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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Month: April 2007 (Page 1 of 2)

Venous oximetry

Abstract

Tissue hypoxia is the central pathophysiological process in shock and an important co-factor in the development of organ dysfunction. Hemodynamic parameters, usually used to assess the perfusion of organs and tissues, like arterial blood pressure, heart rate, urine output and blood gases can be normal in the presence of tissue hypoxia and cannot rule out imbalances between global oxygen supply and demand. Mixed venous oxygen saturation (SvO2) is a sensitive indicator of the adequacy of whole-body tissue oxygenation. However, it requires the placement of a pulmonary artery catheter, which is an invasive procedure with the possibility of numerous complications and is increasingly questioned due to the lack of evidence that it improves outcome. Central venous oxygen saturation (ScvO2) requires the insertion of a central venous catheter, which is routinely used in most critically ill patients, but it reflects the adequacy of oxygenation in the brain and upper part of the body and differs from SvO2. Still, it can be used as a surrogate for mixed venous oxygen saturation because the changes and trends of both variables parallel each other. Both variables are used extensively in the treatment of patients with severe sepsis, shock and trauma. In combination with other hemodynamic and biochemical parameters, they have diagnostic and prognostic value and allow for rational treatment of critically ill patients.

Key words: mixed venous oxygen saturation, central venous oxygen saturation, physiological monitoring, shock

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Erythropoietin in post-resuscitation neurological recovery: is there light at the end of the tunnel?

Abstract

Studies show that erythropoietin, besides its critical role in hematopoiesis, provides neuroprotection in hypoxic-ischemic cerebral injury. Antiapoptotic, anti-inflammatory, angiogenetic, and neurotrophic properties of erythropoietin could increase indications, currently restricted to anemia in chronic renal failure and cancer, to hypoxic-ischemic cerebral insult.
In the adult and neonatal animal model of hypoxic-ischemic cerebral injury, erythropoietin significantly reduces infarct size with attenuation of brain damage, and preservation of cortical integrity. The first human study on the impact of erythropoietin in stroke victims showed that erythropoietin is safe and well tolerated at high doses, and associated with improved neurological outcome. Even with intravenous application, concentrations of erythropoietin in cerebrospinal fluid of these patients were many-fold higher than in non-treated patients.
In successfully resuscitated cardiac arrest victims overall neurological recovery remains poor despite improved cardiopulmonary resuscitation strategies. Post-resuscitation care needs further advances in order to improve final outcome. Through promotion of neuroangiogenesis, inhibition of hypoxia-induced apoptosis in neurons, and thus support of the survival of neurons in the ischemic brain, erythropoietin could be used to improve functional recovery of these patients. Nevertheless, optimal molecular forms of EPO, therapeutic doses, and treatment time window have to be determined in order to lower the incidence of adverse effects and still preserve neuroprotective properties.

Key words: cardiopulmonary resuscitation, erythropoietin, post-resuscitation period, hypoxia.

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Induced hypothermia after cardiopulmonary resuscitation: possible adverse effects

Abstract

The last several years have seen an increased interest in the use of induced hypothermia after witnessed cardiopulmonary resuscitation (CPR). The main reason for its use is protection of the brain and hence, better neurological outcome in these patients. Therefore, induced hypothermia after CPR has become a part of standard recommendations in the 2005 Resuscitation Guidelines. At the same time, hypothermia can have many adverse effects. In the event of pre-hospital and/or in-hospital induction of hypothermia, without adequate monitoring and controlled cooling, hypothermia can cause serious complications, without beneficial effects on the brain. This article explains the most frequent adverse effects of hypothermia and possible hazardous outcomes for patients.

Key words: cardiopulmonary resuscitation, hypothermia, hemodynamics

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First measured intrathoracic blood volume in icu patients indicates the appropriateness of circulatory volume management

Abstract

Hemodynamic monitoring in Intensive Care Unit (ICU) settings is usually introduced when a patient becomes hemodynamically unstable. We analyzed how empirically guided volume management relates to first measured intrathoracic blood volume (ITBV), at the moment of the beginning of Puls Contour Cardiac Output (PiCCO) hemodynamic monitoring.
Data and measurements from 37 ICU patients, divided into four groups according to diagnosis of primary condition, were retrospectively studied. The first group consisted of polytrauma patients, second group of patients with pancreatitis and/or peritonitis, third group were postoperative patients, and fourth group were patients with various medical diagnosis: sepsis, acute respiratory distress syndrome (ARDS), acute lung failure (ALF), and acute heart failure (AHF). PiCCO monitor was introduced when the signs of hemodynamic instability were observed. First measured ITBV was recorded and analyzed according to deviation from reference values.
First measured ITBV was in reference range in 14 (37.8%) patients. Volume overloading was observed in 16 (43.2%) and hypovolemia in 7 (18.9%) patients.
The observed inappropriate blood volume in patients of all studied groups suggests that there is the need for defining indications and earlier application of hemodynamic monitoring, as well as reassessment of usual empirically guided infusion therapy in ICU setting.

Key words: hemodynamic process, intensive care, hypovolemia, monitoring

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Surfactant administration in premature infants with RDS

Abstract

Background. The significant advancement in the treatment of respiratory distress syndrome can be attributed to prenatal identification of high risk pregnancies, prevention of illness through antenatal care, prenatal administration of glucocorticoids, advancement in respiratory support and surfactant therapy. These measures resulted in the reduction of mortality and morbidity rates in preterm infants.
Patients and methods. We analyzed data of 78 preterm babies with respiratory distress syndrome hospitalized in the NICU of the Pediatric Clinic, KCU Sarajevo. All children included in the study were mechanically ventilated and treated with one or more doses of bovine surfactant (Survanta) as rescue therapy. Surfactant was given to children with clinical and radiological signs of RDS, who required FiO2>0,40. We used the standard procedure of giving surfactant therapy to intubated children in sterile conditions, after we confirmed, by X-ray, correct tube placement.
Results. We investigated the clinical efficacy of surfactant in relation to time of administration, O2 requirement and necessity of one or more doses of surfactant. We found that early treatment with surfactant replacement- within 6 hours of birth- is more effective, and resulted in a significant reduction of mortality rate (p<0,01). Treatment with multiple doses is more effective in comparison to one dose, although there was not a significant difference (p<0,20) between the treated groups. There is a significant difference (p<0,01) between groups related to O2 requirement. In the group of babies which required 60% or more O2 concentration in inhaled air at the time of surfactant replacement, mortality rate was significantly higher (p<0,01).
Conclusion. Our study confirmed the benefits of surfactant therapy in preterm babies with respiratory distress syndrome. We confirmed the advantages of early treatment vs. late treatment, but we could not confirm the obvious advantage of multiple over single doses. So, a reasonable recommendation is to treat the infants as soon as clinical signs of developing respiratory distress appear with an individual dose for each infant.

Key words: respiratory distress syndrome, surfactant, preterm

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