Pia Lebiedz

Impact of copeptin on diagnosis, risk stratification, and intermediate-term prognosis of acute coronary syndromes.

BackgroundThe aim of the current study was to evaluate the diagnostic and intermediate-term prognostic impact of C-terminal portion of provasopressin (copeptin) in combination with troponin I.MethodsIn this prospective single-center study we recruited a total of 230 unselected patients with suspected recent acute coronary syndrome (ACS) presenting consecutively at our chest pain unit. Troponin I and copeptin levels were determined at presentation and after 3–6xa0h. Follow-up was performed after 180xa0days.ResultsAcute myocardial infarction (AMI) was the final diagnosis in 107 patients (STEMI: 24, NSTEMI: 83). The median copeptin level was significantly higher in patients having AMI than in those without (20.83 vs. 12.2xa0pmol/L, pxa0<xa00.0001). A troponin I level <0.04xa0ng/mL in combination with copeptin <14xa0pmol/L at admission ruled out AMI with an negative predictive value (NPV) of 97.3xa0%. pxa0=xa00.0045 for the added value of copeptin to troponin I. Kaplan–Meier analysis showed that copeptin levels above the diagnostic cut-off were associated with an elevated intermediate-term (180xa0days) mortality (pxa0=xa00.019), while no patient with copeptin values below the cut-off died. Univariate Cox regression analysis identified copeptin as strong predictor of intermediate-term mortality (HR 4.28, 95xa0% CI 1.58−11.6, pxa0=xa00.004). The predictive performance for prediction of 180-day mortality was significantly better if copeptin was included (C-index of 0.80) compared with that of troponin alone (C-index 0.78, pxa0=xa00.01 for the added value of copeptin to troponin I).ConclusionsAdditional assessment of copeptin allows a rapid and reliable exclusion of AMI and improves diagnostic accuracy in myocardial ischemia. This study showed for the first time that copeptin provides valuable predictive information for risk stratification and intermediate-term outcome in ACS patients.

Characteristics and Outcome of Patients After Allogeneic Hematopoietic Stem Cell Transplantation Treated With Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

Objectives: The acute respiratory distress syndrome is a frequent condition following allogeneic hematopoietic stem cell transplantation. Extracorporeal membrane oxygenation may serve as rescue therapy in refractory acute respiratory distress syndrome but has not been assessed in allogeneic hematopoietic stem cell transplantation recipients. Design: Multicenter, retrospective, observational study. Setting: ICUs in 12 European tertiary care centers (Austria, Germany, France, and Belgium). Patients: All allogeneic hematopoietic stem cell transplantation recipients treated with venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome between 2010 and 2015. Interventions: None. Measurements and Main Results: Thirty-seven patients, nine of whom underwent noninvasive ventilation at the time of extracorporeal membrane oxygenation initiation, were analyzed. ICU admission occurred at a median of 146 (interquartile range, 27–321) days after allogeneic hematopoietic stem cell transplantation. The main reason for acute respiratory distress syndrome was pneumonia in 81% of patients. All but one patient undergoing noninvasive ventilation at extracorporeal membrane oxygenation initiation had to be intubated thereafter. Overall, seven patients (19%) survived to hospital discharge and were alive and in remission of their hematologic disease after a follow-up of 18 (range, 5–30) months. Only one of 24 patients (4%) initiated on extracorporeal membrane oxygenation within 240 days after allogeneic hematopoietic stem cell transplantation survived compared to six of 13 (46%) of those treated thereafter (p < 0.01). Fourteen patients (38%) experienced bleeding events, of which six (16%) were associated with fatal outcomes. Conclusions: Discouraging survival rates in patients treated early after allogeneic hematopoietic stem cell transplantation do not support the use of extracorporeal membrane oxygenation for acute respiratory distress syndrome in this group. On the contrary, long-term allogeneic hematopoietic stem cell transplantation recipients otherwise eligible for full-code ICU management may be potential candidates for extracorporeal membrane oxygenation therapy in case of severe acute respiratory distress syndrome failing conventional measures.

Influence of Red Blood Cell Storage Time on Clinical Course and Cytokine Profile in Septic Shock Patients.

Background: Previous investigations have suggested beneficial effects of fresh versus stored red blood cell transfusion in critically ill patients. The present study investigates the effects of red blood cell storage time on the clinical course and hemodynamic and laboratory parameters in patients with septic shock. Patients and Methods: 18 patients with septic shock received 2 erythrocyte units stored for ≤ 7 days (n = 8) or > 7 days (n = 10). The sequential organ failure assessment (SOFA) score was calculated for 7 days. Hemodynamic parameters (cardiac index, extravascular lung water) were determined using transpulmonary thermodilution. Laboratory parameters (lactate, base excess, C-reactive protein, procalcitonin, IL-1β, IL-6, TNF-α, sVCAM-1, sICAM-1) were monitored before and 1, 3, 6, 12, 24, and 48 h after transfusion. The Mann-Whitney-U test and Neumann test were used for group comparison and trend assessment, respectively. Results: We failed to observe significant differences with respect to SOFA scores between patients receiving fresh or stored erythrocytes. However, a significant trend towards an improvement in the SOFA score was found in the group receiving fresh erythrocytes (p < 0.01). No significant differences in hemodynamic or laboratory parameters were found between both groups. Conclusion: While the present findings do not provide clear-cut evidence supporting beneficial effects of fresh red blood cells in septic shock, they warrant larger randomized studies to confirm or refute such effects.

Amiodarone-induced pulmonary toxicity--a fatal case report and literature review.

Amiodarone is a widely used and very potent antiarrhythmic substance. Among its adverse effects, pulmonary toxicity is the most dangerous without a causal treatment option. Due to a very long half-life, accumulation can only be prevented by strict adherence to certain dosage patterns. In this review, we outline different safe and proven dosing schemes of amiodarone and compare the incidence and description of pulmonary toxicity. Reason for this is a case of fatal pulmonary toxicity due to a subacute iatrogenic overdosing of amiodarone in a 74-year-old male patient with known severe coronary artery disease, congestive heart failure and ectopic atrial tachycardia with reduced function of kidneys and liver but without preexisting lung disease. Within 30xa0days, the patient received 32.2xa0g of amiodarone instead of 15.6xa0g as planned. Despite early corticosteroid treatment after fast exclusion of all other differential diagnoses, the patient died another month later in our intensive care unit from respiratory failure due to bipulmonal pneumonitis.

7-year survey after percutaneous dilatational tracheotomy on a medical intensive care unit.

Purpose Percutaneous dilatational tracheotomy (PDT) is a well-established procedure in intensive care medicine. Several reports confirm a low acute and long-term complication rate. However, dilatational tracheotomy is still often postponed even in patients that are under ventilator support for more than 2 weeks. We present a retrospective study analyzing the subjective long-term results after percutaneous tracheotomy performed at our medical intensive care unit between 2002 and 2008. Methods We used a modified method described by Ciaglia for tracheotomy. We selected 649 patients eligible for the survey among those who had received PDT between 2002 and 2008 and had been dismissed from hospital alive. Results The return rate was 38.5% with 29.8% of the questionnaires being completed by the patients; in 32 cases, relatives reported of the patients death. No patient experienced wound infection; none needed surgical wound revision. Dysarthria was reversible in all 16 cases; 2 patients reported a persistent hoarseness that was preexisting in both cases. One patient experienced a tracheal stenosis and received a tracheal stent; one other required a permanent tracheotomy because of a nonresectable granulation tissue. The overall rate of long-term complications associated with the long-term ventilation and the PDT was 1.8%. Conclusions Percutaneous dilatational tracheotomy is an easily performed, cost-saving method for long-term ventilated patients with a low rate of acute and long-term complications even in old and multimorbid internal medicine patients.

Fulminant invasive pulmonary mucormycosis with Rhizopus oryzae in a patient with severe aplastic anaemia and common variable immunodeficiency

Ruth von Scheven,* Pia Lebiedz,* Tilmann Spieker, Andreas Uekoetter, Wolfgang E. Berdel and Torsten Kessler Department of Medicine A – Hematology, Oncology and Pneumology, University Hospital of Muenster, Muenster, Germany, Department of Medicine C – Cardiology and Angiology, University Hospital of Muenster, Muenster, Germany, Department of Pathology, University Hospital of Muenster, Muenster, Germany and Department of Microbiology, University Hospital of Muenster, Muenster, Germany

Patients with Acute Myeloid Leukemia Admitted to Intensive Care Units: Outcome Analysis and Risk Prediction

Background This retrospective, multicenter study aimed to reveal risk predictors for mortality in the intensive care unit (ICU) as well as survival after ICU discharge in patients with acute myeloid leukemia (AML) requiring treatment in the ICU. Methods and Results Multivariate analysis of data for 187 adults with AML treated in the ICU in one institution revealed the following as independent prognostic factors for death in the ICU: arterial oxygen partial pressure below 72 mmHg, active AML and systemic inflammatory response syndrome upon ICU admission, and need for hemodialysis and mechanical ventilation in the ICU. Based on these variables, we developed an ICU mortality score and validated the score in an independent cohort of 264 patients treated in the ICU in three additional tertiary hospitals. Compared with the Simplified Acute Physiology Score (SAPS) II, the Logistic Organ Dysfunction (LOD) score, and the Sequential Organ Failure Assessment (SOFA) score, our score yielded a better prediction of ICU mortality in the receiver operator characteristics (ROC) analysis (AUC = 0.913 vs. AUC = 0.710 [SAPS II], AUC = 0.708 [LOD], and 0.770 [SOFA] in the training cohort; AUC = 0.841 for the developed score vs. AUC = 0.730 [SAPSII], AUC = 0.773 [LOD], and 0.783 [SOFA] in the validation cohort). Factors predicting decreased survival after ICU discharge were as follows: relapse or refractory disease, previous allogeneic stem cell transplantation, time between hospital admission and ICU admission, time spent in ICU, impaired diuresis, Glasgow Coma Scale <8 and hematocrit of ≥25% at ICU admission. Based on these factors, an ICU survival score was created and used for risk stratification into three risk groups. This stratification discriminated distinct survival rates after ICU discharge. Conclusions Our data emphasize that although individual risks differ widely depending on the patient and disease status, a substantial portion of critically ill patients with AML benefit from intensive care.

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Management of acute-onset and life-threatening respiratory distress of unusual aetiology.

A 30-year-old female experienced severe acute respiratory distress in her apartment assumed to be due to an allergic asthma. Upon arrival of the emergency physician at the scene the patient was unconscious and cyanotic. Auscultation yielded no respiratory sounds despite visible efforts of the patient. Mask ventilation was virtually impossible. Endotracheal intubation was performed but complicated by a distinct resistance. Ventilation remained difficult, despite antiobstructive medication and deep general anaesthesia. Fiberoptic bronchoscopy in the hospital finally showed a bulk of granulomatous tissue located just above the tracheal bifurcation. Here, the authors report a rare case of acute-onset respiratory distress due to Wegeners granulomatosis.