Roles of extracorporeal blood purification in sepsis.

Severe sepsis represents the leading cause of mortality and morbidity in critically ill patients. Although the authors' understanding of the complex pathophysiological alterations that occur in severe sepsis and septic shock has increased greatly, mortality associated with the disorder remains unacceptably high. Recent treatment guidelines have reinforced the importance of early goal directed therapy. Recently, moderate doses of corticosteroid replacement and activated protein C (drotrecogin alfa[activated]) are the therapies demonstrating efficacy. Extra-corporeal blood purification techniques offer a variety of techniques that can efficiently eliminate septic mediators. The rationale for its use in sepsis is sound Animal and human studies show promise with improvements in hemodynamics and mortality, but are limited by number and design. These techniques require large-scale well-conducted studies to demonstrate the validity in sepsis.

The effect of lateral position on oxygenation in ARDS patients: a pilot study.

BACKGROUND: The effect of body position on oxygenation in acute respiratory distress syndrome (ARDS) patients has long been known. Prone position improves the PaO2 in 60-70% of ARDS patients. However the effect of the lateral positions, which are used in routine critical care, has never been reported. OBJECTIVE: To determine whether placing the patient in a lateral position has any effect on oxygenation in ARDS. MATERIAL AND METHOD: Prospective observational study, comparing oxygenation in ARDS patients between supine, right and left lateral positions (> or = 60 degree). RESULTS: We included 18 ARDS patients, their mean aged was 52.2 +/- 19.6 years, 14 were men and the ICU mortality rate was 61.1%. There was no significant change in the mean PaO2, arterial blood gas parameters, respiratory mechanics and hemodynamic parameters between the supine and decubitus positions in the overall group. However there was a trend toward increasing the mean PaO2 during right lateral position compared with the supine position (90.3 +/- 29.0 vs 84.6 +/- 20.4, p = 0.23). Nine patients who responded to the right lateral position had significantly higher mean PaO2 during the right lateral position than in the supine position (107.8 +/- 29.0 vs 85.6 +/- 21.8, p < 0.0001). In this group, four patients had predominant left pulmonary infiltration and five patients had equally bilateral pulmonary infiltration on chest X-ray. Unfortunately, the PaO2 in three patients decreased more than 10 mmHg during right lateral decubitus. CONCLUSION: The PaO2 increased while in the right lateral position in patients with predominant left pulmonary infiltration or bilateral infiltration. This effect may be due to the small sample size. A further large-sized randomized controlled study is needed.

Prediction of mortality by using the standard scoring systems in a medical intensive care unit in Thailand.

In order to evaluate and compare the predictive ability of the APACHE II (Acute Physiology and Chronic Health Evaluation II) and the SAPS (Simplified Acute Physiology Score) scoring systems in relation to outcome in a medical intensive care unit (ICU). The authors reviewed consecutive medical ICU admissions (n = 482) at a tertiary hospital over a 2-year period. For each patient, demographic data, diagnosis, APACHE II score, SAPS score and ICU outcome complied during the first 24 hrs of the ICU stay were obtained. The comparison of predictive ability between APACHE II and SAPS was assessed by forward stepwise logistic regression and area under the receiver operating characteristic (ROC) curves. Overall ICU mortality was 36.93%. Mean APACHE II and SAPS scores were 21.17 +/- 9.35 and 14.61 +/- 6.47, respectively. APACHE II and SAPS scores of nonsurvivors (26.97 +/- 8.27 and 18.01 +/- 5.84 respectively) were significantly higher than those of survivors (17.77 +/- 8.22 and 12.62 +/- 5.99 respectively) (p < 0. 001). Correlation between both systems was excellent (Pearson correlation coefficient, r = 0.825: p < 0.001). The predicted risk of death calculated by using the APACHE II risk of death equation was 38.98%. The predictive ability to discriminate between survivors and nonsurvivors of APACHE II was higher than SAPS according to forward stepwise logistic regression and area under the ROC curves (APACHE II was 0.788 while SAPS was 0.746). In conclusion, the APACHE II scoring system is an efficient predictor for monitoring the hospital outcome and has more predictive ability than the SAPS in the medical ICU patients.

A girl with A glowing tooth : A case of congenital erythropoietic porphyria.

Congenital erythropoietic porphyria is a rare type of porphyria caused by inherited defects of uroporphyrinogen III synthase, an enzyme in the heme biosynthetic pathway. The resultant accumulation of porphyrins causes damage to the skin and erythrocytes, leading to cutaneous photosensitivity and hemolytic anemia. Furthermore, excess porphyrins are also deposited in tissues, bone, and teeth, resulting in a reddish-brown discoloration of the teeth (erythrodontia) which fluoresces under long-wavelength ultraviolet light. In this report, a case of a 9-month old infant girl with recurrent skin eruptions, anemia with hepatosplenomegaly, and erythrodontia is presented. The diagnosis of congenital erythropoietic porphyria was made based on the clinical manifestations and biochemical investigations. The patient was treated successfully with allogenic bone marrow transplantation and is still in remission after almost 3 years posttransplantation.

Thrombocytopenic purpura associated with miliary tuberculosis.

The authors report a case of thrombocytopenia associated with miliary tuberculosis. The patient was a 28-year-old woman who was admitted because of massive upper gastrointestinal hemorrhage and acute respiratory failure. Chest radiographs revealed diffuse bilateral reticulonodular infiltration and complete blood count was significant for severe thrombocytopenia. Bone marrow biopsy was performed to investigate the cause of thrombocytopenia and demonstrated multiple tiny caseating granulomas suggesting miliary tuberculosis (TB). She received anti-TB therapy and a short course of steroid with good response. Platelet count returned to normal limit within 10 days. Although isolated thrombocytopenia is uncommon in TB, it is still important to consider TB in the differential diagnosis of thrombocytopenia, particularly in patients with abnormal chest radiographs. Bone marrow examination is very helpful in this situation.

The clinical course and outcome of generalized tetanus: A 5 - year - experience from the medical intensive care unit, Siriraj Hospital.

A retrospective analysis of patients with tetanus who were admitted to the Medical ICU during January 1995 - December 1999 is reported. The aims were to examine potentially different clinical course as well as outcome. Of 21 patients, 16 were male and 5 were female. The mean age was 44.3 +16 years. The site of infection was noted in 17 patients; and of these, 8 patients sought medical care where tetanus toxoid was given but not passive immunization. The mean incubation period was 6.1 + 8.7 days (range 4-30 days) while the mean period of onset was 3 + 2.7 days (range 1-13 days). Seven patients (33%) died. Six of them had pneumonia as a cause while the other one died from hyperkalemia. The cause of pneumonia in 5 patients was ventilator associated and the other had severe pneumonia following bronchopulmonary aspiration. Early cardiac arrest occurred in 3 patients, two resulted from bronchopulmonary aspiration and one from hyperkalemia. The mean ICU stay was 17 + 24.6 days and the mean duration of ventilation was 12.3 + 24.9 days. The mean cost of treatment was 112,207 + 100,194 baht (range 7,259 - 200,165 baht). In conclusion, tetanus can occur despite post-exposure medical care and the outcome as judged by mortality rates, ICU stays, complications and costs were not satisfactory. Proper post-exposure wound care and immunization needs to be emphasized. Strict adherence to management guidelines regarding the care of these patients and prevention of nosocomial infection are necessary. New treatment modalities which could shorten the disease course or reduce the need to paralyze and provide respiratory support would be useful in improving the patients' outcomes.