René Gust

Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial

BACKGROUND During cardiopulmonary resuscitation (CPR), thrombolysis can help to stabilise patients with pulmonary embolism and myocardial infarction. Moreover, thrombolysis during CPR has beneficial effects on cerebral reperfusion after cardiac arrest. We investigated this new therapeutic approach in patients in whom conventional CPR had been unsuccessful. METHODS We assessed, in a prospective study, patients undergoing CPR after out-of-hospital cardiac arrest for cardiological reasons in whom return of spontaneous circulation was not achieved within 15 min. According to the Ustein criteria, our control group consisted of patients who were assessed during 1 year. After this year patients were treated with a bolus of 5000 U of heparin and 50mg, over 2 min, of tissue-type plasminogen activator (rt-PA treated group). This intervention was repeated if return of spontaneous circulation was not achieved within the following 30 min. For controls only CPR was given. FINDINGS Overall, 90 patients were included; heparin and rt-PA were given to 40 patients. There were no bleeding complications related to the CPR procedures. Of the rt-PA group, 68% (27) had return of spontaneous circulation and 58% (23) were admitted to a cardiac intensive care unit, compared with 44% (22; p=0.026) and 30% (15; p=0.009) of the controls, respectively. At 24 h after cardiac arrest a larger proportion of the rt-PA group than of the controls was alive (35% [14] vs 22% [11], p=0.171), and 15% (six) of rt-PA-treated patients and 8% (four) of controls could be discharged from hospital. INTERPRETATION After initially unsuccessful out-of-hospital CPR, thrombolytic therapy combined with heparin is safe and might improve patient outcome. On the basis of our data a randomised controlled trial might be regarded as ethical.

Effect of patient-controlled analgesia on pulmonary complications after coronary artery bypass grafting.

OBJECTIVE To determine whether treatment with patient-controlled analgesia (PCA) alone or in combination with nonsteroidal anti-inflammatory drugs can prevent postoperative pulmonary complications after cardiac surgery, when compared with conventional nurse-controlled analgesia. DESIGN Randomized controlled trial. SETTING University Medical Center. PATIENTS A total of 120 patients undergoing elective coronary artery bypass grafting. INTERVENTIONS After extubation of the trachea, 120 patients were randomly allocated to three different methods of postoperative pain relief for 72 hrs. In group 1, patients received PCA with a bolus of 1.5 mg piritramide combined with a 10-min lockout interval. Group 2 patients were treated with a combination of PCA and administration of nonsteroidal anti-inflammatory drugs prescribed three times per day. Patients of group 3 received conventional nurse-controlled analgesia. Postoperative assessment included daily visual analog pain scoring (VAS) and chest radiographs. All chest radiographs were graded for the extent of atelectasis by a radiologist blinded as to treatment using a scale from 0 to 9 for each of the three lung fields of the right and left lungs. MEASUREMENTS AND MAIN RESULTS Chest radiograph atelectasis scores and VAS values were similar among the three groups on the first and second days. On the third day, the chest radiograph atelectasis scores of the left lower and the right middle lung field were significantly better in the groups treated with PCA alone (4.7 +/- 3.0; 0.3 +/- 1.0) and in combination with nonsteroidal anti-inflammatory drugs (3.9 +/- 1.1; 0.4 +/- 1.2) than in the control group (5.5 +/- 3.1; 0.8 +/- 1.8). Furthermore, on the third day, the VAS values for maximum pain were higher in the control group (42.6 +/- 19.7) compared with the VAS values in the two groups with PCA (32.2 +/- 17.9 and 34.5 +/- 21.0). CONCLUSIONS PCA significantly decreases postoperative pulmonary atelectasis in patients after coronary artery bypass grafting when compared with nurse-controlled analgesia. In addition, patients treated with PCA experienced a higher quality of analgesia. We therefore conclude that treatment with PCA may reduce respiratory complications after coronary artery bypass grafting.

Effects of continuous (CPAP) and bi-level positive airway pressure (BiPAP) on extravascular lung water after extubation of the trachea in patients following coronary artery bypass grafting

ObjectiveTo evaluate the effects of continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) on extravascular lung water during weaning from mechanical ventilation in patients following coronary artery bypass grafting.DesignProspective, randomized clinical study.SettingIntensive care unit at a university hospital.PatientsSeventy-five patients following coronary artery bypass grafting.InterventionsAfter extubation of the trachea, patients were treated for 30 min with CPAP via face mask (n=25), with nasal BiPAP (n=25), or with oxygen administration via nasal cannula combined with routine chest physiotherapy (RCP) for 10 min (n=25).Measurements and resultsExtravascular lung water (EVLW), pulmonary blood volume index (PBVI) and cardiac index (CI) were obtained during mechanical ventilation (T1), T-piece breathing (T2), interventions (T3), spontaneous breathing 60 min (T4) and 90 min (T5) after extubation of the trachea using a combined dye-thermal dilution method. Changing from mechanical ventilation to T-piece breathing did not show any significant differences in EVLW between the three groups, but a significant increase in PBVI from 155±5 ml/m2 to 170±4 ml/m2 could be observed in all groups (p<0.05). After extubation of the trachea and treatment with BiPAP, PBVI decreased significantly to 134±6 ml/m2 (p<0.05). After treatment with CPAP or BiPAP, EVLW did not change significantly in these groups (5.5±0.3 ml/kg vs 5.0±0.4 ml/kg and 5.1±0.4 ml/kg vs 5.7±0.4 ml/kg). In the RCP-treated group, however, EVLW increased significantly from 5.8±0.3 ml/kg to 7.1±0.4 ml/kg (p<0.05). Sixty and 90 min after extubation, EVLW stayed at a significantly higher level in the RCP-treated group (7.5±0.5 ml/kg and 7.4±0.5 ml/kg) than in the CPAP-(5.6±0.3 ml/kg and 5.9±0.4 ml/kg). No significant differences in CI could be observed within the three groups during the time period from mechanical ventilation to 90 min after extubation of the trachea.ConclusionsMask CPAP and nasal BiPAP after extubation of the trachea prevent the increase in extravascular lung water during weaning from mechanical ventilation. This effect is seen for at least 1 h after the discontinuation of CPAP or BiPAP treatment. Fuether studies have to evaluate the clinical relavance of this phenomenon.

Importance of hypoxic vasoconstriction in maintaining oxygenation during acute lung injury

Objective To investigate the role of hypoxic pulmonary vasoconstriction in the intrapulmonary blood flow redistribution and gas exchange protection during oleic acid acute lung injury. Design Prospective, controlled animal study. Setting Research laboratory of an academic institution. Subjects Three groups of five mongrel dogs. Interventions Induction of acute lung injury by 0.08 mL/kg oleic acid intravenously. Hypoxic pulmonary vasoconstriction inhibition by Escherichia coli endotoxin microdose (15 &mgr;g/kg) pretreatment or by metabolic alkalosis (pH 7.60). Measurements and Main Results Pulmonary arterial and venous resistances were determined by flow-pressure curves and by capillary pressure estimation. Regional lung water and pulmonary blood flow were assessed by positron emission tomography. Oleic acid alone increased the arterial and venous resistances, redistributed blood flow away from edematous areas, and decreased the Pao2 from 507 ± 16 to 373 ± 60 torr on Fio2 1.0 and positive end-expiratory pressure 5 cm H2O. Endotoxin pretreatment inhibited the increase in arterial resistance, suppressed the redistribution, and decreased the Pao2 to 105 ± 22 torr. Alkalosis inhibited the increase in arterial and venous resistances, suppressed the redistribution, and decreased the Pao2 to 63 ± 12 torr. Reversal of the alkalosis increased the arterial and venous resistances, restored the perfusion redistribution, and improved the Pao2 to 372 ± 63 torr. Changes in blood gases conformed to predictions of a computer lung model in which hypoxic pulmonary vasoconstriction was suppressed by endotoxin and alkalosis. Conclusions We conclude that in oleic acid-induced lung injury, a) pulmonary hypertension results from increases in both arterial and venous resistances; b) the increase in arterial resistance is the primary mechanism responsible for the perfusion redistribution and the gas exchange protection; and c) the increase in arterial resistance is most consistent with hypoxic pulmonary vasoconstriction.

Cardiac output measurement by transpulmonary versus conventional thermodilution technique in intensive care patients after coronary artery bypass grafting

OBJECTIVE The aim of the present study was to evaluate the correlation, accuracy, and precision of transpulmonary thermodilution cardiac output (CO) measurement. For this purpose, this technique was compared with the clinical gold standard, the CO measurement by pulmonary artery catheter in patients after coronary artery bypass grafting (CABG). DESIGN A prospective clinical study. SETTING A university medical center. PARTICIPANTS Seventy-five patients in an intensive care unit (ICU) after CABG. INTERVENTIONS Standard (SCO) and transpulmonary thermodilution CO measurement (TPCO) measurements were simultaneously performed in triplicate by central venous injection of cooled saline solution. All variables were recorded at five different time points of measurement during weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS CO measurements yielded 375 data pairs. SCO ranged from 2.0 to 10.2 L/min, and TPCO from 1.3 to 10.6 L/min. During the entire observation period, TPCO measurements tended to yield relatively high values, whereas SCO measurements resulted in lower values. Correlation between TPCO and SCO measurements was significant (r = 0.73; p < 0.05), accompanied by an accuracy with a bias of 0.456 L/min (7.3%) and a precision of 1.156 L/min (18.5%). CONCLUSION In most patients, TPCO measurement will not replace the conventional technique by pulmonary artery catheter, but in some patients it offers an attractive, reliable, and safe method to determine CO.

Bedside troponin T testing is not useful for early out-of-hospital diagnosis of myocardial infarction.

Background: A new commercially available rapid qualitative bedside immunoassay for cardiac troponin T has been developed. The aim of the study was to investigate whether this new rapid bedside cardiac troponin T assay facilitates diagnosing myocardial infarction in a pre‐hospital setting.

Gastric Intramucosal pH: A Predictor of Survival in Cardiac Surgery Patients With Low Cardiac Output?

OBJECTIVE To assess the value of gastric intramucosal pH measurement in patients with low output after cardiac surgery. DESIGN Prospective clinical study. SETTING University hospital. PARTICIPANTS Fifteen patients with low output after cardiac surgery were included. Those who survived the first postoperative day (n = 14) remained in the study. INTERVENTIONS Gastric intramucosal pH and arterial lactate concentrations were measured 6, 12, and 24 hours after admission to the intensive care unit. Intravenous infusion of buffer solutions was strictly avoided during the equilibration period and in the half hour before injection of saline into the gastric balloon of the tonometer. MEASUREMENTS AND MAIN RESULTS Eight patients survived during the 28-day observation period, and six patients died. On admission to the intensive care unit, no difference in cardiac index (1.56 v 1.54 L/min/m2) or pulmonary capillary wedge pressure (17.3 v 17.7 mmHg) was found between survivors and nonsurvivors. During the first 24 hours after surgery, arterial lactate was significantly higher in the nonsurvivor group (61 v 23 mg/dL), but there was no difference between the gastric intramucosal pH of survivors and nonsurvivors (7.41 v 7.42 on admission). CONCLUSIONS Calculated gastric mucosal pH is not an early predictor of survival in cardiac surgery patients with postoperative low cardiac output syndrome. Further studies are required to assess whether the gradient between arterial and intramucosal partial pressure of carbon dioxide (PCO2) might be a more useful predictive value.

30-jähriger Bodybuilder mit septischem Schock und ARDS bei Abusus anabol-androgener Steroide

ZusammenfassungWir berichten über einen 30-jährigen Bodybuilder, der auf dem Boden regelmäßiger intramuskulärer Selbstinjektionen anabol-androgener Steroide einen glutealen Spritzenabszess ausbildete. Nach Abszessspaltung in Allgemeinanästhesie entwickelte er einen septischen Schock und ein fulminantes “acute respiratory distress syndrome” (ARDS). Anhand der Kasuistik sollen neben Aspekten zur Pathogenese, Differenzialdiag-nose und Therapie insbesondere mögliche immunmodulatorische Mechanismen anaboler Substanzen diskutiert werden, die in diesem Fall den Krankheitsverlauf beeinflusst haben könnten.AbstractWe report the case of a 30-year-old body builder who developed a gluteal abscess at the site of injection of regularly self-administered anabolic steroids. After breaking the abscess under general anaesthesia, the patient developed septic shock and fulminant adult respiratory distress syndrome (ARDS). In addition to discussing the pathogenesis, differential diagnosis, and treatment, we focus on the immunomodulatory mechanisms of anabolic substances that may have contributed to the course of the disease in this particular patient.