Egyptian Journal of Critical Care Medicine最新文献

Background

Serum vascular endothelial growth factor (VEGF) levels are increased in sepsis.

Purpose

To investigate the prognostic value of the serum VEGF level in critically ill septic patients regarding the clinical course and final outcome.

Methods

A total of 40 critically ill septic patients were included in a prospective, randomized, single center study. All patients were subjected to the measurement of VEGF levels on admission day (VEGF1) and 48 hours later (VEGF2). CRP levels and Microalbuminuria levels were also measured on admission. APACHE IV and SOFA scores were calculated. Clinical outcome (duration of stay in the ICU, need for MV, need for inotropic/vasopressor support, need for hemodialysis, and survival) was recorded.

Results

In relation to healthy subjects, the mean VEGF 1&2 levels were significantly higher in the septic patients (142 + 28.98 vs 750.5 + 380.34 and 802.07 + 292.65 ng/l; p = 0.001 and <0.001 respectively). Septic patients who required MV, inotropic/vasopressor support and hemodialysis, and also those who died had significantly higher VEGF1 levels compared to those who didn’t require them (p = 0.002, 0.006, 0.008 and 0.001 respectively). VEGF2 level was significantly higher only in those who required inotropic/vasopressor support (p = 0.024). VEGF1 and 2 levels were significantly positively correlated with CRP level, Albumin/Creatinine ratio and APACHE IV score. ROC analysis of the data indicated a sensitivity of 85.15% and a specificity of 92.3% when a VEGF 1 level of 410 ng/l was taken as a predictor of ICU mortality.

Conclusion

The admission VEGF is a useful marker for the evaluation of septic patients.

Background

Patients with inferior wall myocardial infarction (IWMI) associated with right ventricular (RV) infarction have much higher rates of adverse events.

Aim

Tissue Doppler (TDI) systolic annular velocity (S′) and myocardial performance index may be useful predictors of proximal right coronary artery (RCA) stenosis as a culprit lesion in inferior wall myocardial infarction.

Methods

In a prospective study, patients with first episode of acute IWMI underwent early conventional and tissue Doppler echocardiographic assessment (within 24 h) of symptom onset and RV indices; Tricuspid annular systolic plane excursion(TAPSE), myocardial performance index (MPI) and tissue Doppler velocities from RV free wall were measured. Patients underwent coronary angiogram within one month and were divided into two groups (A, B) according to angiographic findings based on the presence or absence of significant proximal RCA stenosis.

Results

There were 35 patients with first episode of IWMI, group A includes (n 14 patients) and group B includes (n 21patients), There was significant difference between groups in TAPSE (1.28 cm vs 1.98 p < 0.001), MPI–TDI (0.69 ± 0.12 vs 0.38 ± 0.05 p < 0.001), and in S′ velocity from RV free wall (0.09 m/s ± 0.02 vs 0.12 m/s ± 0.02 p < 0.001). It was found that S′ < 10 cm/s is a predictor of proximal RCA lesion with a sensitivity of 92.86% and a specificity of 85.71% ppv 81.25, npv 94.74, MPI–TDI > 0.55 with a sensitivity of 92.86% and a specificity of 100%, 100% ppv and 95.45% npv, and TAPSE < 16 mm (sensitivity 93%, specificity 100%).

Conclusion

RV indices (S′ velocity, MPI–TDI and TAPSE) are useful in predicting proximal RCA as infarct related artery in IWMI.

Introduction

The information on patient characteristics and outcome in patients requiring invasive mechanical ventilation (IMV) is critical for better use of resources and clinical decision making in a rural ICU.

Objective

To understand characteristics and outcome of patients on IMV.

Design

This is a retrospective study in patients admitted in medical intensive care unit of a rural hospital who were on IMV during August 2013 to February 2015. Adult patients with failing respiratory drive and/or those who failed oxygen therapy or NIV (non invasive ventilation) were considered eligible for invasive ventilation. Patients exclusively on NIV were excluded (reason for exclusion was to study the outcome in an expensive intervention like IMV). Patients who were weaned and extubated and subsequently shifted to medicine ward were considered “good” outcome and “adverse” (not-extubated) if they died or sought discharge against medical advice.

Outcome measure

All-cause mortality during ICU stay.

Results

A total of 505 patients, of which 74.7% were male with mean age of 52 years (IQ range 38–65 years). Comorbidities were seen in 76.4% patients; significantly higher in not-extubated (94.85% vs 5.15%) (p = 0.008). The ICU stay, days on ventilation and total hospital stay were 5 (3–9) days, 2 (1–5) days and 5(3–9) days respectively. Primary cause for IMV was sepsis, neurological, cardiac, renal and respiratory and others like envenomation, drug overdose, organophosphate poisoning, etc. Hypertension and diabetes were the commonest co-morbidities.

Conclusion

The mortality in patients requiring invasive ventilation support from low-resource setting is high.

Several studies have demonstrated that uremic patients who have preserved left ventricular (LV) systolic function could still have subtle systolic dysfunction. In our study, we assessed the right ventricular (RV) and LV myocardial functions measured by conventional echocardiography and two-dimensional (2D) longitudinal speckle-tracking in hemodialysis and non-dialysis recently diagnosed uremic patients. The study population consisted of 24 newly diagnosed uremic patients, 25 hemodialysis patients, and 20 healthy controls. The RV and LV longitudinal strains were significantly lower in patients than in controls (−9.6 vs. −15.3, P < 0.001 for RV and −11.3 vs. −14.8, p < 0.001 for LV). In the hemodialysis group, the RV longitudinal strain was significantly lower than in the non-dialysis group (p = 0.018). The RV longitudinal strain was correlated with hypertension and LV strain. The 2-D longitudinal speckle tracking can detect early ventricular (left and right) systolic dysfunction in patients with uremia in the presence of normal systolic function by conventional methods.

Background

Electrocardiographic changes are known to occur in patients with acute neurological events but their significance remains uncertain. QT dispersion (QTD) reflects heterogeneity of myocardial repolarization, which is modulated by the central nervous system. QTD has been shown to predict adverse outcomes in various cardiac states.

Objective

To determine the degree of QTD and its relation to outcome in patients with acute neurological events.

Methods

We studied 40 patients admitted to our hospital with acute neurological events and without known cardiac disease. Simultaneous 12-lead ECG was done within 24 h of the onset. QTD was calculated manually as the difference between maximum and minimum QT intervals in at least 11 of 12 leads. Modified Rankin Scale (MRS) was used to assess functional status after 3 months from the onset.

Results

Increased QTD in the 24 h-ECG following the onset of acute neurological events (median = 60, range, 20–120 ms). QTD was higher in patients with intercerebral hemorrhage as compared to non hemorrhagic stroke (67 ± 16 versus 52 ± 26 ms; p = 0.04). The increase in QTD was associated with lower functional outcomes on Modified Rankin Scale ((r = 0.65 and p = 0.001) and with a higher mortality (p = 0.006) at 3 months follow-up. On multivariate analysis, the most independent predictors of mortality were QTD (odds ratio, 1.13; 95% confidence interval, 1.03–1.25) and GCS (odds ratio, 0.366; 95% confidence interval, 0.177–0.758).

Conclusion

Prolonged QTD in the first 24 h of acute neurological events is an independent predictor of short-term functional outcome and mortality following.

Background

Acute myocardial infarction (AMI) is an acute stress state in which plasma copeptin rises. The combination of copeptin and troponin has been suggested to improve the diagnostic performance of acute MI in chest pain patients at time of presentation in the emergency department.

Objective

To investigate the correlation of plasma copeptin levels for early exclusion of acute myocardial infarction in combination with troponin-I.

Methods

This study was conducted in Cairo University hospitals on 40 patients presented to the critical care department with chest pain within 6 h of pain onset as a primary symptom of acute coronary syndrome. Baseline demographic characteristics and clinical data were collected prospectively. Plasma copeptin levels and cTnI were measured by ELISA technique. The primary outcome was diagnosis of AMI.

Results

A negative copeptin and cTnI at baseline ruled out AMI with a negative predictive value of 100%. AMIs not detected by the initial cTnI alone were picked up with copeptin >15.6 pg/ml in first 6 h from onset of chest pain which was confirmed by repeated troponin within 12 h from onset of chest pain.

Conclusion

Combined measurements of troponin and copeptin aid in early and safe rule-out of AMI.

Introduction

The resulting left ventricular (LV) dysfunction in acute STEMI is definitely secondary to loss of myocardial muscle mass (Krumholz et al., 2009; Guerchicoff et al., 2014) but may have an additional component of LV dyssynchrony.

Aim

Detection of LV dyssynchrony in acute STEMI patients and its relation to LV dysfunction in these patients.

Patients and methods

60 patients presenting with acute STEMI were injected with 25 mCi of Tc^99m SestaMIBI prior to primary PCI. Acquisition was deferred after the procedure within 6 h of injection. Images were analyzed using QGS Cedars Sinai software to measure the histogram bandwidth, standard deviation and entropy using GSPECT phase analysis. The results were compared to 60 patients with negative perfusion scans upon maximal exercise imaged using the same protocol during rest.

Results

Our study included a total number of 60 acute STEMI patients, 54 males, mean age 54.8 ± 10.38 years, Compared to 60 controls mean age 50.7 + 20.3 years. Risk factors for CAD were smoking in 41 patients, hypertension in 17, dyslipidemia in 7, diabetes in 15, and positive family history of CAD in 21. 30 patients had acute anterior STEMI and 30 had inferior. LVEDV and LVESV were larger compared to controls; 133.0 ± 88.7 vs. 62.0 ± 19.2 ml and 89.7 ± 82.1 vs. 19.9 ± 12.3 ml respectively, p < 0.001, and lower LVEF 39.0 ± 16.8 vs. 71.1 ± 10.4%, p < 0.001. Histogram bandwidth (BW), standard deviation (SD) and entropy (E) values were significantly higher in patients when compared to controls; 76.2 ± 54.7 vs. 17.8 ± 5.3, 20.7 ± 15.2 vs. 4.1 ± 2.0 and 51.1 ± 18.6 vs. 21.8 ± 7.1 degrees respectively, p < 0.001. BW, SD and E significantly negatively correlated with LVEF in acute STEMI cases; r = −.733, p < 0.001, r = −.75, p < 0.001, and r = −.858, p < 0.001 respectively.

Conclusion

LV dyssynchrony may be acquired acutely very early in STEMI and may have a negative impact on LV ejection fraction.

Several cumbersome scoring systems were developed for prognosis and outcome prediction in sepsis. We intended in this study to evaluate the urinary albumin/creatinine ratio (ACR) as a prognostic predictor in sepsis.

We included 40 adult septic patients in a prospective observational study. We excluded patients with preexisting chronic kidney disease or diabetes mellitus.

After clinical evaluation, urine spot samples were collected on admission and 24 h later for ACR1 and ACR2. Admission APACHE IV score and the highest recorded SOFA score of their daily estimation were considered. We also evaluated the need for mechanical ventilation, inotropic and/or vasoactive support, renal replacement therapy (RRT), and in-hospital mortality.

In a population with 63 (55–71) year old with 29 (72.5%) males, we found that the ACR2 is correlated with the SOFA score (r = 0.4, P = 0.03). SOFA was higher in patients with increasing ACR [14(4.8–16.8) vs 5(3–8), P = 0.01]. None of the ACR measures was correlated with APACHE IV score. ACR2 was higher in patients who needed mechanical ventilation and inotropic and/or vasoactive support [140(125–207) and 151(127–218) mg/g respectively] compared to [65(47–174) and 74(54–162) mg/g], P = 0.01 and 0.009. None of the measured parameters was related to the need of RRT. ACR1, ACR2, APACHE IV and increasing ACR were predictors of mortality. The AUC for mortality prediction was largest for APACHE IV (0.90) then ACR2 (0.88). ACR2 of 110.5 mg/g was 100% sensitive and 86% specific to predict mortality.

We concluded that the urinary ACR may be used as a simple test for prognosis and mortality prediction in sepsis.

Background and aim

Glycosylated hemoglobin (HbA1c) is a more stable and accurate parameter of the glycometabolic state than fasting glycemia. However, its role in predicting the prognosis in acute myocardial infarction patients remains unclear with conflicting results from the available data. This study evaluates the effect of admission HbA1c as a parameter of the glycometabolic state on the clinical outcome in non diabetic acute st segment elevation myocardial infarction (STEMI) patients.

Method

Between June 2012 and December 2014, 208 consecutive STEMI non diabetic patients who underwent primary percutaneous coronary intervention (PPCI) were enrolled. Patients were divided according to the HbA1c level into 2 groups 112 patients in group I (HbA1c ⩽ 5.6%) and 96 patients in group II (HbA1c 5.7–6.4%). In hospital and at 6 months major adverse cardiac outcome (MACE) was calculated.

Results

Mean age was 55.9 ± 7.12 years, 149 were men and there was no significant difference regarding baseline characteristics. Post PPCI TIMI III flow was higher in group I (p = 0.016), angiographic no reflow was higher in group 2 (p = 0.003). No significant difference regarding in hospital MACE (p = 0.44). At 6 month follow up MACE was significantly higher in group 2 (p < 0.001) and this mainly due to higher incidence of target lesion revascularization (TLR) in group 2 (p < 0.001). Multivariate analysis showed that HbA1c is significantly associated with 6 months MACE (hazard ratio 1.9; p = 0.022).

Conclusion

Abnormal glycometabolic state assessed by HbA1c at admission in non diabetic STEMI patients was associated with higher MACE incidence at 6 months follow up.

Background

Cardiovascular disease is the leading cause of death in Egypt and worldwide, placing great strain on the world’s health systems. This is one of the few Egyptian registries dealing with patients with acute coronary syndrome admitted in critical care department, Cairo University.

Methods

This is a retrospective non-controlled cohort study of patients with acute coronary syndrome admitted from January 2010 to December 2012. Retrospective analysis of these patients data were retrieved through reviewing written paper and electronic database.

Results

A total number of 503 patients were enrolled in our study. The mean age was 57.2 ± 10.4 years. Their pain duration was 14 ± 24.4 h. Average length of stay was (7 ± 4.4 days). Primary percutaneous coronary intervention (PCI) was done to 154 patients (30.6%), while we had 105 elective PCI procedures (20.9%). Major adverse cardiac events (MACE) were higher in patients with higher age (60 years vs 56.7 years P value 0.021), STEMI (25.7% vs. 18% in UA/NSTEMI P value 0.002), higher CKMB levels (157iu/l vs 89iu/l P value0.019), and higher Killip class upon presentation (class III-IV 64.9% vs 2.2% class I-II p < 0.001). Patients with UA/NSTEMI who were treated conservatively developed statistically significant higher incidence of MACE as compared to those treated interventionally (23.4% vs. 13.5% P value 0.031). Patients with STEMI who were treated without intervention have significant higher incidence of MACE than those who were treated interventionally (15.4% vs. 5.5% p = 0.46).

Conclusion

1. Higher incidence of MACE was observed in the higher age group, higher levels of cardiac biomarkers, and higher Killip class. 2. Outcome was affected by early interventional treatment in all patient groups.