Renal rescue therapy in early stage of severe sepsis: a case study approach.

OBJECTIVE: The aim of this study was to evaluate the efficacy of noradrenaline and furosemide in combination for the treatment of impending acute renal failure in early stage of severe sepsis. DESIGN: observational case study. SETTING: Nine-bed general ICU in university-affiliated cancer institute. PATIENTS: Severe septic cancer patients admitted to the ICU. MEASURMENTS AND RESULTS: 17 severe septic patients with multiorgan dysfunction syndrome (admission SOFA score, mean 9.1+/-3.0 p, and APACHE II score, mean 20.4+/-5.1 p.) received full intensive treatment including volume expansion, hemodynamic support with noradrenaline infusion and low-dose hydrocortisone. Severe sepsis was documented by proven infection, site of infection and high levels of procalcitonin (mean value 69.8 ng/ml, 7.1-588 ng/ml), C-reactive protein (mean 210 mg/l, range 49-370 mg/l) and low total cholesterol levels (mean 2.36 mmol/l, range 1.3-3.9 mmol/l). Acute renal injury and acute renal failure syndrome were detected in 14 patients (82 %) out of 17. The combination of noradrenaline continuous infusion (0.06-0.12 microg/kg/min) and furosemide infusion (10-30 mg/hr) was used for hemodynamic and renal support. We induced polyuria and reverse acute tubular necrosis to nonoliguric acute renal failure in 11 patients (78.5 %) from 14 septic cancer patients with acute renal injury/failure syndrome. We recorded 35.2 % hospital mortality due to the severe sepsis and septic shock. We used no renal replacement therapy. CONCLUSION: We consider renal rescue protocol as an effective method in the treatment for acute renal injury/failure syndrome in early phase of severe sepsis, when it is instituted very early with low/moderate dosage of noradrenaline and furosemide. (Tab. 6, Ref. 29.)

[Serum neopterin levels in oncology patients in intensive care]. / Hladiny sérového neopterínu u onkologických pacientov v intenzívnej starostlivosti.

BACKGROUND: Elevated neopterin serum levels are associated with diseases that stimulate the cellular immune response. This includes viral infections, autoimmune diseases, transplant rejection and dissemination of certain types of cancer. T-helper lymphocytes and macrophages play a key role in neopterin synthesis. The degree of activation of Th1-lymphocytes is responsible for the production of interferon-gamma and interleukin-2, which stimulate neopterin production in human macrophages. DESIGN AND METHODS: We have designed a prospective observational study to assess the dynamics of serum neopterin levels in 75 oncological patients during post-surgery period. We measured serum neopterin by means of RIA method (radioimmunoassay) in 50 uncomplicated surgery patients (group A), in 15 complicated surgery patients (group B--abdominal sepsis, peritonitis, ileus) and 10 medical ICU patients (group C). Serum levels of neopterin were measured in 5 consecutive periods: before surgery, after surgery, and on the 1st, 2nd, 3rd postoperative days. RESULTS: In all groups, we observed gradual elevation of serum neopterin. The lowest values of neopterin were measured in group A in patients with uncomplicated course following surgery: 6.75 nmol/l, 7.67 nmol/l, 8.9 nmol/l, 10.82 nmol/l and 13.66 nmol/l. A significant increase in serum neopterin levels was measured in group B in patients with septic complications during perioperative period: 18.9; 23.2; 26.82; 29.53 and 27.32 nmol/l. High values of neopterin were also measured in medical ICU patients with disseminated cancer and sepsis during ICU stay: 26.1; 58.1; 28.7 and 22.5 nmol/l. We concluded that serum neopterin levels were increased during the post-surgery period. We observed a significant increase in serum neopterin in patients with severe systemic infection or sepsis or in patients with cancer progression or dissemination (more than 15-20 nmol/l). Neopterin is a simple, reliable and sensitive parameter of cell-mediated immunity, suitable for early diagnosis of viral, autoimmune and transplantant rejection diseases. Neopterin can be used also for non-specific laboratory monitoring of cancer progression and/or dissemination. (Tab. 3, Fig. 4, Ref. 7.)