Z. Molnar

Microalbuminuria does not reflect increased systemic capillary permeability in septic shock

ObjectiveTo investigate the correlation between microalbuminuria and extravascular lung water in patients in septic shock who require mechanical ventilation for severe respiratory failure.Design and settingProspective, observational, clinical study in the 20-bed intensive care unit of a university hospital.Patients and participants25 consecutive patients in septic shock and also in severe respiratory failure requiring mechanical ventilation.InterventionsHemodynamic parameters and extravascular lung water were determined by single arterial thermodilution. Together with each hemodynamic measurement the PaO2/FIO2 ratio and urinary microalbumin to creatinine ratio (M:Cr) was measured. Serum C-reactive protein (CRP) and procalcitonin (PCT) levels were also determined daily.Measurements and resultsThe EVLW index was significantly higher than normal throughout the study. Microalbuminuria was in the normal range on entry and remained so for the rest of the study period. Serum PCT and CRP levels were significantly higher than normal at every assessment points. No significant correlation was found between M:Cr and either EVLW or PaO2/FIO2 .ConclusionsIn this study patients in septic shock with significantly elevated EVLW had normal urinary M:Cr, and there was no correlation between M:Cr and EWLV, and PaO2/FIO2. Therefore based on the current results routine measurements of microalbuminuria to determine endothelial permeability cannot be recommended in critically ill patients.

The effect of N-acetylcysteine on total serum anti-oxidant potential and urinary albumin excretion in critically ill patients

AbstractObjective: To investigate the effects of N-acetylcysteine (NAC) when given as an early treatment to critically ill patients on the serum total anti-oxidant potential (TAP) and urine micro-albumin : creatinine (M : Cr) ratio. Design: Prospective, placebo controlled, double blinded clinical trial. Setting: General intensive care unit in a teaching hospital. Patients: Sixty critically ill patients were recruited but ten were withdrawn due to less than 48 h of ICU stay. Interventions: After envelope randomisation, patients received either NAC (n=23): a bolus of 150 mg/kg in 250 ml of 5 % dextrose followed by a continuous infusion of 12 mg/kg per h in 500 ml of 5 % dextrose over 24 h or, as controls (n= 27), the equal volume of placebo. Treatment lasted for a minimum of 3, up to a maximum of 5, days. Blood and urine samples were collected on admission (0 h) and then 6 hourly up 18 h. Measurements and results: There was no significant difference between NAC and placebo groups regarding the required length of inotropic support, mechanical ventilation and ICU stay. There was no significant difference in TAP or M : Cr ratio over 18 h or between the groups. Conclusions: Our results suggest that NAC had no significant effects on the progress of the TAP and the urinary albumin excretion in our patients, which may suggest that NAC at the given dose has no clinical relevance as an early treatment in the critically ill.

Increased glomerular permeability and pulmonary dysfunction following major surgery: correlation of microalbuminuria and PaO2/FiO2 ratio

Background:  The aim of our trial was to evaluate the ability of microalbuminuria as an indicator of outcome and to investigate its relationship with the postoperative respiratory dysfunction in the initial postoperative period in a high‐risk patient group.

Serum procalcitonin level and leukocyte antisedimentation rate as early predictors of respiratory dysfunction after oesophageal tumour resection.

IntroductionPostoperative care after oesophageal tumour resection holds a high risk of respiratory complications. We therefore aimed to determine the value of systemic inflammatory markers in predicting arterial hypoxaemia as the earliest sign of developing lung injury after oesophageal tumour resection.MethodsIn a prospective observational study, 33 consecutive patients were observed for three days (T1–T3) after admission (T0) to an intensive care unit following oesophageal tumour resection. The daily highest values of the heart rate, axillary temperature, leukocyte count and PaCO2 were recorded. Serum C-reactive protein and procalcitonin concentrations and the leukocyte antisedimentation rate (LAR) were determined at T1 and T2. Respiratory function was monitored 6-hourly measurement of the PaO2/FIO2 ratio, and the lowest value was recorded at T3. Patients were categorised as normoxaemic or hypoxaemic using the cutoff value of 300 mmHg for PaO2/FIO2.ResultsSeventeen out of 33 patients were classified as hypoxaemic and 16 patients as normoxaemic at T3. Increases of temperature at T0 and of the procalcitonin and LAR values at T2 were predictive of hypoxaemia at T3 (P < 0.05, P < 0.01 and P < 0.001, respectively). The area under the receiver-operating characteristic curve was 0.65 for the temperature at T0, which was significantly lower than that for the procalcitonin level at T2 (0.83; 95% confidence interval, 0.69–0.97; P < 0.01) and that for LAR at T2 (0.89; 95% confidence interval, 0.77–1.00; P < 0.001).ConclusionThese results suggest that an elevated LAR (>15%) and an elevated procalcitonin concentration (>2.5 ng/ml) measured on the second postoperative day can predict next-day arterial hypoxaemia (PaO2/FIO2 < 300 mmHg) after oesophageal tumour resection.

Effect of Intravenous N-acetylcysteine in Acute Respiratory Distress Syndrome: A Systematic Review and Meta-analysis [Abstract]

J.R. Masclans, A. Rodriguez, E. Guerrero, J. Bonastre, L. Vidaur, J. Almirall, L. Cordero, B. Gil Rueda, I. Jimenez, M. Martı́n, A. Arenzana, J. Pozo, S. Ruı́z-Santana, J. Vallés, J. Sirvent, L. Lorente, P. Luque, L. Figueira, J. Nava, A. Jareño, C. Hermosa, A. Marques, F. Mariscal, R. Zaragoza, A. Loza, J. Rello, H1N1 SEMICYUC Working Group Hospital Universitario Vall d’Hebron, Barcelona, Spain, Hospital Joan XXIII/CIBER Enfermedades Respiratorias/IISPV, Tarragona, Spain, Hospital Gregorio Marañon, Madrid, Spain, Hospital La Fe, Valencia, Spain, Hospital Donostia, S Sebastian, Spain, H.Mataro, Mataro, Spain, CHUAC, A Coruña, Spain, Hospital Morales Meseguer, Murcia, Spain, Hospital Virgen del Camino, Navarra, Spain, Hospital La Candelaria, Tenerife, Spain, Hospital de la Macarena, Sevilla, Spain, Hospital Reina Sofı́a, Córdoba, Spain, Hospital Dr. Negrı́n, Las Palmas, Spain, Hospital Parc Taulı́/CIBER Enfermedades Respiratorias, Sabadell, Spain, Hospital Trueta/ CIBER Enfermedades Respiratorias, Girona, Spain, Hospital Universitario de Canarias, Tenerife, Spain, Hospital Lozano Blesa, Aragón, Spain, Hospital La Paz, Madrid, Spain, Hospital Mútua Terrassa, Terrassa, Spain, Hospital SAS, Jerez, Spain, Hospital de Henares, Madrid, Spain, Hospital de la Ribera, Valencia, Spain, Hospital Infanta Sofı́a, Madrid, Spain, Hospital Dr. Peset, Valencia, Spain, Hospital NS Valme, Sevilla, Spain, Hospital Universitario Vall d’Hebron/CIBER Enfermedades Respiratorias, Barcelona, Spain INTRODUCTION AND OBJECTIVES. It remains controversial the role of non invasive ventilation (NIV) in patients with acute respiratory failure. The objective of this study was to evaluate the usefulness and effectiveness of NIV to manage influenza A (H1N1) respiratory failure in Spanish ICUs. METHODS. Prospective, observational, multicenter study in 144 Spanish ICUs. Data were obtained from GTEI/ SEMICYUC register (June 15 and December 31, 2009). All adult patients with influenza A (H1N1) confirmed by rt-PCR were included and only patients treated with NIV were considered in the analysis. We evaluated the use and failure of NIV, as well as demographic data, comorbidities and severity scores. The analysis (SPSS 18.0, Inc. Chicago, IL) was performed using Chi square or Fisher exact tests for categorical variables and Student or Mann– Whitney tests for continuous variables. Significant variables from univariate analysis were included in the multivariate model (logistic regression). Differences of p \ 0.05 were considered statistically significant. RESULTS. Among 938 patients registered in the GTEI/SEMICYUC, 632 (67.4%) had completed their ICU admission and was the source of this analysis. Of the 449 (71%) who received mechanical ventilation, 157 (24.8%) were treated with NIV. NIV failed in 92 patients (58.6%) and they had to be subsequently intubated (control group = IT). Sixty-five (41.4%) patients responded to NIV (study group = NIV). The IT group had a higher APACHE II (16.1 ± 7.3 vs. 11.9 ± 6.0, p \ 0.01) and SOFA (7.1 ± 3.8 vs. 4.2 ± 2.8 p \ 0.01) compared to the NIV group. No significant differences in age, comorbidities and LDH levels were observed. Time from onset of symptoms to hospitalization (4.2 vs. 4.1 days) or ICU admission (1.0 vs. 1.0 days) was similar between groups. Shock occurred more frequently in the IT (66.1 vs. 15.6%, p \ 0.01), and they also had more quadrants affected in the thorax X-ray (2.6 ± 1.1 vs. 1.9 ± 1.3, p \ 0.01). Pneumonia (viral and bacterial) was more frequent in the IT (87.0% vs. 72.3%, p \ 0.05) whereas COPD exacerbation was similar (4.9 vs. 10.9%, p = 0.11). The presence of shock (OR = 3.0 95% CI 1.61–5.69, p \ 0.01) and pneumonia (OR = 1.2 95% CI 1.01–1.58, p \ 0.05) were independently associated with NIV failure in the multivariate analysis. Mortality was significantly higher in IT compared to NIV (35.2 vs. 4.7%, p \ 0.01). CONCLUSIONS. NIV is not recommended as an alternative to invasive ventilation in patients affected by influenza A(H1N1) virus pneumonia with severe multiorganic failure or shock. In spite of this, selected patients with mild acute respiratory failure might benefit from this alternative therapy.