Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure--a prospective, double-blind, placebo-controlled trial.
van der Spoel J I,Oudemans-van Straaten H M,Stoutenbeek C P,Bosman R J,Zandstra D F
Intensive care medicine
OBJECTIVE:Critical illness-related colonic ileus (CIRCI) is characterized by the non-passage of stools in critically ill patients as a result of the absence of prokinetic movements of the colon, while the upper gastrointestinal tract functions properly and mechanical ileus is absent: We investigated whether neostigmine resulted in defecation in patients with CIRCI. DESIGN:Double-blinded, placebo-controlled prospective study. SETTING:Eighteen-bed intensive care unit. PATIENTS:Thirty ventilated patients with multiple organ failure with CIRCI for > 3 days. INTERVENTION:Continuous intravenous administration of neostigmine 0.4-0.8 mg/h over 24 h, or placebo. MEASUREMENTS AND RESULTS:Time to first defecation and adverse reactions were recorded. Thirty patients were randomized, 24 could be evaluated. The mean prestudy time was 5 days, mean APACHE II score on admission was 23.2, and mean MOF score on the day of the study was 6.4. Of the 13 patients receiving neostigmine, 11 passed stools, whereas none of the placebo-treated patients passed stools (P < 0.001). After 24 h, the non-responders received in a cross-over fashion neostigmine or placebo respectively. Eight out of the 11 neostigmine patients now passed stools (mean 11.4 h), and none of the placebo patients. Overall, in none of the patients did passage of stools occur during placebo infusion, whereas 19 of the 24 neostigmine-treated patients had defecation (79%). No acute serious adverse effects occurred, but three patients had ischemic colonic complications 7-10 days after treatment. CONCLUSION:Continuous infusion of 0.4-0.8 mg/h of neostigmine promotes defecation in ICU patients with a colonic ileus without important adverse reactions.
Predictive Model for Mortality Risk Including the Wound, Ischemia, Foot Infection Classification in Patients Undergoing Revascularization for Critical Limb Ischemia.
Azuma Nobuyoshi,Takahara Mitsuyoshi,Kodama Akio,Soga Yoshimitsu,Terashi Hiroto,Tazaki Junichi,Yamaoka Terutoshi,Koya Atsuhiro,Iida Osamu
Circulation. Cardiovascular interventions
BACKGROUND:The aim of this study was to develop a predictive model for mortality risk based on preoperative risk factors, including the Wound, Ischemia, Foot Infection (WIfI) classification, in patients undergoing revascularization for critical limb ischemia. METHODS:We analyzed a database of the Surgical reconstruction versus Peripheral Intervention in Patients With Critical Limb Ischemia registry, a multicenter, prospective, observational study that included 520 critical limb ischemia patients (192 surgical and 328 endovascular patients). RESULTS:Multivariate Cox regression analysis identified old age, impaired mobility, low body mass index, renal failure, heart failure, and high WIfI grade as independent risk factors for all-cause mortality (all <0.05). The risk score comprising these risk factors discriminated the mortality risk well; the 2-year survival rate was >90% in the first quantile of the risk score and ≈20% in the fifth quantile. The area under the time-dependent receiver operating characteristics curve was 0.829 for thirty-day mortality and 0.811 for 2-year mortality. Adding more detailed preoperative information to the predictive model revealed that cystatin C-based estimated glomerular filtration rate, left ventricular ejection fraction, and cholinesterase levels were additional independent risk factors, but the predictive accuracy of the model was not significantly improved, according to the time-dependent receiver operating characteristics curve and net reclassification improvement. CONCLUSIONS:The current study developed a risk score for mortality using preoperative risk factors, including the WIfI classification, in critical limb ischemia patients undergoing revascularization.
Plasma cholinesterase correlations in acute surgical and critical illness.
Chiarla C,Giovannini I,Giuliante F,Vellone M,Ardito F,Nuzzo G
AIM:The properties of plasma cholinesterase (CHE) are partly undiscovered. Equally unknown are the correlations between changes in CHE and other blood variables during the acute phase response related to acute surgical and critical illness. METHODS:Data from 432 measurements of CHE and other variables performed in 92 patients were systematically evaluated and processed by regression analysis. RESULTS:There was a strong direct correlation between CHE and albumin (r=0.77, P<0.0001). CHE was also directly correlated to cholesterol, iron binding capacity, hematocrit, prothrombin activity, and inversely correlated to bilirubin and to presence of sepsis or liver dysfunction (P<0.0001 for all). Postoperatively CHE decreased to about 60% of the preoperative value, remaining directly related to it (r=0.69, P<0.0001), and decreasing further in the presence of sepsis or liver dysfunction, with slow reversal of the decrease during recovery from illness. In parenterally fed septic patients the decrease in CHE was moderated by increasing the amino acid dose (P<0.0001). CONCLUSION:In acute surgical and critical illness CHE mostly behaves as a negative acute phase reactant, independently of the modifications related to other already known factors. This should be taken into account when interpreting the implications of decreased CHE in the clinical setting.