R. J. M. Strack van Schijndel

Outcome of ICU treatment in invasive aspergillosis

ObjectiveTo assess the outcome of intensive care treatment in invasive aspergillosis.DesignRetrospective study.SettingUniversity Hospital, Medical Intensive Care Unit (ICU).PatientsTwenty-five patients with invasive aspergillosis who were admitted to the medical ICU in a 5 1/2 year period. Twenty-two had received high-dose chemotherapy for (mainly hematologic) malignancies, one had been treated with cyclosporine and prednisolone for systemic lupus erythematosus, one with high-dose methylprednisolone for polyarteritis nodosa and one had an ARDS after near-drowning.Measurements and resultsThe medical records were reviewed for patient and disease characteristics, outcome, reasons for admission to the ICU, supportive care and antifungal therapy as well as for the results of cultures and autopsy. Out of 25 patients, a definite ante mortem diagnosis could be established in seven. When autopsied patients were included, a total of 15 suffered from proven invasive aspergillosis. Although standard antifungal treatment and maximal available supportive care were given, 23 of 25 patients (92%) died after a mean of 15 (1–51) days in the ICU. Both patients who recovered had received high-dose chemotherapy for hematologic malignancy and showed bone marrow recovery and/or had a localized pulmonary infection.ConclusionsIn patients with highly suspected or proven invasive aspergillosis, admission to an ICU and mechanical ventilation should be considered in cases of localized infection and obvious signs of hematologic recovery. In most other circumstances ICU admission for mechanical ventilation does not seem to improve survival.

Accuracy and reliability of APACHE II scoring in two intensive care units Problems and pitfalls in the use of APACHE II and suggestions for improvement.

Acute Physiology and Chronic Health Evaluation (APACHE) II scoring is widely used as an index of illness severity, for outcome prediction, in research protocols and to assess intensive care unit performance and quality of care. Despite its widespread use, little is known about the reliability and validity of APACHE II scores generated in everyday clinical practice. We retrospectively re‐assessed APACHE II scores from the charts of 186 randomly selected patients admitted to our medical and surgical intensive care units. These ‘new’ scores were compared with the original scores calculated by the attending physician. We found that most scores calculated retrospectively were lower than the original scores; 51% of our patients would have received a lower score, 26% a higher score and only 23% would have remained unchanged. Overall, the original scores changed by an average of 6.4 points. We identified various sources of error and concluded that wide variability exists in APACHE II scoring in everyday clinical practice, with the score being generally overestimated. Accurate use of the APACHE II scoring system requires adherence to strict guidelines and regular training of medical staff using the system.

Disseminated aspergillosis after near-drowning

We report a case of invasive pulmonary aspergillosis after near-drowning complicated by systemic disseminated disease to the heart, kidneys, left adrenal gland and brain. Detection of fungal micro-organisms in the sputum of near-drowning patients should be taken seriously.

A model for the interplay of inflammatory mediators in sepsis--a study in 48 patients.

Previously we studied levels of the cytokine IL-6 and activation of the complement and contact system and of neutrophils in a group of 48 patients with sepsis. Some of these inflammatory parameters appeared to be associated with a poor prognosis. Here we report on the relationships of C4a and C3a (complement activation products), of factor XII and prekallikrein (contact system proteins), of elastase (a protease released by activated neutrophils) and of the cytokine IL-6 to hemodynamic and biochemical parameters measured in those 48 patients at the time of admission to the Intensive Care Unit. No significant correlations between any inflammatory parameter and either systemic vascular resistance or cardiac index were found. Mean arterial pressure significantly correlated with both factor XII and prekallikrein levels. Lactate correlated with C3a and C4a, with elastase, and in particular, with IL-6, whereas it did not correlate with either factor XII or prekallikrein. Platelet numbers inversely correlated with both C3a and C4a, as well as with elastase and IL-6, whereas they positively correlated with factor XII and prekallikrein. Based on these findings we propose a model for the interplay of these fnflammatory mediators in the pathogenesis of sepsis. This model takes into consideration the occurrence of capillary leakage, shock, disseminated intravascular coagulation, thrombocytopenia and of acute phase reactions in sepsis.

Long-term outcome after 60 days of intensive care

Patients with a long stay in the intensive care unit because of chronic critical illness consume many resources, and yet their outcome may be poor. We evaluated the long‐term outcome of patients spending more than 60 days in the intensive care unit. We performed a retrospective cohort and prospective follow‐up study of 78 patients staying more than 60 days in the 19–26 bed mixed intensive care unit of a university hospital from November 1995 to January 2003. The mortality in the intensive care unit was 38%; at 1 and 5 years it was 56% and 67%, respectively. Advanced age, prior pulmonary disease, long duration of renal replacement therapy, a low oxygenation ratio and platelet count and high Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores on day 60 influenced long‐term mortality. A Simplified Acute Physiology Score II of 50 or a Sequential Organ Failure Assessment score of 8 or higher was associated with 100% mortality during follow‐up. The overall 5‐year survival rate of 33% suggests that prolonged intensive care may be worth the effort in certain patients.

Cardiac arrest due to oral potassium intake

A 29-year-old woman suffered a cardiac arrest, due to profound hyperkalaemia, caused by the use of a potassium-containing salt substitute. She was resuscitated, but post-hypoxic brain damage occurred. Some of the sparse literature is reviewed.

Decreased reflection coefficient as a possible cause of low blood pressure in severe septicaemia

A 44-year-old woman developed a septicaemia with low intra-arterially recorded blood pressure values despite vasoactive medication and optimal support. Sphygmomanometer cuff measurements showed higher values than intra-arterial blood pressure records. We suggest a low reflection coefficient of the capillary bed as the cause of this phenomenon. The constant pressure of the sphygmomanometer cuff on the venous tract appeared to create an increase of the reflection coefficient in our patient, thus causing higher blood pressure readings with the sphygmomanometer cuff measurements than expected.

Bilateral pleural effusion and a subsegmental infiltrate due to Chlamydia pneumoniae in a mechanically ventilated patient.

A case of Chlamydia pneumoniae infection with bilateral pleural effusion and a subsegmental pulmonary infiltrate in an intubated and mechanically ventilated critically ill patient is described. Diagnosis was made by polymerase chain reaction on both pleural effusions.

Cyclic variability of blood pressure and heart rate in tetanus

3. Gatecet C, Mebazaa A, Kong R, Guinard N, Kermarrec N, Mateo J, Payen D (1995) Inhaled nitric oxide improves hepatic tissue oxygenation in right ventricular failure: value of hepatic venous oxygen saturation monitoring. Anesthesiology 82:588-590 4. Richard C, Berdeaux A, Delion F, Riou B, Rimailho A, Giudicelli JF, Auzepy P (1986) Effect of mechanical ventilation on hepatic drug pharmacokinetics. Chest 90:837841 5. Nagano K, Gelman S, Parks DA, Bradley EL (1990) Hepatic oxygen supply-uptake relationship and metabolism during anesthesia in miniature pigs. Anesthesiology 72:902910 6. Uusaro A, Ruokonen E, Takala J (1995) Estimation of splanchnic blood flow by the Fick principle in man andproblems in the use of indocyanine green. Cardiovasc Res 30:106-112