All originals are with PH neutral Filmoplast attached.
7. Cine impreso, ficción que penetra la experiencia
patients after cardiac arrest
A Samborska-Sablik, Z Sablik, W Gaszynski, J Goch, K Kula
Medical University of Lodz, Poland
Critical Care2006, 10(Suppl 1):P194 (doi: 10.1186/cc4541) Background and goals The aim of our study was to assess concentrations of N-terminated propeptide type B (NTBNP), a marker of cardiac insufficiency, and MB isoenzyme of creatine kinase (CKMB), which level is adequate to the area of acute myocardial necrosis, and to compare their predictive values of survival in patients after cardiac arrest (CA).
ParticipantsFifty-two patients after CA (CA-patients) of age 62 ± 13 years. In 34 patients CA appeared during acute coronary syndrome. Twenty-six patients died after CA (CA-D), and 26 patients survived and were discharged from hospital (CA-S). MethodsThe state of patients after CA was assessed by scales of proven values of survival after CA used in critical care: Glasgow Coma Scale (GCS), Multiple Organ Dysfunction Score (MODS), Simplified Acute Physiology Score II (SAPS II) and Acute Physiology and Chronic Health Evaluation II (APACHE II). In CA-
patients the concentrations of NTpBNP and CKMB were measured in venous blood samples taken just after CA (day 0) and on two consecutive days (day 1 and day 2) at 8:00 am. In CA-D and CA-S patients the concentrations of NTBNP and CKMB were compared. In regression and survival analysis, predictive values of concentrations of NTBNP and CKMB were assessed. Correlations among concentrations of NTBNP, CKMB and values of the scales used in critical care were estimated by Spearman’s correlation coefficient.
Results The mean concentrations of NTBNP and CKMB were higher in CA-D than in CA-S patients 3 days running but were significantly higher only for NTBNP on day 1 (114,000 ± 112,000 vs 45,100 ± 58,000 pmol/l, P < 0.027). On day 1 similar values of the OR of survival after CA of concentrations of NTBNP (OR 5.7 for concentrations >50,000 or ≤50,000 pmol/l, P < 0.02) and concentrations of CKMB (OR 7.5 for concentrations >40 or ≤40 U/l, P < 0,02) were found, but it was only concentrations of NTBNP whose OR was significant in blood on day 0 (OR 5.8 for concentrations >50,000 or ≤50,000 pmol/l, P < 0.02). The relationship to survival of concentrations of CKMB on day 1 and concentrations of NTBNP on day 0 and day 1 was also confirmed in Kaplan–Meyer survival analysis. Only concentrations of NTBNP revealed good correlation with values of the scales used in critical care.
Conclusions On day 1 after CA, concentrations of NTBNP and CKMB are of predictive values of survival. In blood taken just after CA, only the concentration of NTBNP reveals a predictive value of survival. NTBNP is a better predictor of survival after CA than CKMB because its concentration is of predictive value in the first 2 days after CA and of good fit with scales concerning the severity of state of patients after CA.
P195
Cardiopulmonary exercise testing and NT-proBNP before major vascular surgery: do they correlate?
A Turley, S Dorgan, S Baker, M de Belder, A Parry, G Danjoux
James Cook University Hospital, Middlesbrough, UK
Critical Care2006, 10(Suppl 1):P195 (doi: 10.1186/cc4542) Introduction The counter-regulatory neurohormone N-terminal pro- B type natriuretic peptide (NT-proBNP) is predominantly released from the left ventricle in response to increasing wall tension and is a useful prognostic marker in patients with cardiac failure [1]. Cardiopulmonary exercise (CPX) testing is an objective method of assessing functional cardiac status. The anaerobic threshold (AT), the point at which anaerobic metabolism supplements aerobic metabolism, correlates with the severity of cardiac failure [2]. Objective and methodsAn ongoing, prospective, observational study, to determine the correlation between preoperative CPX testing and measurement of NT-proBNP (Roche) in patients undergoing elective abdominal aortic aneurysm (AAA) repair (open or endovascular [EVAR]). All patients were preassessed by a consultant vascular anaesthetist with particular emphasis on cardiac risk factors and functional capacity (metabolic equivalents [METs]). CPX testing was performed preoperatively, by a blinded investigator, in a standardised manner [3] with calculation of AT made by the V-slope method. NT-proBNP levels were also measured preoperatively, a level >150 pg/ml considered elevated. Results Forty-three patients were recruited, mean (SD) age 71.8 ± 8.9 years. The mean (SD) AT was 10.7 ± 3.2 ml/min/kg. There was no significant correlation between age and AT (r= –0.12, P = 0.45). The median level (range) of NT-proBNP was 322.8 (52–5085) pg/ml. Over 85% of patients had an NT-proBNP level >150 pg/ml. There was a weak negative association between
S83 NT-proBNP and AT (r= –0.24, P = 0.18). Results between open
repair and EVAR are summarised in Table 1. There was a positive correlation between AT and METs (r= 0.41, P < 0.01).
ConclusionThere is no correlation between anaerobic threshold and NT-proBNP levels in patients undergoing elective abdominal aortic aneurysm repair but there was a definite positive correlation between AT and functional capacity (METs). Whether CPX or cardiac biomarkers influences outcome requires further study. References
1. Kleber FX, et al.: Eur Heart J2004, 6:D1-D4. 2. Older P, et al.: Chest1993, 104:663-664. 3. Doust JA, et al.: BMJ2005, 330:625. P196
Plasma levels of pro-atrial natriuretic peptide,
pro-adrenomedullin, and pro-endothelin-1 correlate with the severity of organ dysfunction in critically ill patients F Bloos1, F Brunkhorst1, F Fuchs1, N Morgenthaler2, J Struck2,
A Bergmann2, J Papassotiriou2, K Wegscheider3, K Reinhart1
1University Hospital Jena, Germany; 2BRAHMS AG, Hennigsdorf,
Germany; 3Department of Statistics, University of Hamburg,
Germany
Critical Care2006, 10(Suppl 1):P196 (doi: 10.1186/cc4543) Introduction Prohormones of cardiovascular active mediators may add important information to the clinical status of patients with systemic inflammation. However, only little information is available of how serum levels of such prohormones are affected by the clinical status of critically ill patients. The goal of this study was to identify factors that independently influence prohormone plasma concentrations in an ICU setting.
Methods Citrate plasma samples of 185 patients with either severe sepsis/septic shock (n = 120) or systemic inflammatory response syndrome (SIRS, n= 65) after coronary bypass surgery have been obtained daily, resulting in 2385 samples. The Sequential Organ Failure Assessment (SOFA) score was also determined daily. Midregional pro-atrial natriuretic peptide (MR-proANP), midregional pro-adrenomedullin (MR-proADM), and C-terminal pro-endothelin-1 (CT-proET-1) have been measured by an immunoassay (BRAHMS AG, Germany). For each patient, the maximum values of MR-proANP, MR-proADM and CT-proET-1 were identified. These maximum levels were analyzed with multiple
regression using demographic parameters and parameters of inflammation (leukocytes [WBC], C-reactive protein [CRP], procalcitonin) as well as the SOFA score as independent factors. Results The mean age was 63.5 years. The mortality rate was 27% at a mean APACHE II score of 17.5. Table 1 presents individual regression coefficients if statistically significant. CRP levels did not correlate with any of the measured prohormones. ConclusionsVariations in the levels of measured prohormones are only slightly affected by parameters of inflammation. However, development of organ dysfunction is well reflected by proANP and MR-proADM but only to a lesser degree by CT-proET-1.
P197
Prognostic value of pro-atrial natriuretic peptide, pro- adrenomedullin, and pro-endothelin-1 in critically ill patients F Bloos1, F Brunkhorst1, F Fuchs1, N Morgenthaler2, A Bergmann2,
J Struck2, J Papassotiriou2, K Wegscheider3, K Reinhart1
1University Hospital Jena, Germany; 2BRAHMS AG, Hennigsdorf,
Germany; 3Department of Statistics, University of Hamburg, Germany
Critical Care2006, 10(Suppl 1):P197 (doi: 10.1186/cc4544) Introduction Systemic inflammation is accompanied by cardiovascular dysfunction. Prohormones of cardiovascular active mediators may therefore add important information to the clinical status of these patients. The goal of this study was to describe the prognostic value of three different prohormones in an ICU setting. Methods Citrate plasma samples of 185 patients with either severe sepsis/septic shock (n = 120) or systemic inflammatory response syndrome (SIRS; n= 65) after coronary bypass surgery have been obtained on admission to the ICU. Midregional pro-atrial natriuretic peptide (MR-proANP), midregional pro-adrenomedullin (MR-proADM), and C-terminal pro-endothelin-1 (CT-proET-1) have been measured by an immunoassay (BRAHMS AG, Germany). The prognostic value for ICU survival was estimated by the area under the curve (AUC) of the receiver–operating characteristics (ROC). Results The mean age was 63.5 years. The mortality rate was 27% at a mean APACHE II score of 17.5. AUC values and 95% CIs are presented in Table 1. The AUC of the APACHE II score to predict survival in this study was 0.70 (0.61; 0.80).
Table 1 (abstract P197)
Admission value ROC AUC 95% CI MR-proANP 199.7 pmol/l 0.66 0.57; 0.74 MR-proADM 2.3 nmol/l 0.68 0.59; 0.77 CT-proET-1 70.5 pmol/l 0.64 0.56; 0.73
Conclusion Elevation of all three parameters is significantly associated with a poor prognosis in critically ill patients. Outcome prediction is similar to the APACHE II score.
P198
Impact of positive fluid balance on ICU outcome is influenced by the severity of illness
A Reintam1, P Parm2, H Kern3, J Starkopf2
1East Tallinn Central Hospital, Tallinn, Estonia; 2Tartu University
Clinics, Tartu, Estonia; 3DRK Kliniken, Berlin, Germany
Critical Care2006, 10(Suppl 1):P198 (doi: 10.1186/cc4545) IntroductionLess fluid gain has been suggested to be associated with better survival of ICU patients. We investigated whether the positive fluid balance itself or rather the severity of illness is the major determinant of ICU mortality.
Table 1 (abstract P195)
Open AAA EVAR Pvalue
n 21 22
Age (years) 68.3 74.8 0.02
AT (ml/min/kg) 9.6 11.9 <0.02
NT-proBNP (pg/ml) 292 368 0.9
Table 1 (abstract P196)
MR-proANP MR-proADM CT-proET-1
Age 0.31 0.18 0.27 Gender 0.16 0.34 SOFA score 0.42 0.55 0.22 Creatinine 0.37 0.30 Procalcitonin 0.25 0.26 WBC 0.16
S84
Materials and methodsFour hundred and seventeen medical and surgical adult patients admitted to the general ICU of Tartu University Clinics during 2004 and 2005 were retrospectively studied. Eighty patients were excluded due to missing data. Results The total ICU mortality was 29%. The survivors had significantly smaller fluid gain during the admission day than nonsurvivors (2.6 ± 3.3 l vs 4.7 ± 6.4 l; P < 0.001). The fluid gain was significantly smaller in survivors who had SOFA score ≤10 (2.4 ± 3.3 l vs 3.8 ± 5.6 l in nonsurvivors; P = 0.026), but not for those with SOFA score >10 (4.3 ± 3.7 l vs 5.3 ± 6.9 l; P= 0.525). The fluid balance had no impact on the outcome of the latter subgroup of patients, having lactate >4 mmol/l. However, if these patients had lactate <4 mmol/ they significantly benefit from positive fluid gain (Table 1).
Table 1 (abstract P198)
Fluid gain on the day of admission to the ICU in subgroups of patients (liters)
SOFA score Lactate
(points) (mmol) Survivors Nonsurvivors P value < 10 < 4 2.3 ± 3.1 3.6 ± 2.8 0.074 < 10 > 4 4.0 ± 4.3 4.8 ± 8.0 0.695 > 10 < 4 4.4 ± 3.3 1.5 ± 1.5 0.011 > 10 > 4 4.0 ± 4.6 6.3 ± 7.5 0.296 Data presented as mean ± SD.
ConclusionsThe fluid gain during the admission day is associated with increased mortality of ICU patients. Subgroup analysis revealed that this was true for less severely ill patients (SOFA score ≤10), but not for patients with SOFA score >10. The positive fluid balance per seis not necessarily fatal and its effect on outcome is mainly dependent on the severity of illness.
P199
Determination of ‘unmeasured’ anions in acidotic ICU patients P Pickkers, A Terpstra, M Moviat, W Ruitenbeek, J van der Hoeven
University Hospital Nijmegen, The Netherlands
Critical Care2006, 10(Suppl 1):P199 (doi: 10.1186/cc4546) Metabolic acidosis is one of the most frequent acid–base disorders occurring in the ICU. Major causes of metabolic acidosis in critically ill patients are hyperchloremia, hyperlactatemia and the presence of anions of unknown identity, the so-called ‘unmeasured’ anions. The latter is associated with increased mortality and several diseases: sepsis, shock, liver dysfunction and renal failure. The physicochemical approach described by Stewart can be applied to quantify metabolic acidosis. Accordingly, the strong ion gap (SIG) is a quantitative measure of ‘unmeasured’ anions. We hypothesised that derangements in amino acid and organic acid metabolism and abnormal uric acid concentrations could be an explanation for the SIG.
From 32 adult ICU patients with metabolic acidosis, defined as a pH less than 7.35 and a base excess less than –5 mmol/l, the SIG was calculated in a single arterial blood sample. Two groups were compared: patients with SIG <2 mEq/l and patients with SIG >5 mEq/l. ‘Unmeasured’ anions were examined quantitatively by ion-exchange column chromatography, reverse-phase HPLC and gas chromatography/mass spectrometry measuring, respectively, 25 amino acids, uric acid and organic acids. Some organic acids were determined semi-quantitatively. The Mann–Whitney U test was applied for significance (considered P < 0.05) in all cases. For nominal data, the chi-square test was used.
Aspartic acid, isoleucine, ornithine, uric acid, succinic acid, fumaric acid, p-OH-phenyllactic acid and the semi-quantified organic acids 3-OH-isobutyric acid, pyroglutamic acid and homovanillic acid were all significantly elevated in the SIG >5 group (n= 12, mean = 8.3 mEq/l) compared with the SIG <2 group (n = 8, mean = 0.6 mEq/l). Generally, no major differences in organic acid spectra between both groups were observed. However, in one patient in the SIG >5 group who was in a prolonged fasted state at ICU admission, 3-OH-butyric acid was extremely high: 4.0 mEq/l, corresponding to 25% SIG. Overall, the averaged difference between both groups in total amino acid, uric acid and organic acid concentration contributed to the SIG for, respectively, 3.5% (268 µEq/l, not significant), 2.2% (169 µEq/l, P = 0.021) and 1.0% (79 µEq/l, P = 0.025). The total organic acid concentration consisted of glycolic acid, oxalic acid, methylmalonic acid, succinic acid, fumaric acid, malic acid, adipic acid and p-OH-phenyllactic acid. Comparison of patient characteristics of both groups showed that age, sex, APACHE II score, pH, base excess and lactate were not significant. However, renal insufficiency, sepsis and mortality were more prominent in the SIG >5 group. Also, the apparent strong ion difference (due to a significantly lower plasma chloride), phosphate and urea were significantly elevated in the SIG >5 group.
This study demonstrates that total amino acids, uric acid and organic acids form a minor contribution (6.8%, corresponding to 517 µEq/l) to the SIG in acidotic ICU patients.
P200
Hyperchloremic metabolic acidosis after cardiac surgery D Filipescu, I Raileanu, M Luchian, M Andrei, D Tulbure
‘Prof. C.C. Iliescu’ Institute of Cardiovascular Diseases, Bucharest, Romania
Critical Care2006, 10(Suppl 1):P200 (doi: 10.1186/cc4547) Background Hyperchloremic metabolic acidosis (HCMA) after cardiac surgery is iatrogenic and is due to large volumes of saline infused perioperatively [1]. The aim of the study was to determine the incidence, the clinical implications and the duration of this acid–base disorder in cardiac surgery.
Methods One hundred patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) were included prospectively. Exclusion criteria were: diabetes mellitus, pre-existing acid–base abnormalities, postoperative renal failure or low cardiac output syndrome. All patients received crystalloid (0.9% saline or Ringer’s) and colloid solutions (gelatin). Sampling of arterial blood for gas, acid–base parameters and serum electrolytes were performed at four time points: 30 min after induction of anesthesia (T1), after completion of CPB (T2), at 6 hours (T3) and at 24 hours postoperatively (T4). Values are given as the mean ± SD. We registered the volume of solutions administered intraoperatively and in the first 24 hours postoperatively as well as complications: bleeding, cardiac arrhythmias and organ dysfunctions. (renal, pulmonary or neurological). For statistical analysis we used a t test (P < 0.05).
ResultsSixty-six patients (66%) presented a simple normal-anion gap hyperchloremic acidosis. Twenty-seven patients had no acidosis. The results of the arterial blood sampling are presented in Table 1. The infused volumes are presented in Table 2.
Cardiac arrhythmias were more frequent in patients with HCMA compared with those with no acidosis. There were no statistical differences in the incidence of bleeding or organ dysfunctions. Conclusions HCMA due to saline infusion is common after cardiac surgery. However it is transient (less than 24 hours). Due to the low number of patients in our study, the clinical relevance of
S85 this metabolic acidosis is not clear. The major risk is of undesirable
interventions. Reference
1. Liskaser FJ: Role of pump prime in the etiology and patho- genesis of cardiopulmonary bypass-associated acidosis.
Anesthesiology2000, 93:1170-1174. P201
Prediction of arterial blood gas values from earlobe blood gas values in patients receiving mechanical ventilation A Honarmand
Esfahan Medical Sciences University, Esfahan, Iran
Critical Care2006, 10(Suppl 1):P201 (doi: 10.1186/cc4548) Background Arterial blood gas (ABG) sampling represents the gold standard method for acquiring patients’ acid–base status. The most common complications associated with arterial puncture are pain, arterial injury, and thrombosis with distal ischemia, hemorrhage, and aneurism formation. Earlobe blood gas samplings (EBG) may be useful alternatives to ABG sampling. This study evaluates whether the pH, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), base excess (BE), and bicarbonate (HCO3–) values of EBG accurately predict their ABG
analogs for patients treated by mechanical ventilation in an ICU. MethodsSixty-seven patients who were admitted to the ICU and treated by mechanical ventilation were included in this descriptive study. Blood for ABG analysis was sampled from the radial or brachial arteries. Blood for EBG analysis was sampled simultaneously from ear lobe by contact with a capillary tube tip. Regression equations and mean percentage-difference equations were derived to predict arterial pH, PCO2, PO2, BE, and HCO3–
values from their EBG analogs.
Results A total of 67 simultaneous arterial and earlobe blood samples were obtained from 67 patients. The pH, PCO2, BE, and HCO3–ere all significantly correlated in ABG and EBG. In spite of
a highly significant correlation, the limits of agreement between the two methods were wide for PO2. Earlobe values of PO2 were usually lower than arterial values, with larger differences in the range of normal arterial PO2. On the other hand, the error and the limits of agreement were smaller for PCO2. Regression equations for prediction of pH, PCO2, BE, and HCO3–values were: arterial
pH (pHa) = 1.81 + 0/76 × earlobe pH (pHe) [r = 0.791,
P< 0.001]; PaCO2 = 11/44 + 0/7 × earlobe PCO2 (PeCO2)
[r= 0.774, P < 0.001]; arterial BE (BEa) = 1/14 + 0/95 × earlobe BE (BEe) [r= 0.894, P < 0.001], and arterial HCO3–(HCO
3–a) =
1/41 + earlobe HCO3– (HCO
3–e) [r = 0.874, P < 0.001]. The
predicted ABG values from the mean percentage-difference equations were derived as follows: pHa = pHe × 1.001; PaCO2= PeCO2× 1.04; BEa = BEe × 0.57; and HCO3–a = HCO
3–e ×
1.06.
Conclusions Earlobe blood gas can accurately predict the ABG values of pH, PCO2, BE, and HCO3– for patients receiving
mechanical ventilation. P202
Does the arterial–central venous lactate gradient correlate with the P/F ratio in mechanical ventilated critically ill patients?
R Cordioli, E Moura, D Lima, I Schmidtbauer, D Forte, F Giannini, F Rocha, J Coelho, M Park
Hospital das Clinicas, Sao Paulo, Brazil
Critical Care2006, 10(Suppl 1):P202 (doi: 10.1186/cc4549) Introduction There is evidence about pulmonary production and release of lactate during acute lung injury. The aim of this study was to evaluate whether the arterial–central venous lactate gradient (AVLG) is correlated with the P/F ratio in general ICU patients. MethodsTwenty-four patients requiring mechanical ventilation for at least 72 hours were enrolled. During the first 72 hours, we prospectively collected and recorded central venous and arterial blood samples to analyse blood gases and serum lactate every 24 hours. Ventilator settings as well as general patient characteristics were also recorded. Data are shown as the median and interquartiles. The Spearman correlation test was used and
P< 0.05 was considered significant.
ResultsEleven females and 13 males were evaluated. Median age was 49 (42, 65) years old and the APACHE II score was 23 (19, 33). One-half of patients were admitted with septic shock diagnosis. Four patients had the diagnosis of acute lung injury or acute respiratory distress syndrome at enrollment. The median PEEP was 10 (8, 12) cmH2O, FiO2was 0.4 (0.3, 0.5) and the P/F ratio was 229 (159, 315). The AVLG was evaluated as the variation [(arterial – venous lactate) / arterial lactate] and its median was 0.00 (–0.20, 0.08). In overall group analysis (n= 70), the P/F ratio and AVLG correlation was –0.05 (P = 0.670). In the P/F ≤200 subgroup analysis (n = 25), the P/F ratio and AVLG correlation was 0.08 (P = 0.709).
Conclusions Even though the lungs may produce and release lactate in some patients as sepsis and acute respiratory distress syndrome subjects, we could not find a correlation between the AVLG and the P/F ratio in a general population of critically ill patients. However, our results are probably underpowered.