Percutaneous tracheostomy for long-term ventilated COVID-19-patients: rationale and first clinical-safe for all-experience.

INTRODUCTION: COVID-19 infection has resulted in thousands of critically ill patients admitted to ICUs and treated with mechanical ventilation. Percutaneous tracheostomy is a well-known technique utilised as a strategy to wean critically ill patients from mechanical ventilation. Worldwide differences exist in terms of methods, operators, and settings, and questions remain regarding timing and indications. If tracheostomy is to be performed in COVID-19 patients, a safe environment is needed for optimal care. MATERIAL AND METHODS: We present a guidewire dilating forceps tracheostomy procedure in COVID-19 patients that was optimised including apnoea-moments, protective clothing, checklists, and clear protocols. We performed a retrospective analysis of the outcome after tracheostomy in COVID-19 patients between March 2020 and May 2020. RESULTS: The follow-up of the first 16 patients, median age 62 years, revealed a median intubation time until tracheostomy of 18 days and median cannulation time of 20 days. The overall perioperative complication rate and complication rate while cannulated was 19%, mainly superficial bleeding. None of the healthcare providers involved in performing the procedure developed any symptoms of the disease. CONCLUSIONS: This COVID-19-centred strategy based on flexibility, preparation, and cooperation between healthcare providers with different backgrounds facilitated percutaneous tracheostomy in COVID-19 patients without an increase in the overall complication rate or evidence of risk to healthcare providers. Our findings provide initial evidence that tracheostomy can be performed safely as a standard of care for COVID-19 patients requiring prolonged mechanical ventilation as was standard practice in ICU patients prior to the COVID-19 pandemic to promote ventilator weaning and patient recovery.

Correction to: Chloride content of solutions used for regional citrate anticoagulation might be responsible for blunting correction of metabolic acidosis during continuous venovenous hemofiltration.

Following publication of the original article [1], we have been notified that the approved number by the Ethical Committee was given incorrectly. In the section "Methods" stated that: The Central Ethical Committee of the University Hospital approved the study protocol (B.U.N. 143201318818), this number is incorrect and should be expressed as follows: B.U.N. 143201318819."

Treatment of Ventilator-associated Pneumonia with High-dose Colistin Under Continuous Veno-venous Hemofiltration.

BACKGROUND AND OBJECTIVES: High-dose colistin (COL) ensures adequate treatment of pneumonia caused by multidrug resistant gram-negative bacteria (MDR-GNB) but must be weighed against a higher risk of nephrotoxicity. Continuous veno-venous hemofiltration (CVVH) clears COL by filtering and membrane adsorption that permits to avoid dose accumulation and excessively high peak concentrations. We evaluated clinical/microbiological efficacy of the high-dose COL treatment under CVVH in patients with newly diagnosed MDR-GNB ventilator-associated pneumonia (VAP). METHODS: Observational cohort study in critically ill adult patients with MDR-GNB VAP. Colistimethate sodium (CMS) was administered as a 9 million international units (MIU) of loading dose followed by 3 × 4.5 MIU daily. CVVH was performed over a highly adsorptive membrane. Clinical and microbiological efficacies were assessed at the end of therapy. In survivors, serum creatinine level was evaluated before and at the end of therapy. RESULTS: Fourteen patients (8 male patients, aged 57 ± 14 years) were consecutively included. Isolated pathogens were Pseudomonas aeruginosa in 7, Klebsiella pneumoniae in 5, and other Enterobacteriaceae in 2 patients. A favorable clinical response was observed in 9 patients (64%). Full and presumed microbiological eradication was observed in 12 patients (86%). Two patients were diagnosed with Stage 1 acute kidney injury. CONCLUSIONS: In patients with MDR-GNB VAP, CVVH may represent an interesting option to enable effective high-dose COL treatment.

Correction to: CO2 and O2 removal during continuous veno-venous hemofiltration: a pilot study.

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CO2 and O2 removal during continuous veno-venous hemofiltration: a pilot study.

BACKGROUND: Carbon dioxide (CO2) accumulation is a challenging issue in critically ill patients. CO2 can be eliminated by renal replacement therapy but studies are scarce and clinical relevance is unknown. We prospectively studied CO2 and O2 behavior at different sample points of continuous veno-venous hemofiltration (CVVH) and build a model to calculate CO2 removal bedside. METHODS: In 10 patients receiving standard CVVH under citrate anticoagulation, blood gas analysis was performed at different sample points within the CVVH circuit. Citrate was then replaced by NaCl 0.9% and sampling was repeated. Total CO2 (tCO2), CO2 flow (V̇CO2) and O2 flow (V̇O2) were compared between different sample points. The effect of citrate on transmembrane tCO2 was evaluated. Wilcoxon matched-pairs signed rank test was performed to evaluate significance of difference between 2 data sets. Friedman test was used when more data sets were compared. RESULTS: V̇CO2 in the effluent (26.0 ml/min) correlated significantly with transmembrane V̇CO2 (24.2 ml/min). This represents 14% of the average expired V̇CO2 in ventilated patients. Only 1.3 ml/min CO2 was removed in the de-aeration chamber, suggesting that CO2 was almost entirely cleared across the membrane filter. tCO2 values in effluent, before, and after the filter were not statistically different. Transmembrane tCO2 under citrate or NaCl 0.9% predilution also did not differ significantly. No changes in V̇O2 were observed throughout the CVVH circuit. Based on recorded data, formulas were constructed that allow bedside evaluation of CVVH-attributable CO2 removal. CONCLUSION: A relevant amount of CO2 is removed by CVVH and can be quantified by one simple blood gas analysis within the circuit. Future studies should assess the clinical impact of this observation. TRIAL REGISTRATION: The trial was registered at https://clinicaltrials.gov with trial registration number NCT03314363 on October 192,017.

Impact of maintenance, resuscitation and unintended fluid therapy on global fluid load after elective coronary artery bypass surgery.

INTRODUCTION: Standardized protocols are provided for maintenance and replacement fluid therapy in critically ill patients. However, unintended fluid sources (analgesics, antibiotics and other drugs) are not always taken into account when prescribing intravenous fluid therapy. We evaluated the extent to which maintenance, resuscitation and unintended fluids contributed to total fluid load in elective coronary artery bypass graft patients during their ICU stay. METHODS: Data on intravenous and oral fluid input and output were retrospectively collected from the electronic medical files. RESULTS: Sixty patients were included. Maintenance fluids represented 1435 ± 570mL (49%) and 2214 ± 657mL (71%), resuscitation fluids 847 ± 542mL (29%) and 338 ± 559mL (11%), unintended fluids 639 ± 162mL (22%) and 576 ± 285mL (18%) respectively on day 1 and day 2. Mean oral intake increased almost fourfold (from 258mL to 1017mL) on the second day. CONCLUSION: Postoperative maintenance and resuscitation fluids are responsible for most of the observed total fluid load on the first two days after elective coronary artery bypass graft surgery. Unintended fluid load is underestimated and has to be taken into account during fluid prescription.

The CoCoS trial: Caloric Control in Cardiac Surgery patients promotes survival, an interventional trial with retrospective control.

BACKGROUND & AIMS: Malnutrition is widespread among cardiac surgery patients and is independently related to an adverse postoperative evolution or outcome. We aimed to assess whether nutrition therapy (NT) could alter caloric deficit, morbidity, and mortality in patients scheduled for non-emergency coronary artery bypass graft (CABG) or aortic valve surgery. METHODS: 351 patients undergoing either elective CABG or aortic valve surgery were studied. Patients receiving NT were enrolled from January 2013 until December 2014. A retrospective control group (CT) consisted of 142 matched patients. The primary endpoint was to evaluate whether NT could limit caloric deficit (Intake to Need Deviation). Secondary endpoints addressed the potential effect of NT on morbidity and mortality. Patients were followed for one year after surgery. RESULTS: There was no significant difference in patient, laboratory or mortality profile between the groups. Caloric deficit could be limited in the intervention group, essentially by providing oral feeding and oral supplements. A minority of patients required enteral or parenteral nutrition during their hospital stay. Caloric deficit increased after the second postoperative day because more patients were switched to oral feeding and intravenous infusions were omitted. Combining CABG and aortic valve surgery, male patients in the NT group had significantly less arrhythmia than in the CT group (7% versus 31%; P = 0.0056), while females in the NT group had significantly less pneumonia than in the CT group (7% versus 22%; P = 0.0183). Survival was significantly higher in female NT patients compared to CT patients, both for CABG (100% versus 83%; P = 0.0015) and aortic valve surgery (97% versus 78%; P = 0.0337). CONCLUSION: The results suggest that NT beneficially affects morbidity and mortality in elective cardiac surgery patients. The impact of NT seems more pronounced in women than in men. Registration: Clinicaltrials.gov: NCT02902341.

A newly developed tracheal tube offering 'pressurised sealing' outperforms currently available tubes in preventing cuff leakage: A benchtop study.

BACKGROUND: No currently used tracheal tube offers full protection against aspiration of oropharyngeal secretions into the lower airways. OBJECTIVE: We developed a tracheal tube equipped with two polyvinylchloride (PVC) cuffs with a supplementary port opening between the cuffs through which a continuous positive pressure of 5 cmH2O is provided [double-cuffed PVC (PVCdc)]. We compared this PVCdc with four different cuff types (cylindrical PVC, conical PVC, cylindrical polyurethane and conical polyurethane). DESIGN: A comparison study using an in-vitro benchtop model of an artificial rigid trachea. INTERVENTIONS: Tracheal tubes were placed in the artificial trachea. Both cuffs were kept inflated at 25 cmH2O. Total 3 ml dyed water was placed above the cuff and leakage recorded under static and dynamic [5 cmH2O positive end-expiratory pressure (PEEP) alone or positive pressure ventilation plus 5 cmH2O PEEP] conditions. At the end of the dynamic experiments, PEEP was zeroed (PEEP alone) or the tracheal tubes were disconnected from the ventilator (positive pressure ventilation plus PEEP). RESULTS: In the static model, leakage flows [medians (range)] were 9.8 (6.2 to 20) for the cylindrical PVC, 1.3 (0.2 to 3.8) for the conical PVC, 0.03 (0.007 to 0.1) for the cylindrical polyurethane, 0.04 (0.003 to 0.2) for the conical polyurethane and 0.0 (0.0 to 0.0) ml min for the PVCdc cuff (P < 0.001, PVCdc vs. all other cuffs). In the dynamic setting, no leakage was detected for up to 60 min with any of the cuffs studied. Loss of PEEP or tracheal tube disconnection resulted in dye inflow alongside all cuffs except for the PVCdc (P < 0.001, PVCdc vs. all other cuffs). CONCLUSION: A 'pressure seal' incorporated in a double-cuffed tracheal tube prevented fluid passage into the lower airways. Clinically, this may translate into absence of inflow of bacteriologically contaminated secretions into the lungs and thus a lower incidence of ventilator-associated infection.

Chloride content of solutions used for regional citrate anticoagulation might be responsible for blunting correction of metabolic acidosis during continuous veno-venous hemofiltration.

BACKGROUND: Citrate, the currently preferred anticoagulant for continuous veno-venous hemofiltration (CVVH), may influence acid-base equilibrium. METHODS: The effect of 2 different citrate solutions on acid-base status was assessed according to the Stewart-Figge approach in two consecutive cohorts of critically ill adult patients. The first group received Prismocitrate 10/2 (PC10/2; 10 mmol citrate/L). The next group was treated with Prismocitrate 18/0 (PC18; 18 mmol citrate/L). Both groups received bicarbonate-buffered fluids in post-dilution. RESULTS: At similar citrate flow, the metabolic acidosis present at baseline in both groups was significantly attenuated in PC18 patients but persisted in PC10/2 patients after 24 h of treatment (median pH 7,42 vs 7,28; p = 0.0001). Acidosis in the PC10/2 group was associated with a decreased strong ion difference and an increased strong ion gap (respectively 43 vs. 51 mmol/L and 17 vs. 12 mmol/L, PC10/2 vs. PC18; both p = 0.001). Chloride flow was higher in PC10/2 than in PC18 subjects (25.9 vs 14.3 mmol/L blood; p < 0.05). CONCLUSION: Correction of acidosis was blunted in patients who received 10 mmol citrate/L as regional anticoagulation during CVVH. This could be explained by differences in chloride flow between the applied citrate solutions inducing hyperchloremic acidosis.

Renal blood flow and acute kidney injury in septic shock: an arduous conflict that smolders intrarenally?

Sepsis-induced acute kidney injury (SAKI) is traditionally viewed as a process driven by a reduced blood flow and prone to benefit from vasopressive support. In ovine hyperdynamic septic shock, Lankadeva et al. report a significant and flow-independent intrarenal perfusion and oxygenation "mismatch" jeopardizing the renal medulla that was aggravated by norepinephrine. Medullary and urinary oxygenation changed in parallel, suggesting that urinary oxygenation may act as a biomarker to predict SAKI.

Citrate Formulation Determines Filter Lifespan during Continuous Veno-Venous Hemofiltration: A Prospective Cohort Study.

INTRODUCTION: We conducted an 8-month prospective single-center observational study in patients with acute kidney injury treated with continuous veno-venous hemofiltration (CVVH) to compare the impact of two citrate formulations on filter lifespan (FLS). METHODS: Patients received CVVH at a delivered dose of 25 ml/kg/h. Multivariable linear regression was performed to assess the influence of different variables on circuit lifespan. RESULTS: We included 59 patients, 28 received the 10/2 formulation and 31 received the 18/0 formulation. Median (interquartile range) FLS was significantly prolonged with the 18/0 solution compared with the 10/2 solution (4.10 (2.45-5.75) vs. 2.68 (0.47-4.99) days, p = 0.001). No confounding variables (difference in ionized calcium target, citrate flow or dose, platelet count, hematocrit, vascular access location) affecting filter capacity or lifespan between the 2 formulations were identified. CONCLUSIONS: Under similar conditions of CVVH and calcium targets, a Prismocitrate 18/0 formulation significantly improved FLS as compared with Prismocitrate 10/2.

High-frequency percussive ventilation in severe acute respiratory distress syndrome: A single center experience.

BACKGROUND: Few studies have investigated high-frequency percussive ventilation (HFPV) in adult patients with acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS: We retrospectively analyzed data from critically ill-patients with moderate and severe ARDS who received HFPV. Ventilation and oxygenation were governed according to a predefined protocol. HFPV was continued until patients could be switched to conventional ventilation. RESULTS: A total of 42 patients (20 with pneumonia-related ARDS and 22 non-septic ARDS cases) were evaluable. Baseline demographic characteristics, severity of illness, lung injury score; pH and respiratory variables were comparable between pneumonia and non-sepsis-related ARDS. Within 24 h, HFPV restored normal pH and PaCO2 and considerably improved oxygenation. Oxygenation improved more in non-septic than in pneumonia-related ARDS. Patients with pneumonia-induced ARDS also remained longer HFPV-dependent (7.0 vs. 4.9 days; P < 0.05). Mortality at 30 days was significantly higher in pneumonia-related than in non-sepsis-related ARDS (50% vs. 18%; P = 0.01). CONCLUSIONS: HFPV caused rapid and sustained improvement of oxygenation and ventilation in patients with moderate to severe ARDS. Less improved oxygenation, longer ventilator dependency and worse survival were observed in pneumonia-related ARDS.

Introducing a new generation indirect calorimeter for estimating energy requirements in adult intensive care unit patients: feasibility, practical considerations, and comparison with a mathematical equation.

PURPOSE: Indirect calorimetry (IC) is increasingly advocated for individualizing nutritional therapy in critically ill adult patients, but questions remain regarding its practical implementation. MATERIALS AND METHODS: During 12 weeks, we prospectively assessed utility and practical aspects of IC use. Adult medico-surgical intensive care unit (ICU) patients were daily screened for malnutrition. Indirect calorimetry was planned in subjects considered unable to meet energy requirements on day 3 after admission. Measured energy expenditure (MEE) was compared with calculated (resting/total) energy expenditure. RESULTS: A total of 940 evaluations were performed in 266 patients (age, 63±16 years; 59% males; Acute Physiology and Chronic Health Evaluation II score, 14±8). A total of 230 patients (86.5%) were at risk for malnutrition, and in 118 of them, IC was indicated. Practical considerations precluded measurements in 72 cases (61%). Forty-six calorimetric evaluations revealed an MEE of 1649±544 kcal per 24 hours that poorly correlated with calculated resting energy expenditure (r2=0.19) and calculated total energy expenditure (r2=0.20). Indirect calorimetry measurements were not time-consuming. CONCLUSIONS: Indirect calorimetry was indicated in half but effectively performed in only 20% of a representative intensive care unit population at risk for malnutrition. Correlation between MEE and CEE was poor. CLINICAL RELEVANCY STATEMENT: Indirect calorimetry is increasingly advocated for individualizing nutritional therapy in critically ill adult patients. Practical feasibility is tested in this study. Large differences between measured and calculated energy expenditure are observed. Together with patients' characteristics, feasibility results can guide clinicians or institutes in using IC in their daily clinical practice.

Delayed recovery following laparoscopic partial hepatectomy.

We present a 42-year-old woman with unexpected coma after laparoscopic partial hepatectomy. MRI demonstrated ischaemic cerebral lesions. Further investigation revealed a patent foramen ovale. Cryptogenic stroke arising from a paradoxical carbon dioxide embolism was diagnosed. After 5 days of intensive care, she made a near complete recovery. Perioperative stroke, paradoxical emboli during surgery, patent foramen ovale, carbon dioxide cerebral embolism and therapeutic strategies are discussed.

Retrospective evaluation of possible renal toxicity associated with continuous infusion of vancomycin in critically ill patients.

BACKGROUND: Continuous infusion of vancomycin is increasingly preferred as an alternative to intermittent administration in critically ill patients. Intermittent vancomycin treatment is associated with an increased occurrence of nephrotoxicity. This study was designed to determine the incidence and risk factors of acute kidney injury (AKI) during continuous infusion of vancomycin. METHODS: This was a retrospective, observational, two-center, cohort study in patients with microbiologically documented Gram-positive pneumonia and/or bacteremia and normal baseline renal function. Vancomycin dose was adjusted daily aiming at plateau concentrations of 15-25 µg/mL. AKI was defined as an increase in serum creatinine of 0.3 mg/dL or a 1.5 to 2 times increase from baseline on at least 2 consecutive days after the initiation of vancomycin. Primary data analysis compared patients with AKI with patients who did not develop AKI. A binary logistic regression analysis using the forward stepwise method was used to assess the risk factors associated with AKI. RESULTS: A total of 129 patients were studied of whom 38 (29.5%) developed AKI. Patients with AKI had higher body weight (77.3 ± 15 vs. 70.5 ± 15.2 kg; p = 0.02), more diabetes (79% vs. 54%; p = 0.01), and a higher vasopressor need (87% vs. 59%; p = 0.002). Serum vancomycin levels, body weight, and SAPS 3 score were identified as variables contributing to AKI. The incidence of AKI increased substantially when treatment duration was prolonged (14.9 ± 9.8 vs. 9.2 ± 4.9 days; p = 0.05) and plasma levels exceeded 30 µg/mL. CONCLUSIONS: AKI is frequently observed during continuous vancomycin infusion, particularly when conditions that cause acute (shock) or chronic (diabetes) renal dysfunction are present and vancomycin levels above target range are achieved. Although this study challenges the concept that continuous vancomycin infusion might alleviate the risk of nephrotoxicity in critically ill patients, a direct relationship between vancomycin and nephrotoxicity remains to be proven.

Pharmacokinetics and pharmacodynamics of once-weekly subcutaneous epoetin alfa in critically ill patients: results of a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To describe the erythropoietin pharmacokinetic profile after once-weekly epoetin alfa treatment in critically ill patients. Secondary objectives were to compare pharmacodynamic and safety profiles between active treatment and placebo in these patients. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Medical, surgical, or mixed medical/surgical intensive care units. PATIENTS: A total of 73 anemic critically ill adults with an expected stay of >3 days and a hematocrit value of <38%. INTERVENTIONS: Patients were randomized 2:1 to epoetin alfa, 40,000 IU, administered subcutaneously once weekly (n=48) or matching placebo (n=25) for up to 4 wks. MEASUREMENTS AND MAIN RESULTS: Serum erythropoietin concentration and hematologic variables (percentage reticulocytes [RETI], hemoglobin [Hb], and total red blood cell [RBC] counts) were measured, and area under the serum concentration-time curve from time 0 to the last blood sampling time at time t (t: 120, 144, or 168 hrs) postdose (AUC0-Tlast) for these three variables was determined. Mean serum erythropoietin concentrations in placebo patients were slightly higher than typical physiologic levels of erythropoietin in healthy subjects, although not appropriate for the degree of anemia in these patients. Overall, exposure of endogenous erythropoietin in the placebo group (in terms of AUC0-Tlast) was only about 20% of exposure to exogenous erythropoietin in the epoetin alfa group. Baseline hemoglobin levels were the same in both groups (9.9 g/dL). Mean change in hemoglobin level from baseline through day 29 was 1.9 g/dL and 1.6 g/dL in the epoetin alfa and placebo groups, respectively. Mean AUC(RETI)0-Tlast was higher with epoetin alfa than with placebo and was related to the AUC of erythropoietin. There were no apparent differences in AUC(Hb)0-Tlast and AUC(RBC)0-Tlast between epoetin alfa and placebo groups, which was most likely due to bleeding and transfusion events. Epoetin alfa was safe and well tolerated, with a rate of treatment-emergent complications similar to that seen with placebo. CONCLUSION: Epoetin alfa, once weekly, augmented the erythropoietic response in critically ill patients as indicated by the increased erythropoietin levels and larger AUC(RETI)0-Tlast in treated patients.

Acute dopamine/norepinephrine reuptake inhibition increases brain and core temperature in rats.

The purpose of the present study was to examine the effects of an acute dose of the dual dopamine (DA) and norepinephrine (NE) reuptake inhibitor bupropion (Bup) on brain (T(brain)), body core (T(core)), and tail skin (T(tail)) temperature in freely moving rats and to simultaneously monitor the extracellular neurotransmitter concentrations in the preoptic area and anterior hypothalamus (PO/AH). A microdialysis probe was inserted in the PO/AH, and samples for NE, DA, and serotonin (5-HT) were collected every 20 min before and after the injection of 17 mg/kg of Bup, for a total sampling time of 180 min. T(core) was monitored using a biotelemetry system. T(brain) and T(tail), an index of heat loss response, were also measured. Both NE and DA levels in the PO/AH significantly increased after Bup injection compared with the baseline levels, reaching approximately 450 and 230%, respectively, 40 min after injection. There was no effect on 5-HT release. The neurotransmitter changes were accompanied by a significant decrease in T(tail) and an increase in both T(brain) and T(core) compared with the baseline levels. The present results demonstrate that inhibition of NE and DA reuptake suppresses heat loss mechanisms and elevates T(brain) and T(core) in freely moving rats.

Effects of N-acetylcysteine on microalbuminuria and organ failure in acute severe sepsis: results of a pilot study.

STUDY OBJECTIVE: The level of microalbuminuria is thought to reflect the severity of inflammation-induced systemic vascular permeability and may have prognostic value with regard to organ dysfunction and survival. N-acetylcysteine (NAC) has been shown to decrease capillary leakage in experimental sepsis. The present study investigated the effect of early treatment with NAC on microalbuminuria and organ dysfunction in severe clinical sepsis. DESIGN: Prospective, randomized, placebo-controlled study. SETTING: A 24-bed multidisciplinary ICU in a university teaching hospital. PATIENTS: Thirty-five patients included within 4 h of fulfilling consensus criteria of severe sepsis. INTERVENTIONS: Patients were randomly assigned to receive either NAC (continuous infusion starting with 50 mg/kg/4 h followed by 100 mg/kg/24 h for 44 h; n = 18) or placebo (n = 17) in addition to standard therapy. MEASUREMENTS AND RESULTS: Urine samples for measurement of microalbuminuria/creatinine ratio (MACR) were collected on inclusion and after 4 h, 24 h, and 48 h. Severity of illness and degree of organ failure were determined by using, respectively, the APACHE (acute physiology and chronic health evaluation) II score and the sequential organ failure assessment (SOFA) score. The MACR did not differ over time between the placebo- and the NAC-treated groups. SOFA scores were comparable between both treatment groups at baseline (6.2 +/- 3.9 vs 6.5 +/- 2.7, NAC vs placebo; p = 0.6) and increased during treatment in the NAC-treated patients but not in the placebo group (7.9 +/- 3.7 vs 5.9 +/- 2.5, p = 0.09 and 7.7 +/- 3.8 vs 5.1 +/- 2.1, p < 0.05; NAC vs placebo, respectively, at 24 h and at 48 h). The cardiovascular SOFA score progressively increased during NAC treatment, reaching higher values as compared to time-matched scores in the placebo group. CONCLUSIONS: Early NAC administration does not influence the course of MACR in severe clinical sepsis, suggesting that NAC might not attenuate endothelial damage in this condition. NAC treatment even aggravated sepsis-induced organ failure, in particular cardiovascular failure.

The paradox of hypotension and pheochromocytoma: a case report.

Pheochromocytomas produce, store and secrete catecholamines. Diagnosis is often suspected in young patients with severe hypertension. We present the case of a 47-year-old woman without a previous history of hypertension, whose initial presentation was cardiovascular shock. Despite early diagnosis of the disease, the fulminant evolution of the pheochromocytoma crisis was fatal a few hours after admission. Only a few therapeutic options remain when haemodynamic collapse is catecholamine induced.

Ketosis and cardiac failure: common signs of a single condition.

The metabolic effects of chronic alcohol abuse can induce a broad spectrum of disorders. We describe the case of an initially unidentified alcoholic, poorly nourished woman who presented with ketoacidosis. She developed severe cardiac failure, which did not respond to classical treatment. The administration of intravenous thiamine resulted in an impressive recovery of cardiac function. Laboratory examinations confirmed the diagnosis of alcoholic ketoacidosis and cardiac beriberi. The clinical entity and treatment of these two uncommon disorders are discussed. If recognized early both diseases (and their combination) are fully reversible.