Prognostic value of Pulsatility Index in acute intracerebral hemorrhage.

OBJECTIVE: To investigate whether data obtained by transcranial Doppler (TCD) have prognostic value in patients with intracerebral hemorrhage (ICH). METHODS: A prospective study of patients with an acute (<12 hours from onset of symptoms) spontaneous supratentorial ICH was conducted. Mortality was assessed at 30-day follow-up. TCD parameters were obtained from both middle cerebral arteries: systolic, diastolic, and mean velocities and Pulsatility Index (PI) from the affected and unaffected hemispheres. The following variables were included in a univariate analysis: age, sex, hematoma volume, hypodense volume around the hematoma, total volume, midline shift, ventricular size, Glasgow Coma Scale score, intraventricular hemorrhage, body temperature, white cell count, blood glucose, mean blood pressure, and TCD data. A multivariate analysis was performed with variables that showed significance in the univariate analysis. Receiver-operator characteristic (ROC) curves were obtained. RESULTS: Forty-eight patients (age 66.5 +/- 12.5 years; 28 men) were studied. Mortality at 30 days was 31%. The only predictor of mortality was the Glasgow Coma Scale score (odds ratio [OR] 0.67, CI 0.53 to 0.84, p = 0.001), whereas the PI from the unaffected hemisphere was correlated with mortality (OR 2.3, CI 0.92 to 5.72, p = 0.07). The area under the ROC curve was 0.92. A cutoff for PI from the unaffected hemisphere of 1.75 showed a specificity of 94% and a sensitivity of 80% as a predictor of death at 30 days. CONCLUSIONS: The PI of the unaffected hemisphere may be a predictor of death in acute ICH. These findings suggest that intracranial hypertension is the most likely cause of death in most patients with ICH.

Early diagnosis of brain death in patients treated with central nervous system depressant drugs.

BACKGROUND: Among the main causes for the relatively small number of organ donors, the delay in the diagnosis of brain death plays a major role. Administration of drugs causing central nervous system (CNS) depression prevents diagnosis of brain death by clinical and electroencephalographic criteria until serum clearance of the drug has occurred. Confirming brain death by demonstrating persistent intracranial circulatory arrest might decrease the length of the diagnostic process. We have carried out a prospective study to investigate whether 99 mTc-hexamethyl propylenamino oxime (99mTc-HMPAO) brain scintigraphy and/or transcranial Doppler ultrasound can speed up the diagnosis of brain death in patients treated with CNS depressant drugs. METHODS: All 138 consecutive patients with severe brain lesion that progressed to brain death in our center between January 1994 and December 1996 were controlled. Of them, 36 patients aged 1 to 65 years old (mean=25.6+/-18.3 years) who met clinical and EEG criteria for the diagnosis of brain death, except for the presence of significant serum levels of barbiturates (n=34), opiates (n=8), and benzodiazepines (n=3) were distributed in three groups according to the confirmatory test used; group 1: waiting for the metabolic clearance of CNS depressant drugs, or by demonstrating intracranial circulatory arrest with 99mTc-HMPAO (group 2) or transcranial Doppler (group 3). The delay in diagnosing brain death by the three methods was analyzed. RESULTS: The mean interval between the presumptive and the definitive diagnosis of brain death was 34.4+/-32.2 hr in group 1, 17.7+/-18.3 hr in group 2, and 5.0+/-4.6 hr in group 3 (P=0.004). The between-groups analysis showed that 99mTc-HMPAO and transcranial Doppler decreased the delay in diagnosing brain death with respect to waiting for drug clearance by 49% (P=0.16) and 85% (P<0.001), respectively. Moreover, transcranial Doppler decreased this time by 72% with respect to 99mTc-HMPAO (P<0.01). CONCLUSIONS: Transcranial Doppler ultrasound and 99mTc-HMPAO brain scintigraphy can significantly reduce the time taken to confirm brain death in patients with significant serum levels of CNS depressant drugs. In this setting, transcranial Doppler is superior to 99mTc-HMPAO in reducing the waiting time for a firm diagnosis of brain death.

Amylase, lipase, pancreatic isoamylase, and phospholipase A in diagnosis of acute pancreatitis.

To determine the utility of serum amylase (AMY), lipase (Lp), pancreatic isoamylase (isoA), phospholipase A (PLA), and urine AMY in the diagnosis of acute pancreatitis, samples of serum and urine were obtained on admission and every day thereafter for 5 days from 384 patients with acute abdominal pain. Diagnostic accuracy, determined as the area under the receiver operating characteristic curve, was > 0.975 for serum AMY, Lp, isoA, and urine AMY. For each of these enzymes, a threshold value (twice to sixfold the upper limit of the reference values) offering diagnostic efficiency > 95% could be determined. In contrast, accuracy and efficiency of serum PLA were low. The profiles of these enzymes in acute pancreatitis decreased in a parallel fashion over 5 days except for PLA. We conclude that diagnostic utilities are similar for serum AMY, Lp, isoA, and urine AMY for acute pancreatitis, provided that an appropriate threshold is established.

Acute necrotizing pancreatitis: a multicenter study.

A multicenter study of acute necrotizing pancreatitis (ANP) classified in accordance with the Balthazar criteria (grades D and E), has been performed in 12 teaching hospitals. A total of 233 patients were reviewed, and the mortality rate was 26.6%. The most common etiology was biliary pancreatitis (45.5%). Among the complications, shock, renal insufficiency, pulmonary insufficiency and hemorrhagic gastritis were associated with a mortality rate of 51-66%. Diffuse fluid collections were associated with a higher mortality rate (26.8%) than localized fluid collections (14.5%). In 106 patients with gallstone pancreatitis, early surgery was performed in 17, and 5 patients (29.4%) died. No mortality was observed in 32 patients with delayed surgery. Sphincterotomy was performed in 13 patients, and 4 (30.7%) died. Early surgery (necrosectomy and closed peritoneal lavage) was undertaken in 75 patients, with a mortality rate of 39%. In conclusion, the morbidity and mortality rates of ANP can be improved with proper monitoring, adequate supportive care and the judicious use of surgery based on clinical and morphological findings.

The profile evolution of acute severe poisoning in Spain.

About 5% of the patients admitted to emergency departments with poisonings are seriously ill and need admission to intensive care units (ICUs). This paper presents the result of three multicentric studies carried out in Spain during the last ten years. A study was made of 6 ICUs in 1980, 41 in 1987 and 15 in 1990 with a total of 596 patients. The average age (36) remained stable throughout, but the number of female cases decreased each time. The most frequent cause (79%) was attempted suicide. The products used most frequently were therapeutic drugs (82, 71 and 58%) followed by drugs of abuse, and then agricultural, household and industrial products. We observed a progressive decrease in barbiturates (54, 15 and 2%) and an increase in benzodiazepines and cyclic antidepressants. Therapeutic methods used were mostly gastric lavage (64%), activated charcoal (35%), forced diuresis (43%), extracorporeal therapy (11%) and antidotes. The mortality rate fluctuated between 6.4 and 9.1%, being significantly higher with poisoning by non-therapeutic drugs. In conclusion, the most common poisoning admitted to our ICUs was by psychoactive drugs in suicide attempts. We observed the under-use of activated charcoal and an excessive usage of kidney and extracorporeal methods. The prognosis was worse for poisonings with non-therapeutic drugs.

Splenic hematoma in acute pancreatitis. Role of coagulation disorders.

Splenic hematomas are infrequent complications of acute pancreatitis. In some cases, local factors that may play a role in the pathogenesis of the hematoma (thrombosis of the splenic artery or veins, intrasplenic pseudocysts, perisplenic adhesions, enzymatic digestion) are found. In the absence of local factors, the etiology of splenic hemorrhage remains unknown. We report two cases of splenic hematoma occurring during an acute necro-hemorrhagic pancreatitis associated with renal failure that required renal replacement therapy (hemodialysis and continuous arteriovenous hemodialysis). In both cases, more than half of splenic parenchyma was affected by multiple infarctions. No local factors responsible for the splenic abnormalities were detected in either case. Thrombosis of the splenic arterial microcirculation and a coagulation disorder consistent with disseminated intravascular coagulation was detected in one patient. In the second patient, coagulation disorders secondary to either liver disease, pancreatitis and its septic complications, or extracorporeal circuit heparinization for renal replacement therapy were present. Coagulation disorders should be considered whenever a splenic hematoma is found in a patient with acute pancreatitis. Disseminated intravascular coagulation may be the etiology of a splenic hematoma in acute pancreatitis.

Massive thyroxine intoxication: evaluation of plasma extraction.

Six patients were admitted after erroneous massive intake of levothyroxine (70-1200 mg over an interval of 2-12 days). All patients developed classical symptoms of thyrotoxicosis within 3 days of the first dose; five patients presented grade II-III coma and one became stuporous (days 7-10). Two patients developed left ventricular failure and three had arrhythmias (days 8-11). Total thyroid hormone levels in serum on admission ranged 935-7728 nmol/l for T4 (TT4) and 23-399 nmol/l for T3 (TT3). All patients received treatment with hydrocortisone and Propranolol. Propylthiouracil was also given in 3 cases. Extractive techniques (charcoal haemoperfusion and/or plasmapheresis) were initiated 8-14 days after the first dose of L-T4. The plasma disappearance rate (K) of TT4 with plasmapheresis was 30 times higher, on average, than under standard medical treatment (M). Also, K of TT4 under haemoperfusion was about five times higher than K under M. K changes for TT3 were higher under haemoperfusion than under plasmapheresis. Furthermore, extractive procedures shortened the average half life of TT4, (from 106.5 +/- 44.6 to 59.7 +/- 20.2 h, p less than 0.05).

Miliary tuberculosis and adult respiratory distress syndrome.

Although, miliary tuberculosis is an unusual cause of severe acute respiratory failure, we describe nine patients with miliary tuberculosis who developed adult respiratory distress syndrome. This complication occurred in seven patients despite treatment with antituberculous drugs. In two patients who developed the syndrome, miliary tuberculosis was diagnosed only at postmortem. The presence of pulmonary hypertension in all cases and disseminated intravascular coagulation in seven cases suggests a possible pathophysiologic relationship with severe pulmonary vascular damage. The high mortality rate (88.8%) was associated with nonpulmonary organ system failure. Miliary tuberculosis should be considered in patients with adult respiratory distress syndrome of unknown etiology, and simple diagnostic procedures such as sputum, bronchial brushing, and gastric examination should be followed by invasive diagnostic procedures to confirm this etiology. Since untreated miliary tuberculosis is usually fatal, early recognition of this disease is of great importance, and specific therapy may play a lifesaving role.

Clonidine overdose.

A case of acute intoxication in a 60-yr-old woman who ingested 20 mg of clonidine is presented. The patient showed CNS depression (bradycardia, hypotonia) with systemic hypertension and peripheral vasoconstriction. She was treated with atropine and sodium nitroprusside. There was no recurrence and the patient recovered in 8 days.

Acute severe poisoning in Spain: clinical outcome related to the implicated drugs.

The 91 patients over the age of 10 (57 women and 32 men) with severe self-poisoning admitted to the ICU of a general hospital in Barcelona during the period 1974-1980 have been retrospectively studied. Previous suicidal attempts have been identified among 32 patients; 26 patients presented a history of personality disorders, and 19 had a neurological disease, a chronic physical illness, or a history of alcoholism. Sedative-hypnotic drugs were involved in about half the number of cases, and one fifth of total cases were due to tricyclic antidepressants and phenothiazines. Paracetamol was only involved in 2 cases, and heroin in another 2 cases. Many of the most severe morbidity manifestations were related to overdoses by intermediate-acting barbiturates. Two out of a total of 5 deaths were related to butalbitone overdose. Butalbitone had been ingested as a fixed-dose combination containing butalbitone, propyphenazone, and caffeine, which is freely dispensed as an analgesic in Spain.