key: cord-0033844-n6f4xupw
authors: nan
title: PS 339-563
date: 2005-09-10
journal: Intensive Care Med
DOI: 10.1007/s00134-005-2780-4
sha: e8fd33f28b96974a2e001e9a6f92d5a4aea02f21
doc_id: 33844
cord_uid: n6f4xupw

nan

Bronchoscopy bronchoalveolar lavage (BAL) may be followed by a systemic inflammatory response which clinical effects in critical patients are unknown. We designed this study to examine the effects of fiberoptic bronchoscopy (FOB) with and without BAL on body temperature, systemic arterial pressure, heart rate and supportive therapies requirements in mechanically ventilated patients.

METHODS. 46 consecutive mechanically ventilated patients were prospectively enrolled. FOB with BAL (150 ml of isotonic saline instilled by aliquots of 50 ml) was performed in 29 patients and without BAL in 17. Heart rate and mean arterial pressure were recorded 4 hrs before (time 1), at the beginning (time 2), and 4 (time 3) and 24 hrs after the procedure (time 4). Body temperature, vasopressors, urine output and fluid balance were registered during 24 hrs before and after FOB.

There were not changes in hemodynamic parameters, body temperature nor supportive therapies (p: n.s.) in FOB patients without BAL. On the contrary, in patients with BAL, there was a significant decrease in mean arterial pressure 4 hrs after the procedure (table). Fluid balance and urine output remained unchanged (p: n.s.), but number of patients on vasopressor therapy and mean vasopressors dosage increased after BAL (from 0.20 ± 0.51 µg/kg/min to 0.48 ± 0.92 µg/kg/min; p < 0.01); body temperature did not change (p: n.s.). CONCLUSION. Global tests may better reflect physiological haemostasis than standard screens or individual factor assays in critically ill patients with sepsis. Studies that involve clinically relevant endpoints of bleeding are required. 

Abizanda R 1 , Reig-Valero R 1 , Bisbal-Andres E 1 , Mas-Font S 1 , Sánchez-Morán F 1 , Madero-Peréz J 1 , Iranzo-Velasco J 1 1 Intensive Care Department, Hospital Universitario Asociado General De Castello, Castello, Spain

To limit therapeutic effort (LET) is a reasonable acceptable medical and ethical attitude that must be offered to those cases where the evolution of patients is no good in spite appropiate treatment. Our aim has been to look into the LET decisions and in the participation of patients and surrogates in them.

Retrospective analysis of decision making processes about LET attitudes in a multidisciplinary 19 beds ICU during 2003 and 2004, as compared to practices registered during 1996 and 1999. Since 2003, a consensus attitudes form has been fulfilled between the attending medical team and the surrogates of patients to whom LET was proposed (by any part). The agreement offered differentiated possibilities of LET (no CPR, no increases in FiO2, no use of vasoactive drugs, no use of extracorporeal renal depurative techniques, and so on). Existing agreement for each individual patient was reviewed every time that the attending team or the surrogates ask for that.

During the analyzed years, 118 LET attitudes were performed (60 in 2003 and 58 in 2004) over a whole in ICU mortality of 288 patients (141 and 147). In patients in whom LET was decided, age, severity of illness, risk of death, nursing workload and ICU length of stay, were significantly higher than in patients not subjected to LET. Agreement on LET attitudes, between the attending medical team and the patient's representatives was present in 63 % of cases, and in the 18 % the LET was decided only on professional-technical reasons. In those cases, medical decision was also informed to relatives. The number of patients being discharged from the ICU in whom LET was established was 26 (22 %). Withholding approaches were more than three times higher than withdrawing indications. Shorten of death process, was performed in 12 patients (10 % of LET). These observational data agree with the theoretical approaches established by our group in 1994 1. No claim was presented by relatives or patients against medical attitudes.

CONCLUSION. An increasing transparency in decision making about LET does not meet refusal from the patient's representatives, and, by the contrary, it favours that the decision becomes a collegiate one and makes more easy the implementation of non futile attitudes. 

Rubulotta F M 1 , Gullo A 2 , Levy M M 3 , Ramsay G 4 1 Intensive Care, Gasthuisberg UZ, Leuven, Belgium, 2 Intensive Care, Cattinara, Trieste, Italy, 3 Intensive Care, Brown, Providence, United States, 4 Hospital director, Atrium, Heerlen, Netherlands

The objective of this study is to assess the end-of-life decision-making process in different countries.

Questionnaire administered by the same interviewer to 50 North American physicians after an end-of-life discussion with proxies of patients admitted to a Medical Intensive Care Unit (MICU). Questionnaire administered by the same interviewer to 50 Italian ICU physicians during a regional meeting. Physicians in both countries were asked, using a five point Linkert scale, to indicate their percentage of responsibility in the decision making process.

. USA physicians reported a 43% of responsibility in the end-of life decision-making process in the MICU. Italian physicians claimed 80% of responsibility in the end of life decision making process.

Physicians have different percentage of responsibility in the end-of-life decision making process according to their culture and working environment (1) . 

Decision to withhold or withdraw of life-sustaining treatment for an incapacitated brain-damaged patient raises complex issues regarding legal or medical concerns. It is the main question how a "clear and convincing" evidence based decision can be constituted or who has the right to make decision in end of life for a patient living in persistent vegetative state. Here we present the care of a woman who was left in a persistent vegetative state after having a cardiac arrest.

In 1992, the case of N.U. had a cardiac arrest triggered by a delivery with severe abruption placentae. Hypoxic-ischemic encephalopathy developed after a poor response to resuscitation. After one-year stay in ICU, she was discharged from hospital without a ventilatory support but still required tracheotomy cannula, gastrostomy tube and urinary catheter. Nursing homes caring for incapable patients are not under the cover of health insurance policy in Turkey. So the sole solution for caring Ms. U was being nourished at own home. To both improve and supply a constant care for Ms. U, her sister and her husband agreed on to 'err on the side of life': the final decision was a marriage between Mr. U and sister-in-low.

It perhaps seems like a moral disturbing solution at first sight, but we do not have to forget that the families commonly disagree over how best to care for a loved one. Those unfortunate circumstances need stronger bond shared by each family member, rather than a familial dispute. Participation of sibling into the care of Ms. U, of course, did not improve the neurological outcome or any cognitive function, but resulted in nearly uninterrupted care, which could be so hard to ensure in a different manner. Furthermore since 1992, artificial nutrition and hydration delivered by family without a nurse support, surprisingly maintain normal levels of hematological and biochemical parameters, measured periodically.

We believe that the acceptance of diagnosis by all family members that her condition was irreversible, and then they had submitted to her unfortunate destiny. Nevertheless, it is difficult to analyze underlying factors, which cause perhaps a compulsive marriage. This profound decision, whether reflects what the patient would want for herself or what the family would want for their incapacitated loved one, is rather debatable. 

In order to help relieve conscious patients and family members from the burden of an ICU stay, we introduced in our ICU non-professional hospice volunteers (HV), trained to intervene in palliative care settings. We performed an evaluation after one year.

After an agreement was signed with the HV association, HV's role and hours of presence were defined and adapted between the 4 HV women and the ICU staff. An HV was on duty one afternoon every 2 weeks from 09/2003 to 03/2004 and every week from 04 to 09/2004. HV met 25 patients and 60 family members either upon request or suggestion by the staff. A special logbook could be consulted to transmit information. Evaluation was performed using questionnaires for staff and HV. 

These results clearly indicate that introducing HV in an ICU is considered by a large majority of the medical and nursing staff as useful and appropriate, though some expressed reluctance to share informations with the HV. Satisfaction of patients and family members is being evaluated. A working group has proposed improvements. 

Italy has 472 ICUs. These include adult and pediatric units. We contacted 50 ICUs selected at random all over the country. Local ICU regulations allow family members one visit a day in 89% of cases. Only one family member can enter inside the ICU after wearing gloves, mask and gown in 73% of cases, two family members wearing the same protection in 20% of cases, and more than two people in 7% of ICUs. ICU physicians meet the family members at admission and once a day in 90% of cases. Reasons given for adopting these rules include-in 80% of cases a lack of physical space to receive relatives longer than 30 minutes, in 40% of cases a lack of ICU staff, in 10% of cases concern about an increased risk of infection, and in 10% of cases other reasons. All units have special rules for caring for families of terminal patients.

The communication between physicians and families in Italy could be improved first of all by more space inside the unit, second by dedicating more staff time. Families seem to be adequately supported by the ICU staff in terminal or difficult situations.

Masnou N 1 , Pont T 1 , Gracia R 1 , Salamero P 1 1 Transplant Coordination, Hospital Vall d'Hebron, BCN, Spain

The aim of the study is to compare tissue donation refusal between organ donors and potential tissue donors.

METHODS. prospective and descriptive study of all family interviews from 2000 to 2004, through specifically designed protocol. This included epidemiological data, the manner of comunication to Transplant Coordinator (TC), interview features and perceived family attitude.

There were 3400 deaths in this period. We evaluated as potential tissue donnors 519 patients. A TC carried out the interviews with these families, 42% (217) refused donation. Over 30% were actual tissue donors.We followed 256 patients in brain death in this period. Only 142 could be organ donors, 10% of these families didn't consent to tissue donation; so only 68% of patients could give tissue. We did 784 interviews ; 6% of families were familiar with Spanish law about transplant and presumed consent, and only 2% of people carry donor cards or have made a living will.

Regarding the family ties to the deceased, in the case of organ donation the parents refused in 37% of cases, the partner in 21% ,the children in 16%, siblings in 8% and 17% in the case of more distant relatives.In the case of tissue donors the refusal was from the parents in 8% of cases,the partner in 37%, the children in 40%, siblings in 10% and other relatives in 6% of cases.These differences were due, in part, to the advanced age of the tissue donors. If we relate the cultural level of the interviewed people with the refusals we find the following results: MO low cultural level 29%, average 35% and high 1% while in the tissue group , low18%, average 20% and high 5% (ns). The reasons for family refusal were as follows (MO-MT %): deceased had expressed negative attitude 28/33, family opposition 17/23, resentment of the health system 11/7, difficulties with image of the corpse 17/3, deceased's will unknown 5/12 , contrary religious beliefs 6/1,flat refusals 6/12, others 11/19.Regarding reversed refusals in MO, consent was obtained in 6% of cases and in 11% of MT.

Tissue donation is still the war horse for TC.This is due to a general lack of awareness of every aspect of this subject.There remains to carry out the lengthy task of social education in this area. METHODS. This is a descriptive study on the level of satisfaction of students who received these classes.It was carried out with 4th year students(14y)and 6th(18y).We used a post-course questionnaire, which included:level of interest,clarity and usefulness of explanation, students'environtment.It was agreed by the professionals working on this project not to use audiovisuals.The lesson was structured in six parts: introduction,donation rate, difference between organs and tissues,characteristics of the waiting list,conditions to become an organ donnor(brain death),discussion on transplant law and personal experiences.Sometimes,kidney receptors participated and explained their experiences. 

We considered the experience useful and satisfying.Both the institutions and the students supported the presentation in over 95% of cases.The teachers considered the course enjoyable and accessible.We feel that we need to evaluate the level of comprehension and therefore we have designed a new study with two questionnaires, one prior and one a week after the course so as to evaluate the changes in the students' sensivity and perceptions. 

Organ transplantation activities are dependent on legislation, attitudes of the general public and health care professionals, and the organization of transplantation. Reports from countries throughout the world have emphasized the importance of positive attitudes in health workers on organ donation and transplantation, yet there is a lack of studies on this subject. Even in Spain, the leading country in organ donation rates, there is also an existing shortage of these studies. However, donation rates have not kept pace with demand, resulting in a critical deficit of available healthy organs. It has been suggested that the attitudes of medical personnel regarding organ retrieval is a key success factor to improve organ donation. The aim of this study is to examine attitudes towards organ donation in health care workers.

We analysed a long survey, which evaluates attitudes, knowledge, roles and experience towards organ, and tissue donation and transplantation. This survey was administered to all participants before and after the post graduate courses (2003 and 2004) in organ donation. We studied this changes in term of prognosis (Glasgow outcome scale).

We prospectly studied 51 patients the first 24 hours after SAH. Patients with chronic cardiac disease or brain death were excluded. Clinical characteristics (Glasgow scale, heart rate, systolic blood pressure), cardiac enzymes (troponin I, total serum creatine kinase and myocardial isoenzyme, myoglobin), ECG changes (ST-T changes, prolonged QT and corrected QT intervals), echocardiographic assessment of cardiac function (left ventricular ejection fraction, hypokinesia) were studied on the day of the admission.

Data are shown in the table. 

Only systolic blood pressure 95 bpm were found to be independent factors of poor outcome. Measurements of myocardial specific enzymes and echocardiographic assessment of cardiac function have no prognosis impact in this study. 2)The more the patient sleeps during the day, the more likely to have poor quality sleep at night.

3)Sleep disruption in ICU is related to the degree of illness-severity and length of stay in the unit. 4)Actigraphy is a simple method of assessing sleep that is well tolerated by patients and doesn't interfere with nursing activities.

It is well-known that the ischemia-reperfusion injury in patients resuscitated from cardiopulmonary arrest (CPA) severely damages the brain. Some recent studies have been reported that neuron-specific enolase (NSE) is an useful marker for outcome prediction. The aim of this study was to compare the prognosis of patients resuscitated from CPA with levels of S100 protein and NSE in serum and cerebrospinal fluid (CSF).

Twenty four patients resuscitated from CPA were eligible in this study. Patients were divided into two groups according to the Glasgow Outcome Scale (GOS) at three months after the initiation of therapy. Group G had the favorable neurological outcome and Group P had the poor outcome, evaluated by GOS. The blood and CSF samples were taken within 48 hours after resuscitation and the levels of S100 protein and NSE were compared between the two groups. Jugular bulb oxygen saturation levels were measured when hemodynamics were stabilized. Mann-Whitney's U test was used for continuous variables. Correlations were tested using Spearman's rank correlation test. A P-value less than 0.05 was considered statistically significant.

Six patients in Group G had favorable neurological outcome and eighteen patients in Group P had poor outcome. The levels of S100 protein in serum and CSF (median, 1.55 and 25.4 ng/ml, respectively) in Group P were significantly higher than those (median, 0.05 and 4.05 pg/ml, respectively) in Group G. The levels of NSE in serum and CSF (median, 99.4 and 248.1 ng/ml, respectively) in Group P were significantly higher than those (median, 32.4 and 39.5 ng/ml, respectively) in Group G. Jugular bulb oxygen saturation levels in Group P were significantly higher than those in Group G. The levels of S100 protein in serum correlated well with those of NSE in serum (σ=0.76, P<0.005). The outcome and jugular bulb oxygen saturation levels correlated with the levels of S100 protein in serum (σ=0.81, P<0.005, and σ=0.69, P<0.05, respectively).

The levels of S100 protein in serum and CSF correlated well with NSE and their neurological outcome, so that S100 protein would be an excellent biological predictor in patients resuscitated from CPA.

Grant acknowledgement. This work was supported by the grant 14207060 from the Japan Society for the Promotion of Science, Japan.

Wright K 1 , Munasinge A 1 1 Critical Care and Emergency medicine, Royal Surrey County Hospital, Guildford, United Kingdom

Injury to the cervical spine occurs in 5-10% of blunt multisystem trauma. Spinal immobilisation consists of a hard collar, headblocks and tape immobisation.This immobilisation is maintained until the cervical spine can be cleared of injury. Often this relies on the patient being able to co-operate with a neurological examination. Following head trauma some patients may never regain sufficient neurological ability to co-operate with an examination. Others may remain obtunded for some time. Until the spine is cleared the patient needs to be log-rolled and turned in accordance with spinal care bundles. Complications such as pressure sores can ensue if this is not followed. Evidence has also shown that removal of the cervical spine collar in head injured patients improves venous drainage from the head and so is beneficial in managing intracranial pressure1.We therefore need an approach to clearing the spine in obtunded multisystem trauma patients.

Literature review study leading to institutional protocol.

A safe clearence protocol is suggested.

A protocol guided approach will allow the rapid removal of cervical spine precautions in multisystem injured patients. Patients who have a spinal injury demonstrated are excluded from this approach and are managed in accordance with the spinal service guidance. 

Hypothalamic-pituitary-adrenal (HPA) function has been recently studied in patients with traumatic brain injury (TBI), but few studies have shown its relationship with outcome. The aim of this study was to analyze HPA response and its relationship to Intensive Care Unit (ICU) survival in patients with isolated TBI.

We studied 38 consecutive patients (33 male) with isolated TBI. Norepinephrine (NE) was used to maintain cerebral pressure perfusion over 60 mmHg when necessary. At 24-48 hours following TBI, we recorded values for plasma ACTH, baseline serum cortisol and stimulated cortisol at 30 and 60 minutes after performing high-dose corticotropin stimulation test (HDCST). Mean and SD are reported. Chi-square and logistic regression analysis were done.

Age was 37.5 ± 18.9 years. ISS 25.0 ± 8.7; Apache II 17.4 ± 6.5; GCS score after resuscitation 7.7 ± 3.0. Plasma ACTH was 22.2 ± 42.3 ng/ml (normal values 9-52 ng/ml). Baseline cortisol was 15.6 ± 8.9 ug/dl, stimulated cortisol at 30 minutes 27.3 ± 7.7 ug/dl and at 60 minutes 30.8 ± 7.3 ug/dl. All patients increased at least 9 ug/dl after HDCST or had a stimulated value greater than 20 ug/dl. Overall survival was 73.7% (28 patients). Univariate analysis of variables related to ICU survival showed: Age <45 years (p=0.02),Apache II <15 (p=0.01),ACTH <9 ng/ml (p=0.001),baseline cortisol < 20 ug/dl (p=0.08),use of NE (p=0.20),second-tier measures to control ICP (p=0.02), GCS > 8 (p=0.12). Logistic regression analysis revealed that no need of second-tier measures to control ICP (OR 11.9 CI95% 1.3 to 103.2) and plasma ACTH lower than 9 ng/ml (OR 37.2 CI95% 3.1 to 449.5) were significant independent predictors of ICU survival.

CONCLUSION. 1)Adrenal gland function, assessed by HDCST, is not impaired at early stage of TBI. 2) TBI patients with low levels of plasma ACTH had a high ICU survival.

Paramythiotou E 1 , Katsarelis N 1 , Papakonstantinou K 1 , Stathopoulos G 1 , Varveri M 1 , Fousfoukis S 1 , Roussos A 1 , Karabinis A 1 1 ICU, George Gennimatas General hospital, Athens, Greece

Aspiration of foreign bodies during trauma is a known com-plication. It usually concerns teeth, pieces of food etc and for their removal several procedures, invasive or not -like bronchoscopy or thoracotomy -must be underta-ken. We describe three patients with foreign body aspira-tion in our ICU.

A 20 year -old male was admitted in our ICU with face trauma, a broken mandible and a broken femoral bone. A foreign body was observed in the left lower bronchus on the chest X -ray. An attempt to retrieve it with the flexi-ble bronchoscope failed and the foreign body moved to the right lower bronchus. A rigid bronchoscope was then used with success and the foreign body was removed. It was a part of the broken mandible. The patient was discharged after two weeks. Case 2. A 20 year -old male was admit-ted after a road accident suffering from a severe cerebral injury, a pneumothorax and a broken lower mandible. A fo-reign body (piece of a broken tooth) was aspirated in the right upper bronchus. It was retrieved with a flexible bronchoscope. He remained in a "vegetative" situation for a long time and finally died because of a septic shock. Case 3. A 47 yearold patient was admitted with cerebral injury and a low Glascow coma scale, a pneumothorax and acute respiratory failure. A foreign body was present in his right upper bronchus. The flexible bronchoscope and a basket were used in order to retrieve it. It was a large tooth. His neurological situation never ameliorated and the patient developed a septic shock and a multiorgan fai-lure and died.

Severe cerebral injury may result in foreign body aspira-tion especially when it is accompanied by facial trauma. For comatose patients, x -ray of the chest and thorax C/T scan are the main diagnostic tools for this situation. Retrieval of the foreign bodies is necessary to avoid further complications such as atelectasis, pneumoniae etc. Flexible bronchoscope used through the endotracheal tube is very effective in their removal.

Medical personnel dealing with trauma patients must have a high index of suspicion for the presence of foreign bodies in the tracheobronchial tree. Flexible bronchoscopy or use of the rigid bronchoscope in case of failure, are very use-ful and safe techniques for the removal of these foreign bodies.

Mandila C 1 , Koukoulitsios G 1 , Stathopoulos G 1 , Paramythiotou E 1 , Theodoropoulos G 1 , Karabinis A 1 1 ICU, General Hospital of Athens ''G Gennimatas'', Athens, Greece

We report angiographic detection of vertebral artery dissection (VAD) in two sedated patients in the Intensive Care Unit (ICU). In both cases VAD was suspected solely by the presence of ischemic lesions evident on cervical spine and brain magnetic resonance imaging (MRI).

Two patients were intubated, sedated, and admitted to the ICU with Glascow Coma Scores <7 after having suffered blunt head and neck injuries due to motor vehicle accidents. In the first patient computed tomography (CT) of the brain and cervical spine revealed traumatic subarachnoid haemorrhage, anterior atlas arc fracture, axis fracture, and a C3 body fracture. In addition, brain and cervical spine MRI depicted a medullar contusion at the C7 level, an increased interarticular space C5-C6, and a left cerebellar hemisphere infarct. Based on these findings carotid and vertebral angiography was performed, which showed complete left vertebral artery occlusion at the C6 level with incomplete distal filling due to a hypoplastic right vertebral artery. In the second patient brain CT was normal, while cervical spine CT revealed C4-C5 dislocation with accompanying posterior sliding of C5, and a subdural haematoma at the C2-C3 level on the right. Cervical MRI showed dislocation with spinal cord dissection at the C4-C5 level, and a large ischemic right occipital brain lobe lesion that was ascribed to putative right vertebral artery thrombosis/dissection. Carotid and vertebral angiography revealed bilateral VAD at the C3-C5 level with distal reopacification by collateral perfusion.

Anticoagulant therapy was not administered due to coexisting contraindications (subarachnoid haemorrhage, hemorrhagic contusions, subdural hematoma). The level of consciousness increased step-wise in both patients. While the second patient suffered bilateral VAD, his recovery was more complete than that of the first patient.

In patients with brain and cervical trauma, the coexistence of cerebral lesions due to accompanying VAD is probable. MRI can prompt further investigation by depicting ischemia of vertebral artery-dependent areas. The impact of VAD largely depends on the efficiency of collateral flow to the affected parenchyma.

Maintaining of normal cerebral oxygenation is the main goal of intensive care of patients with severe head injury. It can be achieved by different methods. One of them is hyperoxya. In this study we investigated the influence of different fractions of inspired oxygen (FiO2) on cerebral oxygenation and intracranial pressure (ICP).

Two patients with traumatic brain injury (TBI) with Glasgow Coma Scale 7 on admission enrolled in the study. Patients had one-side lesions and underwent decompressive craniotomy. We compared FiO2 with ICP (n=30), cerebral oxymetry in non-lesioned hemisphere rSO2(nl) (n=15), oxygen partial pressure in cerebral tissue (PtiO2) in lesioned (les) (n=29) and nonlesioned (nl) hemisphere (n=29), PaO2 (n=27), jugular bulb saturation (SjO2) (n=26), O2 extraction ratio (O2ER) (n=26), arterio-venous O2 difference (AVDO2) (n=26) and lactate concentration in jugular bulb (Lac(v)) (n=26). Plasma osmolality, cardiac output, invasive mean arterial blood pressure, paCO2 and blood temperature were stable during investigation.

FiO2 changing from 1 to 0,3 leaded to decrease in PaO2 (M±SD) (402,6±67,9 vs 109,8±43,9 torr ((p<0,0001)), SjO2 (76,5±3% vs 70,6±2,8% (p<0,05)), rSO2(nl) (77,3±5% vs 66±2,8% (p<0,05)), PtiO2(les) (46,8±11,8 vs 19,6±4,4 torr (p<0,01)) and non-significant changes in PtiO2(nl) (26,2±17,2 vs 9,9±3,4 torr), Lac(v) (1,1±0,4 mmol/l vs 1,27±0,6 mmol/l), ICP (15,2±2,7 vs 14,2±4,9 torr), O2ER (0,24±0,03 vs 0,28±0,04) and AVDO2 (4,7±1,8 Vol% vs 1,8±1,8 Vol%).We found good correlation between FiO2 and PaO2 (r=0,89 (p<0,01)), SjO2 (r=0,63 (p<0,01)), rSO2(nl) (r=0,65 (p<0,01)), PtiO2(nl) (r=0,56 (p<0,01)) and PtiO2(les) (r=0,76 (p<0,01)).During comparing of different methods of cerebral oxygenation assessment we found good correlation between SjO2 and PtiO2(nl) (r=0,65 (p<0,05)) and no correlation between SjO2 and PtiO2(les) (r=0,39 (p=0,09)), rSO2(nl) and PtiO2(nl) (r=0,41 (p=0,27)), rSO2(nl) and PtiO2(les) (r=0,39 (p=0,3)).

FiO2 increasing is effective and quick method of cerebral oxygenation improving.ICP is not influenced by FiO2 changes.FiO2 must be noticed during interpretation of high levels of SjO2 and rSO2. Jugular oxymetry reflects the oxygenation mostly of the non-lesioned brain hemisphere. Cerebral oxygenation monitoring can be improved by combination of SjO2 and PtiO2 methods.

Nijboer J M M 1 , Van der Horst I C C 2 , Hendriks H G D 3 , Ten Duis H J 1 , Nijsten M W N 1 1 Surgery, 2 Cardiology, 3 Anesthesiology, University Medical Center Groningen, Groningen, Netherlands

There is a longstanding belief that in trauma patients hematocrit(Ht) is more sensitive than hemoglobin(Hb) in detecting blood loss. This association of Ht with trauma is reflected by numerous references in MEDLINE. We studied the relation between Hb and Ht in trauma patients.

Trauma patients with an ISS>15 from 1996 to 2004 were included. All blood samples taken during the first week in which Hb and Ht were both measured, were analysed.

In 678 patients (mean age 37 ± 23 yrs; 72% male) 2963 paired Hb and Ht values were available. The mean Hb was 6.39 ± 1.40 mmol/L with a range from 1.3 to 10.7 mmol/L. The mean Ht was 0.305 ± 0.07, ranging from 0.061 to 0.505. Hb and Ht had a Pearson R2 of 0.99 (Figure) .

In a large series of trauma patients Hb and Ht behaved as identical parameters. The idea that Ht is different from or superior to Hb is a misconception and there is no reason for determining both Hb and Ht in trauma patients.

Paramythiotou E 1 , Papakonstantinou K 1 , Tsirantonaki M 1 , Kalogeromitros A 1 , Noulas N 1 , Pedonomos M 1 , Apostolakou H 1 , Karabinis A 1 1 ICU, George Gennimatas General hospital, Athens, Greece INTRODUCTION. Propofol is often used as a sedative in ICU patients. Unfortunately large doses may be needed sometimes causing propofol infusion syndrome (PRIS). We are presenting a patient with this syndrome followed by manifestations compatible with a catastrophic antiphospholipid syndrome (CAPS).

A 14 year old female was admitted to our ICU with a multiple trauma. She had many skull fractures, a subarachnoid hemorrhage and a small acute subdural hematoma. She was put to sedation with propofol. Large propofol doses were used to keep her sedated (25 -30 ml/h of propofol infusion 2%) along with noradrenaline and corticosteroids to maintain a normal arter. pressure. Three days later she developed high fever, CPK rose to 75.000 µg/l and a multiple organ failure followed including renal and right heart failure. A CVVHD was immediately started. She was also put on broad spectrum antibiotics and the propofol infusion was interrupted. A week later her situation had become stable, she was free from vasoactive agents and her renal and cardiac functions were reestablished. The blood cultures taken did not prove the presence of bacteremia, though the simultaneous presence of an infection could not be excluded. Thirty -two days after her admission she presented a status epilepticus. A brain C/T and MRI were performed, revealing the presence of multiple hypodense areas not following a vessel distribution. An AntiCardiolipinAntibody titer IgG (1st 113 u, 2nd >130 u ) gave us the hint for a probable CAPS. After a combined therapy with plasma exchange and immunoglobulins she recovered and survived later on.

Propofol infusion is very popular in ICUs hospitalizing patients with cerebral injuries permitting physicians to perform regularly a neurological examination. Large propo-fol doses and concomitant use of corticosteroids and catecholamines with or without sepsis could precipitate PRIS as in our case. Our patient's condition was complicated by the neurological manifestations attributed to probable catastrophic antiphospholipid syndrome. The question aroused is if PRIS could have triggered such an autoimmune disorder.

CONCLUSION. Attention must be paid to propofol doses used for sedation of patients with craniocerebral injuries especially adolescents. Alternative sedation or combination with other sedative and/or analgesics must be considered.

Tsarenko S V 1 , Petrikov S S 1 , Huseynova K T 1 , Krylov V V 2 1 Neurosurgical ICU, 2 Neurosurgery, Sklifosovsky Scientific Research Institute of Emergency Medicine, Moscow, Russian Federation

Invasive measurement of the intracranial pressure (ICP) is known as the best method of intracranial hypertension evaluation. Unfortunately it is associated with high equipment costs and risk of infection complications. We compared non-invasive methods of intracranial hypertension assessment with invasive ICP measurement.

METHODS. 48 patients enrolled in the study (severe head injury (n=32), arterial aneurism rupture (n= 7), hemorrhagic stroke (n=7), arterio-venous malformation (n=2). Average age (M±SD) 44±16. M/F ratio was 35/13. All patients were operated (26 underwent decompressive craniotomy, 13 boneplastic craniotomy and 9 -insertion of ICP sensor only). All patients received invasive ICP monitoring (average time 4,8 ± 3 days). We used Codman intracranial pressure microsensors or ventricular ICP monitoring systems (Hanni-Set, Smith Medical). Average preoperative Glasgo Coma Scale (GCS) was 8,1±2,1. All patients had head CT scan and neurological examination on admission, and dynamically in postoperative period. We compared ICP values with CT scan data (volume of zones with high and low density, signs of lateral and axial dislocation), GCS and neurological signs of brain stem dislocation.

Analyses of all data showed correlation between ICP and GCS (r= -0,48; p<0,00001; n=109), neurological signs of brain stem dislocation (r=0,4; p<0,00001; n=109), volume of zones with high and low density (r=0,25; p=0,016; n=95) and lateral dislocation on head CT scan (r=0,24; p=0,016; n=101). Then ICP values obtained before the mass lesion evacuation were compared with preoperative head CT scan and neurological signs of brain stem dislocation. We found good correlation between ICP and signs of axial (r=0,59; p<0,00001; n=42) and lateral dislocation (r=0,43; p=0,004; n=42) on head CT scan. We did not find correlation between ICP values and GCS (r=-0,02; p=0,196; n=48), neurological signs of brain stem dislocation (r=0,27; p=0,07; n=42) and volume of zones with high and low density on CT scan (r=0,3; p=0,06; n=30).

We found that invasive ICP monitoring is the best method of intracranial hypertension assessment. Neurological examination or CT scan data can not reflect all cases of ICP changes but they can be used as screening methods of intracranial hypertension estimation.

Markogiannakis H 1 , Sanidas E 2 , Messaris E 1 , Tsiftsis D 2 1 1st Department of Propaedeutic Surgery, Hippocration Hospital, Athens Medical School, University of Athens, Athens, 2 Department of Surgical Oncology, Herakleion University Hospital, Herkleion Medical School, University of Crete, Herakleion, Greece

Nonoperative management (NOM) is considered to be the treatment of choice for carefully selected blunt hepatic trauma patients. The objective of this study is to identify and evaluate the factors that can safely predict NOM of these patients.

Our study is a retrospective analysis of Trauma Registry data of all 55 consecutive adult blunt hepatic trauma patients admitted in a Greek Level I Trauma Center over a 4-year period. Factors that were included in the analysis were: sex, age, mechanism of injury, initial vital signs, grade of liver injury, concomitant injuries, and injury scoring systems used for total injury severity estimation.

Nineteen patients (34%) were immediately operated, whereas 36 (66%) were initially selected for NOM. Concomitant abdominal, pelvic and spinal cord trauma, high Injury Severity Score (ISS), low International Classification of Diseases -9th revision Injury Severity Score (ICISS), and low Probability of survival (Ps) were predictive factors for operative management of these patients. Immediately operated patients suffered statistically significantly more frequently concomitant abdominal (84.2% vs 47.2%, p=0.004), pelvic (42.1% vs 16.7%, p=0.03), and spinal cord injuries (36.8% vs 2.8%, p=0.005) than conservatively treated patients. Additionally, immediately operated patients with blunt liver injury were significantly more severely totally injured than those treated with NOM as expressed by higher ISS (27.2±3.2 vs 19±1.5, p=0.01), lower ICISS (0.49±0.04 vs 0.74±0.03, p=0.003), and lower Ps (0.79±0.04 vs 0.93±0.02, p=0.005). Moreover, the percentage of patients that were admitted in the ICU and mortality rate were significantly lower in patients treated with NOM than those treated with immediate operation (47.2% vs 78.9%, p=0.002 and 5.5% vs 21%, p=0.03, respectively). Thirty-three patients that were initially selected for NOM were successfully treated conservatively; thus, the rate of success of NOM was 92%.

CONCLUSION. NOM of blunt hepatic trauma patients is safe and efficient resulting in significant reduction of ICU admission and mortality. Concomitant abdominal, pelvic and spinal cord trauma, ISS, ICISS, and Ps are predictive factors for operative or nonoperative management of these patients.

Ruler van O 1 , Lamme B 1 , Reitsma J B 2 , Gouma D J 1 , Boermeester M A 1 1 Surgery, 2 Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, Netherlands

The decision when to perform a relaparotomy for secondary peritonitis is largely subjective and experience-based. To date there is no reliable scoring system that aids the decisional process by predicting relaparotomy outcome. Our aim was to identify variables predictive of a positive outcome of relaparotomy in the acute phase of the disease.

The study population was derived from a retrospective cohort of secondary peritonitis patients(n=219). Patients with a positive relaparotomy (n=62) were compared to patients undergoing a negative relaparotomy (n=55) and patients undergoing an index laparotomy only (n=102). A prediction model was build from a logistic regression model by the addition of patient, peritonitis, operative and postoperative variables. A stepwise build-up of predictive models incorporating the chronology in which information is achieved in clinical practice was used. Variables entered were assessed on clinical judgment and statistical analysis. 

Accounting for chronology of information, postoperative variables are most predictive for positive relaparotomy. This implicates that information on the clinical course after the index laparotomy is required to predict who will need a relaparotomy. Further adjustment and external validation of this model and development of a prediction rule is needed in a prospective, cross-sectional series of patients with secondary peritonitis.

Schöniger-Hekele A 1 , Klingbacher E 2 , Hiesmayr M 2 1 Department of Cardiac Thoracic Vascular Anaesthesia and Intensive Care, 2 Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria

In general ICU-patients nasal carriage of Staphylococcus aureus was associated with a higher risk of developing staphylococcal infections and death. The aim of this study was to determine the impact of MSSA-colonisation on postoperative infections and LOS in elective cardiac surgery patients.

We prospectively collected all data for the analysis. The cohort consisted of 122 patients, that underwent routine preoperative nasal swab one week before surgery. Only patients with MRSA were treated topically with Mupirocin.

Before surgery 46 patients (37,7%) were identified as Staphylococcal aureus nasal carriers, while 62,3% were free of nasal colonization. Compared to the non-carriers the MSSA-carriers did not have a significant difference of the total and Staphylococcus aureus infection rate. Other indicators of infection and inflammation parameters(CRP, leukocytes)did not show significant differences. 

Data-mining searched publications from 8 common languages for randomised clinical trials that supplemented with IMPACT® before and/or after major elective surgery. Infectious complications, mortality, and hospital stay were primary outcomes.

Seventeen studies (n=2305) were analyzed, and 14 (n=2083) described patients undergoing elective GI surgery. Studies were conducted in 7 countries, however, the clinical effects of IMPACT® treatment were homogenous across the set of trials. IMPACT® use significantly reduced postoperative infections overall (p < 0.0001), and anastomotic leaks in GI surgical patients (p = 0.003). Furthermore, IMPACT® use shortened the average hospital stay by 2.5 d (p < 0.0001), and a trend was observed towards reduced risk of mortality. Considerable differences in country-specific operation modalities were noted. In a Chinese trial, nosocomial infection prevalence was unusually low, 3% when supplemented with a control formula vs. 0% with IMPACT®. In all other trials, nosocomial rates were 18-67% with control feeds vs. 3-38% with IMPACT®. In Germany and Switzerland, hospital stays were extended for GI surgical patients. There, average stays were 20 d for the IMPACT® group and 30 d for the control group vs. 11 d and 13 d, respectively, in all other countries.

CONCLUSION. IMPACT® specialized nutrition support, as a component of infection control during surgery, is valuable for all methods practiced worldwide. 

To determine the incidence of nosocomial infection in critically ill patients with brain trauma.

It is a prospective study performed during 12 months of the patients with brain trauma admitted in a 24-beds medical-surgical ICU of a 650-beds university hospital. Infections were diagnosed according to CDC criteria. Infections were classified bassed on the onset moment as early onset and late onset: Early onset (EO) were those developed during the first 4 days of ICU-stay; and Late onset (LO) were those developed 5 days after ICU-admission. The statistical analysis was performed using SPSS 11.0 program. Continuous variables are reported as means and standard deviation, and categoric variables as percentages. 

Turkmen A 1 , Turgut N 1 , Altan A 1 , Medetoglu A 1 , Gökkaya S 1 1 Department of Anaesthesiology and Reanimation, Okmeydani Training Hospital, Istanbul, Turkey

Airway suctioning is classically performed with disconnection of the patient from the ventilator and the introduction of suction catheter into endotracheal tube. Several authors suggest that application of closed suction catheters (CSC)in intubated patients for more than 24 h is safe and can reduce the costs associated with mechanical ventilation. Therefore, we evaluated the possible role of prolonged application of CSC in causing enhanced colonization of the lower respiratory tract.

The prospective, randomized study included 39 mechanically ventilated patients. The CSC tips, tracheobronchial aspirates of each patient were examined for microbial growth. We analyzed the data with the Student's t test for paired samples and Fisher Exact test.

Application for 72 h significantly enhanced the microbial growth on the CSC tips (TABLE) . 

To decrease VAP incidence in the ICU is necessary to implement infection control policies. Nevertheless that implementation is not always simple and requires effort by the ICU workers. New infection control policies were applied in our ICU in 2003. Those recommendations were adapted from the published guidelines concerning the prevention of VAP and adapted to our ICU. Particular concern was made on the handwashing and contact isolation precautions. To analysed the impact of these measures the incidence of VAP was analysed before and after that implementation.

Prospective study of all patients admitted in the ICU for more than 24 hours, between 2002 and 2004. Patients data collected included the number of ventilation days, the date of the VAP diagnosis with or without microbiological confirmation. The VAP diagnosis was made by new radiographic infiltrate for at least 48 h and at least two of the following criteria: fever > 38.5°C or < 35.0°C; leukocytes > 10,000/µL or < 3,500/µL, purulent sputum, or isolation of pathogenic bacteria from lower respiratory tract. The microbiological samples were collected by proximal or distal bronchial aspirated.

The VAP diagnosis was made on the patients receiving mechanical ventilation, 113, 164 and 166 patients during the study period. 

Theodorakopoulou M 1 , Lignos M 1 , Diamantakis A 2 , Zoupa P 2 , Stelliou A 2 , Karabekiou I 2 , Armaganidis A 1 1 ICU, 2 Nursing icu, Attiko University Hospital, Athens, Greece

Hand hygiene is the most important action to control spread of nosocomial infections.Hand washing compliance among health care workers remains low.The objective of this study was to assess compliance of hygiene in our ICU.

A 3 month prospective study on a 5 bed ICU of a university hospital.Antiseptic solution were placed at the bottom side of each bed and one hand washing facility exists within the unit.3 well instructed observers recorded opportunities of hand washing, and actual performance of hand washing or hand disinfection. Observation time was set at 2 hrs. It was performed on morning and afternoon shifts all days of the week.Every observer monitored 2 beds.The staff was not informed of the study.Staff was classified according to their work status (doctors, nurses etc.).

. 360 hrs of observations were recorded in 180 sessions. A total of 7880 opportunities for hand hygiene were observed. See Table 1 for hand washing opportunities and actual hand washing compliance among the staff. The average hand washing opportunities were 8.76 opp/pt/hr and the average actual hand washing was 5.10 act.wash/pt/hr.Hand washing compliance was similar for doctors,nurses and nursing assistants.Medics, physiotherap, and visiting doctors showed significant difference in actual hand washing compliance.The overall compliance rate was 4592/7880 (58.3%). 

It is a prospective study during 30 months of the patients admitted in ICU during 24 hours o more. Were taken throat swab, tracheal aspirate and urine on admission and twice weekly.

Were registered the colonization and infection by pseudomonas. The infections were diagnosed according to CDC criteria. The infections were classified bassed on thorat flora as: Primary endogenous (PE) when they were caused by germs that were already colonizing the throat on the ICU admission; Secondary endogenous (SE) when they were caused by germs that were not colonizing the throat on the ICU admission but were acquired during the stay in ICU; Exogenous (EX) when they were caused by germs which were not colonizing the throat. The infections were classified bassed on the onset moment as: Early onset (EO) were those developed during the first 4 days of ICU-stay; Late onset (LO) were those developed 5 days after ICU-admission. CONCLUSION. In our serie, the most of infections caused by pseudomonas were pneumonias, had a late onset and were secundary endogenous. 

Prolonged critical illness is characterized by feeding-resistant wasting of lean body mass. This catabolic state is due to an impaired activity of the thyroid and GH axes, since restoration of physiological levels of IGF-1 and thyroid hormones by continuous infusion of TRH+GHRP-2 is capable to induce anabolism [1] . Whereas the cause of hyposomatropism during prolonged critical illness is mainly located within the hypothalamus, concomitant changes in peripheral thyroid hormone metabolism are involved in the low T3 syndrome. The aim of this study was to examine these peripheral changes into more detail in an animal model of prolonged critical [2] .

Burn-injured, parenterally fed, New Zealand White rabbits (4 x n=8) were randomized to receive 4-d treatment with saline, TRH (60 \mug/kg/h) ,GHRP-2 (60 \mug/kg/h), or TRH+GHRP-2. Blood glucose was maintained below 180 mg/dL by continuous insulin infusion. Endocrine and biochemical organ system markers were studied. Animals were sacrificed for assay of deiodinase activity in snap frozen samples.

Infusion of TRH+GHRP-2 and TRH increased hepatic activity of type 1 deiodinase (D1) versus the saline group (P= 0.02 and 0.1 resp.), restoring TT3 levels within physiological range. Only combined infusion of TRH+GHRP-2 induced a significant increase in IGF-1 levels into the range observed in healthy rabbits. Administration of TRH alone resulted in a further decline of serum IGF-1 levels.

(1) Infusion of GHRP-2+TRH is able to restore peripheral thyroid hormone and serum IGF-1 levels within the physiological range, mainly due to re-activation of D1.

(2) D1 activity during critical illness is regulated via alterations in the thyroid axis.

(3) Reactivation of the thyroid axis in prolonged critical illness, without concomitant reactivation of the GH-axis, might worsen catabolism. and Strong Ion Difference (SID) approach, to our knowledge is still not available a systematic comparison. The approach to SID may be more or less rigorous: we can calculate the apparent SID (the difference between strong ions, SIDapp) or the effective SID (the sum of weak anions, SIDeff); moreover, when computing the SID variation (ÄSID) the reference value of SID can be considered fixed (40 mEq/l) or variable (the expected SID) as a function of total non volatile weak acids concentration. The aim of this study was to suggest how the computation of ÄSID should be sophisticated in order to obtain a good correspondence with BE in ICU patients. CONCLUSION. The rigorous computation of the corrected ÄSID seems to be necessary in the ICU population, because of non-neglectable concentration of unmeasured anions and of diffuse and serious hypoalbuminemia in these patients. Moreover, ÄSID is a measure of plasma buffer base variation, so it should be compared with an equivalent BE formulation, that is plasma BE.

Leditschke I A 1 , Southcott E 2 , Gissane J 1 , Enslin A 1 , Hickman P E 3 , Potter J M 3 1 Intensive Care Unit, 2 ACT Pathology, 3 Australian National University Medical School, The Canberra Hospital, Canberra, Australia

Recently it has been shown that total plasma cortisol measured by immunoassay may not detect elevations in plasma free cortisol in hypoproteinaemic critically ill patients(1). We investigated the relationship between urinary free cortisol and total serum cortisol in a group of critically ill patients.

METHODS. 5 patients were studied within 24 hours of ICU admission. Patients with neurotrauma or oliguria were excluded. Hourly total plasma cortisol and 4-hourly urinary cortisol were measured for 24 hours using routine immunoassay for the plasma samples and high performance liquid chromatography for the urine samples. Statistical analysis was performed using Graphpad Instat software.

Summary results for total plasma cortisol at the mid point of the urine collection and urinary free cortisol are shown in Table 1 . Using a non parametric (Spearman r) test of correlation, urinary free cortisol was found to correlate moderately well with total plasma cortisol; Spearman r = 0.7063, 95% confidence intervals 0.4533 to 0.8533, p 

To further investigate this topic, we conducted a prospective study of patients admitted to a general adult ICU. Morning blood samples were taken within 24 hours of ICU admission to measure plasma cortisol, corticotropin (ACTH), dehydroepiandrosterone sulphate (DHEAS), free thyroxine (fT4), tri-iodothyronine (T3), thyroid-stimulating hormone (TSH) and prolactin (PRL).

. 150 critically ill patients (120 males) with diverse underlying diagnoses, having a median age of 50 years (range 17-84 years) were enrolled. Their median APACHE II and SOFA scores were 11 and 6 respectively. There were no differences between survivors and non-survivors in plasma cortisol, ACTH, fT4, and T3. In contrast, survivors had higher median values for TSH (0.70 mcIU/l vs. 0.48 mcIU/l, p=0.04), DHEAS (1638 ng/dl vs. 995 ng/dl, p=0.04) and PRL (13 ng/ml vs. 9 ng/ml, p=0.03) compared to non-survivors.

Our data indicate that hormone concentrations differ between survivors and nonsurvivors acutely ill patients. Further studies are required to investigate whether endocrine measurements are helpful in predicting clinical outcome.

Mekontso-Dessap A 1 , Lellouche N 2 , Brochard L 1 , Brun-Buisson C 1 , Dubois-Randé J 2 1 Medical Intensive Care Unit, 2 Coronary Care Unit, Henri Mondor Hospital, Créteil, France

Relative adrenal insufficiency has been demonstrated to be associated with increased mortality in septic shock patients. Cardiogenic shock (CS) induces a stress response involving the adrenal cortex, but functional hypoadrenalism has never been investigated in this setting. The aim of the present study was to prospectively evaluate adrenal function in patients admitted to intensive and coronary care unit for cardiogenic shock.

METHODS. 40 consecutive patients (35 men) admitted for CS, with a mean age of 66 ± 16 years were included. Patients submitted to any steroid therapy or etomidate were excluded. 4 patients needed mechanical ventilation and 4 patients were equipped with an intraaortic balloon pump. Causes of CS included acute myocardial infarction (n=14), cardiomyopathy (n=13), arrrythmia (n=3), and others (n=10). Patients underwent a high dose short corticotrophin test (SCT) and relative adrenocortical insufficiency (nonresponders) was defined by a rise in cortisol less than 90 microg/L after stimulation.

. 13 (32.5%) patients were classified as nonresponders and 27 (67.5%) as responders. No significant difference was evidenced between responders and nonresponders concerning clinical characteristics and outcome (Table 1) . 

In contrast to international guidelines, it is common practice in some ICU's in the Netherlands to treat septic critically ill patients with high dose dexamethason on admission. Increase in mortality might be associated with the induction of adrenal failure. We compared adrenal function in patients with high, single dose (100 mg) dexamethason (dexa) with patients receiving no steroids during the study period.

We studied ventilated patients with MODS admitted for emergency reasons. Excluded were patients after elective surgery, with an expected short stay or steroid use. Cortisol (Co) was measured day 1 and 4 at 6.00 AM. At day 4 the Co response 30 and 60 minutes after 250 mcgr synthetic ACTH was determined. The patients did not receive corticosteroids, other than dexa on admission if they were included in the dexa+ group.

All 25/25 patients (100%) with dexa had baseline Co levels on day 4 below 0.69 mmol/l, compared to 7/8 (88%) in the control group (NS). However, adequate Co response (rise in Co of more than 0.25 mmol/l, 60 min after 250 mcg synthetic ACTH iv) was 100% in patients with dexa and 50% (4/8) for patients without dexa. In a case control analysis APACHE score was not a determinant. 

Neutrophils are believed to occupy a prominent position in the pathogenesis of organ failure that arises from the systemic inflammatory response syndrome (SIRS). The epidermal growth factor-like 7-transmembrane (EGF-TM7) family of molecules are a group of glycoproteins whose structure suggests a dual role in cell adhesion and intracellular signaling. Two members of this family, hCD97 and the EGF molecule-containing mucin-like hormone receptor (EMR2) are expressed on human monocytes and macrophages. The aim of this study was to examine the expression of hCD97 and EMR2 on neutrophils from patients with SIRS and ascertain if they were associated with sepsis or the clinical course of disease. 

We analysed erythropoietin, interleukin-3 (IL-3), interleukin-6 (IL-6), and interleukin-12p70 (IL-12p70) in the blood of 301 patients (controls n=250) with circulating NRBCs.

In-hospital mortality of NRBC-negative and NRBC-positive patients was 1.2% (3/250) and 22.6% (68/301; P<0.001), respectively. In-hospital mortality increased with the NRBC concentration ( Figure 1 ). 85.7% (12/14) of patients with more than 500 NRBCs/µl in the peripheral blood died. Multiple logistic regression revealed a significant association between the appearance of NRBCs in the blood and age (odds ratio 1.019; 1.009-1.030; P<0.001), erythropoietin (odds ratio 1.017; 1.007-1.027; P<0.001), IL-3 (odds ratio 1.293; 1.180-1.417; P<0.001), and IL-6 (odds ratio 1.138; 1.016-1.275; P<0.05), respectively. Gender and IL-12p70 were not significantly associated with the appearance of NRBCs in the blood To estimate the red blood cell production in the bone marrow the increase in the reticulocyte concentration in blood was measured. The reticulocyte concentration in NRBC-positive patients was 69±2/nl, being significantly higher than in NRBC-negative patients (60±2/nl; P<0.01). Furthermore, in the course of hospitalization the increase in the reticulocyte concentration in NRBC-positive patients was significantly higher (24±2/nl; n=224) than in NRBC-negative patients (11±3/nl; n=126; P<0.01).

CONCLUSION. An association of the appearance of NRBCs were found with increased levels of erythropoietin, IL-3, and IL-6, respectively. Therefore, NRBCs in the circulation could be an indicator which summarises hypoxic and inflammatory injuries. Thus, generally the appearance of NRBCs in blood is a valid parameter to identify patients at high mortal risk. Moreover, the increased number of reticulocytes in the blood of NRBC-positive patients may indicate that the appearance of NRBCs is not associated with disturbed bone marrow function as far as the erythropoiesis is concerned.

Grant acknowledgement. Sysmex Europe Corp. 

Macrophage migration inhibitory factor (MIF) was originally described as a Tlymphocyte derived cytokine that inhibits the migration of the macrophages at the site of inflammation(1).Subsequently it was also identified as a stress induced hormone released from the anterior lobe of the pituitary in response to some pro-inflammatory stimuli (2) .The glucocorticoid counterbalancing proinflammatory actions of MIF have been thoroughly documented.

Our study compared postoperative changes in serum MIF levels of patients undergoing bowel and liver resections. 28 patients were recruited in our descriptive study.Patients in the first group (A) underwent only hepatic resection without surgically opening the bowel. The other group (B) comprised of patients who have had bowel resection with surgical bowel opening. MIF, IL-1β, IL-8, prealbumin, albumin, α fibrinogen and C-reactive protein levels were measured before and immediately after the operations and also for three consecutive days. To evaluate organ functions the MODS-test was used. Statistical analysis was carried out by means of SPSS for Windows, applying the Mann-Whitney test.

A higher level of MIF (4505 pg/ml /1489-7148/) was found in group A as compared to that of group B immediately after the operations, that proved to be significant. Other parameters monitored in this study were not statistically different between the two sets of patients.

Higher elevations in MIF levels with liver resections compared to bowel resections might be attributable to MIF release from damaged liver cells. The presumably minimal endotoxin exposure during the bowel surgery was either insufficient or inefficient to induce relevant MIF elevations in our patients. 

Chromogranins are prohormones, precursors of numerous peptides displaying various biological activities. Some even have antifungal and antibacterial properties. As catecholamines, they result from secretory granules of the chromaffin cells in adrenal medulla. Aims of the study: to analyze the physiological secretion of CGB and its derivatives in healthy subjects; and to compare its characteristics with those of patients undergoing the stress of septic shock.

METHODS. 4 healthy voluntaries and 3 patients with septic shock were included. Samples of serums were taken at several times to establish a kinetic of secretion. Serum proteins were studied by mono and two-dimensional electrophoresis with anti-CGB specific immunodetection, using polyclonal antibodies; and by chromatography (RP-HPLC) with specific immuno-detection of each eluted sample, and then by mass spectrometry (MALDI TOF) and antimicrobial tests.

The healthy subjects' electrophoretic profiles are identical. We did not find fragments of molecular weights (MW) lower than 20 kDa. But patients' profiles show a great number of short fragments. There were no qualitative modifications of monodimensional electrophoresis profile over time in healthy subjects, whereas for patients, we observed the disappearance of a 37 kDa band and of short fragments of weak MW. This modification occurs 4 hours after the end of the infusion of norepinephrine. RP-HPLC chromatograms show strong similarities between controls and patients. However the peaks of albumin (HSA) and transferrin are higher in healthy controls. For the whole population, we observe at the end of the chromatogram, 2 immonreactive peaks: the peak of HSA (immunoreactive zone which corresponds to an association of CGB and HSA); and an isolated peak after HSA peak.

CONCLUSION. This is the first study of CGB secretion in human serum. We show noticeable differences between healthy controls and patients with septic shock. The clinical improvement of a patient corresponds to the modifications of the electrophoretic profile (backwards to the profile of a healthy control). For the first time, an association is also shown between the HSA and the CGB. In septic shock, the free CGB seems to be more abundant. 

Patients with septic shock or non infectious SIRS within 48 hours of admission were included and allocated to the following groups according to usual criteria : group 1 (surgical patients with septic shock), group 2 (surgical patients with SIRS), group 3 (medical patients with septic shock) and group 4 (medical patients with SIRS). PCT at study entry was compared between groups 1 and 2 and between groups 3 and 4 to determine the diagnostic cutoff value for septic shock in surgical and in medical patients respectively. 

Identifying sepsis in intensive care unit (ICU) can be difficult. We assessed the utility of the biphasic aPTT waveform (BPW) and procalcitonin (PCT) determinations, alone or combined, for the diagnosis of sepsis in ICU patients.

This prospective observational study included 200 adult patients admitted to a 31-bed university hospital medical-surgical ICU during a 3-month period. The presence of sepsis, severe sepsis or septic shock was determined on the day of admission by standard clinical and laboratory criteria, without knowledge of aPTT or PCT. aPTT transmittance waveforms (bioMérieux MDA System) and PCT levels (BRAHMS PCT Lumitest) were determined on the day of admission. Threshold values for the prediction of any form of sepsis were assessed by receiver operating characteristic (ROC) curves. The BPW was detected when the slope of the pre-coagulation phase (slope_1) exceeded the threshold value (i.e., became more negative). 

The combined assessment of aPTT transmittance waveforms and PCT levels provides a rapid means of identifying septic patients on ICU admission.

Van Nuffelen M 1 , Abraham A 1 , Zakariah A 1 , Vincent J L 1 1 Intensive care medecine, Erasme University Hospital, Brussels, Belgium

Both C-reactive protein (CRP) and procalcitonin (PCT) concentrations have been proposed to monitor sepsis in acutely ill patients. The aim of this study was to study their time course in septic ICU patients.

The study included 97 infectious episodes (mean age: 60 years, ratio M/F: 2/1), as defined by standard CDC criteria. Patients were divided into two groups, depending on their evolution: favorable (clinical and white blood cell count) or unfavorable (need for additional procedure and/or change in antibiotic regimen). CRP was measured daily by direct immunoturbimetry and PCT by immuno luminometric assay.

and PCT were as follows(median values): where Day 0 represents the day where antibiotics were started.

CONCLUSION. CRP and PCT kinetics in septic patients show no significant trend in patients who respond favorably to therapy. However, an increase in these variables indicates a poor response.

Percutaneous tracheotomy (PT) is frequent in the ICU to help wean patients from MV. We compared the effectiveness and airway management of laryngeal mask-airway (LMA) vs endotracheal intubation (EI)

We included 40 consecutive intubated adult patients in the ICU who required PT, randomized into two groups of 20. One group had a ProSeal LMA and the other underwent laryngoscope-assisted partial withdrawal of the endotracheal tube. Ventilator settings in both groups were: volume-control ventilation, FiO2 1, minute volume 8.8 l, PEEP 0. Arterial blood gas pressure was measured before the start of each PT and before insertion of the tracheotomy tube. Data were recorded concerning the duration of the procedure from commencing airway manipulation to insertion of tracheotomy tube and airway complications RESULTS. 67% of patients were men (median age 55 years). Reasons for tracheotomy were a low level of consciousness(48%), lung disease (25%), neuromuscular disease (20%) and airway obstruction (7%). No significant changes were seen in duration, pH, p02 or pC02. Complications included six accidental extubation, four tube cuff tears, four guidewire bends and four difficulty to insert the tracheotomy tube. Three patients planned for LMA required EI because of impossibility to place correctly the Pro-Seal laryngeal mask-airway. No other complications arose in this group 

The differential diagnosis between sepsis and SIRS is of considerable importance in burn patients. Delay in the initial adequate treatment increases the mortality rate. The aim of this study was to assess whether plasma Procalcitonin (PCT) level was related to sepsis, burn size and organ failure in severely burned patients over the entire clinical course.

METHODS. Forty one patients, mean age 53 ± 23 (SD), (range 18-80 year), mean burn size 43.7 ± 22 (SD) % of body surface area (BSA), (range 18% -95 % BSA) were included in our study. All patients were classified daily in one of the following three categories: negative, SIRS, sepsis according to the definitions of the ACCP/SCCM. A total of 227 patient days were evaluated: negative (n: 162), SIRS (n: 28), sepsis (n: 37). Measurement of PCT levels and evaluation of organ function by SOFA score were performed daily until discharge from ICU.

Admission PCT levels were significantly higher in patients with burn size >60% of BSA than in those with burn of less than 60% of BSA (0.57ng/ml vs 2.6 ng/ml, p=0.01). PCT plasma concentrations differed among the three diagnostic classes and were higher in sepsis than in SIRS (  Table 1) . A statistically significant correlation was observed between PCT levels and SOFA score (r= 0.49, p<0.001 (Pearson' bivariate correlation)). 

The optimal timing of tracheotomy in critically ill patients requiring prolonged mechanical ventilation (MV) is debated. Recent studies suggest that early tracheotomy could substantially reduce both infectious morbidity and mortality. In a prospective, randomized, study we compared early tracheotomy with prolonged endotracheal intubation in ICU patients needing prolonged ventilatory support.

Patients projected to need ventilatory support for > 7 days were prospectively randomized to either early (open or percutaneous) tracheotomy within 4 days (ET) or prolonged intubation (PI) with or without delayed tracheostomy. The primary end-points were: 28 days mortality and cumulated incidence of nosocomial pneumonia, and number of ventilatory free days between day 1 and 28. Time in the ICU and on MV, 60 days mortality, number of septic episodes, accidental extubation and amount of sedation were recorded as secondary end-points. A sample size of 470 patients was determined for a reduction of the 28 days mortality from 45% to 32%¨(two-sided, power=0.8).

The study was prematurely closed because of poor accrual, after 123 patients (ET=61, PI=62)have been included. No difference was found between the 2 groups for any of the primary (Table 1 ) or secondary end-points. In addition, laryngeal or tracheal damage and time for resuming oral nutrition did not differ between the 2 groups. 

Early PDT has several advantages when long-term mechanical ventilation is adamant. However, in patients suffering from TBI, one major concern are increased intracranial pressures (ICP´s). During PDT, decrease of venous return and hypercapnia might seriously comprise ICP. Therefore, changes in ICP´s during videobronchoscopic guided PDT were measured.

METHODS. 40 patient with TBI,treated at our neurosurgical intensive care unit, required long-term (> 15 days) mechanical ventilation due to intracranial lesions. Indication and feasibility to perform PDT were evaluated in patients treated with severe TBI from the day 1 after admission on a daily routine. ICP levels below 20 mmHg (over at least 6 hours) without extended ICP treatment and no ICP increase > 15 mmHg during neck extension was considered to be a safe timepoint for PDT. Videobronchoscopic guided, single-step PDT with modified Ciaglia technique (Blue Rhino, Cook, Germany) was performed in 38 patients, in two patients PDT had do be aborted for anatomic reasons.

As operation time we defined begin of videobronchoscopy until the intra-tracheal position of the tracheostoma was confirmed. ICP´s were recorded either through intraparenchymal catheters (n= 14) or by external ventricular catheters (n= 24). METHODS. An anonymous questionnaire was distributed among Croatian anaesthesiologists at three universities (Zagreb, Split, Rieka) and during two anaesthesia meetings (Split, Dubrovnik) between Sept. 2003 and May 2004.

. 152 completed forms were returned which was 31% of the 450 anaesthesiologists in Croatia. Male and female respondents were 37% and 63%, respectively, with a mean age of 42.4 years. They had been practicing anesthesia from 1 to 32 years with 91% practicing in an academic center, and 9% in a community hospital. 51% completed a difficult airway course, receiving training at their hospital or at a meeting such as the European Society of Anaesthesiology. Per respondent per year, an average of 975 anesthetics were performed, with 638 patients having endotracheal intubation. The most frequently preferred laryngoscope blade was Macintosh (75%) followed by Miller (21%) and McCoy (4%). 83% indicated they rarely failed an intubation using a conventional laryngoscope. In difficult airway situations, following laryngoscopy, the technique of choice was the laryngeal mask airway followed by the gum elastic bougie. For anticipated difficult intubations, 54% performed sedated awake intubation, and 29% used the flexible bronchoscope. While the ASA difficult airway algorithm was used by 42% of respondents, 25% stated that they used an internally developed difficult airway protocol.

Croatia. Laryngoscopy and sedated awake intubation are used more frequently than fiberoptic bronchoscopy. The ASA difficult airway algorithm was used by 42% of the anaesthesiologists surveyed. 

In a randomized crossover trial, 25 special forces (sf)-medics of the Royal Netherlands Army and 19 residents in anesthesiology performed cricothyrotomies using two different emergency airway devices on larynges from freshly slaughtered pigs (1) . We compared the Quicktrach with the Portex Emergency Cricothyroidotomy Kit. All data were analyzed using SPPS version 11.0 (Wilcoxon test for non-normal distributed 2-paired comparison and McNemar test for nominal values).

The Quicktrach-technique was done significant faster than the Portex-technique in both groups. Intratracheal placement of the cannula was achieved by 14 (56%) sf-medics and 12 (63%) residents using the Portex-technique and using the Quicktrach-technique by 18 (72%) sf-medics and 15 (79%) residents. 

Despite the fact that it was a procedure performed in very critically ill patients, tracheostomy was associated with very few minor complications in this sample. We hipothetized that this low rate of complications is due in part to the very high expertise of the operators involved in the realization of conventional tracheostomies in the two centers.

Grant acknowledgement. The authors are indebted with Dr. Ederlon A. C. Rezende for his support and suggestions.

Kiessling A H 1 , Isgro F 1 , Skuras J 1 , Lehmann A 2 , Pieper S 2 , Saggau W 1 1 Klinikum Ludwigshafen, Cardiac Surgery, 2 Klinikum Ludwigshafen, Anaesthesiology, Ludwigshafen, Germany

Tracheotomies are routinely performed for severely ill patients with respiratory failure. The procedure facilitates the weaning procedures by reducing dead space and decreasing airway resistance, by improving secretion clearance and by decreasing the risk of aspiration. This intervention is correlated with a poor survival rate. The aim of the investigation was the evaluation of the quality of life scores (QOF) and outcome after cardiac surgical procedures.

The retrospective, non-randomized follow up study was performed in a single surgical intensive care unit in 49 patients after cardiac procedures and surgical tracheotomy. Preoperative data and items were collected and outcomes analyzed after a mean follow up period of 2.9 years. A written questionnaire for the documentation of the SF 36 score and Beck depression scale were used. In addition to the test battery, healing outcome and vocal function were components of the questioning. 

Overinflation of the endotracheal tube cuff (> 25 mmHg) may cause tracheal damage and complications such as tracheal stenosis and tracheo-oesophageal fistula. We have surveyed the practice of tracheal cuff pressure measurement in our medical-surgical intensive care unit (ICU) and evaluate the impact of a regular cuff pressure monitoring program (CPMP) on reducing cuff overinflation.

Cuff pressure have been evaluated over three periods (P1= before CPMP, P2 = 3 months after CPMP and P3 = 3 years after CPMP) obtained in 100 measurements in 35-40 patients each period. The CPMP consists of regular cuff pressure monitoring twice a day.

Comparing to the first period, mean cuff-pressure decreased in the second period from 42±22mmHg to 26±13mmHg (p< 0.001) and the rate of overinflated cuffs from 77% to 24% (p< 0.001). In the third period, mean pressure was in the normal range (21±19 mmHg) but there was a significant increase in underinflated cuffs. However, in these patients, the operator hasn't noticed any leakage around the tube cuffs.

A regular cuff pressure monitoring program can reduce significantly the overinflation of tracheal cuffs in ICU and this may lead to prevent subsequent complications. ICU medical stuff may also maintain this protocol by a regular education of the nurse team in order to always keep endotracheal tube cuff pressures in the normal range preventing over (tracheal damage) and underinflation side effects (nosocomial pneumonia). Further studies are needed to evaluate this educational procedure on the outcome of the ICU patients. 

Forty-three patients (27 men, 16 women) with a mean age of 54.8 and a mean simplified acute physiologic score (SAPS) II of 49.3 were studied. Three patients were excluded because of insufficient data. TS was done because of traumatic brain injury with persistent Glasgow Coma score <8 (nineteen patients), unsuccessful weaning -failure of spontaneous breathing trial in 2 or more occasions (8 patients), hypoxic encephalopathy (6 patients) and prolonged invasive ventilation (6 patients). In the subgroup of 8 patients with unsuccessful weaning, spontaneous breathing could be achieved in seven patients by day 1 to day 7 (mean of 3.0 days) after TS. In 24 patients, TS has been considered an adjunctive intervention for the weaning process, and in these patients, spontaneous breathing was achieved in 17 patients and BiPAP ventilation in 3 patients. Thirty nine patients could be discharged from ICU (mean of 8.1 days after TS) in spontaneous breathing (36 patients) or BiPAP ventilation (3 patients). Mortality analysis revealed a total of 18 deaths (four in the ICU, 9 during hospital stay and 5 after hospital discharge at six months). In patients with hypoxic encephalopathy (6), five deaths were observed during hospital stay. Complication rate was low, with local haemorrhage in seven patients.

Our study revealed that TS was useful as an adjunctive therapy in the weaning process in the majority of patients and could reduce ICU stay; however, the subgroup of patients with hypoxic encephalopathy did not benefit from TS and should be considered for alternative strategies of airway protection.

Zgoda 

We report a prospective case series of 10 successful percutaneous tracheostomy procedures in the critically ill without complication. The balloon-tracheostomy tube apparatus (Image 1) was placed overwire then inflated to form the stoma, then deflated. The tracheostomy tube followed the deflated balloon into the airway. Almost no anterior tracheal compression took place. The average procedure time from puncture to tube placement was 4-6 minutes.

Ten ICU patients underwent BFPT. Six of the 10 patients had a successful tube placement after only 1 balloon dilation. The rest had successful tracheostomy placement after a second dilation. One of these 10 patients had a previous tracheostomy and the procedure was successful with 2 balloon dilation attempts at the site of the previous tracheostomy. Two were coagulopathic with INR>2 and/or platelet count(s) of less than 50K. The average estimated blood loss was less than 2mL. One patient had an obvious tracheal ring fracture without immediate clinical significance. There was no posterior tracheal wall damage, no pneumothorax, and no obvious damage to the anterior neck.

Thus far, there have been 10 consecutive tracheostomy tubes placed without bleeding complications, or damage to the posterior tracheal wall but more study is needed. BFPT is an easy and effective means of placing an elective tracheostomy tube at the bedside in the ICU. 

Despite surgical percutaneous emphysema is a recognised complication following percutaneous tracheostomy [1] ,it is not usually reported with a fenestrated trachesotomy tube as the direct cause [2] .The rationale to use a fenestrated tube when performing percutaneous tracheostomy is to eliminate the need to change the tube when the patient is weaned from mechanical ventilation.

Report of a cluster of complications associated with fenestrated tracheostomy tubes placed percutaneously. In our trust (3 hospitals) within a 4 week period 8 patients developed subcutaneous emphysema (one with an associated pneumothorax). The cases were performed by experienced doctors. All using Portex Blue Rhino kits, with the insertion of Tracoe-Twist fenestrated tracheostomy tubes (using the non-fenestrated inner cannula); Bronchoscopic guidance was used in all of the cases.We also have performed a bench top study on the fenestrated tubes to find the source of leak.

Eight patients developed subcutaneous emphysema (one with an associated pneumothorax).The emphysema was immediate in some, but only becoming apparent several hours after insertion in the majority.In at least two,the emphysema was so extensive that it compromised the patients' airway making exchanging the tracheostomy impossible and oral endotracheal intubation very difficult. Fortunately there were no directly attributable deaths or hypoxic injuries. The bench top study revealed air can track between the inner and outer cannulae at quite low pressures.

Surgical percutaneous emphysema is a complication following percutaneous tracheostomy using fenesterated tubes which can lead to pneumothorax and airway compromise.It seems that the fenestrations can remain in the pre-tracheal fascia with air tracking between the inner and outer cannula leading to the development of subcutaneous emphysema.We have now changed our practice to insert only non-fenestrated tubes for percutaneous tracheostomies. 

Therapeutic hypothermia (TH) improves outcome after cardiac arrest (CA) due to ventricular fibrillation (VF). However, due to lack of protocols and to technical difficulties inherent to its practical application, this treatment has not been widely implemented in daily practice. We evaluated whether TH could be effectively introduced in ICU practice and assessed its impact on patient outcome.

We retrospectively analyzed 110 comatose patients resuscitated from out-of-hospital CA due to VF and non-VF rhythms (asystole or pulseless electrical activity In patients with circulatory shock before initiating the treatment, TH was also beneficial (4/10 patients had good outcome vs 0/9 patients treated with SR, p=0.03). In contrast, TH had no impact on the outcome of survivors of CA due non-VF rhythms (2/12 patients in the TH group survived with good neurological outcome vs 1/12 in the SR group).

CONCLUSION. Therapeutic hypothermia can be safely and effeciently introduced in ICU practice for the treatment of all comatose patients resuscitated from cardiac arrest with a major impact on the outcome of patients resuscitated from CA due to VF, independently from their hemodynamic status. In contrast, our data do not support the use of therapeutic hypothermia after cardiac arrest due to asystole or pulseless electrical activity. 

Lavery G G 1 , Hickland B 1 , Caddell P1, Dillon M 1 , Northern, Ireland Intensive Care Society Audit Group 1 1 Regional Intensive Care Unit, Royal Hospitals Trust, Belfast, United Kingdom

Since October 2000, a centralized service has facilitated the interhospital transfer (IHT) of over 1400 critically-ill adult patients using a standard ambulance and mobile ICU equipment. Quality of escort is an important factor in the transport of all potentially unstable patients (1, 2) and so all IHTs are performed by an experienced ICU team (1 doctor and 1 nurse) . The aim of this project was to assess the use and the quality of this service.

Information regarding the indications for, and conduct of, IHT was recorded prospectively for all patients transferred by the service over 1 yr (03/04-02/05). ICUs prospectively collected data including admission APACHE II score and ICU (and hospital) outcomes. All data were entered on a central database (MS Access). 

Molnar T 1 , Köszegi T 2 , Bogar L 1 , Szakmany T 1 1 Anesthesiology and Intensive Therapy, 2 Institute of Laboratory Medicine, University of Pecs, Pecs, Hungary

It has been proposed, that procalcitonin (PCT) might be used as a prognostic factor for outcome after cardiac arrest (1) . To date no studies addressed the question whether PCT levels are different after VF and PEA induced in-hospital cardiac arrest.

METHODS. 45 consecutive patients were studied following cardiac arrest. PCT levels were measured on ICU admission (T 0 ), then on the first (T 24 ) and third day (T 72 ) post-arrest. For statistical analysis Mann-Whitney U test and chi-square test were used with SPSS 11.5. Data are presented as median and interquartile range.

Out of the 45 patients 37 suffered PEA and 8 VF arrest. There was no significant difference between the groups regarding age, male/female ratio and anoxic time and time to ROSC. Mortality was 77% vs. 12.5% in the PEA and VF groups, respectively, p<0.01. Serum PCT levels were significantly higher in the PEA group (Table 1) . S100B levels did not differ significantly between the two groups. Serum PCT: 3.5(0.10-8.95) vs.0.9(0.33-1.86) and S100B:2.99(1.36-5.42) vs.1.19(0.19-2.33) were significantly higher at T 0 among non-survivors in the PEA group, p<0.05 respectively, whereas in the VF group no such difference was observed. CONCLUSION. Significantly lower inflammatory response was detected in patients initially in VF arrest, with significantly better survival compared to PEA arrest, although anoxic time and time to ROSC was similar in the two groups as reflected by nearly identical S100B levels. However, patients with PEA arrest often have long, undetected hypoxic period, which may trigger the release of inflammatory markers such as PCT. The significantly higher PCT and S100B values in the nonsurvivor group of PEA patients may indicate the potential prognostic value of such measurements. 

Horn J 1 , Zandbergen E J G 2 , Vos P E 3 , Verlooy P 4 , Van Dijk G W 5 , Vroom M B 1 , Hijdra A 6 1 IC, AMC, Amsterdam, 2 Neurology, Rijnstate, Arnhem, 3 Neurology, UMC, Nijmegen, 4 Neurology, OLVG, Amsterdam, 5 Neurology, UMCU, Utrecht, 6 Neurology, AMC, Amsterdam, Netherlands

After cardiopulmonary resuscitation (CPR) many patients develop post-anoxic encephalopathy (PAE) often accompanied by myoclonic seizures or epilepsy.(1,2)Treatment is often difficult, several strategies have been advocated. (3, 4) In this study we investigated the medication used in these patients.

From the database of the Propac study, a prospective cohort study in PAE patients, we selected patients with myoclonic or epileptic seizures. Medication used to treat these conditions was extracted from the records.

In 188 patients, 97 showed myoclonic seizures or epilepsy. Records of 76 patients could be retrieved. Differentiation between myoclonus and epilepsy was difficult, we used the description as found in the records. Eleven patients received no medication. Treatment was started in 65 patients (86%): in 58 (89%)a benzodiazepine, in 35 (54%) another antiepileptic drug, in 32 a combination of both. Clonazepam was used most often (36 patients, 62%). Valprioc acid was used in 19 patients (54%), phenytoin in 16. Seventeen patients (out of 65) received propofol and in 14 patients a second benzodiazepine was administered. Outcome after 1 month: 66 had died (87%), 7 were in coma, vegetative state or severely handicapped (9%) and 3 were moderately handicapped or completely recovered.

CONCLUSION. Dutch neurologists prefer benzodiazepines in patients with seizures in post-anoxic encephalopathy, often combined with an antiepileptic drug. Myoclonic status reacts poorly to medication, however, treatment is often started because of problems in daily care or mechanical ventilation. In this study we found that the different types of seizures were often not specified in the records, despite the consequences on prognosis. We suggest to use the definition proposed by Wijdicks et al for myoclonus status.1 In this study epileptic or myoclonic seizures in patients with post-anoxic encephalopathy seemed to be related to poor outcome, as 96% had a poor outcome. 

We conducted an etiologic study among parturients presenting a cerebrovascular stroke.

The aim was to determine the frequency of the various types of vascular accident and their moment of arisen,to underline the factors of risk and to estimate the prognosis of vascular accidents in this population(P-values <0,05 were considered to be statiscally signifiant).

Among our 25 patients,17 had an ischemic accident,12 of which had venous origin,5 an arterial origin and 8 had an hemorragic accident .the majority of damage occurs in the 3 rd quarter of pregancy or in the post-partum. Five of our patients had no risk factor and 20 had several risk factors.As for the arterial accident , the etiologic inquiry was not decisive for four patients.They had however several risk factors of thrombosis vascular. Five patient with an ischemia died and three of the patients having a bleeding died. Uni-varieted logistic regression did not find statiscally-significant result concerning mortality in relation with the age,the term gestationnel or the type of accident .

CONCLUSION. Cerebrovascular strokes complicating the evolution of a pregnancy remain an unknown entity. They can cause sequela and have fatal issues.Studies including a larger number of patients are requested in order to decrease the incidence and the important morbi-mortality. They are also meant to find out all risk factors,take them in to consideration and therefore work on their mechanism.

Bubnova I D 1 , Dobrinin I N 1 , Astakhov A A 1 1 Anaesthesiology and Reanimatology, Ural Postgraduate Medical Academy, Chelyabinsk, Russian Federation

One of the ways for the cerebral perfusion support in severe brain trauma (SBT) patients is the cardiac output optimization. But we must know whether the decreasing of hypovolemia range be better for brain protection or not in each case. This study we tried to reveal if the the topic level of central haemodynamic regulation disturbances (CHRD) can determine the response on the volume load (VL).

In the previous works we showed that the patients with SBT may have different types of the haemodynamic regulation due to interfere of the humoral and the autonomic nervous stimulus. This study we examined 52 patients with 3 main regulatory types. All patients were under artificial ventilation and had 11 and less GCS. For the estimation of the type and topic level of CHRD we compared the absolute data and the variability (spectral power (SP) in 0 -0.5 Hz band) of blood pressure (BP), heart rate (HR), peripheral vessels pulse (PVP), and stroke volume (SV), determined by the bioimpedans method. Also we determined the variability of EEG amplitude in the alone biparietal channel. All comparisons were made before and after infusion of 500,0 ml of 6% Stabisol. Especial attention were paid to the P2 (0.05-0.075 Hz) and P4 (0.2-0.5Hz) bands of SV, which reflect the hormonal, more often ADH activity (P2) and predominantly connect with patients breathing (P4). Last findings showed it may be used as a marker of hypovolemia.

The patients with the worst type of regulation (a result of brain stem dysfunction) responded on the VL by the SV increasing in 87,5% cases. But they showed a decreasing SP of P4 only in 43,7%, and SP of P2 increased in 62,5%. In cases of hypothalamic dysfunction (type 2) the SV grew in 50% patients, SP of P4 decreased in 62,5% and P2 increased in 50%. The patients with the best adaptive type of regulation (type 1) responded on the volume load only in 42,8%, but had SP of P4 decreasing in 78,5% and low growth of P2 (21,4%). Surprisingly, in some cases we revealed the great decreasing of variability of HR, BP, PVP and EEG amplitude as a transformation from type 1 or 2 to 3 after infusion.

In SBT the VL partly compensates hypovolemia, but creates an exertion in regulatory system, especially in case of significant CHRD. So we need to find out the predictive marker of response on the VL in different level of brain damage.

Engström M 1 , Schött U 1 , Reinstrup P 1 1 Anaesthesia and Intensive Care, Lund University Hospital, Lund, Sweden

Acidosis has been found to be a predictor of worse outcome in trauma patients suffering from exsanguination. It has, however, not been studied if acidosis may be a causal factor in the development of coagulopathy. Rotational thromboelastography (ROTEG) is a coagulation monitoring tool that is gaining increasing popularity as it seems to be more sensitive and specific than routine coagulation tests in detecting defects of the coagulation system. Clot formation time (CFT) and Alpha Angle are ROTEG parameters primarily dependent on the rate of fibrin formation and the platelet activity.

METHODS. 5 blood samples of 5 ml each were obtained from 6 healthy volunteers. One sample was studied without any additions. Three samples were adjusted to pH 7.2, 7.0 and 6.8 by the addition of 25, 50 and 75 µL of 1M hydrochloric acid (HCl). The last sample was first adjusted to a pH of 6.8 by the addition of 75 µL of HCl and then reversed to a pH of 7.4 by addition of 30 µL of tromethamol (THAM) 3.3 mmol/ml. After adaptation of the pH to the desired level ROTEG was performed to study the coagulation system.

We found a strong correlation between decreasing pH levels and an impairment of the coagulation (p<0.00001) (Figure 1 ). The impairment of the coagulation caused by the acidosis was reversible after addition of the buffer THAM. 

In subarachnoid haemorrhage (SAH), old age and high clinical grade at presentation are poor prognostic factors. Treatment for these patients has been largely conservative. With endovascular coil embolisation a less invasive treatment option has become available(1). This study focuses on elderly and high grade patients admitted to the NICU.

Retrospective analysis of 167 patients with aneurysmal SAH. Demographic features, WFNS grade at presentation (low grade: 1&2), Fisher grade, data for aneurysm site and mode of intervention were recorded. Outcome at three months coded according to the modified Rankin score (good outcome: Rankin 0-2). CONCLUSION. Our data suggest that favourable outcomes (Rankin score 0-2) can be achieved in elderly patients with high grade (WFNS 3-5) SAH. 35% of 20 high grade patients >60 years made a good recovery. This may be due to the less invasive nature of coil embolisation and careful patient selection. 

Gama R X 1 , Oller A M 1 , Bortoletto T C 1 , Almeida C R M 1 , Gurgel A P A 1 , Henrique L M P 1 , Zanini A A 1 , Faintuch J 1 1 Central Pharmacy, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil

Lipid-based parenteral nutrition (TPN) mixtures are deemed safer than glucosebased preparations as regards possibility of hyperglycemia, but few comparative studies are available. Aiming to determine glucose concentrations during such therapy, a clinical study was done.

Stable septic patients submitted to TPN (n= 96) during a 12-month period were investigated on the 1st and the 7th day of therapy. Both glucose-based (Group I, n= 29, 3.3±1.2% of total calories as fat) and lipid-based (Group II, n= 67, 25.8±9.2% of calories as fat) programs were employed.

Groups were comparable regarding age (55.5±14.7 vs 59.0±14.1 years , NS), gender (55.2% females in both groups) and features of septic problems . Energy intake was slightly higher in the lipid-based preparations, but without statistical difference (1120±376 vs 1352±550 kcal/day ). CONCLUSION. 1) Glucose-based TPN was associated with moderate hyperglycemia when compared to a lipid-containing prescription in this septic population; 2) No clinically significant hyper or hypoglycemia was registered. 

Guidelines for blood transfusion (BT) are based on plasmatic haemoglobin value (Hb) and on clinical state. Apart cardiac and septic patients, the threshold value of Hb for BT is 7 g/dL. The aim of the study was to evaluate the central venous oxygen saturation (ScvO2) as a guide for BT decision.

METHODS. 60 patients of general and urologic surgery for whose a BT was discussed were included. ScvO2 (%) and Hb (g/dL) were measured before and after BT. The following parameters were registered: age, history of cardiovascular disease (CV), presence of sepsis, number of blood units. Patients were retrospectively divided into 2 groups according to ScvO2 before BT < or > 70 %.

Overall, demographic characteristics were similar. BT provided a significant increase of Hb for each patient while ScvO2 value rose significantly only in patients with ScvO2 before BT <70% (table 1) . Results are given in median (range). * Wilcoxon test for values before vs after BT; # Mann-Whitney test or Chi-2 for ScvO2 < vs > 70 %; significance for p< 0.05. 8.05 (6.4-9.8) Hb after BT 9.8 * (7.9-11.9) 9.6 * (7.9-11.6) 9.9 * (8.5-11.9) CONCLUSION. Among the 60 patients studied, only those with a low ScvO2 before BT had a better tissue oxygenation by Hb increase. ScvO2 might be an interesting parameter to help the clinician in his decision of postoperative BT.

Szakmany T 1 , Dodd M 2 , Dempsey G 1 , Lowe D 2 , Rogers S N 2 1 Department of Anaesthesia, 2 Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, United Kingdom

Perioperative blood transfusion is reported to be related to cancer recurrence and reduced survival1. To date, little is know about the effects of blood transfusion on outcome in oropharyngeal cancer. We undertook this study to test the hypothesis that perioperative blood transfusion has an adverse effect on survival of patients with oropharyngeal cancer.

METHODS. 557 patients undergoing oropharyngeal cancer resection were evaluated from Jan 1992 to December 2002. Transfusion rate, units of blood transfused and tumour stage were recorded. The primary outcome measure was oropharyngeal cancer death within two years. Cox logistic regression was used to assess the association between cancer death and blood transfusion. Data are presented as median (interquartile range).

Overall transfusion rate was 65% (362/557), units of blood transfused 3 (1) (2) (3) (4) (5) . Mortality was 20.1% (112/557). Mortality was significantly higher in the transfused group (Table 1 .) However, in the Cox regression analysis only tumour size, stage and clear resection margins were predictive of survival. After stratification of patients for these predictors, transfusion did not affect disease specific survival. 

In patients who are supported by mechanical ventilation with tracheostomy and who undergo neck surgery because of the neck trauma or neck infection, there is some risk of dislocation of the tracheostomy tube, contamination of the fixation device during daily surgical wound management and daily nursing care. The object of this study is to clarify the usefulness and safety of our technique of easily detachable fixation of tracheostomy tube with small clip in these patients.

METHODS. 5 patients who underwent this technique were examined. We detach the clip fixing the tracheostomy tube during daily surgical wound management and attached it as soon as finishing wound management.

We did not experienced dislocation of the tube during daily surgical management and daily nursing care in all cases. We easily protected contamination of fixation device of the tracheotomy tube during surgical wound management.

Our technique of fixing the tracheostomy tube using detachable small clip is useful and safe in patients who are supported by mechanical ventilation with tracheostomy and who undergo neck surgery because of the neck trauma or neck infection.

Schachtrupp A 1 , Toens C 2 , Afify M 1 , Lawong G 1 , Schumpelick V 1 1 Surgery, RWTH Aachen, Aachen, 2 Surgery, Marien Hospital, Dusseldorf, Germany

In the presence of abdominal compartment syndrome (ACS) the increased intraabdominal pressure (IAP) leads to organ damage and reduced cardiac output (CO). Decompression is of utmost importance but occasionally circulatory collapse occurred. Moreover, it is unknown whether reperfusion will increase organ damage. Aim of the underlying study was to determine the influence of decompression on circulation and organ damage in a porcine model of the ACS.

We investigated 18 pigs (DL, 50 kg). In two groups (each n=6), IAP was increased to 30 mmHg for 18h using CO2. In one group a period of decompression lasting for a period of 6h followed. In the control group, IAP remained unchanged for 24h. All animals received a basic volume substitution of 2 ml/kg. Additionally, 500ml of kristalloids were given whenever the continuously monitored CO was lower than the control reading of 70 ml/min x kg. Heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP) and urine output (UO) were recorded. At the end of the experiment, specimen from the lung, liver, kidney and bowel were taken for histological examination. Moreover, liver tissue was examined for the expression of ICAM-1 displaying leukocyte sticking. Statistical analysis was done using analysis of variance as well as paired and unpaired ttesting. A p<0.05 was considered significant. In case of repeated pairwise testing, level of significance was adjusted.

RESULTS. CO did not differ between groups but additional volume was needed in study groups. HR, MAP and UO did not differ. CVP was significantly increased. After decompression, hemodynamic parameters remained stable, UO increased significantly. Medium grade histological was found after 18h of increased IAP. Reperfusion did not increase organ damage. The highest expression of ICAM-1 was found after 18h of increased IAP without reperfusion.

CONCLUSION. In this model, administration of additional volume was sufficient to preserve CO despite the presence of an IAP of 30 mmHg. Decompression did not lead to circulatory collapse. Nonetheless, organ damage was present which was not increased by decompression. These results imply, that in the presence of critically increased IAP, adequate volume substitution is needed together with an immediate decompression in order to avoid organ damage. 

There were 8 episodes of ventilator associated pneumonia in 8 patients of total 250 admitted patients (3.2%) and 105 patients who required mechanical ventilation support (7.6%). The mean ventilator associated pneumonia rate was 15.6/1000 ventilator days. Leading causative agents detected in our PICU patients were Pseudomonas aeruginosa (3.8%),Enterococcus (2.8%) and Staphilococcus aureus (0/9%). All patients with ventilatory associated pneumonia survived.

Ventilator associated pneumonia occurs at significant rates among mechanically ventilated PICU patients.

Ultrasonic guided pleural aspiration is a safe ed accurate method of obtaining fluid in pleural effusion, caused by several mechanisms (pneumonia, cancer, congestive heart failure etc). Drainage could improve pulmonary ventilation and allow the laboratory examination of the fluid, useful for the differential diagnosis. Pneumothorax (Pnx)is the principal complication of thoracentesis. For this reason, five years ago, the Emergency Department of this hospital, adopted the Plastic Catheter (PC)in use for IV infusion in order to perform a pleural drainage. The aim of this study was to evaluate the effectivness of this method compared with the more common Metallic Needle (MN)contents in the set for thoracentesis. where insert the needle. After a local injection of anesthetic lidocaine, one of the two needles was chosen. In particular, for the PC, after the inserction, the metallic core was removed and only the plastic tube was left in place and connected to the drainage system. Pleural aspiration was removed when the patient had thoracic pain, cough or fluid flow ceased. By ultrasonography, at the point of drainage, was measured the space between the two pleural layers and this was considered a parameter of drainage entity: the lower the space, the greater the drainage. Results were analised on a statistical manner by t test of Student for impaired data.

Patients who underwent thoracentesis by PC had more complete thoracic drainage (pleuric space 5,8 +/-3,2 cm vs 12,7 +/-4,2 cm; p < 0,03)without case of Pnx (0 vs 1).

Ultrasound is more accurate than plain chest radiography for estimating pleural fluid volume and aids thoracentesis. Chest drainage by plastic catheter increases efficacy and safety. 

Prospective randomized study included 40 enterally fed patients with an expected mechanical ventilation period of at least 6 days. The diagnosis of VAP was based on clinical, radiological and bacteriological criteria. Qualitative and quantitative bacteriological study of microorganisms isolated from gastric content as well as from upper and lower respiratory tract was carried out on the 1st, 4th and 6th day of the therapy. Material from lower respiratory tract was taken by protected specimen brush (PSB) using bronchoscope. 

INTRODUCTION. VAP is a frequent nosocomial infection. Since delayed appropiate antimicrobial therapy worsens prognosis, broad-spectrum antibiotics are frequently administered. Early clues on potential microorganisms involved could help select a more focused antimicrobial therapy. The known relation between VAP and upper airways colonization prompted us to determine if UAS at the time of ICU admission (Day 1) could accurately identify microbial agents involved in early VAP (within the first 5 days following tracheal intubation).

136 consecutive ICU patients who had a Clinical Pulmonary Infection Score (CPIS) consistent with the diagnosis of VAP between 1996 and 2001 were retrospectively analyzed. UAS (nose and throat) were obtained at Day 1 for all patients, and specific pathogens (other than normal oropharyngeal flora) were cultured. Pulmonary plugged specimen (PPS) were obtained whenever VAP was suspected and were considered positive beyond 10 3 CFU/ml. The concordance between UAS at Day 1 and the first PPS was analyzed. 

In level I(unit-based),6.8%(95% CI 6.6-6.9)of patients stayin >2d, acquired at least one episode of IAPN. The percentage varied strongly according to the country (4.0 to 15.5%),type of ICU (7.2% in mixed,5.5% in medical and 4.6% in surgical ICUs) and percentage of intubation. Incidence density (ID)per 1000 patient-days was 5.3(5.0-5.6)in ICUs with <30% of intubation, 9.2 (8.9-9.7) in ICU with 30-59% intubation and 10.8(10.4-11.1) in >60% of intubation, p<0.001). The median n of days from admission to IAPN were 12.8(10.7-17.7). The most frequently isolated were P aeruginosa (17.9%) and S aureus (16.2%), with large variations between countries.GP cocci were isolated in 28.7%, GNB-enterobacteriaceae in 27.4%,GNB non-enterobacteriaceae 31.8% and Fungi/parasites 10.2%. Table 1 shows the distribution of micro-organism according to the time of onset of IAPN. In level II surveillance (patient-based) intubation utilisation ratio was 0.49 (0.38-0.71) and deviceadjusted indicator: 19.9 IAPN* 1000/ intubation days (4.0-22.0). 

18% of all general critical care patients were transferred for their care. These patients accounted for 25% of all bed days in the network. Transferred patients had a mean ICU stay of 10 days, 3 days longer than non-transferred patients (p=0.014) together with a slightly longer hospital stay. There was also a small (1.6%) increase in hospital mortality associated with transfer which was not statistically significant. 

There is a large number of Level 1 patients who are at risk of deterioration or have stepped down from higher levels of care.These patients can be looked after on an acute ward with additional support from the critical care/outreach team The Critical Care Network has 73 level 2 beds and the audit identified 232 level 2 patients.159(68.53%)of these patients(at the time of the audit) could not access a Level 2/HDU bed despite their condition warranting care in an HDU area. The care delivered to this group of patients is therefore by staff trained for a Level 0/1 area.With 82 level 3 beds, capacity for level 3 patients was appropriate on this day with 5 beds available. The Networks patient transfer activity for 2004 was 500 Non Clinical Transfers and 300 Clinical Transfers.

Sepsis is one of the leading causes of death in intensive care medicine (ICM). The rapid diagnosis and management of sepsis is critical to successful treatment. Since 1999 we have integrated diagnostic and treatment feature of severe sepsis into our Berlin Simulation Training in order to optimize team functions. Lectures and interactive simulation scenarios are combined and discussed. Participants are postgraduates with differing professional experience in ICM (PE).

To evaluate the structure, content and impact of those courses participants of four simulation courses in 2004 were given anonymised questionnaires both in advance and immediately after the course. 28 pairs of items were defined to measure the acquirement of knowledge in sepsis and the impact of several teaching METHODS. Participants were also asked whether the course content should have been given earlier or later during their postgraduate training. Answers were given on a five point scale (Likert-like) and results are given as median and interquartile range (IQR).

Participants' PE in ICM varied from two months to 14 years. All participants expressed benefits from the course. Both lectures and scenarios were evaluated helpful to identify sepsis patients earlier.

Most of the participants thought that the course was at a right point of time during their postgraduate training (PT) (n=15, median of ICM/PE 1.5a, IQR 1-4a) and 12 participants thought that this course would have been even more helpful if had been given earlier during their PT [n=12, PE 2.5a (1.5-5.5a)]. "The course was being helpful concerning future identification of sepsis patients" -2 (2-3). "The lectures were being helpful concerning future identification of sepsis patients" -2 (1.5 -2) "The scenarios were being helpful concerning future identification of sepsis patients" -2 (1.5-3) "The scenarios were realistic" -2 (2-3) and "I enjoyed the course" -1 (1-2)

CONCLUSION. Simulation courses to train early identification and timely treatment of septic patients are very helpful and appreciated at every stage of PE in ICM. Simulation courses should be integrated as early as possible.

Jermin S P 1 , Kapila I 1 , Dyson M 1 1 Critical Care, South Manchester University Hospital, Manchester, United Kingdom

There is a recognised shortage of ICU beds in the UK.Critical care outreach services help reduce pressures on critical care by providing clinical support, increasing staff skills and by providing educational support(1). Early identification of sick patients may lead to a reduction in number of admissions to ICU, length of in hospital and ICU stay (2) . This study aims to compare the level of care of all inpatients on a normal 'in hours'working day(tuesday) with those of all in patients on an average winter 'out of hours' day(sunday)

Data was collected from every inpatient in the hospital(excluding psychiatric,paediatric and long term rehabilitation patients) on an average Tuesday in April 2004 between the hours of 0900-1600 and then on a Sunday in January 2005 between the hours 0900-1600 . Data consisted of levels of care(using UK Intensive Care Society definitions)(3) during both periods but also included demographic details for the second period.Presence of respiratory rate(used as an index of deterioration) recording was also noted for the second period. CONCLUSION. The current complement of level 2 and 3 beds in the hospital is 18 and 20(dependant on staffing levels)respectively.Despite some flexibilty in using level 3 beds for level 2 patients and assuming an 80% bed occupancy, there is a considerable need for more level 2 capacity particularly during the winter period.Extension of the current theatre recovery area into a 4 bedded post-operative HDU could provide additional beds .Outreach services would also need to be vastly extended. 

Abizanda R 1 , Nicolás-Picó J 1 , Mateu-Campos L 1 , Carregui-Tusón R 1 , Sánchez-Morán F 1 , Mas-Font S 1 , Ferrándiz-Sellés A 1 1 Intensive Care Department, Hospital Universitario Asociado General de Castelló, CASTELLÓ, Spain

When no ICU specific analytical accounting is available, the only indicators of direct costs are the number of ICU stays per patient, and pharmacy costs. It is usually accepted that these pharmacy costs represent between 10 and 15 % of total costs, and that they are very much influenced by therapeutic attitudes of the attending teams and the introduction of new pharmacological options or the change in the already existing ones. Our aim is to analyze the changes in pharmacy costs occurred during the interval between 1996 and 2003.

METHODS. This is a retrospective analysis performed on a multidisciplinary 19 beds ICU activity, in a teaching referral hospital. The analysis has been performed through data coming from the managerial departments and the Pharmacy Service, and costs have been classify as related to therapeutic group (Pharmacy instructions from the Spanish National Health System) and to individual active drugs. The analysis collects information raised from the ICU daily patients chart.

Pharmacy costs amount ranged between 16,8 % in 1996 and 12,3 % in 2002. Since then a slight increment in pharmacy costs has been detected up to 14,6 %. The reasons for cost decrements are linked to the progressive control on albumin use and antibiotic policies. By the contrary, Increasing percentages are associated to the introduction of new sepsis therapeutic approaches (drotecogin) and the routine introduction of antiplatelet agents in non elevated ST coronary syndromes. The "top twenty" drugs cost evolution is presented, and in a constant fashion the two firs places represent the use of sedatives (propofol) and fibrinolytic agents in AMI (tecneplase).

Factors that allow or avoid to keep the stability of what pharmacy costs represent are strictly linked to changes in physician attitudes (abandon of non demonstrable efficacy of certain agents -albumin -, the incorporation of new options -drotrecogin, antiplatelets -and the maintenance of consolidated practices -fibrinolytic agents, sedatives, nutritional strategies. Physician teams are obliged to keep this information "alive" in order to avoid unnecessary raises in direct costs.

Cotogni P 1 , Bini R 2 , Forno G 3 , Porta C 3 , Aliffi S 3 , Ranieri V M 1 , Pittiruti M 4 1 Anestesia e Rianimazione, 2 Chirurgia d'Urgenza, 3 School of Nursing, University of Turin, Turin, 4 Chirurgia Generale, Catholic University, Rome, Italy

Enteral nutrition (EN) is the preferred method for nutrient delivery in ICU critically ill patients. Nonetheless, there is always a significant gap between prescribed and delivered feed. This is partly due to 'patient-related' problems, e.g. gastrointestinal (GI) intolerance to EN, but also by logistic 'management-related' events which imply transient nutrient delivery interruptions, which are often mandatory but sometimes avoidable. The aims of this study (prospective, descriptive study of EN delivery in 4 teaching hospital ICUs) were (a) to analyze the causes for EN transient interruptions; (b) to assess whether a specific nurse training might be associated with better nutrient delivery.

In two ICUs (group A), all nurses had been previously trained in EN through a 16 h education module, while nurses of other ICUs (group B) had not. Over a period of 30 months, we studied all ICU pts receiving EN (either alone or combined to parenteral nutrition). Pts receiving EN for < 7 days were excluded. EN was administered as a continuous (24/24 h) intragastric infusion of a standard polymeric diet. We recorded any transient interruption of nutrient delivery lasting more than 15 min, noting the duration and the cause.

We examined 244 pts fed by EN accounting for 2537 EN days (10.4+2.6 days/pt). In the groups, patient populations were similar in SAPS, diagnosis on admission to ICU, complications, days of mechanical ventilation and mortality. The main causes of transient EN delivery discontinuation were mechanical (11%), or secondary to diagnostic and therapeutic procedures (59%), or related to true GI intolerance to EN (30%). Comparing groups, we found that group A was characterized by a lower incidence of discontinuations for mechanical causes (p<.01), as well as by a shorter duration of interruption due to mechanical causes (p<.001), to procedures (p<.001), or to intolerance (p<.01). Also, the difference between prescribed and delivered feed was significantly lower in group A (p<.001).

Our study shows that (a) the majority of discontinuations of EN delivery is secondary to 'management-related' causes and not to patient's intolerance; (b) a specific training in artificial nutrition of the ICU nurses may be effective in increasing nutrient delivery by reducing incidence and duration of those EN discontinuations which are not 'patient-related'.

Saura P 1 , Ortiz D 2 , Prat R 2 , Fernández R 2 , Artigas A 2 1 Critical Care Center, Hospital de Sabadell, Sabadell, Spain, 2 Critical Care Center, Hospital de Sabadell, Sabadell,

The role of ICU staff on cost containment is a matter of debate being drugs consumption, diagnostic test and fungible the main able to be improved. We hypothesised that these items could have the major impact in cost variability per patient in the ICU. Our objective was to prospectively evaluate the relative role of these variables compared with other classical items as length of stay, quality of life, age, severity of illness.

Design: Prospective cohort study Setting: 26-bed Intensive care unit Patients: 200 consecutive patients with a length of stay longer than 24 hours. Measurements: We prospectively recorded: demographic data, SPAS II score and Diagnostic Related Group on admission, length of ICU stay, Health-related quality of life (Euroqol 5D), and consumption of fungible, pharmaceutical and diagnostic procedures. The costs of the fungible, pharmaceutical and diagnostic tests were recorded from the hospital administrative database as cost per unit. We elaborated a multivariate linear predictive model in order to analyse the variables causing the variability of the cost per patient. 

Patient transfer between hospitals is associated with increased mortality (1), and patients transferred from intensive care unit (ICU) to ICU have also been shown to have increased mortality (2) . The aim of our analysis was to compare our mortality figures with those of published data.

. A retrospective analysis of 2,481 patients admitted to a 13-bedded unit in a university teaching hospital over a 6-year period. We compared those patients admitted from our own hospital (INTERNAL) with patients transferred from other ICUs (EXTERNAL ICU) and those transferred from other hospitals from an area outside ICU (EXTERNAL OTHER). We compared ICU mortality with APACHE II predicted mortality and calculated the standardized mortality ratio (SMR). RESULTS. Over the 6 year period, 2,481 patients were admitted into the ICU. Forty-nine(2%)were transferred from another ICU, 124(5%)were transferred from areas outside the ICU in other hospitals and 2308 (93%) were admitted from our own hospital. Mortality figures are shown in the table. CONCLUSION. Lipid solutions enriched with w-3 fatty acids are safe, well tolerated in patients with ARDS, and without changes in the hemodynamic or gas exchange of these patients.

CDC defintions for nosocomial infections

Nosocomial infections in pediatric intensive care units in United States

Nosocomial respiratory infections

PICU ventilator-associated pneumonia

Nosocomial pneumonia in the PICU (Abstract K-452)

Pediatric ventlator-associated pneumonia

Last's Anatomy

The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis

Incidence of nutritional risk and causes of inadequate nutritional care in hospitals

Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials

R:An update on perioperative management of diabetes

Intensive insulin therapy in critically ill patients

INTRODUCTION. The objective of this study was to evaluate the use of human resources in ICU comparing the planned level with the operative level.

Prospective study involving all the patients admitted in the ICU between 2001 and 2004. Simplified Therapeutic Intervention Scoring System (TISS 28) was used to assess nurse workload in the ICU. Provision of resources was measured as the number of nurses per ICU bed (patient nurse ratio -P/N). The operative level of care was calculated dividing the measured TISS points equivalent to the nursing activities of one nurse per shift. The efficiency in the use of nursing manpower was based on the number of available nurses, the amount of work that one nurse can perform per shift and the level of TISS during the study. The work utilization ratio was calculated. Severity of illness was evaluated by the APACHE II score. CONCLUSION. The APACHE II score remained elevated through the study period. The measured TISS was higher than planned and as a result the work utilization ration was above 100%. Nevertheless the number of patients admitted increased every year and the mortality remained lower that the expected by the APACHE II score. 

Adverse drug reactions (ADR) are common in hospitalised patients, but few empirical data are avalaible regarding patients with serious ADR requiring intensive medical care. As morbidity linked to ADR remain underappreciated, delay for diagnosis may contribute to organ failure requiring artificial life support. The aim of this study was to determined the proportion of admissions related to serious ADR and potential avoidability.

We have prospectively included all adults patients coming from university hospital admitted in a 14-bed medical intensive care unit (ICU) in a french university hospital in Bordeaux, France, during a 6-month period. For each patient, we have determined if serious ADR have contributed to organ(s) failure(s) requiring admission by follow-up and with 2 independant clinical pharmacologists. Clinical pharmacologists have estimated the strenght of relationship between drug(s) prescribed in hospital and potential avoidable ADR as the cause of organ failure.RESULTS. Of 344 patients admitted from medical ICU between may and october 2003, 48 (13,4%) were hospitalised because of almost one organ failure related to ADR, 31% of cases ADR were potentially avoidable. Coma, seizures with acute respiratory failure and metabolic life-threatening disorders were the most frequently avoidable ADR and linked to drugs prescribed in a short delay before admission. Artificial life support was required in 83% of cases.Vasopressives drugs were prescribed in 12 cases , hemodialysis in 5, non invasive ventilation in 12, and mechanical ventilation was needed in 16 cases.The Mean of Simplified Acute Physiologic Score II of work load Omega score, of length of stay and the rate of mortality were not significantly different between patients with or without ADR.

Serious ADR were a frequent reason of admission (13,4%) and were often potentially avoidable if cautions of prescriptions would have been taken into account. Measures are needed to improve ADR detection and reduce drug-induced morbidity. 

Performing every interventional procedure strictly lege artis is of significant importance not only to the patient, but also to the medical personnel. Ensuring the maximum alertness to stay strict to the rules and performing by book leads to minimal complications, more wise decisions and reduction of the cost as it minimizes the single use material waste.

: In our polyvalent six bed ICU we installed cameras providing full surveillance of each bed. All of the cameras were in use for two weeks registering every interventional procedure on 24hour basis. Medical and nursing stuff were aware of the registration process. The whole medical team reviewed the collected videos every five days. We totally registered 62 central vein catheterizations, 16 oro-tracheal intubations, three tracheostomy operations, 55 radial artery catheterizations, 58 rhinogastric tube insertions, 43 urinary bladder catheterizations, 4 pulmonary artery catheterizations 5 bronchoscopies, and six chest drainage procedures. All procedures were graded on 1 to 10 scale, in respect with asepsia,, antisepsia ,speed of performance, material waste and complications.

Procedure Days 1 -5 Days 6 -10  Days 11 -15  Central veins access  8  9  9  Radial artery access  7  8  8  Pulmonary artery access  9  8  10  Tracheal intubations  8  9  9  Bladder catheteriasations  8  9  10  Levin tube insertion  7  8  9  Bronchoscopy  8  9  10  Tracheostomy  9  9 10 Bulau insertion 8 9 9CONCLUSION. Increased stress among the medical personnel was noted due to the presence of the cameras, although procedures were more exact as the time advanced in spite of the fact that the duration in time of each procedure seemed to be longer. Complication rates were constant. [1] , thereby increasing providers' financial risk considerably [2] . In future, reimbursement in Germany will be based on a special procedure (OPS 301) which may be quantified through a specific, patientdependent cost predictor score. The aim of this study was to develop and validate such a score capable of predicting the total direct costs of intensive care services in large teaching hospitals.

Individualized clinical as well as economic information was collected for all consecutive patients across 15 mostly surgical ICUs in 10 university hospitals across Germany during a 2 month period. Resource consumption covered hotel and personnel costs, medication, laboratory tests, diagnostic and invasive procedures. Resources were valued with local costs through bottom up costing. An "ICU cost predictor score" (ICU-CPS) was devised by combining a routine measure of severity of illness (daily SAPS II score without GCS) with a daily measure of selected medical interventions (10 highly rated parameters of TISS-28: mechanical ventilation, multiple catecholamines, >5 l daily fluid replacement, peripheral artery catheter, pulmonary artery catheter, haemofiltration, intracranial pressure measurement, alkalosis/acidosis treatment, special interventions, actions outside ICU) during the entire ICU stay.

Based on a preliminary analysis of 892 patients from 12 ICUs, the ICU-CPS demonstrated a strong positive correlation of 0.871 (p < 0.01, 2-tailed) with total ICU costs. This coefficient varied from 0.778 to 0.921 between ICUs. The correlation of the ICU-CPS score with costs was better than that of SAPS II (without GCS) (0.850; p<0.01, 2-tailed). The mean ICU-CPS per day was 37 ± 15 (mean ± SD). Average costs per day were € 1,272 ± 5,611. On average, each score point of the ICU-CPS thus corresponded to a cost of 34.

The preliminary results of this study indicate that intensive care services may be adequately reimbursed on the basis of the ICU-CPS predictor score, taking into account patients' acute severity of illness as well as required medical interventions.

The aim of our study was to analyse variable cost determinants of severe sepsis treated in intensive care units in Hungary.

We selected a non-random sample of 6 intensive care units. Each unit identified 10 patient retrospectively, who were treated with severe sepsis. The resource use of variable costs were collected on a daily basis (for day 1-3) from medical and nursing documents. These costs were divided into disposables, radiology, biochemistry, blood products and drugs&fluids. Personnel costs were calculated from annual salary report and the indirect costs were calculated by the financial directors.

The mortality of severe sepsis in our sample (n=60) was found to be 61.6 %, with average lenght of stay 15.9 (SD 9.2). Mean ICU cost per day of severe sepsis was 429 Euro. There were no differences found between day 1-3 cost of radiology, biochemistry and blood products, however, disposables had much higher cost on day 1 (p=0.002). Drugs&fluids costs were higher on day 1 only for those patients who did not survive. Analysing drugs&fluids by grouping them into 7 categories, we found that colloid use was significantly higher on day 1 in those, who died later (1013 ml vs. 1244 ml, p=0.045). There was no correlation found between APACHE II scores and any cost components. 

EGDT has shown significant reduction in mortality and health care resource consumption 1 and is recommended by the Surviving Sepsis Campaign 2 . This study assessed data from severe sepsis and septic shock patients prior to implementation of an EGDT program and projected the potential impact on resource utilization at our hospital.

We queried the clinical data repository and found 1081 emergency department(ED)patients admitted from Jan 2002-Dec 2004 meeting search criteria including: patients >18 years, hospital admission from the ED with documented infection, antibiotic treatment and requiring vasopressors (day 0,1), ventilator assistance (day 0,1), new dialysis (day 0-7) or a serum lactate >4 mmol/L. Exclusion criteria were admission GI bleed or traumatic injury. Based on resource utilization data from the Henry Ford Health Systems corporate data stores, percent differences between EGDT and non-EGDT groups were calculated and applied. Assuming constant mortality, the projected impact on hospital resource consumption and costs was assessed.

Cost savings was assoicated with survivors. Increased costs were noted in non-survivors. Cost benefit favored EGDT. . Four consecutive TPTD measurements were performed with ice-cold saline. The volume of the injectate varied between 3 and 5 ml depending on bodyweight. The mean of 4 consecutive measurements with a normal TD curve and injectate temperature lower than 11°Celsius was considered as the gold standard.

A total of 117 quadruple measurements fulfilled the quality control criteria. Mean cardiac index (CI) was 4,45 l/min/m2 (SD 1,5). The mean coefficient of variation (percentage of the SD of the mean) for quadruple TPTD measurements of CI was 10,5% (SD 6,6). The table shows the differences between 1 measurement, the mean of 2 and the mean of 3 measurements in comparison with the mean of 4 measurements. 

Measurements were performed at our catheterisation laboratory in seven children with a bodyweight of 5 -13,1 kg. EVLW was measured with the COLD system (COLD, Pulsion Medical Systems) incorporating both TPTD and TPDD techniques. Ice-cold indocyanine green was injected close to the right atrium. Changes in temperature and dye concentration were measured using a special catheter located in the distal aorta.

Mean cardiac index (CI) was 4,1 l/min/m2 (SD 0,9) and mean EVLW-TPDD was 11,9 ml/kg (7,5 -22,0). Repeatability (1.96 x SD of the difference between repeated measurements) for CI, EVLWI-TPTD and EVLWI-TPDD were 0,52 l/min/m2, 1,63 ml/kg and 2,1 ml/kg respectively. The bias between the two methods is -2,36 ml/kg with a precision of 1,89.CONCLUSION. Transpulmonary thermodilution appears to be an adequate method to measure EVLW in children. Children may have higher normal values of EVLW compared to adults. 

Loh T F 1 1 Children Intensive Care Unit, KK Hospital, SIN, Singapore

A common approach for insertion of central venous catheter is to access the subclavian vein via subclavian approach. This approach is associated with arterial puncture and air leak 1,2. Local pressure is difficult to apply as the vein runs under the clavicle. We describe an axillary approach to access the subclavian vein in paediatric patients.

Patients were selected for this approach when conventional approaches for central venous access were exhausted or contraindicated. The patient's arm is kept abducted with slight external rotation perpendicular to the thorax with the dorsum of the palm flat to the bed. Head is turned to the contralateral side. The axillary artery is palpated and followed as it inserts into the apex of the axilla lateral to the teres minor when it becomes the subclavian artery. The axilla vein runs medial to the artery becoming anterior to the artery as it enters the axilla apex to become the subclavian vein3. A puncture is made medial to the artery at the base of axilla and directed towards the axilla apex. The needle is punctured 10-15 degrees to the skin and limited to the apex of the axilla. Confirmation of venous access is made by free flow of blood. The catheter is inserted using the Seldinger technique and secured. Chest XR done to confirm placement.

. 5 paediatric patients were selected for this approach. Arterial puncture was made in one patient and hemostasis secured with direct local pressure and subsequent insertion was successful. Access required a mean of 2.2 attempts. One patient hand was swollen 6 days after the line inserted but Doppler study did not reveal any venous thrombosis and the line left in situ. Routine limb neuromuscular and vascular assessments were made. No malposition or air leak was seen on CXR.No local or line related infections were documented. Catheters were removed after 8.3 days. Follow up (mean of 2 weeks) after the catheter was removed showed normal hand power and movement in all patients.

Axillary approach maybe a novel alternative to central venous catheter insertion in paediatric patients when conventional approaches are not possible. change was recorded on capnography in all 281 tests performed. Radiographs confirmed correct placement of NGT throughout study period. In the subgroup of children(n=13)who had an endotracheal placement the time to complete capnograph colour change was ≤ 15 seconds, (median 7 (5-15)) in all cases.

In critically ill children sufficient gastric aspirate can be obtained for pH testing and capnography rapidly discriminates between NGT placed correctly from those passed in to the trachea. 

A one year prospective & observational study included all admissions (n=216) until 48h after discharge. Cultures for bacteria and fungi and antibiotic sensitivity tests (19 antibiotic using Bauer-Kirby disc diffusion method) were obtained on admission [ blood, stool, urine & cerebrospinal fluid (if needed)] and repeated on suspicion of NIs .All cannulae, endotracheal tube (ET) aspirates & tips, nasogastric tubes & different catheters were cultured. All PICU health care workers (HCWs) were subjected to throat & under-finger nails culture as well as inanimate objects , both on bimonthly basis. The referral place (ward or emergency), PRISM III score, length of stay (LOS) & fate, were recorded. reports of the Dutch society of pediatrics concerning transport and stabilizing critically ill children, resulted in a reorganization of the transport of critically ill children in the Netherlands. As of February 2004, all children in the Northwestern region of the Netherlands requiring mechanical ventilation were transported by pediatric intensive care teams of the VU and AMC University Medical Centers. These teams consist of a pediatric intensivist or anesthesiologist (in training) and pediatric intensive care unit (PICU) nurse and were on call 24 hours, 7 days per week. The objective is to report the first year results and to compare an experienced (AMC) and a novice (VUmc) center.

Demographic data, diagnosis at admission and severity of illness score (PRISM) and duration of transport (preparation, travel time, intervention in other hospital and complications during transport) were prospectively collected. All data were analyzed per center and in total in order to identify any difference between both PICU-teams. Transport frequency was divided according to PICU-capacity (40% VUmc and 60% AMC). Statistic analysis included student t-test for continuous variables and chi2 test for dichotomous variables.

In total 100 patients were transported by either PICU-team. Half of the transports took place during the evening or night. Demographics, PRISM-score and admission diagnosis were comparable. Mean transport time was 2 hours and 17 minutes. There was a significant difference in preparation time . Results concerning other transportation variables are similar for both clinics. Neither PICU-team reported complications during transport.

A continuous PICU transport system carried out by two specialized centers is feasible and efficient. Apart from a difference in preparation time, which may be influenced by a multitude of factors, there were no differences concerning other transport variables between an experienced and inexperienced team.

After cardiac surgery it is not uncommon that a solitary collapse of a lobe, e.g., the left lower lobe develops. It has been difficult to experimentally study therapeutic interventions for lobar atelectasis due to lack of suitable animal models. The aim of this study was therefore to develop a reproducible model in pigs.METHODS. 10 anesthetized pigs were tracheotomized and ventilated VCV, FiO2 1.0, PEEP 10 cmH2O, VT 8 ml/kg. This ventilation was maintained under the experiment except during the lung recruitment maneuver (LRM). A bronchial blocker (Cook C-AEBS-7.0) was inserted in the right lower lobe (about 50 cm from the ET-tube opening) by the use of a fiberoptic bronchoscope. To ensure a correct position, the balloon of the blocker was inflated shortly and thereafter deflated under inspection via the bronchoscope. Thereafter, a LRM (PCV with peak pressure of 40 cmH2O, PEEP 10 cmH2O, I:E 1:1 and RR of 6/min during 2 min) was performed to optimize the lung volume history after which end-expiratory lung volume (EELV), quasistatic compliance of the respiratory system (Crs) were measured and blood gases (mixed venous and arterial) were obtained. The balloon of the bronchial blocker was inflated, the air of the isolated lobe exsufflated and measured ("lobe volume"). Thereafter the lobe was selectively lavaged (with a "lobe volume" of 37°C 0.9% NaCl) using a syringe 15 times or until no frothing of the lavaged fluid was seen. EELV, Crs and blood gases were obtained. In one pig CT thorax was done and another pig was thoracotomized and the lungs were inspected. Statistics:Wilcoxon.

The "lobe volume" was 66±21 ml (mean±SD). After the selective lobe lavage, EELV decreased from 886±170 to 698±166 (p<0.002), PaO2 from 76±9 to 40±14 (p< 0.004)and crs decreased from 32±6 to 22±7 (p<0.002).Both CT and the inspection of the lung showed atelectasis of the right lower lobe.

A reproducible experimental lobe atelectasis can be obtained by selective lobe lavage in pigs. This method may be used experimentally for studying methods treating atelectasis. 

Garcia-Hernandez R 1 , Perez-Vela J L 1 , Corres M A 1 , Hernandez-Sanchez E 1 , Renes E 1 , Gutierrez J 1 , Arribas P 1 , Perales N 1 1 PostoperativeCardiac Unit, Hospital Doce de Octubre, Madrid, Spain

In the literature donor´s norepinephrine (NE) usage was considered high vasoactive support and leads to refuse heart graft implantation.The sortage of available donor hearts limits cardiac transplantation and nowadays some authors point that vasoactive drugs (VAD) could be useful to improve donors hemodynamics and so graft function in the recipient. OBJETIVE: To assess graft function and ICU evolution in patients who underwent cardiac transplantation depending on donor´s NE dose.

Retrospective study from 1998 until 2004 of intrahospital donors and theirs recipients Two groups were set: Low NE dose: donors who received <0.2mcg/Kg/min or no NE; High NE dose: donors who received >/= 0.2 mcg/Kg/min. We assessed in the donors: number, type, length and dosage of VAD; volume intake and clamp time; in the recipients: presurgical left ventricular eyection fraction (LVEF); extracorporeal circulation (ECC) time; incidende of ventricular disfunction, cardiogenic shock, primary graft failure (PGF); mortality and others ICU evolution parameters (incidence of Acute Renal Failure-ARF-, Acute Lung Injury/Respiratory distress -ALI/ARDS-, sepsis, length of DVA usage, mechanical ventilation and ICU admission, etc...). Statistical analysis was done with t-Student´s test and chi(2) (using Yates´ or Fisher´s modification when indicated). CONCLUSION. In our serie, the donor´s NE dose did not have an influence on the heart graft disfunction or in the others items assessed. The NE use for hemodynamic management on heart donors could not worsen the recipients evolution, but new studies with high number of patiemts should be developed in order to set a clear limit in the dosage used.

Jacquet L 1 , Rubay J 2 , Vancaenegem O 1 , Laarbaui F 1 , Lovat R 1 , Noirhomme P 2 1 Cardio-vascular intensive care, 2 Cardio-vascular surgery, Saint-Luc University Hospital, Brussels, Belgium

Many patients with complex congenital heart disease,the majority having been operated on during their first years of live, are now adults and pose unusual problems for cardiologists, surgeons and intensivists caring for adult patients.

We have reviewed the charts of patients >15 years old who were admitted in our cardiovascular ICU after operation for GUCH from january 2000 to december 2004 in order to describe their specific outcome.

During this 5 years period, data from 38 pts (15 males,12 females and 1 XXYY karyotype) were collected. The mean age was 31 y (rang 15-59).Among these, 35 had tetralogy of Fallot and had been already operated before, 17 having had 2 previous surgical procedures. The main indication for surgery was pulmonary insufficiency and 34 pts received a pulmonary homograft. 

Retrospective review of all ECHO examinations in this setting over a one-year period (Jan2004 -Jan2005)

We performed 135 ECHO in 77 patients (15% of 489). ECHOs were carried out during the first 24 hours in 16% and on the next day in 13%. Sixty-eight percent were performed during the first 5 postop days. ECHO was performed as urgent in 20%, semi-urgent (>8 hours) in 29% and for control in 51% of cases (64% TTE, 36% TEE). 76% were carried out by cardiologists and 24% by anesthesiologists. However, 52% of the urgent ECHOs were performed by anesthesiologists. Indications were: hemodynamic instability (23%), cardiac transplantation follow-up (13%), cardiac ischemia (13%), cardiac function follow-up (11%), and suspected cardiac tamponade (9%). Findings were left ventricular dysfunction (26%), hyperdynamic left ventricle (23%), right ventricle dysfunction (21%), new segmental wall motion abnormalities (12%) and hypovolemia/vasodilation (8%). 33% were normal or similar to previous ECHOs. New myocardial infarction was diagnosed in 22%. ECHO induced changes in patient management in 60%: resternotomy (4%), medical therapy (48%) and others (8%)(IABP insertion/removal, anti-rejection therapy). Main changes in therapy were: inotropic agents (59% increase, 34% decrease) and IV fluid administration (27%). In 23% ECHO findings were unexpected/unrelated to the symptoms. 58% of patients were also managed with a pulmonary artery catheter(PAC). In 6% of these there was no agreement between two techniques. Number of ECHO carried out by the anesthesiologists increased from 9% in the first four months of the study to 27% in the second four months and to 49% during the last four months.

In this study, ECHO provided important diagnostic and therapeutic data on postoperative cardiac surgical patients. Findings led to management changes in 60% of patients. ECHO should be included in training of physicians working in CSICU. is 7.39%. The mean age is 59 ± 19 years. The mean BMI is 27 ± 3.9 kg/m2. Patients with normal BMI (20-25 kg/m2) and patients with more than normal weight(above 25 BMI) had a similar outcome. (Fig.1 ) We ruled out that younger age compensates for a possible higher mortality in heavier patients.However, the age turned out to be similar in the different BMI groups and cannot be held accountable for lack of increased mortality in patients with more than normal weight. (Fig.2) .CONCLUSION. BMI does not show to increase mortality in cardiac surgical patients, despite of possible increased comorbidities.

Samalavicius R 1 , Misiuriene I 1 , Norkiene I 1 , Juozaitis M 1 , Baublys A 1 1 Department of cardiac anaesthesia, Vilnius University Hospital, Vilnius, Lithuania

Obesity is one of the risk factors for adverse outcomes of major surgery. We assesed the influence of obesity on outcomes of CABG in our institution.

The data of 3178 consecutive patients, who underwent coronary artery bypass grafting at Vilnius University Heart surgery Clinic between January 1, 2000 and December 31, 2004 were analysed. Obesity was defined as body mass index > 30.0 kg/m2. Obese patients (n=887) were compared to remaining group of patients. Preoperative risk factors, postoperative outcomes, mortality rates were analysed. Associations between obesity and postoperative outcomes were analysed. 

In a prospective observational study we assesed nutritional status of 211 consecutive cardiac surgery patients with a nutritional risk screening form, which contained BMI, food intake, weight lost and stress factor. We evaluated mortality, ICU stay and frequency of impaired healing in the groups in nutritional risk and with normal nutrition.

We identified 54 from 211 (25,6%) patients as in nutritional risk. Both groups did not significantly differ in age, BMI, left ventricle function, preoperative serum albumin level, prevalence of chronic renal failure or perifery vascular disease. There were significantly more diabetics (51,9% vs. 34,2%, p<0,05) and patients with COPD (30,8% vs. 10,3%, p<0,001) in risk group. We found out the rate of complicated wound healing 12,3% (all sites and grades). There was significantly higher rate of complicated wound healing (28,3% vs. 7% p<0,0001) and longer ICU stay (51,6 vs. 24,2 hrs., p<0,01) in group in risk compared to group without risk. There was trend to higher mortality in risk group, statisticaly nonsignificant(9,4% vs. 3,2%). We identified diabetes, COPD and nutritional risk as to be preoperative independent risk factors of impaired healing in elective cardiac surgery by multivariate analysis.CONCLUSION. Cardiac surgery patients have a similar prevalence of nutritional risk as general population of patients. Simple screening form is able to identify group of patients in increased risk of impaired healing. Maximum SOFA during first three days (maxSOFA3d) and deltaSOFA between first and third postoperative days (deltaSOFA31) revealed to have strongest correlation to mortality (p=0.005, ROC area 0.793 and p=0.006, ROC area 0.0784 respectively). The maxSOFA3d of 15 points corresponded to mortality with sensitivity of 0.000 and specificity of 0.012. MaxSOFA3d correlated to the ICU stay (p=0.001).CONCLUSION. The sequential assessment of organ dysfunction during the first three days postoperatively is an independent predictor of mortality and morbidity in cardiac surgery patients.

Hájek R 1 , Rùžièková J 1 , Zezula R 1 , Fluger I 1 , Nìmec P 1 , Jarkovský J 2 , Nemethová D 2 1 Cardiac Surgery, University Hospital Olomouc, Olomouc, 2 Center of Biostatistics, Masaryk University, Brno, Czech Republic INTRODUCTION. Thromboleastography (TEG) is reliable and extensively used method of haemostasis monitoring. Using TEG as a bed-side method, we are able to detect a coagulation disorders, especially hypercoagulation and fibrinolysis METHODS. In prospective randomized study two groups of elective cardiac surgery patients were compared. Patients of Group A (n=144) were monitored both conventional lab tests and simultaneously with TEG. The following TEG measurements were performed: 1st -baseline after the anesthesia induction, 2th-at rewarming on CPB (with heparinase) and 3th-immediately after ICU admission (both nativ and heparinase). Patients of Group B (n=146) were monitored only using lab tests. Pre and postoperative coagulation status, incidence of thrombocytopenia, fibrinolysis,blood loss , transfusion therapy, surgical reexploration were evaluated. Changes of hemostatic profile using TEG diagnostic algorithm and also changes of pre-and postop.lab tests were evaluated RESULTS. Both groups were comparable by age (66,1/67,4) , male gender (72%,7/ 68,5%) and surgery type. The lab coagulation tests including platelet count were within normal range in both groups before surgery. No diference between both groups were recorded in : average blood loss during and postoperative, incidence of surgical reexploration because of bleednig , red blood cell, fresh frozen plasma and platelet transfusion and using of aprotinin. In both groups lab values of Quick test, platelet count and fibrinogen were lower and aPTT and TT were higher after surgery. The changes of TEG parameters characterised by coagulation index : CI1>CI2, CI1<CI3. Frequency of coagulagulation patterns: TEG 1 : enzymatic hypercoaguability 14,1%, platelet hypercoag. 13,3%, sec.fibrinolysis 9,4%. TEG 2 : low platelet function 14,1%, primary fibrinolysis 14,1%, low clotting factors 7,8%. TEG 3 (heparinase): enzymatic hypercoag.. 9,4%, platelet hypercoag. 9,4%, low platelet function 9,4%. Only one parameter-Quick test value(%) correlated with ECC duration (R-0,23, p<0,01)in both groups.

This study shows no diference of therapy between groups monitored with TEG compared with conventional lab tests. Most of patients in TEG group showed the signs of hypercoagulation on TEG before and after elective surgery. . 

To achieve a better glucose control in diabetic cardiac surgery patients a three to five-fold increase of basal insuline dose has been suggested. (1) .Our objective was to determine wether three or five-fold increase in basal insulin-dose during hypothermic CPB makes a better glycemic control without risks.METHODS. 74 type II diabetes patients were included in this prospective study. Two hours before surgery a continuous endovenous insulin infusion was started to achieve the target glucose level RESULTS. (Median+/-SD)29 pts were excluded due to off-pump surgery. One due to continuous hypoglycemia .ITG showed lower blood glucose levels(160 +/43 mgdl-1)than CG(194+/-69mgdl-1) during intraoperative period (p<0.05). 35% of ITG and 12% of CG patients presented at least one blood glucose level.Mean time with blood glucose levels CONCLUSION. 1-In Type II diabetic patients sheduled to cardiac surgery a five-fold increase in insulin dose at the begining of CPB achived intraoperatively safe and better glycemic control than three-fold increase;.2-Patients with better glycemic control had less infections and shorter hospital stay as it was also demonstrated by others (2) .This results give support to stablish Insulin protocols that allow a tight glycemic control in the perioperative setting.

Giuliano K K 1 1 Patient Monitoring, Philips Medical Systems, Andover, United States INTRODUCTION. The purpose of this research was to develop a predictive model for the early identification of sepsis using the currently recommended physiologic parameters that are continuously or frequently monitored in the critical care setting.

Data from the Project IMPACT ® international dataset were used to assess whether a combination of the physiologic parameters of heart rate, mean arterial blood pressure, body temperature and respiratory rate could distinguish between critically ill adult patients with a diagnosis of sepsis and those without a diagnosis of sepsis in the first 24 hours of intensive care unit admission.

All four predictor variables used in the analyses (respiratory rate, heart rate, mean arterial blood pressure, and temperature) differed significantly between the septic and nonseptic patient groups. However, using logistic regression, only two out of the four predictor variables (mean arterial blood pressure and temperature) were independently associated with being septic. According to Hosmer and Lemeshow goodness-of-fit tests, the logistic regression model was a good fit and explained between 10.2% and 13.6% of the variance. Using the significant predictors of temperature and mean arterial blood pressure, the odds ratio for having sepsis was 2.126 for patients with a temperature of 38OC or higher and 3.874 for patients with a mean arterial blood pressure of less than 70mmHg. In addition, the odds of having sepsis were 4.63 times greater if the patient had both of these physiologic conditions present.

The results of this research provide support for the use of some of the currently recommended clinical monitoring guidelines for patients with sepsis. However, the results also underscore the limitations of using these variables for sepsis monitoring, since this group of variables alone was not sufficient for discriminating between critically ill patients with and without sepsis. More work needs to be done to see if these variables would perform better if different cut-off values were used. 

Zubani F 1 , De Peri E 1 , Rasulo F 1 , Candiani A 1 , Latronico N 1 1 Intensive Care Unit, Spedali Civili, University Hospital of Brescia, Brescia, Italy INTRODUCTION. More than 70 percent of patients with sepsis syndrome or septic shock present altered mental status manifested by decreasing attention, disorientation, agitation, obtundation and in worst cases profound stupor and coma (Septic Encephalopathy). We don't know the exact physiopathological mechanism which cause SE, but many clinical studies have shown that cerebral blood flow (CBF) is reduced in these patients. The current study was performed to evaluate the behaviour of cerebrovascular autoregulation during systemic inflammatory response syndrome (SIRS), sepsis syndrome, septic shock and multiple organ failure (MOF).

We have studied all patients with SE admitted into the Intensive Care Unit of the Spedali Civili University Hospital of Brescia from January 2004 to September 2004. Cerebral autoregulation has been evaluated bilaterally in the MCA territory with theTransient Hyperemic Response Test (THRT).

Twelve patients were included in this study and 50 THRT have been totally performed. Cerebral autoregulation was impaired in 64% of THRT: the two conditions most associated with worst cerebrovascular response are sepsis (66,6%) and MOF (80%); patients with septic shock have shown unexpectedly the best autoregulatory response. In patients with infections caused by gramnegative organisms cerebral autoregulation was impaired in 100% of measurements: there are many evidences in literature about endotoxin's ability to influence cerebral blood flow. Another important factor able to influence the behaviour of cerebral blood-vessels is PaCO2: the effect of hypercapnia is more evident in patients with septic shock and with MOF, particularly, the share of patients with septic shock with cerebral autoregulation completely impaired, was hypercapnic in 100% of measurements.

Cerebral autoregulation was impaired in the most part of measurements. Gramnegative organisms and hypercapnia play a fundamentally roll in the loss of this mechanism. CONCLUSION. Platelet transfusion is associated with longer ICU stay and 15% increased risk of death.

Rudiger A 1 , Fischler M 2 , Harpes P 3 , Gasser S 4 , Hornemann T 5 , Von Eckardstein A 5 , Maggiorini M 2 1 Wolfson Institute of Biomedical Research, University College London, London, United Kingdom, 2 Medical ICU, University Hospital, 3 Department of Biostatistics, University, Zurich, 4 Medicine, Regional Hospital, Zofingen, 5 Clinical Chemistry, University Hospital, Zurich, Switzerland INTRODUCTION. B-type natriuretic peptide (BNP) and its N-terminal portion (NT-proBNP) may be useful in the assessment of cardiac preload in patients with chronic heart failure. However, it remains controversial whether or not this option is still valid in critically ill patients. To resolve this question we sought to establish the relationship between natriuretic peptide levels and surrogates of cardiac preload and inflammation in this kind of population.METHODS. This retrospective study included 12 critically ill patients with heart failure and/or refractory shock, all monitored with a pulmonary artery catheter (PAC). Linear correlations between hemodynamic and laboratory parameters were performed using relative differences and described by the Pearson correlation coefficient (r). A mixed linear model for repeated measurement was used to control for repeated effects.

The analysis included 75 measurements from patients with heart failure (n=6) and septic shock (n=6). Mean (SD) age was 65 (15) years, and 67% were men. ICU-and hospital mortalities of the population were 59% and 67%. BNP and NT-proBNP correlated (p<0.001) well with C-reactive protein (r=0.65 and r=0.67), to a lesser extent with leukocyte count (r=0.40 and r=0.47) and central venous pressure (r=0.39 and r=0.27), but not (p>0.05) with the pulmonary artery occlusion pressure (r=0.12 and r=0.12). These relationships were confirmed in mixed linear model analyses for repeated measurements.

Supported by other clinical observations and evidence from laboratory studies, our results suggest that inflammation is a important stimulus for BNP and NT-proBNP elevations in humans. Natriuretic peptide levels may therefore not be used as surrogates of cardiac preload in critically ill patients with heart failure or shock. 

Animal studies suggest that melatonin plays an adjunctive role in defence mechanisms to overcome severe illness and, accordingly, melatonin seem to affect morbidity and mortality.We report on correlations between nocturnal melatonin serum levels and measures of illness severity in 302 patients consecutively admitted to a medical intensive care unit.

On the day of admittance at 02:00 h am blood for the determination of serum melatonin levels was obtained and illness severity was assessed according to the Acute Physiology And Chronic Health Evaluation score (APACHE) and the Therapeutic Intervention Scoring System (TISS).

For the entire study group there was a weak negative correlation between TISS and nocturnal melatonin concentration (r = -1.22, p<0.04) while such correlation was not observed for melatonin and APACHE. Subgroup analysis revealed that in patients with sepsis both APACHE and TISS scores correlated negatively with nocturnal melatonin concentrations (n = 14, APACHE: r = -0.656, p<0.02; TISS: r = -0.544, p<0.05). Such correlation did not occur in other disease entities like coronary syndromes or intoxications.

Our study indicates that melatonin is specifically affected by serious infectious disease and low melatonin levels may contribute to the adverse outcome of sepsis.

Baykara N 1 , Aydemir E 1 , Solak M 1 , Toker K 1 1 Anesthesiology and Reanimation, University of Kocaeli, School of Medicine, Kocaeli, Turkey

The purpose of the present study to assess changes in antidiuretic hormone (ADH), growth hormone(GH) levels and hemodynamic response during a standart weaning protocol in patients with COPD.

This study was carried out in 15 patients undergoing ventilatory treatment with synchronized intermittent mandatory ventilation (SIMV)+PEEP for respiratory failure due to COPD. Their durations of mechanical ventilation (MV) were between 3-7 days. Exclusion criteria were:abnormal left or right ventricular function,abnormal liver or renal function,diabetes mellitus,CNS disease or MV exceeding one week. Weaning was carried out in 3 stages of 60 min each, from 1 / 2 of the initial rate of SIMV (SIMV1/2 ) +PEEP, to continuous positive airway pressure (CPAP), to spontaneous breathing. Systolic blood pressure, diastolic blood pressure,heart rate,central venous pressure,pulmonary capillary wedge pressure,cardiac output,hourly urine output,plasma osmolality and ADH, GH were measured during at each ventilatory condition.

Hemodynamic parameters did not change significantly among the ventilatory conditions. ADH concentrations during SIMV+ PEEP and SIMV I /2+PEEP were similar and were significantly higher than during spontaneous breathing. ADH concentration during CPAP was not significantly different from spontaneous breathing. Even though statisticallyinsignificant,hourly urine output was higher during CPAP and spontaneus breathing than during SIMV+PEEP and SIMV1/2+PEEP modes. GH level did not change significantly among ventilatory conditions.

Accordingly, weaning appears to be well tolerated from a hemodynamic standpoint in COPD patients with normal cardiac function after short term MV. CPAP is the ventilator mode causing the least ADH secretion in patients with COPD.

Jukes A L 1 , Saayman A G 1 1 Critical Care Directorate, University Hospital of Wales, Cardiff, United Kingdom

Enteral feeding is the preferred method of nutritional support in the critically ill patient (Jolliett et.al., 1999) . The enteral feeding protocol within our unit advocates prompt replacement of wide-bore tubes with fine-bore feeding tubes once enteral tube feeding is established to maximise patient comfort and safety. The aim of this review was to compare the current fine-bore feeding tube used within the critical care directorate (CCD), Medicina (Entrafeed, 7fg or ENG) with that manufactured by Merck, (Corflo, 8fg or CNG). It was hypothesised that as a result of the specific features of the CNG tube, it would be easier to aspirate; reduce the incidence of occlusions; and have increased radio opacity when compared with the ENG.METHODS. An audit proforma was completed for 41 patients who had a fine-bore feeding tube placed within the CCD: 20(ENG); 21(CNG) placed. The patients were followed until feeding was stopped due to a complication, or no longer required. Chest x-rays were reviewed by a consultant at the end of the study, unaware of NG type.

All nasogastric feeding tubes were placed by medical staff. Very few measured the tube length required to insert prior to placement. Auscultation, was used in 24% of tubes placed. Aspiration of gastric contents was attempted in 68% of tubes but only obtained in 10(24%)tubes (7 ENG, 3CNG). Only 5 of these had a pH of 4 or less, confirming gastric placement. All patients received a chest x-ray, visibility comparable (17 ENG and 16 CNG clearly visible on x-ray). There were 5 occlusions (4 ENG, 1 CNG). Many tubes were accidentally displaced or pulled out by patients (6 ENG, 11 CNG). The majority of tubes (76%) remained insitu for 14 days or less (14 ENG, 17 CNG).

The results of the review did not warrant a change in the type of nasogastric feeding tube used within the CCD. It has highlighted that education and training of doctors is required within the CCD regarding the placement, and appropriate methods used to confirm correct NG position. Radiological confirmation of NG tube position is advised on initial placement in critically ill patients. However, attempts should be made to aspiration and pH test to assist subsequent confirmation, avoiding unnecessary x-rays. 

Administration of lipid solutions to critically ill patients may be associated with changes in laboratory and gas exchange parameters. Lipid solution composure may impact in these changes. METHODS. Investigate gas exchange and hemodynamic changes in patients with ARDS treated with a lipid solution enriched with w-3 fat acids. Prospective, randomise, double blind study of parallel groups. Sixteen patients with ARDS within 48 hours of diagnosis were randomised in two groups. Group A (n=8) received lipid solution Lipoplus® 20% B.Braun Medical (50% MCT, 40% LCT, 10% w-3) and group B (n=8) Intralipid® 20% (100% LCT). Lipid solution was given over 12 hour at 0.12 mg/kg/h. Hemodymanic and gas exchange parameters were analysed before treatment and at 12 and 24 h of lipid solution infusion. Statistics: BMDP, Wilcoxon and Sign tests.

The following table shows the percentage of change after lipid solution infusions compared with baseline levels. No side effects were observed with both lipid solutions in the patients studied. 

Immunonutrition is a balanced nutritional support containing immune enhancing substances like arginine and omega-3-fatty acids. The aim of this study is to find out if immunonutrition can reduce the number of blood transfusions and blood loss in cardiac patients.

In this prospective and double-blind study we randomised 130 patients who either received immunonutrition or an isocaloric placebo. Comparison of the group was done with repeatedmeasures ANOVA.

We could not find a difference concerning postoperative blood loss and blood transfusions.

1086 ± 609 1018 ± 834 (mean ± SD) Number of blood transfusions 1,3 ± 2 1,7 ± 2,7 per patient (mean ± SD) infection rate (%) 12 13 Length of stay (hospital) 9 ± 7 9 ± 14 (median ± SD) CONCLUSION. We could not prove a significant advantage of immunonutrition as reported in the literature. (1) . The objective was to apply RIFLE in the postoperative cardiac population and to analyze outcome, length of ICU stay (LOS) and mortality for each subgroup.

We stratified patients according to their preoperative plasmatic creatinine (PPC in mg/dl). Theoretic plasmatic creatinine is obtained according to simplified formula MDRD (modification of diet in renal disease) (2) . The expected mortality was calculated using logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) (3).

We evaluated 1814 patients: 977 with PPC < 1; 629 with PPC < 1'5; and 208 patients were classified according to "R" (PPC 1'5-2), "I" (PPC 2-3), "F" (>3 without renal replacement therapy (RRT)), "Fo" (oliguria treated by RRT). "Fo" subgroup suffered major complications than non-oliguria subgroups (p< 0'05). CONCLUSION. 1. Mortality was equal in "I" and "F" patients, but higher than "R" group (p < 0'0001) and lower than "Fo" (p < 0'0001). 2. LOS was similar in "RIF". 3. "Fo" LOS was longer than "RIF" LOS. 4. "Fo" group suffered more severe complications and developed acute renal failure as a part of multi-organ dysfunction syndrome (MODS), which needed multiple organ support therapy (MOST). 

Standard hemofiltration is reported to improve hemodynamics and survival in animal models of septic or endotoxic shock. In humans, despite the lack of convincing data, hemofiltration is thought to be the gold standard to treat acute renal failure (ARF) in case of septic shock. We compared survival of septic ARF treated with IHD or continuous veno-venous hemodiafiltration (CVVHDF) in the prospective randomised Hemodiafe study.

We performed post-hoc analysis of data from a prospective, multicenter (21 centers) randomised study. Patients with ARF (urea > 36 mmol/l or serum creatinine > 310 micromol/l or oliguria) associated with MODS (LOD > 5) and needing renal replacement therapy were enrolled. They were randomised to receive IHD or CVVHDF performed with the same membrane (polyacrylonitrile, AN69) and a bicarbonate based buffer. Guidelines to improve hemodynamic tolerance and efficiency were provided. Primary endpoint was 60-day survival evaluated in an intention-to-treat analysis. Septic ARF was defined if any sepsis was diagnosed before the occurrence of ARF. Data are presented as mean±SEM

Among the 360 patients enrolled in Hemodiafe, the overall septic population consisted of 224 pts (66±13 y.o., M164/F60, SAPS II 65±14, LOD score 9.8±2.4) randomised in the IHD (n=126) or in the CVVHDF group (n=98). Eighty-nine percent of patients had septic shock and 97 % were under mechanical ventilation. Mean serum urea and mean serum creatinine were respectively 30.4±13 mmol/l and 388±151 micromol/l just before the first session. The 60-day survival in the whole population of the study was 32 % with no significant difference between the two groups (respectively 32,6 % and 31,5 % in CVVHDF and IHD). Survival was significantly lower in septic patients compared to non septic (26,3% versus 41,8 % P = 0,007). In septic patients, we found no significant difference in survival between the two treatment groups (respectively 23,5 % versus 28,6 % in CVVHDF and IHD P = 0,23).

Standard CVVHDF does not offer any survival benefit compared to IHD to treat septic ARF associated with MODS. 

Methods for evaluation of glomerular filtration rate -GFR-(24-hours creatinine clearance -24hCrCl-or Cockcroft-Gault formula -CG-) are not well suited for critically ill patients: 24hCrCl requires a steady state and CG has not been completely validated. Shorter time CrCl can be used but this method has not been evaluated in unstable patients. We intend to demonstrate that 2hours CrCl (2hCrCl) is similar to 24hCrCl even in unstable patients

Prospective study on adult ICU patients. We calculate 2hCrCl, 24hCrCl and CG estimate. 2hCrCl was measured at the beginning of the 24hCrCl interval. Age, sex, weight and diagnosis were recorded and for the 24 hours period registered SOFA, nutrition, diuretics, nephrotoxics, hypotension or hypoxemia, use of vasopressors and regularity of urine flow. We defined 2 groups: patients recently admitted (less than 24 hours) and in stable condition and expected stable renal function. Statistical analysis: Paired T-test, Pearson Correlation Coefficient and Partial Correlation Coefficients RESULTS. 93 patients, 41 (44.1%) on admission and 52 (55.9%) in stable condition. In 2 cases (2.2%) 2hCrCl was lost and in 11 (11.8%) 24hCrCl because methodological problems. 80 patients completed the protocol (43 stable and 37 on admission) and were included for analysis. No differences were detected in both groups. Mean 2hCrCl was 124.08±88.2 and 24hCrCl 117.46±72.9 mL/min with a mean difference of 6.6±62.1 (p 0.34). 2hCrCl correlated well with 24hCrCl (coefficient 0.72, p<0.001) and less well with CG formula (coefficient 0.67, p<0.01). These coefficients were not affected by group of patient, antecedents, sex, age, SOFA score, and use of diuretics, nutrition or nephrotoxic drugs, hypotensive episodes, hypoxemia, use of vasopressors and irregular urine flow. We observed less aggregation for values in the high range of clearance; analysing only patients with CrCl below 80 (n=31) the correlation was even higher (0.73, p<0.05)CONCLUSION. 2hClCr correlates well with 24hCrCl, is easier to obtain, is most reproducible and eliminates unnecessary delays and methodological problems complicating 24hCrCl. 2hCrCl can be a good estimate of GFR in ICU, even in unstable patients