Intensive Care Medicine

The use of a rigid cervical collar is widely recommended for patients with impaired consciousness following a head injury. This report suggests that such collars may cause significant increases in intracranial pressure in some patients and that this should be borne in mind when they are used.

Missing values occur in nearly all clinical studies, despite the best efforts of the investigators, and cause frequently unrecognised biases. Our aims were (1) to assess the reporting and handling of missing values in the critical care literature; (2) to describe the impact of various techniques for handling missing values on the study results; (3) to provide guidance on the management of clinical study analysis in case of missing data. We reviewed 44 published manuscripts in three critical care research journals. We used the Conflicus study database to illustrate how to handle missing values. Among 44 published manuscripts, 16 (36.4 %) provided no information on whether missing data occurred, 6 (13.6 %) declared having no missing data, 20 (45.5 %) reported that missing values occurred but did not handle them and only 2 (4.5 %) used sophisticated missing data handling methods. In our example using the Conflicus study database, we evaluated correlations linking job strain intensity to the type and proportion of missing values. Overall, 8 % of data were missing; however, using only complete cases would have resulted in discarding 24 % of the questionnaires. A greater number and a higher percentage of missing values for a particular variable were significantly associated with a lower job strain score (indicating greater stress). Among respondents who fully completed the job strain questionnaire, the comparison of those whose questionnaires did and did not have missing values showed significant differences in terms of age, number of children and country of birth. We provided an algorithm to manage clinical studies analysis in case of missing data. Missing data are common and generate interpretation biases. They should be reported routinely and taken into account when modelling data from clinical studies.

pH niêm mạc dạ dày (pHi) và áp lực oxy dưới da (PscO2) đã được so sánh với các thông số tưới máu truyền thống ở bệnh nhân phẫu thuật đại trực tràng theo kế hoạch và được liên hệ với kết quả lâm sàng. Mười bệnh nhân đã được nghiên cứu trước và sau phẫu thuật và các nghiên cứu oxy mô cũng đã được thực hiện trên một nhóm 10 tình nguyện viên khỏe mạnh. Phản ứng của PscO2 với việc hít thở oxy chứng tỏ là yếu tố dự đoán nhạy cảm nhất về kết quả lâm sàng. Trong số 10 bệnh nhân, có 8 người không có phản ứng với thử thách O2, trong khi tất cả 10 tình nguyện viên trong nhóm đối chứng đều có phản ứng. Trong số 8 bệnh nhân đó, có 6 người chủ yếu gặp phải các biến chứng nhiễm trùng trong khi chỉ có 3 người có lượng nước tiểu chẳng đủ trong thời gian phẫu thuật và không có ai có dấu hiệu của bệnh toan động mạch hoặc toan niêm mạc dạ dày. Nghiên cứu hiện tại gợi ý một mối liên hệ khả thi giữa kết quả lâm sàng và các dấu hiệu oxy hóa của tình trạng thiếu tưới máu mô sau thử thách O2 ở những bệnh nhân phẫu thuật, ngay cả khi có lượng nước tiểu đầy đủ và pH thành dạ dày bình thường.

Measurement of functional residual capacity (FRC) during mechanical ventilation is important to standardise respiratory system compliance and adjust the ventilator settings to optimise lung recruitment. In the present study we compared three methods to measure FRC. The bias flow nitrogen washout technique (FRCN2MC), the multiple breath nitrogen washout (FRCMBNW) and the multiple breath sulphur-hexafluoride washout using the molar mass signal of an ultrasonic flow meter (FRCMBSF6) were compared in six adult monkeys after endotracheal intubation and during spontaneous breathing and mechanical ventilation at three different positive end-expiratory pressure (PEEP) levels of 0, 5 and 10 cmH2O. Animal research laboratory. We found good agreement between all three methods and they all accurately measured changes in FRC when PEEP was increased. The coefficients of variance of the three measurement techniques were in the same range (1.3–9.2%). The measurement of the tracer gas concentration with the molar mass signal of the ultrasonic flow meter provides a good and simple alternative to respiratory mass spectrometer for FRC measurements in ventilated subjects.

Infected pancreatic necrosis (IPN) is a highly morbid complication of acute necrotising pancreatitis (ANP). Since there is evidence of early-onset immunosuppression in acute pancreatitis, immune enhancement may be a therapeutic option. This trial aimed to evaluate whether early immune-enhancing Thymosin alpha 1 (Tα1) treatment reduces the incidence of IPN in patients with predicted severe ANP. We conducted a multicentre, double-blind, randomised, placebo-controlled trial involving ANP patients with an Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥ 8 and a computed tomography (CT) severity score ≥ 5 admitted within 7 days of the advent of symptoms. Enrolled patients were assigned to receive a subcutaneous injection of Tα1 1.6 mg every 12 h for the first 7 days and 1.6 mg once a day for the subsequent 7 days or matching placebos (normal saline). The primary outcome was the development of IPN during the index admission. A total of 508 patients were randomised, of whom 254 were assigned to receive Tα1 and 254 placebo. The vast majority of the participants required admission to the intensive care unit (ICU) (479/508, 94.3%). During the index admission, 40/254(15.7%) patients in the Tα1 group developed IPN compared with 46/254 patients (18.1%) in the placebo group (difference -2.4% [95% CI − 7.4 to 5.1%]; p = 0.48). The results were similar across four predefined subgroups. There was no difference in other major complications, including new-onset organ failure (10.6% vs. 15%), bleeding (6.3% vs. 3.5%), and gastrointestinal fistula (2% vs. 2.4%). The immune-enhancing Tα1 treatment of patients with predicted severe ANP did not reduce the incidence of IPN during the index admission.

Objective: To assess the safety and the bedside feasibility of a new computerised method to record the static pressure-volume curves (Pst/V) of the respiratory system.¶Design: The Pst/V curves were recorded in 13 medical patients with the acute respiratory distress syndrome (ARDS). During the Pst/V curve tracing the following parameters were recorded: time required for the recording and the automatic analysis of the Pst/V curve and modifications in electrocardiograms, blood pressure, and arterial oxygen satmation (SaO2).¶Setting: The study was performed in the intensive care unit of the University of Naples “Federico II”.¶Results: No statistically significant modifications in heart rate (HR, b min–1), blood pressure (BP, mmHg), and SaO2 were observed between conditions at baseline (HR 97.2 ± 17.7; BP 65.4 ± 9.3; SaO2 93.6 ± 2.0), during the recording (HR 99.8 ± 19.5; BP 66.2 ± 11.6; SaO2 93.7 ± 2.4), and 2 min after the procedure (HR 98.2 ± 17.8; BP 65.2 ± 11.7; SaO2 93.7 ± 1.9). The Pst/V curves were recorded in 8.38 ± 1.19 min and fully analysed in 2.69 ± 0.85 min. Mean value of static compliance was 41.1 ± 12.7 ml cmH2O–1. A lower inflection point was found in ten patients (mean value 9.2 ± 1.9 cmH2O).¶Conclusions: In ARDS patients, the present new computerised method gave valuable data to ordinary intensivists and was shown to be safe, easy, and fast.