PURPOSE: A variety of rescue therapies were proposed to treat acute respiratory distress syndrome (ARDS) during the H1N1 influenza pandemic when conventional ventilation strategies failed. Here we report outcomes in patients with ARDS from H1N1 pneumonia who received Airway Pressure Release Ventilation (APRV).

Introduction: Maintenance of tight blood glucose control in cardiovascular surgery patients is associated with fewer complications and reduced mortality. Intensive insulin therapy is therefore an important component of the critical care of these patients. Traditional insulin infusion protocols do not account for individual patient differences in insulin resistance, resulting in suboptimal management. This study was undertaken to assess the efficacy of a novel insulin infusion regimen guided by patient-specific insulin resistance. Methods: A novel insulin infusion protocol utilizing an array of insulin titration curves based on patient-specific insulin resistance was developed by a multidisciplinary care team and implemented in our institution. Clinical data and glycemic indices of the first 100 consecutive cardiovascular surgery patients treated with the insulin resistance guided (IRG) regimen were compared with data from the preceding 100 patients treated with a conventional insulin infusion protocol. Results: Patients treated with the IRG regimen had improved glycemic control (see Figure 1). Normoglycemia (CBG 80-125) was maintained for more hours per day in the IRG group than the conventional insulin protocol group (19.8 vs. 15.8 hours, p<0.001). Diabetic patients had even greater improvement in glycemic control with the IRG regimen (19.3 vs. 14.2 hours, p<0.001). Episodes of hypoglycemia per day were reduced from 1.05 to 0.16 in the entire study population and from 1.48 to 0.00 among diabetic patients. The incidence of perioperative surgical site infections (SSI) also decreased after implementation of the IRG regimen (12.9/100 vs. 7.6/100, p=0.39). Independent predictors for increased total daily insulin dose were administration of epinephrine, phenylephrine, dobutamine, and milrinone. Conclusions: Insulin therapy guided by patient-specific insulin resistance leads to improved glycemic control in cardiovascular surgery patients. Normoglycemia is more consistently maintained and episodes of hypoglycemia are reduced, leading to improved compliance with current American Diabetes Association guidelines for glycemic control in the surgical patient. Use of IRG protocols has the potential to improve outcomes following cardiovascular surgery.

Pulmonary oedema and impairment of oxygenation are reported as common consequences of haemorrhagic shock and resuscitation (HSR). Surprisingly, there is little information in the literature examining differences in crystalloid type during the early phase of HSR regarding the development of pulmonary oedema, the impact on oxygenation and the haemodynamic response. These experiments were designed to determine if differences exist because of crystalloid fluid type in the development of oedema, the impact on oxygenation and the haemodynamic response to fluid administration in early HSR.

Treatment of hyperglycemia with an insulin infusion protocol (IIP) has improved outcomes in ICU and cardiac surgery patients [1]. Many studies have reported morning glucose values as representative of whole-day glucose control. We recently demonstrated that in a mixed ICU population this assumption does not hold [2]. Since it has been proposed that glucose control may be especially important in cardiac surgery ICU patients, we asked whether morning glucose accurately represented whole-day glucose and determined whether glucose varied over the course of the day in this patient group.

Introduction Benzodiazepine treatment of life-threatening gamma-hydroxybutyrate (GHB) withdrawal is frequently unsatisfactory. Animal studies suggest strongly that treatment with GABA(B) agonists, such as baclofen, will be a more effective strategy.Methods A case report from the medical intensive care unit (ICU) of the university tertiary care hospital.Results A 61-year-old woman was admitted to the medical ICU for severe withdrawal symptoms from chronic GHB use. This manifested as delirium, tremor, and seizures despite only small decreases in GHB dose and treatment with benzodiazepines. The addition of baclofen allowed the rapid sequential decreases in the GHB dose without seizure or delirium and resulted in long-term improvement of her tremor.Conclusions Baclofen, a GABA(B) agonist, may be a useful agent in the treatment of severe GHB withdrawal.

In this communication, we estimated the Lempel-Ziv complexity (LZC) on over 40 h of arterial blood pressure, (ABP) recordings corresponding to 18 mechanically ventilated animal subjects. In this study, all subjects underwent a period of abrupt hemodynamic changes after an induced injury involving severe blood loss leading to hemorrhagic shock, followed by fluid resuscitation using either lactated ringers or 0.9% normal saline. The LZC metric experienced a statistically significant increase (p < 0.01) immediately following the induced injury and a statistically significant reduction following the administration of fluid therapy (p < 0.01). These results indicate that LZC of ABP may be useful as a dynamic metric to assess fluid responsiveness.

Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism.Clinical data indicate that endogenous levels of hydrogen sulfide are diminished in various forms of cardiovascular diseases.The aim of the current study was to investigate the effects of hydrogen sulfide supplementation on cardiac function during reperfusion in a clinically relevant experimental model of cardiopulmonary bypass.Twelve anesthetized dogs underwent hypothermic cardiopulmonary bypass.After 60 minutes of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n = 6), or the sodium sulfide infusion (1 mg/kg/hour, n = 6).Biventricular hemodynamic variables were measured by combined pressure-volume-conductance catheters.Coronary and pulmonary blood flow, vasodilator responses to acetylcholine and sodiumnitroprusside and pulmonary function were also determined.Administration of sodium sulfide led to a significantly better recovery of left and right ventricular systolic function (P < 0.05) after 60 minutes of reperfusion.Coronary blood flow was also significantly higher in the sodium sulfide-treated group (P < 0.05).Sodium sulfide treatment improved coronary blood flow, and preserved the acetylcholine-induced increases in coronary and pulmonary blood (P < 0.05).Myocardial ATP levels were markedly improved in the sulfide-treated group.Thus, supplementation of sulfide improves the recovery of myocardial and endothelial function and energetic status after hypothermic cardiac arrest during cardiopulmonary bypass.These beneficial effects occurred without any detectable adverse hemodynamic or cardiovascular effects of sulfide at the dose used in the current study.

Treatment of hyperglycemia with an insulin infusion protocol (IIP) has improved outcomes in intensive care unit (ICU) patients (1,2). While morning glucose has been reported, little is known about variation of blood glucose for patients on IIP, causing uncertainty about the optimal treatment of ICU patients (3–5). Our objectives were to test whether morning glucose represented whole-day glucose and to determine whether glucose varied over the course of the day. In ICU patients receiving IIP, glucose was lower in the early morning, correlated poorly with average glucose, and varied with an ultradian pattern. In this prospective, single-center, observational study in the ICUs of a university tertiary care hospital, we recorded all glucose measurements in two cohorts of ICU patients receiving an IIP targeting blood glucose 80–110 mg/dl. Supplementary details are available in an online appendix (available at http://dx.doi.org/10.2337/dc07-0865.). Between 20 May 2006 and 6 August 2006, 141 ICU patients were treated with IIP, 8 of whom received insulin for two periods, resulting in 149 patient episodes. The average duration of insulin use for an episode was 115 ± 9 h (range 5–604). Forty-one percent ( n = 11,670) of glucose measurements during this period were in the target range (80–110 mg/dl) (Fig. 1 A ). In preliminary data acquired between May 2004 and June 2005, the proportion of measurements in the target range increased initially and then stabilized (Fig. 1). Twenty-six percent of patients experienced at least one glucose value <60 mg/dl, and 2.7% had a glucose value <40 mg/dl. The IIP was designed to control glucose within 8 h (1), and slightly more glucose measurements beyond 8 h (42%, n = 10,766) were in range ( P = 0.014) (Fig. 1 B ). The mean and median of this positively skewed, non-Gaussian distribution ( P < 0.0001, Kolmogorov-Smirnov test) were 118.5 …

Pulmonary edema is a common consequence of hemorrhagic shock resuscitation. The type and amount of fluid used in resuscitation may be important determinants of the amount of edema formed. Ringers' lactate (RL) and normal saline (NS) remain common resuscitative fluids. These experiments were designed to measure the extravascular lung water (EVLW) after resuscitation from hemorrhagic shock with RL vs NS, to determine whether the fluid type results in differences in the amount of EVLW, and to determine whether there exists a threshold amount of fluid that results in the development of edema.

Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism.Clinical data indicate that endogenous levels of hydrogen sulfide are diminished in various forms of cardiovascular diseases.The aim of the current study was to investigate the effects of hydrogen sulfide supplementation on cardiac function during reperfusion in a clinically relevant experimental model of cardiopulmonary bypass.Twelve anesthetized dogs underwent hypothermic cardiopulmonary bypass.After 60 minutes of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n = 6), or the sodium sulfide infusion (1 mg/kg/hour, n = 6).Biventricular hemodynamic variables were measured by combined pressure-volume-conductance catheters.Coronary and pulmonary blood flow, vasodilator responses to acetylcholine and sodiumnitroprusside and pulmonary function were also determined.Administration of sodium sulfide led to a significantly better recovery of left and right ventricular systolic function (P < 0.05) after 60 minutes of reperfusion.Coronary blood flow was also significantly higher in the sodium sulfide-treated group (P < 0.05).Sodium sulfide treatment improved coronary blood flow, and preserved the acetylcholine-induced increases in coronary and pulmonary blood (P < 0.05).Myocardial ATP levels were markedly improved in the sulfide-treated group.Thus, supplementation of sulfide improves the recovery of myocardial and endothelial function and energetic status after hypothermic cardiac arrest during cardiopulmonary bypass.These beneficial effects occurred without any detectable adverse hemodynamic or cardiovascular effects of sulfide at the dose used in the current study.

Tieu, Brandon MD; Enomoto, Miko T. MD; Phillips, Charles MD; Hagg, Daniel MD; Wiesberg, Tracy MD; Muller, Patrick BS; Schreiber, Martin MD Author Information

INTRODUCTION: Botulism can occur naturally as a food-borne illness caused by ingestion of pre-formed botulinum toxin, typically types A, B or E from Clostridium botulinum. Clostridium baratii as a causitive agent of human botulism has been reported only rarely in the medical literature(1). We report an unusual case of botulism caused by type F toxin produced by C. baratii.