Effects of hydrocortisone on microcirculatory alterations in patients with septic shock.

OBJECTIVE: To evaluate the effects of hydrocortisone on microcirculatory blood flow alterations in patients with septic shock. DESIGN: Prospective, open-label study. SETTING: A 31-bed, medico-surgical intensive care unit of a university hospital. PATIENTS: Twenty patients with septic shock. INTERVENTIONS: Intravenous hydrocortisone (50 mg/6 hr). MEASUREMENTS AND MAIN RESULTS: An orthogonal polarization spectral device (Cytoscan ARII, Cytometrics; Philadelphia, PA) was used to investigate the sublingual microcirculation in 20 patients who received so-called "stress doses" of hydrocortisone as part of their management for septic shock. Hemodynamic measurements and orthogonal polarization spectral images were obtained before administration of the first dose (50 mg) of hydrocortisone and 1, 2, 4, and 24 hours later. Measurements were also made before an adrenocorticotropic hormone (ACTH) test, whenever performed. Global hemodynamic variables were similar at all study time points. Microcirculatory variables improved slightly already at 1 hour after the start of hydrocortisone administration. In particular, perfused vessel density increased from 5.7 (4.8-6.4) to 7.2 (6.5-9.0)n/mm, p < 0.01, which was due to combined increases in small vessel density from 5.2 (4.6-6.2) to 6.0 (5.1-7.5)n/mm, p < 0.01, and in the proportion of perfused vessels from 82.1 (68.7-88.0) to 89.2 (83.4-92.6)%, p < 0.01. There were no differences in microcirculatory variables during hydrocortisone administration between ACTH test responders and nonresponders. CONCLUSIONS: The administration of moderate doses of hydrocortisone in septic shock results in a modest but consistent improvement in capillary perfusion, independent of the response to the ACTH test. The mechanisms underlying this effect need to be elucidated.

Multicenter, randomized, controlled trials evaluating mortality in intensive care: doomed to fail?

OBJECTIVES: To determine how many multicenter, randomized controlled trials have been published that assess mortality as a primary outcome in the adult intensive care unit population, and to evaluate their methodologic quality. DATA SOURCE: A sensitive search strategy for randomized controlled trials was conducted in the Cochrane Central Register of Controlled Trials and in MedLine using the PubMed interface. STUDY SELECTION: All publications of adult, multicenter randomized controlled trials carried out in the intensive care unit, with mortality as a primary outcome, and including >50 patients were selected. DATA EXTRACTION: Seventy-two randomized controlled trials were retrieved and were classified according to their effect on mortality: beneficial, detrimental, or neutral. DATA SYNTHESIS: Ten of the studies reported a positive impact of the studied intervention on mortality, seven studies reported a detrimental effect of the intervention, and 55 studies showed no effect on mortality. CONCLUSIONS: This literature search demonstrates that relatively few of the randomized controlled trials conducted in intensive care units and using mortality as a primary outcome show a beneficial impact of the intervention on the survival of critically ill patients. Methodological limitations of some of the randomized controlled trials may have prevented positive results. Other forms of evidence and end points other than mortality need to be considered when evaluating interventions in critically ill patients.

How microcirculation data have changed my clinical practice.

PURPOSE OF REVIEW: The present review discusses how microcirculation assessment, which was recently made feasible, has altered clinical practice. RECENT FINDINGS: Experimental data have provided important information on microcirculation alterations in disease states. Recent advances in imaging techniques have allowed microcirculation studies in critically ill patients. Derangements in microcirculation are variable and unpredictable, associated with organ dysfunction and outcome, and can be improved by therapeutic interventions. Recent studies not only confirm the beneficial effects of some drugs on the microcirculation, but also suggest new mechanisms of actions of these drugs. In particular, the interaction between the endothelial surface and circulating cells, and especially white blood cells, seems to be crucial. Although these imaging techniques provide important information, these remain difficult to implement at the bedside. Assessment of vasoreactivity using transient occlusion tests and indirect measurements of microvascular blood flow with laser Doppler or near infrared spectroscopy may be good alternatives. SUMMARY: Microcirculation alterations are present in shock states, mainly septic shock, and can have a prognostic role and be the target of therapeutic interventions. To date, microcirculation analysis remains in the field of clinical investigation, but recently interesting clinical data have encouraged assessment of the microcirculation at the bedside.

Apresentaçäo atípica de sífilis em um paciente com o vírus da imunodeficiência humana: relato de caso e revisäo da literatura / Atypical presentation of syphilis in a patient with virus of the human: case report and literature review

Introdução: A incidência da infecção pelo Treponema pallidum tem aumentado significativamente na última década, e a co-infecção com o vírus da imunodeficiência humana (HIV) é um achado freqüente. O HIV parece modificar a apresentação clínica da sífilis, e formas anômalas e malignas têm sido descritas na literatura. Objetivo: Relatar um caso de paciente com Aids e uma apresentação atípica de sífilis. Relato do caso: G.R.S.P., sexo masculino, 38 anos, branco, homossexual, com diagnóstico de HIV em 1991, foi admitido em nosso serviço com queixa de dor retal, obstipação e apresentando lesões de pele papulares eritematosas e descamativas disseminadas por toda a superfície corporal, excetuando-se a face. Ausência de manifestações neurológicas e exame liquórico inconclusivo para sífilis. A retossigmoidoscopia mostrou exulcerações na borda e canal anal. Contagem de CD4 428 cel./mmü, carga viral para o HIV 73.000 cópias, VDRL 1:256, FTA-ABS positivo para IgC e IgM. A citologia por coloração pela prata foi positiva para Treponema pallidum, tanto em lesões de pele quanto em ânus. Três meses antes apresentava carga viral de 25.000 cópias e era assintomático. Foi tratado com ceftriaxona 2g por 10 dias e evoluiu com resolução do quadro. Conclusão: Esta caso mostra uma apresentação inicial atípica da sífilis em paciente com Aids, mostrando que a co-infecção altera a história natural da sífilis; a presença destas duas patologias deve sempre ser lembrada em pacientes de risco. Existe uma correlação no caso descrito entre infecção pelo T.pallidum e um aumento significativo da carga viral do HIV