[Show abstract][Hide abstract] ABSTRACT: In critically ill children, in-line microfilters may reduce the incidence of the systemic inflammatory response syndrome (SIRS), the overall complication and organ dysfunction rate. No data on the use of in-line microfilters exist in critically ill adults.
In this prospective, randomized, controlled open-label study, we evaluated the influence of in-line microfilters on systemic immune activation in 504 critically ill adults with a central venous catheter in place and an expected length of stay in the intensive care unit >24 h. Patients were randomized to have in-line microfilters placed into all intravenous lines (intervention group) or usual care (control group). The primary endpoint was the number of intensive care unit days with SIRS. Secondary endpoints were the incidence of SIRS, SIRS criteria per day, duration of invasive mechanical ventilation, intensive care unit length of stay, the incidence of acute lung injury, maximum C-reactive protein, maximum white blood cell count, incidence of new candida and/or central-line-associated bloodstream infections, incidence of new thromboembolic complications, cumulative insulin requirements and presence of hyper- or hypoglycemia.
The study groups did not differ in any baseline variable. There was no difference in the number of days in the intensive care unit with SIRS between microfilter and control patients [2 (0.8–4.7) vs. 1.8 (0.7–4.4), p = 0.62]. Except for a higher incidence of SIRS in microfilter patients (99.6 vs. 96.8 %, p = 0.04), no difference between the groups was observed in any secondary outcome parameter. Results did not change when only patients with an intensive care unit length of stay of greater than 7 days were included in the analysis. The rate of adverse events was comparable between microfilter and control patients. In two patients allocated to the microfilter group, the study intervention was discontinued for technical reasons. Use of in-line microfilters was associated with additional costs.
The use of in-line microfilters failed to modulate systemic inflammation and clinical outcome parameters in critically ill adults.
Trial registration: Clinical Trials NCT01534390
Annals of Intensive Care 11/2015; 5(1):36. DOI:10.1186/s13613-015-0080-x · 3.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The use of ECMO to stabilize critically ill patients with severely depressed cardiac function and hemodynamics increased in the last years due to broader availability, better performance and easier implantation of the devices. The present guidelines of the Austrian Society of Cardiology focus on the use of ECMO in adult non-operated patients with cardiac diseases. Not only indications and contraindications are highlighted, but also the equally important issues of monitoring, complication management, measures during implantation and operation, and weaning of the devices are treated in detail. Thereby the present guidelines aim to optimize the use of ECMO in the individual centers, and aim to help current non-ECMO centers in developing a local ECMO-program or to contact ECMO-centers for discussion of individual patients.
Wiener klinische Wochenschrift 03/2015; 110(6). DOI:10.1007/s00508-015-0743-5 · 0.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Miosis occurs following exposure to toxins that decrease the sympathomimetic tone, increase the cholinergic tone, or exert sedative-hypnotic effects, but has not been reported in insulin poisoning.
A 64-year- old woman without co-morbidities was found unconscious next to an empty insulin pen. Her Glasgow Coma Scale was 3 with absent reflexes, bilateral reactive miosis, and injection marks across the abdominal wall. The patient was endotracheally intubated, mechanically ventilated, and transferred to this hospital. At admission, the blood glucose level was 34 mg/dL. Glasgow Coma Scale remained at 3, with persistent bilateral reactive miosis. The toxicology screening was negative for ethanol, barbiturates, tricyclic antidepressants, phenothiazines, amphetamines, cannabinoids, salicylates, acetaminophen, and cocaine. Cranial computed tomography with angiography and magnetic resonance imaging (MRI) did not show any structural brain lesions. Intravenous glucose was continued at 6-14 g/h for 3 days. On repeated neurological examinations, the patient remained deeply comatose, with partial loss of cranial nerve function. Bilateral reactive miosis persisted for 4 days. From day 5 on, the patient awoke progressively. At discharge, the patient was fully alert and orientated, without a focal neurological deficit.
Prolonged bilateral reactive miosis can be a clinical symptom accompanying metabolic encephalopathy in severe insulin poisoning. Functional impairment of the pons due to relative hypoperfusion during hypoglycemia may serve as a reasonable pathophysiologic explanation for this phenomenon.
American Journal of Case Reports 01/2015; 16:1-3. DOI:10.12659/AJCR.892324
[Show abstract][Hide abstract] ABSTRACT: IntroductionLiberal and over-aggressive use of vasopressors during the initial period of shock resuscitation may compromise organ perfusion and worsen outcome. When transiently applying the concept of permissive hypotension it would be helpful to know at which arterial blood pressure terminal cardiovascular collapse occurs.Methods
In this retrospective cohort study, we aimed to identify the arterial blood pressure associated with terminal cardiovascular collapse in 140 patients who died in the intensive care unit while being invasively monitored. Demographic data, co-morbid conditions and clinical data at admission, during 24 hours before and at the time of terminal cardiovascular collapse were collected. The systolic, mean and diastolic arterial blood pressure immediately before terminal cardiovascular collapse was documented. Terminal cardiovascular collapse was defined as an abrupt (<5 min) and exponential decrease in heart rate (>50% compared to preceding values) followed by cardiac arrest.ResultsThe mean¿±¿standard deviation (SD) of the systolic, mean and diastolic arterial blood pressure associated with terminal cardiovascular collapse was 47¿±¿12, 35¿±¿11 and 29¿±¿9 mmHg. Patients with congestive heart failure (39¿±¿13 versus 34¿±¿10 mmHg; P¿=¿0.04), left main stem stenosis (39¿±¿11 versus 34¿±¿11 mmHg; P¿=¿0.03) or acute right heart failure (39¿±¿13 versus 34¿±¿10 mmHg; P¿=¿0.03) had higher arterial blood pressures than patients without these risk factors. Patients with severe valvular aortic stenosis had the highest arterial blood pressures associated with terminal cardiovascular collapse (systolic, 60¿±¿20; mean, 46¿±¿12; diastolic, 36¿±¿10 mmHg), but this difference was not significant. Sepsis patients and patients exposed to sedatives or opioids during the terminal phase exhibited lower arterial blood pressures than patients without sepsis or administration of such drugs.Conclusions
The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients was very low and varied with individual co-morbid conditions (for example congestive heart failure, left main stem stenosis, severe valvular aortic stenosis, acute right heart failure), drug exposition (for example sedatives or opioids) and the type of acute illness (for example sepsis).
[Show abstract][Hide abstract] ABSTRACT: Hemodialysis is considered the renal replacement technique of choice to control life-threatening hypercalcemia. In this case series, the experience with continuous veno-venous hemodiafiltration (CVVHDF) with regional citrate anticoagulation to control five hypercalcemic crises in four patients is summarized. Overall maximum ionized and total calcium levels were ranged from 1.72-2.01 mmol/L and 3.1-4.2 mmol/L, respectively. All patients presented with impaired consciousness, cardiac arrhythmias and/or acute oliguria despite therapy. Trisodium-citrate was administered at 3 mmol/h (hourly calcium replacement 1.15-2.75 mmol). This allowed a controlled decrease of ionized calcium levels below 1.4 mmol/L within 4 hours (IQR, 2.5-10) and resolution of neurological symptoms within 15.5 hours (IQR, 12-22.8). The duration of CVVHDF was one day in those patients in whom hypercalcemia was the reason for admission. Four asymptomatic episodes of mild hypocalcemia occurred in two patients. No patient developed relevant abnormalities of serum sodium levels or pH, experienced cardiac arrhythmia or required transfusion of blood products during CVVHDF. One patient with metastatic bronchial carcinoma experienced rebound hypercalcemic crisis thirteen days following a one day session of CVVHDF with regional citrate anticoagulation.In conclusion, CVVHDF with regional citrate anticoagulation appears to be effective and potentially safe to rapidly normalize calcium levels in hypercalcemic crisis.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 12/2014; 61(2). DOI:10.1097/MAT.0000000000000186 · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To the Editor,A 44-year-old man (185 cm, 80 kg) was mechanically ventilated and referred to a university hospital because of severe pneumonia-associated acute respiratory distress syndrome (ARDS; Fig. 1a). A few hours after intensive care unit admission, veno-venous extracorporeal membrane oxygenation (ECMO; outflow cannula—23 Fr: right femoral vein; inflow cannula—19 Fr: right internal jugular vein) had to be initiated because of refractory hypoxemia (PaO2, 53 mmHg) and hypercapnia (PaCO2, 144 mmHg) regardless of invasive ventilator settings (biphasic positive airway pressure with inspiratory oxygen concentration, 100 %; positive end-expiratory pressure, 15 mbar; peak pressure, 36 mbar; respiratory rate, 32 bpm). To hasten lung recruitment, the decision was made to put the patient into the prone position. However, full prone position led to compression of lines at their insertion site by the patient's weight, compromised extracorporeal blood flow and lowered the efficacy of ECMO thera ...
Wiener klinische Wochenschrift 12/2014; 127(3-4). DOI:10.1007/s00508-014-0645-y · 0.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Perioperative fluid management plays a fundamental role in maintaining organ perfusion, and is considered to affect morbidity and mortality. Targets according to which fluid therapy should be administered are poorly defined. This systematic review aimed to identify specific targets for perioperative fluid therapy. The PubMed database (January 1993-December 2013) and reference lists were searched to identify clinical trials which evaluated specific targets of perioperative fluid therapy and reported clinically relevant perioperative endpoints in adult patients. Only studies in which targeted fluid therapy was the sole intervention were included into the main data analysis. A pooled data analysis was used to compare mortality between goal-directed fluid therapy and control interventions. Thirty-six clinical studies were selected. Sixteen studies including 1224 patients specifically evaluated targeted fluid therapy and were included into the main data analysis. Three specific targets for perioperative fluid therapy were identified: a systolic or pulse pressure variation <10-12%, an increase in stroke volume <10%, and a corrected flow time of 0.35-0.4 s in combination with an increase in stroke volume <10%. Targeting any one of these goals resulted in less postoperative complications (pooled data analysis: OR 0.53; CI95, 0.34-0.83; P=0.005) and a shorter length of intensive care unit/hospital stay, but no difference in postoperative mortality (pooled data analysis: OR 0.61; CI95, 0.33-1.11; P=0.12). This systematic review identified three goals for perioperative fluid administration, targeting of which appeared to be associated with less postoperative complications and shorter intensive care unit/hospital lengths of stay. Perioperative mortality remained unaffected.
[Show abstract][Hide abstract] ABSTRACT: Restoration of adequate tissue perfusion is the goal of resuscitation in septic shock. A growing understanding of microcirculatory dysfunction in sepsis led to a change in resuscitation practice away from targeting arterial and central venous pressures and towards tissue perfusion-guided protocols. This change in the approach to resuscitation was accompanied by a change in the role of vasoconstrictors. This review summarizes the pathophysiological and therapeutic mainstays of septic shock resuscitation and attempts to critically evaluate the scientific evidence on the use of vasopressin as a non-adrenergic vasoconstrictor in septic shock. Based on the published study results vasopressin appears to be of potential benefit in adult patients with moderate septic shock (norepinephrine requirements < 15 μg/min) and lacking signs of systemic hypoperfusion (e.g. normal arterial lactate levels). A vasopressin infusion with the sole target to increase arterial blood pressure despite the presence of systemic hypoperfusion is dangerous and can result in a critical deterioration of tissue perfusion.
Der Anaesthesist 05/2014; 63(6). DOI:10.1007/s00101-014-2335-6 · 0.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Dermatomyositis is a chronic inflammatory disorder characterized by muscular and dermatologic symptoms with variable internal organ involvement. This is the first report on a patient with acute dermatomyositis and fulminant systemic capillary leak syndrome.
A 69-year-old Caucasian woman with chronic dermatomyositis presented with clinical signs of severe hypovolemic shock and pronounced hemoconcentration (hematocrit, 69%). Her colloid osmotic pressure was 4.6mmHg. Following a bolus dose of prednisolone (500mg), fluid resuscitation was initiated. During volume loading, anasarca and acute respiratory distress rapidly developed. Echocardiography revealed an underfilled, hypokinetic, diastolic dysfunctional left ventricle with pericardial effusion but no signs of tamponade. Despite continued fluid resuscitation and high-dosed catecholamine therapy, the patient died from refractory shock 12 hours after intensive care unit admission. A laboratory analysis of her complement system suggested the presence of C1 inhibitor deficiency as the cause for systemic capillary leakage. The post-mortem examination revealed bilateral pleural, pericardial and peritoneal effusions as well as left ventricular hypertrophy with patchy myocardial fibrosis. Different patterns of endomysial/perimysial lymphocytic infiltrations adjacent to degenerated cardiomyocytes in her myocardium and necrotic muscle fibers in her right psoas major muscle were found in the histological examination.
This case report indicates that acute exacerbation of chronic dermatomyositis can result in a fulminant systemic capillary leak syndrome with intense hemoconcentration, hypovolemic shock and acute heart failure. In the presented patient, the cause for diffuse capillary leakage was most probably acquired angioedema, a condition that has been associated with both lymphoproliferative and autoimmunologic disorders.
Journal of Medical Case Reports 01/2014; 8(1):28. DOI:10.1186/1752-1947-8-28
[Show abstract][Hide abstract] ABSTRACT: Ventricular torsion is an important component of cardiac function. The effect of septic shock on left ventricular torsion is not known. Because torsion is influenced by changes in preload, we compared the effect of fluid loading on left ventricular torsion in septic shock with the response in matched healthy control subjects.
We assessed left ventricular torsion parameters using transthoracic echocardiography in 11 patients during early septic shock and in 11 age- and sex-matched healthy volunteers before and after rapid volume loading with 250 mL of a Ringer's lactate solution.
Peak torsion and peak apical rotation were reduced in septic shock (10.2 ± 5.2° and 5.6 ± 5.4°) compared with healthy volunteers (16.3 ± 4.5° and 9.6 ± 1.5°; P = 0.009 and P = 0.006 respectively). Basal rotation was delayed and diastolic untwisting velocity reached its maximum later during diastole in septic shock patients than in healthy volunteers (104 ± 16% vs 111 ± 14% and 13 ± 5% vs 21 ± 10%; P = 0.03 and P = 0.034, respectively). Fluid challenge increased peak torsion in both groups (septic shock, 10.2 ± 5.3° vs 12.6 ± 3.9°; healthy volunteers, 16.3 ± 4.5° vs 18.1 ± 6°; P = 0.01). Fluid challenge increased left ventricular stroke volume in septic shock patients (P = 0.003).
Compared with healthy volunteers, left ventricular torsion is impaired in septic shock patients. Fluid loading attenuates torsion abnormalities in parallel with increasing stroke volume. Reduced torsional motion might constitute a relevant component of septic cardiomyopathy, a notion that merits further testing in larger populations.
The Canadian journal of cardiology 12/2013; 29(12):1665-1671. DOI:10.1016/j.cjca.2013.10.007 · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Definitions of shock and resuscitation endpoints traditionally focus on blood pressures and cardiac output. This carries a high risk of overemphasizing systemic hemodynamics at the cost of tissue perfusion. In line with novel shock definitions and evidence of the lack of a correlation between macro- and microcirculation in shock, we recommend that macrocirculatory resuscitation endpoints, particularly arterial and central venous pressure as well as cardiac output, be reconsidered. In this viewpoint article, we propose a three-step approach of resuscitation endpoints in shock of all origins. This approach targets only a minimum individual and context-sensitive mean arterial blood pressure (for example, 45 to 50 mm Hg) to preserve heart and brain perfusion. Further resuscitation is exclusively guided by endpoints of tissue perfusion irrespectively of the presence of arterial hypotension ('permissive hypotension'). Finally, optimization of individual tissue (for example, renal) perfusion is targeted. Prospective clinical studies are necessary to confirm the postulated benefits of targeting these resuscitation endpoints.