pituitrin and Respiratory-Distress-Syndrome

During the last 5 years, new randomized trials in critically ill patients have challenged a number of traditional treatment strategies in intensive care. The authors review eight studies that helped change their medical practices.

Topics: Adrenal Cortex Hormones; Clinical Trials as Topic; Critical Care; Humans; Insulin; Phenylpropanolamine; Respiration, Artificial; Respiratory Distress Syndrome; Shock; Vasopressins

The clinical spectrum of sepsis, severe sepsis, and septic shock is responsible for a growing number of deaths and excessive health care expenditures. Until recently, despite multiple clinical trials, no intervention provided a beneficial outcome in septic patients. Within the last 2 years, studies that involved drotrecogin alfa (activated), corticosteroid therapy, and early goal-directed therapy showed efficacy in those with severe sepsis and septic shock. These results have provided optimism for reducing sepsis-related mortality.

Topics: Adrenal Cortex Hormones; Clinical Protocols; Critical Care; Critical Illness; Dopamine; Fibrinolytic Agents; Hemodynamics; Hemostatics; Heparin; Humans; Insulin; Multiple Organ Failure; Protein C; Recombinant Proteins; Respiration, Artificial; Respiratory Distress Syndrome; Sepsis; Shock, Septic; Vasopressins

Randomised controlled trials (RCTs) enrolling patients with sepsis or acute respiratory distress syndrome (ARDS) generate heterogeneous trial populations. Non-random variation in the treatment effect of an intervention due to differences in the baseline risk of death between patients in a population represents one form of heterogeneity of treatment effect (HTE). We assessed whether HTE in two sepsis and one ARDS RCTs could explain indeterminate trial results and inform future trial design.. We assessed HTE for vasopressin, hydrocortisone and levosimendan in sepsis and simvastatin in ARDS patients, on 28-day mortality, using the total Acute Physiology And Chronic Health Evaluation II (APACHE II) score as the baseline risk measurement, comparing above (high) and below (low) the median score. Secondary risk measures were the acute physiology component of APACHE II and predicted risk of mortality using the APACHE II score. HTE was quantified both in additive (difference in risk difference (RD)) and multiplicative (ratio of relative risks (RR)) scales using estimated treatment differences from a logistic regression model with treatment risk as the interaction term.. The ratio of the odds of death in the highest APACHE II quartile was 4.9 to 7.4 times compared to the lowest quartile, across the three trials. We did not observe HTE for vasopressin, hydrocortisone and levosimendan in the two sepsis trials. In the HARP-2 trial, simvastatin reduced mortality in the low APACHE II group and increased mortality in the high APACHE II group (difference in RD = 0.34 (0.12, 0.55) (p = 0.02); ratio of RR 3.57 (1.77, 7.17) (p < 0.001). The HTE patterns were inconsistent across the secondary risk measures. The sensitivity analyses of HTE effects for vasopressin, hydrocortisone and levosimendan were consistent with the main analyses and attenuated for simvastatin.. We assessed HTE in three recent ICU RCTs, using multivariable baseline risk of death models. There was considerable within-trial variation in the baseline risk of death. We observed potential HTE for simvastatin in ARDS, but no evidence of HTE for vasopressin, hydrocortisone or levosimendan in the two sepsis trials. Our findings could be explained either by true lack of HTE (no benefit of vasopressin, hydrocortisone or levosimendan vs comparator for any patient subgroups) or by lack of power to detect HTE. Our results require validation using similar trial databases.

Topics: Adult; Aged; Anti-Inflammatory Agents; APACHE; Cardiotonic Agents; Critical Illness; Female; Guideline Adherence; Hospital Mortality; Humans; Hydrocortisone; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Intensive Care Units; Male; Middle Aged; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Sepsis; Simendan; Simvastatin; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Acute Kidney Injury; Fluid Therapy; Humans; Respiratory Distress Syndrome; Sepsis; Vasoconstrictor Agents; Vasopressins

Topics: Anti-Bacterial Agents; Cervical Vertebrae; Demeclocycline; Fluid Therapy; Humans; Oliguria; Respiratory Distress Syndrome; Spinal Cord Injuries; Vasopressins

The European Society of Intensive Care Medicine Annual Congress offers the opportunity for basic scientists and clinicians to share recent findings. Apart from the large number of free communications, several sessions of the congress were dedicated to state-of-the-art tutorials given by established speakers. The areas of interest of the attendees were widely distributed as usual, a reflection of the large array of so-called 'critical illnesses'. The results of clinical trials and experimental findings using recently developed drugs were presented, essentially in the fields of inflammation, sepsis, and acute lung injury. The benefits of several new compounds observed experimentally need to be confirmed clinically. The European Society of Intensive Care Medicine Congress is well established as a unique opportunity to implement and to promote a collaboration between European basic scientists and clinicians.

Topics: Anti-Bacterial Agents; Critical Care; Critical Illness; Ethics, Clinical; Ethics, Medical; Europe; Humans; Inflammation; International Cooperation; Nitric Oxide; Respiratory Distress Syndrome; Sepsis; Signal Transduction; Vasopressins

Although controlled mechanical ventilation (CMV) with positive end-expiratory pressure (PEEP) has a central place in the treatment of acute respiratory failure (ARF), several side effects of this technique have to be faced. CMV with PEEP may induce pulmonary barotrauma, disturbance of cardiac performance, impairment of renal function and fluid retention. Atrial natriuretic peptides (ANP) are released from the atria upon stretching and play a major role in the control of sodium and fluid balance. Therefore it was logical to determine plasma levels of alpha-ANP in CMV. A study performed in 7 patients suffering from ARF suggested that alpha-ANP plasma levels were depressed during PEEP at 15 cm H2O in comparison with PEEP at 0 cm H2O (ZEEP). The decrease in plasma levels of alpha-ANP was evident in samples taken from superior vena cava, right atrium, pulmonary artery and radial artery as well. The decrease in alpha-ANP was associated with a decline in cardiac index, creatinine clearance, urinary output and urinary sodium excretion. Experiments in volume- expanded healthy volunteers also suggest that CMV with PEEP is able to depress plasma levels of alpha-ANP. The reasons behind the decline in release of alpha-ANP may be atrial compression by the distended lungs and the well-known reduction of venous return to the heart. Other possible factors promoting fluid retention during CMV with PEEP are the decrease in cardiac index and glomerular filtration rate, changes in intrarenal distribution of blood flow, and a stimulation of release of antidiuretic hormone via stretch receptors in the left atrium and baroreceptors in aorta and carotid arteries.

Topics: Animals; Atrial Natriuretic Factor; Humans; Kidney; Positive-Pressure Respiration; Respiratory Distress Syndrome; Vasopressins; Water-Electrolyte Imbalance

Bilateral tuberculous pneumonia with the syndrome of inappropriate secretion of antidiuretic hormone was the cause of the adult respiratory distress syndrome in an elderly patient. Early recognition and prompt therapy enabled the patient to make a complete recovery without the necessity for mechanical ventilation. With the shift of care of tuberculous patients out of the sanitorium, the practicing physician should be aware of the varied manifestations of tuberculosis.

Topics: Aged; Blood Urea Nitrogen; Electrolytes; Humans; Male; Oxygen Inhalation Therapy; Pulmonary Fibrosis; Radiography; Respiratory Distress Syndrome; Tuberculosis, Pulmonary; Vasopressins