Continuous positive airway pressure vs. proportional assist ventilation for noninvasive ventilation in acute cardiogenic pulmonary edema

Objective To compare continuous positive airway pressure (CPAP) and proportional assist ventilation (PAV) as modes of noninvasive ventilatory support in patients with severe cardiogenic pulmonary edema. Design and setting A prospective multicenter randomized study in the medical ICUs of three teaching hospitals. Patients Thirty-six adult patients with cardiogenic pulmonary edema (CPA) with unresolving dyspnea, respiratory rate above 30/min and/or SpO₂ above 90% with O₂ higher than 10 l/min despite conventional therapy with furosemide and nitrates. Interventions Patients were randomized to undergo either CPAP (with PEEP 10 cmH₂O) or PAV (with PEEP 5–6 cmH₂O) noninvasive ventilation through a full face mask and the same ventilator. Measurements and results The main outcome measure was the failure rate as defined by the onset of predefined intubation criteria, severe arrythmias or patient's refusal. On inclusion CPAP (n = 19) and PAV (n = 17) groups were similar with regard to age, sex ratio, type of heart disease, SAPS II, physiological parameters (mean arterial pressure, heart rate, blood gases), amount of infused nitrates and furosemide. Failure was observed in 7 (37%) CPAP and 7 (41%) PAV patients. Among these, 4 (21%) CPAP and 5 (29%) PAV patients required endotracheal intubation. Changes in physiological parameters were similar in the two groups. Myocardial infarction and ICU mortality rates were strictly similar in the two groups. Conclusions In the present study PAV was not superior to CPAP for noninvasive ventilation in severe cardiogenic pulmonary edema with regard to either efficacy and tolerance. T. Rusterholtz and P.-E. Bollaert contributed equally to this study. This work was supported in part by Respironics Inc., Murrysville, PA, USA.     

Transthoracic monitoring of the impedance of the right lung in patients with cardiogenic pulmonary edema

OBJECTIVE: To evaluate the suitability of the new electrical impedance monitor RS-205 for monitoring of cardiogenic pulmonary edema (CPE). DESIGN: Prospective, controlled study. SETTING: A department of internal medicine in a 1,200-bed university-affiliated, teaching hospital. PATIENTS: Sixty patients, aged 52-80 yrs, 30 without CPE (controls) and 30 with or at high risk for CPE. INTERVENTIONS: Internal thoracic impedance (ITI) was monitored by the RS-205. The RS-205 is approximately three times more sensitive than the Kubicek monitor, and it eliminates the effect of the drift of skin-to-electrode impedance. This is achieved by eliminating skin electrode impedance by a special algorithm, thus allowing measurement of ITI rather than total transthoracic impedance. Measuring ITI, the main component of which is lung impedance, is a noninvasive and safe method. CPE was diagnosed in accordance with well-accepted clinical and roentgenological criteria. MEASUREMENTS AND MAIN RESULTS: The controls' initial ITI was 68.3 +/- 12.38 ohms. During 6 hrs of monitoring, the ITI attained a minimum average value of -1.3 +/- 2.08% and a maximum average value of 4.6 +/- 3.56% relative to baseline. In all patients entering CPE, ITI decreased by 14.4 +/- 5.42% on the average (p <.001) 1 hr before the appearance of clinical symptoms. In patients with evolving CPE, ITI decreased significantly compared with controls (22.25 +/- 9.82%, p <.001). In patients at the peak of pulmonary edema, ITI was 2.1 times lower than in the control group (33.1 +/- 10.90 ohms, p <.001). In the last hour before the resolution of CPE, ITI increased in all patients by 17.7 +/- 19.74% compared with the peak of disease (p <.05). After the resolution of pulmonary edema, ITI increased in all patients by 44.14 +/- 26.90% compared with the peak of disease (p <.001). Importantly, the trend in ITI in all patients changed in accordance with the dynamics of CPE. A mixed general linear model shows that ITI values correlated well with the degree of crepitation, a direct characteristics of CPE. CONCLUSIONS: The RS-205 is suitable for monitoring patients at high risk of CPE development. It enables detection of CPE and the monitoring of patients at all stages of CPE.     

Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS

Objective To test whether assessing pulmonary permeability by transpulmonary thermodilution enables to differentiate increased permeability pulmonary edema (ALI/ARDS) from hydrostatic pulmonary edema. Design Retrospective review of cases. Setting A 24-bed medical intensive care unit of a university hospital. Patients Forty-eight critically ill patients ventilated for acute respiratory failure with bilateral infiltrates on chest radiograph, a PaO₂/FiO₂ ratio < 300 mmHg and extravascular lung water indexed for body weight ≥ 12 ml/kg. Intervention We assessed pulmonary permeability by two indexes obtained from transpulmonary thermodilution: extravascular lung water/pulmonary blood volume (PVPI) and the ratio of extravascular lung water index over global end-diastolic volume index. The cause of pulmonary edema was determined a posteriori by three experts, taking into account medical history, clinical features, echocardiographic left ventricular function, chest radiography findings, B-type natriuretic peptide serum concentration and the time-course of these findings with therapy. Experts were blind for pulmonary permeability indexes and for global end-diastolic volume. Measurements and results ALI/ARDS was diagnosed in 36 cases. The PVPI was 4.7 ± 1.8 and 2.1 ± 0.5 in patients with ALI/ARDS and hydrostatic pulmonary edema, respectively (p < 0.05). The extravascular lung water index/global end-diastolic volume index ratio was 3.0 × 10⁻² ± 1.2 × 10⁻² and 1.4 × 10⁻² ± 0.4 × 10⁻² in patients with ALI/ARDS and with hydrostatic pulmonary edema, respectively (p < 0.05). A PVPI ≥ 3 and an extravascular lung water index/global end-diastolic index ratio ≥ 1.8 × 10⁻² allowed the diagnosis of ALI/ARDS with a sensitivity of 85% and specificity of 100%. Conclusion These results suggest that indexes of pulmonary permeability provided by transpulmonary thermodilution may be useful for determining the mechanism of pulmonary edema in the critically ill. This article is discussed in the editorial available at:     

RETRACTED ARTICLE: Noninvasive assessment of cardiac output using thoracic electrical bioimpedance in hemodynamically stable and unstable patients after cardiac surgery: a comparison with pulmonary artery thermodilution

Objective To compare noninvasive cardiac output (CO)measurement obtained with a new thoracic electrical bioimpedance (TEB) device, using a proprietary modification of the impedance equation, with invasive measurement obtained via pulmonary artery thermodilution.Design Prospective, observational study.Setting Surgical intensive care unit (ICU) of a university-affiliated community hospital.Patients and participants Seventy-four adult patients undergoing elective cardiac surgery with routine pulmonary artery catheter placement.Interventions None.Measurements and results Simultaneous paired CO and cardiac index (CI) measurements by TEB and thermodilution were obtained in mechanically ventilated patients upon admission to the ICU. For analysis of CI data the patients were subdivided into a hemodynamically stable group and a hemodynamically unstable group. The groups were analyzed using linear regression and tests of bias and precision. We found a significant correlation between thermodilution and TEB (r = 0.83; n< 0.001), accompanied by a bias of –0.01 l/min/m² and a precision of ±0.57 l/min/m² for all CI data pairs. Correlation, bias, and precision were not influenced by stratification of the data. The correlation coefficient, bias, and precision for CI were 0.86 (n< 0.001), 0.03 l/min/m², and ±0.47 l/min/m² in hemodynamically stable patients and 0.79 (n< 0.001), 0.06 l/min/m², and ±0.68 l/min/m² in hemodynamically unstable patients.Conclusions Our results demonstrate a close correlation and clinically acceptable agreement and precision between CO measurements obtained with impedance cardiography using a new algorithm to calculate CO from variations in TEB, and those obtained with the clinical standard of care, pulmonary artery thermodilution, in hemodynamically stable and unstable patients after cardiac surgery.     

Influence of extravascular lung water on transpulmonary thermodilution-derived cardiac output measurement

Objective The transpulmonary thermo-dye dilution technique enables assessment of cardiac index (CI) intrathoracic blood volume index (ITBVI) and extravascular lung water index (EVLWI). Since the extent of lung edema may influence the reliability of CI measurement by transpulmonary thermodilution due to loss of indicator, we analyzed the impact of EVLWI on transpulmonary thermodilution-derived CI in critically ill patients. Design Retrospective, clinical study. Setting Surgical intensive care unit in a university hospital Patients and methods With ethics approval we analyzed data from 57 patients (38 men, 19 women; age range 18–79 years) who, for clinical indication, underwent hemodynamic monitoring by transpulmonary thermo-dye dilution and pulmonary artery thermodilution (572 measurements). All patients were mechanically ventilated and had received a femoral artery thermo-fiberoptic and pulmonary artery catheter which were connected to a computer system (Cold-Z021, Pulsion Medical Systems, Munich, Germany). For each measurement, 15–17 ml indocyanine green(4–6 °C) was injected central venously. Injections were made manually and independently from the respiratory cycle. Linear regression was used for statistical analysis. Interventions and main results The difference between transpulmonary and pulmonary artery thermodilution CI was not correlated with EVLWIfor all measurements (n = 572, r = 0.01, p = 0.76) and when using only the first simultaneous measurement (n = 57, r = 0.08, p = 0.56). Furthermore, EVLWI was not correlated with transpulmonary thermodilution CI (n = 572, r = 0.07, p = 0.08). Coefficient of variation for transpulmonary thermodilution CI was 7.7 ± 4.3%. Conclusion Measurement of cardiac output by transpulmonary thermodilution is not influenced by EVLWI in critically ill patients and loss of indicator as the underlying reason is probably overestimated.     

Pituitary-adrenal responses to human corticotropin-releasing hormone in critically ill patients

Objective To investigate the pattern of pituitary-adrenal responses to human corticotropin-releasing hormone (hCRH) in critically ill patients and to examine the relation between responses and clinical outcome. Design and setting Prospective study in consecutive critically ill patients in a general intensive care unit in a teaching hospital. Patients The study included 37 critically ill, mechanically ventilated patients with diverse underlying diagnoses (28 men, 9 women; median age 56 years). Interventions A morning blood sample was obtained to measure baseline cortisol, corticotropin (ACTH), and cytokines. Patients were then injected with 100 μg hCRH, and plasma cortisol and ACTH were measured over a period of 2 h. Measurements and results In the overall patient population baseline and peak cortisol concentrations following hCRH were 16 ± 5 and 21 ± 5 μg/dl, respectively, and median baseline and peak ACTH levels 23 and 65 pg/ml, respectively. Higher ACTH levels and longer release of cortisol were noted in nonsurvivors (n = 18) than in survivors (n = 19). Furthermore, nonsurvivors had higher concentrations of interleukin 8 (115 vs. 38 pg/ml) and interleukin 6 (200 vs. 128 pg/ml) than survivors. Conclusions Critically ill patients demonstrate altered pituitary-adrenal axis responses to hCRH. This is particularly evident in the sickest patients with the highest degree of inflammatory profile who ultimately do not survive.     

双水平正压通气在急性心源性肺水肿中的应用

目的:探讨双水平正压通气治疗急性心源性肺水肿的疗效。方法:收集内科2003年1月至2007年8月收治的92例急性心源性肺水肿患者的临床资料并进行分析。治疗组46例在应用常规抗心源性肺水肿药物的同时联用BiPAPS/T30或BiPAP-Synchrony呼吸机进行无创通气治疗,对照组46例只应用常规药物治疗。结果:治疗组患者临床症状、体征明显改善,心率、呼吸频率、血压与治疗前比较显著降低,SaO2与治疗前比较显著增高(P<0.05),总有效率93.5%。对照组总有效率仅为82.6%。结论:双水平正压通气治疗急性心源性肺水肿疗效确切。     

Automatic adjustment of noninvasive pressure support with a bilevel home ventilator in patients with acute respiratory failure: a feasibility study

Objective To test the feasibility of applying noninvasive ventilation (NIV) using a prototype algorithm implemented in a bilevel ventilation device designed to adjust pressure support (PS) to maintain a clinician-set alveolar ventilation in patients with acute respiratory failure after initial stabilization. Design and setting Prospective crossover interventional study in an intensive care unit, university hospital. Patients 19 patients receiving NIV for acute hypercapnic respiratory failure (13 men, 6 women; mean age 70 ± 11 years). Methods The same bilevel ventilator was used with manually adjusted PS and with the automated algorithm (autoPS), set to maintain the same alveolar ventilation as in PS. Sequence (measurements at end of each period): (a) prior to initiating NIV (baseline 1); (b) 45 min with manually set PS; (c) 60 min without NIV; (d) 45 min with autoPS; (e) 60 min without NIV; (f) 45 min with manually set PS. Results The magnitude of decrease in PaCO₂ and increase in pH with autoPS was comparable to that of conventional PS, with the same alveolar ventilation and level of PS. No technical problem occurred in autoPS mode, and no NIV trial had to be discontinued because of patient discomfort. Conclusions These results suggest that the alveolar ventilation based automatic control of PS during NIV with a bilevel device is feasible and leads to beneficial effects in patients with acute respiratory failure comparable to those of manually set PS. Further studies should now explore the potential of this system over longer periods in patients with acute and chronic respiratory failure. Financial support for this study was provided by Resmed in the form of an unrestricted grant     

Dramatic beneficial effects of sildenafil in recurrent massive pulmonary embolism

Objective Sildenafil has a well established pulmonary vasodilatory effect, but has seldom been used in critically ill patients. We report a case of severe recurrent pulmonary embolism in which sildenafil was used as a rescue therapy. Results After oral administration of 50 mg of sildenafil, cardiac index increased from 2.1 l/min/m² to 3.2 l/min/m²; mean pulmonary artery pressure decreased from 56 mmHg to 46 mmHg, and pulmonary vascular resistance index decreased from 700 dynes/cm⁻⁵/m² to 425 dynes/cm⁻⁵/m², without reduction of arterial systemic pressure. Clinical condition also improved during the following days under treatment of 50 mg sildenafil three times daily. Conclusions These observations should stimulate studies with sildenafil in the ICU setting. Sildenafil is easy to administer in every ICU and at any time. If its potential is confirmed, it may be a life-saving drug in some emergency situations caused by severe pulmonary hypertension. The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.     

Postresuscitation myocardial dysfunction: correlated factors and prognostic implications

Objective To evaluate the clinical factors correlated with postresuscitation myocardial dysfunction and the prognostic implication such dysfunction may have. Design and setting Prospective observational study in a university medical center Patients 58 adult patients successfully resuscitated from nontraumatic out-of-hospital cardiac arrest over 2 years. Measments and results Echocardiographic evaluation of the left ventricular systolic and diastolic functions was performed 6 h postresuscitation and was analyzed in correlation to the clinical features and resuscitation factors. Univariate analysis revealed left ventricular ejection fraction (LVEF) to be significantly lower in patients with hypertension, past history of myocardial infarction, resuscitation duration longer than 20 min, defibrillation, and use of more than 5 mg epinephrine. Isovolumic relaxation time (IVRT) was significantly longer in patients with noncardiac cause and initial rhythm of nonventricular fibrillation/tachycardia. Multiple regression analysis showed epinephrine dose and past history of myocardial infarction to be independent factors for LVEF, while the cause of cardiac arrest was independently associated with IVRT. For prognosis, 27 patients survived to hospital discharge. Both LVEF under 40% and IVRT 100 ms or longer were associated with poor survival outcomes. In Cox regression analysis IVRT 100 ms or longer served as an independent factor predicting poor survival prognosis. Conclusions Postresuscitation left ventricular dysfunction is correlated with a number of clinical factors, among which past history of myocardial infarction, epinephrine dose, and the cause of cardiac arrest play independent roles. Meanwhile, IVRT 100 ms or longer 6 h postresuscitation predicts poor survival outcomes and serves as a marker of poor prognosis. Electronic supplementary material This article has been selected for the initiative “Publishing the Review Process”, and the material related to its review process can be obtained on-line as Electronic Supplementary Material using the Springer Link server located at and is accessible for authorized users.     

Postresuscitation accelerated idioventricular rhythm: a potential prognostic factor for out-of-hospital cardiac arrest survivors

Objective Data are lacking on the relationship between postresuscitation ECG and outcome in out-of-hospital cardiac arrest (OHCA). We examined the prognostic information that postresuscitation ECG rhythm can provide for predicting outcome in OHCA survivors. Methods The retrospective observational study enrolled 56 successfully resuscitated nontraumatic adult OHCA patients. Postresuscitation 12-lead ECGs of the enrolled patients were interpreted independently by two cardiologists. We compared baseline clinical characteristics, CPR process, and outcome in the 8 patients with postresuscitation accelerated idioventricular rhythm (AIVR, n = 8) and the 48 without AIVR. Results The AIVR group had a higher proportion of patients with coronary artery disease (50% vs. 15%), initial ventricular tachycardia/fibrillation rhythm (50% vs. 8%), and cardiac origin of OHCA (75% vs. 23%). AIVR patients had longer total CPR duration (32 vs. 18 min) and higher dose of epinephrine use (10 vs. 3 mg). Postresuscitation AIVR was associated with an increased incidence of repeated CPR within 1 h after return of spontaneous circulation (38% vs. 4%), and lower 7-day survival rate (0% vs. 50%). Conclusions AIVR on postresuscitation ECG offers a prognostic factor related to a higher repeated CPR rate within 1 h after return of spontaneous circulation and a lower 7-day survival rates in successfully resuscitated OHCA victims.     

Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective case control study

Objective To compare surgical and endovascular stent graft (ESG) treatment of blunt thoracic aortic injury (BAI) in the emergency setting.Design and setting Retrospective case control study in two surgical intensive care units of a university hospital.Patients 30 patients who presented with BAI between 1995 and 2005: 17 treated surgically and 13 by ESG. The two groups were comparable for the severity of trauma and mean delay before treatment; the mean age was higher in the ESG group (46 ± 18 vs. 35 ± 15 years).Results In the surgical group time spent in the operating theater was longer (310 ± 130 vs. 140 ± 48 min) and blood losses higher (2000 ± 1300 vs. no significant bleeding); aortic clamping time was 48 ± 20 min. The mortality rate was 15% with ESG (n = 2) and 23% with surgery (n = 4). Complications of the procedure were more frequent in the surgical group (1 vs. 7). In the ESG group there was one pulmonary embolism. In the surgical group there were three neurological complications, one acute aortic dissection, one perioperative rupture, one periprosthetic leak, and one septic shock. Two complications (postoperative aortic dissection and paraplegia) appeared in the same patient in the surgical group. Intensive care unit length of stay, duration of mechanical ventilation, and catecholamine support were similar in the two groups.Conclusions Stent graft for emergency treatment of BAI is efficient and is associated with fewer complications than surgical treatment.     

Relative adrenal insufficiency in patients with severe acute pancreatitis

Objective Inadequate cortisol levels and adrenal dysfunction may play a role in the pathophysiology of severe acute pancreatitis. This study aimed to analyse the incidence of relative adrenal insufficiency (RAI) in these patients, to identify factors associated with RAI and to describe how adrenal responsiveness affects outcome. Design Prospective observational multicenter study. Patients Twenty-five patients with severe acute pancreatitis. Interventions A short Synacthen test (SST) was performed within 5 days after admission to the hospital. The incidence of RAI, defined as an increment after SST of less than 9 μg/dl was the primary endpoint of the study. Serum cortisol was measured at baseline and at 30 and 60 min after administration of 250 μg adrenocorticotropic hormone. Measurements and results Median baseline cortisol level was 26.6 μg/dl, and increased to 43.2 μg/dl and 48.8 μg/dl after 30 min and 60 min respectively. RAI was found in 16% of all patients and in 27% of patients with organ dysfunction. Patients with RAI were more severely ill and had higher SOFA scores from days 4 to 7 after admission. All patients with RAI developed pancreatic necrosis, and all of them needed surgical intervention. Twenty-eight-day mortality was significantly higher in patients with RAI (75% vs. 5%, p = 0.007). Patients who died had a lower increment in cortisol levels after the SST than patients who survived. Conclusion RAI is frequent in patients with severe acute pancreatitis and organ dysfunction. It occurs in patients with more severe pancreatitis and is associated with increased mortality. An abstract of this work was presented at the 27th International Symposium on Intensive Care and Emergency Medicine (ISICEM) in Brussels, March 2007.     

Effects of a single-lung recruitment maneuver on the systemic release of inflammatory mediators

Objective To study the hypothesis, that systemic levels of pro-inflammatory and anti-inflammatory cytokines may be affected by a single recruitment maneuver in mechanically ventilated patients.Design Prospective, interventional clinical trial.Setting Intensive care unit of a university hospital.Patients Sixteen mechanically ventilated patients with clinical and radiological signs of atelectasis.Interventions A single recruitment maneuver (RM) was performed by elevating the airway pressure to 40 cmH₂O for 7 s.Measurements and main results Plasmatic concentrations of interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12p70 and tumor necrosis factor (TNF-α), arterial blood gases and hemodynamic parameters were measured immediately before and 5–360 min after the RM. The RM caused a minor, nevertheless significant improvement of oxygenation (p = 0.02) and carbon dioxide elimination (p = 0.006) as well as a moderate drop of the mean arterial pressure (p = 0.025). In contrast, plasma concentrations remained unaffected by the RM in all six mediators measured.Conclusion A single inflation with an airway pressure of 40 cmH₂O for 7 s improved gas exchange only slightly and did not modify systemic levels of inflammatory mediators in mechanically ventilated patients with radiological evidence of atelectasis.This study was supported by departmental funds     

Antibiotic management of suspected nosocomial ICU-acquired infection: Does prolonged empiric therapy improve outcome?

Objective To characterize empiric antibiotic use in patients with suspected nosocomial ICU-acquired infections (NI), and determine the impact of prolonged therapy in the absence of infection. Design and setting Multicenter prospective cohort, with eight medical-surgical ICUs in North America and Europe. Patients 195 patients with suspected NI. Methods The diagnosis of NI was adjudicated by a blinded Clinical Evaluation Committee using retrospective review of clinical, radiological, and culture data. Results Empiric antibiotics were prescribed for 143 of 195 (73.3%) patients with suspected NI; only 39 of 195 (20.0%) were adjudicated as being infected. Infection rates were similar in patients who did (26 of 143, 18.2%), or did not (13 of 52, 25.0%) receive empiric therapy ( p = 0.3). Empiric antibiotics were continued for more than 4 days in 56 of 95 (59.0%) patients without adjudicated NI. Factors associated with continued empiric therapy were increased age ( p = 0.02), ongoing SIRS ( p = 0.03), and hospital ( p = 0.004). Patients without NI who received empiric antibiotics for longer than 4 days had increased 28-day mortality (18 of 56, 32.1%), compared with those whose antibiotics were discontinued (3 of 39, 7.7%; OR = 5.7, 95% CI 1.5–20.9, p = 0.005). When the influence of age, admission diagnosis, vasopressor use, and multiple organ dysfunction was controlled by multivariable analysis, prolonged empiric therapy was not independently associated with mortality (OR = 3.8, 95% CI 0.9–15.5, p = 0.07). Conclusions Empiric antibiotics were initiated four times more often than NI was confirmed, and frequently continued in the absence of infection. We found no evidence that prolonged use of empiric antibiotics improved outcome for ICU patients, but rather a suggestion that the practice may be harmful. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest

Objective To report the feasibility, complications, and outcomes of emergency extracorporeal life support (ECLS) in refractory cardiac arrests in medical intensive care unit (ICU). Design and setting Prospective cohort study in the medical ICU in a university hospital in collaboration with the cardiosurgical team of a neighboring hospital. Patients Seventeen patients (poisonings: 12/17) admitted over a 2-year period for cardiac arrest unresponsive to cardiopulmonary resuscitation (CPR) and advanced cardiac life support, without return of spontaneous circulation. Interventions ECLS femoral implantation under continuous cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane oxygenator. Measurements and results Stable ECLS was achieved in 14 of 17 patients. Early complications included massive transfusions (n = 8) and the need for surgical revision at the cannulation site for bleeding (n = 1). Four patients (24%) survived at medical ICU discharge. Deaths resulted from multiorgan failure (n = 8), thoracic bleeding (n = 2), severe sepsis (n = 2), and brain death (n = 1). Massive hemorrhagic pulmonary edema during CPR (n = 5) and major capillary leak syndrome (n = 6) were observed. Three cardiotoxic-poisoned patients (18%, CPR duration: 30, 100, and 180 min) were alive at 1-year follow-up without sequelae. Two of these patients survived despite elevated plasma lactate concentrations before cannulation (39.0 and 20.0 mmol/l). ECLS was associated with a significantly lower ICU mortality rate than that expected from the Simplified Acute Physiology Score II (91.9%) and lower than the maximum Sequential Organ Failure Assessment score (> 90%). Conclusions Emergency ECLS is feasible in medical ICU and should be considered as a resuscitative tool for selected patients suffering from refractory cardiac arrest. This article is discussed in the editorial available at:     

Extravascular lung water to blood volume ratios as measures of permeability in sepsis-induced ALI/ARDS

Objective We studied the relationship, and the effect of fluid loading on this, between the ratio of extravascular lung water (EVLW) to intrathoracic/pulmonary blood volumes (ITBV, PBV) and the radionuclide pulmonary leak index (PLI) to protein during sepsis-induced acute lung injury/acute respiratory distress syndrome (ALI/ARDS).Design and setting A prospective observational study, in the intensive care unit of a university hospital.Patients Twenty-two consecutive mechanically ventilated patients with sepsis-related ALI/ARDS from pneumonia (n = 12) or extrapulmonary sources (n = 10), without elevated cardiac filling pressures.Intervention Crystalloid (1700–1800 ml) or colloid (1000–1800 ml) fluid loading until target filling pressures.Measurements and results Protein permeability was assessed noninvasively over the lungs with help of ⁶⁷Ga-labeled transferrin and ^99mTc-labeled red blood cells (Pulmonary leak index, upper limit normal 14.1 × 10⁻³ /min) and EVLW and blood volumes by the thermal-dye transpulmonary dilution technique before and after fluid loading. Prior to fluids the pulmonary leak index related to the ratio of EVLW/ITBV and EVLW/PBV (r _s = 0.46) particularly when the pulmonary leak index was below 100 × 10⁻³ /min and in extrapulmonary sepsis (PLI vs. EVLW/PBV r _s = 0.71). Fluid loading did not alter EVLW, EVLW/ITBV, or EVLW/PBV or the relationship to PLI.Conclusion The data demonstrate that EVLW/ITBV or EVLW/PBV are imperfect measures of increased protein permeability in mechanically ventilated patients with sepsis-induced ALI/ARDS particularly when the PLI is severely increased and during pneumonia, independent of fluid status.     

Noninvasive mechanical ventilation in acute cardiogenic pulmonary edema

Acute cardiogenic pulmonary edema is a frequent life-threatening emergency. During the last 10 years, increasing attention has focused on the use of noninvasive ventilation to treat patients with various forms of acute respiratory failure. Numerous physiologic data and clinical studies support the use of noninvasive ventilation during cardiogenic pulmonary edema. Noninvasive ventilation results in rapid improvement of clinical signs of respiratory distress and gas exchange and decreases the need for endotracheal intubation for patients in the ICU with acute hypercapnic respiratory failure related to cardiogenic pulmonary edema. However, no sustained benefit (, decreased late mortality) or benefit for less severe forms of cardiogenic pulmonary edema has been demonstrated yet. Moreover, there are still few data that support the use of a specific mode of ventilation over the others.     

Can dynamic indicators help the prediction of fluid responsiveness in spontaneously breathing critically ill patients?

Objective To investigate whether the respiratory changes in arterial pulse (ΔPP) and in systolic pressure (ΔSP) could predict fluid responsiveness in spontaneously breathing (SB) patients. Because changes in intrathoracic pressure during spontaneous breathing (SB) might be insufficient to modify loading conditions of the ventricles, performances of indicators were also assessed during a forced respiratory maneuver. Design Prospective interventional study. Setting A 34-bed university hospital medico-surgical ICU. Patients and participants Thirty-two SB patients with clinical signs of hemodynamic instability. Intervention A 500-ml volume expansion (VE). Measurements and results Cardiac index, assessed using transthoracic echocardiography, increased by at least 15% after VE in 19 patients (responders). At baseline, only dynamic indicators were higher in responders than in nonresponders (13 ± 5% vs. 7 ± 3%, p = 0.003 for ΔPP and 10 ± 4% vs. 6 ± 2%, p = 0.002 for ΔSP). Moreover, they significantly decreased after VE (11 ± 5% to 6 ± 4%, p < 0.001 for ΔPP and 8 ± 4% to 6 ± 3%, p < 0.001 for ΔSP). ΔPP and ΔSP areas under the ROC curve were high (0.81 ± 0.08 and 0.82 ± 0.08; p = 0.888, respectively). A ΔPP ≥ 12% predicted fluid responsiveness with high specificity (92%) but poor sensitivity (63%). The forced respiratory maneuver reproducing a dyspneic state decreased the predictive power. Conclusions Due to their lack of sensitivity and their dependence to respiratory status, ΔPP and ΔSP are clearly less reliable to predict fluid responsiveness during SB than in mechanically ventilated patients. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely. This study was presented at the American Thoracic Society international conference, 2005, San Diego, California. This article is discussed in the editorial available at: .     

Glutamine kinetics during intravenous glutamine supplementation in ICU patients on continuous renal replacement therapy

Objective To investigate glutamine kinetics during continuous renal replacement therapy (CRRT) in multiple organ failure (MOF) patients with and without exogenous intravenous glutamine supplementation. Design and patients In a pragmatic clinical study 12 patients without urine production receiving CRRT were prospectively randomized in a cross-over design to receive glutamine intravenously for 20 h before placebo or placebo before glutamine on two consecutive days. Alanyl-glutamine or placebo (saline) was infused. Measurements Plasma glutamine concentration was measured in artery, femoral vein, and filtration fluid. Blood flow across the leg was measured and the efflux of glutamine calculated. The rate of appearance of glutamine was calculated from the plasma decay curve of glutamine concentration on the day of treatment. Results Glutamine supplementation increased plasma concentrations from 570 ± 252 to 831 ± 367 μmol l⁻¹. Glutamine losses into the filtration fluids were similar during treatment and control days: 25 ± 13 vs. 24 ± 11 mmol 24 h⁻¹, corresponding to 3.6 ± 1.9 and 3.5 ± 1.6 g 24 h⁻¹, respectively. Net glutamine balance across the leg was also similar on treatment and control days: 150 ± 138 and 188 ± 205 nmol min⁻¹ 100 ml⁻¹, respectively. The rate of appearance of glutamine was 54 ± 17 g 24 h⁻¹. Conclusion The loss of glutamine into the ultrafiltrate during CRRT in MOF patients suggests a greater need for exogenous glutamine than in patients without renal failure. The leg efflux and the filtration losses of glutamine were not affected in response to intravenous glutamine supplementation.