Altered immune parameters in chronic alcoholic patients at the onset of infection and of septic shock

INTRODUCTION: Chronic alcoholic patients have a threefold to fourfold increased risk for developing a severe infection or septic shock after surgery, which might be due to altered immune response. The aim of this outcome matched study was to investigate proinflammatory and anti-inflammatory immune parameters during the course of infection and subsequent septic shock in chronic alcoholic patients, and to compare these parameters with those in nonalcoholic patients. METHODS: Twenty-eight patients from a cohort of fifty-six with either pneumonia or peritonitis and subsequent septic shock were selected. Fourteen patients were chronic alcoholics whereas fourteen were nonalcoholic patients. Chronic alcoholic patients met criteria (Diagnostic and Statistical Manual of Mental Disorders IV, of the American Psychiatric Association) for alcohol abuse or dependence. Measurements were performed during the onset of infection (within 24 hours after the onset of infection), in early septic shock (within 12 hours after onset of septic shock) and in late septic shock (72 hours after the onset). Blood measurements included proinflammatory and anti-inflammatory cytokines. RESULTS: Chronic alcoholic patients exhibited significantly lower plasma levels of IL-8 (P < 0.010) during the onset of infection than did matched nonalcoholic patients. In early septic shock, chronic alcoholic patients had significantly decreased levels of IL-1β (P < 0.015), IL-6 (P < 0.016) and IL-8 (P < 0.010). The anti-inflammatory parameters IL-10 and tumour necrosis factor receptors I and II did not differ between alcoholic and nonalcoholic patients. CONCLUSION: At the onset of infection and during early septic shock, chronic alcoholic patients had lower levels of proinflammatory immune parameters than did nonalcoholic patients. Therefore, immunomodulatory therapy administered early may be considered in chronic alcoholic patients at the onset of an infection because of their altered proinflammatory immune response

Pulse contour analysis after normothermic cardiopulmonary bypass in cardiac surgery patients

INTRODUCTION: Monitoring of the cardiac output by continuous arterial pulse contour (CO(PiCCOpulse)) analysis is a clinically validated procedure proved to be an alternative to the pulmonary artery catheter thermodilution cardiac output (CO(PACtherm)) in cardiac surgical patients. There is ongoing debate, however, of whether the CO(PiCCOpulse )is accurate after profound hemodynamic changes. The aim of this study was therefore to compare the CO(PiCCOpulse )after cardiopulmonary bypass (CPB) with a simultaneous measurement of the CO(PACtherm). METHODS: After ethical approval and written informed consent, data of 45 patients were analyzed during this prospective study. During coronary artery bypass graft surgery, the aortic transpulmonary thermodilution cardiac output (CO(PiCCOtherm)) and the CO(PACtherm )were determined in all patients. Prior to surgery, the CO(PiCCOpulse )was calibrated by triple transpulmonary thermodilution measurement of the CO(PiCCOtherm). After termination of CPB, the CO(PiCCOpulse )was documented. Both CO(PACtherm )and CO(PiCCOtherm )were also simultaneously determined and documented. RESULTS: Regression analysis between CO(PACtherm )and CO(PiCCOtherm )prior to CPB showed a correlation coefficient of 0.95 (P < 0.001), and after CPB showed a correlation coefficient of 0.82 (P < 0.001). Bland-Altman analysis showed a mean bias and limits of agreement of 0.0 l/minute and -1.4 to +1.4 l/minute prior to CPB and of 0.3 l/minute and -1.9 to +2.5 l/minute after CPB, respectively. Regression analysis of CO(PiCCOpulse )versus CO(PiCCOtherm )and of CO(PiCCOpulse )versus CO(PACtherm )after CPB showed a correlation coefficient of 0.67 (P < 0.001) and 0.63 (P < 0.001), respectively. Bland-Altman analysis showed a mean bias and limits of agreement of -1.1 l/minute and -1.9 to +4.1 l/minute versus -1.4 l/minute and -4.8 to +2.0 l/minute, respectively. CONCLUSION: We observed an excellent correlation of CO(PiCCOtherm )and CO(PACtherm )measurement prior to CPB. Pulse contour analysis did not yield reliable results with acceptable accuracy and limits of agreement under difficult conditions after weaning from CPB in cardiac surgical patients. The pulse contour analysis thus should be re-calibrated as soon as possible, to prevent false therapeutic consequences

Impairment of cognitive function in different domains early after lung transplantation

In this prospective observational pilot study patients with the diagnosis of end-stage lung disease and listed for lung transplantation underwent a cognitive function test battery before and after lung transplantation to investigate postoperative cognitive function in three domains (visual and verbal memory, executive functioning, concentration/speed of processing). Additionally we investigated intraoperative risk factors for postoperative cognitive dysfunction. In total, 24 patients were included in this pilot study. The incidence of postoperative cognitive dysfunction was 58.3%. In the cognitive dysfunction group, the domains executive functioning and concentration/attention were significantly impaired whereas memory was not affected. Patients with cognitive impairment had a significantly longer ICU stay. The strongest independent risk factor for the development of cognitive dysfunction was operation time. No influence of cerebral oxygen desaturations on cognitive dysfunction was found. This might have important implications for early psychological rehabilitation strategies in this high-risk patient collective

Comparison of 6 % hydroxyethyl starch and 5 % albumin for volume replacement therapy in patients undergoing cystectomy (CHART): study protocol for a randomized controlled trial

Background The use of artificial colloids is currently controversial, especially in Central Europe Several studies demonstrated a worse outcome in intensive care unit patients with the use of hydroxyethyl starch. This recently even led to a drug warning about use of hydroxyethyl starch products in patients admitted to the intensive care unit. The data on hydroxyethyl starch in non–critically ill patients are insufficient to support perioperative use. Methods/Design We are conducting a single-center, open-label, randomized, comparative trial with two parallel patient groups to compare human albumin 5 % (test drug) with hydroxyethyl starch 6 % 130/0.4 (comparator). The primary endpoint is cystatin C ratio, calculated as the ratio of the cystatin value at day 90 after surgery relative to the preoperative value. Secondary objectives are inter alia the evaluation of the influence of human albumin and hydroxyethyl starch on further laboratory chemical and clinical parameters, glycocalyx shedding, intensive care unit and hospital stay and acute kidney injury as defined by RIFLE criteria (risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage kidney disease) criteria. Discussion There is a general lack of evidence on the relative safety and effects of hydroxyethyl starch compared with human albumin for volume replacement in a perioperative setting. Previously conducted studies of surgical patients in which researchers have compared different hydroxyethyl starch products included too few patients to properly evaluate clinical important outcomes such as renal function. In the present study in a high-risk patient population undergoing a major surgical intervention, we will determine if perioperative fluid replacement with human albumin 5 % will have a long-term advantage over a third-generation hydroxyethyl starch 130/0.4 on the progression of renal dysfunction until 90 days after surgery

Predictive Ability of the Stability and Workload Index for Transfer Score to Predict Unplanned Readmissions After ICU Discharge

Objective: Unplanned readmission of hospitalized patients to an ICU is associated with an increased mortality and hospital length of stay. The ability to identify patients at risk, who would benefit from prolonged ICU treatment, is limited. The aim of this study is to validate a previously published numerical index named the Stability and Workload Index for Transfer in a heterogeneous group of ICU patients. Design: In this retrospective data analysis, the Stability and Workload Index for Transfer score was calculated for all patients, and the ability of the score to predict readmission was compared with the original publication. Setting: Four ICUs, one intermediate care unit, and one postanesthesia care unit of the department of anesthesia and intensive care of a university hospital. Patients: All consecutive patients treated in one of the units. Interventions: None. Measurements and Main Results: Unplanned ICU readmissions or unexpected death within 7 days of ICU discharge. The data of 7,175 patients were included in the analysis. Five hundred ninety-six patients were readmitted or died within 7 days of discharge. The patients who are readmitted to the ICU are significantly older and have significantly higher scores that define the severity of disease at the time of admission and discharge of their first ICU stay. The source of admission for the initial ICU stay did not differ (p = 0.055), and the last Glasgow Coma Scale and the last Pao(2)/Fio(2) ratio before discharge from the ICU were higher in patients who did not need a readmission to the ICU. The performance of the Stability and Workload Index for Transfer score is poor with an area under the receiver operator curve of 0.581 (95% CI, 0.556-0.605; p < 0.001). Conclusions: Based on the data from our patients, the proposed Stability and Workload Index for Transfer score by Gajic et al is not ideal in aiding the clinician in the decision, if a patient can be discharged safely from the ICU and further research is necessary to define the patients at risk for readmission

Gender-Specific Differences in Low-Dose Haloperidol Response for Prevention of Postoperative Nausea and Vomiting: A Register-Based Cohort Study

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications after general anesthesia and surgery, with young non-smoking females receiving postoperative opioids being high-risk patients. This register-based study aims to evaluate the effect of low-dose haloperidol (0.5 mg intravenously) directly after induction of general anesthesia to reduce the incidence of PONV in the postoperative anesthesiological care unit (PACU).Multivariable regression models were used to investigate the association between low-dose haloperidol and the occurrence of PONV using a patient registry containing 2,617 surgical procedures carried out at an university hospital.Haloperidol 0.5 mg is associated with a reduced risk of PONV in the total collective (adjusted odds ratio = 0.75, 95% confidence interval: [0.56, 0.99], p = 0.05). The results indicate that there is a reduced risk in male patients (adjusted odds ratio = 0.45, 95% confidence interval: [0.28, 0.73], p = 0.001) if a dose of 0.5 mg haloperidol was administered while there seems to be no effect in females (adjusted odds ratio = 1.02, 95% confidence interval: [0.71, 1.46], p = 0.93). Currently known risk factors for PONV such as female gender, duration of anesthesia and the use of opioids were confirmed in our analysis.This study suggests that low-dose haloperidol has an antiemetic effect in male patients but has no effect in female patients. A confirmation of the gender-specific effects we have observed in this register-based cohort study might have major implications on clinical daily routine

A case series on the value of tau and neurofilament protein levels to predict and detect delirium in cardiac surgery patients

BACKGROUND: Delirium following cardiac surgery is a relevant complication in the majority of elderly patients but its prediction is challenging. Cardiopulmonary bypass, essential for many interventions in cardiac surgery, is responsible for a severe inflammatory response leading to neuroinflammation and subsequent delirium. Neurofilament light protein (NfL) and tau protein (tau) are specific biomarkers to detect neuroaxonal injury as well as glial fibrillary acidic protein (GFAP), a marker of astrocytic activation. METHODS: We thought to examine the perioperative course of these markers in a case series of each three cardiac surgery patients under off-pump cardiac arterial bypass without evolving delirium (OPCAB-NDEL), patients with a procedure under cardio-pulmonary bypass (CPB) without delirium (CPB-NDEL) and delirium after a CPB procedure (CPB-DEL). Delirium was diagnosed by the Confusion Assessment Method for the ICU and chart reviews. RESULTS: We observed increased preoperative levels of tau in patients with later delirium, whereas values of NfL and GFAP did not differ. In the postoperative course, all biomarkers increased multi-fold. NfL levels sharply increased in patients with CPB reaching the highest levels in the CPB-DEL group. CONCLUSION: Tau and NfL might be of benefit to identify patients in cardiac surgery at risk for delirium and to detect patients with the postoperative emergence of delirium

Early use of methylene blue in vasoplegic syndrome: a 10-year propensity score-matched cohort study

Background: Vasoplegic syndrome is associated with increased morbidity and mortality in patients undergoing cardiac surgery. This retrospective, single-center study aimed to evaluate the effect of early use of methylene blue (MB) on hemodynamics after an intraoperative diagnosis of vasoplegic syndrome (VS). Methods: Over a 10-year period, all patients diagnosed with intraoperative VS (hypotension despite treatment with norepinephrine ≥0.3 μg/kg/min and vasopressin ≥1 IE/h) while undergoing heart surgery and cardiopulmonary bypass were identified, and their data were examined. The intervention group received MB (2 mg/kg intravenous) within 15 min after the diagnosis of vasoplegia, while the control group received standard therapy. The two groups were matched using propensity scores. Results: Of the 1022 patients identified with VS, 221 received MB intraoperatively, and among them, 60 patients received MB within 15 min after the diagnosis of VS. After early MB application, mean arterial pressure was significantly higher, and vasopressor support was significantly lower within the first hour (p = 0.015) after the diagnosis of vasoplegia, resulting in a lower cumulative amount of norepinephrine (p = 0.018) and vasopressin (p = 0.003). The intraoperative need of fresh frozen plasma in the intervention group was lower compared to the control group (p = 0.015). Additionally, the intervention group had higher creatinine values in the first three postoperative days (p = 0.036) without changes in dialysis incidence. The 90-day survival did not differ significantly (p = 0.270). Conclusion: Our results indicate the additive effects of MB use during VS compared to standard vasopressor therapy only. Early MB administration for VS may significantly improve the patients’ hemodynamics with minor side effects

ZigBee-based wireless sensor network localization for cattle monitoring in grazing fields

This paper presents the design of a localization scheme in wireless sensor networks (WSN) for cattle monitoring applications in grazing fields. No additional hardware was required for distance estimation since they were performed using the link quality indication (LQI), which is a standard feature of the ZigBee protocol. The ratiometric vector iteration (RVI) algorithm was implemented and modified to work with LQI measurements instead of the usual received signal strength indication (RSSI). Experimental results show acceptable localization performance given the requirements of usual cattle monitoring applications at low cost and low power consumption. © 2010 Elsevier B.V