Abstract: Anisakiasis is caused by a fish parasite of the Nematode family. This kind of rare helminthozoonosis can mainly be found in countries where consumption of raw fish is traditionally high like Japan, the Netherlands, Pacific Islands, South Europe, Scandinavia, USA, and Canada. Man is the wrong hoste. Clinical manifestation depends on the localisation of penetration in the GI tract. In Japan, predominantly the stomach is affected in 97 % of cases, probably due to hypo- and achlorhydria; whereas mainly intestinal anisakiasis occurs in Europa. We report on a 67-year-old male patient with a gastric infestation of anisakiasis. The patient was on proton pump inhibitor which migh have caused the localisation of the infestation. The anisakis was an accidental endoscopic finding in a patient for control of an H. p.-positive gastric ulcer. Otherwise the patient was free of pain. The helminth (larva III) was endoscopically extracted. Thereafter, the patient remained in good health. Anisakis serology as well as repeated differential blood counts were without finding. The uneventful medical history and the normal blood findings indicate that our patient had a very early stage of infestation of anisakiasis. The patient reported no stay outside of Austria within the last years. However, he consumed on a regular basis "rolled pickled herring" produced by a well-known Viennese company for canned fish. This is the first documented case of this rare helminthozoonosis acquired in Austria.
Abstract: A 33-year-old previously healthy man was admitted to the hospital with a 6-day history of diffuse abdominal pain and constipation. He was afebrile, looked unwell with a pale skin and displayed an elevated blood pressure. He had no peritoneal sign, and bowel sounds were normal. Blood tests were remarkable for a hematocrit of 26 % and mean cell volume of 83 fl, bilirubin levels were slightly elevated. Abdominal radiographs, abdominal ultrasound and computed tomography showed stool throughout the colon with a non-specific bowel gas pattern. Moreover, colonoscopy and gastroscopy provided no information on the underlying cause of the patient's severe pain. He was treated with fluids and spasmolytic drugs until the result of the urinary porphyrin level was received, which showed an elevated concentration of 1608 microg/d. Consequently, the plasma lead concentration was determined showing an elevated level of 92.3 microg/d. The examination of blood slides revealed erythrocytes with basophile stippling. On physical examination, a bluish discoloration could be seen along the gums. After starting the detoxication therapy with DMPS - 1800 mg p. o. for the first two days followed by 600 mg DMPS daily - the complaints disappeared. In spite of an extensive anamnestic exploration the source of the lead intoxication could not be found until now.
Abstract: Intestinal shunting procedures followed by gastrointestinal bypass surgery have been used as therapeutic modalities in the treatment of morbid obesity since the mid 1950s. Enthusiasm reached its peak in the early 1960s with the introduction of the jejunoileal bypass, however began to wane as various complications were identified in the remote postoperative period and later. Finally, the jejunoileal bypass was abandoned in the 1980s. Apart from renal disorders, it frequently resulted in abnormal liver function and liver failure which are attributed to fatty infiltration. We report a 56-year-old woman, who underwent jejunoileal bypass surgery 23 years ago. She was admitted to our ICU because of hepatic encephalopathy IV, caused by upper gastrointestinal bleeding. Beside hepatic encephalopathy there were signs of severe liver failure (INR 2.8, cholesterol 32 mg/dl, ICG PDR 5%). Liver biopsy showed fatty infiltration and cirrhosis. Excluding other causes of liver disease, severe fatty liver disease following jejunoileal bypass surgery was diagnosed. The very late onset of severe liver disease emphasizes the importance of lifelong follow-up of these patients.
Abstract: STUDY OBJECTIVES: To address the value of plasma B-type natriuretic peptide (BNP) concentrations as a diagnostic tool for determining the cardiac etiology of pleural effusions, and to determine possible differences of plasma BNP concentrations before and after pleurocentesis in patients with congestive heart failure (CHF). DESIGN: Observational study. SETTING: Tertiary care hospital. PATIENTS: Consecutive series of 64 patients with indications for diagnostic pleurocentesis. The final diagnosis of the underlying disease was assessed by clinical criteria. Seven patients were excluded due to pleural effusions of equivocal origin or due to obvious hemothorax secondary to trauma. INTERVENTION: Pleurocentesis attempting to drain effusions dry. Plasma BNP concentrations were measured directly before pleurocentesis and 24 h after the intervention. During these 24 h, the dosages of patients' medications were held constant. MEASUREMENTS AND RESULTS: In distinguishing between patients with pleural effusions caused by CHF (n = 31) and patients with pleural effusions attributable to other causes (n = 26), the area under the curve was 0.974 (SE, 0.021; 95% confidence interval, 0.892 to 0.997) for plasma BNP. A BNP cutoff concentration of 2,201 ng/L had a sensitivity of 77% and a specificity of 100% in the diagnosis of CHF. The median plasma BNP concentrations in patients with pleural effusions caused by CHF (n = 31) did not change within 24 h after pleurocentesis compared with the concentrations obtained before the procedure (before pleurocentesis, 3,227 ng/L; 24 h after pleurocentesis, 2,759 ng/L; p = 0.189), despite a median removal of 1,100 mL pleural fluid. CONCLUSIONS: Plasma BNP concentrations of patients with pleural effusions of unknown origin may be an aid in the diagnosis of CHF as the underlying cause. If plasma BNP is used as a surrogate marker of global cardiac function, there is no indication of hemodynamic improvement caused by pleurocentesis alone in patients with CHF and pleural effusions.
Abstract: A hypertensive crisis is characterized by a massive blood pressure increase of sudden onset, with systolic pressures in excess of 220 mmHg or diastolic pressures of more than 120 mmHg usually being found in patients with underlying hypertensive disease. Of decisive importance for the severity of the patient's presenting state, however, is not the absolute level of the blood pressure, but rather the extent of the acute blood pressure increase. Of decisive importance for the therapeutic approach to the acute case is whether the hypertensive crisis is accompanied by organic manifestations (hypertensive emergency) or is unaccompanied by this life-threatening clinical presentation (hypertensive urgency). The former patients must always be hospitalized, and the preferential treatment is parenteral medication, which is associated with a more rapid and calculable onset of action than can be achieved via the oral or sublingual route.
Abstract: AIM: To test the efficacy of cholylsarcosine (synthetic conjugated bile acid) and ox bile extracts (mixture of natural conjugated bile acids) on fat absorption, diarrhea, and nutritional state in four short bowel syndrome (SBS) patients with a residual colon not requiring parenteral alimentation. METHODS: The effect of cholylsarcosine (2 g/meal) on steatorrhea and diarrhea was examined in short-term balance studies with a constant fat intake in all four patients. The effect of continuous cholylsarcosine ingestion on nutritional state was assessed by changes in body weight in three patients. In two patients, the effects of cholylsarcosine were compared with those of ox bile extracts. Because of the low incidence rate of SBS this is not a controlled study. RESULTS: In balance studies, cholylsarcosine increased fat absorption from 65.5 to 94.5 g/day (a 44 % increment), an energy gain of 261 kcal/d. Fecal weight increased by 26 %. In two patients natural conjugated bile acids also reduced steatorrhea, but greatly increased diarrhea. As outpatients consuming an unrestricted diet and ingesting cholylsarcosine, three patients gained weight at an average rate of 0.9 kg/week without worsening of diarrheal symptoms. CONCLUSIONS: Cholylsarcosine is efficacious and safe for enhancing fat absorption and nutritional status in short bowel syndrome patients with residual colon. Natural conjugated bile acids improve steatorrhea to a smaller extent and greatly worsen diarrhea.
Abstract: BACKGROUND: This study evaluated the short-term and long-term effects of the angiotensin II type 1 receptor antagonist candesartan cilexetil on hemodynamics, neurohormones, and clinical symptoms in patients with congestive heart failure (CHF). METHODS: In this multicenter, double-blind, parallel-group study, 218 patients with CHF (New York Heart Association class II or III) with impaired left ventricular function (ejection fraction < or =40%) and pulmonary capillary wedge pressure > or =13 mm Hg were randomly assigned to 12 weeks of treatment with placebo (n = 44) or candesartan cilexetil (2 mg [n = 45], 4 mg [n = 46], 8 mg [n = 39], or 16 mg [n = 44]) once daily after a 2-week placebo run-in period. Hemodynamic measurements were performed by right heart catheterization over a 24-hour period after single (day 1) and repeated (3-month) treatment with the study drug. RESULTS: On regression analysis of the time-response curves, single and multiple doses of candesartan cilexetil produced sustained, significant, and dose-dependent reductions in pulmonary capillary wedge pressure (short-term effect P =.036, long-term effect P =.035) and mean pulmonary arterial pressure (short-term effect P =.031, long-term effect P =.042). Systemic vascular resistance showed a trend toward decreasing with dose on short-term and long-term treatments. No consistent changes were seen in cardiac index. Compensatory increases in plasma renin activity and angiotensin II levels with decreases in aldosterone and atrial natriuretic peptide were dose-dependent and significant. Candesartan cilexetil improved clinical symptoms, stabilized patient New York Heart Association status compared with placebo, and was judged to be an efficacious treatment by the investigators. More patients receiving placebo stopped the trial prematurely because of an adverse event than in any candesartan cilexetil group, and there was no excess of deaths in any treatment group. Candesartan was safe and well tolerated at all dosages. CONCLUSIONS: Candesartan cilexetil demonstrated significant short-term and long-term improvements in hemodynamic, neurohormonal, and symptomatic status and was well tolerated in patients with CHF.
Abstract: Complications due to diagnostic colonoscopy are very rare. Perforation is the most frequent colon-related event. So far only ten cases of acute appendicitis after colonoscopy have been reported in the literature. We present the case of a 79-year-old man who developed acute appendicitis after diagnostic colonoscopy. Diagnosis was aggravated by the fact that in the patient's history an appendectomy had been performed 65 years earlier. Because of the rarity of this event it is doubtful whether the endoscopic examination was causal or coincidental. However, in cases of pain after colonoscopy, appendicitis has to be included in the differential diagnosis.
Abstract: DEFINITION, PATHOPHYSIOLOGY, THERAPY: The hypertensive crisis is characterized by a massive, acute rise in blood pressure. Patients with underlying hypertensive disease usually have an increase in systolic blood pressure values > 220 mmHg and diastolic values > 120 mmHg. The severity of the condition, however, is not determined by the absolute blood pressure level but by the magnitude of the acute increase in blood pressure. Thus, in the presence of primarily normotensive baseline values (such as those in eclampsia), even a systolic blood pressure > 170 mmHg may lead to a life-threatening condition. The most important causes are non-compliance (reduction or interruption of therapy), inadequate therapy, endocrine disease, renal (vessel) disease, pregnancy and intoxication (drugs). The management of this condition greatly depends on whether the patient has a hypertensive crisis with organ manifestation (hypertensive emergency) or a crisis without organ manifestation (hypertensive urgency). By documenting the medical history, the medical status and by simple diagnostic procedures, the differential diagnosis can be established at the emergency site within a very short period of time. In the absence of organ manifestations (hypertensive urgency) the patient may have non-specific symptoms such as palpitations, headache, malaise and a general feeling of illness in addition to the increase in blood pressure. In a hypertensive urgency the patient's blood pressure should not be reduced within a few minutes but within a period of 24 to 48 hours. Such adjustment can be achieved on an out-patient basis, however, only if the patient can be followed up adequately for early detection of a renewed attack. In the absence of follow-up facilities, the patient's blood pressure should be reduced over a period of 4 to 6 hours, if necessary in an out-patient emergency service. While intravenous medication is given preference when a rapid effect is desired, oral medication may be used for gradual reduction on an out-patient basis, depending on the patient's medical history and on any underlying chronic disease. Organ manifestations in the course of a hypertensive emergency concern the cardiovascular system and are associated with the symptoms of acute left-ventricular heart failure, the acute coronary syndrome or acute aortic dissection. In the brain the patient may have symptoms of hypertensive encephalopathy, hemorrhage, ischemia; in the kidney he/she may develop acute failure. The patient's blood pressure should be reduced rapidly during the treatment. It should not be reduced to the normal value, but by approximately 20-30% of the baseline value. The reason for a stepwise reduction in blood pressure is the fact that patients with chronic hypertension have an altered autoregulation curve. Acute normotension would lead to hypoperfusion in these patients. Those with aortic dissection or pulmonary edema are excepted from the rule of gradual blood pressure reduction. In the presence of these diseases, blood pressure must be reduced rapidly to normal values. Patients with a hypertensive emergency should always be admitted to the hospital. Parenteral treatment is given preference, since the effect of the treatment is rapid and occurs within a calculable period of time. Thus, parenteral treatment can also be better regulated than medication administered orally or by the sublingual route. Several antihypertensives are available for this purpose. The selection of the substance greatly depends on the existing organ failure as well as the reliable effectiveness and the regulability of the applied antihypertensive.
Abstract: OBJECTIVES: Acute renal failure is a complication in critically ill patients that has been associated with an excess risk of hospital mortality. Whether this reflects the severity of the disease or whether acute renal failure is an independent risk factor is unknown. The aim of this study was to analyze severity of illness and mortality in a group of critically ill patients with acute renal failure requiring renal replacement therapy in a number of Austrian intensive care units. DESIGN: Prospective, multicenter cohort study. PATIENTS AND SETTING: A total of 17,126 patients admitted consecutively to 30 medical, surgical, and mixed intensive care units in Austria over a period of 2 yrs. MEASUREMENTS AND MAIN RESULTS: Analyzed data included admission data, Simplified Acute Physiology Score, Logistic Organ Dysfunction system, Simplified Therapeutic Intervention Scoring System, length of intensive care unit stay, intensive care unit mortality, and hospital mortality. Of the admitted patients, 4.9% (n = 839) underwent renal replacement therapy because of acute renal failure (renal replacement therapy patients). These patients had a significantly higher hospital mortality (62.8% vs. 15.6%, p<.001), which remained significantly higher even when renal replacement therapy patients were matched with control subjects for age, severity of illness, and treatment center. Since univariate analysis demonstrated further intensity of treatment to be an additional predictor for outcome, a multivariate model including therapeutic interventions was developed. Five interventions were associated with nonsurvival (mechanical ventilation, single vasoactive medication, multiple vasoactive medication, cardiopulmonary resuscitation, and treatment of complicated metabolic acidosis/alkalosis). In contrast, the use of enteral nutrition predicted a favorable outcome. CONCLUSIONS: The results of our study suggest that acute renal failure in patients undergoing renal replacement therapy presents an excess risk of in-hospital death. This increased risk cannot be explained solely by a more pronounced severity of illness. Our results provide strong evidence that acute renal failure presents a specific and independent risk factor for poor prognosis.
Abstract: Various clinical parameters, neurological examination models, biochemical tests, electrophysiological procedures and neuro-imaging techniques have been studied with respect to the detection of cerebral hypoxia in patients after cardiopulmonary resuscitation. These parameters were critically evaluated by the members of the Austrian interdisciplinary consensus conference. Based on the results of scientific publications, the consensus meeting identified 26 parameters, which allow the prognostic evaluation of cerebral hypoxia after cardiopulmonary resuscitation. Among these parameters, however, the strength of evidence and the level of recommendation are different.
Abstract: BACKGROUND: The effects of food restriction on energy metabolism have been under investigation for more than a century. Data obtained are conflicting and research has failed to provide conclusive results. OBJECTIVE: The objective of this study was to test the hypothesis that in lean subjects under normal living conditions, short-term starvation leads to an increase in serum concentrations of catecholamines and thus to an increase in resting energy expenditure. DESIGN: Resting energy expenditure, measured by indirect calorimetry, and hormone and substrate concentrations were measured in 11 healthy, lean subjects on days 1, 2, 3, and 4 of an 84-h starvation period. RESULTS: Resting energy expenditure increased significantly from 3.97 +/- 0.9 kJ/min on day 1 to 4.53 +/- 0.9 kJ/min on day 3 (P < 0.05). The increase in resting energy expenditure was associated with an increase in the norepinephrine concentration from 1716. +/- 574 pmol/L on day 1 to 3728 +/- 1636 pmol/L on day 4 (P < 0.05). Serum glucose decreased from 4.9 +/- 0.5 to 3.5 +/- 0.5 mmol/L (P < 0.05), whereas insulin did not change significantly. CONCLUSIONS: Resting energy expenditure increases in early starvation, accompanied by an increase in plasma norepinephrine. This increase in norepinephrine seems to be due to a decline in serum glucose and may be the initial signal for metabolic changes in early starvation.
Abstract: OBJECTIVE: Hydroxyethyl starch (HES) is mainly eliminated via the kidneys. Any information about extrarenal elimination obtained so far has been either incomplete or contradictory. The objective of this study was to quantify the intestinal excretion of infused HES with a mean molecular weight of 200,000 and a molar substitution of 0.5 (HES 200/0.5) and to compare the reappearance/recovery rate in urine and plasma. DESIGN: Prospective clinical study without control group. SETTING: The study was conducted at the Institute of Hypertension of the Society of Clinical Pharmacology, Vienna, Austria, which is an establishment for research in volunteers. PARTICIPANTS: The results of six out of seven healthy male volunteers were appropriate for analysis. One trial subject had to be excluded from the study because of severe protocol violation (mixing of stool and urine samples). INTERVENTIONS AND METHODS: Each volunteer was administered 500 ml of 10% HES 200/0.5 in a 0.9% NaCl solution intravenously within 1 h. A gut lavage with 6 l of a polysaccharide free solution was continuously administered from 3 h prior to until 2 h after the HES infusion to facilitate the collection of the samples and to exclude any source of error at analysis. HES was quantified with the hexokinase method. MEASUREMENTS AND RESULTS: Right from the beginning of the infusion until 10 h after its completion, the cumulative HES excretion with feces (principle parameter) and urine as well as selective plasma volume and HES plasma level were measured. Six and 14 h after the infusion had been completed, the recovery rates of HES in urine were about 30% and 40%, respectively, and in plasma about 23% and 8%, respectively. By contrast, not more than a kind of "background noise amount" of HES (about 0.2 %) could be recovered in feces ( mean value in % of the infused amount of the substance). Six and 14 h after the infusion had been completed, the total recovery rates of HES were 53% and 49%, respectively. CONCLUSION: In a physiologically unimpaired gut HES 200/0.5 is not, or only to an infinitesimal extent, eliminated via the intestine. The question if there is any alternative path to renal excretion for HES still remains to be answered. As the calculated reappearance/recovery rate of HES is only about 50 % of the administered dose, further investigations as to the final fate of HES appear necessary.
Abstract: OBJECTIVE: The mortality of patients with liver cirrhosis admitted to an intensive care unit (ICU) has been found to be high. This study was performed to assess the physiological and laboratory parameters which are able to identify on ICU admission the cirrhotic patients who are most likely to die. DESIGN: Prospective clinical trial. METHODS: Two groups of patients were analysed. Group A consisted of 196 consecutive cirrhotic patients admitted to our medical ICU for various reasons. For the detection of independent outcome predictors, we used a multiple logistic regression model. Based on these variables, the 'intensive care cirrhosis outcome (ICCO) score' was calculated. The ability to discriminate between survivors and non-survivors was determined by receiver operating characteristic curves, and the area under the curve was calculated. Group B consisted of 70 consecutive cirrhotic patients for prospective validation of the ICCO score. RESULTS: Applying multiple logistic regression analysis, bilirubin, cholesterol, creatinine clearance and lactate were found to be independently associated with the hospital mortality. The ICCO score was 0.3707 + (0.0773 x bilirubin (mg/dl)) - (0.00849 x cholesterol (mg/dl)) -(0.0155 x creatinine clearance (ml/min)) + (0.1351 x lactate (mmol/l)), giving an area under a receiver operating characteristic curve of 0.9. Increasing score values were associated with an increase in mortality. All patients with an ICCO score > +2.6 died. CONCLUSIONS: Application of the ICCO score is rapid and available at the patient's bedside, and its application is simple and reproducible. In cirrhotic patients, the ICCO score has a high ability to discriminate between survivors and non-survivors. The ICCO score may facilitate estimation on ICU admission of the prognosis of critically ill cirrhotic patients.
Abstract: Severe renal dysfunction or even acute renal failure necessitating renal replacement therapy are rather infrequent observations in patients following cardiopulmonary resuscitation. A low flow situation alone does not seem to be sufficient for renal breakdown and in addition other factors, such as preexisting renal disease, severe infections or congestive heart failure must be present. We report a patient, in whom during cardiopulmonary resuscitation a central venous catheter was placed which inadvertently was located in the aortic arch. Through this malpositioned line increasing and finally excessive amounts of epinephrine (in total 150 mg) were injected because of inadequate therapeutic response. After finally successful resuscitation the patient developed rhabdomyolysis and acute renal failure, which required hemodialyis therapy. Intraarterial infusion of the vasoconstrictor catecholamine obviously caused a critical reduction in renal and skeletal muscle perfusion. Nevertheless, the patient was discharged from hospital in good neurologic condition and with normal renal function.
Abstract: BACKGROUND & AIMS: Appropriate management of primary gastric lymphoma is controversial. This prospective, multicenter study aimed to evaluate the accuracy of endoscopic biopsy diagnosis and clinical staging procedures and assess a treatment strategy based on Helicobacter pylori status and tumor stage and grade. METHODS: Of 266 patients with primary gastric B-cell lymphoma, 236 with stages EI (n = 151) or EII (n = 85) were included in an intention-to-treat analysis. Patients with H. pylori-positive stage EI low-grade lymphoma underwent eradication therapy. Nonresponders and patients with stage EII low-grade lymphoma underwent gastric surgery. Depending on the residual tumor status and predefined risk factors, patients received either radiotherapy or no further treatment. Patients with high-grade lymphoma underwent surgery and chemotherapy at stages EI/EII, complemented by radiation in case of incomplete resection. RESULTS: Endoscopic-bioptic typing and grading and clinical staging were accurate to 73% and 70%, respectively, based on the histopathology of resected specimens. The overall 2-year survival rates for low-grade lymphoma did not differ in the risk-adjusted treatment groups, ranging from 89% to 96%. In high-grade lymphoma, patients with complete resection or microscopic tumor residuals had significantly better survival rates (88% for EI and 83% for EII) than those with macroscopic tumor residues (53%; P < 0.001). CONCLUSIONS: There is a considerable need for improvement in clinical diagnostic and staging procedures, especially with a view toward nonsurgical treatment. With the exception of eradication therapy in H. pylori-positive low-grade lymphoma of stage EI and the subgroup of locally advanced high-grade lymphoma, resection remains the treatment of choice. However, because there is an increasing trend toward stomach-conserving therapy, a randomized trial comparing cure of disease and quality of life with surgical and conservative treatment is needed.
Abstract: OBJECTIVES: To evaluate the prognostic performance of the original Simplified Acute Physiology Score (SAPS) II in Austrian intensive care patients and to evaluate the impact of customization. DESIGN: Analysis of the database of a multicenter study. SETTING: Nine adult medical, surgical, and mixed intensive care units (ICUs) in Austria. PATIENTS: A total of 1733 patients consecutively admitted to the ICUs. MEASUREMENTS AND RESULTS: The database included admission data, SAPS II, length of stay, and hospital mortality. The Hosmer-Lemeshow goodness-of-fit test for the SAPS II showed a lack of uniformity of fit (H = 89.1, 10 df, p < 0.0001; C = 91.8, 10 df, p < 0.0001). Subgroup analysis showed good performance in patients with cardiovascular (medical and surgical) diseases as the primary reasons for admission. A new predictive equation was derived by means of the logistic regression. Goodness-of-fit was excellent for the customized model (SAPS IIAM) (H = 11.2, 9 df, p = 0.33, C = 11.6, 9 df, p = 0.24). The mean standardized mortality ratio (SMR) changed from 0.81 +/- 0.26 to 0.93 +/- 0.29 with customization. CONCLUSIONS: SAPS II was not well calibrated when applied to all patients. However, it performed well for patients with cardiovascular diseases as the primary reason for admission and may thus be applied to these patients. Standardized mortality ratios that are calculated from scoring systems without known calibration must be viewed with skepticism.
Abstract: OBJECTIVES: To evaluate the ability of an interdisciplinary data set (recently defined by the Austrian Working Group for the Standardization of a Documentation System for Intensive Care [ASDI]) to assess intensive care units (ICUs) by means of the Simplified Acute Physiology Score II (SAPS II) for the severity of illness and the simplified Therapeutic Intervention Scoring System (TISS-28) for the level of provided care. DESIGN: A prospective, multicentric study. SETTING: Nine adult medical, surgical, and mixed ICUs in Austria. PATIENTS: A total of 1234 patients consecutively admitted to the ICUs. INTERVENTIONS: Collection of data for the ASDI data set. MEASUREMENTS AND MAIN RESULTS: The overall mean SAPS II score was 33.1+/-2.1 points. SAPS II overestimated hospital mortality by predicting mortality of 22.2%+/-2.9%, whereas observed mortality was only 16.8%+/-2.2%. The Hosmer-Lemeshow goodness-of-fit test for SAPS II scores showed lacking uniformity of fit (H = 53.78, 8 degrees of freedom; p < .0001). TISS-28 scores were recorded on 8616 days (30.6+/-1.5 points). TISS-28 scores were higher in nonsurvivors than in survivors (30.4+/-0.9 vs. 25.7+/-0.4, respectively; p < .05). No significant correlation between mean TISS-28 per patient per unit on the day of admission and mean predicted hospital mortality (r2 = .23; p < .54) or standardized mortality ratio per unit (r2 = -.22; p < .56) was found. CONCLUSIONS: Implementation of an interdisciplinary data set for ICUs provided data with which to evaluate performance in terms of severity of illness and provided care. The SAPS II did not accurately predict outcomes in Austrian ICUs and must, therefore, be customized for this population. A combination of indicators for both severity of illness and amount of provided care is necessary to evaluate ICU performance. Further data acquisition is needed to customize the SAPS II and to validate the TISS-28.
Abstract: BACKGROUND AND AIMS: We questioned whether heavy chronic alcohol abuse influences extrahepatic organ failure and ICU mortality in cirrhotic patients admitted to a medical intensive care unit. PATIENTS AND METHODS: Medical records of 208 consecutive cirrhotic critically ill patients were reviewed. Patients were classified into two groups. Group A comprised 144 patients with liver cirrhosis due to heavy chronic alcohol abuse and group B, 64 patients with liver cirrhosis due to non-alcoholic causes. The presence of extrahepatic organ failures in patients of both groups was assessed with parameters determined on the day of admission to the ICU. Furthermore, ICU mortality was determined. RESULTS: The occurrence of extrahepatic organ failure was similar in group A and group B (83% vs. 80%; p = NS). The rate of extrahepatic organ failure was 1.7 +/- 1.2 organs in group A, compared to 1.4 +/- 1 organs in group B (p = NS). ICU mortality was 53% in group A and 44% in group B (p = NS). An increase in the number of extrahepatic organ failures was associated with a concomitant increase in ICU mortality in both groups of patients. CONCLUSION: The occurrence of extrahepatic organ failure and ICU mortality was not different between patients with liver cirrhosis secondary to heavy chronic alcohol abuse and patients with liver cirrhosis due to nonalcoholic causes. Cirrhotic patients should be admitted to a medical intensive care unit for extended intensive care treatment prior to the occurrence of extrahepatic multiple organ failure, independent of the underlying aetiology.
Abstract: This study sought to compare the efficacy and safety of intravenous flecainide and sotalol for immediate cardioversion of atrial fibrillation. We performed a prospective, randomized, single-blind, multicenter trial, including 106 hemodynamically stable patients with atrial fibrillation, stratified according to duration of the arrhythmia. Exclusion criteria included severely reduced left ventricular systolic function, recent antiarrhythmic therapy, and hypokalemia. Patients were randomly assigned to receive either intravenous flecainide or intravenous sotalol. Trial medication was given at a dose of 1.5 mg/kg body weight (maximum 150 mg). Overall, 28 of 54 patients (52%) given flecainide and 12 of 52 patients (23%) given sotalol converted to sinus rhythm during the first 2 hours after start of the infusion (p = 0.003). Multivariate analysis confirmed that treatment allocation to flecainide, an arrhythmia duration of < or = 24 hours, higher plasma magnesium level at baseline, higher age for men, and lower age for women independently increases the probability of conversion. The frequency of adverse effects was not significantly different in the 2 treatment groups.
Abstract: OBJECTIVES: A comparison of data from different intensive care units (ICUs) needs standardized documentation. In this study the ASDI documentation standard for intensive care was tested in clinical practice. Goal of the study was to evaluate parameters and functionality required for a national, interdisciplinary documentation system for intensive care. DESIGN: 13 ICUs participated in a 4-week trial using the provided program for documentation of all admitted patients during the observation period. In addition, a questionnaire was distributed to the unit coordinators. RESULTS: 376 patients were documented in 1591 patient days. Valid SAPS II scores were found in only 29% of the discharged patients (39.1 +/- 15.5 points). Time needed for data entry exceeded preset limits (ten minutes per patient and day) in 38% of the cases. All participants affirmed the necessity of a documentation standard for intensive care, giving quality control and cost analysis as the most important reasons. CONCLUSION: The ASDI data set fitted existing needs very closely. Only 7 out of 122 parameters (5.7%) were found to be superfluous and thus removed. Measures to reduce documentation effort to the default limits were a) a new, date orientated concept for manual recording, b) rede-sign of the user interface with new, user friendly data entry possibilities, and c) the integration of statistical analysis and reports in the documentation system. The revised data set represents a broad-based consensus, which seems to be well-suited as foundation for the national quality assurance program.
Abstract: Gut lavage by ingestion of large volumes of electrolyte solutions has been shown to be an effective method of cleansing the colon before colonoscopy, barium enema or surgery. Absorption of water and electrolytes, which might be hazardous to patients who are unable to readily excrete an additional sodium and/or water load, is prevented by addition of non-absorbable substances to the solutions, but systematic studies are lacking. We have evaluated the influence of three solutions for gut lavage with different electrolyte composition (sodium concentration 67 mmol/l and 125 mmol/l) and addition of different non-absorbable substances (mannitol and polyethylene glycol [PEG]) on water and electrolyte homeostasis and subjective tolerance, both in healthy volunteers and in patients before endoscopy of the colon. In a randomized, blind study 6 liters of the three solutions were administered via a nasogastric tube to 6 healthy volunteers during 4 hours (i.e. 1.5 l/h). Body weight, serum concentrations of sodium, potassium and of phosphate were measured before infusion of the solution and after the last rhythmic rectal effluent. No significant changes were observed in any of the studied parameters and the incidence of side effects (nausea, abdominal cramps) was comparable. In an additional clinical double blind study, 26 patients before diagnostic colonoscopy were asked to drink 4 liters of the gut lavage solutions as quickly as possible in order to clean out the colon. The time for drinking was significantly shorter in patients using the mannitol and low sodium solution (204 +/- 70 minutes) than in patients drinking the solution with polyethylene glycol and a high sodium concentration (387 +/- 137 minutes). There was a tendency to a longer drinking period in patients ingesting the solution with polyethylene glycol and low sodium (306 +/- 106 minutes). Thus, the acceptance for solutions containing polyethylenglycol and high sodium concentration is reduced because of low palatibility. Again no influence on serum electrolyte concentrations or body weight could be observed in any patient, the spectrum of side effects was similar and the cleansing effect of all three solutions was adequate. In conclusion solutions for gut lavage containing a balanced electrolyte concentration and nonresorbable substances such as mannitol or polythylenglycol are equivalent. However, solutions containing mannitol and a low sodium concentration are better tolerated by the patients but the use of mannitol is limited because of the risk of releasing explosive gases during interventional endoscopy. To enhance the acceptance and palatibility of solutions for gut lavage containing polethylenglycol the addition of flavoured substances is recommended.
Abstract: Prostaglandin E ( 1 ) (PGE ( 1 ) ) is a naturally occurring paracrine hormone that is used pharmacologically for treatment of peripheral occlusive arterial disease and to maintain ductus-arteriosus patency in neonates with congenital heart disease until the primary condition is operable. PGE ( 1 ) treatment also has been associated with reduction in pulmonary arterial pressure and increase in cardiac output in patients with left ventricular failure. In contrast, in isolated cases, patients with heart failure reportedly have developed pulmonary edema while receiving PGE ( 1 ). Therefore, to better define the effect of PGE ( 1 ) in heart failure, this double-blind study investigated the effect of PGE ( 1 ) on extravascular lung water in intensive-care patients with severe heart failure (New York Heart Association [NYHA] classes III and IV) and slightly above-normal extravascular lung water. Intravenous infusion of 60 microg PGE ( 1 ) (Prostavasin; Schwarz Pharma, Monheim, Germany) over a period of 2 hours caused no significant change in lung water relative to the baseline values (9.8 +/- 4.3 mL/kg before the infusion, 9.3 +/- 3.2 mL/kg after 1 hour, and 9.4 +/- 3.5 mL/kg after 2 hours) or to values observed in placebo-treated patients (6.5 +/- 3.3 mL/kg before the infusion, 7.1 +/- 2.7 mL/kg after 1 hour, and 7.0 +/- 3.2 mL/kg after 2 hours). Thus, administration of PGE ( 1 ) is unlikely to cause or worsen pulmonary edema in patients with severe heart failure (NYHA classes III and IV).
Abstract: Prostaglandin E1 (PGE1) is a physiologic vasodilator, which is broadly used in the therapy of peripheral arterial occlusive disease. In addition, the successful use of PGE1 in patients with severe heart failure has been described in several studies, where a decrease in pulmonary artery pressure and an increase in cardiac output were observed. In contrast to these positive effects, the development of lung edema was reported in individual cases after the infusion of PGE1 in patients with heart disease. We therefore conducted a double-blind study to evaluate the effect of PGE1 on extravascular lung water (EVLW) in patients with heart failure (NYHA III-IV) and borderline increased EVLW. Seven patients received an infusion of PGE1 (Prostavasin) at a dosage of 60 micrograms over 2 hours, while in 6 patients (control group) isotonic saline was given as placebo. EVLW was measured using a double indicator method at time points -15 h, -9 h before and at the start of the infusion, 1 h and 2 h during infusion, as well as +1 h, +4 h, +7 h, and +22 h after termination of the infusion. Infusion of PGE1 did not alter EVLW both in comparison to pre-study values (9.8 +/- 4.3 ml/kg bw preinfusion. 9.3 +/- 3.2 ml/kg bw after 1 hour and 9.4 +/- 3.5 ml/kg bw after 2 hours) or to the control group (6.5 +/- 3.3 ml/kg bw preinfusion, 7.1 +/- 2.7 ml/kg bw after 1 hour and 7.0 +/- 3.2 ml/kg bw after 2 hours). We conclude that there is no evidence that PGE1 might contribute to the development, or worsening of lung edema by inducing extravascular lung water accumulation and can, thus, be savely given to patients with even a severe degree of heart failure (NYHA III-IV).
Abstract: Cognitive brain dysfunction is a common complication of end-stage renal disease. To investigate the cerebral effect of renal transplantation, we studied P300 event-related potentials--an objective marker of cognitive brain function--trailmaking test and Mini-mental state in 15 chronic hemodialysis patients and 45 matched healthy subjects. Before transplantation, patients showed prolonged P300 latency (364 vs. 337 ms, P < 0.01), smaller amplitude (15.2 vs. 19.1 microV) and scored lower (P < 0.05) in trailmaking test and Mini-mental state as compared to healthy subjects. Following renal transplantation (14 months), P300 latency decreased (337 ms, P < 0.01 vs. before) and amplitude increased (17.4 microV, P < 0.05 vs. before), indicating improved cognitive brain function. The trailmaking test and Mini-mental state tended to improve. Following transplantation, P300 findings, trailmaking test and Mini-mental state were not different from healthy subjects. Additional studies following erythropoietin treatment in 6 of the 15 hemodialysis patients revealed decreased (improved) P300 latency (351 vs. 379 ms before, P < 0.05) with further decrease following transplantation (341 ms, P = 0.06). Our findings indicate that cognitive brain dysfunction in hemodialysis patients may be fully reversed by successful renal transplantation.
Abstract: OBJECTIVE: To find the most adequate prognostic scoring system for predicting ICU-outcome in patients with decompensated liver cirrhosis in a medical intensive care unit (ICU). DESIGN: Retrospective analysis of patients' records over a 10-year period. SETTING: A medical ICU at the university medical center of Vienna. PATIENTS AND PARTICIPANTS: 94% (n = 198) of all patients with cirrhosis admitted to our medical ICU throughout the 10-year study period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: From data obtained at admission and at 48 h after admission, scores were calculated using the following scoring systems: Acute Physiology and Chronic Health Evaluation (APACHE) II and III, Scale for Composite Clinical and Laboratory Index Scoring (CCLI), Mayo Risk Score, and Child's Classification. Statistical analysis for the prognostic variables was performed using the chi-square test, t-test, Youden index, and area under a receiver operating characteristic (ROC) curve. APACHE III was found to be the most reliable outcome predictor at admission and after 48 h for patients with decompensated liver cirrhosis (AUC = 0.75 and 0.8, respectively). CONCLUSIONS: To predict the outcome for patients with decompensated cirrhosis of the liver admitted to a medical ICU liver failure alone is not decisive. Liver-specific scoring systems (Mayo Risk Score, CCLI) are adequate, but the APACHE II and III proved to be more powerful, because they include additional physiologic parameters and therefore also take into account additional complications associated with this liver disorder.
Abstract: INTRODUCTION: Patient Data Management Systems (PDMS) for ICUs collect, present and store clinical data. Various intentions make analysis of those digitally stored data desirable, such as quality control or scientific purposes. The aim of the Intensive Care Data Evaluation project (ICDEV), was to provide a database tool for the analysis of data recorded at various ICUs at the University Clinics of Vienna. SETTINGS: General Hospital of Vienna, with two different PDMSs used: CareVue 9000 (Hewlett Packard, Andover, USA) at two ICUs (one medical ICU and one neonatal ICU) and PICIS Chart+ (PICIS, Paris, France) at one Cardiothoracic ICU. CONCEPT AND METHODS: Clinically oriented analysis of the data collected in a PDMS at an ICU was the beginning of the development. After defining the database structure we established a client-server based database system under Microsoft Windows NI and developed a user friendly data quering application using Microsoft Visual C++ and Visual Basic; RESULTS: ICDEV was successfully installed at three different ICUs, adjustment to the different PDMS configurations were done within a few days. The database structure developed by us enables a powerful query concept representing an 'EXPERT QUESTION COMPILER' which may help to answer almost any clinical questions. Several program modules facilitate queries at the patient, group and unit level. Results from ICDEV-queries are automatically transferred to Microsoft Excel for display (in form of configurable tables and graphs) and further processing. CONCLUSIONS: The ICDEV concept is configurable for adjustment to different intensive care information systems and can be used to support computerized quality control. However, as long as there exists no sufficient artifact recognition or data validation software for automatically recorded patient data, the reliability of these data and their usage for computer assisted quality control remain unclear and should be further studied.
Abstract: OBJECTIVE: Computerized Patient Data Management Systems (PDMS) have been developed for handling the enormous increase in data collection in ICUs. This study tries to evaluate the functionality of such systems installed in Europe. DESIGN: Criteria reflecting usefulness and practicality formed the basis of a questionnaire to be answered accurately by the vendors. We then examined functions provided and their implementation in European ICUs. Next, an "Information Delivery Test" evaluated variations in performance, taking questions arising from daily routine work and measured time of information delivery. SETTING: ICUs located in Vienna (Austria), Antwerp (Belgium), Dortmund (Germany), Kuopio (Finland). PARTICIPANTS: 5 PDMS were selected on the basis of our inclusion criteria: commercial availability with at least one installation in Europe, bedside-based design, realization of international standards and a prescribed minimum of functionality. RESULTS: The "Table of Functions" shows an overview of functions and their implementation. "System analyses" indicates predominant differences in properties and functions found between the systems. Results of the "Information Delivery Tests" are shown in the graphic charts. CONCLUSIONS: Systems with graphical data presentation have advantages over systems presenting data mainly in numerical format. Time has come to form a medical establishment powerful enough to set standards and thus communicate with industrial partners as well as with hospital management responsible for planning, purchasing and implementing PDMS. Overall, communication between clinicians, nurses, computer scientists and PDMS vendors must be enhanced to achieve the common goal: useful and practical data management systems at ICUs.
Abstract: Elimination and hydrolysis of fat emulsions containing long-chain (LCT) or long- and medium-chain triglycerides (MCT, 50:50) were compared in eight patients with advanced chronic hepatic failure (CHF) and six healthy control subjects by using a two-stage constant infusion protocol. In control subjects clearance of MCT was slightly higher than that of LCT (1.93 +/- 0.34 vs 1.55 +/- 0.3 mL.kg-1.min-1, P < 0.05). The rise in plasma triglycerides was similar and the release of free fatty acids was higher during MCT (P < 0.02). In CHF patients, clearance of both LCT and MCT was comparable with that in healthy subjects and the rise in plasma triglycerides and release of free fatty acids was identical. We conclude that a clinically relevant infusion rates the elimination of lipid emulsions containing LCT or LCT and MCT and the release of free fatty acids thereof is not altered in patients with CHF and that intravenous lipids are a suitable source of energy and essential fatty acids (and phospholipids) for parenteral nutrition.
Abstract: The incidence of nosocomial pneumonia in long-term ventilated patients has been reduced by stress ulcer prophylaxis with sucralfate. In a double-blind trial we studied whether gentamicin administered topically to the oropharynx (OPG) had additional clinical benefits in these patients. 67 critically ill adult patients fulfilled entry criteria for > or = 5 days on ventilation. The OPG group received 40 mg gentamicin, the control group received 5% dextrose topically administered to the oropharynx 4 times a day. During OPG, pharyngeal colonization rate (21 vs 44%) and tracheal secretion colonization rate (12 vs 41%) were significantly lower than during placebo (p < 0.05). Despite these differences nosocomial pneumonia rate (3 vs 12%), duration of mechanical ventilation [15.8 +/- 11.1 vs 19.9 +/- 37.5 days (means +/- SD)] and mortality (27 vs 41%) were not significantly affected by OPG. Moreover, 13 of 15 bacteria (87%) that occurred during OPG were resistant to gentamicin. Despite its reduction of bacterial colonization rates of pharyngeal and tracheal secretions, OPG did not seem to offer additional clinical benefits in long-term mechanically ventilated patients on stress ulcer prophylaxis with sucralfate.
Abstract: Two hundred and forty-two elderly patients (> 65 years) with acute renal failure (ARF) treated at a predominantly medical intensive care unit between 1975 and 1990 were retrospectively analyzed for underlying diseases, severity of disease (as evaluated by the rate of ventilated patients, septicemia and APACHE II score, respectively), causes of ARF, acute and chronic risk factors for the development of ARF, complications during treatment and outcome. Overall mortality was 61%; 28 patients (12%) died in spite of resolution of ARF so actually, 49% of the patients died in ARF. Outcome was comparable to other age groups with overall mortality being 57% in patients < 18 years and 59% in those 19-65 years. Moreover, within the group of elderlies mortality did not increase with age and was 60% in those aged 65-68 and 54% in those aged > 80 years, respectively. The need for renal replacement therapy, plasma creatinine > 6 mg/dl, anuria, BUN > 120 mg/dl, ventilator dependency and the presence of septicemia all negatively affected outcome. During the years 1975 to 1990 mortality decreased from > 70% to < 50% (p < 0.02). This improvement of survival was seen in spite of an increase in the severity of disease (1975-1982: 20% ventilated patients, 24% with septicemia, 1983-1990 51% and 40%, respectively, p < 0.01). We conclude that age per se is not an important determinant of survival in patients with ARF and that prognosis has improved considerably during the last 15 years and this was seen in spite of an increase in the severity of disease. It is not justified to withhold therapy in elderly patients acquiring ARF.
Abstract: The elimination of intravenously infused amino acids was evaluated in six patients with acute renal failure (ARF), 6 with conservatively treated chronic renal failure (CRF), 6 subjects receiving regular hemodialysis treatment (RDT), and 5 healthy control subjects. In ARF, CRF, and RDT groups, whole-body clearance (Cltot) of the 10 amino acids was elevated (113.5 +/- 1.5; 94.2 +/- 1.5 and 127.6 +/- 12.4, respectively, vs 85.2 +/- 4.8 mL.kg-1.min-1 in control subjects, P < 0.001). In ARF, Cltot of histidine, lysine, and methionine was higher and Cltot of phenylalanine and valine was lower as compared with control subjects. In CRF, Cltot of tryptophan and histidine was elevated and Cltot of phenylalanine was reduced; in RDT, Cltot of histidine, methionine, tryptophan, lysine, isoleucine, and leucine was raised. In all groups the relative clearance (% of total clearance) of phenylalanine and valine was reduced, and relative clearance of histidine and tryptophan was elevated. We conclude that in renal failure the elimination of amino acids from the intravascular space is profoundly altered and that the pattern of metabolic aberrations is similar in ARF, CRF, and RDT groups.
Abstract: Prediction of individual outcome after cardiopulmonary resuscitation is of major medical, ethical, and socioeconomic interest but uncertain. We studied the early predictive potency of evoked potential recording after cardiac arrest in 66 resuscitated patients who returned to spontaneous circulation but were unconscious and mechanically ventilated. Detailed long-latency and short-latency sensory evoked potentials were recorded and neurological evaluations were done 4-48 h after admission to intensive care. In all 17 patients with favourable outcome (cerebral performance categories 1 and 2) the cortical evoked potential N70 peak, a reliable measure of cortical function, was detected between 74 and 116 ms. In 49 patients with bad outcome (categories 4 and 5) the N70 peak was absent in 35 or found with a delay between 121 and 171 ms in 14 (p < 0.05 vs favourable outcome). Thus the predictive ability was 100% with cutoff of 118 ms. To confirm reproducibility and validity, repeated tracings, and linked-earlobe referenced techniques were done and gave similar results. Early recording of long-latency evoked potentials after cardiopulmonary resuscitation is highly predictive of outcome.
Abstract: Two chronically ill patients with limited nutritional intake during several weeks developed prolonged lactic acidosis. As no other causes of hyperlactaemia could be identified, thiamine deficiency was suspected. Supplementation of 600 mg thiamine resulted in a rapid normalisation of serum lactate levels (in patient 1 from 10.9-2.4 mmol/l; in patient 2 from 11.8-2.0 mmol/l) and acid base status (patient 1: pH from 7.11-7.30, bicarbonate from 8.6-21.2 mmol/l; patient 2: pH from 7.24-7.46, bicarbonate from 16-28 mmol/l; before and after treatment, respectively). Thiamine deficiency was confirmed by the degree of stimulation of erythrocyte transketolase activation by adding thiamine pyrophosphate, evaluated before and after thiamine replacement therapy. Stimulation decreased in patient 1 from 170% to 17% and in patient 2 from 20% to 0%, respectively. In addition to the metabolic derangement right ventricular heart failure was confirmed by echocardiography in both patients and again this was rapidly reversible by thiamine supplementation. We conclude that in malnourished patients unexplained prolonged lactic acidosis may result from thiamine deficiency, which is rapidly reversible by thiamine replacement therapy.
Abstract: This case report describes the successful treatment of severe methotrexate intoxication in a 72-year-old female patient. Following two prior uneventful courses of a polychemotherapy regimen including low-dose intravenous (i.v.) methotrexate, the patient presented with fever, polymucositis, incipient pyodermia, acute renal failure and pancytopenia 9 days after the third application. Severe methotrexate overdose was confirmed by serum levels. Using a polypragmatic treatment approach focusing on renal function and including granulocyte-macrophage-colony-stimulating factor (GM-CSF) this life threatening and nearly fatal intoxication was successfully treated. This case report demonstrates that GM-CSF might contribute to rapid reconstitution of leukopoiesis once methotrexate serum levels are in the subtoxic range.
Abstract: Endothelin-1 (ET-1), a potent vasoconstrictor peptide produced by endothelial cells and degraded predominantly in the pulmonary vasculature, has been implicated in the development of various organ dysfunctions. To determine the pathophysiologic role of ET-1 in adult respiratory distress syndrome (ARDS) and the impact of impaired lung function on transpulmonary peptide handling, we compared plasma levels and pulmonary ET-1 balance in 14 patients with ARDS and in seven healthy control subjects. To obtain comparable conditions in both groups, the ET-1 level was raised in the control group by exogenous infusion (0.4 pmol/kg/min) to 9.4 +/- 0.8 pmol/L. ARDS was accompanied by a hyperdynamic circulatory pattern with increased cardiac output and depressed total vascular resistance but, simultaneously, pulmonary hypertension. Venous ET-1 concentration was massively increased in ARDS (9.8 +/- 1.2 versus 2.1 +/- 0.2 pmol/L, p < 0.001). In control subjects, the lung cleared the major fraction of ET-1 (fractional extraction 43 +/- 8.8%, uptake 12.5 +/- 2.5 pmol/min). In contrast, in ARDS there was a pronounced pulmonary releases into the circulation (32.8 +/- 10.3 pmol/min). We conclude that ET-1 concentrations are elevated in ARDS as the result of both increased formation and decreased disposal. Lung failure affects not only gas exchange but also nonrespiratory, metabolic pulmonary functions.
Abstract: The hemorrheological determinants plasma fibrinogen, plasma viscosity, red cell aggregation, and hematocrit were studied in 11 patients before and 4 and 24 hr after a 15 g immunoglobulin infusion to assess the effect of intravenous immunoglobulin administration on blood rheology in septic shock. Four hr after the immunoglobulin administration, plasma fibrinogen decreased significantly [472 (175-950) vs. 522 (182-1,050) mg/dl before administration; median (range); P < 0.01]; after 24 hr, plasma fibrinogen tended to increase again [501 (185-980); n.s.]. No changes were seen in plasma viscosity, red cell aggregation, hematocrit, and coagulation status 4 and 24 hr after immunoglobulin administration. In patients with septic shock, intravenous immunoglobulin administration leads to a decrease in plasma fibrinogen, whereas plasma viscosity and red cell aggregation remain unaffected. The explanation for the decrease in fibrinogen remains speculative.
Abstract: Elimination and hydrolysis of fat emulsions containing long-chain (LCT; Intralipid) or long- and medium-chain triglycerides (MCT; Lipofundin MCT) were compared in seven patients with acute renal failure (ARF) and six healthy control subjects. In control subjects, clearance of MCT was slightly higher than that of LCT (1.93 +/- 0.34 vs 1.55 +/- 0.3 mL.kg body wt-1.min-1, P less than 0.05). The rise in plasma triglycerides was similar and the release of free fatty acids was higher during MCT (P less than 0.02). In ARF, clearance of both LCT and MCT was equally reduced (0.53 +/- 0.12 vs 0.59 +/- 0.14 mL.kg body wt-1.min-1, P less than 0.01 vs control subjects). Again, the rise in triglycerides was comparable. Free fatty acid release was higher during MCT but lower than in control subjects. Plasma concentrations of glucose and lactate were not affected in control subjects but increased during both LCT and MCT in ARF. Thus elimination of both LCT and MCT is profoundly decreased in ARF. The impaired lipolysis in ARF cannot be circumvented by the use of MCT.
Abstract: In the presence of ascites ultrasound is not appropriate to distinguish between gallbladder perforation and acute acalculous cholecystitis. However, the correct and early diagnosis of gallbladder perforation is important for the treatment and prognosis. We report 4 critically ill patients with ascites. All patients had evidence of gallbladder perforation by ultrasound and underwent cholecystectomy: 2 patients had gallbladder perforation, but 2 had acalculous cholecystitis without perforation. Markedly elevated serum alkaline phosphatase was the only discriminating finding indicating gallbladder perforation.
Abstract: The impact of renal failure on the elimination and hydrolysis of three sources of tyrosine for parenteral nutrition, the dipeptides alanyltyrosine (Ala-Tyr), glycyltyrosine (Gly-Tyr), and N-acetyltyrosine (NAc-Tyr) was investigated in eight patients on regular hemodialysis therapy (HD) and seven healthy controls (CON). In CON, whole body clearance (Ctot) of Ala-Tyr (3,169 +/- 198 ml/min) was higher than Gly-Tyr (1,781 +/- 184, P less than 0.001), and both exceeded NAc-Tyr (284 +/- 24, P less than 0.001). In HD, Ctot of Ala-Tyr was not different from CON, but Ctot of Gly-Tyr (858 +/- 73, P less than 0.001) and NAc-Tyr (129 +/- 30, P less than 0.02) was decreased. The rise in plasma levels of constituent amino acids was higher in Ala-Tyr vs. Gly-Tyr (P less than 0.01). In HD, the pattern was similar, although the increase in Tyr was less than in CON. Plasma Tyr did not increase with NAc-Tyr in either group. Urinary loss of peptides was neglible, but 60% of NAc-Tyr infused was excreted by CON. The half-life of peptides incubated in CON and HD plasma was unchanged for Ala-Tyr (12.3 +/- 0.9 vs. 14.6 +/- 1.9 min) and prolonged for Gly-Tyr in HD (101.7 +/- 4.9 vs. 131.3 +/- 12, P less than 0.05). Thus renal failure does not impair Ala-Tyr disposal and delays Gly-Tyr utilization. These differential effects on peptide assimilation underscore the importance of peptide structure on metabolism. Both peptides, but not NAc-Tyr, may serve as a nutritional substrate in renal failure patients.
Abstract: Diagnostic and prognostic value of evoked potentials (EP) were studied in 5 patients with severe herpes simplex encephalitis (HSE). Latency of the third negative cortical N70 peak, elicited by median nerve stimulation, was prolonged in 3 survivors with Glasgow coma score of less than or equal to 6 (115 vs 71 ms in controls, p less than 0.05), but normal after improvement of the acute disease. N70 right to left interhemisphere difference was increased initially in the 4 survivors (26 vs 3 ms in controls, p less than 0.05) indicating focal brain involvement, a crucial finding in HSE. The first cortical N20 peak was preserved in all survivors even during deep coma where evaluation of brain function is difficult. Auditory brainstem EP were normal in all patients and useful to exclude brainstem death. In severe HSE, somatosensory long-latency EP are an effective monitor of the level of impaired consciousness and can detect brain focal signs. Short-latency N20 components may be predictive of the outcome.
Abstract: Transplantation of the lung has gained increasing importance during the last years and is now an established therapy for end stage lung disease. After a 3 years period of preparation the first single lung transplantation (SLTX) was performed at the Second Surgical Department of the University of Vienna in November 1989, followed by the first double lung transplantation (DLTX) in April 1990. Until the end of 1990 11 patients underwent SLTX and 6 DLTX. 7 of the 11 SLTX patients and 4 of the 6 DLTX patients are at present alive with significantly improved lung function and therefore markedly improved quality of life.
Abstract: Forty cases of hemolysis (drop of hematocrit greater than 12%/12 h) were retrospectively analyzed for hyperamylasemia and pancreatic complications. In 15 subjects the serum amylase level was greater than 360 U/l, i.e., three times the normal range, in ten the amylase level exceeded 900 U/l. Excluding patients in circulatory shock and/or hepatic coma, acute pancreatitis as defined by an elevation of serum amylase and clinical signs (epigastric pain) was present in four, with additional ultrasound findings (pancreatic swelling) and/or laparatomy/postmortem findings in a further six subjects (total ten patients = 25%) with various causes of hemolysis: autoimmune hemolysis 2, microangiopathic hemolytic anemia 2, toxicemia, G-6-PDH deficiency, septic abortion, malaria, Wilson's disease, and hypophosphatemia, one case each. In all subjects acute renal failure and in seven an activation of intravascular coagulation was seen. Three patients died (33% vs 47% of all hyperamylasemic patients and 46% of the whole group), but none of the deaths was attributed to pancreatitis. Pancreatic postmortem findings were diffuse edema and patchy parenchymal necrosis in two cases and petechial bleeding in one case. We conclude that acute pancreatitis is a complication of massive hemolysis, occurring at a prevalence of above 20%. It may progress from diffuse edema and inflammation to focal necrosis, rarely if ever to gross hemorrhage, and does not contribute to the high mortality of massive hemolysis. Back pain in hemolysis might originate from the pancreas rather than from the kidneys.
Abstract: In 11 patients with decompensated cirrhosis and deteriorating renal function, the effect of the vasoconstrictor substance 8-ornithin vasopressin (ornipressin; POR 8; Sandoz, Basel, Switzerland) on renal function, hemodynamic parameters, and humoral mediators was studied. Ornipressin was infused at a dose of 6 IU/h over a period of 4 hours. During ornipressin infusion an improvement of renal function was achieved as indicated by significant increases in inulin clearance (+65%), paraaminohippuric acid clearance (+49%), urine volume (+45%), sodium excretion (+259%), and fractional elimination of sodium (+130%). The hyperdynamic circulation was reversed to a nearly normal circulatory state. The increase in systemic vascular resistance (+60%) coincided with a decrease of a previously elevated renal vascular resistance (-27%) and increase in renal blood flow (+44%). The renal fraction of the cardiac output increased from 2.3% to 4.7% (P less than 0.05). A decline of the elevated plasma levels of noradrenaline (2.08-1.13 ng/mL; P less than 0.01) and renin activity (27.6-14.2 ng.mL-1.h-1; P less than 0.01) was achieved. The plasma concentration of the atrial natriuretic factor increased in most of the patients, but slightly decreased in 3 patients. The decrease of renal vascular resistance and the increase of renal blood flow and of the renal fraction of cardiac output play a key role in the beneficial effect of ornipressin on renal failure. These changes develop by an increase in mean arterial pressure, the reduction of the sympathetic activity, and probably of an extenuation of the splanchnic vasodilation. A significant contribution of atrial natriuretic factor is less likely. The present findings implicate that treatment with ornipressin represents an alternative approach to the management of functional renal failure in advanced liver cirrhosis.
Abstract: Acute methadone detoxification was induced by the intravenous administration of naloxone during simultaneous intravenous sedation with midazolam, a fully reversible short-acting benzodiazepine, in seven patients addicted to opiates. Within hours the patients tolerated full doses of naltrexone. This technique enables patients to transfer easily, quickly, and safely from methadone to naltrexone maintenance.
Abstract: OBJECTIVE: To evaluate the impact of respiratory alkalosis on the elimination of intravenously infused lactate. DESIGN: Prospective, randomized, crossover study. SETTING: Medical ICU of a university hospital. PATIENTS: Eight patients treated by ventilatory support for neurologic or neuromuscular diseases. INTERVENTIONS: Patients were investigated on two occasions: during normoventilation (pH 7.42 +/- 0.1, PCO2 41 +/- 2 torr [5.5 +/- 0.2 kPa]) and during respiratory alkalosis (pH 7.59 +/- 0.1, PCO2 27 +/- 2 torr [3.6 +/- 0.2 kPa]) induced by controlled hyperventilation. To evaluate lactate elimination kinetics, 1 mmol/kg body weight of L-lactic acid was infused over 5 mins. MEASUREMENTS AND MAIN RESULTS: Arterial lactate concentrations and blood gas values were determined before and repeatedly after the infusion. Lactate elimination variables were calculated from the plasma curve by using a two-compartment model. Respiratory alkalosis increased plasma lactate from 1.56 +/- 0.1 to 2.49 +/- 0.2 mmol/L (p less than .001). The lactate elimination half-life increased from 4.57 +/- 0.2 mins at pH 7.42, to 9.96 +/- 1.1 mins during pH 7.59 (p less than .01), and beta half-life increased from 12.2 +/- 1.9 to 44.1 +/- 1 mins (p less than .01). Whole-body clearance decreased 40% from 24.2 +/- 2.9 to 14.3 +/- 2.0 mL/kg body weight-min (p less than .01). CONCLUSIONS: Respiratory alkalosis increases the basal concentration of plasma lactate and decreases clearance of infused lactic acid. These findings provide further evidence of the adverse effects of alkalosis.
Abstract: In 27 (78%) of 36 patients with massive hemolysis (defined as a fall in hematocrit of more than 12% within 12 h due to intravascular red cell destruction), hypertriglyceridemia (plasma triglycerides greater than 175 mg/dl) was present or appeared within two days after the hemolytic crisis. Eighteen subjects with triglycerides exceeding 300 mg/dl (peak 516 +/- 39 mg/dl) were further analyzed. The development of hyperlipidemia was independent of the etiology of hemolysis (microangiopathic hemolytic disease 7, toxicemia 3, parainfectious complications 3, autoimmune hemolysis 2, glucose-6-phosphate dehydrogenase deficiency 2). Factors known to increase plasma triglycerides, such as shock, infections, or pancreatitis, were present in only a few cases. Hemolysis-associated complications were activation of intravascular coagulation (16), coma (13), acute renal failure (13), and respiratory insufficiency (5), organ dysfunctions indicating diffuse microvascular injury. Plasma triglycerides fell within a few days if the cause of red cell destruction was eliminated. In 5 of the 8 patients presenting with triglycerides below 175 mg/dl, severe hepatic dysfunction was present. We conclude that hemolysis causes transient hyperlipidemia, either directly by red cell destruction or indirectly by inducing intravascular coagulation, and possibly due to both increased triglyceride synthesis and decreased catabolism.
Abstract: Energy expenditure and substrate oxidation rate for fat, glucose and protein were evaluated by indirect calorimetry in 20 normal individuals, 35 patients with acute hepatitis and 22 patients with biopsy-proven alcoholic cirrhosis in the postabsorptive state. Measurements were done in the resting state after an overnight fast (10 to 12 hr). Oxygen consumption (ml/min/1.73 m2) in normal subjects, in patients with acute hepatitis and in patients with cirrhosis was 206.5 +/- 4.0 (mean +/- S.E.M.), 216.4 +/- 4.7 and 228.8 +/- 7.1 (p less than 0.05 vs. controls), respectively. When related to body surface area (kcal/min/1.73 m2), resting energy expenditure did not differ between normal subjects (0.98 +/- 0.02), patients with acute hepatitis (1.03 +/- 0.02) and cirrhotic patients (1.06 +/- 0.03). However, when related to 24-hr urinary creatinine excretion as an estimate of lean body mass, energy expenditure was increased in cirrhosis (p less than 0.0001). In cirrhosis an inverse association between the severity of liver disease according to Pugh and oxygen consumption and resting energy expenditure was found. In cirrhotic patients the percentages of total calories derived from fat (86% +/- 5%), carbohydrate (2% +/- 4%) and protein (12% +/- 1%) were different from those of normal controls who metabolized 45% +/- 4%, 38% +/- 4%, 17% +/- 1%, respectively. In acute hepatitis no alterations in metabolism could be found apart from a decreased protein oxidation rate. In conclusion no appreciable changes in energy metabolism exist in acute hepatitis. The pattern of fuel use in cirrhosis resembles that in starvation.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Energy metabolism was measured by indirect calorimetry in 86 patients with various forms of renal failure and in 24 control subjects. In patients with acute renal failure with sepsis, oxygen consumption, carbon dioxide production, and resting energy expenditure were increased (P less than 0.05). In other groups with renal failure (acute renal failure without sepsis, chronic renal failure with conservative treatment or hemodialysis, and severe untreated azotemia) these indices were not different from those of control subjects. Urea nitrogen appearance was decreased in patients with chronic renal failure undergoing conservative treatment, in those with severe untreated azotemia, and in hemodialysis patients (P less than 0.05). We conclude that renal failure has no influence on energy expenditure as long as septicemia is absent. Reduced urea nitrogen appearance rates in chronic renal failure are due to a reduced energy and protein intake. Wasting is a consequence of decreased food intake but not of hypermetabolism in chronic renal failure.
Abstract: The present study was designed to investigate hemodynamics and gas exchange during weaning from mechanical ventilation (assist/control mode) to spontaneous breathing with continuous high flow (chf)-CPAP, and to study the predictive value of these parameters in respect of longterm success or failure of weaning. Hemodynamic and gas exchange parameters were obtained in 10 patients without severe pulmonary and cerebral dysfunction at -240, -60, -30, and -15 min before, and at +15, +30, +45, +60, +120, +180, +240 min after chf-CPAP. During chf-CPAP significant increases in heart rate/min (92 +/- 17 to 103 +/- 20), cardiac index (3.9 +/- 0.7 to 4.4 +/- 1.0 1/min.m2), respiratory rate/min (15 +/- 1 to 28 +/- 7), PaCO2 (36.7 +/- 3.0 to 41.2 +/- 5.9 torr) and oxygen delivery (12.2 +/- 2.7 to 13.9 +/- 2.3 ml/min.kg) were found. Arterial and pulmonary artery pressures rose only briefly within the first hour. All other parameters changed non-significantly. In the 4 patients who required mechanical ventilation 12 to 34 hours after the end of the study we found a significantly more pronounced increase in heart rate than in those who where weaned successfully (114 +/- 19 vs 89 +/- 9). Increases in heart rate, respiratory rate, cardiac index, PaCO2 and oxygen delivery can therefore be expected during weaning from mechanical ventilation to spontaneous breathing with CPAP. A pronounced increase in heart rate may suggest a weaning failure.
Abstract: In a double-blind placebo-controlled trial of 18 patients, methohexitone blocked objective signs of opiate withdrawal caused by a bolus injection of naloxone. Furthermore, in continuing the naloxone therapy for 48 hours, no withdrawal signs appeared. Levels of withdrawal distress returned to normal levels within six days. This approach can be regarded as an effective and well tolerated withdrawal therapy with low drop-out rates.
Abstract: During a constant infusion of dopamine (DA 4.5 micrograms/kg/min), the plasma levels of DA reached at 30 min of infusion were 81 +/- 6.9 ng/ml and 71.6 +/- 14.8 ng/ml in patients with hepatic encephalopathy (HE) and control patients, respectively. In both groups of patients, the plasma levels of DA did not change between 30 and 60 min of continuous DA infusion. The DA infusion was associated with an increase of arterial blood pressure, heart rate and cardiac index. In the patients with HE, the increase in cardiac index was directly correlated with the plasma level of DA (r = 0.843, p less than 0.01). The present results clearly demonstrate that in HE circulating DA does not accumulate during continuous infusion of DA. They further provide evidence that the increase in circulating catecholamines in HE reflects increased release from the sympatho-adrenal system.
Abstract: In a small clinical trial, a new therapeutic approach was studied, whether naloxone, in high dosage over a prolonged period of time, will attenuate withdrawal symptoms in acute opiate detoxification. Six opiate addicts, satisfying DSM III-R criteria of opiate dependence, were given 10 mg naloxone under short barbiturate anaesthesia, followed by repeated doses of 0.4 mg/h naloxone for at least 72 h. Acute onset of withdrawal symptoms brought about a high dose of naloxone could be suppressed by the short barbiturate anaesthetic; neither continuous supply nor cessation of the naloxone regimen after 96 h caused any severe withdrawal symptoms. Morphine and naloxone measurements in blood at the start of naloxone therapy enabled pharmacokinetic explanations for this paradoxical action of naloxone to be excluded.
Abstract: In nine patients with decompensated alcoholic cirrhosis of the liver and impaired renal function the effect of 8-ornithin vasopressin (ornipressin) on renal function and haemodynamic parameters was studied. Ornipressin was infused at a dose of 6 IU/h over a period of four hours. During ornipressin infusion an improvement of renal function was achieved as indicated by an increase of creatinine clearance (76 (15)%; p less than 0.01), urine volume (108 (29)%; p less than 0.05) and sodium excretion (168 (30)%; p less than 0.05). The hyperdynamic circulation of hepatic failure, as characterised by increased cardiac index and heart rate as well as decreased systemic vascular resistance was reversed to a nearly normal circulatory state during ornipressin infusion. The raised noradrenaline plasma concentration (1.74 (0.31) ng/ml) and plasma renin activity (13.5 (3.9) ng/ml/h) were lowered during ornipressin infusion to 0.87 (0.21) ng/ml and 5.9 (2.1) ng/ml/h, respectively (p less than 0.01). The efficacy of a vasoconstrictor agent in reverting a hyperdynamic state and improving renal function provides evidence for the substantial role of accumulation of vasodilator substances and subsequent activation of sympathetic nervous system and renin-angiotensin-axis in the pathogenesis of renal dysfunction in hepatic failure. Values are expressed as mean (SE).
Abstract: For opiate detoxification 6 volunteer opiate addicts were intravenously administered 10 mg naloxone within one hour while under barbiturate anesthesia. During administration of naloxone none of the patients demonstrated significant changes in the hemodynamic parameters of heart rate, mean arterial pressure, cardiac index, peripheral resistance or in the oxygen saturation. After patients awoke from anesthesia, they experienced no or only minimal withdrawal symptoms. Possible explanations for the suppression of withdrawal symptoms are discussed.
Abstract: Oxygen consumption was measured simultaneously by the reverse Fick-principle (V02FICK) and by indirect calorimetry ("Metabolic Measurement Cart Horizon") (V02MMC) in 31 critically ill patients; 24 men and 7 women. Seventeen patients were breathing spontaneously, 14 patients were on mechanical ventilation. The fractional inspiratory oxygen concentration (FI02) in ventilated patients ranged from 0.21 to 0.4 (mean 0.302). Total oxygen consumption as measured by indirect calorimetry was 286.7 +/- 59.7 ml/min (mean +/- SD), and measured by reverse Fick-principle 258.9 +/- 52.2 ml/min (mean +/- SD). The coefficient of correlation between the two methods was r = 0.873. The absolute difference of oxygen consumption between reverse Fick-method and indirect calorimetry was 11.3%. Regression analysis according to Theil revealed a similar regression between spontaneously breathing and mechanically ventilated patients for the studied FI02 values below 0.4. It is concluded that indirect calorimetry is a reliable method for measuring oxygen consumption in spontaneously breathing as well as mechanically ventilated critically ill patients.
Abstract: Induced detoxification treatment of opiate addicts by means of naloxone was developed at the intensive care unit of the Department of Psychiatry at the University of Vienna. Two methods were tested 1. Rapid opiate withdrawal by means of a staggered naloxone regimen. 2. Ultrashort opiate detoxification during general anaesthesia using high doses of naloxone. In an open trial 15 patients were treated with staggered doses of naloxone while under tiapride. The various discomforts were satisfactorily reduced, and the detoxification syndrome was limited to 50 hours. In a second open trial 6 patients were administered 10 mg naloxone under general anaesthesia. All naloxone induced withdrawal syndromes can be suppressed by barbiturate anaesthesia. They do not appear even after the effect of the anaesthesia wears off if the patient is kept on a naloxone regimen as long as opiates remain present in the circulatory system. Both methods shorten detoxification treatment and provide smooth transition to a naltrexone maintenance programme.
Abstract: Several lines of evidence suggest that tyrosine formation is impaired in renal failure. The concentration of tyrosine is decreased and the phenylalanine/tyrosine ratio is increased in plasma and in skeletal muscle cells. After an oral or intravenous load, the rise of plasma phenylalanine is augmented, the clearance is decreased, oxidation is diminished and the corresponding rise of plasma tyrosine level is blunted. Tyrosine elimination and oxidation are not altered in uremia. The defect in tyrosine formation may be especially important in uremic patients on a low protein diet supplemented with tyrosine-free essential amino acid preparations and in subjects on artificial nutritional support. Thus, tyrosine should be regarded as a conditionally essential amino acid in renal failure and should be supplied exogenously, at least in these patient groups. Oral tyrosine supplementation was shown to replete plasma and intracellular pools and improve nitrogen balance in chronic renal failure patients on a low protein diet. However, because of poor solubility in aqueous solutions, tyrosine cannot be included in the free form in amino acid solutions for parenteral nutrition. To circumvent stability or solubility problems, tyrosine containing dipeptides and/or N-acetyl-tyrosine may serve as tyrosine sources for parenteral supply. Renal failure does not affect alanyl-tyrosine hydrolysis, and there is an immediate increase of plasma tyrosine concentration after peptide infusion. Elimination and hydrolysis of glycine-tyrosine is retarded in renal failure, but the clearance exceeds clinically relevant infusion rates. After infusion of N-acetyl-tyrosine, no increase in plasma tyrosine is seen, and the half-life N-acetyl-tyrosine is grossly prolonged in uremia.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Thirty-two long-term ventilated patients were randomly selected for a study of the efficacy of sucralfate (1 g six times per day via gastric tube) versus ranitidine (six 50-mg to six 100-mg doses per day intravenously) for the prevention of upper gastrointestinal bleeding. The patients of the two treatment groups (each 16) were comparable with respect to diseases precipitating acute respiratory failure and risk factors of bleeding, e.g., renal failure, thrombopenia, coagulopathy, and anticoagulant treatment. Mean duration of mechanical ventilation was 7.4 in sucralfate- and 7.7 days in ranitidine-treated patients. During mechanical ventilation, macroscopically visible bleeding developed in three of the sucralfate-treated (18.7 percent) and seven of the ranitidine-treated (43.7 percent) patients. Until the end of the study, only three of the sucralfate-treated but nine of the ranitidine-treated (56.2 percent) patients bled; the difference between the two treatment groups was at all times significant (p less than 0.05). Packed red blood cells had to be administered to the three bleeding patients in the sucralfate group and to seven bleeding in the ranitidine group. Therefore it seems that sucralfate prevented mostly minor bleeding. The high bleeding rate during ranitidine treatment was presumably due to the high number of pH-nonresponders, as almost 30 percent of the gastric aspirates of this group had a pH less than 5. During treatment no difference was found in positive blood culture specimens and bronchial secretions between the two groups. However, nosocomial pneumonia developed in two ranitidine-treated patients, whereas that complication developed in none of the sucralfate-treated patients. In long-term ventilated patients, sucralfate prevented minor upper gastrointestinal bleeding significantly better than ranitidine. However, this does not imply that major upper gastrointestinal bleeding can be prevented by either sucralfate or ranitidine in these patients.
Abstract: Fluid replacement is a major issue in the treatment of patients with diabetic ketoacidosis. During this therapy, development of pulmonary edema has been reported and attributed to an increase in pulmonary microvascular pressure and a decrease in colloid-osmotic pressure (COP). Because clinically apparent pulmonary edema is associated with an increase in extravascular lung water (EVLW) and impairment of pulmonary gas exchange, we studied the effect of fluid replacement on EVLW, COP, pulmonary hemodynamics and gas exchange parameters in 8 patients with diabetic ketoacidosis (blood glucose greater than 300 mg/dl, pH less than 7.1). EVLW was estimated by the thermal-dye technique. All variables were successively determined upon admission (A), after initial fluid replacement (IFR), when glucose had fallen below 180 mg/dl, after 8 h of intravenous glucose treatment (G), and after 24 h of total parenteral nutrition (TPN). Despite a total net fluid intake of 6.0 +/- 1.61, a significant decrease (p less than 0.001) in COP from 29.6 +/- 5.5 at A to 18.8 +/- 2.2 mmHg after TPE and a significant increase (p less than 0.001) in PCWP from 4 +/- 2 at A to 10 +/- 3 mmHg after TPE, EVLW remained almost unchanged. EVLW was 5.1 +/- 2.8 at A, 5.3 +/- 2.1 after IFR, 4.8 +/- 1.4 after G, and 5.3 +/- 1.7 ml/kg after TPN. However, PaO2 decreased from 137 +/- 17 at A to 87 +/- 10 mmHg after TPE (p less than 0.001), while Qs/Qt increased significantly (p less than 0.05). The alterations in gas exchange may be indicative of pulmonary dysfunction but as they were not associated with accumulation of EVLW, they may as well reflect the compensation of metabolic derangements in diabetic ketoacidosis.
Abstract: Stress ulcer bleeding is a serious complication of critical illness and is associated with increased morbidity and mortality. For the prophylaxis of stress ulcers, antacids, H2-blockers, or sucralfate are prescribed. While H2-blockers inhibit the secretion of gastric acid, sucralfate appears to provide protection without reducing levels of gastric acid. Inhibition of acid secretion increases gastric pH, allowing bacterial overgrowth of the stomach by Gram negative bacteria, which colonize the pharynx and trachea and increase the risk of nosocomial pneumonia. For this reason, H2 blockers appear disadvantageous, though they offer adequate prophylaxis for stress ulcer bleeding. As it does not increase gastric pH, sucralfate provides adequate protection against Gram negative gastric overgrowth, however its prophylactic efficacy is not generally accepted. Therefore, we compared the H2-blocker ranitidine to sucralfate in the prophylactic treatment of stress ulcer bleeding and studied the incidence of positive bacteriological findings in the blood and bronchial secretions of the two groups. In a randomized study, 84 patients undergoing general intensive care received either ranitidine (6 x 50 to 6 x 100 mg daily i.v.) or sucralfate (6 x 1 g via gastric tube or per os). Both groups were comparable with respect to age, underlying disorders, and factors predisposing to the development of stress ulcers.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: The effects of the benzodiazepine antagonist flumazenil were studied in 20 episodes of hepatic encephalopathy (HE) in 17 patients with acute (n = 9) or chronic (n = 8) liver failure who had not responded to conventional therapy. Patients with a history of benzodiazepine intake were excluded. Changes in HE stage, in Glasgow coma scale, and in somatosensory evoked potentials were measured. In 12 of 20 episodes HE stage improved. The response to treatment occurred rapidly (within 3-60 min). In 8 of these 12 episodes HE worsened 0.5-4 h after treatment. In 5 of the 8 episodes that did not respond to flumazenil patients had clinical evidence of brain oedema. Flumazenil may be valuable in the treatment of HE in acute and chronic liver failure.
Abstract: The hemodynamic pattern in patients with cirrhotic liver disease shows a hypercirculatory state, with elevated cardiac output and decreased systemic vascular resistance. Studies on myocardial function gave different results, whereby non hepatic factors as a cause of myocardial dysfunction are reasonable. Decreased vascular resistance is predominantly caused by an accumulation of vasodilating substances. A dysfunction of vasoconstricting systems could not be found. A previously discussed interference of the sympathetic nervous system could not be confirmed in further studies. This hypercirculatory state may be catastrophic in hypovolemic states, as in acute bleeding, or concomitant septic hyperdynamic states, because the initial compensatory mechanisms are not available any more.
Abstract: Hemofiltration has been advocated for reduction of extravascular lung water (EVLW) in both clinical and experimental ARDS. The influence of hemofiltration on EVLW was studied retrospectively in 10 patients with this syndrome. After 2 to 38 hours' hemofiltration net fluid balance was -3640 +/- 3609 ml. EVLW remained almost unchanged (from 17.6 +/- 5.4 before to 15.6 +/- 4.1 ml/kg after hemofiltration). In 4 patients a reduction of over 15% in EVLW was achieved, whereas in the remaining 6 patients EVLW changed within a range of +/- 10%. However, hemofiltration caused a decrease in cardiac output and oxygen delivery, thereby adversely affecting its benefits on EVLW and gas exchange. In ARDS hemofiltration should be performed under careful hemodynamic monitoring and only in some of the patients an immediate reduction in EVLW can be achieved.
Abstract: The influence of high-dose prednisolone on extravascular lung water (EVLW) was studied in a randomized trial in patients with noncardiac pulmonary edema. The patients were treated every 6 hours for 48 hours with 2 g of prednisolone-hemisuccinate or placebo. In the prednisolone-group (n = 7) EVLW decreased from 16.4 +/- 6.2 before to 11.8 +/- 5.1 ml/kg after treatment (p less than 0.05). Additionally alveolar-arterial oxygen gradient (AaDO2/FiO2), pulmonary vascular resistance and heart rate decreased, while arterial oxygen tension (PaO2/FiO2) and mean arterial pressure increased (p less than 0.05). In the placebo-group (n = 7) EVLW increased slightly from 17.5 +/- 3.1 before to 19.3 +/- 10.3 ml/kg after treatment. Additionally all other parameters did not change significantly in this group. Although no statistical significant difference was found between the two groups of treatment, a decrease in EVLW was observed in all prednisolone-treated patients, whereas a pronounced increase in EVLW was found in 3 placebo-treated patients. Probably, those patients would have benefited from high-dose prednisolone treatment. High-dose prednisolone reduced EVLW and improved hemodynamics and gas exchange in patients with noncardiac pulmonary edema, whereas placebo did not achieve comparable effects. Therefore, high-dose prednisolone appears beneficial in noncardiac pulmonary edema in respect of EVLW, hemodynamics, and gas exchange.
Abstract: Intravenous bolus kinetics of amino acids and calculation of the kinetic parameters with an 1-compartment model revealed weak spots. Therefore, a new study design with a loading and maintenance dose and description of the plasma concentration time data with a 2-compartment model was created and studied in 9 healthy volunteers. After an over night fast the amino acid mixture Thomaeamin n 10% was infused with a loading dose of 20 mg AA/kg-1 X min-1 for 5 min and a maintenance dose of 5 mg AA/g-1 X min-1 for 55 min. The postinfusion period lasted 120 min. The PAA was determined with a Biotronic LC 6001 and the kinetic parameters were calculated by a Wang 2200 computer with the TOPFIT program package. The results showed mean values (means +/- SE) of the volume distribution between 4.7 +/- 0.6 till 9.4 +/- 1.8 liters, an elimination rate constant of 1.7 +/- 0.5 till 11.0 +/- 2.0 h-1, a total clearance of 186 +/- 37 till 846 +/- 66 ml X min-1 and transfer or endogenous production rate between 12 +/- 0.8 till 135 +/- 16 mumol kg-1 X h-1. The total transfer amounts to 17.6 mmol kg-1 X d-1 (= 2.2 g AA/kg-1 X d-1). It can be concluded that an optimal study design for the investigation of AA kinetics should increase the PAA levels 2-3 fold above basal during the infusion period.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: The pharmacokinetics of ceftazidime and netilmicin were evaluated under septicemic conditions. In a longitudinal study, both drugs were administered simultaneously (ceftazidime 2.0 g 20 min constant i.v. infusion and netilmicin 150 mg i.v. bolus injection) every 12 hours to patients who had a positive blood culture and hyperdynamic circulatory functions. Twenty-four hours after the first period of this pharmacokinetic study, identical parameters were evaluated under dipyrone induced normothermic conditions. The mean residence time and the volume of distribution was significantly altered during septicemia compared to normal conditions. With respect to the relative distribution properties ceftazidime tended to be distributed to a greater extent to the tissue compartment, whereas netilmicin showed an opposite behaviour. Beside significant correlations of absolute values, i.e. blood volume vs. volume of distribution, and relative values, i.e. total peripheral resistance vs. extraction rate, all other attempts failed to show any meaningful correlation. Owing to the heterogenous alterations of metabolic and hemodynamic functions and pharmacokinetic parameters, respectively, the data gained from this study do not allow any statistically validated conclusion regarding the pathophysiological mechanisms involved, although these findings are in accordance with animal experiments.
Abstract: Resting energy expenditure was measured by indirect calorimetry in 11 patients (8 men, 3 women) with severe heart failure. The study was done after an over night fast (10-12 h). 5 patients suffered from idiopathic cardiomyopathy, 5 patients from coronary heart disease and 1 patient from congestive heart failure following from viral myocarditis. The cardiac index was 2.09 +/- 0.5 l/min/m2, the pulmonary capillary wedge pressure 24.6 +/- 8.0 mm Hg. Resting energy expenditure was 1.175 +/- 0.176 kcal/min/1.73 m2. The basal energy expenditure calculated according to Harris and Benedict was 1.008 +/- 0.055 kcal/min/1.73 m2. The difference was statistically significant (p less than 0.05). Respiratory quotient was 0.775 +/- 0.06 as a result of a high oxidation rate for fat (64.8% of total energy expenditure). These results show that after an overnight fast the caloric requirements of patients with severe heart failure are increased. This increased energy expenditure could be an explanation for the malnutrition often found in patients with severe chronic heart failure.
Abstract: Reproducibility of thermal-dye extravascular lung water (EVLW) estimation by a lung water computer was studied by performing ten consecutive measurements in 45 critically ill patients. EVLW ranged over a wide spectrum from 187 to 1163 ml (2.4 to 18.6 ml/kg). The mean coefficient of variation of ten consecutive measurements was 13.6%. Spontaneously breathing patients showed significantly (p less than .05) higher coefficients of variation (16.1 +/- 6.8%) than patients on mechanical ventilation (10.8 +/- 4.2%). Other factors affecting reproducibility could not be clearly identified. Because in lung water estimation mean values of consecutive measurements are compared, we defined an EVLW determination as the mean value of three consecutive EVLW measurements. When comparing consecutive EVLW determinations in hemodynamically stable patients, we found in many that consecutive EVLW determinations varied no more than +/- 15%. These differences probably have to be attributed to the reproducibility of EVLW measurements and have to be considered, when changes in thermal-dye lung water measured by a lung water computer are discussed.
Abstract: Severe hyperlactemia of 8.7, 8.6 and 7.9 mmol/l, respectively, developed in three patients with hyperosmolar syndromes (two hypernatremic, 417 and 415 mosmol/kg H2O; one hyperglycemic 437 mosmol/kg H2O) during rehydration treatment with 5% fructose in water (fructose dosage 0.5 g/kg body wt. per hour). After resolution of the electrolyte disturbances, the infusion of fructose at the same dosage increased the plasma lactate concentration in two of the patients to 4.9 and 4.0 mmol/l, indicating near normalization of hepatic lactate utilization. Thus, in addition to peripheral insulin resistance and decreased muscular glucose utilization, the hyperosmolar state is associated with a reduced tolerance to fructose. This is most likely due to an osmolality-dependent impairment of hepatic gluconeogenesis. In rehydration therapy for hyperosmolar syndromes, fructose-containing infusion solutions should no longer be used.
Abstract: The use of positive end-expiratory pressure (PEEP) has been highly recommended because of its favourable effects on pulmonary gas exchange and circulation. It was the aim of this study to investigate the influence of PEEP on extravascular lung water (EVLW), which was estimated by the thermal-dye technique. In 12 intensive care patients PEEP was changed every 30 minutes from 0 to 5, 10, 15 and 0 cm H2O, thereby causing a non-significant increase in EVLW of 2, 10, 7 and 1%. Analysis of individual EVLW-dynamics revealed a more than 20% increase in 6 of 7 patients with normal EVLW (5.8 +/- 0.9 ml/kg), whereas this occurred in only one of the five patients with elevated EVLW (10.9 +/- 1.1 ml/kg). Intraindividual regression analysis between EVLW and PaO2/FiO2, AaDO2/FiO2, Qs/Qt, and CO revealed no correlation between these parameters. Therefore, shorttime application of PEEP did not affect EVLW. Patients with normal EVLW were more prone to show increased EVLW during PEEP than patients with elevated EVLW. PEEP-induced improvement of gas exchange and pulmonary shunt were not accompanied by changes in EVLW.
Abstract: A patient who received an erroneous transfusion of outdated and partly homogenized blood is reported. Although marked hemoglobinemia was present, only transient hemodynamic, pulmonary, and renal alterations were observed. Massive embolism of microaggregates and norepinephrine release might explain our findings. Dopamine (3 micrograms/kg . min) might have beneficial effects on renal function in this pseudohemolytic transfusion reaction.
Abstract: Plasma amino acid concentrations and the elimination of parenterally administered amino acids were investigated in 12 patients with nonhypercatabolic acute renal failure. A distinctive plasma amino acid pattern could be observed: plasma concentrations of phenylalanine and methionine were increased, those of valine and leucine decreased. Of the nonessential amino acids, cystine, taurine und tyrosine had elevated but none of them reduced plasma concentrations. The elimination of amino acids was evaluated in a monocompartment model after bolus injection of an amino acid solution containing essential and nonessential amino acids. Pharmacokinetic parameters of 17 amino acids were calculated. The mean elimination half-time was raised by 25%. The elimination half-time of phenylalanine, methionine, glutamic acid, proline and ornithine was increased. Histidine was the only amino acid with--however insignificantly--accelerated elimination from the intravascular compartment. The total clearance rate and total transfer rate was not altered (107 and 97% of normal, respectively). The clearance of threonine, lysine, serine, glycine and histidine was increased, of valine, phenylalanine, glutamic acid and to a minor degree of methionine was decreased. The transfer rate of methionine, lysine, glycine was elevated, of valine, aspartic acid, glutamic acid and ornithine reduced. The demonstration of these pronounced alterations of amino acid elimination in acute renal failure may have major consequences in parenteral amino acid therapy.
Abstract: Critically ill patients are prone to stress-induced ulcerations in the upper gastrointestinal tract, which might lead to life-threatening bleeding. Therefore, an effective stress ulcer prophylaxis is absolutely indicated and H2-blocking agents, anticholinergics, antacids, sucralfate, enteral nutrition and prostaglandin E analoges are recommended. H2-blocking agents seem to provide effective prophylaxis, but severe side effects seem to limit their application. Most of all, as they are less effective as antacids and as they cause considerable costs. Additionally H2-blocking agents elevate gastric pH, thereby favouring microbic colonisation of gastric juice. Microorganism from gastric juice may reach the tracheobronchial system and lead to nosocomial pneumonias. The contaminated gastric juice may also be considered as endogenous source for sepsis and entero-colitis. The anticholinergic agent pirenzepine does not increase gastric pH and seems to be effective in neurological and neurosurgical intensive care patients. Antacids are effective in stress ulcer bleeding prophylaxis, but favour bacterial overgrowth, are badly tolerated by patients and cause a high amount of nursing time. Sucralfate seems to be as effective as antacids, is better tolerated and does not elevate gastric pH. The remaining acidity of gastric juice blocks bacterial contamination. After all, the smallest costs of effective stress ulcer prophylaxis, makes sucralfate to the medicament of first choice. However, in severely ill patients, a combined stress ulcer prophylaxis with two or more agents seems to be necessary.
Abstract: Elimination of parenterally administered amino acids was investigated in patients with chronic renal failure (CRF) (10 on conservative treatment = CT, 13 on regular hemodialysis therapy = HD). In a bolus injection protocol 0.1 g amino acids as a 10% solution containing essential and nonessential amino acids were infused and pharmacokinetic parameters of 17 amino acids were calculated. The mean elimination half life was increased by 40% in CT and 87% in HD (p less than 0.001 CT and HD versus controls). Total clearance was reduced in CT (p less than 0.001 versus HD and controls). In CT clearance of phenylalanine, proline, alanine, histidine and arginine was reduced, of none of the amino acids elevated. In HD clearance of methionine, lysine, aspartic acid and serine was increased, of proline decreased. The total transfer rate was reduced in CT (p less than 0.025 versus controls) and transfer of threonine, aspartic acid, glutamic acid, alanine, histidine and arginine was reduced in these patients. Mainly due to elevated basal plasma concentration transfer of methionine was elevated in CT and HD. In dialysis patients transfer of isoleucine, tryptophan, glycine and serine was increased. Despite variations of absolute values of clearance between the two groups investigated relative clearance rates of amino acids were similar because of a uniform increase of clearance of about 37% in HD compared to CT (p less than 0.001). Results indicate that the elimination of parenterally administered amino acids is grossly altered in uremia and that in patients on CT and HD a uniform elimination pattern can be observed.
Abstract: Haemodynamic data were obtained in 26 patients with hepatic failure admitted to the intensive care unit of the First Department of Medicine, Vienna University. There was a significant increase in heart rate (101 vs 78 beats/min) and decreased diastolic pressure (56 vs 71 mm Hg) as compared with healthy persons. The cardiac index was elevated (5.1 vs 3.5 l/m2) and the total peripheral resistance was lowered (621 vs 1130 dyn/sec/cm-5). The systolic blood pressure was within the normal range except in 8 patients whose illness was complicated by sepsis. In those 8 patients the systolic blood pressure (86 vs 128 mm Hg), the diastolic blood pressure (42 vs 61 mm Hg) and the total peripheral resistance (434 vs 764 dyn. sec. cm-5) were all decreased as compared with patients with hepatocellular disease without sepsis. The decreased total peripheral resistance, however, was not associated with a further increase in the heart rate or stroke volume. On the contrary, in these 8 patients the left ventricular performance was lowered. The increase in cardiac output was not associated with an increase in oxygen consumption in patients without sepsis. Oxygen consumption was increased in patients with hepatocellular insufficiency and sepsis (157 ml/m2 vs 123 ml/m2) and this was accompanied by a diminished oxygen extraction rate (16% vs 26% in these 8 patients.
Abstract: Measurement of extravascular lung water (EVLW) was performed by the thermal-dye technique in 55 critically ill patients. The EVLW values were compared with the corresponding radiographic, hemodynamic and functional pulmonary data. EVLW values revealed a positive correlation with the chest X-ray score (CXR) (r = 0.836; p less than 0.001), mean pulmonary artery pressure (PP) (r = 0.414; p less than 0.01), pulmonary capillary wedge pressure (PCWP) (r = 0.353; p less than 0.01), venous admixture (Qs/Qt) (r = 0.288; p less than 0.05), and alveo-arterial oxygen difference/fraction of inspired oxygen (AaDO2/FiO2) (r = 0.441; p less than 0.001). No correlation was found between EVLW values and colloid-osmotic pressure minus PCWP (COP-PCWP) (r = 0.221). Though different positive correlations between EVLW values and these parameters were found, they cannot replace EVLW measurement. Rather, EVLW measurement provides additional information on the degree of pulmonary edema which is useful in differentiating between cardiac and non-cardiac pulmonary edema and in states of radiologic over- or underestimation of EVLW.
Abstract: The in vitro activity of fosfomycin against 90 strains of methicillin- and gentamicin-resistant Staphylococcus aureus was studied in an in vitro microtitre system using Mueller-Hinton broth supplemented with glucose-6-phosphate. In parallel the antistaphylococcal activity of cefamandole, N-formimidoyl-thienamycin, clindamycin, fusidic acid and vancomycin was determined with the same organisms. The following MIC50 (MIC95) values were obtained: fosfomycin 8 (128) mg/l, cefamandole 8 (greater than 64) mg/l, clindamycin 0.25 (16) mg/l, fusidic acid less than 0.25 (less than 0.25) mg/l, vancomycin 1 (2) mg/l and N-formimidoyl-thienamycin 4 (16) mg/l. A high MIC/MBC ratio was noted for cefamandole, in contrast to fosfomycin.
Abstract: Total post-heparin lipolytic activity (PHLA), hepatic triglyceride lipase (HTGL) and protamine inactivated lipoprotein lipase (LPL) and plasma lipoprotein pattern were investigated in 8 patients with acute renal failure (ARF). PHLA was determined at 5, 10, 15, 30, 45 and 60 minutes after heparin administration (100 U/kg b.w.). Maximal PHLA in ARF was 6.12 +/- 1.56 mumol FFA/ml/h at 10 minutes versus 14.62 +/- 4.29 at 45 min in controls (= 42%, p less than 0.001). PHLA was reduced in ARF throughout the study period (p less than 0.001). Maximal HTGL activity (3.06 +/- 0.84 mumol FFA/ml/h) was obtained at 10 min in ARF versus 8.97 +/- 3.11 after 15 min in controls (= 34%, p less than 0.001). HTGL in ARF differed from controls at all points of determination (p less than 0.001). LPL maximum was 3.12 +/- 1.93 mumol FFA/ml/h at 15 min in ARF and 7.65 +/- 3.44 at 45 min in controls (= 40%, p less than 0.001). LPL activity was different from controls at 30, 45 and 60 min (p less than 0.001) but not at 5, 10 and 15 min after heparin injection. Due to a rapid decrease of LPL activity (half maximal activity after 34 min in ARF versus 94 min in controls, p less than 0.05) activity half life of PHLA was diminished in ARF (49 min in ARF versus 112 min in controls, p less than 0.01). Thus both the activity of HTGL and LPL is impaired in ARF. Because of the different activation kinetics of the two PHLA fractions no conclusions concerning maximal enzyme activities can be drawn from single determinations as suggested in previous studies on chronic renal failure.
Abstract: To obtain further pathophysiological details concerning the development of cardiovascular disturbances in severe liver disease, the state of the autonomic nervous system, the function of the baroreceptor reflex pathway and the responsiveness of the cardiovascular system to noradrenaline, angiotensin II and isoprenaline were investigated in 11 patients with hepatic encephalopathy and in 10 healthy control subjects. Increased plasma levels of noradrenaline and adrenaline and an attenuated increase in heart rate in response to atropine were found in patients with hepatic encephalopathy. These changes and the hemodynamic disturbances tended to be more pronounced in patients with hepatic encephalopathy Grades III-IV as compared to hepatic encephalopathy Grades I-II. The increase in systolic blood pressure induced by infusion of noradrenaline (400 ng per kg per min) and angiotensin II (20 ng per kg per min) was higher in the patients than in healthy control subjects (hepatic encephalopathy Grades I-II: p less than 0.001; hepatic encephalopathy Grades III-IV: p less than 0.02). The changes in mean and diastolic blood pressure in response to angiotensin II were more pronounced in hepatic encephalopathy grades I-II than in hepatic encephalopathy Grades III-IV (p less than 0.02). The decrease of heart rate in response to blood pressure increase in patients with hepatic encephalopathy was not different from control subjects except a smaller decrease during angiotensin II infusion in hepatic encephalopathy grades III-IV (p less than 0.05). The responsiveness to isoprenaline was diminished (p less than 0.001). The present results indicate that the increased activity of the sympathetic nervous system in hepatic encephalopathy is associated with decreased parasympathetic tone.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: An infusion with Ornipressin (8-ornithin vasopressin) in a patient with decompensated alcoholic liver cirrhosis increased urinary volume from 30 ml/h to 500 ml/h, creatinine clearance from 24 to 65 ml/min, and fractional sodium excretion from 0.86% to 11.1%. Free water clearance decreased from -10.2 ml/h to -26.2 ml/h and noradrenaline plasma concentrations dropped from 2.04 to 1.37 ng/ml. After stopping Ornipressin infusion all values returned to initial concentrations. Possible effects are an increase of renal blood flow secondary to an increase in arterial blood pressure, possibly potentiated by the vasodilatory effect of the fall in noradrenaline and/or angiotensin concentration.
Abstract: Endotracheal misdirection of narrow bore nasogastric feeding tubes resulted in perforation of the lung, pneumothorax and hydrothorax in two intensive care patients. Both were intubated with cuffed endotracheal low pressure tubes, one patient was on respirator therapy with neuromuscular relaxation. Feeding tubes were inserted by experienced personnel with the assistance of a steel stylet without difficulties. Aspiration of fluid was misinterpreted as proof of correct positioning, the liquid being however pleural effusion and not gastric juice. Similarly auscultation of gurgling sounds in the upper epigastrium was not a reliable sign of intragastric position. Insertion of nasoenteric feeding tubes may be complicated by perforation of the upper gastrointestinal tract and lung in poorly responsive patients with cuffed endotracheal devices during neuromuscular blockage. In these patients a laryngoscope and forceps should be used to ensure free passage of the tube into the oesophagus. Röntgenographic confirmation of correct positioning of the tube immediately after insertion is mandatory.
Abstract: Extravascular lung water (EVLW) was estimated in 53 critically ill patients by the chest radiograph (CXR) and the thermal dye technique. The comparison between these two methods revealed a direct and positive correlation (r = 0.83, p less than 0.001). However, EVLW-values obtained by the thermal dye technique showed considerable overlap between cases of radiographic low grade pulmonary edema and we were able to identify several reasons for radiographic over- or underestimation of EVLW. In these patients EVLW-measurement by the thermal dye technique provides additional information, thereby probably influencing further treatment.
Abstract: Substance P (determined as immunoreactive substance P [i-SP]), noradrenaline, and adrenaline were measured in plasma of 18 patients with hepatic coma (stage I-IV), 16 healthy controls, and 10 critically ill patients without evidence of hepatocellular disease. Plasma i-SP (119 +/- 13 fmol/ml) was significantly higher in patients with hepatic coma than in healthy controls (13 +/- 2 fmol/ml) or control patients (23 +/- 4 fmol/ml). Plasma i-SP rose in parallel with plasma noradrenaline and adrenaline. There was a significant direct correlation between plasma i-SP and noradrenaline. Increase in plasma i-SP and noradrenaline was associated with a decrease in systemic vascular resistance and an increase in cardiac index and was most pronounced in those patients who finally died in coma. Deterioration in the dying patients was accompanied by a further significant increase in plasma i-SP. Immunoreactivity was identified as authentic SP by high performance liquid chromatography in 3 representative patients. Accumulation of the vasodilating peptide SP in plasma of patients with hepatic coma may be important in the pathogenesis of the cardiovascular disturbances associated with this disease.
Abstract: Patients with severe virus hepatitis and a prothrombin concentration below 25% have a bad prognosis. This is due to direct consequences of hepatic failure and to the rather frequent complications of this disease. The clinical course of such patients is essentially dependent upon the degree of liver regeneration, which again is dependent upon the mass of hepatocytes which are able to regenerate and upon the so called hepatotrophic factors. Patients with severe hepatitis suffer during the first weeks rather frequently from nausea and loss of appetite and for that reason their nutrition is insufficient. In the study recorded here 9 cases were investigated (7 patients with hepatitis B, 2 patients with hepatitis non A non B). The question was asked, if partial parenteral nutrition in addition to a liver diet not containing meat would improve liver function. It could be shown that the prothrombin concentration, which could not be improved by vitamine K1 supplements, was increased during a 7 day parenteral nutrition period from 19,3 +/- 2,9% to 41,5 +/- 8,1% (p less than 0,05), serum albumine and cholinesterase activity improved as well. During the first day of treatment there was a significant fall of ammoniac from 115 +/- 10 mumol to 73 +/- 10 mumol/l (p less than 0,05), at the same time production of urea did not increase. All patients survived. The results show, that parenteral nutrition can improve liver function and decrease the catabolic status of metabolism.
Abstract: Haemodynamic data were obtained during haemodialysis on 21 occasions in 7 patients with septicaemia and pancreatitis, and in 5 patients with primary renal failure without septicaemia or pancreatitis. In the former group of patients there was a lowering of the blood pressure 30, 60, 90 and 120 minutes after haemodialysis had been initiated, which was significantly greater than in the later group. The drop in the blood pressure was caused by a decreased cardiac output. The pulmonary wedge pressure dropped in all patients. Peripheral resistance and heart rate did not change during the whole procedure.
Abstract: In the management of intoxications, the major goals are enhanced elimination of the toxin from the organism and prevention of further absorption. Absorption of an orally administered substance from the gastrointestinal tract can be decreased by adequate washing of the stomach. Delayed absorption of the substance from the small intestine cannot be avoided by this procedure and after the gastric lavage, a nonspecific absorbent must be administered and diarrhea induced (1). This study demonstrates that iatrogenic diarrhea via gut lavage can also eliminate toxins already absorbed by the body.
Abstract: 4 cases of baclofen intoxication were reported to the Vienna Poison Information Center during the years 1974-1982. These cases are presented and are discussed along with previously published cases of baclofen intoxication. A review of symptomatology and therapy is given.
Abstract: Non-cardiac pulmonary edema comprises all types of pulmonary edema not caused by increase of left ventricular filling pressure and elevated pulmonary capillary pressure. In one year 42 patients at our intensive care unit developed non-cardiac pulmonary edema. In a retrospective study the clinical, radiological and functional changes in patients with non-cardiac pulmonary edema were determined. 76% of the patients had multiple causes for development of non-cardiac pulmonary edema. Sepsis was the most frequent predisposing disease. Over-all mortality reached up to 69%. Additional organ failure caused an increase in mortality. Patients without complications had the best prognosis. Mechanical ventilation (69%), high-dose corticosteroids (50%), hemodialysis with ultrafiltration (33.3%) and hemofiltration (7.1%) were used for treatment of non-cardiac pulmonary edema.
Abstract: Plasma lipid and lipoprotein composition was investigated in acute renal failure (ARF). Forty-seven percent of the patients showed hypertriglyceridemia, whereas serum cholesterol was slightly reduced. Triglyceride (TG) content, predominantly of LDL and to a lesser degree of VLDL, was elevated. Cholesterol concentrations of HDL and LDL fractions were markedly reduced. HDL-TG and VLDL-cholesterol were in the normal range. Forty percent of the patients had a type IV hyperlipoproteinemia. Post-heparin lipolytic activity (PHLA) was reduced owing to an inhibition of hepatic-TG-lipase (HTGL) activity, whereas protamine-inactivated LPL was in the normal range. Fractional elimination (K2) of parenterally administered fat emulsions, determined by an intravenous fat tolerance test (IVFTT) was reduced to 2.44% min, about half of normal. The fat elimination rate increased but did not normalize during parenteral nutrition with amino acids and glucose, suggesting enhanced lipid deposition. Alterations of lipid metabolism develop early in ARF (by 4 days) and, in general, are not influenced by residual renal function, urinary output, or duration of renal failure.
Abstract: The effect of sublingual nifedipine (20 mg) on haemodynamics at rest and during bicycle ergometry in supine position was assessed in 22 patients with precapillary pulmonary hypertension (obstructive form: n = 17, restrictive form: n = 2, combined obstructive-restrictive: n = 3). At rest nifedipine resulted in an increase of cardiac frequency from 85 to 89/min, during exercise from 109 to 120/min (P less than 0.05). Concomitantly the mean arterial blood pressure decreased significantly both at rest and during exercise. The mean pulmonary arterial pressure showed significant reduction from 42.9 to 36.2 mm Hg (P less than 0.0005) only during exercise. The total body vascular resistance at rest decreased by 21% (P less than 0.005), during exercise by 15% (P less than 0.1). Pulmonary arteriolar resistance at rest decreased by 9%, during maximum loading by 34% from 312 to 215 dyn X s X cm-5 (P less than 0.05). Nifedipine was shown to be a suitable agent for lowering right ventricular afterload in secondary pulmonary hypertension due to chronic lung disease. The beneficial effect at rest depends on the extent of the pulmonary arteriolar resistance and the mean pulmonary arterial pressure. However, during exercise conditions it can be observed in the majority of patients (93%). Due to the variable response haemodynamic assessment is required prior to routine use in order to establish patients with optimal response.
Abstract: Lipid metabolism and elimination of parenterally administered fat were investigated in 15 patients with acute renal failure (ARF). The mean triglyceride level was elevated to 2.56 +/- 1.43 mmol/l and the mean cholesterol level was 3.32 +/- 0.66 mmol/l, which is slightly below the normal range. A type IV hyperlipoproteinaemia was present in 47 per cent of the patients. The triglyceride content of LDL and VLDL was elevated and the cholesterol concentration of HDL and of LDL was reduced markedly. The fractional removal rate of triglycerides (K2) evaluated by an intravenous fat tolerance test using a bolus technique was reduced to 2.44 +/- 1.56 per cent/min which is about half of normal and correspondingly the elimination half life was prolonged to 28.4 min. No correlation could be demonstrated between the impairment of fat elimination and residual renal function, basal and VLDL triglyceride concentration or HDL cholesterol content.
Abstract: Epidemiological, clinical and therapeutic aspects obtained from 38 cases of intoxication with the antiemetic drug "cyclizine" in children and adults are discussed. The relative frequency of accidentally or purposely performed overdosage shows a decreasing tendency. The introduction of regulations after the prescription of cyclizine compounds, leaving a limited dose available without prescription and the introduction of a safety package to prohibit misuse by children are reported in their relationship with the epidemiologic data. A toxic dose of 5 mg/kg body weight, a minimal lethal dose (MLD) of about 80 mg/kg are evaluated and compared with previous published data. Differences of age in the development of the clinical picture of the cyclizine-intoxication with a disposition for the evolvement of convulsions in children compared to the total lack of convulsions in adults have to be pointed out. The management of overdoses follows general principles of treatment like gastric lavage, supporting care and includes the specific treatment with the antidote "physostigmin-salicylate", which causes a shortening of the time of recovery.
Abstract: Over the past 8 years the Poison Information Centre of Vienna was confronted 24 times with acute chlorproxithene (CPTX) poisoning. In adults doses of 2 g and more caused severe intoxication, but serious toxic manifestations were observed already at low dosage in children (after the ingestion of less than 5 mg/kg body weight). In one case unexpected death due to cardiac failure occurred as long as 49 hours after CPTX intake. The favorable outcome in one patient treated with gut, as well as gastric lavage indicates that this therapeutic strategy may be of value in the management of CPTX intoxication.
Abstract: A new diagnostic key has been established based on the reports of 3845 critically ill patients in our medical intensive care unit. The clinical diagnoses in these patients were classified in 22 different groups according to different organs or etiological entities (diseases of the liver, infectious diseases, intoxications etc.). 42 different laboratory parameters were selected for classification of metabolic or organ-related complications. Combining of clinical diagnoses with laboratory values characterizes the seriously ill patient. Our new system proved to be practicable in describing the degree, complications and prognosis of disorders in intensive care medicine. The results are demonstrated in patients with hepatic coma.
Abstract: Accidental ingestion by children of NaF tablets for caries prophylaxis is a frequent event. However, our own experience from the Poison Information Centre in Vienna and reports from other centers show that these accidents usually do not present a serious risk. The mechanism of fluoride toxicity and symptoms of poisoning are briefly reviewed. The case of a boy who died after ingesting 16 mg fluoride/kg, but whose cause of death is not certain beyond doubt, is discussed.
Abstract: Incidence and extent of pulmonary complications were evaluated retrospectively in 101 patients with hepatic coma (34 patients with acute liver failure, 57 patients with hepatic encephalopathy and 10 patients with mixed forms). 76 patients (73.3%) had pulmonary complications (pulmonary edema 57 cases, pneumonia 20 cases, tracheobronchitis 30 cases). Lethality of the group with pulmonary complications was 97% as compared to 16% in the group without pulmonary complications. Pathogenesis of pulmonary complications is not completely clear; different mechanisms are being discussed like central mechanisms, vascular lesions caused by metabolic or toxic factors, cardiac failure, and increased susceptibility to infection. In 9 out of 59 cases (15.3%) with respiratory failure no morphological changes could be observed in the lungs; in these cases intrapulmonary shunts might have been the cause for the pulmonary complications. The incidence of pulmonary complications increased by a factor of 2.4 during intensive care unit treatment of the patients; this increase shows, that intensive care unit treatment still has to be improved.
Abstract: Therapeutic methods for treating poisoned men are based on the principles of intensive care therapy. The elimination of toxins depends on the circulatory circumstances; an enhancement of poison elimination can be achieved in providing a normal circulation. In the treatment of most cases of poisoning gastric and gut lavage will be sufficient. An extracorporeal toxin elimination with hemodialysis or hemoperfusion will be reserved for special cases, because of increased technical and personal expense and a higher complication rate, compared to other methods of treatment in poisoning. Forced diuresis is a simple method, but the efficacy is reduced to a small number of substances. Also reduced to certain toxins is the method of elimination with hyperventilation.
Abstract: Hypoxic, central lobular necrosis of the liver has been observed in patients with severe shock of different origin. In many cases diagnosis is not established, since clinical symptoms are unrevealing, and since SGPT levels rise rather late in the course of the disease. 3,788 patients have been treated in the intensive care unit of the Department of Medicine of the Vienna Medical School, within 10 years; liver damage caused by shock has been found during this period only in 32 cases. Diagnosis was established in 31 cases because of highly elevated SGPT levels, and substantiated in 5 cases by liver biopsy; diagnosis was established in one case by biopsy only. The median value of SGPT activity was 1,160 U/l and of lactate concentration 7.5 mmol/l. In 18 patients shock was caused by acute myocardial infarction, in 4 patients by pulmonary infarction and in 3 patients by cardiac as well as pulmonary events. In 4 cases there were heart valve lesions, one case had myocarditis, one case acute pancreatitis and one case hemorrhagic shock. Lethality was 78.1%. There was no correlation between central venous pressure and the maximal SGPT levels. There was however a correlation between prothrombin time and creatinine clearance. In conclusion: In severe shock typical lesions of the liver may originate as a complication of shock, this complication being due to reduced blood flow leading to central lobulare necrosis of liver cells.
Abstract: A blood lipid-lipoprotein elevating effect of the diuretics hydrochlorothiazide and chlorthalidone in mildly hypertensive men has been established by a cross-over, randomized controlled trial, confirming previous clinical observations. Compared to baseline, plasma total cholesterol increased 6% and 8% and triglycerides 17% and 15% under treatment with hydrochlorothiazide and chlorthalidone, respectively. A cholesterol-lowering diet largely prevents this increase. Because these effects may be long-lasting and may cancel part of the potential benefit of blood pressure control in mildly hypertensive patients, with thiazide diuretics attention should be given to prescription of a cholesterol-lowering diet and to periodic monitoring of blood lipid levels. Different antihypertensive agents might be considered in patients with elevated blood lipid levels. Other antihypertensive agents currently in use need to be studied for potential effects on lipid metabolism.
Abstract: 66 patients with hepatic coma were treated from 1972 to 1979 in the intensive care unit. Incidence and etiology of bacterial infections in these patients were evaluated retrospectively. Bacterial cultures were positive in a high proportion of the cases investigated as compared to the situation on a normal ward. Bacterial cultures were performed in 51 patients (77.3%); cultures from 35 patients were positive. Gramnegative bacteria accounted for 56.4%, grampositive bacteria for 34.8% and candida albicans for 8.8% of all the cases. It is pointed out, that invasive diagnostic and therapeutic manoeuvers in intensive care patients carry a high risk of infection.
Abstract: Data of the Poison Information Center in Vienna and analysis of the literature indicate: 1) Accidental ingestion of corrosives by children occurs frequently, but rarely causes dangerous complications or sequelae (edema of the larynx, perforation and stricture formation in the esophagus or stomach). This is in contrast to attempted suicides by adults. 2) The first and most important step after the accident is the intake of copious amounts of water. The dangers of neutralizing acid or lye are discussed. 3) Only symptoms and signs, not kind or pH of the caustic agent afford a reliable guide for deciding whether or not the child needs further observation and treatment. This paper deals with first aid measures only, not with further treatment (e.g. shock treatment, prophylaxis of stricture formation etc.).
Abstract: In ten non dialyzed patients with chronic renal failure, 18 patients on regular dialysis treatment and 70 renal transplant recipients alpha-1-antitrypsin and fibrinogen levels were investigated. Alpha-1-antitrypsin and fibrinogen concentrations were highest in dialyzed patients with values of 314 +/- 98 and 485 +/- 127 mg/dl respectively. In renal transplant recipients a significant positive correlation between alpha-1-antitrypsin and fibrinogen concentration was found (p less than 0.001). High alpha-1-antitrypsin and fibrinogen levels seem to be a possible consequence of reactive processes due to underlying disease or complications. Our results seem to indicate that both alpha 1-antitrypsin and fibrinogen can be classified as "acute phase protein".
Abstract: Ingestion of plant material rarely gives rise to manifest clinical intoxication. This is due to the relatively low toxicity of most of the poisonous plants of Central Europe. Veratrum album is an important exception on account of its highly toxic alkaloids. Seven cases of overt intoxication from veratrum album have been reported to the Austrian Poison Information Centre during the past 5 years. On the basis of these case reports toxicological and clinical aspects of this rare form of poisoning are discussed.
Abstract: An analysis of 28 cases of amanita phalloides poisoning serves as basis for a discussion of the clinical features and therapeutic problems involved. A critical review of recent experimental investigations in animals points to new possibilities in the treatment of amanita phalloides poisoning.
Abstract: Forced diuresis (FD) is a frequently used method for eliminating toxins. Its therapeutic effect has yet to be evaluated by a controlled clinical trial. In the absence of such a trial its usefulness can be judged only indirectly from urinary excretion rates. In former times the usual clinical laboratory procedures could not differentiate between the unchanged toxin and its metabolites. Using more selective methods, the discussions of the effect of FD in eliminating various drugs were renewed. The problem for the indication of FD is not only a missing knowledge about the kind and amount of the ingested drug, but also when knowing it, the missing evaluation of the effect of FD on its excretion. In such cases the pharmacokinetic behaviour of the drug can be helpful. If paying enough attention to the contraindications, to the principles of electrolyte and water balance, the complication rate is low. Many infusion regimes are proposed for this treatment, but only a standardized procedure can increase the safety and efficiency of this method. More complicated and more expensive methods should be used, when there is an intoxication with a substance of high mortality or when there is no effect of FD on eliminating the toxin.
Abstract: The Poison Control Centre in Vienna registered 4018 inquires regarding possible poisoning in children over a two-year period. The peak incidence occurred in the age group between 2 and 3 years and poisoning chiefly took place in the mornings and in the afternoons, the most frequently ingested substances being household chemicals and drugs. A study in 100 households showed ignorance and carelessness in dealing with chemical substances. An analysis of inquiries concerning medicines revealed the influence of packaging and external characteristics on the frequency of poisoning with these substances. Possibilities which might be of value in the prevention of poisoning in children are discussed.
