Severe acute pancreatitis: treatment with somatostatin.
Planas M. Perez A. Iglesia R. Porta I. Masclans JR. Bermejo B.
Intensive Care Unit, Hospital General Universitari Vall d'Hebron, Barcelona, Spain.
OBJECTIVE: To investigate the efficacy of somatostatin for the treatment of severe acute pancreatitis. DESIGN: Prospective, randomized and unblinded study. SETTING: A general intensive care unit (ICU) in a university hospital. PATIENTS: 50 patients with severe acute pancreatitis. INTERVENTIONS: All patients received the conventional treatment for this clinical condition. The study group received, in addition, somatostatin over a 10-day period. MEASUREMENTS AND RESULTS: We evaluated age, gender, etiology of the pancreatitis, severity of the illness, complications, length of hospitalization, and mortality in the ICU. The patients were classified as severe (Acute Physiology and Chronic Health Evaluation II score, Ranson's criteria, and computed tomography Balthazar classification). Biliary lithiasis was the most common etiologic factor (63.6% in the control group, 37.5% in study group; NS). The study group required fewer overall surgical interventions than the control group (45.8 vs 86.4%; p = 0.005). Late surgical procedures related to the evolution of pancreatic necrosis were more common in the controls (63.6 vs 37.5%; p = 0.07). No differences in length of stay in hospital or mortality in the ICU were observed. CONCLUSION: The only advantage of somatostatin administration in the patients studied was a slight reduction in the need for surgery due to local complications.
Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care.
Pitimana-aree S. Forrest D. Brown G. Anis A. Wang XH. Dodek P.
St Paul's Hospital, Vancouver, B.C., Canada.
OBJECTIVE: To develop, implement and evaluate a practice guideline for stress ulcer prophylaxis. DESIGN: Before-after study. SETTING: Ten-bed Intensive Care Unit (ICU) and 4-bed Step-down Unit in a teaching hospital. PATIENTS AND PARTICIPANTS: Fifty patients admitted during 1 year before and 50 patients admitted 3-6 months after introduction of the guideline. INTERVENTION: Introduction of the practice guideline by dissemination of pocket cards, seminars and "academic detailing". MEASUREMENTS AND RESULTS: Appropriateness (defined as proportion of days in which the prophylaxis met the criteria in the guideline), incidence of gastrointestinal bleeding and of ventilator-associated pneumonia, length of stay in ICU and in hospital, ventilator days. ICU mortality and medication costs for stress ulcer prophylaxis. After the introduction of the guideline, appropriateness increased from 75.8% to 91.1%, and medication costs decreased from C $2.50/day to C $1.30/day. There were no differences in any clinical outcomes. Predictors of appropriate use or the withholding of prophylaxis were the introduction of the guideline, lack of an indication for prophylaxis and number of days studied. CONCLUSIONS: Introduction of this guideline was associated with an increase in appropriateness of prophylaxis and a decrease in medication costs.
Pro-inflammatory cytokine release and mediation of the acute phase protein response in fulminant hepatic failure.
Wigmore SJ. Walsh TS. Lee A. Ross JA.
University Department of Surgery, Royal Infirmary of Edinburgh, UK.
OBJECTIVE: To study the relationship between interleukin-6 (IL-6), tumour necrosis factor (TNF) and the acute phase protein C-reactive protein (CRP) in patients with fulminant hepatic failure (FHF) and to investigate the potential of peripheral blood mononuclear cells (PBMC) isolated from these patients to stimulate CRP production by isolated human hepatocytes in vitro. SETTING: Patients with FHF were studied at the time of their admission to the intensive care unit. STUDY DESIGN: Serum TNF and IL-6 were measured in 12 patients with FHF, PBMC from 6 of these patients were then cultured in the presence and absence of lipopolysaccharides (LPS). TNF and IL-6 in serum and supernatants were measured by ELISA. PBMC supernatants were added to isolated human hepatocytes and CRP production was measured. RESULTS: Serum IL-6 (348 +/- 172 pg/ml) and TNF (118.5 +/- 15.5 pg/ml) were elevated compared with healthy controls (not detected) and these observations were matched by elevated serum CRP in patients with FHF (38.9 +/- 7 mg/l). Both the production of IL-6 and TNF by PBMC isolated from patients with FHF and the potential of supernatants from these cells to stimulate CRP production by hepatocytes in vitro was significantly reduced compared with controls. CONCLUSION: Despite the observation that patients with FHF have an elevated hepatic acute phase response, PBMC from patients with FHF have reduced potential to produce IL-6 and TNF and elicit an acute phase response in vitro by the time of patient admission to the intensive care unit. One explanation for this observation is early activation and exhaustion of PBMC in vivo.
Bioavailability of ciprofloxacin after multiple enteral and intravenous doses in ICU patients with severe gram-negative intra-abdominal infections.
de Marie S. VandenBergh MF. Buijk SL. Bruining HA. van Vliet A. Kluytmans JA. Mouton JW.
Erasmus University Medical Center, Rotterdam/Dijkzigt Hospital, Department of Medical Microbiology and Infectious Diseases, Rotterdam, The Netherlands. firstname.lastname@example.org
BACKGROUND: Few data are available on the pharmacokinetics of multiple enteral dosing of ciprofloxacin in critically ill intensive care patients and none for those with severe gram-negative intra-abdominal infections (GNIAI). OBJECTIVE: To determine the bioavailability of enteral ciprofloxacin in tube-fed intensive care patients with severe GNIAI. DESIGN: A randomized crossover study. SETTING: University-based medical center. PATIENTS: 5 critically ill intensive care patients with GNIAI and an estimated creatinine clearance > 25 ml/ min who received continuous tube feeding. INTERVENTIONS: Multiple doses of enteral 750 mg b.i.d. versus 400 mg b.i.d.i.v. ciprofloxacin. MEASUREMENTS: The calculated 12-h area under the serum concentration versus time curve after 750 mg b.i.d. enteral dosing was equivalent to that after 400 mg b.i.d.i.v. The mean bioavailability of enteral dosing was 53.1% [95% confidence interval (CI) 43.5-62.8]. In seven additional patients, the mean serum steady-state concentration at 2 h after enteral administration was 3.9 microg/ml (95% CI 1.9-5.9), not significantly different from that found in the crossover study (p = 0.4). CONCLUSIONS: In tube-fed intensive care patients with severe GNIAI, the bioavailability of enteral ciprofloxacin is adequate.