Introduction The use of moderate hypothermia during experimental cardiac surgery is associated with decreased expression of tumour necrosis factor (TNF)-α in myocardium and with myocardial protection. In order to identify the cellular mechanisms that lead to that repression, we investigated the effect of hypothermia during cardiac surgery on both main signalling pathways involved in systemic inflammation, namely the nuclear factor-κB (NF-κB) and activating protein-1 pathways.
Objectives Antithrombin (AT) has been proven to have major impact on perioperative activation of the coagulation system. The aim of this prospective, controlled, single-blind clinical trial was to determine the impact of AT substitution on perioperative thrombin formation. Methods Forty male coronary artery bypass graft patients participated in the trial. Prior to skin incision, 30 patients received AT according to a formula targeted at 120% AT activity before extracorporeal circulation (ECC), plus an additional 1000 U (group A, n = 10), 2000 U (group B, n = 10) or 3000 U (group C, n = 10) of AT in order to compensate for increased consumption during ECC. Control patients did not receive any AT substitution (group D, n = 10). The following parameters were determined perioperatively and until the fifth postoperative day: AT levels, parameters of coagulation activation (prothrombin fragment F 1.2 , thrombin-antithrombin complex, D-dimer), inflammation (IL-6) and myocardial perfusion (troponin). Statistical comparison between groups was performed using analysis of variance, followed by Fisher's PLSD (P < 0.05) after ECC. Results AT substitution resulted in a significant increase in AT during ECC and until the first postoperative day (POD1), followed by a steep decrease at days 2-5. AT substitution attenuated thrombin generation significantly, as indicated by decreased concentrations of prothrombin fragments F 1.2 , thrombin-antithrombin complexes and D-dimer at the end of surgery. Troponin was significantly higher during the postoperative period in patients who did not receive AT substitution (Fig. 1). Conclusions A substantial decrease in AT must be taken into account not only during ECC but also in the early postoperative period, indicating major enhancement of coagulation activation. High-dose AT substitution attenuates coagulation activation significantly. Attenuation of hemostatic activation may reduce postoperative complications, as lower postoperative troponin levels may indicate in AT substituted patients.
Introduction Community-acquired pneumonia remains a common condition worldwide. It is associated with significant morbidity and mortality. The aim of this study was to evaluate conditions that could predict a poor outcome. Design Retrospective analyse of 69 patients admitted to the ICU from 1996 to 2003. Demographic data included age, sex and medical history. Etiologic agents, multiorgan dysfunction, nosocomial infections, SAPS II and PORT scores were recorded for each patient. For statistical analysis we used a t test, chi-square test and Mann-Whitney U test on SPSS ® . A value of P less than 0.05 was considered significant. Results Forty-seven patients were male and 22 patients were female. Mean age was 52 years. Sixty-seven percent had serious pre-morbid conditions including pulmonary disease (34.8%), cardiac problems (36.2%), diabetes (13%) and chronic liver disease (5.8%); 40.6% were smokers, drug abusers or alcohol dependents. Sixtyeight patients required invasive mechanical ventilation. The average length of ventilation was 13.5 days, median 8 days. The mean SAPS II score was 40.14 and the mean PORT score was 141. The mortality rate was 27.5% (SAPS II estimated mortality, 35%). Complications reported were ARDS (40.6%), septic shock (34.8%), acute renal failure (2.9%), cardiac arrest (8.7%) and nosocomial infeccions (46.4%). Mortality rates were higher for previous hepatic (75%) and metabolic (33%) diseases. We found a close association between crude mortality and SAPS II score (P = 0.003) and development of complications (P = 0.0028). Respiratory dysfunction (P = 0.006) and septic shock (P = 0.022) were most significantly related to mortality. No significant differences were founded regarding age, comorbidities, PORT score, etiologic agents, nosocomial infections and length of invasive mechanical ventilation. Conclusions Previous hepatic chronic disease was strictly related to higher mortality as well as isolation of MRSA. ARDS and septic shock predicted a poor outcome. SAPS II score was the best severity indicator of mortality. Objective It is known that the closed tracheal suction system (CTSS) produces less hemodynamic and gasometric deterioration than an open tracheal suction system (OTSS). Use is limited because no decrease in the incidence of ventilator-associated pneumonia (VAP) was found and also because it is more expensive. But, is daily periodic change of the CTSS necessary? The aim of this study was to analyze the incidence of VAP using a CTSS without periodic change versus an OTSS. Methods It is a prospective study of ICU patients from 1 January 2004 to 31 October 2004. Patients who required mechanical ventilation (MV) were randomized into two groups: one group was suctioned with CTSS without periodic change and another group with OTSS. An aspirate tracheal swab and a throat swab on admission and afterwards twice weekly were taken. VAP was classified based on throat flora in endogenous and exogenous samples. The statistical analysis was performed by chi-square test and Student's t test, and w...
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