Egyptian Journal of Critical Care Medicine最新文献

Ongoing studies investigating the intra abdominal pressure (IAP) shifted the belief of mesenteric circulation not to be only a culprit of decreased arterial hypoperfusion, but also other hydrostatic forces may impose its perfusion and may also act directly on the tissues. While the gut theory stated the engine of multiorgan dysfunction syndrome (MODS), abdominal perfusion pressure (APP) was examined in MODS patients to assess mesenteric circulation instead of merely abdominal arterial hypoperfusion.

Aim

We aimed to study the correlation between increased fluid gain and low APP and increased risk for visceral organ hypoperfusion.

Patients and methods

106 MODS patients were studied retrospectively, and included if a SOFA subscore of ⩾2 was recorded in at least 2 organ systems, routine laboratory investigations, lactate, fluid gain was defined as the cumulative positive fluid gained during resuscitation. Vital signs were recorded and IAP (measured through UB, closed loop small volume technique) and APP which is derived from the equation (mean arterial blood pressure MAP – intraabdominal pressure IAP) and Liver SOFA subscore were calculated as indirect markers of mesenteric hypoperfusion.

Results

The APP on admission was negatively correlated with lactate and fluid gain (r = −0.388 and −.225 P = 0.0001 and .021 respectively).

The lower the APP, the worse the Liver SOFA subscore (85.3 ± 14.2, 75.7 ± 15.3, 73.1 ± 24.6, 76.6 ± 16.8 and 66 ± 17.1 p 0.012), SOFA and lactate were the significant predictors for APP.

Conclusion

Low APP and positive fluid gain are associated with deteriorating visceral circulation manifested by high lactate levels and deteriorating liver function.

Introduction

Thyroid dysfunction is associated with mortality in critically ill patients. We investigated the predictive value of the thyroid hormone compared to CRP in septic patients.

Methods

80 patients were included in a prospective, randomized study done in the critical care department.

Results

FT3, FT4, and TSH levels on the fifth day were below the normal range in 61.3%, 31.2%, and 23.8% patients respectively. There was a significant decrease in the FT3 level on admission compared to the fifth day (p < 0.001). By comparison of thyroid hormone levels in patients with sepsis, severe sepsis and septic shock; we found the mean level of FT3 was lower in patients with septic shock (1.3 ± 0.4 pg/ml) and severe sepsis (1.7 ± 0.2 pg/ml) as compared to patients with sepsis (2.4 ± 1.2 pg/ml). The mean FT3 level increased in survivors (2.9 ± 1.03 pg/ml) compared to non survivors (1.9 ± 0.89 pg/ml) (p < 0.001). Correlation of FT3 on the 5th day to CRP (r = −0.332, p = 0.039), FT3 on 5th day to IL-6 (r = −0.339, p = 0.035) in non survivors. Correlation of FT3 on the 5th day to APACHE II (r = −0.359, p = 0.025) and SOFA score (r = −0.427, p = 0.007). ROC curves indicated that FT3 on the 5th day had the greatest power for predicting ICU mortality (sensitivity 87.2% and specificity 73.2%). CRP (sensitivity 100% and specificity 92.7%) is a better tool than IL-6 (sensitivity 92.3% and specificity 80.5%) in predicting mortality in sepsis.

Conclusion

FT3 levels were negatively correlated to CRP and IL-6 levels as well as APACHE II, SOFA scores. FT3 may be used as a marker of disease severity and a predictor of mortality.

Background

In early stages of septic shock, impaired myocardial function plays an important prognostic role. AEF and Plasma BNP level may be a valuable prognostic factor for patients with sepsis.

Objective

We aimed also to evaluate the value of atrial ejection force (AEF) B-type natriuretic peptide (BNP) in predicting the outcome of sepsis, severe sepsis and septic shock patients.

Methods

40 patients presenting with sepsis, severe sepsis or septic were included in the study. The patients had undergone transthoracic Echocardiographic examinations and BNP measurements on the 1st and 3rd day of admission. The patients were retrospectively divided into survivors and non survivors.

Results

There was a significant statistical difference in BNP level (P = 0.0001) between the two groups. BNP showed a statistically significant rise in the non survival group from day 1 to day 3 (p = 0.002) and a statistically significant decrease from day 1 to day 3 in the survived group (p = 0.001). As regards the echo findings there was a statistically significant difference AEF 3rd day between survivors and non survivors (P = 0.0001). The ROC curve showed that BNP 1st day, 3rd day are good tests for prediction of mortality in patients with sepsis.

Conclusion

Atrial ejection force on the first day of admission, unlike BNP level, might not be used as an independent predictor of mortality in patients with sepsis. BNP level correlates with the severity of sepsis. According to our study, AEF in the third day may be a good predictor for survival of patients presenting with sepsis.

Introduction

Adequate volume resuscitation is very important for a favorable outcome of critically ill patients. Both over and under filling of intravascular volume could be deleterious. Static indices including central venous pressure, pulmonary capillary wedge pressure, left ventricular end-diastolic area, mean arterial pressure (MAP) and tachycardia are commonly used and are known to be of little value in discriminating responders from non-responders. On the other hand dynamic indices such as pulse pressure variation (PPV), inferior vena cava diameter, superior vena cava diameter, aortic blood flow, which are based on variation on the left ventricular stoke volume, have been shown to be more accurate predictors of fluid responsiveness in mechanically ventilated patients. In this study we are evaluating the ability of stroke volume variation (SVV) obtained by Vigileo–FloTrac device to predict fluid responsiveness in patients with acute circulatory failure under complete passive, volume controlled mechanical ventilation and correlating it to manually calculated PPV.

Materials and methods

Twenty five patients aged above 18 years, with acute circulatory failure and at least one sign of tissue hypoperfusion requiring fluid resuscitation and mechanical ventilation were included. Excluded are patients with cardiogenic shock, acute pulmonary edema, LVEF <50%, atrial fibrillation, frequent ectopics, significant aortic or mitral valve abnormalities or renal failure. Candidates were subjected to thorough clinical evaluation, lab investigation and ECG. Following sedation, muscle relaxation and maintenance of mean arterial pressure >65 mmHg by norepinephrine, 500 ml of Hes-steril were administered over 10 min. Static and dynamic hemodynamic parameters were taken in supine position before and after fluid challenge. Patients who had an increase of cardiac index measured by trans-thoracic echocardiography ⩾15% of baseline measurement were considered responders.

Results

Fourteen patients were fluid responders. Before fluid challenge SVV and PPV were significantly higher in responders than non-responders (p = 0.0001 for each). SVV ⩾ 8.15% predicted responders with a sensitivity of 100% and specificity 81.1% (AUC 0.906). PPV ⩾ 10.2 also predicted responders with a sensitivity of 92.9% and specificity of 90.9% (AUC 0.974). The higher the SVV before fluid challenge the higher the percentage of increase of CI following fluid challenge (r = 0.733, p = 0.00). PPV showed the same correlation pattern with percentage increase of CI (r = 0.798, p = 0.00).

Conclusions

Baseline stroke volume variation ⩾8.15% predicted fluid responsiveness in mechanically ventilated patients with ac