Comparison of exponential truncated biphasic versus damped sine wave monophasic shocks in transthoracic cardioversion of atrial fibrillation

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<ul><li><p>S1</p><p>Available online</p><p>Critical Care Volume 7 Suppl 2, 200323rd International Symposium on Intensive Care and EmergencyMedicineBrussels, Belgium, 1821 March 2003</p><p>Published online: 3 March 2003This article is online at 2003 BioMed Central Ltd (Print ISSN 1364-8535; Online ISSN 1466-609X)</p><p>P1 Endocrine dysfunction in the immediate period following traumatic brain injury</p><p>I Dimopoulou, S Tsagarakis, G Assithianakis, M Christoforaki, M Theodorakopoulou, A Kouyialis, S Korfias, N Thalassinos, C RoussosDepartment of Critical Care Medicine and Department of Endocrinology, Evangelismos Hospital, Athens, GreeceCritical Care 2003, 7(Suppl 2):P001 (DOI 10.1186/cc1890)</p><p>Studies on head injury-induced pituitary dysfunction are limited innumber and conflicting results have been reported. To further clarifythis issue, 29 consecutive patients (24 males), with severe (n=21)or moderate (n=8) head trauma, having a mean age of3717 years were investigated in the immediate post-traumaperiod. All patients required mechanical ventilatory support for855 days and were enrolled in the study within a few days beforeICU discharge. Basal hormonal assessment included measurementof cortisol, corticotropin, free thyroxine (fT4), thyrotropin (TSH),testosterone (T) in men, estradiol (E2) in women, prolactin (PRL),and growth hormone (GH). Cortisol and GH levels were measuredalso after stimulation with 100g human corticotropin releasinghormone (hCRH) and 100g growth hormone releasing hormone(GHRH), respectively. Cortisol hyporesponsiveness was consid-ered when peak cortisol concentration was less than 20g/dl fol-lowing hCRH. TSH deficiency was diagnosed when a subnormal</p><p>serum fT4 level was associated with a normal or low TSH. Hypogo-nadism was considered when T (males) or E2 (women) were belowthe local reference ranges, in the presence of normal PRL levels.Severe or partial GH deficiencies were defined as a peak GHbelow 3g/l or between 3 and 5g/l, respectively, after stimulationwith GHRH. Twenty-one subnormal responses were found in 15 ofthe 29 patients (52%) tested; seven (24%) had hypogonadism,seven (24%) had cortisol hyporesponsiveness, five (17%) hadhypothyroidism, and two patients (7%) had partial GH deficiency.</p><p>These preliminary results suggest that a certain degree of hypo-pituitarism occurs in more than 50% of patients with moderate orsevere head injury in the immediate post-trauma period, with cortisolhyporesponsiveness and hypogonadism being most common. Furtherstudies are required to elucidate the pathogenesis of these abnor-malities and to investigate whether they affect long-term morbidity.</p><p>P2 Cortisol reserve in head trauma victims: evaluation with the low-dose (1g) corticotropin (ACTH) stimulation test</p><p>I Dimopoulou, A Kouyialis, S Tsagarakis, M Theodorakopoulou, G Assithianakis, M Christoforaki, N Thalassinos, C RoussosDepartment of Critical Care Medicine and Department of Endocrinology, Evangelismos Hospital, Athens, GreeceCritical Care 2003, 7(Suppl 2):P002 (DOI 10.1186/cc1891)</p><p>To investigate cortisol reserve in head trauma, 35 consecutivepatients (30 men) with a mean age of 36 16 years were studied560 days after physical injury. Patients were enrolled in the studywithin a few days before ICU discharge. First, a morning bloodsample was obtained to measure baseline cortisol, and ACTHplasma levels. Subsequently, 1g synthetic ACTH was injectedintravenously and, 30 min later, a second blood sample was drawnto determine stimulated plasma cortisol. Patients having stimulatedcortisol levels below 18g/dl were defined as nonresponders tothe low-dose stimulation test (LDST). Mean ( SD) values forACTH, baseline, and stimulated cortisol concentrations were</p><p>49 27 pg/ml, 19.7 5.5g/dl and 23.6 6.7g/dl, respectively.Six of the 35 patients (17%) failed the LDST. Nonresponders weresimilar to responders with regard to age, gender, and severity ofhead injury. However, nonresponders more frequently requiredvasopressors (6/6 vs 14/29, P = 0.02) and for a longer time inter-val (median, 293 hours vs 24 hours, P = 0.01) to maintain haemo-dynamic stability compared with responders to the LDST.</p><p>In conclusion, adrenal cortisol secretion following dynamic stimula-tion is deficient in a subset of head injury patients; this condition isassociated with vasopressor dependency.</p><p>P3 Steroid hormone synthesis is impaired in patients with severe sepsis</p><p>M Angstwurm, A Rashidi Kia, J Schopohl, R GaertnerMedical Intensive Care Unit, Medizinische Klinik, Ziemssenstrae 1, 80336 Munich, GermanyCritical Care 2003, 7(Suppl 2):P003 (DOI 10.1186/cc1892)</p><p>In patients with severe illness, adrenal insufficiency is often sus-pected and treatment with hydrocortisone has been shown todecrease mortality. However, the pathophysiology of an adrenalfailure is only partially understood.</p><p>We analyzed the synthesis of different steroid hormones withinthe adrenal in severely ill patients in a prospective study usingthe established high dose stimulation test with syntheticcosyntropin.</p></li><li><p>S2</p><p>Critical Care March 2003 Vol 7 Suppl 2 23rd International Symposium on Intensive Care and Emergency Medicine</p><p>Using commercially available essays, the steroid hormones proges-terone, cortisole, testosterone, dehydroepiandrostenedione (DHEAS)and 17-estradiol were determined before, and 30 and 60 minafter stimulation with cosyntropin. Patients were characterized byscoring systems (APACHE II, SAPS II, MOD score). The underly-ing admission diagnosis grouped patients in septic, cardiogenicshock or control.</p><p>Sixty-five patients (22 in cardiogenic and 43 in septic shock, fiveand nine women, mean age 58 years, APACHE score of 20) werecompared with 34 control patients (17 cancer patients, 10 healthy,four pulmonary emphysema and three other).</p><p>At baseline, septic and cardiogenic patients showed similar cortisollevels (21 and 21g/dl), higher than control (15g/dl, P</p></li><li><p>S3</p><p>Available online</p><p>the cerebral cortex surrounding an evacuated focal contusion orunderlying an evacuated haematoma (worse position). The perfu-sion rate was 0.3l/min and samples were taken every 30 or60 min. The levels of glucose, pyruvate, lactate, glutamate, andglycerol were analysed and displayed bedside.</p><p>Measurements and main results In 108 patients, 18 episodes ofmoderate (1215 mmol/l) and six episodes of pronounced(&gt; 15 mmol/l) hyperglycaemia occurred. Moderate hyperglycaemiadid not change intracerebral levels of lactate, pyruvate, glutamate,</p><p>glycerol or lactate/pyruvate ratio. During pronounced hypergly-caemia lactate concentration increased. A pronounced cerebrallactic acidosis and a moderate increase in interstitial glycerol con-centration indicating cell membrane degradation was observed in asingle patient with pronounced, long-lasting hyperglycaemia.</p><p>Conclusions Cerebral energy metabolism was affected by tran-sient hyperglycaemia only at blood glucose concentration above15 mmol/l as shown by a moderate increase in interstitial lactatelevel.</p><p>P6 Hyperglycemia at admission to ICU is independently associated with increased serum levels of IL-6 and reduced ex vivoTNF-alpha production</p><p>HE Wasmuth1, F Lammert1, J Graf2, EA Purucker1, A Koch1, C Gartung1, D Kunz3, AM Gressner3, S Matern11Department of Medicine III and 2Department of Medicine I, and 3Institute of Clinical Chemistry and Pathobiochemistry, University HospitalAachen, Aachen University, Pauwelsstrae 30, 52074 Aachen, GermanyCritical Care 2003, 7(Suppl 2):P006 (DOI 10.1186/cc1895)</p><p>Background Hyperglycemia has been shown to be an independentrisk factor of mortality in patients with stroke and myocardial infarc-tion. Furthermore, strict control of hyperglycemia reduces mortalityand rates of infectious complications in surgical ICU patients. Theaim of the present study was to investigate immunological changesin medical patients in relation to blood glucose at admission to ICU.</p><p>Patients and methods Overall, 189 consecutive medical ICUpatients were enrolled. At admission, blood glucose and serumlevels of IL-6, IL-8, IL-10, and TNF-alpha were measured. Further-more, monocyte HLA-DR expression and ex vivo TNF-alpha pro-duction in whole blood after stimulation with LPS were determined.In all patients, SAPS II score was calculated for day of admissionto ICU. Hyperglycemia was defined as a venous blood glucose&gt; 126 mg/dl in fasting and &gt; 200 mg/dl in nonfasting individuals.Frequencies in contingency tables were calculated with Fishersexact test. Logistic regression was used with hyperglycemia as thedependent variable and immune parameters, SAPS II score, andhistory of diabetes as covariates.</p><p>Results Overall mortality within the study period was 20.1%. Patientswith hyperglycemia had an increased risk of mortality in the ICU com-pared with patients with normoglycemia at admission (29.3% vs15.2%; OR=2.3, P=0.03). Sepsis according to Bone criteria wasequally distributed between groups (14.3% vs 10.7%; P&gt;0.05). Atlogistic regression analysis, higher serum levels of IL-6, a reducedex vivo production of TNF-alpha, and a history of diabetes were inde-pendently associated with hyperglycemia at admission to ICU(P=0.007, P0.05).</p><p>Conclusions Independent of SAPS II score and underlyingdisease, hyperglycemia at admission to ICU is associated withimmunological changes that are frequently observed in critically illpatients (immunoparalysis). Particularly, a reduced ex vivo produc-tion of TNF-alpha might contribute to the increased risk for infec-tious complications and death in patients with acute and chronichyperglycemia.</p><p>P7 Influence of insulin clearance to glucose tolerance in acutely ill severe patients: analysis with glucose clamp method bymeans of artificial pancreas</p><p>M Hoshino1, Y Haraguchi2, M Sakai1, I Mizushima1, Y Morita1, M Kobayashi11Department of Intensive and Critical Care Medicine, Tokyo Police Hospital, Fujimi 2-10-41, Chiyoda-ku, 102-8161 Tokyo, Japan; 2Tokyo Disaster Medical Center, Tokyo, JapanCritical Care 2003, 7(Suppl 2):P007 (DOI 10.1186/cc1896)</p><p>Purpose Acutely ill patients often have glucose intolerance (GI),which is one of the factors preventing appropriate nutritionalsupport. However, mechanisms of GI are not clearly understood.Among the factors that influence GI, insulin sensitivity (IS) andinsulin clearance (IC) are considered to be the important factors,because insulin is one of the most important factors which controlglucose metabolism and insulin therapy is usually performed forpatients with GI. We investigated glucose tolerance in terms of ISand IC in acutely ill severe patients by the glucose clamp method(GC) by means of a bedside-type artificial pancreas (STG-22:NIKKISO Corporation, Tokyo, Japan).</p><p>Method Thirty-one patients (27 patients had sepsis) in whomblood glucose levels were controlled by means of the artificial pan-creas were investigated. First measurement of GC was performedin acute condition or within 3 days after admission for all thepatients, and second measurement was done 1 week after the firstmeasurement for 13 patients. GC was performed with clamped</p><p>blood glucose level of 80 mg/dl and Insulin Infusion Rate (IIR) of1.12 and 3.36 mU/kg per min. I1/I3 and M1/M3 indicate the bloodinsulin level (U/ml) and glucose disposal rate : M value (mg/kg permin), when IIR is 1.12/3.36 mU/kg per min, respectively (normalvalue of M1: 510 mg/kg per min). M1/I1: (M1/I1 1000) was cal-culated as the parameter of IS (normal value of M1/I1: more than50 mg/l per kg per min perU). IC was calculated from the follow-ing formula: IC = (3.361.12) 1000/(I3I1) (normal value of IC:1015 ml/kg per min). Glucose tolerance was analyzed in terms ofM1, IS (M1/I1), and IC.</p><p>Results 1) The proportion of the patients who had M1 levels lessthan 5 mg/kg per min (GI), IS (M1/I1) less than 50 mg/l per kg permin per U (insulin resistance), and IC more than 15 ml/kg per min(increased IC) were 66% (29/44), 27% (12/44), and 61%(27/44), respectively. 2) Among the patients with GI (n = 29), only38% (11/29) of the patients had insulin resistance. Sixty-twopercent (18/29) of the patients with GI had normal IS, and 83% of</p></li><li><p>S4</p><p>Critical Care March 2003 Vol 7 Suppl 2 23rd International Symposium on Intensive Care and Emergency Medicine</p><p>them (15/18) had increased IC (mean SD of IC, I1:22 3.8 ml/kg per min, 38.3 9.5U/ml, n = 15). 3) Among thepatients with normal glucose tolerance (n = 15), 93% (14/15) ofthem had normal IS. However, one patient had both insulin resis-tance (M1/I1 = 43.5 mg/l per kg per min perU) and decreased IC(IC = 3.9 ml/kg per min, I1 = 131U/ml).</p><p>Interpretation and conclusions 1) IC was the important factorthat influenced the glucose tolerance in acutely ill severe patients,although the mechanisms of the change of IC was unclear. 2) Suffi-cient insulin administration was considered to be necessary fromthe aspect of metabolic and nutritional control for those patientswith increased IC.</p><p>P8 Bone turnover in prolonged critical illness: effect of vitamin D</p><p>P Vanhove, D Van Roosbroeck, P Wouters, L De Pourcq, R Bouillon, G Van den BergheDepartment of Intensive Care &amp; LEGENDO, Leuven University Hospital, Herestraat 49, 3000 Leuven, BelgiumCritical Care 2003, 7(Suppl 2):P008 (DOI 10.1186/cc1897)</p><p>Introduction In prolonged critical illness, substantially increasedbone resorption and osteoblast dysfunction have been reported inthe face of low 25-hydroxy vitamin D [25(OH)D] concentrations.The current prospective, randomized, controlled study investigatesthe impact of increased daily vitamin D supplement during intensivecare on the time course of bone turnover and its major regulatorssuch as cytokines and calciotropic hormones.</p><p>Methods Critically ill patients, assumed to require &gt;10 days ofintensive care, were compared with healthy matched controls andrandomly allocated to a daily vitamin D supplement of either200 IU (low dose) or 500 IU (high dose). Of the 33 patientsincluded, 22 remained in ICU for &gt;10 days and were analyzed.Urine from 24 hour collections and blood was sampled daily forcharacterization of vitamin D status, bone turnover and inflammation.</p><p>Results The 12 patients who received the high dose vitamin D and10 patients who received the low dose were comparable at base-line. At intensive care admission, serum concentrations of25(OH)D, 1,25(OH)2D, DBP, ionized calcium, osteocalcin, IL-1and sIL-6-R were lower than in controls; PTH and bone-specificalkaline phosphatase levels were normal; serum carboxy and amino</p><p>terminal of propeptide type-I collagen, serum and urinary collagencross-links (CTX, PYD and DPD) as well as IL-6, TNF- and OPGwere several fold elevated. sRANKL was undetectable.</p><p>The high dose increased circulating 25(OH)D (P&lt; 0.05) butnormal levels were not reached and low 1,25(OH)2D levels notaltered. High dose vitamin D slightly increased osteocalcin anddecreased carboxy terminal propeptide type-I collagen (P&lt; 0.05).Bone-specific alkaline phosphatase and collagen cross-linksmarkedly increased wit...</p></li></ul>