Group Of Intensive Care Unit Patients Research Articles

Inhaled Sedation with Volatile Anesthetics for Mechanically Ventilated Patients in Intensive Care Units: A Narrative Review.

Inhaled sedation was recently approved in Europe as an alternative to intravenous sedative drugs for intensive care unit (ICU) sedation. The aim of this narrative review was to summarize the available data from the literature published between 2005 and 2023 in terms of the efficacy, safety, and potential clinical benefits of inhaled sedation for ICU mechanically ventilated patients. The results indicated that inhaled sedation reduces the time to extubation and weaning from mechanical ventilation and reduces opioid and muscle relaxant consumption, thereby possibly enhancing recovery. Several researchers have reported its potential cardio-protective, anti-inflammatory or bronchodilator properties, alongside its minimal metabolism by the liver and kidney. The reflection devices used with inhaled sedation may increase the instrumental dead space volume and could lead to hypercapnia if the ventilator settings are not optimal and the end tidal carbon dioxide is not monitored. The risk of air pollution can be prevented by the adequate scavenging of the expired gases. Minimizing atmospheric pollution can be achieved through the judicious use of the inhalation sedation for selected groups of ICU patients, where the benefits are maximized compared to intravenous sedation. Very rarely, inhaled sedation can induce malignant hyperthermia, which prompts urgent diagnosis and treatment by the ICU staff. Overall, there is growing evidence to support the benefits of inhaled sedation as an alternative for intravenous sedation in ICU mechanically ventilated patients. The indication and management of any side effects should be clearly set and protocolized by each ICU. More randomized controlled trials (RCTs) are still required to investigate whether inhaled sedation should be prioritized over the current practice of intravenous sedation.

Study of Coagulopathies in Covid 19 Positive Patients & Their Correlation with Outcome of Disease

INTRODUCTIONCOVID-19 started in November 2019 as an infection with a new strain of Corona virus and spread across all geographic regions. It has been observed that various coagulation abnormalities are not infrequent in COVID-19. Bleeding and coagulation abnormalities have surfaced as one of the mechanisms that could be related to increased mortality associated with it. Through our work, we look forward to discovering more on this association & we believe our study could provide new insight that could save additional lives.AIMS & OBJECTIVES- To study coagulation abnormalities in Covid-19 Positive patients.- To correlate these coagulation abnormalities with severity of disease and outcome of Covid-19 Positive patients.Material & Methods:This is a prospective study being carried out on the Intensive Care Unit (ICU) admitted Covid 19 positive patients, in a tertiary care hospital. Fifty cases have been studied so far, to look for coagulation abnormalities. Covid 19 positive patients by RNA detection by RT PCR method, admitted in ICU of hospital have been investigated for Prothrombin Time (PT), Activated Partial Thromboplastin Time (APTT), Thrombin Time (TT), Fibrinogen levels and D-Dimer levels.The results of these investigations were correlated with clinical condition of these ICU patients, to assess the prognosisand outcome, of Covid-19 Positive patients.Results:Fifty COVID positive patients admitted in ICU have been studied & out of these 19 patients eventually expired (Non-survivors group) and 31 recovered from their illness (Survivors group).These fifty patients were investigated,at the time of presentation in ICU.Prothrombin time (PT)was prolonged in Covid 19 positive patients. Prothrombin time (PT) values in theSurvivors group ranged from 13.47 to 15.36 seconds(Mean 14.42 seconds). Prothrombin time (PT) values in theNon-survivors group ranged from 13.63 to 15.43 seconds (Mean 14.53 seconds).Normal control of Prothrombin time (PT) was 13 seconds. Prothrombin time (PT) values in the Survivors group were compared with Non-survivors group with ap value = 0.865(statistically not significant).Activated partial thromboplastin time (APTT)values in theSurvivors group ranged from 33.44 to 36.38 seconds(Mean 34.91 seconds). Activated partial thromboplastin time (APTT) values in theNon-survivors group ranged from 33.68 to 38.32 seconds(Mean 36.00 seconds). Normal control of activated partial thromboplastin time (APTT) was 34 seconds. Activated partial thromboplastin time (APTT) values in the Survivors group were compared with Non-survivors group with ap value = 0.397(statistically not significant).Thrombin time (TT)values in theSurvivors group ranged from 17.61 to 19.81 seconds(Mean 18.71 seconds). Thrombin time (TT) values in theNon-survivors group ranged from 18.68 to 22.32 seconds(Mean 20.50 seconds). Normal control of thrombin time (TT) was 18 seconds. Thrombin time (TT) values in the Survivors group were compared with Non-survivors group with ap value = 0.072(statistically not significant).Fibrinogen levelsin theSurvivors group ranged from 378 mgm/dl to 441mgm/dl(Mean 410mgm/dl). Fibrinogen levels in theNon-survivors group ranged from 331 mgm/dl to 419mgm/dl(Mean 375mgm/dl). Normal values for fibrinogen levels were 150 to 450 mgm/dl. Fibrinogen levels in the Survivors group were compared with Non-survivors group with ap value = 0.184(statistically not significant).D-Dimer levelswere increased in Covid 19 positive patients. D-Dimer levels in theSurvivors group ranged from 854 ngm/ml to 1847ngm/ml(Mean 1401ngm/ml). D-Dimer levels in theNon-survivors group ranged from 1308 ngm/ml to 2858 ngm/ml(Mean 2083ngm/ml). Normal values for D-Dimer levels were 135 to 250 ngm/ml. D-Dimer levels in the Survivors group were compared with Non-survivors group with ap value = 0.130(statistically not significant).ConclusionOurs is a small single centre study, however, shows coagulopathies in Covid 19 positive patients. Although, there is a difference between coagulation abnormalities in survivor & non-survivor group of ICU patients but this difference is statistically not significant.DisclosuresNo relevant conflicts of interest to declare.

Achieving Protein Targets in the ICU Using a Specialized High-Protein Enteral Formula: A Quality Improvement Project.

To meet protein needs in critical illness (CI), guidelines suggest ≥1.2-2.5g protein/kg/d; however, most intensive care unit (ICU) patients receive ≤0.7g/kg/d. Higher protein enteral nutrition (EN) formulas may be part of the solution to provide prescribed protein. Our objective was to demonstrate that an EN formula with 37% protein can deliver ≥80% of prescribed protein, without overfeeding calories within the first 5 days of feeding and to describe ICU clinicians' experience. This quality improvement (QI) project included patients requiring exclusive EN for up to 5 days from 6 Canadian ICUs. Rationale for choosing formula, patient's BMI (kg/m2 ), nutrition targets, daily protein and energy delivered, feeding interruptions, and general tolerance were recorded. Forty-four of 49 patients received the formula ≥2 days. Average protein prescribed was 137.5 g/d (82.5-200) or 1.9 g/kg/d (1.5-2.5). Average protein delivered was 116.9g/d (33.5-180) or 1.6 g/kg/d (0.4-2.4). Seventy-five percent to 83% of patients received ≥80% prescribed protein on days 2-5. Average energy prescribed was 1638.6 kcal/d (990-2500) or 17.8 kcal/kg (11-26). Average energy delivered was 1523.9 kcal/d (693.0-2557.5) or 17.3 kcal/kg/d (1.35-64.7). The formula was well tolerated with no gastrointestinal symptoms reported in 38(86%) patients. The most common reasons to prescribe the formula were obesity and use of fat-based medications. We demonstrated in a QI study that a high-protein EN formula was tolerated in a small, heterogeneous group of ICU patients and effective in meeting protein targets without overfeeding.

Evidence for the effectiveness of chlorhexidine bathing and health care-associated infections among adult intensive care patients: a trial sequential meta-analysis

BackgroundHealth care associated infections (HAI) among adults admitted to the intensive care unit (ICU) have been shown to increase length of stay, the cost of care, and in some cases increased the risk of hospital death (Kaye et al., J Am Geriatr Soc 62:306-11, 2014; Roberts et al., Med Care 48:1026-35, 2010; Warren et al., Crit Care Med 34:2084-9, 2006; Zimlichman et al., JAMA Intern Med 173:2039-46, 2013). Daily bathing with chlorhexidine gluconate (CHG) has been shown to decrease the risk of infection in the ICU (Loveday et al., J Hosp Infect 86:S1-S70, 2014). However, due to varying quality of published studies, and varying estimates of effectiveness, CHG bathing is not universally practiced. As a result, current opinion of the merit of CHG bathing to reduce hospital acquired infections in the ICU, is divergent, suggesting a state of ‘clinical equipoise’.This trial sequential meta-analysis aims to explore the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections, and address the question: do we need more trials?MethodsA systematic literature search was undertaken to identify trials assessing the effectiveness of chlorhexidine bathing to reduce risk of infection, among adult intensive care patients. With particular focus on: (1) Blood stream infections (BSI); (2) Central Line Associated Blood Stream Infections (CLABSI); (3) Multi-Resistant Drug Organism (MRDO); (4) Ventilator Associated Pneumonia; and, Catheter Associated Urinary Tract Infections (CAUTI). Only randomised-control or cluster randomised cross-over trials, were include in our analysis. A Trial Sequential Analysis (TSA) was used to describe the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections.ResultsFive trials were included in our final analysis - two trials were individual patient randomised-controlled, and the remaining cluster-randomised-crossover trials. Daily bathing with CHG was estimated to reduce BSI in the ICU by approximately 29% (Der-Simonian and Laird, Random-Effects.(DL-RE) Incidence Rate Ratio (IRR) = 0.71, 95% confidence interval (CI) 0.51, 0.98); reduce CLABSI in the ICU by approximately 40% (DL-RE IRR = 0.60, 95% CI 0.34, 1.04); reduce MDRO in the ICU by approximately 18% (DL-RE IRR = 0.82, 95% CI 0.69, 0.98); no effect in reducing VAP in the ICU (DL-RE IRR = 1.33, 95% CI 0.81, 2.18); and, no effect in reducing CAUTI in the ICU (DL-RE IRR = 0.77, 95% CI 0.52, 1.15). Upper (superiority) monitoring boundaries from TSA were not crossed for all five specific infections in the ICU.ConclusionRoutine bathing with CHG does not occur in the ICU setting, and TSA suggests that more trials are needed to address the current state of ‘clinical equipoise’. Ideally these studies would be conducted among a diverse group of ICU patients, and to the highest standard to ensure generalisability of results.

Mandatory criteria for the application of variability-based parameters of fluid responsiveness: a prospective study in different groups of ICU patients.

Stroke volume variation (SVV) has high sensitivity and specificity in predicting fluid responsiveness. However, sinus rhythm (SR) and controlled mechanical ventilation (CV) are mandatory for their application. Several studies suggest a limited applicability of SVV in intensive care unit (ICU) patients. We hypothesized that the applicability of SVV might be different over time and within certain subgroups of ICU patients. Therefore, we analysed the prevalence of SR and CV in ICU patients during the first 24 h of PiCCO-monitoring (primary endpoint) and during the total ICU stay. We also investigated the applicability of SVV in the subgroups of patients with sepsis, cirrhosis, and acute pancreatitis. The prevalence of SR and CV was documented immediately before 1241 thermodilution measurements in 88 patients. In all measurements, SVV was applicable in about 24%. However, the applicability of SVV was time-dependent: the prevalence of both SR and CV was higher during the first 24 h compared to measurements thereafter (36.1% vs. 21.9%; P<0.001). Within different subgroups, the applicability during the first 24 h of monitoring ranged between 0% in acute pancreatitis, 25.5% in liver failure, and 48.9% in patients without pancreatitis, liver failure, pneumonia or sepsis. The applicability of SVV in a predominantly medical ICU is only about 25%-35%. The prevalence of both mandatory criteria decreases over time during the ICU stay. Furthermore, the applicability is particularly low in patients with acute pancreatitis and liver failure.

Sleep in critically ill, mechanically ventilated patients with severe sepsis or COPD.

The standard method for scoring polysomnographic (PSG) sleep is insufficient in the intensive care unit (ICU). A modified classification has been proposed, but has not been tested in specific groups of ICU patients. We aimed firstly to (1) use the modified classification to describe sleep in two groups of ICU patients: a severe sepsis group and a chronic obstructive pulmonary disease (COPD) group, and (2) to compare sleep stage distribution in the groups; secondly to compare the PSG findings with nurses' sleep evaluation. Non-sedated mechanically ventilated patients with severe sepsis or COPD completed up to 20-hours PSG recording in each patient. A modified classification for scoring sleep in ICU was used for scoring the PSGs. Sleep assessment by nurses was done at 15minutes intervals. We included 16 patients with severe sepsis and 17 patients with COPD. Half of the patients in the severe sepsis group and 59% in the COPD group had atypical sleep. We found significantly different sleep stage distribution in the two groups, with the COPD group having a higher proportion of atypical sleep (54.4% vs 48.7%, P<.0001). No correlation between nurse sleep assessment and PSG was found in cases of atypical sleep (P<.0001). Normal PSG sleep characteristics as defined by standard classification are absent in many conscious, non-sedated critically ill patients on mechanical ventilation. Nurse sleep evaluation does not correlate with PSG if atypical sleep is present in the PSG, which limits the reliability of subjective sleep assessment in this patient population.

Oxidative Stress and Acute Kidney Injury in Critical Illness: Pathophysiologic Mechanisms-Biomarkers-Interventions, and Future Perspectives.

Acute kidney injury (AKI) is a multifactorial entity that occurs in a variety of clinical settings. Although AKI is not a usual reason for intensive care unit (ICU) admission, it often complicates critically ill patients' clinical course requiring renal replacement therapy progressing sometimes to end-stage renal disease and increasing mortality. The causes of AKI in the group of ICU patients are further complicated from damaged metabolic state, systemic inflammation, sepsis, and hemodynamic dysregulations, leading to an imbalance that generates oxidative stress response. Abundant experimental and to a less extent clinical data support the important role of oxidative stress-related mechanisms in the injury phase of AKI. The purpose of this article is to present the main pathophysiologic mechanisms of AKI in ICU patients focusing on the different aspects of oxidative stress generation, the available evidence of interventional measures for AKI prevention, biomarkers used in a clinical setting, and future perspectives in oxidative stress regulation.

Research : Association of Low-Amplitude QRSs with False-Positive Asystole Alarms

Although electrocardiographic monitoring is valuable for continuous surveillance of intensive care unit (ICU) patients, false alarms are common and have been cited as a cause of alarm fatigue. ANSI/AAMI EC12:2002 states that electrocardiograms (ECGs) should not detect a QRS if the waveform is less than 0.15 mV (1.5 mm) for adult patients, in order to avoid mislabeling P waves or baseline noise as QRSs during complete heart block or asystole. However, ECG software algorithms often use more conservative QRS thresholds, which may result in false-positive asystole alarms in patients with low-amplitude QRS complexes. To 1) assess the frequency of low QRS amplitude in a group of ICU patients with one or more false-positive asystole alarms and 2) determine whether low-amplitude QRSs are associated with false-positive asystole alarms during continuous ECG monitoring. Hospital-acquired standard 12-lead ECGs were examined in a group of 82 ICU patients who had one or more false-positive asystole alarms. Low QRS amplitude was defined as a unidirectional (only positive or negative) QRS of less than 5 mm in two of four leads (I, II, III, and V1). Low-amplitude QRSs were present in 45 of 82 (55%) patients. The presence of low-amplitude QRSs did not differ according to age, sex, or race. Patients treated in the cardiac ICU had the highest proportion of low-amplitude QRSs. An equivalent proportion of patients had false-positive asystole alarms by group (no low-amplitude QRSs 95% vs. low-amplitude QRSs 87%; P = 0.229). Eight patients (10%) had both true- and false-positive asystole alarms (two [5%] with no low-amplitude QRSs and six [13%] with low-amplitude QRSs; P = 0.229). Low-amplitude QRS, as assessed from hospital 12-lead ECGs, occurs frequently and is more common in cardiac ICU patients. However, this ECG feature did not identify patients with false-positive asystole alarms during continuous ECG monitoring.

Age, risk, and life expectancy in Norwegian intensive care: a registry-based population modelling study.

BackgroundKnowledge about the expected life years gained from intensive care unit (ICU) admission could inform priority-setting decisions across groups of ICU patients and across medical specialties. The aim of this study was to estimate expected remaining lifetime for patients admitted to ICUs during 2008–2010 and to estimate the gain in life years from ICU admission.MethodsThis is a descriptive, population modelling study of 30,712 adult mixed ICU admissions from the Norwegian Intensive Care Registry. The expected remaining lifetime for each patient was estimated using a decision-analytical model. Transition probabilities were based on registered Simplified Acute Physiology Score (SAPS) II, and standard and adjusted Norwegian life-tables.ResultsThe hospital mortality was 19.4% (n = 5,958 deaths). 24% of the patients were estimated to die within the first year after ICU admission in our model. Under an intermediate (base case), optimistic (O), and pessimistic (P) scenario with respect to long-term mortality, the average expected remaining lifetime was 19.4, 19.9, and 12.7 years. The majority of patients had a life expectancy of more than five years (84.8% in the base case, 89.4% in scenario O, and 55.6% in scenario P), and few had a life expectancy of less than one year (0.7%, 0.1%, and 12.7%). The incremental gain from ICU admission compared to counterfactual general ward care was estimated to be 0.04 (scenario P, age 85+) to 1.14 (scenario O, age < 45) extra life years per patient.ConclusionsOur research demonstrated a novel way of using routinely collected registry data to estimate and evaluate the expected lifetime outcomes for ICU patients upon admission. The majority had high life expectancies. The youngest age groups seemed to benefit the most from ICU admission. The study raises the question whether availability and rationing of ICU services are too strict in Norway.

Statistical and prognostic analysis of dynamic changes of platelet count in ICU patients

Laboratory tests are a primary resource to diagnose patient’s diseases. However, physicians often make decisions based on the available information, which commonly includes the last test results as a static picture and have limited perspective of the role of trends in commonly measured parameters in enhancing the diagnostic process. By providing a dynamic patient profile the diagnosis could be more accurate and, as a consequence, physicians could anticipate changes in recovery trajectory and prescribe interventions more effectively. Intensive care unit (ICU) patients need continuous monitoring, which commonly includes the assessment of several blood components. One of these components is the platelet count which is used in assessing blood clotting. However, platelet counts represent a dynamic equilibrium of many simultaneous processes including altered capillary permeability, inflammatory cascades, as well as the coagulation process. To characterize the value of dynamic changes in platelet counts we applied analytic methods to datasets of critically ill patients in (i) a homogeneous population of ICU cardiac surgery patients, where an observation appears to be predictive of patient’s complications and mortality and (ii) a heterogeneous group of ICU patients to confirm the previous observation.

Chronic hyperglycemia in critically ill: Another piece in the glycemic control puzzle

Chronic hyperglycemia in critically ill: Another piece in the glycemic control puzzle

The hidden sepsis marker: aPTT waveform analysis

Thromb Haemost 2008; 100: 9–10 Downey et al. published a paper in 1997 entitled ‘Novel and diagnostically applicable information from optical waveform analysis of blood coagulation in disseminated intravascular coagulation’ (1). Using a new automated coagulation analyzer, the MDA-180, the authors observed that during measurement of the aPTT, some samples became turbid immediately after addition of the calcium chloride reagent, well before clot formation. These plasma samples were mainly from intensive care unit (ICU) patients, which also fulfilled the diagnostic criteria for disseminated intravascular coagulation (DIC). The ‘biphasic waveform’ (BPW) recorded during optical measurement of the aPTT was thus introduced as a diagnostic marker for DIC (2). The authors found BPW also in some patients without DIC, and speculated that the phenomenon was related to coagulation activation or presence of pre-formed fibrin complexes. At that time, our laboratory was involved in an analysis of the effects of ancrod, a thrombin-like snake venom enzyme used for treatment of ischemic stroke (3). Ancrod induces massive intravascular fibrin formation, but none of our probands treated with ancrod developed BPW, indicating that BPW was not related to intravascular fibrin formation. Finally, Toh et al. were able to show that BPW was due to calcium-dependent complex formation between C-reactive protein (CRP) and very low density lipoprotein (VLDL) (4). Actually, this phenomenon had been described 20 years earlier. Cabana et al. showed that VLDL formed precipitating complexes with CRP, and these complexes were not observed in the presence of EDTA (5). In the same year, Hulman et al. reported that the serum of acutely ill patients agglutinated fat emulsions prepared from soybean oil designated for intravenous infusions, resulting in ‘creaming’ of the sera (6). Free calcium ions were necessary for ‘creaming’, and no ‘creaming’ was observed if citrate was added to the sera. The authors concluded that ‘creaming’ was a property of acute phase sera, and that this phenomenon is the explanation for adverse reactions to intravenous lipid emulsions, related to lipid microembolism, such as fever, shivering, precordial pains, nausea and vomiting. A ‘fat emulsion agglutination test’ was developed for measurement of CRP (7). It was later shown that the ‘creaming’ phenomenon in response to intravenous lipids was only observed in patients with highVLDL levels (8). Rowe et al. further characterized the interaction between CRP and VLDL and concluded that CRP may be related in some way to lipoprotein metabolism (9). It was also shown in experiments on rabbits that the CRP-VLDL complexes formed in acute phase serum contained predominantly β-VLDL, an abnormal apo-B containing lipoprotein low in apo-E content (10, 11). Inflammatory stimuli such as endotoxin induce the upregulation of VLDL secretion in the liver (12). Bennett et al. reported that endotoxin has a distinct effect on structural properties of VLDL, resulting in improved utilization by the heart as energy substrate (13). The authors did not consider the possibility that complex formation of CRP and VLDL might be involved. BPW is an indicator of a systemic inflammatory response, as observed in sepsis. Chopin et al. studied 187 patients with 217 episodes of systemic inflammatory response syndrome, of which 34 were classified as sepsis, 26 as severe sepsis, and 50 as septic shock. The diagnostic sensitivity and specificity of BPW for the combined group of severe sepsis and septic shock was 92% and 67%, respectively. Both CRP and procalcitonin displayed a lower diagnostic sensitivity (14). Another recent study showed a sensitivity of BPW for sepsis of 81%, with a specificity of 76% in ICU patients (15). Combination of aPTT waveform analysis with procalcitonin measurement did not increase sensitivity but raised specificity to 94%. In our own study on ICU patients, the diagnostic sensitivity of BPW for sepsis was 74%, with a specificity of 81% (16). Within the group of ICU patients with systemic inflammatory response syndrome, BPW identifies a group with increased mortality rate. In the study of Toh et al., the mortality rate of patients with BPW was 44%, compared to 26% in the patients without BPW (17). In the study of Bakhtiari et al., mortality of patients with and without BPW was 43% and 32%, respectively (18). In our study, the mortality rate of ICU patients with and without BPW was 36.8% and 13.1%, respectively (16). Use of the aPTT waveform analysis is not limited to ICU patients. Smith et al. have shown that also non-ICU patients with BPW are more likely to have positive blood cultures (19). Similarly, the study now published by Hussain et al. (20) shows that BPW can identify patients with sepsis within a specific high-risk patient group. Myelosuppressive therapy results in neutropenia

The effect of tracheostomy on outcome in intensive care unit patients

Percutaneous dilatation tracheostomy (PDT) is increasingly being used in the intensive care unit (ICU), and has probably increased the number of procedures performed. The primary aim of this study was to document the short- and long-term outcome of patients with a tracheostomy performed during an ICU stay. Patients in our ICU who underwent an unplanned tracheostomy between 1997 and 2003 were included in this analysis. The type of tracheostomy (PDT or surgical tracheostomy) and time of the procedure were registered prospectively in our ICU database. Survival was followed using the People's Registry of Norway and morbidity data from the individual hospital record. These patients were also compared with a group of ICU patients ventilated for more than 24 h, but managed without a tracheostomy. We also compared patients who had early tracheostomy (less than median time to procedure) with those who had late tracheostomy. Of the 2844 admissions (2581 patients), unplanned tracheostomy was performed during 461 admissions (16.2%) on 454 patients (17.6%). The median time to tracheostomy was 6 days. The ICU, hospital and 1-year mortality rates were 10.8, 27.1 and 37.2%, respectively, significantly less than those of the group ventilated without tracheostomy. The median time to decannulation was 14 days. Patients who had early tracheostomy had a more favourable long-term survival than those who had late tracheostomy. No procedure-related mortality was registered. In our ICU, having a tracheostomy performed was associated with a favourable long-term outcome with regard to survival, and early tracheostomy improved survival in addition to consuming less ICU resources.

Human cytomegalovirus infections in nonimmunosuppressed critically ill patients

To assess the occurrence of active human cytomegalovirus (HCMV) infection and HCMV disease and to evaluate potential risk factors in immunocompetent intensive care patients after major surgery or trauma. A prospective clinical study. An anesthesiological intensive care unit (ICU) in a university hospital. Fifty-six anti-HCMV immunoglobulin G (IgG) seropositive patients without manifest immunodeficiency whose simplified acute physiology score (SAPS II) value rose to >or=41 points during their ICU stay. Once a week, the patients were examined for active HCMV infection by polymerase chain reaction and by viral cultures from blood and lower respiratory tract secretions. Three times a week, detailed clinical examination for signs of HCMV disease was carried out. Twenty of the 56 ICU patients (35.6%) who met the study criteria of a SAPS II score >40 points and anti-HCMV IgG seropositivity developed an active HCMV infection as diagnosed by the detection of HCMV DNA in leukocytes, plasma, or respiratory tract secretions. In seven patients, the virus was isolated in the respiratory tract secretions. Severe HCMV disease appeared in two patients with pneumonia or encephalitis respectively. In patients with active HCMV infection, the mortality tended to be higher (55%) than in those without (36%); the duration of intensive care treatment of the survivors was significantly longer in the patients with active HCMV infection (median 30 vs. 23 days; p = .0375). Univariate testing for factors associated with active HCMV infection showed the importance of sepsis at admission (p = .011) and prolonged pretreatment on the ward or in an external ICU (p = .002); the relevance of underlying malignant disease was borderline (p = .059). Multiple regression analysis identified only sepsis to be independently associated with active HCMV infection (p = .02; odds ratio, 4.62). Even in a group of ICU patients without manifest immunodeficit who were anti-HCMV IgG seropositive and had reached a SAPS II score of >or=41 points, active HCMV infection occurred frequently (35.6%). Septic patients were affected twice as often as the total study population. In 2 of the 20 cases, active HCMV infection progressed to severe HCMV disease. Proper diagnosis demands special clinical attention combined with extended virological examinations. Further studies in a larger patient group should evaluate the influence of HCMV on ICU mortality.

Pharmacokinetics of amikacin in intensive care unit patients.

To characterize the population pharmacokinetics of amikacin in intensive care unit (ICU) patients and to analyse whether these patients show different kinetic behaviour on the basis of their clinical diagnoses. The patient population comprised 104 medical ICU patients on amikacin treatment for several presumed or documented Gram-negative infections. Four study groups were defined according to patients' clinical diagnosis: sepsis group (n = 39), trauma group (n = 20), pneumonia group (n = 21) and 'other diagnosis' group (n = 24). The pharmacokinetic parameters for amikacin in these patients were then compared. The ICU patients were found to have increased values for the amikacin volume of distribution (0.52 +/- 0.21 litres/kg), whereas total amikacin clearance expressed as a linear function of creatinine clearance was Cl (ml/min/kg) = 0.13 +/- 0.86 ClCR, which is not significantly different from other estimations reported in the literature. However, this relationship revealed statistically significant differences among the four groups of ICU patients. Moreover, the septic and trauma patients showed higher (but not statistically significant) values for the amikacin volume of distribution. The amikacin pharmacokinetic parameters obtained should allow Bayesian individualization of amikacin doses in patients admitted to medical ICUs, on the basis of their clinical diagnoses.

Upon-admission adrenal steroidogenesis is adapted to the degree of illness in intensive care unit patients.

Adrenal function was studied in 2 groups of intensive care unit (ICU) patients with varying degrees of illness, as determined by Acute Physiological and Chronic Health Evaluation (APACHE). The 15 seriously ill patients with high APACHE scores (greater than or equal to 25) had elevated Therapeutic Intervention Scores and increased mortality compared to the 15 ill patients (APACHE, less than or equal to 10; 67% vs. 27%). Plasma cortisol, aldosterone, and androstenedione concentrations were increased in the ICU patients compared to those in normal subjects (n = 23), being greater in the seriously ill patients. Plasma dehydroepiandrosterone sulfate (DHEAS) concentrations were low in both groups of ICU patients. The ratios of aldosterone or androstenedione to cortisol were not altered, whereas the DHEAS to cortisol ratios were reduced in the ICU patients. ACTH injection elicited increases in plasma cortisol, aldosterone, and androstenedione concentrations in both groups of ICU patients, and the ratios of aldosterone and androstenedione to cortisol did not change. In the seriously ill patients, plasma DHEAS increased, so that the DHEAS to cortisol ratio did not change, whereas in less ill patients plasma DHEAS did not increase, so that the DHEAS to cortisol ratio was reduced. In this study of patients admitted to an ICU, impairment of adrenal steroid secretion appears to be specific for DHEAS. Although plasma cortisol was elevated in ill patients proportional to the degree of illness, the contribution of the concomitant decrease in DHEAS to this increase is not clear.