Cytokines clearance during venovenous hemofiltration in the trauma patient.

The objective of the study was to investigate whether continuous venovenous hemofiltration (CVVH) would facilitate removal of substantial amounts of tumor necrosis factor (TNF) and interleukin-6 (IL-6) from the circulation in traumatized critically ill patients with multiple organ dysfunction syndrome. The study design was a prospective, nonblind, randomized controlled trial that was set in the trauma intensive care unit of a tertiary university referral hospital. Thirty consecutive critically ill, mechanically ventilated trauma patients with multiple organ dysfunction syndrome (without renal failure) were included in the study. Patients were randomized to either CVVH or conventional treatment. Blood and ultrafiltrate samples were collected from each patient before the initiation of CVVH and after 24, 72, and 168 hours of therapy. In the control group, blood samples were collected during the same periods. In the 30 patients studied, 15 had hemofiltration and 15 did not. Both groups were similar with regard to age (36+/-18 years v 36+/-14 years) and severity scores (injury severity score, 32+/-16 v 30+/-11; APACHE II score, 22+/-7 v 21+/-6; Goris score, 5.2+/-1.7 v 5.2+/-1.8). Before CVVH, TNF and IL-6 could be detected in the serum of all patients. The mean concentration of TNF was 17+/-22 pg/mL in patients and 22+/-20 pg/mL in control subjects (P = NS). The mean concentration of IL-6 was 2,153+/-2,824 pg/mL in patients and 1,774+/-1,637 pg/mL in control subjects (P = NS). We found a TNF and IL-6 substantial elimination with CVVH (excretion of TNF [microg/d] at 24, 48, and 168 hours: 112.6+/-161.2, 105.2+/-149.4, and 143.1+/-170.0; excretion of IL-6 [microg/d]: 1,655+/-719, 3,091+/-489, and 2,420+/-366). However, no significant difference was found in serum cytokines concentration between groups during the study: mean serum TNF concentration decreased from the pretreatment level to a mean level of 12+/-9.6 pg/mL in patients and 21+/-27 pg/mL in control subjects. Similar results were found with IL-6 concentration that decreased from the pretreatment level to a mean of 554+/-731 pg/mL in patients and 382 +/-568 pg/mL in control subjects. In conclusion, CVVH is associated with removal of substantial amounts of TNF and IL-6 from the circulation in traumatized critically ill patients, but the profile of these mediators is similar to that of controls, suggesting a nonclinically relevant elimination. Further prospective, randomized, clinical trials are needed to support our results.

[Intrahospital transportation of critical patients]. / Transporte intrahospitalario en pacientes críticos.

Critically ill patients often need to be transferred for a short period of time for diagnostical or therapeutical reasons to other areas outside the intensive care unit which are less safe than their own unit and suppose a potential risk of deterioration in the patient's status. We analyse prospectively the intrahospitalary transfer in 50 patients and study the hemodynamic, ventilatory and neurological variations before and after the transfer. 93.7% of our patients were transferred for diagnostical reasons, basically to the radiodiagnosis service (85.4% for TAC performance), only 6.25% were transferred for therapeutical reasons, all of them to the operating theatre. All the patients included in the study were subjected to: -mechanic ventilation, electrocardiographic monitoring (ECG), invasive arterial monitoring (TA), monitoring of arterial saturation of O2 using pulsioximetry, drugs infusion through volumetric bombs and intracraneal pressure monitoring through intra-ventricular catheter (in 18 cases). The intrahospitalary transfer was performed with: -Portable ventilator, ECG monitoring, TA, PIC and pulsioximetry. Before and after the transfer different parameters were registered: -Inspiratory fraction of O2 (FiO2), TA, cardiac frequency, PIC, arterial gasometry (pH, PAO2, PACO2). There were no complications in any of the cases, the gasometric alterations were due to the change of respiratory parameters for the transfer (increase of the FiO2 and prophylactic ventilation in all the cases). We recommend: -Use of the portable ventilator, volumetric bombs, hemodynamic monitoring and uninterrupted pulsioximetry and the presence of qualified staff (doctor and ICU nurse) during the transfer.

[Evaluation of the complications of the use of enteral diet with fiber in critical patients]. / Valoración de las complicaciones del uso de dieta enteral con fibra en pacientes críticos.

Our proposal consisted of analyzing whether the use of diets with fibre in the enteral nutrition (EN) of critical patients had an effect on the incidence of diarrhoea and vomiting, which are frequent complications in EN via nasogastric tube. For this purpose, in 1990 we followed a uniform EN protocol in our polyvalent I.C.U. A prospective analysis was made of a group of patients on a fibre diet (n = 30). The results were compared with those obtained in a previous group on a non-fibre diet (n = 42). Both groups were homogeneous with regard to age, date of initiation of the EN, duration of the diet and reason for ceasing the diet. We observed an incidence of diarrhoea (8/22 in the fibre group, compared to 5/37 in the non-fibre group, P + NS) and an increase in gastric residue (8/22 compared to 8/34, p = NS) which was similar in both groups. Incidence of vomiting was higher in the fibre group (7/23 compared to 0/42, P less than 0.01), perhaps due to a higher volume administered in the fibre group (1,001.7 +/- 176 compared to 679.2 +/- 210, P less than 0.001), although there were no cases of clinically significant bronchoaspiration. In conclusion, we can say that incidence of diarrhoea was similar in both groups, as well as the increase in gastric residue, despite a considerably higher volume administered in the fibre group. Incidence of vomiting was higher in the fibre group, with no cases of clinically significant bronchoaspiration.(ABSTRACT TRUNCATED AT 250 WORDS)