Stanislaw Jankowski

Correlation of serial blood lactate levels to organ failure and mortality after trauma

To define the value of serial measurements of blood lactate levels after trauma, the present study investigated the correlation between blood lactate, mortality, and organ failure in 129 trauma patients, including 100 intensive care unit (ICU) survivors and 29 ICU fatalities. On admission, injury severity score (ISS) was higher and Glasgow coma score (GCS), revised trauma score (RTS), and trauma revised ISS (TRISS) were lower in the nonsurvivors than in the survivors. Serial arterial blood lactate levels were measured on admission and at least three times a day until normalization. Both initial lactate and highest lactate levels were higher in the nonsurvivors than in the survivors. Organ failure developed in 84 (65%) of the 129 patients. Patients with organ failure had significantly lower RTS and TRISS. Initial lactate and highest lactate levels were significantly higher in patients with organ failure than without organ failure (3.4 [0.7 to 12.7] versus 2.4 [0.4 to 7.6] mEq/L and 4.1 [0.7 to 12.7] versus 2.8 [0.4 to 8.9] mEq/L, respectively, both P < .01). The duration of hyperlactatemia averaged 2.2 days in the former but 1.0 day in the latter patients (P < .01). The data therefore indicate that not only the initial or the highest lactate value but also the duration of hyperlactatemia can be correlated with the development of organ failure. These observations stress the importance of the initial resuscitation in the prevention of organ failure. Serial blood lactate measurements are reliable indicators of morbidity and mortality after trauma.

Blood interleukin 10 levels parallel the severity of septic shock

PURPOSE The aim of this study was to investigate the relation between interleukin (IL) 10, tumor necrosis factor alpha (TNF alpha), IL-1, and IL-6 levels in patients with septic shock and relate these cytokine levels to the development of organ failure. PATIENTS AND METHODS In 11 patients with septic shock of recent onset, blood was sampled for determinations of TNF, IL-1, IL-6, and IL-10. The degree of organ failure was scored for four organ systems (respiratory, hepatic, renal, hematologic) in the first 48 hours of the study. RESULTS The APACHE II score was 21 +/- 4. Three patients died. IL-10 levels were directly correlated with TNF levels (r = 0.73, P < .05) and IL-6 levels (r = 0.67, P < .05); and inversely correlated with total C3 (r = -0.73, P < .05) and CH50 (r = -0.68, P < .05). Both IL-10 and TNF levels were correlated to the organ failure score (r = 0.75 and r = 0.68, both P < .01). Six patients with high IL-10 levels (> 60 pg/mL) had lower C3 (37 +/- 11 v 62 +/- 10 mg/dL) and CH50 (32 +/- 7 v 68 +/- 19%), and higher organ failure scores (5.7 +/- 0.8 v 3.8 +/- 1.3) than those with low IL-10 levels (all P < .05). CONCLUSION Although IL-10 has an inhibitory effect on the production of cytokines, it is released together with TNF and IL-6 in patients with septic shock. IL-10 blood levels are directly related to the severity of inflammation and the development of organ failure in septic shock.

Administration of an antibody to E-selectin in patients with septic shock.

OBJECTIVES To determine the safety and pharmacokinetics of a murine monoclonal antibody to E-selectin in patients with newly developed septic shock. DESIGN Open-label, prospective, phase II pilot study with escalating doses of the antibody. SETTING Intensive care unit of a 900-bed university hospital. PATIENTS Nine patients who survived the first 24 hrs of septic shock. INTERVENTIONS In addition to standard therapy, an intravenous bolus of a murine monoclonal antibody to E-selectin, CY1787, was given at doses of 0.1 mg/kg (n = 3), 0.33 mg/kg (n = 3), and 1.0 mg/kg (n = 3). MEASUREMENTS AND MAIN RESULTS CY1787 was well tolerated in all patients. Signs of shock resolved in all patients, and organ failure entirely reversed in eight patients. All patients survived the 28-day follow-up. Administration of CY1787 was associated with an early and brisk increase in PaO2/FIO2 ratio (p < .001), from 146 +/- 38 mm Hg (19.5 +/- 5.1 kPa) to 205 +/- 45 mm Hg (27.3 +/- 6.0 kPa) after 2 hrs, and 250 +/- 58 mm Hg (33.3 +/- 7.7 kPa) after 12 hrs. A dose-related effect of CY1787 was suggested by an earlier weaning from catecholamine therapy and a faster resolution of organ failure in the high-dose group. Development of antimouse antibodies was documented in eight patients. CONCLUSIONS This pilot study indicates that this antibody to E-selectin appears to be safe and may represent a promising form of therapy in septic shock.

Correction of hypocalcaemia in the critically ill: What is the haemodynamic benefit?

ObjectiveThe prevalence of hypocalcaemia is known to be elevated in critically ill patients, but the expected benefit from calcium repletion in hypocalcaemic patients has not been well defined. The objective of the present study was therefore prospective determination of the cardiovascular response to calcium administration in critically ill patients with hypocalcaemia.PatientsA total of 17 patients found to have ionized hypocalcaemia (Ca2+<1.05 mmol/l) from a group of 32 patients who were invasively monitored as part of their ICU management.InterventionSlow intravenous injection of 1 g of calcium chloride.Measurements and resultsCaclium administration was followed by an increase in mean arterial pressure from 77±8 to 90±12 mmHg (P<0.01). There was no significant change in cardiac filling pressures or heart rate. Cardiac index and systemic vascular resistance increased slightly but not significantly (from 2.67±0.92 to 2.81±1.25 l/ min·m2 and from 2133±647 to 2378±817 dynes·s·cm−5m−2, respectively). Left ventricular stroke work index increased from 23±8 to 32±13 g·m/m2 (P<0.01). These changes were maintained for 60 min.ConclusionsThe correction of hypocalcaemia can result in a significant increase in arterial pressure that can persist for at least 1 h. Despite an associated improvement in left ventricular function, cardiac index and oxygen delivery do not increase significantly.

Hemodynamic effects of 6% and 10% hydroxyethyl starch solutions versus 4% albumin solution in septic patients

STUDY OBJECTIVE To compare the hemodynamic effects of two different concentrations of pentastarch hydroxyethyl starch (HES; 200/0.5) solutions with a 4% human albumin solution for fluid resuscitation. DESIGN Open-label, randomized, controlled study. SETTING Medical-surgical intensive care unit. PATIENTS 34 consecutive, hemodynamically stable, adult patients with sepsis and suspected hypovolemia. INTERVENTIONS Patients received a 400 mL infusion of either 10% HES (n = 11), 6% HES (n = 10), or 4% albumin (n = 13) over 40 minutes. MEASUREMENTS Hemodynamic and blood data were collected 40, 70, 100, and 160 minutes after the start of the fluid challenge. MAIN RESULTS Cardiac index, stroke volume index, and left ventricular stroke work index increased more in the 10% HES group than the 6% HES or albumin groups (P < 0.05). Oxygen delivery increased only in the 10% HES group. A decrease in hemoglobin concentration occurred in all three groups but was greatest in the 10% HES group. CONCLUSIONS HES is as effective as albumin for volume resuscitation in septic patients.

Calcium administration for cardiovascular support in critically ill patients: When is it indicated?

Calcium has a fundamental role in the maintenance of myocardial function and vascular tone. The ionized form of calcium is the most important physiologically, and this form needs to be measured to assess physiologically active calcium levels. Ionized hypocalcemia can occur as a result of various pathophysiological disturbances, and it is seen frequently in critically ill patients. Several investigators have observed a poorer prognosis in those patients with ionized hypocalcemia. It is unclear whether calcium supplementation is beneficial in these patients. It may improve cardiovascular performance, but, in contrast, it may contribute to cellular damage (especially during hypoxia following cardiopulmonary resuscitation). In sepsis, there may be an increased cellular influx of calcium, which may be deleterious to cellular function; indeed, calcium entry blockers in this situation may be protective. We review the role of calcium as an inotropic agent, its interaction with other inotropic agents, and its use during blood transfusion and during cardiopulmonary resuscitation.

Why should ionized calcium be determined in acutely ill patients

Three forms of calcium are found in the blood: the protein bound form, the chelated form and the ionized form. Of these, the ionized form (Ca2’) is the most important physiologically and is essential to many cellular reactions. In a normocalcaemic subject, Ca” levels of 1.05 to 1.25 mmol/L are maintained by a complex interplay between vitamin D, parathormone, and calcitonin hormone systems. Of particular relevance to the physician in the intensive care unit (ICU) is the fundamental role of Ca2+ in the maintenance of haemodynamic status. In particular, Ca” influences arterial pressure and systemic vascular resistance and hence plays a fundamental role in the regulation of microvascular tone. Calcium ions are also essential to the maintenance of myocardial contractility. Ionized hypocalcaemia is often a factor of poor prognosis and has been correlated with increased incidence of sepsis, longer duration of stay in ICU and increased mortality rates (1-3). Severe hypocalcaemia. that is less than 40 to 50% of the normal, can result in reduced ventricular contractility, bradycardia, impaired vascular tone and decreased arterial pressure. The exact balance between hypocalcaemia as a cause and hypocalcaemia as a consequence in such cases is not always clear (4). Whilst hypocalcaemia can be detrimental, too much calcium can also be injurious. Hypercalcaemia has been associated with cell death (particularly during reperfusion), synergistical enhancement of digoxin-related cardiac damage, and diminution of the effects of adrenergic agents.