiquitous mould infections and in most patients, the source is presumed to be air-borne infections during surgical procedures. Prevention of these infections requires special attention of ventilation systems in operating rooms. Post-operative aspergillosis occurs mainly in immunocompromised patients as well as those who receive corticosteroids temporarily. We report a case of a 71-year-old immunocompromised patient who developed multiple lower limb embolisms due to Aspergillus niger originating from an aortitis of the ascending aorta nine months following coronary artery bypass graft (CABG) surgery.

Cerebral perfusion alterations and cognitive decline in critically ill sepsis survivors

Introduction: We investigated the association between cerebral perfusion perturbations in sepsis with possible cognitive decline (CD) after patients’ discharge from the intensive care unit (ICU). Methods: We studied 28 patients with sepsis and Lawton’s Instrumental Activities of Daily Living scale (IADL) scores ≥5 who were discharged from a university ICU institution. We evaluated cerebral circulatory parameters (pulsatility index (PI) and cerebral blood flow index (CBFi) was calculated based on the measured velocity of the middle cerebral artery. Use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test was performed daily, and either the Mini Mental State Examination test (MMSE) or Clock Drawing test was performed at ICU discharge. CD was categorized as persistent coma, positive CAM-ICU test at discharge, MMSE <24, or an abnormal Clock test. Results: Patients had a median pre-ICU IADL score of 6.3 (95% CI 5.9–6.7). Fourteen patients (50%) had CD at discharge. Two were in persistent coma despite sepsis resolution. Information recall was the most affected mental function of the other 12 patients. Only on the first day, patients with CD had higher PI and lower CBFi compared to those without CD (2.2 ± 0.7 vs. 1.4 ± 0.5, p = 0.02; 363 ± 170 vs. 499 ± 133, p = 0.03, respectively). Multivariable analysis revealed delirium, but not PI, as an independent prognostic factor for CD (OR: 29.62, 95%CI 1.91–458.01, p = 0.01). Conclusion: Delirium, but not cerebral perfusion alterations, is an independent risk factor for cognitive impairment in septic patients who were discharged from the ICU.

Tongue necrosis as a complication of vasoconstrictor agents in the intensive care setting

The tongue is well irrigated by the lingual and submandibular arteries along with numerous collaterals that are invariably present. This rich vascular supply makes tongue necrosis exceptional. Tongue necrosis has been reported in giant cell arteritis, Wegener’s granulomatosis, malignant tumors, previous radiation to the neck, intraarterial injections, emboli, ergotism, essential thrombocytosis, and calciphylaxis [1–3, 5]. We report a case of tongue necrosis due to a combination of different vasoconstrictive agents in the intensive care setting.

Ease of Using a Dedicated Percutaneous Closure Device after Inadvertent Cannulation of the Subclavian Artery: Case Report

Inadvertent puncture of the subclavian artery is a relatively frequent and potentially disastrous complication of attempted central venous access. Due to its noncompressible location, accidental subclavian arterial cannulation may result in hemorrhage as the sheath is removed. We report a new case of successful percutaneous closure of the subclavian artery which had been inadvertently cannulated, using a closure device based on a collagen plug (Angio-Seal, St. Jude Medical). This was performed in a patient who had received maximal antiplatelet and anticoagulation therapies because of prior coronary stenting in the context of cardiogenic shock. There was no prior angiographic assessment, as arterial puncture was presumed to have been distal to the right common artery and vertebral arteries. No complications were observed in this high-risk patient, suggesting that this technique could be used once the procedure has been evaluated prospectively.

Influence of bedside blood insulin measurement on acute coronary syndrome pathways.

BACKGROUND The aim of the study was to evaluate the influence of blood insulin measurements on acute coronary syndrome (ACS) pathways. METHODS All patients admitted to the emergency department within 12 months for acute, retrosternal, constrictive chest pain lasting for more than 30 minutes; cardiogenic pulmonary edema; electrocardiogram ST changes; and echographic alterations were included. The study parameters were clinical (age, sex, blood pressure, presence of pulmonary rales and gallop), including classic laboratory tests associated with troponin T, blood insulin levels, and hemoglobin A1C, and echographic values. These were taken on admission and throughout hospital stay. All patients underwent a coronary angiography for ACS diagnosis confirmation as well as treatment intention. RESULTS Sixty patients were included in the study. Abnormal blood insulin levels were present on admission in 47% of the population. Blood insulin level was significantly correlated to thrombolysis in myocardial infarction coronary perfusion score (Spearman Rank, 0.55, P < 0.0001). Abnormal insulinemia was normalized with reperfusion. Insulin was administered essentially to the 16 patients with hypoinsulinemia. Patients with hypoinsulinemia seem to have the most severe coronary lesions and highest Killip score. CONCLUSIONS In ACS, insulin levels are altered in half of the patients. After the investigators noted its tight correlation with the thrombolysis in myocardial infarction coronary flow score, its determination could be important in ACS for triggering emergency coronary angiography for percutaneous coronary intervention. This could modify the critical pathways of ACS patients in the emergency department.

Upper gastrointestinal bleeding related to emphysematous cholecystitis due to Clostridium perfringens

We describe the case of a 46-year-old man admitted for upper gastrointestinal bleeding in the context of cirrhosis. A deep bleeding duodenal ulcer was treated by sclerotherapy. Abdominal pain and fever lead us to perform an abdominal computed tomography, which demonstrated emphysematous cholecystitis. An emergency cholecystectomy was performed and antimicrobial therapy initiated. The patient recovered uneventfully. Links between ulcers and emphysematous cholecystitis are discussed.

Treatment of thrombotic thrombocytopenic purpura.

TTP treated with Rituximab after initial PE. A 59-year-old man was hospitalised for aphasia, paresis of the inferior right facial nerve, and fever (38 °C). His blood analysis revealed low platelets (15,000/mm3), haemolytic microangiopathic anaemia (hemoglobin=10.2 g/dl, schistocytes 8%, LDH 1,300 UI/l, haptoglobin 0.05 g/l), and renal failure (creatinine=123.9 mmol/l, urea=18.5 mmol/l). PE with 60 ml/kg fresh frozen plasma daily and methylprednisolon (1 mg·kg·day) was started. Although neurological symptoms and thrombopenia resolved after four PE, two PE/week were needed in order to achieve a platelet count of >100,000/mm3. Methylprednisolon was tapered off after 2 weeks. ADAMTS13 activity (AA) was undetectable and inhibitor activity (IA) was 16 BU/ml before the first PE. During PE AA was <5% and IA was oscillating between 2 BU/ml and 8 BU/ml. After Rituximab was administered at 375 mg·m2·week during 4 weeks, the platelet count stabilized at >150,000/mm3, PE was discontinued, AA was 7.5%, and IA became undetectable. The patient has been in remission for 9 months. In conclusion, although only anecdotal reports are available, Rituximab is very promising in the treatment of TTP with deficiency of AA and IA. Prospective studies, however, are difficult to perform due to the rareness of TTP.

Drotrecogin alfa (activated) for severe sepsis: Could we consider a shorter treatment period in patients with a favorable course?

PURPOSE The objective of this study was to develop a model to identify patients in whom drotrecogin alfa (activated) (DAA) might be administered for periods shorter than the recommended 96 hours. METHODS We did a retrospective chart review of all 124 patients treated with a standard 96-hour infusion of DAA in a 31-bed department of intensive care. Using a stepwise approach, we identified and combined parameters that could help predict outcomes to achieve the best sensitivity associated with 100% specificity. RESULTS Twenty-one (17%) of the 124 patients had a favorable outcome (left the intensive care unit within 5 days of DAA initiation); of these, 11 had an increase in arterial pH in the first 24 hours of treatment compared with 22 (21%) of the 103 patients with intermediate (intensive care unit stay >5 days after DAA initiation) or unfavorable (died within 5 days of DAA initiation) outcomes (P = not significant). Eight (72.7%) of these 11 patients and no other patient showed a decrease in sequential organ failure assessment score of at least 50% during the first 24 hours (P < .001). By combining these 2 variables, we could identify, with 100% specificity, 8 of the patients with a favorable outcome (38%) who made a prompt recovery. CONCLUSIONS A simple model based on sequential organ failure assessment score and arterial pH can help identify patients with a rapid favorable course in whom a shorter duration of DAA treatment may be justified.