VM Ranieri, PM Suter, C Tortorella, et al (Universita di Bari, Italy; Universite de Geneva, Switzerland; Univ of Toronto, Canada)
Effect of Mechanical Ventilation on Inflammatory Mediators in Pateints with Acute Respiratory Distress Syndrome : A Randomized Controller Trial
JAMA 282: 54-61, 1999
Mechanical ventilation can escalate or cause an inflammatory response and acute lung injury. The influence of mechanical ventilation on the lung and systemic cytokine levels was assessed in patients with acute respiratory distress syndrome in a randomized controlled trial.
This study offers stimulating data in patients with ARDS, showing elevation of multiple cytokines in BAL fluid and plasma in patients treated with conventional ventilator settings, and a decrease in these mediators over a period of time in patients treated with a protection ventilation strategy. Patients in the protective protocol were treated with lower end-expiratory pressures, tidal volumes and fraction of inspired oxygen. The mechanisms by which ventilator-induced injury might be mediated remain uncertain, and clinical trials of lung protective strategies have yielded variable results. However, in this study, Ranieri and colleagues offer striking evidence for the link between mechanical ventilation and acute inflammatory lung injury, and the potential for benefit by limiting lung distention.
Goldhaber SZ [Harvard Med school]
N. Engl J Med 339 : 93-104, 1998
The best approach to diagnosis of pulmonary embolism is a careful history and physical examination with selective testing as indicated.
Dyspnea is the major symptom.
Tachypnea is the major sign.
A massive embolism is suspected in patients with Dyspnea, Syncope or cyanosis whereas with pleuritic pain, cough or hemoptysis are more likely to have a small embolism near the pleura.
To rule out acute pulmonary embolism perfusion lung scanning is still the most important test.
Main stage of treatment is heparin.
Unless contraindicated, patient should receive intensive heparin anticoagulation usually 5000 to 10000 units bolus followed by continuous infusion at a rate of 18 units per kg per hour; which should be given during the diagnostic working. This usually produces a therapeutic partial thromboplastin time of 60 to 80 seconds. Patients with venous thrombosis associated with metastatic cancer may receive short or long term heparin therapy to prevent recurrent thrombosis.
Once a patient has reached a therapeutic partial thromboplastin time – it is usually safe to start warfarin therapy, although at least 5 days of continuous intravenous heparin is recommended to achieve true anticoagulation. Anticoagulation should continue preferably for 6 months and not 6 weeks to prevent recurrences.
Current understanding of the importance of the right ventricular dysfunction enables more accurate prognosis in patients with pulmonary embolism. Finally, the take home message is that surgeons should have a low threshold to evaluate seemingly minor post operative complications viz, fever, tachycardia because many of these patients have small pulmonary embolism that are effectively treated by aggressive anticoagulation.
Heyland DK, for the Canadian Critical Care Trials Group [Queens Univ, Kingston, Ont, Canada; et al]
The Clinical Utility of Invasive Diagnostic Techniques in the Setting of Ventilator – Associated Pneumonia
Chest 115: 1076-1084, 1999
Ventricular-associated pneumonia [VAP] is often diagnosed on clinical grounds alone and contributes to the morbidity, mortality and costs of caring for critically ill patients. Overdiagnosis may be disastrous with the use of needless antibiotics and the delay in recognition of the true diagnosis.
The utility of invasive investigations like bronchoscopy, with protected brush catheter [PBC] bronchoalveolar lavage [BAL] was evaluated in 92 patients receiving ventilatory support with a clinical suspicion of VAP.
The results showed that VAP was often overdiagnosed after BAL or PBC after these procedures. Patients received fewer antibiotics. Both groups had similar duration of mechanical ventilation and ICU stay. Those who underwent PBC/BAL had a lower mortality.
Invasive diagnostic testing may boost physicians confidence in the diagnosis and management of VAP.
Kristen Moller and Peter Skinhoj (Dept of Infectious Diseases, Denmark)
Guidelines for managing acute bacterial meningitis
BMJ, Vol.320, 13 May 2000, pg.1290
Nearly one in four adults with acute bacterial meningitis will die and many survivors sustain neurological deficits. The outcome has not changed despite potent antibiotics and specialised intensive care units.
Standardised guidelines are issued by British Infection Society. Family doctors may give benzylpenicillin before admission to hospital. After admission to hospital, widely accepted empirical treatment is a third generation cephalosporine, such as cefotaxim or ceftriaxone, with ampicillin if listerial meningitis cannot be ruled out. In patients with obvious meningococcal disease, penicillin is the drug of choice. Pneumococci are less susceptible to penicillin and rifampicin is useful for truly penicillin resistant penumococci. Selection of appropriate treatment for patients who are hypersensitive to beta-lactams is difficult. Meropenem or broad spectrum quinolones may be considered. There is little evidence that they work.
Supportive treatment is debated. Corticosteroids reduce neurological deficit in children with Haemophilus influenzae or broad spectrum quinolones may be considered. There is little evidence that they work.
Corticosteroids reduce neurological deficit in children with haemophilus influenzae, but evidence in adults is lacking. Glycerol or mannitol if there is intracranial hypertension, full fluid replacement is necessary.
Speedy diagnosis and treatment will serve patients well.
J Briegel, H Forst, M Haller, et al (Ludwig-Maximilians-Universitat Munchen, Munich)
Stress Doses of Hydrocortisone Reverse Hyperdynamic Septic Shock: A Prospective, Randomized, Double-blind, Single-center Study.
Crit Care Med 27:723-732, 1999.
Past studies have showed that stress doses of hydrocortisone were ineffective in septic shock. However, recent studies have shown that a patient in septic shock may have relative adrenocortical insufficiency.
In septic shock, a 100mg loading dose of hydrocortisone was given within 30 min, and followed by an infusion of (0.18mg/kg/hr) hydrocortisone. After reversal of shock, the dose was reduced to 0.08mg/kg/hr and continued for 6 days.
This significantly reduces the duration of vasopressor support and may shorten the time for resolution of sepsis induced organ dysfunction.
MB Malay, Jr Ashton RC, DW Landry, et al (Allegheny Gen Hosp, Pittsburgh, Pa; Columbia, Univ, New York)
Low-Dose Vasopressin in the Treatment of Vasodilatory Septic Shock
J Trauma 47: 699-705, 1999.
Refractory hypotension not responding to epinephrine in septic shock is potentially fatal. It has been suggested that asopressin used concomitantly could give better results.
The vasopressor was infused at a rate of 0.04U/min. This permitted maintenance of arterial pressure thus allowing withdrawal of vasopressors.
MWA Angstwurm, J Schottdorf, J Schopohl, et la (Univ of Munich, Germany)
Selenium Replacement in Patients with Severe Systemic Inflammatory Response Syndrome Improves Clinical Outcome.
Crit Care Med 27: 1807-1813, 1999.
Systemic inflammatory response syndrome (SIRS) causes substantial morbidity and mortality. It has also been recorded that selenium concentrations are reduced in SIRS. This is a pilot study on the effects of selenium replacement on SIRS related morbidity and mortality.
Selenium was replaced as i.v. sodium selenite in a decreasing dosage over a period of 10 days.
Within 30 days, patients had normal selenium and glutathione peroxidose levels. There was significant reduction in Acute Physiologic and Chronic Health Evaluation III scores as compared to controls. Only 14% (as against 43% in controls) had renal failure and the mortality was 34% against 54% in the control group.
JE Gadek, and the Enteral Nutrition in ARDS Study Group (Ohio State Univ, Columbus; et al )
Effect of Enteral Feeding with Eicosapentaenoic Acid, g-Linolenic Acid, and Antioxidants in Patients with Acute Respiratory Distress Syndrome.
Crit Care Med 27: 1409-1420, 1999.
Low carbohydrate, high fat nutritional support for ventilated patients reduces demands on the respiratory system and decreases the severity of the inflammatory injury. Animal studies show that diets rich in eicosapentaenoic acid, g-linolenic acid and antioxidants can moderate inflammation. This is a prospective double blind randomized controlled trial (multi-centered) to evaluate the effect of a diet supplemented with EPA, GLA and antioxidants on the clinical outcome of ARDS.
The patients on the test diet required fewer days of ventilatory support in ICU or on supplemental oxygen and had less new organ failure. The infection rates were the same but the test diet patients had fewer adverse events.
VM Ranieri, PM Suter, C Tortorella, et al (Univ of Toronto)
Effect of Mechanical Ventilation on Inflammatory Mediators in Patients with Acute Respiratory Distress Syndrome: A Randomized Controlled Trial.
JAMA 282:54-61, 1999
Mechanical ventilation can escalate or cause an inflammatory response and acute lung injury. The influence of mechanical ventilation on the lung and systemic cytokine release was assessed in patients with ARDS.
Two groups were assessed (1) a control group and (2) a lung protective strategy group.
At baseline physiologic characteristics and cytokine concentrations were similar. But after 24 and 36 hours, there were significant between-group differences in tidal volume, end-inspiratory plateau pressures and PEEP. The lung protective strategy group had significantly better results. It could be concluded that mechanical ventilation can produce a cytokine response that may be diminished by minimising overdistension and recruitment and derecruitment of the lung.
PC Hebert, for the Canadian Critical Care Trials Group (Univ of Ottawa, Canada; et al)
A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care,
N Engl J Med 340: 409-417, 1999.
The optimal transfusion strategy for cirtically ill anaemia patients has not been standardised. A randomised, controlled study was undertaken comparing a restrictive (when Hb <7.0gms/dL) with a liberal approach (when Hb <10gms/dL).
The study was conducted on 838 critically ill patients randomly assigned to one of the two groups.
The overall 30 days mortality was similar. Mortality rates were significantly lower in the restrictive group in less acutely ill patients but was similar in critically ill patients. The mortality during hospitalization was significantly lower in the restrictive group.
S Deb, B Martin, L Sun, et al (Natl Naval Med Ctr, Bethesdam Md; Walter Reed Army Med Ctr, Washington, DC; Uniformed Services Univ of the Health Sciences, Bethesda, Md)
Resuscitation With Lactated Ringer’s Solution in Rats with Hemorrhagic Shock Induces Immediate Apoptosis.
J Trauma: Injury Infect Crit Care 46: 582-589, 1999.
For patients in haemorrhagic shock, reperfusion injury can cause cell damage, leading to cell death and organ failure. Apoptotic cell death is thought to play an important role in the pathophysiology of haemorrhagic shock. The effects of resuscitation with lactated Ringer’s solution on cell apoptosis were assessed.
It was seen that the use of lactated Ringer’s solution for resuscitation caused a significant increase in cell apoptosis in the small intestine and the liver as compared with other agents used for resuscitation.
FA Luchette, BRH Robinson, LA Friend, et al (Univ of Cincinnati, Ohio)
Adrenergic Antagonists Reduce Lactic Acidosis in Response to Hemorrhagic Shock
J Trauma : Injury Infect Crit Care 46: 873-880, 1999.
During haemorrhagic shock, lactic acidosis and plasma catecholamines are significantly increased. The increase in circulating catecholamines have a greater effect on the post haemorrhagic lactic acidosis than do poor perfusion and tissue hypoxia.
The use of a-blockers with a b-blocker significantly reduces plasma lactate levels, but had no effect on tissue perfusion. In an in-vitro study propranolol eliminated the increased lactate production by muscle in response to epinephrine.
The results question the use of lactate clearance as a resuscitation end point for patients with haemorrhagic shock.
E Barquist, E Fein, D Shadick, et al (Univ of Miami, Fla)
A Randomized Prospective Trial of Amphotericin B Lipid Emulsion Versus Dextrose Colloidal Solution in Critically ill Patients.
J Trauma 47: 336-340, 1999.
Amphotericin B is the drug of choice in fungal infections in critically ill patients. However, it carries at least a 50% risk of nephrotoxicity, inspite of preventive measures.
A trial was conducted using a combination of Amphotericin B with 20% intralipid solution in critically ill patients with positive fungal cultures of peritoneum, sputum or blood. The dose was 1mg/kg/d as against 0.5mg/kg/d given to controls (with 5% dextrose).
It was found to have less nephrotoxicity than Amphotericin with Dextrose. It can safely be given at a higher total cumulative dose.
RS Hotchkiss, PE Swanson, CM Knudson, et al (Washington Univ, St Louis)
Overexpression of Bcl-2 in Transgenic Mice Decreases Apoptosis and Improves Survival in Sepsis.
J Immunol 162: 4148-4156, 1999
Sepsis is associated with extensive lymphocyte apoptosis, which may reduce nflammation, but impairs host defences.
The effect of Bcl-2 (a protein product) has been shown to prevent apoptotic cell death. Its effect on lymphocyte apoptosis was studied in a rat model comparing 2 sets. (1) transgenic mice that selectively overexpressed B cl-2 in T lymphocytes as well as in endotoxin resistant species and (2) the endotoxin sensitive species.
The Bcl-2 overexpressors showed complete protection against sepsis induced apoptosis. The protective effect may result from the preservation of mitochondrial membrane potential.
The aim of the study is to assess the influence of preoperative portal vein embolization on the long-term outcome of liver resection for colorectal metastases.
30 patients underwent PVE and 88 patients did not before resection of 4 or more liver segments. The groups were comparable in terms of sex, age, number and type of metastases (synchronous vs metachronous) and number of courses of neoadjuvant chemotherapy.
The main criterion for PVE was that resection was technically feasible but contraindicated because the remnant liver was too small (as estimated by CT scan volumetry). It was done when the estimated rate of remnant functional liver parenchyma (ERRFLP) was 40% or less.
PVE was feasible in all patients. There were no deaths with a complication rate of 3%. The post ERRFLP was significantly increased as compared to pre PVE value. Liver resection was performed in 19 patients (63%) with a mortality of 4% and complication rate of 7%. The survival rates after hepatectomy in both groups were comparable.
The authors conclude that PVE allows more patients with unresectable liver metastases to benefit from surgery.
Lena Gamrin, Pia Essen, Eric Hultman, et al (The Department of Anesthesiology and Intensive Care and Clinical Chemistry II, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden; and the Department of S6urgery at State University of New York,Stony Brook, New York)
Protein-Sparing Effect in Skeletal Muscle of Growth Hormone Treatment in Critically III Patients.
Annals of Surgery, April 2000, 231(4), 577-586.
This study investigates the effect of growth hormone (GH) treatment on skeletal muscle protein catabolism in patients with multiple organ failure in the ICU.
20 critically ill ICU patients were randomized into 2 groups – one as control and the other with GH (0.3U/kg/day). Percutaneous muscle biopsy was taken before and 5 days after treatment starting on day 3 to 42 of the patient’s ICU stay. Protein content, protein synthesis, water nucleic acids and free amino acids were analysed.
The fractional protein synthesis rate and muscle free glutaminic increased in the GH group. Total intramuscular water did not increase but the intracellular water increased.
It is concluded that treatment with GH in patients with multiple organ failure, stimulated muscle protein synthesis, increased muscle free glutaminic and increased into a cellular water.
Byers RJ, Eddleston JM, Pearson RC, et al [Univ of Manchester, Manchester Royal Infirmary, England]
Dopexamine Reduces the Incidence of Acute Inflammation in the Gut Mucosa After Abdominal Surgery in High-risk Patients
Crit Care Med 27: 1787-1793, 1999
About 20% of critically ill patients have acute inflammation in the stomach/duodenum. Dopexamine has dopaminergic receptor agonist properties but no alpha or beta  effects. It may exhibit anti-inflammatory effects. Thus, a study was devised to examine endoscopically and histologically the effect of Dopexamine on gut mucosa. The study represented the side arm of a large, prospective, randomized, controlled, multicenter European Study [Effect of Dopexamine on Outcome after Major Abdominal Surgery].
38 patients with at least one high risk criterion, who were undergoing major abdominal surgery of at least 1.5 hours duration, were submitted to endoscopy and biopsy of the upper gastrointestinal tract immediately after anesthesia. After being stabilized, patients received placebo [Group A, n=12], 0.5 micro-g/Kg per minute of dopexamine [Group B, n=13], and 2.0 micro-g/kg per minute of dopexamine [ Group C, n=13]. At 72 hours, endoscopy and biopsy were repeated in 27 patients. Upper gut blood flow was estimated using tonometry. pH was calculated at baseline, after surgery, and 2,6,12,24,30 and 36 hours after surgery.
Gastric pH decreased significantly and similarly in all the three groups, with the greatest increase being recorded at the end of surgery. Erythema or hemorrhagic changes were found in 33.3% of Group A, 38.5% of Group B, and 15.4% of Group C. Erosive disease was seen in 25%, 7.7% and 38.5% respectively. At 72 hours, endoscopy revealed that the number of patients with no detectable abnormality had decreased to 25%, 20%, and 33.3% respectively. Polymorphonuclear neutrophil proliferation was seen in 86%, 37.5% and 37.5% respectively. There was no correlation between endoscopy and histologic findings.
Dopexamine does protect against the ill effects of decreased pH during surgery though it does not prevent such a decrease.
Hebert PC, et al for the Canadian Critical Care Trials Group [Univ. of Ottawa, Ontario]
A Multicentric, Randomized Controlled Clinical Trial of Transfusion Requirements in Critical Care
N Engl J Med 340:409-417, 1999
The optimal transfusion strategy for critically ill anemic patients has not been determined. To understand the potential risks and benefits of transfusions in critically ill patients, a randomized, controlled clinical trial compared a restrictive versus a liberal approach to red cell transfusions.
The study group consisted of 838 critically ill patients admitted to hospitals or ICUs in Canada, over a 4 year period. Consecutive critically ill normovolemic patients were randomly assigned to either a restrictive strategy [transfusion when hemoglobin level fell below 7.0 g/dL], or a liberal strategy [transfusion when hemoglobin level fell below 10 g/dl]. The primary outcome measure was 30-day death from all causes. Secondary outcomes included 60-day death from all causes.
The overall 30-day mortality rate was not significantly different in the two groups. Mortality rates were lower in younger, less acutely ill patients in the restrictive group, though not in patients with severe cardiac disease. The mortality rate during hospitalization was significantly lower in the restrictive group compared to the liberal transfusion strategy group.
Restrictive red cell transfusion strategy [hemoglobin levels below 7.0 g/dL], was as effective as, and in some cases superior to, the liberal transfusion strategy [hemoglobin levels below 10 g/dL], in critically ill normovolemic anemic patients, except in those with severe cardiac disease.
Hanson CW III, Deutschman CS, Anderson HL III, et al [Univ of Pennsylvania, Philadelphia : Univ of California, Irvine]
Effects of an Organized Critical Care Service on Outcomes and Resource Utilization : A Cohort Study
Crit Care Med 27: 270-274, 1999
Practice patterns are under scrutiny at both institutional and national levels to eliminate inefficiency, lower costs, and improve clinical results. Critical care medicine would seem to be particularly susceptible to the current forces of change. The cost and effectiveness of two patterns of critical care practice, in an academic medical center, were examined to determine whether presence of an on-site, organized, supervised critical care service improves care and reduces resource utilization.
Two patients cohorts admitted to a surgical intensive care unit [SICU] were compared. One group received care from an on-site critical care team, supervised by an intensive care specialist. The other group received care from a team with patient care responsibilities in multiple sites supervised by a general surgeon. The primary outcome measures were duration of stay, resource utilization, complication rates, resultant effects on added investigations, consultations, and terminal outcomes.
The results showed patients receiving care from an on-site critical care service had higher Acute Physiology and Chronic Health Evaluation II [APACHEII] scores, yet they spent less time in SICU, used fewer resources, had fewer complications, and had lower total hospital charges. These differences were more pronounced with increasing severity of illness.
Pronovest PJ, Jenckes MW, Dorman T, et al [John Hopkins Univ, Baltimore, MD]
Organizational Characteristics of Intensive Care Units Related to Outcomes of Abdominal Aortic Surgery
JAMA 281: 1310-1317, 1999
ICUs at different institutions vary widely in terms of morbidity and mortality rates. The effects of ICU structure and care processes on these outcomes are not known. The effects of ICU organization on the clinical and economic outcomes for patients undergoing abdominal aortic surgery were studied.
Hospital data on 2987 patients on whom abdominal aorta surgery was performed, in the state of Maryland, over a two year period, was analyzed. Data on organizational characteristics of ICUs were obtained from medical directors. The main outcomes assessed were in-hospital mortality, and length of total hospital and ICU stay.
The in-hospital mortality rates ranged from 0% to 66%. ICUs that did not have daily rounds by an ICU physician showed a 3-fold increase in in-hospital mortality after adjustment for patient demographic, co-morbidity, severity of illness, hospital and surgeon volume, and hospital characteristics. Other outcomes, such as cardiac arrest, acute renal failure, septicemia, and reintubation, were also more likely at centers without daily rounds by an ICU physician.
Leape LL, Cullen DJ, Clapp MD, et al [Harvard School of Public Health : Massachusetts Gen. Hospital; Brigham and Women’s Hosp., Boston]
Pharmacist Participation on Physicians Rounds and Adverse Drug Events in the Intensive Care Unit
JAMA 282: 267-270, 1999
Although studies show that pharmacist review of ICU prescription orders prevents mistakes and lowers drug costs by reducing drug use, there have been no studies on the benefits of having a pharmacist present in the ICU at the time drugs are prescribed. The efficacy of pharmacist participation in a medical ICU in preventing adverse drug events [ADEs] was tested in a controlled clinical trial.
Between February 1 and July 31, 1993 [Phase 1 Preintervention] and October 1, 1994 and July 7, 1995 [Phase 2 postintervention], the effect of pharmacist intervention was tested in a 17-bed ICU [the study unit] and compared with no pharmacist intervention in a 15-bed coronary care unit with similar occupancy rate [the control unit].
ADEs were compared for 75 randomly selected patients in each of the 3 groups from amongst all patients admitted to the study unit in Phase 1 and 2, and all patients admitted to the control unit in Phase 2. An experienced pharmacist made daily morning rounds with ICU personnel in the study unit; an experienced pharmacist was available for consultation but did not make daily rounds in the control unit. Outcome measures included measurements of ADEs, interventions the pharmacist made, and the acceptance of pharmacist interventions by the physicians and nurses.
The overall rate of preventable ordering and ADEs/1000 patient days decreased by 66% in the study unit from Phase 1 to 2, with significant savings in drugs costs. The rate of ADEs came down significantly in the study group from Phase 1 to 2. In the control group the rate of ADEs continued to remain high.
Of the 398 pharmacist interventions reported, 366 were related to ordering and 362 were accepted by the physicians. Pharmacist – initiated clarifications or correction of incomplete orders, wrong dose, wrong frequency, inappropriate choice, or duplicate therapy accounted for 46% of interventions. Drug interactions or adverse reactions were prevented in 22 cases.
The presence of a pharmacist at rounds in ICUs significantly reduces incidence of ADEs and result in substantial cost savings.
Darouiche RO for the Catheter Study Group [Baylor College of Medicine, Houston, et al]
A Comparison of Two Antimicrobial -Impregnated Central Venous Catheters
N. Engl J Med 340: 1-8, 1999
Previous studies have shown that rates of central venous catheter colonization and catheter related blood stream infection can be significantly reduced through the use of catheters impregnated with minocycline and rifamycin or with chlorhexidine and silver sulphadiazine. However, no studies have directly compared the benefits of the two types of catheter. Minocycline/rifamycin and chlorhexidine/silver sulphadiazine catheters were compared for their ability to prevent colonization and catheter-related blood stream infections.
The prospective, multicenter trial included adult patients considered at high risk for catheter-related infection who were likely to require a central venous catheter for 3 days or longer. The patients were randomized to receive polyurethane triple-lumen catheters impregnated with minocycline/rifamycin on the luminal and external surfaces or with chlorhexidine/silver sulphadiazine on the external surface only. Catheter tips and subcutaneous segments were cultured by both the roll-plate and sonication methods after removal, with peripheral blood cultures performed as indicated. The analyses included a total of 738 catheters with evaluable culture results.
The two catheter groups were similar in their clinical characteristics and infection risk factors. The catheter colonization rate was 8.3% with monocycline/rifamycin impregnated catheters vs 22.8% in the other group. The former were also associated with lower rate of blood stream infection [0.3% vs 3.4%]. The authors emphasize that adequate aseptic technique must complement the use of monocycline/rifamycin impregnation of central venous catheters.
D.S. Walsh, P. Siritongtaworn, K. Pattanapanyasat. P. Thavichaigarn, P. Kongcharoen, N. Jiarakul, P. Tongtawe, K. Yongvanitchit, C. Komoltri, C. Dheeradhada, F.C. Pearce, W.P. Wiesmann and H.K Webster [**]
[** Department of Immunology and Medicine, US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Departments of Surgery, Hematology and Clinical epidemiology, Siriraj Hospital, Department of Surgery, Pharmongkutklao [Royal Thai Army] Hospital, and Department of Surgery, Police Hospital, Bangkok, Thailand and Division of Surgery, Walter Reed Army Institute of Research, Washington, DC, USA ]
Lymphocyte Activation After Non-Thermal Trauma
Br. J. of Sur., Volume 87, Number 2, February, 2000, Pg. 223-230
Service injury causes immunologial changes that may contribute to a poor outcome. Longitudinal characterization of lymphocyte response patterns may provide further insight into the basis of these immunological alterations.
Venous blood obtained seven times over 2 weeks from 61 patients with injury severity scores over 20 was assessed for lymphocyte and activation markers together with serum levels of interleukin [IL]2, IL-4, soluble IL-2 receptor [sIL-2R], soluble CD4 [sCD4], soluble CD8 [sCD8] and interferon g.
Severe injury was associated with profound changes in the phenotypic and activation profile in the phenotypic and activation profile of circulating lymphocytes. Activation was indicated by increased number of T cells expressing CD25, sIL-2R and sCD4 and sCD8 were found in-patients with sepsis syndrome.
Polytrauma is associated with dramatic alterations in the phenotypic and activation profile of circulating lymphocytes which are generally independent of clinical course. In contrast several lymphocyte soluble factors including sCD4 and SIL-2R, paralleled the clinical course. These data provide new insight into lymphocyte responses after injury and suggest the further assessment of soluble factors as clinical correlates.
Helen F Galley , ( Academic Unit of Anaesthesia and Intensive Care, Department of Medicine, Aberdeen ).
Commentary – Renal Dose Dopamine : Will the message now get through ?
Lancet, Vol.356, 23/30 December, 2000, pg. 2112
Deterioration in renal function is common in critically ill patients under intensive care. It lengthens patient’s stay in the intensive – care unit and their risk of death. Management of such cases is restricted to supportive measures and critical care doctors are eager for any new approach that might prevent the onset of renal dysfunction or hasten its recovery.
Dopamine is used in intensive – care units as an inotropic and vosoactive agent. At low or “renal” doses (0.5 to 2.0 mg/kg per min ) its actions are mainly dopaminergic . In laboratory animals and healthy volunteers low doses of dopamine increase renal blood flow and GFR and inhibit proximal tubular reabsorption of sodium, which result in natriuresis. Such findings have not been clearly shown in patients in intensive care. Despite no evidence of benefit, low-dose dopamine has been widely used for preventing renal failure in the critically ill patients.
The large study conducted by the Australian and NewZealand Intensive Care Society (ANZICS), clinical trials group confirms the lack of renal protection offered by low-dose dopamine in the critically ill. Dopamine can also be harmful . There is no justification for using “renal dose” dopamine in the critically ill.
Auleley G-R, Ravaud P, Giraudeau B, et al (Assistance Publique-Hopitaux de Paris; Saint-Louis Hosp, Paris; Cochin Hosp, Paris; et al)
Implementation of the Ottawa Knee Rules in France: A Multicenter Randomized Controlled Trial
JAMA 277: 1935-1939, 1997
This is a multicenter randomized clinical controlled trial involving 5 Paris University teaching hospitals (2 for intervention and 3 as controls) to evaluate the impact of this rule during a 5 month intervention period as well as to note the effect of using posters alone to sustain the effect of the rules.
Control hospitals were given data collection forms, but not preprinted rules. In the intervention group, meetings were held to explain and distribute the rules. These rules were also posted in the emergency departments and data collection forms were distributed. The outcome was measured as the number of patients referred for radiography. There were 1005 controls and 906 patients in the intervention group.
Before intervention 98.5% of controls and 98% of intervention group were referred for radiography. During intervention, 99.6% of controls and 76% of intervention group requested radiographs (reduction of 22.4% in intervention group).
In the postintervention period 83.1% were referred for radiography in the intervention group against 98% in control group.
Implementation of the Ottawa ankle rules resulted in a significant reduction in the number of radiographs requested.
Tuli S, Tator CH, Fehlings MG, et al (Univ of Toronto)
Occipital Condyle Fractures
Neurosurgery 41: 368-377, 1997
Occipital condyle fractures (OCF) present a diagnostic challenge.
This is a retrospective study of 93 patients (medical records and radiographs) who had sustained trauma and had undergone CT scan of the skull and cervical spine.
Of 93 cases studied, 3 had OCF (2 women 64 years and a 27-year old man). 2 had vehicular accidents and one had a fall down a flight of stairs. All 3 had neck pain but no cranial nerve deficits. CT identified OCF in 2 patients only and missed the diagnosis in one (eventually diagnosed by a high resolution CT scan during retrospective study).
Review of literature showed 58 living patients with OCF and 38 diagnosed at autopsy. Cranial nerve deficits were seen in 31%; delayed deficits in 38%.
Cervical spine X rays revealed no fracture in 96%. A new classification of OCF is proposed on the degree of ligamentous laxity and presence of displacement observed on CT and by the determination of O-C1-C2 instability
Plewa MC, Delinger M (St Vincent Mercy Med Ctr, Toledo, Ohio; Med College of Ohio, Toledo)
The False-positive Rate of Thoracic Outlet Syndrome Shoulder Maneuvers in Healthy Subjects
Acad Emerg Med 5: 337-342, 1998
This study has been conducted on 53 healthy volunteers who had no symptoms of Thoracic Outlet Syndrome (TOS).
Shoulder maneuvers including Adsons test (AT), costoclavicular maneuver (CCM), elevated arm stress test (EAST), and supraclavicular pressure (SCP) were performed for diagnostic evaluation. Participants were evaluated for pulse quality and the presence of pain/paresthesias.
All maneuvers resulted in change of pulse quality but most commonly with EAST. Paresthesias were also most often seen with EAST (only in the upper extremity, not radiating to neck, head or chest in any case).
There was no pain with the AT and CCM maneuvers and pain was seen in only one case with SCP. Overall, pulse alteration, pain and paresthesias were present in 74%, 21% and 47%, respectively, of participants.
No participants had positive findings with all maneuvers. Outcomes with reasonable false positive rates included pain with AT (7%), CCM (7%), SCP (10%), or any two shoulder (TOS) maneuvers (10%).
In TOS, pulse alternations and paresthesias (after shoulder maneuvers are unreliable in general).
Pandey R, McNally E, Ali A, et al (John Radcliffe Hosp, Oxford England)
The Role of MRI in the Diagnosis of Occult Hip Fractures
Injury 29: 61-63, 1998
Traumatic hip fractures are common particularly in the elderly. Clinical examination and initial radiography may be inconclusive. Misdiagnosis significantly alters prognosis, morbidity, management and length of hospital stay and cost of treatment.
In this study, MRI was performed on 33 patients with posttraumatic painful hips and negative radiographs. Fractures were diagnosed when an area of intermediate signal intensity on the T1-weighted images, representing trabecular edema, traversed by a low signal intensity line depicted by the fracture.
10 of 33 cases revealed no fracture. None of these subsequently went on to fracture 100% true negative findings.
The MRIs revealed that 40% of patients had a fractured neck of the femur, 15% had intertrochanteric fractures, and 11% had other fractures around the hip. One patient had a tumor.
MRI is recommended in all patients with traumatic significant hip pain and negative plain radiographs.
Reinus WR, Strome G, Zwemer FL Jr (Washington Univ, St. Louis)
Use of Lumbosacral Spine Radiographs in a Level II Emergency Department
AJR 170: 443-447, 1998
This study determines the reasons clinicians ask for lumbosacral spine radiographs in an emergency department. The study includes 482 patients examined for low backache in a level II emergency department (ED).
Physicians were asked to complete a request form before ordering a lumbosacral spine X ray.
The most common indications for the X ray were low back pain (92%) and trauma (36%), in 42% patient expectation and medicolegal concern related to insurance or litigation. 88% of patients had a neurologic deficit. 4% had history of neoplasm.
The most common suspected lesion was strain and fracture (56% and 20% respectively). 86% had normal findings or spondylosis. Fractures were detected in 55%, of these 10 were definitely acute fractures. 7 had osseous metastases. 37 patients with neurologic deficits had findings that did not correlate with abnormalities observed on lumbosacral spine X rays. Decompression was not needed in any of the fractures.
Weiss HB, Friedman DI, Coben JH (Univ of Pittsburgh, Pa)
Incidence of Dog Bite Injuries Treated in Emergency Departments
JAMA 279: 51-53, 1998
The incidence and characteristics of dog bite injuries for the United States have been calculated.
This is a retrospective study. The E-code E906.0 was used to determine the incidence of dog bites treated in Emergency Departments (ED).
The annualized weighted estimate of the incidence of new dog bites and related injuries in EDs of USA over the 3-year period observed was 333,687, a rate of 12.9/10,000 persons. They represented 0.4% of all ED visits during this period.
This works out as 914 new dog bite injuries requiring ED visits. The median age of the patients was 15 years. Children between 5-9 years had the highest incidence (60.7/10,000). Children more than adults were likely to have bites on the neck, face and head (73% vs 30%). The highest incidence is in the summer. More than 50% of dog bites occurred at home.
94% of cases were treated in ED and sent home. The remainder required admission. There was a 4% hospitalization rate among nearly 334,000 dog bites treated on EDs in USA.
Jacobson JA, Powell A, Craig JG, et al (Henry Ford Hosp, Detroit)
Wooden Foreign Bodies in Soft Tissue: Detection at US
Radiology 206: 45-48, 1998
Radiolucent foreign bodies (FB) are extremely difficult to detect. It is imperative to detect and remove them, as retained FBs may lead to severe infections and may lead to malpractice lawsuits.
The use of ultrasonography (US) for detection of wooden FBs implanted in cadaveric specimen has been evaluated.
Using 5-mm-long incisions in the plantar soft tissues of 3 cadaver feet, wooden FBs were randomly placed. Ten FBs 5 mm x 1 mm and ten of the size of 2.5 mm x 1 mm were implanted.
US was performed to detect the presence of a FB. There was a 86.7% sensitivity for detection of the 25 mm x 1 mm sized FB and 96.7% specificity. There was an overall negative predictive value of 83%. A positive predictive value of 98%, specificity of 96.7% and a sensitivity of 90%.
US is an effective tool for detecting wooden FBs in soft tissue that are radiolucent.