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Background Medication discrepancies between actual and documented therapy often arise at patient transfer between wards. Intensive care unit(ICU) patients are particularly prone because of polymedication, frequent therapy changes and impaired consciousness, with also an increased risk for drug related problems (DRPs). Purpose To determine the type and frequency of medication discrepancies and DRPs on admission, during ICU stay and on transfer to the ward, and the clinical pharmacist’s role in prevention. Material and methods This was a prospective before and after study on adult patients after informed consent, in two ICU units (general and cardiology; 12 beds) in a tertiary care university hospital. During an 8 week observation period (October 2015 to January 2016) a clinical pharmacist conducted a standardised drug reconciliation on ICU admission, twice weekly drug review and review on patient transfer. These data were compared with physicians’ notes and prescriptions. Discrepancies and potential DRPs were classified using a standardised flow chart. During a subsequent 16 week intervention period (January–May 2016), the pharmacist additionally entered compiled drug histories in the patient files, participated in clinical rounds and proactively provided feedback. Results 111 patients were included (observation 50; intervention 61). On ICU admission, we found a significant difference in the number of drugs found after medication reconciliation by the physician compared with the pharmacist (observation 5.5 vs 8.5/patient; intervention 6 vs 8/patient; both p Conclusion A clinical pharmacist, integrated in a multidisciplinary ICU team, can make a significant contribution to medication safety by preventing drug discrepancies on admission, by identification of DRPs during ICU stay and by reducing discrepancies on transfer to a normal ward. No conflict of interest

To investigate which factors contribute to conflicts between healthcare professionals and family members from ethnic minority groups during medically critical situations in hospital.Descriptive, ethnographic research.Ethnographic fieldwork was carried out in one intensive care unit (ICU) of a multi-ethnic urban hospital in Belgium in the period January-June 2014. Data were collected by means of negotiated interactive observation, in-depth interviews with healthcare professionals and examining the patients' medical files. Data were analysed using grounded theory procedures.Conflicts were primarily related to the participants' different views on 'good care'. Healthcare providers' (HCPs') views on good care were primarily grounded on a biomedical care model, whereas families' views on good care were mainly inspired by a holistic care approach. According to HCPs, giving good care included fighting the disease efficiently with great scientific competence, but family members considered this rather as attending to the patient and giving bedside care, amongst other things. The HCPs' biomedical vision on good care was strengthened by the strict application of ward regulations, characterizing the ICU setting. The families' holistic views on good care were strengthened by specific ethno-familial characteristics, including their ethno-cultural background. However, ethno-cultural differences only contributed to conflict if the policy context on the ICU could provoke this conflict.Conflicts cannot be exclusively linked to ethno-cultural differences. Structural, functional characteristics of the ICU contribute substantially to conflict development. Effective conflict prevention should, therefore, not only focus on ethno-cultural differences but should also focus sufficiently on the structural context and ward policy.

Background Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with severe respiratory failure. Indirect calorimetry (IC) is a safe and non-invasive method for measuring resting energy expenditure (REE). No data exist on the use of IC in ECMO-treated patients as oxygen uptake and carbon dioxide elimination are divided between mechanical ventilation and the artificial lung. We report our preliminary clinical experience with a theoretical model that derives REE from IC measurements obtained separately on the ventilator and on the artificial lung. Methods A patient undergoing veno-venous ECMO for acute respiratory failure due to bilateral pneumonia was studied. The calorimeter was first connected to the ventilator and oxygen consumption (VO2) and carbon dioxide transport (VCO2) were measured until steady state was reached. Subsequently, the IC was connected to the membrane oxygenator and similar gas analysis was performed. VO2 and VCO2 values at the native and artificial lung were summed and incorporated in the Weir equation to obtain a REEcomposite. Results At the ventilator level, VO2 and VCO2 were 29.5 ml/min and 16 ml/min. VO2 and VCO2 at the artificial lung level were 213 ml/min and 187 ml/min. Based on these values, a REEcomposite of 1703 kcal/day was obtained. The Faisy–Fagon and Harris–Benedict equations calculated a REE of 1373 and 1563 kcal/day. Conclusion We present IC-acquired gas analysis in ECMO patients. We propose to insert individually obtained IC measurements at the native and the artificial lung in the Weir equation for retrieving a measured REEcomposite.

Study objective: The level of microalbuminuria is thought to reflect the severity of inflammation-induced systemic vascular permeability and may have prognostic value with regard tc organ dysfunction and survival. N-acetylcysteine (NAC) has been shown to decrease capillary leakage in experimental sepsis. The present study investigated the effect of early treatment with NAC on microalbuminuria and organ dysfunction in severe clinical sepsis. Design: Prospective, randomized, placebo-controlled study. Setting: A 24-bed multidisciplinary ICU in a university teaching hospital. Patients: Thirty-five patients included within 4 h of fulfilling consensus criteria of severe sepsis. Interventions: Patients were randomly assigned to receive either NAC (continuous infusion starting with 50 mg/kg/4 h followed by 100 mg/kg/24 h for 44 h; n = 18) or placebo (n = 17) in addition to standard therapy. Measurements and results: Urine samples for measurement of microalbuminuria/creatinine ratio (MACR) were collected on inclusion and after 4 h, 24 h, and 48 h. Severity of illness and degree of organ failure were determined by using, respectively, the APACHE (acute physiology and chronic health evaluation) II score and the sequential organ failure assessment (SOFA) score. The MACR did not differ over time between the placebo- and the NAC-treated groups. SOFA scores were comparable between both treatment groups at baseline (6.2 ′ 3.9 vs 6.5 ′ 2.7, NAC vs placebo; p = 0.6) and increased during treatment in the NAC-treated patients but not in the placebo group (7.9 ′ 3.7 vs 5.9 ′ 2.5, p = 0.09 and 7.7 ′ 3.8 vs 5.1 ′ 2.1, p < 0.05; NAC vs placebo, respectively, at 24 h and at 48 h). The cardiovascular SOFA score progressively increased during NAC treatment, reaching higher values as compared to time-matched scores in the placebo group. Conclusions: Early NAC administration does not influence the course of MACR in severe clinical sepsis, suggesting that NAC might not attenuate endothelial damage in this condition. NAC treatment even aggravated sepsis-induced organ failure, in particular cardiovascular failure.

At that time only a fewof the recommended measures were based onscientific evidence, but the medical world acceptedthem as international precepts that formed the goldstandard for resuscitation care. Although they hadbeen evolved only on the basis of national experienceand requirements within the USA, they quicklyacquired medicolegal significance both within andbeyond the borders of the USA.Since then, many additional national guidelines havebeen developed and published to replace or comple-ment the 1974 standards.

Objective: To determine which patients in septic shock may develop myocardial depression during adjuvant therapy with N-acetylcysteine (NAC). Design: Open, interventional study. Setting: Medicosurgical intensive care unit in a university hospital. Subjects: Twelve consecutively enrolled patients with acute pneumonia-induced septic shock. Interventions: Following fluid and catecholamine resuscitation, all patients received NAC as a 150 mg/kg "bolus" over 15 min, followed by a continuous infusion of 50 mg/kg/4 h and 100 mg/kg/16 h. Measurements and main results: Assessment of left ventricular (LV) function by transoesophageal echocardiography and plasma measurements of cardiac troponin I (cTnI) were performed after haemodynamic stabilization and repeated 24 h later. Total plasma NAC amount was measured by HPLC before administration and 0.5, 2, 6 and 24 h post-infusion. Six patients were cTnI-positive (cTnI values exceeding 0.4µg/l) at baseline (mean value 3.8(0.5-12.3)µg/l) and at 24h (mean value 4.7(0.7-17...

Indirect calorimetry (IC) is considered to be the standard method for estimating energy requirements in intensive care unit (ICU) patients. Hence, most ICU clinicians still rely on various mathematical formulas to calculate caloric requirements in their patients. We assessed whether measurements obtained by IC reached agreement with the results of such commonly used equations.Retrospective study in consecutively hospitalized patients in a mixed medico-surgical adult ICU. Resting energy expenditure (REE) was measured by IC in all patients as a standard procedure within our routine nutritional care planning and simultaneously calculated from 10 distinct predictive equations. IC was performed with the VmaxTM Encore 29n calorimeter (VIASYS Healthcare Inc, Yorba Linda, CA). Bland-Altman plots and regression analysis were used to assess agreement between measured and calculated REE.The study included 259 critically ill patients: 161 subjects (62%) met final analysis criteria (age 63 ± 16 years; 58% males). Measured REE was 1571 ± 423.5 kcal/24 h with VO2 0.23 ± 0.06 L/min and VCO2 0.18 ± 0.05 L/min. Calculated values correlated very weakly with IC-derived measurements. Only the Swinamer equation and the Penn State 2010 reached an R²0.5. Widely used formulas in daily ICU practice such as the adjusted Harris Benedict, Faisy-Fagon, and ESICM '98 statement equations, reached R² values of respectively only 0.44, 0.49, and 0.41. Calculation resulted in under- as well as overestimation of REE. Global formulas reached no acceptable correlation in elderly or obese critically ill patients.In critically ill adult patients, measured REE poorly correlated with calculated values, regardless what formula was used. Our findings underscore the important role of IC to adequately estimate energy requirements in this particularly frail population.

Septic encephalopathy and critical illness polyneuropathy are two syndromes, appearing at different stages in critically ill patients. Their aetiology is unclear, but many arguments seem to associate them with respiratory insufficiency in a context of systemic inflammatory response syndrome (S.I.R.S.) and multiple organ dysfunction syndrome (M.O.D.S.). Septic encephalopathy appears early in the course of sepsis, diagnosis is based on clinical picture and electro-encephalogram. The exact pathogenesis is unclear. Prognosis is related to the underlying pathology, and treatment is supportive. Critical illness polyneuropathy is a predominantly motor axonal dysfunction, occurring in a setting of respiratory insufficiency, S.I.R.S., and M.O.D.S. A weaning problem often indicates the presence of critical illness polyneuropathy. Diagnosis is made on history, clinical picture and electromyographic studies. Indeed, motor and sensory conduction studies show a reduction of the amplitude of action potentials. In a later stage fibrillations and positive sharp waves emerge, with a further reduction of action potentials. Follow-up examinations reveal signs of axonal regeneration. The exact aetiology is unknown, but may be related to sepsis and M.O.D.S. Sepsis and M.O.D.S. are associated with the release of "mediator" substances, and somewhere in this cascade, there might be a toxin, influencing the nerve. A differential diagnosis with myopathy and neuromuscular transmission defects has to be made. Specific treatment is absent, and prognosis is related to the underlying pathology.

We report the case of a patient who co-ingested a tricyclic antidepressant (2500 mg of doxepin) and a neuroleptic drug (3500 mg of prothipendyl). Following overdose either agent can affect the central nervous and cardiovascular systems, inducing arrhythmias, conduction disturbances and hypotension. The presented case illustrates that a combined overdose of tricyclic antidepressants and neuroleptics enhances the possible toxic effects of each drug and especially the risk for adverse cardiac events. The clinical features and management of this combined intoxication are discussed. Treatment with sodium bicarbonate readily corrected a potentially life-threatening cardiac arrhythmia and is therefore suggested to be imperative in the treatment of these cases.

To investigate the effect of cisapride, a relatively new prokinetic agent, on gastric emptying in critically ill patients.Prospective, randomized, controlled study.Adult medical/surgical intensive care unit in a university hospital.Twenty-one consecutively enrolled patients, requiring prolonged mechanical ventilation and enteral feeding.Patients were randomized to receive either no cisapride or 10 mg of cisapride four times daily, which was added to a standard enteral nutrition feeding protocol.Gastric emptying was evaluated by daily measurements of gastric residue and on days 5 through 7 by bedside scintigraphy. Normal values for gastric clearance of a tracer-labeled test meal and for measurements obtained in the supine position were determined in ten healthy volunteers. The mean time at which 50% of the technetium 99m-labeled test meal was eliminated from the stomach (T 1/2) in this control group was 31 +/- 15 mins. In ten critically ill patients (enteral nutrition group), gastric emptying was markedly delayed after 5 to 7 days of enteral feeding (mean T 1/2 = 78 +/- 40 mins; p.002 as compared with the control group). In contrast, patients treated with cisapride (cisapride group) showed an accelerated gastric emptying (mean T 1/2 = 18 +/- 7 mins; p.05 as compared with controls; p.005 as compared with enteral nutrition group). The mean gastric residue over a 1-wk period was also significantly lower in the cisapride group than in the enteral nutrition group (17.7 +/- 8.9 vs. 94.5 +/- 33.4 mL; p.001).The data indicate that gastric emptying in critically ill, sedated, and mechanically ventilated patients can be significantly improved by adding cisapride to a routine enteral feeding protocol.

Despite the use of increasingly potent antibiotics and aggressive cardiovascular monitoring and support, Gram-negative bacteremia and ensuing sepsis and septic shock remain a leading cause of morbidity and mortality after surgery and in critically ill patients. In previous years several new agents and techniques have been developed to improve management and outcome of severe Gram-negative infections. A recently introduced treatment is passive immunotherapy by administration of poly- or monoclonal anti-endotoxin antibodies. The current view--sustained by experimental and human studies--on the mechanism of protection afforded by immunotherapy is that the harmful effects of endotoxin are neutralized by cross-reactive antibodies to the core glycolipid structure of rough mutant Gram-negative bacilli. Two recent large clinical trials reported impressive results achieved through the use of monoclonal anti-endotoxin antibodies in certain subgroups of patients with Gram-negative sepsis. However, this treatment is empirical, expensive and it does not affect overall sepsis mortality. Cytokines such as tumor necrosis factor alpha and interleukin-1 play a pivotal role in sepsis. Experimental studies suggest that specific antagonism of these mediators might offer great perspectives for the treatment of Gram-negative sepsis. An early multi-pharmacological approach aimed at interruption of multiple steps underlying the inflammatory septic cascade will probably constitute the most promising future treatment of severe Gram-negative infectious disease.

The metabolic effects of chronic alcohol abuse can induce a broad spectrum of disorders. We describe the case of an initially unidentified alcoholic, poorly nourished woman who presented with ketoacidosis. She developed severe cardiac failure, which did not respond to classical treatment. The administration of intravenous thiamine resulted in an impressive recovery of cardiac function. Laboratory examinations confirmed the diagnosis of alcoholic ketoacidosis and cardiac beriberi. The clinical entity and treatment of these two uncommon disorders are discussed. If recognized early both diseases (and their combination) are fully reversible.

The efficacy of four analgesics, distinct concerning analgesic power and mechanism of action, was evaluated for pain relief in patients suffering from single peripheral injury. Patients were randomly allocated to receive either propacetamol (the pro-drug of paracetamol) 20 mg/kg i.v., piritramide 0.25 mg/kg i.m., tramadol 1 mg/kg i.v. or diclofenac 1 mg/kg i.v. Pain scores were measured by the patient using the visual analogue scale (VAS) and by an observer using a 4-point verbal rating scale (VRS). Cardiorespiratory variables and side effects were recorded. One hundred and sixty patients were included, 131 completed the study. Groups matched for demography and baseline pain levels. In general pain scores decreased with time. No significant differences were found between groups at any particular time point. VAS scores were significantly (p < 0.02) lower than baseline scores 30 minutes after injection in all treatment groups except for the piritramide group where significance (p < 0.01) was reached after 60 minutes. VRS score analysis showed a similar trend although significances differed. In the piritramide group significantly more side effects were noted than in the other groups (p < 0.05). We conclude that intravenous propacetamol, tramadol and diclofenac are equally efficacious for emergency analgesic treatment of single peripheral trauma.

Background: Cardiac depression in severe sepsis and septic shock is characterized by left ventricular (LV) failure. To date, it is unclear whether clinically unrecognized myocardial cell injury accompanies, causes, or results from this decreased cardiac performance. We therefore studied the relationship between cardiac troponin I (cTnI) and T (cTnT) and LV dysfunction in early septic shock. Methods: Forty-six patients were consecutively enrolled, fluid-resuscitated, and treated with catecholamines. Cardiac markers were measured at study entry and after 24 and 48 h. LV function was assessed by two-dimensional transesophageal echocardiography. Results: Increased plasma concentrations of cTnI (≥0.4 μg/L) and cTnT (≥0.1 μg/L) were found in 50% and 36%, respectively, of the patients at one or more time points. cTnI and cTnT were significantly correlated (r = 0.847; P Conclusions: These findings suggest that in septic shock, clinically unrecognized myocardial cell injury is a marker of LV dysfunction. The latter condition tends to occur more often in severely ill older patients with underlying cardiovascular disease. Further studies are needed to determine the extent to which myocardial damage is a cause or a consequence of LV dysfunction.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease often not recognized until it is far advanced. Medical management does not reverse the effects of the disease, nor does it prevent its progression. Pulmonary thromboendarterectomy is the preferred treatment. We present the case of a patient in whom CTEPH was mistaken for an interstitial lung disease with mediastinal lymph node enlargement. The mediastinal lymph node enlargement was due to vascular transformation of the lymph node sinuses (VTS). This is an unusual case of chronic thromboembolic pulmonary hypertension with vascular transformation of the lymph node sinuses.

Splenic abscess is an uncommon entity and usually results in the death of the patient when left undiagnosed. A case is presented where bacteraemia with an anaerobic Gram-positive bacillus was associated with splenic abscess. Despite treatment with splenectomy and antibiotics the patient developed a multiple organ dysfunction syndrome (MODS) and died. Of particular interest was the isolation of Clostridium novyi type A from the blood in a patient without gas gangrene but with splenic suppuration.

Three cases of community-acquired pneumonia (CAP), requiring intensive care admission, are presented. The clinical picture of a "typical" bacterial pneumonia in the three patients led to an initial empirical treatment with amoxicillin clavulanic acid or 2(nd) generation cephalosporins. The treatment had to be changed in all three because of clinical failure. Erythromycin was added to the therapy with good clinical evolution. Serology confirmed atypical organisms to be responsible. Only the chest X-ray might have suggested an "atypical" or a "viral-like" agent. A proposition is made for an empirical combination of antibiotics in severely ill patients with CAP with more than unilobar consolidation.

Conventional intermittent hemodialysis in the critically ill patient can be associated with hemodynamic and respiratory instability. Intermittent hemodialysis induced arterial hypotension might be detrimental. We therefore studied the influence of intermittent hemodialysis on systemic and regional oxygen transport in critically ill patients.Prospective descriptive study.Medical/surgical 24-bed intensive care unit in a university hospital.Eleven critically ill patients admitted to the intensive care unit (APACHE III score: 82 +/- 12) and developing multiple organ dysfunction syndrome with acute renal failure. All patients were mechanically ventilated and hemodynamically stable with inotropic support. Systemic oxygen transport variables were calculated, and arterial blood lactate concentration was measured before, during, and after intermittent hemodialysis. Tonometer PCO2 was measured using a tonometer, and arterial-tonometer CO2 gap was used as an indicator of intestinal intramucosal acidosis.Intermittent hemodialysis induced an increase in calculated systemic oxygen consumption (P0.01). During intermittent hemodialysis there was a significantly higher need of inotropic support (P0.05) to maintain arterial blood pressure, cardiac index, and calculated systemic arterial oxygen delivery. The arterial-tonometer CO2 gap increased significantly during and after the procedure.In critically ill patients with multiple organ dysfunction syndrome intermittent hemodialysis induces an increase in oxygen consumption. Despite higher inotropic support to maintain systemic calculated oxygen delivery intestinal intramucosal acidosis occurs during intermittent hemodialysis and may even persist after the procedure is terminated.

We describe the case of an adolescent who developed a severe but fully reversible cardiac dysfunction with low blood levels of carboxy haemoglobin (COHb = 10%) after a prolonged exposure to carbon monoxide. A 15-year-old male was admitted with a Glasgow Coma Scale of 8/15 with suspected postictal state and postanoxic encephalopathy. The cardiorespiratory failure which he developed soon after admission mandated mechanical ventilation, inotropic support and ultimately left ventricular support by intra-aortic balloon counterpulsation. The cardiac dysfunction was documented by radionuclide imaging and echocardiography. The patient fully recovered without neurological deficit. A low blood COHb concentration is a poor safety indicator since high tissue levels of accumulated carbon monoxide can be associated with coma and fulminant cardiorespiratory failure requiring advanced life support facilities. Language: en

Cimetidine is commonly used for stress ulcer prophylaxis in intensive care patients. Cimetidine contains an imidazole structure. Similar drugs have been shown to inhibit steroid synthesis by blocking cytochrome P450-dependent reactions in the adrenal cortex. It is suggested that bolus injections of cimetidine suppress the normal corticosteroid production. This might be deleterious since a decreased cortisol response seems to be associated with increased mortality during chronic severe stress. We therefore performed a prospective, randomized, and controlled study to assess the effect of a short-term continuous infusion of either cimetidine or ranitidine, a non-imidazole H2-pantagonist, upon cortisol secretion in a cohort of hemodynamically stable intensive care patients. Twenty patients were consecutively enrolled following determined inclusion criteria and divided in three treatment groups: 6 controls, 7 cimetidine- and 7 ranitidinetreated subjects. Both cimetidine (1200 mg) and ranitidine (200 mg) were administered by infusion pump over 24 hrs. A short corticotropin test was done within 24 hrs after admission (d0) and repeated 7 days thereafter (d7). On both occasions, plasma cortisol was measured immediately before the test and 30 min afterwards. The three treatment groups presented a normal cortisol response at d0 and d7. Peak cortisol levels after stimulation did not show any significant difference for both the cimetidine and the ranitidine group, either at d0 or at d7. Moreover, this response at d0 and d7 was also not significantly different from the one observed in the controls. From this study we can conclude that one week treatment with conventional intravenous doses of cimetidine does not induce significant alterations of the cortisol response in hemodynamically stable ICU patients.

Nosocomial pansinusitis (N P) is most often described in nasotracheally intubated patients with craniocerebral or facial trauma. We retrospectively reviewed its occurrence and complications in the course of prolonged mechanical ventilation in orotracheally intubated patients without maxillofacial or cranial injuries. N P was deemed to be present when (1) CT scan showed opacification and/or air-fluid levels in the maxillary, ethmoid and sphenoid sinuses and (2) aspiration of both maxillary sinuses yielded pus, cultures of which revealed a high concentration of micro organisms. Nosocomial pneumonia and bacteremia were considered related to the N P if the organisms found in the sinus were identical to those recovered from the blood and/or the bronchi. During an 18-month study period, 38 cases of sinusitis were diagnosed. N P was present in 13 patients: 18 organisms (12 Gram-negative, 5 Gram-positive and 1 Candida albicans) were isolated. Pneumonia occurred in 8 patients, 6 with multi-resistant Pseudominas aeruginosa and 2 with methicillin resistant Staphylococcus aureus. Pseudomonas aeruginosa was isolated from the blood, lung and sinus in two patients. This study demonstrates that N P is relatively frequent in patients requiring long-term mechanical ventilation, even in the absence of predisposing factors. N P in these patients is mostly monomicrobial with multi-resistant Pseudomonas aeruginosa and Staphylococcus aureus as the main causative agents.

SummaryA 58-year-old patient suffered from persistent Candida glabrata fungaemia. Transocsophagcal echocardiography detected a central venous catheterrelated intracardiac thrombosis. Cardiotomy permitted the removal of the catheter and its adherent clot. Candida glabrata was cultured from the thrombus.

Rationale: Nutrition plays a very important role in surgical patients. Malnutrition has been proven to be an independent risk factor in correlation to postoperative outcome. Little is known about the cumulative energetic intake of patients undergoing cardiac surgery, certainly when compared to their caloric needs. Methods: An observational study was conducted in patients undergoing elective CABG (Coronary artery bypass graft) or valve surgery at the University Hospital Brussels, from February 2012 to April 2012. Preoperative nutritional status was assessed using the NRS 2002, a blood sample and a clinical evaluation. Metabolic needs were calculated using the Harris Benedict formula. The daily caloric intake was objectified by a nutritionist, on the Intensive Care Unit and the ward. Intravenous solutions, parenteral and enteral nutrition were taken in to account in the caloric intake. The caloric deficits were determined. Results: Of the 19 patients that were included mean age was 70±10 years and 74% were male. Mean APACHE II score was 13±6. The Total Energy Expenditure was 2049±430 kcal/day. The Total Caloric Intake was 765±450 kcal/day (37% of the TEE). On 213 days of hospitalization, the energy deficit was 265,835±606 kcal. Only patients who received parenteral or enteral feeding (10%) achieved their recommended caloric intake on 4 occasions. Conclusion: Caloric deficits, although relatively easy treatable, are a major and underestimated problem in patients undergoing elective cardiac surgery.

Unplanned extubations (UEs) can be accidental or intentional (autoextubation). The incidence of UE is 1–4/100 ventilator-days and is considered a quality indicator for nursing care in the ICU. We studied the effect of a predominantly nurse-driven endotracheal tube care (ETTC) protocol on incidence, circumstances, and outcome of UEs in orotracheally intubated mechanically ventilated patients.

We report a patient with amniotic fluid embolism (AFE) in whom the occurrence of late onset, severe pulmonary oedema was due to isolated left ventricular (LV) failure. Following institution of diuretics and inotropic support, the situation promptly improved and follow-up haemodynamic assessment showed complete recovery of LV function. This report indicates that reversible LV failure may occur late after AFE and emphasises the usefulness of pulmonary artery catheterisation for proper assessment and guidance of therapy of pulmonary oedema in AFE.

Elevated intraabdominal pressure and the abdominal compartment syndrome seem to be the recent hype at critical care conferences. The objective of this longitudinal, observational study is to document epidemiologic data on intraabdominal pressure (IAP) in patients admitted to a mixed medical and surgical intensive care department (ICU) of an university hospital and to determine the value of routine monitoring of IAP. All adult patients admitted for an expected minimum stay of 48 hours in the ICU were included, provided that they needed an indwelling urinary bladder catheter. Included patients were followed until discharge from the ICU or until death, whichever came first. Final outcome at hospital discharge was determined. The IAP was measured in a non-invasive manner through the aspiration port of a standard indwelling bladder catheter, in a modification of the procedure as originally described by Kron et al. The IAP was measured twice daily until discharge from the ICU or until there was no further need of a bladder catheter (i.e. a bladder catheter was not left in place for the sole purpose of measuring IAP). Furthermore, demographic, pathologic, and diagnostic data, as well as physiologic, hemodynamic, and biochemical parameters were recorded. Several disease severity scores were calculated. We present the results of the first 125 patients included. A total of 1451 measurements were performed. Patients were stratified into two groups depending on 30-day survival or outcome at discharge from hospital. Forty-one patients (652 measurements) did not survive. Mean IAP for this group was 8.9 (range -6 to 24, SD 4.5). We recorded 130 IAP-values over 12 mmHg (20%) of which seven IAP-values over 19 mmHg (1%) in six patients. Eighty-four patients (799 measurements) had a favourable outcome. Mean IAP for this group was 7.6 (range -6 to 30, SD 4.6). We recorded 112 IAP-values over 12 mmHg (14%) of which 10 IAP-values over 19 mmHg (1%) in five patients. The two-tailed student's t-test for the IAP between the two groups was significant (P < 0.0001). However, elevation of IAP-values did not necessarily coincide with demise. We could not demonstrate a linear correlation between IAP-values and values of other parameters. From our present data we can conclude that IAP is generally higher in non-survivors than in survivors, but that survivors can have elevated values of IAP. Routine monitoring of IAP in all patients admitted to the ICU does not seem warranted.

An important number of acute intoxications can be ascribed to the abuse of, until now, non-prescription carbromal preparations. Prolonged use of these drugs also leads to chronic intoxication with bromide accumulation. The clinical features and treatment of three suicidal Obral overdoses and of two patients presenting with bromism are presented. Laboratory findings, from admission to recovery, consist of qualitative TLC and quantitative HPLC drug assays in body fluids and the determination in plasma of the two competing ions chloride and bromide. The high frequency of acute intoxications and carbromal induced bromism stresses the need to bring these preparations under prescription.

Pulmonary emboli, even small, cause irreparable lung damage. Recurrent pulmonary emboli further increase the amount of non functional lung tissue and may result in incapacitating respiratory disease or death. It is therefore mandatory that the disease be correctly diagnosed and adequately treated. As prevention is better than cure, every patient presenting with clinical signs of deep venous thrombosis (DVT) should be correctly explored. The site and size of thrombosis must be visualized preferably with contrast venography with imaging of the veins of the limbs, iliac veins and vena cava. Risk factors such as obesity, immobilization etc. must be taken into account. Underlying disease such as heart disease and venous insufficiency must be treated. Malignancy must be looked for as in a recent series of patients with primary DVT which were studied, 15% presented with an up till then unknown malignant disease. In patients presenting with recurrent DVT this percentage rose to 20%. When a patient presents with DVT of the femoro-iliac vena cava axis, aggressive treatment must be adopted. Fibrinolysis or if this is contra-indicated, thrombectomy will be used. A vena cava filter may be necessary and longterm anticoagulation is mandatory. The same rationale is applicable in cases of pulmonary embolus whether it is a primary event or a recurrence.

Because of its potential use in the detection of right ventricular myocardial infarction, we performed radionuclide ventriculography in 80 consecutive cases of electrocardiographically anterior acute MI. Regional wall motion of both ventricles was studied on amplitude-phase images. Forty-five patients (56%) showed normal right ventricular function and 35 (44%) regional right ventricular dyskinesia: 19 in the septal, 14 in the apical and 2 in the free wall region. Right ventricular septal, respectively apical asynergy were virtually always associated with asynergy in the homologous parts of the left ventricle. This could be a consequence of the proximity of these regions, or alternatively be due to a common vascular supply. Thus it remains uncertain if asynergy in these regions signifies necrosis of part of the right ventricular wall. Free wall asynergy was considered as evidence of right ventricular wall necrosis. Thus, in our study group the prevalence of right ventricular myocardial infarction in anterior left ventricular myocardial infarction was at least 2.5%.

The Eisenmenger's syndrome (E.S.) was redefined by Wood (1958) as pulmonary hypertension with reversed or bidirectional shunt at the aortopulmonary, ventricular or atrial level. This eponym is applicable to 12 different congenital cardiac lesions. Pregnancy in patients with E.S. is a particularly hazardous situation in respect to the prohibitive features of maternal and perinatal mortality (Gleicher et al., 1979; JonesHowitt, 1965; Neilson et al., 1971).

The arrhythmogenic action of antiarrhythmic agents, especially the class I antiarrhythmic drugs, is well known. However till now only few such side effects were reported for propafenone in comparison with other class I antiarrhythmic drugs. We report a case of asymptomatic monomorphic ventricular tachycardia occurring during propafenone therapy with normal plasma level. Stopping this drug was quickly followed by recovery of sinus rhythm.

The study deals with one aspect of cost benefit analysis of infection control, namely the measurement of extra costs incured by patients who acquired nosocomial infections (NI) in intensive care units (ICU). The consequences of NI are expressed in terms of length of stay, extra drug and antibiotic costs, extra sterile supply used and mortality. Infected patients stayed at the ICU twice as long as non - infected patients, the mean cost of antibiotics prescribed was four times higher, the mean value of other drugs and infusion fluids was approximately 1 1/2 times higher. Three methods for measuring cost are compared: the physician's assessment method, comparison of infected patients with all non - infected patients and matched control analysis.

We analytically and clinically evaluated Abbott's IMx assay for creatine kinase (CK) isoenzyme MB (CK-MB) in serum. Over a 1-year period, the method was more specific but less precise than catalytic isoenzyme measurements by electrophoresis or immunoinhibition. Sera from different individuals without electrophoretic evidence of CK-MB but containing macro CK type 1 (n = 20), mitochondrial CK (n = 5), or CK-BB (n = 5) were scored as CK-MB negative by the IMx. Likewise, CK-MB-negative by the sera remained so after addition of purified human CK-MM (< or = 7600 U/L) or CK-BB (< or = 8100 U/L). For 39 patients admitted for suspicion of uncomplicated acute myocardial infarction (precordial pain for < or = 4 h), the diagnostic performance of the IMx CK-MB assay on admission and 4 h later was superior to that of total CK activity and compared well with that of CK-MB activity measured by electrophoresis or immunoinhibition. An admission, myoglobin showed a higher diagnostic sensitivity, specificity, and predictive value than did CK-MB and was the most informative test. Diagnostic performance on admission and 4 h later was further improved by considering positivity for myoglobin and for CK-MB by IMx and for the change in each over the first 4 h of hospitalization as criteria. Twelve hours after admission, diagnostic performance was further improved for all CK and CK-MB methods but began to decline for myoglobin.

Excerpt To the editor: Ingestion of even slight quantities of the herbicide paraquat often leads to a fatal outcome within 24 hours due to damage of cell membranes by superoxide ions (O-) with subs...