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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Month: May 2011

The endocannabinoid system in sepsis – a potential target to improve microcirculation?

Abstract

During the last decade, research has identified the endocannabinoid system (ECS) as a key regulator of essential physiological functions, including the regulation of microvascular and immune function. Indeed, increasing evidence now suggests that release of endocannabinoids and activation of cannabinoid receptors occurs during sepsis and that manipulation of the ECS may represent an important therapeutic target to improve microcirculation in sepsis. In this review, the pharmacology and physiology of the ECS and the involvement of cannabinoids, cannabinoid receptors and non-CB1R/CB2R pathways related to ECS activation will be described. This information will increase our comprehension of the role of lipid signaling pathways in sepsis and may lead to the identification of new drug targets for the treatment of impaired microcirculation.

Key words: systemic inflammation, sepsis, microcirculation, lipid mediators, cannabinoids, cannabinoid receptors

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Perioperative fenoldopam for the prevention of acute renal failure in non-cardiac surgery, randomized clinical trial

Abstract

Purpose. Acute renal failure is a serious complication of surgery causing morbidity and mortality. The aim of this study was to evaluate the efficacy of fenoldopam, a selective dopamine-1 receptor agonist, in patients at high risk of perioperative renal dysfunction.
Methods. In this prospective single-center randomized double-blind trial we enrolled 64 patients undergoing major surgery. Patients received either fenoldopam at a dosage of 0.05 mcg/kg/min or dopamine at a dosage of 2.5 mcg/kg/min after anesthesia induction for a 12-hour period. The primary endpoint was defined as 25% serum creatinine increase from baseline after surgery.
Results. All the patients included were at high risk of perioperative renal dysfunction and underwent major surgery. The two groups (fenoldopam versus dopamine) were homogenous cohorts and no difference in outcome was observed. The incidence of acute renal failure was similar: 11/32 (34%) in the fenoldopam group and 14/32 (44%) in the dopamine group (p=0.6). The postoperative serum creatinine peak was also similar in the two groups. No in-hospital death was observed.
Conclusion. Despite an increasing number of reports suggesting renal protective properties of fenoldopam, we observed no difference in clinical outcome compared to dopamine in a high-risk population undergoing major surgery.

Key words: fenoldopam, acute renal failure, major surgery, serum creatinine

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Successful resuscitation of out of hospital cardiac arrest patients in the emergency department

Abstract

Background. We examined factors associated with the successful resuscitation, in the emergency department (ED), of adult, out-of-hospital cardiac arrest (OHCA) patients.
Methods. The study cohort consisted of adult patients (over 18 years of age) who presented to the ED in 2009 with a diagnosis of cardiac arrest. Data were retrieved from the institutional database.
Results. A total of 122 adult, non-traumatic, OHCA patients were enrolled in the study. There were no significant differences between the sustained return of spontaneous circulation (ROSC) and non-sustained ROSC groups in initial body temperature (P = 0.420), time to successful intubation (P = 0.524), time to first intravenous epinephrine injection (P = 0.108), blood sugar levels (P = 0.122), hematocrit (P = 0.977), cardiac enzymes (P = 0.116) and serum sodium level (P = 0.429). Leukocytosis (P = 0.047) and cardiac rhythm of pulseless ventricular tachycardia/ ventricular fibrillation and pulseless electrical activity (P = 0.022), were significantly associated with sustained ROSC. In contrast, patients with more severe acidosis (P = 0.003) and hyperkalemia (P < 0.001) had a reduced likelihood of achieving sustained ROSC. After multiple variable logistic regression analysis adjusting for variables, the correlation between sustained ROSC and leukocytosis and hyperkalemia remained high (leukocytosis, P = 0.007, odds ratio [OR] 3.655, 95% CI 1.422-9.395; hyperkalemia, P = 0.001, OR 0.169, 95% CI 0.057-0.500)
Conclusion. Patients suffering an OHCA were appropriately resuscitated after arriving at the ED. Successful resuscitation in adult OHCA victims was determined by the patient’s status, in particular their white blood cell count and potassium level.

Key words: adult out of hospital cardiac arrest, return of spontaneous circulation, in-hospital phase, hyperkalemia, leukocytosis

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Outbreak of nosocomial bacteremias, caused by Enterobacter gergoviae and Enterobacter aerogenes, in the neonatal intensive care unit, case – control study

Abstract

In this case-control study we describe epidemiological characteristics and evaluate risk factors for bacteremias caused by a rare human pathogen Enterobacter gergoviae, and Enterobacter aerogenes, among neonates in the intensive care unit, under conditions of nosocomial outbreak.
Crude rate of bacteremias was 16 per 1000 admissions. Bacteremias most commonly occurred between 7th to 30th day of hospitalization and were 1.9 times more frequent in males than females. The following risk factors were significantly associated with the development of bacteremias: a) colonization or infection of neonates prior to the onset of bacteremia with Enterobacter spp. (OR=3.4, 95%CI=1.2-9.9) or non-Enterobacter spp. (OR=7.9, 95%CI=1,2-52.5); b) use of antimicrobial drugs most notably ceftazidime (OR = 7.8, 95% CI = 1.6.-38.6), or amikacin (OR = 7.5, 95% CI = 2.8-19.9); and c) invasive interventions: mechanical ventilation (OR = 4.7, 95% CI = 1.6-13.5), umbilical catheterization (OR = 3.1, 95% CI = 1.1-13.3), or nasogastric tube insertion (OR = 3.8, 95% CI = 1.8-8). These results show that some previously described risk factors for developing Enterobacter bacteremia were equally applicable in the case of Enterobacter gergoviae infections.
In addition, the report represents an important contribution to establishing E. gergoviae as a relevant human pathogen with epidemiological potential, as it is the first case-control report in the region and one of a few in the world, analyzing outbreaks of bacteremias in the neonatal intensice care unit (ICU) caused by E. gergoviae.

Key words: neonatal intensive care unit, bacteremia, Enterobacter gergoviae, Enterobacter aerogenes, risk factors

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