Egyptian Journal of Critical Care Medicine最新文献

Background

Despite the fact that colistin has a significant activity against MDR gram-negative organisms, its toxicity limits its use. However, the limited therapeutic options due to increasing antibiotic resistance have made re-evaluation of older antibiotics inevitable. In contrast, lack of data to guide the usage of these drugs demands for studies on their safety and efficacy. This studies the clinical outcomes and safety of colistin at a tertiary care centre in Mumbai.

Materials and methods

A prospective observational study was conducted at P.D. Hinduja Hospital, Mumbai for a period of seven months. Diagnosis of infection was based on CDC guidelines and APACHE II score was used to assess the severity of illness. Clinical and microbiological response to colistin was evaluated along with the incidence of nephrotoxicity (RIFLE criteria) and neurotoxicity.

Results

Sixty-two patients (median age 56 years, with documented gram negative bacterial infection and mean APACHE II score 22) received colistin. Clinically favourable response was seen in 71% patients. However, the mortality among the study population was 27%. Univariate analysis identified pneumonia and ICU admission as independent factors for adverse outcome. Deterioration of renal function was observed in 35.89% as per RIFLE criteria. 6 (9.6%) patients demonstrated neurotoxicity.

Conclusion

Colistin is effective in treatment of gram negative infections and its use should be reappraised. However since colistin is the last resort it is imperative to make its best use to ensure that it remains as a safe and effective mode of treatment when need be.

Background

Left ventricular dyssynchrony plays an important role in predicting response to cardiac resynchronization therapy (CRT).

Methods

Thirty patients underwent CRT implantation. Assessment of left ventricular (LV) dyssynchrony was done through Gated SPECT LV phase analysis.

Results

Thirty patients received CRT (mean age 58.7 ± 9.0, 24 males). CRT implantation had a favorable prognosis on cardiac functions (LVEF preimplantation: 26.8 ± 4.7% versus 29.1 ± 6.4% post-implantation; P = 0.002). Reverse LV remodeling (⩾15%) was documented in 19 patients. Temporal changes in LV dyssynchrony parameters were correlated to LV reverse remodeling. Applying ROC curve for LV phase analysis showed that a cutoff value of 152° for histogram bandwidth had a sensitivity of 72.7% and specificity of 63.2% for predicting CRT non-response status. Also, a cutoff value of 54° for histogram standard deviation had a sensitivity of 81.8% and specificity of 63.2%.

Conclusion

Responders of CRT showed improved LV dyssynchrony profiles. Utilizing Gated SPECT LV analysis could provide predictors for CRT non-response. Reverse LV remodeling is associated with temporal improvements in LV dyssynchrony parameters.

It has been shown that patients with heart failure have high levels of brain or type B natriuretic peptide (BNP), and that there is a correlation between these and the severity of their condition. Many studies report that monitoring BNP levels could be a sensitive method for diagnosing heart failure and performing risk stratification, and that they could act as an independent predictor of adverse events helping clinicians arrive at a prognosis.

To achieve this purpose we studied 30 patients with CHF (27 males, mean age 57 years) undergoing CRT implantation.

The main finding of our study was that CRT exerted a substantial reduction in plasma BNP levels among responders, but no significant change in nonresponders after 3 months follow-up, only responders showed a significant decrease in plasma BNP levels (229.64 pg/ml ± 111) as compared to non-responders (468 pg/ml ± 96) P value <0.01. Response could be predicted with a cut-off value of 360 pg/ml, with a sensitivity and specificity of 90.9% and 87.5%, respectively.

In conclusion, BNP monitoring is potentially a good prognostic indicator of LV functional recovery and reverse remodeling after CRT can accurately identify echocardiographic responders after CRT. Percentage change in plasma BNP levels from baseline to 3 months was the strongest predictor of long-term response to CRT and may have potential to predict outcome.

Background: Electrical Cardiometry allows measurement of fluid status using thoracic fluid content (TFC), cardiac output, cardiac index, systemic vascular resistance index which could be ideal noninvasive hemodynamic monitoring for patients undergoing hemodialysis (HD). Objectives: Investigating the relation between changes in TFC and amount of fluid removal during HD session and to monitor hemodynamic parameters to avoid episodes of hemodynamic compromise during HD session. Methods: Thirty critically ill patients on HD were enrolled. Clinical assessment of volume overload and hemodynamics (BP, MAP, CVP), monitored by Electrical Cardiometry ICON® before HD and all through sessions. Results: Out of studied patients males represented 46.7% (n = 14) with mean age 48 ± 16 years. There was positive correlation between UF volume and TFC (r = 0.410, P = 0.025). Out of the 30 pts studied 18 pts (60%) were hemodynamically stable vs 12 pts (40%) that had hypotension represented by non responders group and had lower TFC compared to the hemodynamically stable group (26.45 kohm⁻¹ vs 37.8 kohm⁻¹) with P value of 0.004 indicating that they were hypovolemic. Out of the 30 pts studied 18 pts (60%) weren’t congested vs 12 pts (40%) remained persistently congested after accomplishing HD session with significantly higher TFC when compared to those who got rid of congestion (43.14 ± 9.9 kohm⁻¹ vs 25.44 ± 5.5 kohm⁻¹) with P value of 0.0001 indicating that they were still hypervolemic. Using analysis of ROC curve TFC at 25.34 kohm⁻¹ was a significant predictor of hypotension with P value of 0.002, AUC 83.4%, sensitivity 67% and specificity 100%. Also TFC cutoff value predicting persistent congestion was 37.02 kohm⁻¹ with P value of 0.0001, AUC 95.8%, sensitivity 83% and specificity 100%. Conclusion: Electrical Cardiometry is an evolving noninvasive tool for adjusting fluid status of critically ill patient on RRT using thoracic fluid content as an indicator of fluid status that could be used to avoid hemodynamic instability and persistent volume overload and congestion during and after HD session.

Extracorporeal support (ECMO) is indicated in severe heart or lung failure with 80% risk of mortality. In experienced centers, overall survival to discharge ranges from 40% in cardiac arrest (ECPR) to 70% for respiratory failure in adults, 80% in children and newborns with prolonged ECMO support, severe lung injury can recover to normal function, re-defining irreversible lung injury. In the future ECMO will be automatically controlled with care out of ICU or at home.

Introduction

Currently Extracorporeal Membrane Oxygenation (ECMO) is used for long-term support of respiratory and/or cardiac function, ECMO is primarily indicated for patients with temporary severe ventilation and/or oxygenation problems that they are unlikely to survive conventional lung protective mechanical ventilation.

Aim of the work

We describe our experience in the management of a case of opioid-induced acute respiratory distress syndrome with ECMO.

Methods

A 22 year old female, known Heroin addict, admitted with severe ARDS, failed to improve with conventional ventilation, Murray Lung Injury Score was 3.5, RESP score (8) was 4, underwent Veno-venous (V-V) ECMO via femoro-atrial approach using Maquet Cardiohelp console. The ECMO run duration was 12 days. Successful decannulation was done after weaning off ECMO by decreasing FiO₂ on ECMO, and continuing mechanical ventilation on pressure support ventilation.

Results

Successful weaning of ECMO on day 12 and successful extubation on day 14.

Conclusion

ECMO can be used safely and successfully in the treatment of Heroin induced ARDS.

Extracorporeal Membrane Oxygenation (ECMO) is emergently used for long-term support of respiratory and/or cardiac functions. ECMO is most useful in cases when the primary lung insult is reversible. CESAR trial in 2009 showed survival benefits in severe ARDS patients when transferred to an ECMO center compared to those receiving standard care in their ICU.

Organophosphate (OP) compounds are large groups of chemicals used in domestic and industrial settings. These compounds are still used in different forms in developing countries. It can affect the respiratory system through causing: rhinorrhea, bronchorrhea, bronchospasm, cough and severe respiratory distress. Respiratory failure is the most life threatening condition and requires immediate intervention.

We present a case report of OP induced severe ARDS in which conventional lung protective ventilation failed to maintain adequate oxygenation that was accomplished by ECMO.

Maintaining higher sedation in patients undergoing ECMO therapy is crucial. Currently no definite sedation strategy has been proposed in the literature, as the pharmacokinetics of the medications in these patients is still not clear. We would like to report a case of a patient with uncontrollable diverse clinical response to medications during arteriovenous (AV) compared to venovenous (VV) ECMO.