Extravascular lung water index improves the diagnostic accuracy of lung injury in patients with shock

Introduction: The diagnosis of acute lung injury (ALI) may be more robust if more accurate physiological markers can be identified. Extravascular lung water (EVLW) is one possible marker, and it has been shown to correlate with respiratory function and mortality in patients with sepsis. Whether EVLW confers diagnostic value in a general population with shock, as well as which index performs best, is unclear. We investigated the diagnostic accuracy of various EVLW indices in patients with shock. Methods: We studied a prospective, observational cohort of 51 patients with shock admitted to a tertiary ICU. EVLW was measured within 6 hours of ICU admission and indexed to actual body weight (EVLW/ABW), predicted body weight (EVLW/PBW) and pulmonary blood volume (EVLW/PBV). The relationship of these indices to the diagnosis and severity of lung injury and ICU mortality were studied. Positive and negative likelihood ratios, pre- and posttest odds for diagnosis of lung injury and mortality were calculated. Results: All EVLW indices were higher among patients with lung injury and significantly correlated with respiratory parameters. Furthermore, all EVLW indices were significantly higher in nonsurvivors. The use of EVLW improves the posttest OR for the diagnosis of ALI, acute respiratory distress syndrome (ARDS) and severe lung injury (sLI) by up to eightfold. Combining increased EVLW and a diagnosis of ALI, ARDS or sLI increases the posttest odds of ICU mortality. EVLW/ABW and EVLW/PBV demonstrated the best diagnostic performance in this population. Conclusions: EVLW was associated with degree of lung injury and mortality, regardless of the index used, confirming that it may be used as a bedside indicator of disease severity. The use of EVLW as a bedside test conferred added diagnostic value for the identification of patients with lung injury

Assessing left ventricular systolic function in shock: evaluation of echocardiographic parameters in intensive care

Introduction: Assessing left ventricular (LV) systolic function in a rapid and reliable way can be challenging in the critically ill patient. The purpose of this study was to evaluate the feasibility and reliability of, as well as the association between, commonly used LV systolic parameters, by using serial transthoracic echocardiography (TTE). Methods: Fifty patients with shock and mechanical ventilation were included. TTE examinations were performed daily for a total of 7 days. Methods used to assess LV systolic function were visually estimated, "eyeball" ejection fraction (EBEF), the Simpson single-plane method, mean atrioventricular plane displacement (AVPDm), septal tissue velocity imaging (TDIs), and velocity time integral in the left ventricular outflow tract (VTI). Results: EBEF, AVPDm, TDIs, VTI, and the Simpson were obtained in 100%, 100%, 99%, 95% and 93%, respectively, of all possible examinations. The correlations between the Simpson and EBEF showed r values for all 7 days ranging from 0.79 to 0.95 (P < 0.01). the Simpson correlations with the other LV parameters showed substantial variation over time, with the poorest results seen for TDIs and AVPDm. The repeatability was best for VTI (interobserver coefficient of variation (CV) 4.8%, and intraobserver CV, 3.1%), and AVPDm (5.3% and 4.4%, respectively), and worst for the Simpson method (8.2% and 10.6%, respectively). Conclusions: EBEF and AVPDm provided the best, and Simpson, the worst feasibility when assessing LV systolic function in a population of mechanically ventilated, hemodynamically unstable patients. Additionally, the Simpson showed the poorest repeatability. We suggest that EBEF can be used instead of single-plane Simpson when assessing LV ejection fraction in this category of patients. TDIs and AVPDm, as markers of longitudinal function of the LV, are not interchangeable with LV ejection fraction

The heart in the critically ill patient- an echocardiographic study

The thesis describes aspects of left ventricular systolic and diastolic function examined with echocardiography in patients with systemic inflammation and shock. Background: Myocardial depression is a well-known complication in critically ill patients with shock. Echocardiography is increasingly used for assessing left ventricular (LV) function in these patients. Aims: 1) To describe the feasibility and reliability of LV systolic function parameters, and the association between different types of measurements 2) To investigate the time course of LV systolic and diastolic function parameters 3) To examine the relation of LV longitudinal function to other LV function parameters and biomarkers 4) To determine whether LV function parameters and cardiac biomarkers are associated with mortality. Methods: Transthoracic echocardiographic, hemodynamic parameters as well as laboratory measurements were assessed daily for a total of 7 days. Measurements from day 1 were assessed for their relation to short (28-day) and long term (1-year) mortality. Results: LV systolic function parameters were easily obtainable (93% to 100%) and had acceptable repeatability (coefficient of variation 3.1% to 10.6%). Eyeball ejection fraction and atrioventricular plane displacement¹ provided the most reliable results. The different parameters variably correlated to each other, and showed substantial variation over time (r= 0.101 to 0.949). LV systolic function parameters improved over time whereas most LV diastolic function parameters did not. The LV longitudinal parameter mitral annular plane excursion (MAPSE)¹ correlated significantly with markers of both LV systolic and diastolic function and with the cardiac biomarker high-sensitive troponin T. MAPSE was significantly associated with 28-day mortality but not long term mortality. High-sensitive TNT was an independent marker of 1-year mortality and was a univariate predictor of 28-day mortality. Some echocardiographic measurements of LV filling pressure were significantly associated with 1-year mortality. Conclusion: Transthoracic echocardiography is variably feasible in hemodynamically unstable, ventilated patients with different methods of measuring LV systolic function. Eyeball EF is reliable and can be used instead of more formal methods of EF quantification. The addition of parameters assessing LV longitudinal function, for example, MAPSE, is an advantage. MAPSE seemed even to reflect LV diastolic function and myocardial injury. Serial evaluations over the seven-day observation period revealed that most markers of LV diastolic function remained unchanged despite improvement of LV systolic function, markers of critical illness and systemic hemodynamic parameters. Echocardiographic measurements of LV filling pressure should be assessed as they may be related to long term mortality. The association of the cardiac biomarker high-sensitive Troponin with long term mortality was strong. ¹The terms atrioventricualar plane displacement (AVPD) and mitral annular plane systolic excursion (MAPSE) are used interchangeably

Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery-A randomized clinical study.

Abstract is not availabl

”Så fort det finns någonting att klättra på så väljer barn att klättra på det” : En studie om upplevelsen av riskfylld lek i förskolan

Barns lek kan innehålla riskfyllda moment då individens förmåga utmanas och ibland överstigs. Den riskfyllda leken fyller en viktig funktion för barnets utveckling men kan även vara problematisk för vuxna i barnets närhet. Syftet med denna studie är att undersöka hur riskfylld lek upplevs av personal i svensk förskola samt vilka erfarenheter som finns av barns risktagande. Kvalitativa, semi-strukturerade intervjuer har genomförts i denna studie. Sex förskollärare och två rektorer har intervjuats kring sina upplevelser, erfarenheter och tankar kring barns risktagande i lek. Resultatet visar att förskolepersonal har en positiv attityd till barns riskfyllda lek och bland annat menar att utveckling kräver utmaning. Trygghet ses som en förutsättning för utforskande och i förlängningen risktagande samt att utmana sig och att våga. Pedagogens och förskolans förhållningssätt samt förutsättningar inom organisationen ses lägga grund för vilka valmöjligheter som barn ges i leken. Situationer som av vuxna upplevs vara allt för farliga kan uppstå i leken och strategier som pedagoger använder för att reglera risker i barns lek har identifierats i studien