Abstract

Objectives. We examined the relationship between partial end-tidal CO2 (pet) and mean arterial pressure in patients with traumatic hemorrhagic shock, who were receiving constant minute ventilation.
Methods. In 61 patients we continuously measured pet CO2 with a capnograph, direct arterial pressure via a cannula, oxygen levels via pulse oximetry and body temperature.
Results. We observed significant changes in pet CO2 (increase) after volume resuscitation and a quantitative linear relationship between pet CO2 and mean arterial pressure.
Conclusions. Partial end-tidal CO2 can be used as a reliable non-invasive monitoring device in patients with hemorrhagic shock when minute ventilation is relatively constant. The monitoring of pet CO2 might also be a useful guide for volume resuscitation in hemorrhagic shock, especially in the pre-hospital setting.

Keywords: end- tidal CO₂, mean arterial pressure, hemorrhagic shock, relationship

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

Abstract

Introduction. Some studies have shown that the presence of bradycardia in hemorrhage-caused-hypotension is associated with a better prognosis. The aim of this retrospective study was to compare bradycardic and tachycardic responses to hemorrhaging in a pre-hospital setting and to evaluate the outcome.

Patients and methods. All patiens were adults (>18 years) with tachycardia and bradycardia hypotension (hemorrhaging) in a pre-hospital setting. We compared a tachycardic group with a bradycardic group using the following criteria: age, gender, APACHE II on admission, trauma vs. non-trauma patients, outcome (survival) and the use of vasopressors.
Results. Over a two year period, 107 patients were screened. The tachycardic group was younger in age than the bradycardic group. Tachycardia was significantly more common in males. The bradycardic group had better APACHE II on admission and also better outcome (survival). Mortality was lower in bradycardic patients than in tachycardic patients.
Conclusion. Bradycardia is a real phenomenon in hemorrhaging patients in a prehospital setting. It might be associated with both better APACHE II on admission and better outcome.

Keywords: bradycardia, hypotensive (hemorrhagic) patients, prehospital setting, APACHE II, prognosis.

Abstract

Intraabdominal hypertension can induce a significant dysfunction of cardiovascular, respiratory, renal, and gastrointestinal and central nervous systems. Recently, a prospective multicenter epidemiological study concluded that the intraabdominal hypertension observed in intensive care units was associated with an increased risk of mortality in critically ill patients. In this review, we summarize current literature data concerning definitions and measurement of intraabdominal pressure and discuss the importance of intraabdominal hypertension in critically ill patients. We conclude that intraabdominal pressure should be taken into consideration along with other standard pressure measurements in critically ill patients.

Keywords: intraabdominal pressure, intraabdominal hypertension, abdominal compartment syndrome

Abstract

Alcohol intake contributes directly or indirectly to 15 to 20% of medical problems in primary care or an inpatient setting. It is estimated that approximately 500,000 episodes of withdrawal will be severe enough to require pharmacologic intervention. The total cost to the United States economy from alcohol abuse was estimated to be $185 billion for 1998. This review attempts to put forth a practical and evidence based approach towards the inpatient management of alcohol withdrawal. Various agents and their pharmacology are described. Strength of evidence regards to efficacy and shorter inpatient stays is examined.

Key words: substance abuse, pharmacology, addiction, pathophysiology, critical care

Abstract

The objective of this study was to evaluate the use of central venous catheters (CVCs) in the Pediatric intensive care unit (PICU) of Split University Hospital (SUH). We reviewed the records of all children that had CVCs and were hospitalized between January 2002 and March 2006. Patients were evaluated with respect to their age, gender, catheter type, indication for CVC insertion, site and side of the body of CVC insertion. The duration of catheter use and eventual complications were also taken into consideration. A total of 352 CVCs were inserted in 300 children. Patient age ranged from 0 to 18 years. The average catheter insertion time was 12.88 days. We noted 66 (18.8%) CVC-related complications. Complications related to CVCs insertion were malposition of catheter (5.4%) and pneumothorax (0.9%). Occlusion of CVCs (4.3%), catheter related-bloodstream infections (CRBI) (4.0%), dislodgment (3.7%) and catheter damage (0.6%) were complications associated with lenght of CVCs use. We conclude that central venous catheterization is a safe and efficient procedure with minimal complications in pediatric patients.

Key words: central venous catheter, indications, complications, children.

Abstract

Elevated intraabdominal pressure (IAP) has been claimed to play a role in abdominal compartment syndrome. We assessed the correlation between the values of IAP, abdominal perfusion pressure (APP) and clinical scoring systems including SIRS, MODS and APACHE II and the patients' survival rate in patients admitted to the ICU with acute abdomen due to ileus, intestinal perforation, peritonitis and trauma.
We measured IAP and APP in 50 surgical patients. In this study the IAP was measured in a non-invasive manner via urinary bladder pressure. The APP was calculated as the difference between mean arterial pressure and IAP values.
A significantly higher IAP was found in the non-survivors' group in comparison with the survivors' group. On the other hand, the APP inversely correlated with disease severity scores including SIRS, MODS and APACHE II, whereas IAP values did not show any correlation to these clinical parameters. These findings suggest that IAP and APP may be useful tools in the clinical evaluation of patients with acute abdomen.

Key words: intraabdominal pressure, abdominal perfusion pressure, acute abdominal syndrome

Abstract

This article is a short review of vasoactive drugs which are in use in todays clinical practice. In the past century, development of vasoactive drugs went through several phases. All of these drugs are today divided into several groups, depending on their place of action, pharmacological pathways and/or effects on target organ or organ system. Hence, many different agents are today in clinical practice, we have shown comparison between them. These agents provide new directions in the treatment of cardiovascular compromise, suggesting that the primary goal of therapy is to produce a vasodilatory effect of the circulation rather than to reverse hemodynamic failure by using inotropic agents, with their inherent risks and side effects.

Key words: vasoactive agents, inotropic agents, levosimendan, phosphodiesterase III inhibitors

Abstract

Amyloidosis is a rare disorder characterized by the deposition of amorphous, extracellular, insoluble fibrillar protein in various tissues of the body. Pulmonary hypertension usually occurs in the last stages of the disease with co-existing left ventricular failure. Amyloidosis causing pulmonary hypertension in a patient with no evidence of left ventricular failure is rarely mentioned in literature. Here, we present a patient with IgA gammopathy presenting with pulmonary hypertension leading to progressive right heart failure and death.

Key words: amyloidosis, pulmonary hypertension, IgA gammopathy

Abstract

Aspiration of barium sulphate is a well-recognized complication, occurring accidentally during examinations of the upper gastrointestinal system using contrast media. Rarely, large amounts of barium sulphate are inadvertently aspirated into the lung. Certain conditions affecting the anatomical and functional integrity of the oropharynx and oesophagus suggest predisposing factors. Aspiration of barium sulphate is not expected to cause severe lung injury due to its relatively non-irritant matter. On the other hand, acute inflammation or even death attributed either to high or low density preparations of barium sulphate, have been reported.
We present two patients, both with a history of schizophrenia, who developed acute respiratory failure requiring mechanical ventilation, following aspiration of large amounts of barium, during an upper gastrointestinal radiographic contrast study. One patient died following massive aspiration which led to multiple organ dysfunction syndrome, while the other, although sub- acutely complicated by pneumonia, was successfully treated.
Beside presentation of cases, several aspects of investigation, differential diagnosis, treatment and prevention are discussed. Complications of barium sulphate aspiration depend upon the density and quantity of the aspirated solution, the extent of tracheobronchial distribution and the general physical condition of the patient. In severe cases, early treatment and close follow up with high-resolution computed tomography are mandatory to prevent progression towards fibrosis. Patients with psychiatric disorders, apart from other conditions predisposing to aspiration, should be dealt with particular caution, when performing the above-mentioned procedures.

Key words: barium, barium sulphate, aspiration pneumonia, lung CT, lung scintigraphy