The adrenocorticotropic hormone-induced cortisol response in acute pancreatitis

The evidence that severe acute pancreatitis can result in critical illness-related corticosteroid insufficiency following impaired adrenal secretion is accumulating. The study by Peng and coworkers in Critical Care certainly contributes to that idea, even though the question whether relative adrenal insufficiency should prompt for treatment by substitution doses of corticosteroids remains unresolved. The study is discussed in terms of the risk factors, circumstances and significance of impaired corticosteroid secretion by adrenals in severe acute pancreatitis

Escapement of the Cape rock lobster (Jasus lalandii ) through the mesh and entrance of commercial traps

Metal-framed traps covered with polyethylene mesh used in the fishery for the South African Cape rock lobster (Jasus lalandii) incidentally capture large numbers of undersize (<75 mm CL) specimens. Air-exposure, handling, and release procedures affect captured rock lobsters and reduce the productivity of the stock, which is heavily fished. Optimally, traps should retain legalsize rock lobsters and allow sublegal animals to escape before traps are hauled. Escapement, based on lobster morphometric measurements, through meshes of 62 mm, 75 mm, and 100 mm was investigated theoretically under controlled conditions in an aquarium, and during field trials. SELECT models were used to model escapement, wherever appropriate. Size-selectivity curves based on the logistic model fitted the aquarium and field data better than asymmetrical Richards curves. The lobster length at 50% retention (L50) on the escapement curve for 100-mm mesh in the aquarium (75.5 mm CL) approximated the minimum legal size (75 mm CL); however estimates of L50 increased to 77.4 mm in field trials where trapentrances were sealed, and to 82.2 mm where trap-entrances were open. Therfore, rock lobsters that cannot escape through the mesh of sealed field traps do so through the trap entrance of open traps. By contrast, the wider selection range and lower L25 of field, compared to aquarium, trials (SR = 8.2 mm vs. 2.6 mm; L25 =73.4 mm vs. 74.1 mm), indicate that small lobsters that should be able to escape from 100-mm mesh traps do not always do so. Escapement from 62-mm mesh traps with open entrance funnels increased by 40−60% over sealed traps. The findings of this study with a known size distribution, are related to those of a recent indirect (comparative) study for the same species, and implications for trap surveys, commercial catch rates, and ghost fishing are discussed

Changes in Circulating Procalcitonin Versus C-Reactive Protein in Predicting Evolution of Infectious Disease in Febrile, Critically Ill Patients

Objective:Although absolute values for C-reactive protein (CRP) and procalcitonin (PCT) are well known to predict sepsis in the critically ill, it remains unclear how changes in CRP and PCT compare in predicting evolution of: infectious disease, invasiveness and severity (e.g. development of septic shock, organ failure and non-survival) in response to treatment. The current study attempts to clarify these aspects.Methods:In 72 critically ill patients with new onset fever, CRP and PCT were measured on Day 0, 1, 2 and 7 after inclusion, and clinical courses were documented over a week with follow up to Day 28. Infection was microbiologically defined, while septic shock was defined as infection plus shock. The sequential organ failure assessment (SOFA) score was assessed.Results:From peak at Day 0-2 to Day 7, CRP decreased when (bloodstream) infection and septic shock (Day 0-2) resolved and increased when complications such as a new (bloodstream) infection or septic shock (Day 3-7) supervened. PCT decreased when septic shock resolved and increased when a new bloodstream infection or septic shock supervened. Increased or unchanged SOFA scores were best predicted by PCT increases and Day 7 PCT, in turn, was predictive for 28-day outcome.Conclusion:The data, obtained during ICU-acquired fever and infections, suggest that CRP may be favoured over PCT courses in judging response to antibiotic treatment. PCT, however, may better indicate the risk of complications, such as bloodstream infection, septic shock, organ failure and mortality, and therefore might help deciding on safe discontinuation of antibiotics. The analysis may thus help interpreting current literature and design future studies on guiding antibiotic therapy in the ICU

Acute lung injury, overhydration or both?

Acute lung injury or acute respiratory distress syndrome (ALI/ARDS) in the course of sepsis is thought to result from increased pulmonary capillary permeability and resultant edema. However, when the edema is assessed at the bedside by measuring the extravascular thermal volume by transpulmonary dilution, some ALI/ARDS patients with sepsis may have normal extravascular lung water (EVLW). Conversely, a raised EVLW may be present even when criteria for ALI/ARDS are not met, according to GS Martin and colleagues in this issue of Critical Care. This commentary puts the findings into a broader perspective and focuses on the difficulty, at the bedside, in recognizing and separating various types of pulmonary edema. Some of these forms of edema, classically differentiated on the basis of increased permeability and cardiogenic/hydrostatic factors, may overlap, whereas the criteria for ALI/ARDS may be loose, poorly reproducible, relatively insensitive and nonspecific, and highly therapy-dependent. Overhydration is particularly difficult to recognize. Additional diagnostics may be required to improve the delineation of pulmonary edema so as to redirect or redefine treatment and improve patient morbidity and, perhaps, mortality. Monitoring EVLW by single transpulmonary thermal dilution, for instance, might have a future role in this process

Hypothalamo-pituitary-adrenal axis activity after intracranial catastrophies: what is enough?

This commentary on a paper by Bendel and colleagues in the previous issue of Critical Care describes the difficulty in assessing the sufficiency of adrenal responses to endogenous, stress-induced adrenocorticotropic hormone (ACTH) release by the pituitary or to exogenous ACTH administration in the critically ill patient in general, and after subarachnoid hemorrhage in particular. It is argued that comparisons with responses under circumstances of equal stress as well as assessments of severity of disease are necessary to judge the sufficiency of cortisol responses to endogenous and exogenous ACTH before treatment is considered. There are no universally applicable cutoff values for cortisol levels – and increases in cortisol levels with increasing levels of ACTH – for the diagnosis of relative adrenal insufficiency (or as it is now commonly termed, critical illnes-related corticosteroid insufficiency) following, for example, subarachnoid hemorrhage or other intracranial catastrophes. The paper by Bendel and colleagues is critically discussed in view of these concepts

A plethora of angiopoietin-2 effects during clinical sepsis

The interesting study by Davis and colleagues in the current issue of Critical Care expands on the increasingly recognized role of angiopoietins in human sepsis but raises a number of questions, which are discussed in this commentary. The authors describe an association between elevated angiopoietin (ang)-2 levels and impaired vascular reactivity, measured by the partly nitric oxide-dependent finger hyperemic response to forearm vascular occlusion, in patients with sepsis. This suggests that the ang-1/2-Tie2 system is involved in a number of pathophysiologic, phenotypic and perhaps prognostic alterations in human sepsis, on top of the effect on pulmonary endothelial barrier function. The novel inflammatory route may be a target for future therapeutic studies in human sepsis and acute lung injury, including those with activated protein C