Inter-α-inhibitor heavy chain H4 and sepsis-related coagulation disturbances: Another link between innate immunity and coagulation

Background

The protease inhibitor inter-α-inhibitor heavy chain H4 (ITIH4) has been described as an acute-phase reactant and could potentially aid in sepsis monitoring and prognostication.

Objectives

To investigate ITIH4 plasma levels in sepsis patients compared with healthy controls and to examine the association between ITIH4 and acute-phase response markers, blood coagulation, and organ dysfunction in sepsis.

Methods

We performed a post hoc study to a prospective cohort study. Patients with septic shock (n = 39) were enrolled upon intensive care unit admission. ITIH4 was analyzed using an in-house immunoassay. Standard coagulation parameters, thrombin generation, fibrin formation and lysis, C-reactive protein, organ dysfunction markers, Sequential Organ Failure Assessment score, and disseminated intravascular coagulation (DIC) score were registered. ITIH4 levels were also investigated in a murine Escherichia coli sepsis model.

Results

ITIH4 did not display acute-phase behavior as mean ITIH4 levels were not increased in patients with septic shock or in E. coli-infected mice. However, ITIH4 exhibited large interindividual variation in patients with septic shock compared with healthy controls. Low ITIH4 was associated with sepsis-related coagulopathy, including a high DIC score (mean ITIH4: DIC, 203 μg/mL vs non-DIC, 267 μg/mL, P = .01), low antithrombin (r = 0.70, P < .0001) and decreased thrombin generation (mean ITIH4: first peak thrombin tertile, 210 μg/mL vs third peak thrombin tertile, 303 μg/mL, P = .01). ITIH4 showed moderate correlation with arterial blood lactate (ρ = -0.50, P < .001) but only weak correlations with C-reactive protein, alanine transaminase, bilirubin, and Sequential Organ Failure Assessment score (all, ρ < 0.26, P > .05).

Conclusion

ITIH4 is associated with sepsis-related coagulopathy but is not an acute-phase reactant during septic shock.

Reduced Mannose-Binding Lectin-Associated Serine Protease (MASP)-1 is Associated with Disturbed Coagulation in Septic Shock

Background Activation of the complement system is part of the dysregulated immune response in sepsis. The mannose-binding lectin-associated serine proteases (MASP)-1 and -2 activate the lectin pathway of the complement system. Besides, these proteins can activate coagulation in vitro. However, the role of the lectin pathway proteins in the development of sepsis-related disseminated intravascular coagulation (DIC) is only sparsely investigated.

Aim This article investigates the association between lectin pathway proteins and coagulation disturbances in septic shock patients.

Materials and Methods We included 36 septic shock patients from the intensive care unit, Aarhus University Hospital, Denmark. Blood samples were obtained within 24 hours after admission (day 1), and subsequently on day 2 and day 3. Plasma concentrations of mannose-binding lectin (MBL), H-ficolin, M-ficolin, CL-L1, CL-K1, MASP-1, -2 and -3, MBL-associated proteins of 19 and 44 kDa as well as complement factor C3dg were assessed. Standard coagulation parameters, thrombin generation, thrombin–anti-thrombin (TAT) complex and pro-thrombin fragment 1 + 2 were measured. Sequential Organ Failure Assessment (SOFA) score, DIC score and 30-day mortality were assessed.

Results Reduced MASP-1 plasma concentration was associated with DIC score ≥5 (p = 0.02), impaired thrombin generation (p = 0.03) and lower plasma TAT complex levels (p = 0.03). No association was found between lectin pathway proteins and SOFA score or 30-day mortality.

Conclusion Reduced MASP-1 concentrations were associated with impaired coagulation in septic shock patients. This indicates that increased MASP-1 activation and consumption is associated with the more severe coagulation disturbances in sepsis and points to a possible role for MASP-1 in sepsis-related DIC.

Kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial

OBJECTIVES

To explore whether a strategy of more intensive antibiotic therapy leads to emergence or prolongation of renal failure in intensive care patients.

DESIGN

Secondary analysis from a randomised antibiotic strategy trial (the Procalcitonin And Survival Study). The randomised arms were conserved from the primary trial for the main analysis.

SETTING

Nine mixed surgical/medical intensive care units across Denmark.

PARTICIPANTS

1200 adult intensive care patients, 18+ years, expected to stay +24 h.

EXCLUSION CRITERIA

bilirubin >40 mg/dl, triglycerides >1000 mg/dl, increased risk from blood sampling, pregnant/breast feeding and psychiatric patients.

INTERVENTIONS

Patients were randomised to guideline-based therapy ('standard-exposure' arm) or to guideline-based therapy supplemented with antibiotic escalation whenever procalcitonin increased on daily measurements ('high-exposure' arm).

MAIN OUTCOME MEASURES

Primary end point: estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2). Secondary end points: (1) delta eGFR after starting/stopping a drug and (2) RIFLE criterion Risk 'R', Injury 'I' and Failure 'F'. Analysis was by intention to treat.

RESULTS

28-day mortality was 31.8% and comparable (Jensen et al, Crit Care Med 2011). A total of 3672/7634 (48.1%) study days during follow-up in the high-exposure versus 3016/6949 (43.4%) in the 'standard-exposure arm were spent with eGFR <60 ml/min/1.73 m(2), p<0.001. In a multiple effects model, 3 piperacillin/tazobactam was identified as causing the lowest rate of renal recovery of all antibiotics used: 1.0 ml/min/1.73 m(2)/24 h while exposed to this drug (95% CI 0.7 to 1.3 ml/min/1.73 m(2)/24 h) vs meropenem: 2.9 ml/min/1.73 m(2)/24 h (2.5 to 3.3 ml/min/1.73 m(2)/24 h)); after discontinuing piperacillin/tazobactam, the renal recovery rate increased: 2.7 ml/min/1.73 m(2)/24 h (2.3 to 3.1 ml/min/1.73 m(2) /24 h)). eGFR <60 ml/min/1.73 m(2) in the two groups at entry and at last day of follow-up was 57% versus 55% and 41% versus 39%, respectively.

CONCLUSIONS

Piperacillin/tazobactam was identified as a cause of delayed renal recovery in critically ill patients. This nephrotoxicity was not observed when using other beta-lactam antibiotics.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00271752.

The impact of pre-admission morbidity level on 3-year mortality after intensive care: a Danish cohort study

BACKGROUND

Chronic diseases are common among intensive care unit (ICU) patients and may worsen their prognosis. We examined the prevalence and impact of pre-admission/index morbidity among ICU patients compared with a general population cohort.

METHODS

Our study encompassed all 28,172 adult patients admitted to ICUs in northern Denmark in 2005-2007 and 281,671 age- and sex-matched individuals from the general population. We used a nationwide hospital registry to obtain a 5-year history of 19 chronic diseases and computed Charlson Comorbidity Index (CCI) for each study participant and grouped them into low (CCI=0), moderate (CCI=1-2), and high (CCI=3+) morbidity levels. We computed mortality and mortality rate ratios (MRRs) adjusted for confounders, and compared the mortality between ICU patients and the general population cohort.

RESULTS

Low, moderate, and high pre-admission morbidity levels were present in 51.5%, 34.1%, and 14.4% of ICU patients, respectively. In these groups, 30-day mortality was 10.8%, 18.4%, and 26.7%, respectively. Three-year mortality was 21.3%, 43.1%, and 63.2%, respectively. The adjusted 30-day MRR was 1.30 [95% confidence intervals (CI): 1.21-1.39] and 1.86 (95% CI: 1.71-2.01) for ICU patients with moderate and high morbidity levels, both compared with a low morbidity level. The general population had a lower morbidity level and mortality at all morbidity levels throughout the study period. Interaction between ICU admission and high morbidity level added 5.1% to the mortality during the second and third year of follow-up.

CONCLUSION

A high pre-admission morbidity level was frequent among ICU patients and associated with a worsened prognosis. Morbidity had more impact on mortality among ICU patients compared with a general population cohort.

[Capacity in Danish intensive care units. A national survey of capacity, cancellations and transfers of critically ill patients]

INTRODUCTION

A shortage of intensive care beds and fully-booked intensive care units has a range of undesirable consequences for patients and personnel, eg. transfer to other intensive care units, cancellation of operations, tighter visitation criteria and an increase in the work-load. The problem is illustrated in a national survey.

MATERIALS AND METHODS

The survey was undertaken in 3 parts and comprised all 50 adult intensive care units in Denmark. Part 1 was a questionnaire encompassing demographic data, the number of open intensive care beds and how often under or over capacity was experienced in the department. Parts 2 and 3 consisted of a daily registry of the capacity and occupancy rate in the intensive care departments for two weeks along with a contemporary registry of the number of admittances, transfers and cancellations of operations.

RESULTS

In Denmark only 2% of all somatic beds are intensive care beds. Under capacity, defined as a 100% occupancy rate, was experienced weekly or monthly in 80% of all intensive care units in Denmark. Occupancy rate was high, a medium of 78%, highest in level III intensive care units with an 88% occupancy rate. The numbers for transfers were equivalent to 800-1000 patient transfers per year. The number of cancelled operations was equivalent to 2000 per year.

CONCLUSION

This survey documents that there is a problem with the capacity in Danish intensive care units. Establishing more intensive care beds in selected departments, ensuring personnel for the beds already established and establishing intermediate care beds could relieve the shortage of beds.

[The endocrinology of the critically ill]

Critical illness is characterized by one or more failing organs. Hormonal regulation of metabolism changes during the course of critical illness and is related to the severity of disease. Hormonal effects and inflammatory reactions are important and interrelated factors with respect to outcome. Recent large scale insulin infusion studies have demonstrated beneficial effects on both the immune response and coagulation systems. Future research will show whether further hormonal substitution can reveal similar results.

Transthoracic echocardiography for cardiopulmonary monitoring in intensive care

BACKGROUND AND OBJECTIVE

To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardiographic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring.

METHODS

The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a university hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed. Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions and contractility were assessed.

RESULTS

Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In 24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive.

CONCLUSIONS

By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in 97% of critically ill patients.

ICP during anaesthesia with sevoflurane: a dose-response study. Effect of hypocapnia

In patients with a supratentorial cerebral tumor, an increase in sevoflurane concentration from 1.5% (0.7 MAC) to 2.5% (1.3 MAC) did not change the intracranial pressure (ICP) significantly (12 to 14 mm Hg (medians)). However, a significant increase in cerebral blood flow (CBF) from 29 to 39 ml/100 g/min (medians) was disclosed. During administration of sevoflurane 1.5% and 2.5%, a significant decrease in ICP (3.5 and 3.0 mm Hg (median) respectively) was found when PaCO2 was decreased by 0.8 kPa.

Effects of sevoflurane on intracranial pressure, cerebral blood flow and cerebral metabolism. A dose-response study in patients subjected to craniotomy for cerebral tumours

BACKGROUND

Studies concerning the cerebrovascular effects of sevoflurane in patients with space-occupying lesions are few. This study was carried out as a dose-response study comparing the effects of increasing sevoflurane concentration (1.5% (0.7 MAC) to 2.5% (1.3 MAC)) on cerebral blood flow (CBF), intracranial pressure (ICP), cerebrovascular resistance (CVR), metabolic rate of oxygen (CMRO2) and CO2-reactivity in patients subjected to craniotomy for supratentorial brain tumours.

METHODS

Anaesthesia was induced with propofol/fentanyl/atracurium and maintained with 1.5% sevoflurane in air/oxygen at normocapnia. Blood pressure was maintained constant by ephedrine. In group 1 (n = 10), the patients received continuously 1.5% sevoflurane. Subdural ICP, CBF and CMRO2 were measured twice at 30-min intervals. In group 2 (n = 10), sevoflurane concentration was increased from 1.5% to 2.5% after CBF1. CBF2 was measured after 20 min during 2.5% sevoflurane. Finally, CO2-reactivity was studied in both groups.

RESULTS

In group 1, no time-dependent alterations in CBF, CVR, ICP and CMRO2 were found. In group 2, an increase in sevoflurane from 1.5% to 2.5% resulted in an increase in CBF from 29 +/- 10 to 34 +/- 12 ml 100 g-1 min-1 and a decrease in CVR from 2.7 +/- 0.9 to 2.3 +/- 1.2 mmHg ml-1 min 100 g (P < 0.05), while ICP and CMRO2 were unchanged. CO2-reactivity was maintained at 1.5% and 2.5% sevoflurane.

CONCLUSION

Sevoflurane is a cerebral vasodilator in patients with cerebral tumours. Sevoflurane increases CBF and decreases CVR in a dose-dependent manner. CO2-reactivity is preserved during 1.5% and 2.5% sevoflurane.

Unilateral vocal cord paralysis following endotracheal intubation

The present report describes a case of postoperative paralysis of the left recurrent laryngeal nerve in a patient undergoing surgery at a site far from the anatomic course of the nerve. Possible aetiological factors, symptoms, management and prophylaxis are discussed.

Rupture of the stomach caused by manual ventilation during laryngospasm

We report a case, in which laryngospasm developed due to a failed intubation under sedation. During ventilation tension pneumoperitoneum developed resulting in cardiac and respiratory failure. Laparotomy revealed two tears on the lesser curvature of the stomach. Factors influencing stomach rupture are discussed.

[Respiratory insufficiency caused by a vocal cord polyp. An accidental finding during respiratory function tests]

We present a case in which a 58-year-old woman was admitted for spirometry due to progressive dyspnoea. She had a history of chronic obstructive pulmonary disease treated for more than 20 years. The flow-volume loop indicated an upper airway obstruction. An otolaryngologic examination revealed a vocal cord polyp. It was excised and the patient's dyspnoea was relieved. The following spirometry indicated that the upper airway obstruction had been removed. The aim of this case report is to demonstrate that the flow-volume loop is a useful method in diagnosing and quantifying upper airway obstructions.

[Pulmonary edema after upper airway obstruction]

Post obstructive pulmonary edema (POPE) is a rare, but potentially dangerous condition. We present two patients with post-anaesthetic POPE. The literature is reviewed and aetiology, risk factors, pathogenesis, symptoms, prophylaxis and management are discussed. The condition is often associated with upper airway obstruction related to anaesthesia, but is also related to other causes of upper airway obstruction. Development of pulmonary edema can be delayed for up to 90 minutes. The treatment consists of oxygen therapy by nasal catheter or by mask with continuous positive airway pressure. In severe cases, intubation and mechanical ventilation by respirator with positive end-expiratory pressure is necessary. Further therapy is controversial and without significant effect. With sufficient therapy, almost all patients regain their habitual condition within 24-48 hours and present a normal chest X-ray.

Effect of previous frequency of headache, duration of fasting and caffeine abstinence on perioperative headache

We have examined the relationship between perioperative headache and various factors in 219 patients who fasted from midnight and underwent minor surgery under general anaesthesia. Four to six hours after operation all patients completed a questionnaire on previous frequency of headache, daily consumption of caffeine and occurrence of perioperative headache. The duration of fasting, type of surgery, premedication and anaesthetic agents used were obtained from the anaesthetic record. After multivariate logistic regression analysis a significant risk of preoperative headache was found in patients who normally experienced headache more than twice a month (odds ratio (OR): 7.7; confidence interval (CI): 2.9-20.1), had a daily caffeine consumption > 400 mg/24 h (OR: 5.0; CI: 1.6-14.8) and who were anaesthetized after 12:00 (OR: 3.7; CI: 1.4-9.8). The risk of postoperative headache was significantly greater in patients with preoperative headache (OR: 16.9; CI: 6.5-43.8), daily caffeine consumption > 400 mg/24 h (OR: 3.9; CI: 1.5-9.6) and in those patients who received atracurium, which was similar to the risk of tracheal intubation.

Working with the resident in difficulty

The resident in difficulty is an omnipresent and seemingly intractable problem. Some definitions of this concept are explored, as are means and methods of problem identification. Principles of successful intervention are discussed, as well as some obstacles to successful intervention. Utilization of interpersonal process recall, behavioral techniques, and a more insight-oriented approach in the remediation process are emphasized. The role of the faculty in responding to the resident in difficulty is explored, with special consideration to pitfalls and possibilities. The article concludes with a series of questions and directions for future exploration.

Identification of endogenous gibberellins from sorghum

Gibberellins (GA) A(1), A(19), and A(20) were identified in shoot cylinders containing the apical meristems from sorghum (Sorghum bicolor L.). Extracts were purified by sequential SiO(2) partition chromatography and reversed-phase C(18) high performance liquid chromatography and biologically active (dwarf rice cv Tan-ginbozu microdrop assay) fractions were subjected to gas chromatography-selected ion monitoring. Based on the use of [(3)H]GA and [(2)H](d(2))GA internal standards, amounts of GA(1), GA(19), and GA(20) were estimated to be 0.7, 8.8, and 1.5 namograms per gram dry weight of tissue, respectively.

Sequential nonverbal behavior in the patient-physician interview

This study demonstrates that there is a definite constancy to nonverbal behavioral interaction between patient and physician in a defined office interview setting. This work also introduces the technique of lag sequential analysis into family medicine research. Further refinements of study design and technique are needed in future studies to elucidate information that would be helpful to physicians in the management and care of patients and in patient education.

Procedures performed by family physicians, internists, and a Medex in a small group practice

Encounter forms for all patient visits to a small group practice (two internists, three family physicians, and one Medex) were examined retrospectively for October 1979 and January, April, and July 1980. A total of 5,694 patient encounters (2,327 male, 3,367 female) were recorded during the four months studied. Diagnostic and therapeutic procedures were performed on 592 patients (9.6 percent), 321 male and 271 female. The family physicians performed fewer procedures on their patients (6.1, 7.5, and 8.6 percent of the total patients seen). The Medex did 18.4 percent of all office procedures for that time period. The ten most commonly performed procedures included electrocardiogram (ECG), rhythm strip or ambulatory ECG, splint application, suture removal, pulmonary function test, suturing, exercise treadmill test, wart removal, removal of skin lesion or punch biopsy, application or removal of plaster cast, and application of ace wrap, sling, or collar. The majority of the procedures performed by the family physicians were also done by the Medex; however, the diversity of the procedures performed by the family physicians was comparable with that of the internists. There were large economic differences between groups, with the internists having the highest total billings and the Medex the lowest average charge per procedure performed.

Assessment of nonverbal communication in the patient-physician interview

The interview portion of 34 patient-physician visits at a family medical center was videotaped. Videotapes were screened by two judges in two major nonverbal categories, immediacy and relaxation. Physician and patient were scored separately at 40-second intervals for 11 component parameters of the two major categories. These scores were correlated with patient satisfaction and understanding, ascertained by post-interview questionnaire. For analytical purposes, patients were assigned to low or high satisfaction groups and low or high understanding groups. Statistically significant (P less than or equal to 05) differences between low and high satisfaction groups were demonstrated with respect to overall physician immediacy; five individual physician nonverbal parameters; and two individual patient nonverbal parameters. Similar statistical results were obtained for understanding groups. This preliminary investigation suggests that nonverbal behavior of the physician in the patient-physician interview is important in determining patient satisfaction and understanding.