Surviving sepsis: going beyond the guidelines

The Surviving Sepsis Campaign is a global effort to improve the care of patients with severe sepsis and septic shock. The first Surviving Sepsis Campaign Guidelines were published in 2004 with an updated version published in 2008. These guidelines have been endorsed by many professional organizations throughout the world and come regarded as the standard of care for the management of patients with severe sepsis. Unfortunately, most of the recommendations of these guidelines are not evidence-based. Furthermore, the major components of the 6-hour bundle are based on a single-center study whose validity has been recently under increasing scrutiny. This paper reviews the validity of the Surviving Sepsis Campaign 6-hour bundle and provides a more evidence-based approach to the initial resuscitation of patients with severe sepsis

24 segment high field permanent sextupole magnets

We report on the design, construction, and magnetic field measurements of a system of high field sextupole magnets made from NdFeB compounds. The magnets are utilized as a focusing system for neutral hydrogen (or deuterium) atoms in a polarized atomic beam source based on Stern-Gerlach spin separation. Each magnet consists of 24 segments of permanently magnetized material differing in remanence and coercivity to reduce demagnetization. According to quadratic extrapolation to the pole tip the magnetic flux density reaches values of up to B-0=1.69 T. Three-dimensional field calculations using the MAFIA code were carried out to optimize the magnet performance and to avoid demagnetization by selecting appropriate materials for the individual segments. Measurements of the radial, azimuthal, and longitudinal magnetic flux density distributions were carried out by means of a small Hall probe (100x200x15 mu m(3)). The measurements with the small probe permitted to extract experimentally higher order multipole components very close (similar to 100 mu m) to the inner surface. Experimental values obtained are compared to predictions based on MAFIA calculations and on the Halbach formalism. (C) 2000 American Institute of Physics. [S0034-6748(00)05309-0]

Effects of Fluids on the Macro- and Microcirculations.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901

Neuromuscular Blockade with Rocuronium Bromide Increases the Tolerance of Acute Normovolemic Anemia in Anesthetized Pigs

Background: The patient's individual anemia tolerance is pivotal when blood transfusions become necessary, but are not feasible for some reason. To date, the effects of neuromuscular blockade (NMB) on anemia tolerance have not been investigated. Methods: 14 anesthetized and mechanically ventilated pigs were randomly assigned to the Roc group (3.78 mg/kg rocuronium bromide followed by continuous infusion of 1 mg/kg/min, n = 7) or to the Sal group (administration of the corresponding volume of normal saline, n = 7). Subsequently, acute normovolemic anemia was induced by simultaneous exchange of whole blood for a 6% hydroxyethyl starch solution (130/0.4) until a sudden decrease of total body O-2 consumption (VO2) indicated a critical limitation of O-2 transport capacity. The Hb concentration quantified at this time point (Hb(crit)) was the primary end-point of the protocol. Secondary endpoints were parameters of hemodynamics, O-2 transport and tissue oxygenation. Results: Hb(crit) was significantly lower in the Roc group (2.4 +/- 0.5 vs. 3.2 +/- 0.7 g/dl) reflecting increased anemia tolerance. NMB with rocuronium bromide reduced skeletal muscular VO2 and total body O-2 extraction rate. As the cardiac index increased simultaneously, total body VO2 only decreased marginally in the Roc group (change of VO2 relative to baseline -1.7 +/- 0.8 vs. 3.2 +/- 1.9% in the Sal group, p < 0.05). Conclusion: Deep NMB with rocuronium bromide increases the tolerance of acute normovolemic anemia. The underlying mechanism most likely involves a reduction of skeletal muscular VO2. During acellular treatment of an acute blood loss, NMB might play an adjuvant role in situations where profound stages of normovolemic anemia have to be tolerated (e.g. bridging an unexpected blood loss until blood products become available for transfusion). Copyright (C) 2011 S. Karger AG, Base

Evidence for conventional superconductivity in Bi2_2PdPt and prediction of topological superconductivity in disorder-free γ\gamma-BiPd

We present comprehensive investigations into the structural, superconducting, and topological properties of Bi$_2$PdPt. Magnetization and heat capacity measurements performed on polycrystalline Bi$_2$PdPt demonstrate a superconducting transition at $\approx$ 0.8 K. Moreover, muon spin relaxation/rotation ($\mu$SR) measurements present evidence for a time reversal symmetry preserving, isotropically gapped superconducting state in Bi$_2$PdPt. We have also performed density-functional theory (DFT) calculations on Bi$_2$PdPt alongside the more general isostructural systems, BiPd$_{x}$Pt$_{1-x}$, of which Bi$_2$PdPt and $\gamma$-BiPd are special cases for $x=0.5$ and $x=1$ respectively. We have calculated the $Z_2$ topological index from our DFT calculations for a range of substitution fractions, $x$, between $x=0$ and $x=1$ characterizing the topology of the band structure. We find a non-trivial topological state when $x>0.75$ and a trivial topological state when $x<0.75$. Therefore our results indicate that BiPd$_{x}$Pt$_{1-x}$ could be a topological superconductor for $x>0.75$.Comment: 10 pages, 7 figure

The Development of Peptide-Based Tools for the Analysis of Angiogenesis

SummaryLimitations to the application of molecularly targeted cancer therapies are the inability to accurately match patient with effective treatment and the absence of a prompt readout of posttreatment response. Noninvasive agents that rapidly report vascular endothelial growth factor (VEGF) levels using positron emission tomography (PET) have the potential to enhance anti-angiogenesis therapies. Using phage display, two distinct classes of peptides were identified that bind to VEGF with nanomolar affinity and high selectivity. Co-crystal structures of these different peptide classes demonstrate that both bind to the receptor-binding region of VEGF. 18F-radiolabelling of these peptides facilitated the acquisition of PET images of tumor VEGF levels in a HM7 xenograph model. The images obtained from one 59-residue probe, 18F-Z-3B, 2 hr postinjection are comparable to those obtained with anti-VEGF antibody B20 72 hr postinjection. Furthermore, VEGF levels in growing SKOV3 tumors were followed using 18F-Z-3B as a PET probe with VEGF levels increasing with tumor size

Glutamine supplementation

Intravenous glutamine supplementation is standard care when parenteral nutrition is given for critical illness. There are data of a reduced mortality when glutamine supplementation is given. In addition, standard commercial products for parenteral nutrition do not contain any glutamine due to glutamine instability in aqueous solutions. For the majority of critical ill patients who are fed enterally, the available evidence is insufficient to recommend glutamine supplementation. Standard formulation of enteral nutrition contains some glutamine: 2-4 g/L. However, this dose is insufficient to normalize glutamine plasma concentration

Dynamic and volumetric variables reliably predict fluid responsiveness in a porcine model with pleural effusion

Background: The ability of stroke volume variation (SVV), pulse pressure variation (PPV) and global end-diastolic volume (GEDV) for prediction of fluid responsiveness in presence of pleural effusion is unknown. The aim of the present study was to challenge the ability of SVV, PPV and GEDV to predict fluid responsiveness in a porcine model with pleural effusions. Methods: Pigs were studied at baseline and after fluid loading with 8 ml kg−1 6% hydroxyethyl starch. After withdrawal of 8 ml kg−1 blood and induction of pleural effusion up to 50 ml kg−1 on either side, measurements at baseline and after fluid loading were repeated. Cardiac output, stroke volume, central venous pressure (CVP) and pulmonary occlusion pressure (PAOP) were obtained by pulmonary thermodilution, whereas GEDV was determined by transpulmonary thermodilution. SVV and PPV were monitored continuously by pulse contour analysis. Results: Pleural effusion was associated with significant changes in lung compliance, peak airway pressure and stroke volume in both responders and non-responders. At baseline, SVV, PPV and GEDV reliably predicted fluid responsiveness (area under the curve 0.85 (p<0.001), 0.88 (p<0.001), 0.77 (p = 0.007). After induction of pleural effusion the ability of SVV, PPV and GEDV to predict fluid responsiveness was well preserved and also PAOP was predictive. Threshold values for SVV and PPV increased in presence of pleural effusion. Conclusions: In this porcine model, bilateral pleural effusion did not affect the ability of SVV, PPV and GEDV to predict fluid responsiveness

Hemodynamic Observations of Tumo Yoga Practitioners in a Himalayan Environment

Abstract Background: Few attempts have been made to evaluate the physiology of traditional Eastern health practices. The goal of this study was to evaluate the hemodynamic effects of the mysterious Buddhist practice of tumo. Tumo is a meditative practice that produces inner heat through the alleged cultivation of body energy-channels. Methods: This study was performed by members of an international expedition to the Himalayan Mountains in the Republic of India. The study was performed in an unpopulated outdoor mountainous area at an altitude of 16,400 ft with ambient temperatures between -10 and -15°C. Two (2) cohorts of subjects were studied: healthy non-yogi volunteers and tumo practitioners. All of the subjects were stripped down to their underclothes and exposed to the subzero atmospheric temperatures for 5 minutes. The volunteers were then passively rewarmed while the tumo practitioners performed tumo for up to 10 minutes. Blood pressure, heart rate, and stroke volume index (SVI) and cardiac index were measured noninvasively using a NICOMÔ hemodynamic monitor, while carotid blood flow and biventricular performance were determined echocardiographically at each stage of the experiment. The total peripheral resistance index (TPRI), left ventricular ejection fraction (LVEF), and tricuspid annular plane systolic excursion (TAPSE) were determined using standard formula. Results: Fourteen (14) subjects (six volunteers and eight tumo practitioners) completed the study. There was one female subject in each group. With cold exposure, the SVI and carotid blood flow decreased while the TPRI increased significantly in both groups. In the volunteer group, these changes retuned to baseline with rewarming. Following tumo, the cardiac index (4.8 -0.6 versus 4.0 -0.5 l/m 2 ; p &lt; 0.01), carotid blood flow (445 -127 versus 325 -100 mL/min/m 2 , p &lt; 0.01), LVEF (68 -5 versus 64 -7%; p &lt; 0.05) and TAPSE (2.9 -0.4 versus 2.4 -0.5 cm; p &lt; 0.01) were significantly higher when compared with baseline, while the TPRI was significantly lower (1786 -189 versus 2173 -281; p &lt; 0.01). Conclusions: Tumo was associated with a hyperdynamic vasodilated state with increased biventricular performance. We postulate that tumo results in a massive increase in sympathetic activity with activation of brown adipose tissue and marked heat production. The increased heat production may explain the paradoxical vasodilatation in tumo practitioners exposed to subzero temperatures