Early Resuscitation Of Patients Research Articles

Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock.

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.

Relationship between PiCCO parameters and achieving target blood pressure in early resuscitation of patients with septic shock at Khanh Hoa general hospital, Khanh Hoa province in 2023

Hemodynamic resuscitation guided by the Pulse Contour Cardiac Output (PiCCO) system is an advanced, reliable and minimally invasive method. In prospective interventional study, 40 patients with septic shock admitted to the Intensive Care Unit of Khanh Hoa General Hospital from August 2022 to September 2023. Measure PiCCO parameters at several times. The rate of achieving target blood pressure at the time 1 hour (T1) was 87.5% (n = 35), at the time 3 hours (T3) was 90.0% (n = 36). At T1 and T3, Global End-Diastolic Volume Index (GEDVI), Extravascular Lung Water Index (EVLWI) and Systemic Vascular Resistance Index (SVRI) were related to achieving target blood pressure (p < 0.05). At T1, there were significant differences exist between two groups: GEDVI (764.2 ± 172.8 vs 659.4 ± 26.5mL/m2, p = 0.02); EVLWI (10.4 ± 2.6 vs 13.9 ± 2.79mL/kg, p = 0.02); SVRI (1658.8 ± 594.1 vs 1094.8 ± 135.2DS/ cm5/m2, p = 0.01). At T3, after urgent resuscitation, the significant differences between groups were: GEDVI (756.3 ± 141.1 vs 668.0 ± 10.3mL/m2, p = 0.01); EVLWI (10.9 ± 2.9 vs 14.1 ± 1.8mL/kg, p = 0.03); SVRI (1676.67 ± 628.3 vs 1127 ± 370.3DS/cm5/m2, p = 0.049). Early resuscitation according to the guidance of the PiCCO system helps achieve target blood pressure better in patients with septic shock. GEDVI, EVLWI and SVRI are indexes on the PiCCO system related to achieving target blood pressure.

The Use of Intraosseous Infusion in the Early Resuscitation of Patients With Extremely Severe Burns.

According to research, shock, the most common complication of extremely severe burns, is also the leading cause of mortality among patients with such burns. The case fatality rate reaches 83.45% when the total burn area exceeds 90%. The American Heart Association in 2020 recommended the intraosseous (IO) access after the peripheral access and prior to the central venous access when venous cannulation is either difficult or delayed. The use and experience with intraosseous infusion in extremely severe burns are still limited. We report efficacy and safety results from 19 burn patients treated with IO infusion between June 2020 and December 2022. In these patients, the mean injury time of burns was 1.55 ± 1.10 hours, the mean burn surface area was 86.24% ± 11.33%, the mean catheterization time was 49.68 ± 10.11 seconds, and the mean emergency retention time was 2.75 ± 1.74 hours, the mean actual fluid supplement amount was 5,533.68 ± 3,077.19 mL, the mean hourly urine volume of the patient was 93.31 ± 60.94 mL, the mean emergency detention time was 4.16 ± 2.97 hours, and the mean duration of hospitalization was 34.50 ± 25.38 days. The results demonstrated a clinically meaningful improvement and higher response rate vs peripheral venous cannulation and an acceptable safety profile in those patients.

Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension

BackgroundIntravenous fluids and vasopressor agents are commonly used in early resuscitation of patients with sepsis, but comparative data for prioritizing their delivery are limited.MethodsIn an unblinded superiority trial conducted at 60 U.S. centers, we randomly assigned patients to either a restrictive fluid strategy (prioritizing vasopressors and lower intravenous fluid volumes) or a liberal fluid strategy (prioritizing higher volumes of intravenous fluids before vasopressor use) for a 24-hour period. Randomization occurred within 4 hours after a patient met the criteria for sepsis-induced hypotension refractory to initial treatment with 1 to 3 liters of intravenous fluid. We hypothesized that all-cause mortality before discharge home by day 90 (primary outcome) would be lower with a restrictive fluid strategy than with a liberal fluid strategy. Safety was also assessed.ResultsA total of 1563 patients were enrolled, with 782 assigned to the restrictive fluid group and 781 to the liberal fluid group. Resuscitation therapies that were administered during the 24-hour protocol period differed between the two groups; less intravenous fluid was administered in the restrictive fluid group than in the liberal fluid group (difference of medians, −2134 ml; 95% confidence interval [CI], −2318 to −1949), whereas the restrictive fluid group had earlier, more prevalent, and longer duration of vasopressor use. Death from any cause before discharge home by day 90 occurred in 109 patients (14.0%) in the restrictive fluid group and in 116 patients (14.9%) in the liberal fluid group (estimated difference, −0.9 percentage points; 95% CI, −4.4 to 2.6; P=0.61); 5 patients in the restrictive fluid group and 4 patients in the liberal fluid group had their data censored (lost to follow-up). The number of reported serious adverse events was similar in the two groups.ConclusionsAmong patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy. (Funded by the National Heart, Lung, and Blood Institute; CLOVERS ClinicalTrials.gov number, NCT03434028.)

Exploring the relationship between capillary refill time, skin blood flow and microcirculatory reactivity during early resuscitation of patients with septic shock: a pilot study.

Capillary refill time (CRT), a costless and widely available tool, has emerged as a promising target to guide septic shock resuscitation. However, it has yet to gain universal acceptance due to its potential inter-observer variability. Standardization of CRT assessment may minimize this problem, but few studies have compared this approach with techniques that directly assess skin blood flow (SBF). Our objective was to determine if an abnormal CRT is associated with impaired SBF and microvascular reactivity in early septic shock patients. Twelve septic shock patients were subjected to multimodal perfusion and hemodynamic monitoring for 24h. Three time-points (0, 1, and 24h) were registered for each patient. SBF was measured by laser doppler. We performed a baseline SBF measurement and two microvascular reactivity tests: one with a thermal challenge at 44°C and other with a vascular occlusion test. Ten healthy volunteers were evaluated to obtain reference values. The patients (median age 70years) exhibited a 28-day mortality of 50%. Baseline CRT was 3.3 [2.7-7.3] seconds. In pooled data analysis, abnormal CRT presented a significantly lower SBF when compared to normal CRT [44 (13.3-80.3) vs 193.2 (99.4-285) APU, p = 0.0001]. CRT was strongly associated with SBF (R2 0.76, p < 0.0001). An abnormal CRT also was associated with impaired thermal challenge and vascular occlusion tests. Abnormal CRT values observed during early septic shock resuscitation are associated with impaired skin blood flow, and abnormal skin microvascular reactivity. Future studies should confirm these results.

Vasoactive and/or inotropic drugs in initial resuscitation of burn injuries: A systematic review.

BackgroundAccording to current guidelines, initial burn resuscitation should be performed with fluids alone. The aims of the study were to review the frequency of use of vasoactive and/or inotropic drugs in initial burn resuscitation, and assess the benefits and harms of adding such drugs to fluids.MethodsA systematic literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, UpToDate, and SveMed+ through 3 December 2021. The search included studies on critically ill burn patients receiving vasoactive and/or inotropic drugs in addition to fluids within 48 h after burn injury.ResultsThe literature search identified 1058 unique publications that were screened for inclusion. After assessing 115 publications in full text, only two retrospective cohort studies were included. One study found that 16 out of 52 (31%) patients received vasopressor(s). Factors associated with vasopressor use were increasing age, burn depth, and % total body surface area (TBSA) burnt. Another study observed that 20 out of 111 (18%) patients received vasopressor(s). Vasopressor use was associated with increasing age, Baux score, and %TBSA burnt in addition to more frequent dialysis treatment and increased mortality. Study quality assessed by the Newcastle‐Ottawa quality assessment scale was considered good in one study, but uncertain due to limited description of methods in the other.ConclusionThis systematic review revealed that there is a lack of evidence regarding the benefits and harms of using vasoactive and/or inotropic drugs in addition to fluids during early resuscitation of patients with major burns.

English

BACKGROUND Organo phosphorous compound poisoning is one of the most common suicidal poisonings in India. The various clinical entities that determine the clinical course and outcome in the ICU of OPC poisoning patient are type of the compound and dose of poison. Delayed presentation and multi-organ failure are some of the major factors that decide the outcome of the patient. This study was conducted to assess the clinical outcome of patients with OPC poisoning on assisted ventilation and assess the various factors that determine the outcome. METHODS A prospective observational study was conducted for a period of 6 months at a government tertiary care hospital in Chennai. All patients with history and clinical signs of OPC poisoning requiring mechanical ventilation for respiratory support were included as our study subjects. Outcome of patients was measured in terms of either recovery or death and factors influencing the outcome such as type of OPC compound, amount consumed, onset and duration of respiratory muscle weakness and pseudocholinesterase levels were considered. RESULTS In the 172 subjects, 108 (62.7 %) patients were successfully extubated from mechanical ventilator and 64 (37.2 %) patients expired. Patients aged more than 40 years, patients who consumed methyl parathion with quantity of poison more than 50 ml, patients with serum cholinesterase levels less than 500, patients who were atropinised for more than 3 days and who were on mechanical ventilation for more than 3 days were the factors found to have a statistically significant association (P &lt; .05) for causing death among patients with OPC poisoning. CONCLUSIONS The mortality among the OPC poisoning patients who were on mechanical ventilation was found to be very high. Early resuscitation of patients with OPC poisoning might reduce the morbidity and mortality. KEYWORDS Organo-Phosphorous Compound Poisoning, Mechanical Ventilation, Clinical Outcome

COMBINATION OF CENTRAL VENO-ARTERIAL CARBON DIOXIDE GAP WITH ARTERIO-VENOUS OXYGEN CONTENT DIFFERENCE DURING RESUSCITATION AS A PREDICTOR OF MULTI-ORGAN DYSFUNCTION IN SEPTIC PATIENTS

Background: Venous-to-arterial carbon dioxide difference (PvaCO2) the Pcv-aCO2/arterial-to-venous oxygen content difference (Ca-cvO2) ratio may reflect the adequacy of blood flow during shock states. We sought to test whether the development of Pv-aCO2 PcvaCO2/ arterial-to-venous oxygen content difference ratio during the very early phases of resuscitation is related to multi-organ dysfunction and outcomes in a population of septic patients resuscitated targeting the usual oxygen-derived and hemodynamic parameters. Aim of the Work: To evaluate the changes in central venous-toarterial carbon dioxide difference (Pcv-aCO2 gap) and in PcvaCO2/ arterial-to-venous oxygen content difference (Ca-cvO2) ratio [Pcv-aCO2/Ca-cvO2 ratio] during the early resuscitation in sepsis and septic shock as a predictor for development of multi-organ dysfunction and mortality. Patients and Methods: This prospective observational study wasperformed in a 24-bed mixed ICU in a university-affiliated hospital. We examined all septic patients with a new episode admitted to the emergency room or proceeding from clinical wards during a 24-month period. After approval by Ethical Medical Committee and obtaining informed consent, simultaneous blood samples were collected from the central venous line and the arterial catheter for obtaining venous and arterial gases respectively at T0, and 6 hours (T6), 12 hours (T12) and 24 hours (T24) later. Patients were classified twice; the first one into groups (A and B) according to PcvO2 gap and the second one into groups (C and D) according to Pcv-aCO2/Ca-cvO2 ratio. Group (A) Decreasing PcvaCO2 (high at T0, declining at T6), Group (B) Persistently high PcvaCO2 (high at T0 and T6), Group (C) Decreasing Pcv-aCO2/Ca-cvO2ratio (high at T0, declining at T6), Group (D) Persistently high PcvaCO2/ Ca-cvO2 ratio (high at T0 and T6).Results: During the 24-month period, 58 septic patients older than 18 years with a new episode were screened. Patients with advanced cirrhosis (n = 4), patients with severe chronic obstructive pulmonary disease (n = 8) and pregnant women (n = 4) were not included for analysis; additionally, two patients refused the procedure. The final sample was therefore 40 patients. Our recent study found that patients with persistently high Pcv-aCO2 gradient at T6 [8.64 ± 1.66] developed more organ dysfunction and have had a higher mortality rate (61.1%). This study showed that the persistently elevated Pcv-aCO2/Pa-vO2 ratio at time 6 was associated with a mortality rate of 73.7% of the patients. While decreasing of PcvaCO2/ Pa-vO2 ratio within the first 6 hours of resuscitation was associated with a survival rate of 90.5%. Conclusion: Data support the hypothesis that persistence of high PCO2 Gap and high Pcv-aCO2/ Pa-vO2 ratio during the early resuscitation of patients in sepsis is associated with significant higher multi-organ dysfunction and poor outcomes in critically-ill patients.

Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry

Aortic occlusion is a potentially valuable tool for early resuscitation in patients nearing extremis or in arrest from severe hemorrhage. The American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry identified trauma patients without penetrating thoracic injury undergoing aortic occlusion at the level of the descending thoracic aorta (resuscitative thoracotomy [RT] or zone 1 resuscitative endovascular balloon occlusion of the aorta [REBOA]) in the emergency department (ED). Survival outcomes relative to the timing of CPR need and admission hemodynamic status were examined. Two hundred and eighty-five patients were included: 81.8% were males, with injury due to penetrating mechanisms in 41.4%; median age was 35.0 years (interquartile range 29 years) and median Injury Severity Score was 34.0 (interquartile range 18). Resuscitative thoracotomy was used in 71%, and zone 1 REBOA in 29%. Overall survival beyond the ED was 50% (RT 44%, REBOA 63%; p= 0.004) and survival to discharge was 5% (RT 2.5%, REBOA 9.6%; p= 0.023). Discharge Glasgow Coma Scale score was 15 in 85% of survivors. Prehospital CPR was required in 60% of patients with a survival beyond the ED of 37% and survival to discharge of 3% (all p > 0.05). Patients who did not require any CPR before had a survival beyond the ED of 70% (RT 48%, REBOA 93%; p < 0.001) and survival to discharge of 13% (RT 3.4%, REBOA 22.2%, p= 0.048). If aortic occlusion patients did not require CPR but presented with hypotension (systolic blood pressure <90 mmHg; 9% [65% RT; 35% REBOA]), they achieved survival beyond the ED in 65% (p= 0.009) and survival to discharge of 15% (RT 0%, REBOA 44%; p= 0.008). Overall, REBOA can confer a survival benefit over RT, particularly in patients not requiring CPR. Considerable additional study is required to definitively recommend REBOA for specific subsets of injured patients.

Norepinephrine exerts an inotropic effect during the early phase of human septic shock

BackgroundWe conducted this study to investigate whether norepinephrine increases cardiac contractility when administered during the early phase of septic shock. MethodsWe studied 38 patients with septic shock who had been resuscitated for <3 h and whose mean arterial pressure (MAP) remained <65 mm Hg. Echocardiographic variables were obtained before (T0) and after either initiation or an increase in the dose of a norepinephrine infusion to increase MAP to ≥ 65 mm Hg (T1). We collected left ventricular ejection fraction (LVEF), velocity-time integral of the left ventricular outflow tract (VTI), tissue Doppler imaging of mean systolic velocity of the lateral tricuspid annulus (Sa) and of the lateral mitral annulus (Sm), and tricuspid annular plane systolic excursion (TAPSE). ResultsThere were significant (P<0.05) increases from T0 to T1 in MAP [mean (sd): from 56 (7) to 80 (9) mm Hg], LVEF [from 49 (13) to 56 (13)%], VTI [from 18 (5) to 20 (6) cm], Sm [from 10.8 (5.1) to 12.1 (5.0) cm s–1], TAPSE [from 1.8 (0.5) to 2.0 (0.5) cm], and Sa [from 13.0 (5.6) to 15.1 (6.4) cm s–1]. In the subgroup of 15 patients with LVEF ≤45%, significant increases in VTI [from 16 (8) to 18 (7) cm] and in LVEF [from 36 (7) to 44 (10)%] were observed. ConclusionsNorepinephrine administration during early resuscitation in patients with septic shock increased the cardiac systolic function despite the presumed increase in left ventricular afterload secondary to the increased arterial pressure. Whether such an effect persists over time remains to be evaluated. Clinical trial registrationNCT02750683.

Prognostic Value of Venous to Arterial Carbon Dioxide Difference during Early Resuscitation in Critically Ill Patients with Septic Shock.

Context:The partial pressure of venous to arterial carbon dioxide gradient (PCO2 gap) is considered as an alternative marker of tissue hypoperfusion and has been used to guide treatment for shock.Aims:The aim of this study was to investigate the prognostic value of venous-to-arterial carbon dioxide difference during early resuscitation of patients with septic shock and compared it with that of lactate clearance and Acute Physiology and Chronic Health Evaluation II (APACHE-II) score.Settings and Design:Forty patients admitted to one Intensive Care Unit were enrolled.Subjects and Methods:APACHE-II score was calculated on admission. An arterial blood gas, central venous, and lactate samples were obtained on admission and after 6 h, and lactate clearance was calculated. Patients were classified retrospectively into Group I (survivors) and Group II (nonsurvivors). Pv-aCO2 difference in the two groups was evaluated.Statistical Analysis Used:Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.Results:At T0, Group II showed high PCO2 gap (8.37 ± 1.36 mmHg) than Group I (7.55 ± 0.95 mmHg) with statistically significant difference (P = 0.030). While at T6, Group II showed higher PCO2 gap (9.48 ± 1.47 mmHg) with statistically significant difference (P < 0.001) and higher mean lactate values (62.71 ± 23.66 mg/dl) with statistically significant difference (P < 0.001) than Group I where PCO2 gap and mean lactate values became much lower, 5.91 ± 1.12 mmHg and 33.61 ± 5.80 mg mg/dl, respectively. Group I showed higher lactate clearance (25.42 ± 6.79%) with statistically significant difference (P < 0.001) than Group II (−69.40–15.46%).Conclusions:High PCO2 gap >7.8 mmHg after 6 h from resuscitation of septic shock patients is associated with high mortality.

Evaluation of Perfusion Index as a Predictor of Vasopressor Requirement in Patients with Severe Sepsis.

We evaluated the ability of perfusion index (PI) to predict vasopressor requirement during early resuscitation in patients with severe sepsis. All consecutive patients with clinically suspected severe sepsis as defined by the criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference were included. Perfusion variables included PI, arterial lactate level, central venous oxygen saturation, and the difference between central venous carbon dioxide and arterial carbon dioxide pressures, and were recorded before resuscitation and 6 h thereafter. We enrolled 36 patients with severe sepsis. Twenty-one patients required vasopressors, whereas 15 did not. The cut-off of the PI value for predicting vasopressor requirement was ≤0.3. This cut-off value had a sensitivity of 100% and a specificity of 93%; the area under the curve was 0.96 (95% confidence interval 0.8-0.99, P < 0.0001). The cut-off of the arterial lactate level for predicting vasopressor requirement was ≥1.8 mg dL. This cut-off value had a sensitivity of 82% and a specificity of 80%; the area under the curve was 0.84 (95% confidence interval 0.68-0.94, P < 0.0001). Other perfusion variables failed to predict vasopressor requirement in patients with severe sepsis. We concluded that PI and arterial lactate level are good predictors of vasopressor requirement during early resuscitation in patients with severe sepsis. Further studies are warranted to investigate whether monitoring PI during resuscitation improves the outcome of patients with septic shock.

What's new in volume therapy in the intensive care unit?

The administration of intravenous fluid to critically ill patients is one of the most common but also one of the most fiercely debated interventions in intensive care medicine. During the past decade, a number of important studies have been published which provide clinicians with improved knowledge regarding the timing, the type and the amount of fluid they should give to their critically ill patients. However, despite the fact that many thousands of patients have been enrolled in these trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Early adequate resuscitation of patients in shock followed by a restrictive strategy may be associated with better outcomes. Colloids such as modern hydroxyethyl starch are more effective than crystalloids in early resuscitation of patients in shock, and are safe when administered during surgery. However, these colloids may not be beneficial later in the course of intensive care treatment and should best be avoided in intensive care patients who have a high risk of developing acute kidney injury. Albumin has no clear benefit over saline and is associated with increased mortality in neurotrauma patients. Balanced fluids reduce the risk of hyperchloraemic acidosis and possibly kidney injury. The use of hypertonic fluids in patients with sepsis and acute lung injury warrants further investigation and should be considered experimental at this stage. Fluid therapy impacts relevant patient-related outcomes. Clinicians should adopt an individualized strategy based on the clinical scenario and best available evidence. One size does not fit all.

Initial fractal exponent of heart rate variability is associated with success of early resuscitation in patients with severe sepsis or septic shock: a prospective cohort study

IntroductionHeart rate variability (HRV) reflects autonomic nervous system tone as well as the overall health of the baroreflex system. We hypothesized that loss of complexity in HRV upon intensive care unit (ICU) admission would be associated with unsuccessful early resuscitation of sepsis. MethodsWe prospectively enrolled patients admitted to ICUs with severe sepsis or septic shock from 2009 to 2011. We studied 30 minutes of electrocardiogram, sampled at 500 Hz, at ICU admission and calculated heart rate complexity via detrended fluctuation analysis. Primary outcome was vasopressor independence at 24 hours after ICU admission. Secondary outcome was 28-day mortality. ResultsWe studied 48 patients, of whom 60% were vasopressor independent at 24 hours. Five (10%) died within 28 days. The ratio of fractal alpha parameters was associated with both vasopressor independence and 28-day mortality (P = .04) after controlling for mean heart rate. In the optimal model, Sequential Organ Failure Assessment score and the long-term fractal α parameter were associated with vasopressor independence. ConclusionsLoss of complexity in HRV is associated with worse outcome early in severe sepsis and septic shock. Further work should evaluate whether complexity of HRV could guide treatment in sepsis.

Management of bacterial infections in cirrhosis

Bacterial infections are very frequent in advanced cirrhosis and become the first cause of death of these patients. Despite numerous experimental data and significant advances in the understanding of the pathogenesis of sepsis in cirrhosis, the outcome remains poor. Classical diagnostic parameters such as C-reactive protein and SIRS criteria have less diagnostic capacity in the cirrhotic population, often delaying the diagnosis and the management of bacterial infection. Prompt and appropriate empirical antibiotic treatment of infection and early resuscitation of patients with severe sepsis or septic shock are essential in determining patient's outcome. A strategy of careful restriction of prophylactic antibiotics to the high-risk populations could reduce the spread of multidrug resistant bacteria. This review is focused on the currently recommended diagnostic, therapeutic and prophylactic strategies for bacterial infections in the cirrhotic population.

Does Whole-Body CT in Early Trauma Resuscitation Increase Survival?

Whole-body computed tomography (CT) is increasingly being used as a diagnostic tool during early resuscitation of patients with major blunt trauma, but

Near-Infrared Spectroscopy in Patients with Severe Sepsis: Correlation with Invasive Hemodynamic Measurements

Clinicians have begun using near-infrared spectroscopy (NIRS) to monitor tissue perfusion in hemorrhagic shock, as the technique allows continuous noninvasive monitoring of tissue hemoglobin oxygen saturation (StO(2)) and the tissue hemoglobin index (THI). We hypothesized that StO(2) measurements in patients with severe sepsis would be associated with the severity of their illness and would correlate with invasive hemodynamic measurements. We measured mean arterial pressure (MAP), serum lactate concentration, blood hemoglobin concentration, StO(2), and THI in nine healthy volunteers and ten patients with septic shock in a surgical intensive care unit (ICU). Enrolled patients had a pulmonary artery catheter, and had family able to give informed consent. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score at enrollment for the patients was 19 +/- 5 (standard deviation) points. Volunteers and patients were similar with respect to age and sex. To collect NIRS data, we used the InSpectra Tissue Spectrometer, Model 325 (Hutchinson Technology, Inc., Hutchinson, MN). For three consecutive days, we obtained invasive hemodynamic measurements three times daily, simultaneously with NIRS measurements, and metabolic cart measurements once daily. Patients with severe sepsis had significantly lower thenar muscle StO(2) values (p = 0.031) than healthy volunteers. Near-infrared spectroscopy-derived mixed venous oxygen saturation (NIRSvO(2)) and StO(2) measured from the thenar eminence in patients with severe sepsis correlated with SvO(2) from the pulmonary artery catheter (p < 0.05). In this group of patients, StO(2) did not correlate significantly with lactate concentration, base deficit, or APACHE II score. Near-infrared spectroscopic measurements of StO(2) correlated with invasive hemodynamic measurements in patients with severe sepsis but did not correlate with severity of illness. These findings suggest that NIRStO(2) may be a clinically useful measurement in monitoring patients with severe sepsis. Further study of this device in early resuscitation of patients with sepsis is necessary.

Improved Organ Function at 24 Hours is Associated with Increased Microcirculatory flow during the Early Resuscitation of Patients with Sepsis

Improved Organ Function at 24 Hours is Associated with Increased Microcirculatory flow during the Early Resuscitation of Patients with Sepsis