Spontaneous splenic rupture in two patients with hematologic malignancy

BACKGROUND: Spontaneous splenic rupture (SSR) is a very rare complication described in several hundred patients, mainly as case reports. It is defined as a splenic rupture without antecedent injury. The authors of the present paper describe the only two SSR cases diagnosed at the Hemato-oncology department, coincidentally in one year. PATIENTS: The first patient was admitted to hospital because of planned chemotherapy for relapsed hairy cell leukemia. The second was directed to the Hemato-oncology outpatient department because of anemia and painful splenomegaly diagnosed by a physician. The diagnose of hematologic malignancy (diffuse large B-cell lymphoma) was determined subsequently on the basis of histological examination of the spleen. CONCLUSION: It is necessary to consider SSR not only in patients with known diagnosis of malignant disease but in the patients with negative anamnesis, too. The aim of the paper is to draw attention to the existence of this complication.     

血液恶性肿瘤患者肠道菌群分析

目的 将血液恶性肿瘤患者肠道菌群与健康个体进行比较,观察血液肿瘤患者肠道菌群结构的变化,探讨肠道菌群与血液恶性肿瘤发生发展的联系。方法 收集血液恶性肿瘤患者与健康志愿者粪便样品,提取样品中菌群总DNA,然后通过变性凝胶梯度电泳（DGGE）技术分析肠道菌群多样性和差异性。结果 血液恶性肿瘤组与健康组肠道菌群的DGGE指纹图谱有明显差异。与正常组相比,患者组肠道大肠埃希菌呈现过度增长趋势,有益菌柔嫩梭菌减少或缺失,某些患者肠道内一些细菌呈现特异性增长,如粪肠球菌、硫磺肠球菌、约氏不动杆菌等。结论 与健康对照组相比,血液恶性肿瘤患者肠道菌群结构与多样性发生改变,这可能为血液恶性肿瘤早期抗感染提供实验依据。     

Effects of ambulance transport in critically ill patients.

Two groups of critically ill patients were transferred by ambulance from other hospitals to a central intensive therapy unit. The effect of transport was reviewed retrospectively in 46 patients and prospectively in 20 patients. Of the 46 patients reviewed retrospectively six became hypotensive, six became hypertensive, and seven developed delayed hypotension. One patient developed fits and six out of 13 patients had a rise in arterial PCO-2 of 1-6-4-1 kPa (12-31 mm Hg). Of the 20 patients reviewed prospectively, one patient became hypertensive due to overtransfusion, one had a fit, but none became hypotensive. Three out of four cases of delayed hypotension were related to starting intermittent positive pressure ventilation. Arterial PCO-2 fell in one patient and arterial PCO-2 rose in two, each change being related to changed oxygen therapy or narcotics. There were no changes in other cardiovascular or respiratory indices, body temperature, or urine production. Earlier transfer, resuscitation before transfer, continuing medical care during the journey, and hence a slower smoother journey seemed to be important factors in the management of these patients. Our findings, may have important implications in the future regional organization of the care of critically ill patients.     

Correlation of blood rheology with vascular resistance in critically ill patients.

Blood rheologic measurements together with peripheral resistance determinations in vivo were made in 27 critically ill patients. Eighteen of these patients (group I) suffered from violent trauma or operative injury and the other 9 (group II) were patients with generalized sepsis. As a result of fluid therapy all patients underwent hemodilution, resulting in a decrease in blood viscosity. This drop in blood viscosity was counteracted to some extent by an increased plasma viscosity due to elevated fibrinogen levels and a decreased red cell deformability associated with massive transfusions of stored blood. The correlation of vivo hemodynamics with blood rheological data made it possible to separate the relative roles of vascular dimensions and blood viscosity in affecting the total peripheral resistance. This approach permitted us to distinguish varying degrees of vasoconstriction in nonseptic patients in low flow states (group I) and varying degrees of vasodilation in septic patients (group II). This type of analysis serves to elucidate the pathophysiology of hemodynamic alterations in disease and provides a rational basis for devising an effective therapeutic program.     

Choice of fluids in critically ill patients

Background

Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia.

Main text

Until recently, because of their excellent safety profile, fluids were not considered “medications”. However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions.

Conclusions

The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma).

     

Early prolonged neutrophil activation in critically ill patients with sepsis

We hypothesised that plasma concentrations of biomarkers of neutrophil activation and pro-inflammatory cytokines differ according to the phase of rapidly evolving sepsis. In an observational study, we measured heparin-binding protein (HBP), myeloperoxidase (MPO), IL-6 and IL-8 in 167 sepsis patients on intensive care unit admission. We prospectively used the emergence of the first sepsis-associated organ dysfunction (OD) as a surrogate for the sepsis phase. Fifty-five patients (of 167, 33%) developed the first OD > 1 h before, 74 (44%) within ± 1 h, and 38 (23%) > 1 h after intensive care unit admission. HBP and MPO were elevated at a median of 12 h before the first OD, remained high up to 24 h, and were not associated with sepsis phase. IL-6 and IL-8 rose and declined rapidly close to OD emergence. Elevation of neutrophil activation markers HBP and MPO was an early event in the evolution of sepsis, lasting beyond the subsidence of the pro-inflammatory cytokine reaction. Thus, as sepsis biomarkers, HBP and MPO were not as prone as IL-6 and IL-8 to the effect of sample timing.     

Trace element requirements in critically ill burned patients

Critically ill burned patients are characterized by a strong oxidative stress, an intense inflammatory response, and months-long hypermetabolism, all of which are proportional to the severity of injury. Trace element (TE) deficiencies have repeatedly been described. The clinical course is complicated by organ failures, infections, and delayed wound healing, which can be partly attributed to TE deficiencies.Among critically ill patients, TE deficiencies are the most severe in major burns, who suffer a specific copper deficiency. Plasma TE concentrations are low during any critical illness, as a result of TE losses in biological fluids, low intakes, dilution by fluid resuscitation, and redistribution from plasma to tissues mediated by the inflammatory response. The large exudative losses cause negative TE balances. Intravenous supplementation trials show that early substitution improves recovery, reduces infectious complications (particularly nosocomial pneumonia), normalize thyroid function, normalize skin tissue levels, improve wound healing and shorten hospital stay.Nevertheless, prolonged high dose delivery may be deleterious, as TE have potential for toxicity. In major burns, supplements up to 4 mg of Cu/day, 500 mg Se/day and 40 mg Zn/day for 3 weeks have been found to be safe and effective. The intravenous route appears the only way to deliver the doses required to achieve antioxidant and clinical effects. Further research is required to determine the optimal combination and doses for different severities of injury.     

国产伏立康唑治疗侵袭性真菌感染6例临床观察

目的观察国产伏立康唑治疗恶性血液病患者侵袭性真菌感染（IFI）的临床疗效和安全性。方法以国产伏立康唑治疗6例发生于恶性血液病患者的侵袭性真菌感染,观察疗效及不良反应。结果6例患者中,有效4例,其中完全反应3例,部分反应1例。1例用药第6天出现低钾血症。结论国产伏立康唑是治疗恶性血液病患者侵袭性真菌感染的安全有效的药物,     

危重症肠道屏障功能障碍患者的营养治疗研究进展

营养不良普遍存在于危重症患者疾病发展过程中,并且与危重症患者的预后密切相关。因此,营养支持已成为危重症患者治疗的一个重要组成部分。认识危重症患者营养与代谢状态的改变,合理的营养支持方法与时机,通过调整能量的供给、控制高血糖和应用免疫营养素等措施,提高危重症患者营养支持的安全性、有效性,可以改善危重症患者的预后。     

Validation of a prognostic score in critically ill patients undergoing transport.

Fifty consecutive critically ill patients transported between hospitals by a mobile intensive care team were assessed prospectively using a modification of the acute physiology and chronic health evaluation (APACHE II) sickness scoring system. Assessments were made before and after resuscitation, on return to base, and after 24 hours of intensive care. No patient died during transport. Twenty two patients died subsequently in hospital and 28 survived to return home. The mean score for the non-survivors before resuscitation was 21.7 and for the survivors 12.2 (p less than 0.0005). Among the non-survivors there was a significant fall in score with resuscitation but this did not alter their subsequent outcome. Neither group deteriorated during transport. The sickness score is a powerful method for determining prognosis, and employed longitudinally it may be useful in the assessment of treatment. It has important implications for the administration and organisation of regional intensive care services.     

Cardiopulmonary interactions during mechanical ventilation in critically ill patients

Cardiopulmonary interactions induced by mechanical ventilation are complex and only partly understood. Applied tidal volumes and/or airway pressures largely mediate changes in right ventricular preload and afterload. Effects on left ventricular function are mostly secondary to changes in right ventricular loading conditions. It is imperative to dissect the several causes of haemodynamic compromise during mechanical ventilation as undiagnosed ventricular dysfunction may contribute to morbidity and mortality.