ARMI News - Part 8

Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation: Drug Dosage Between Groups

Drug dosage was compared using both absolute dosage and dose per body weight. There was no statistical difference in body weight between groups (p = 0.06). However, there was an observed lower body weight in the IS group compared to the other two groups (Table 1). Drug dosage differed significantly between the groups (Table 2). Patients in the CS group received the largest amount of sedation and narcotics. Patients in the CS/NMBA group received the least amount of narcotics. There was no statistically significant difference in sedation dose between the CS and CS/NMBA groups. Patients in the IS group were fully alert and able to request pain medication and received the least amount of both sedatives and narcotics. Four patients received sedation, and three of these patients received morphine concomitantly. The other two patients did not receive any drugs. In the CS group, all patients received both morphine and sedation. In the CS/ NMBA group, only three patients received morphine in addition to CS. One patient in the CS group received haloperidol for agitation. further

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Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation: Severity of Illness

Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation: Severity of IllnessA nonsignificant trend (p = 0.07) of increasing severity of illness (APACHE II), greatest in the CS/NMBA group relative to the IS group, was noted. The LIS was significantly higher in the CS and CS/NMBA groups (p < 0.001) than in the IS group. The LIS in the CS/NMBA group was 50% greater than in the CS group (p < 0.016; Table 1). There was no significant difference between the groups regarding length of stay in the ICU prior to the day of study, and no correlation existed between length of stay and sleep data. Use of vasopressor drugs was greatest in the CS/NMBA group, of whom 50% required hemodynamic support.
Mode of mechanical ventilation varied between the groups. None of our patients were receiving assist-control ventilation. Pressure support (PS) ventilation was used throughout the entire 24-h period in only 2 of the 18 patients: 1 patient in the IS group and 1 patient in the CS group. comments

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Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation: Patient Demographics

The NMBA administered was vecuronium by continuous infusion and titrated using the Dulin-Williams standard train-of-four protocol. The anxiolytic medication lorazepam was administered for sedation and titrated to a Ramsey score of 3 to 4. Morphine sulfate was administered intermittently or by continuous infusion for analgesia. All medication doses were recorded.
Data were collected from the patients’ record for severity of illness, admitting diagnosis, microbiology culture results, and laboratory chemistry. Severity of illness was measured by the calculated APACHE (acute physiology and chronic health evaluation) II score and the lung injury score (LIS).
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Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation: Polysomnography and Scoring

Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation: Polysomnography and ScoringAll subjects were monitored continuously for 24 h using polysomnography recorded on an eight-channel, portable EEG device (Neurotrac II model M1283A; Telefactor; Philadelphia, PA) interfaced with a monitor (model M1094B; Hewlett-Packard; Andover, MA). Gold cup electrode placement was performed according to the international 10/20 system in the following montage: O1-F7, O2-F8, T3-Cz, C3-A2, C4-A1, four electrooculogram (EOG) electrodes were applied for determining vertical and horizontal eye movement, and two chin electrodes were placed. Electrode application was performed by one trained nurse (L.M.) and the author (K.A.H.). Electrode impedance was maintained at < 10,000 ohms. there

Data were archived on an external hard drive for later analysis with customized software on a standard personal computer. Sleep recordings were scored manually in 30-s epochs by a registered polysomnography sleep technician (blinded to patient group) using standard Rechtschaffen and Kales criteria. Epochs with delta frequency that did not meet the 75-^V criteria or stage 1 or 2 requirements were scored as nonclassifiable. To account for an expected decrease in amplitude of delta waves associated with aging, a modified delta (mDelta) criteria was also used and consisted of a frequency criterion of < 4 Hz and an amplitude criterion of > 50 |j,V (peak to peak).

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Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation: Study Site

The study was performed between June 1, 1999, and December 31, 2000, in the adult medical ICU at the University of California, Davis. The study protocol and consent form were approved by the Institutional Review Board of the Human Subjects Committee. Written informed consent was obtained from the patient or family member if the patient had any altered sensorium or was unable to read or write. All patients were in private rooms that were enclosed on three sides and separated from the nursing station and equipment room by a sliding glass door. All rooms had windows and were similarly located with respect to external noise sources.
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Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical Ventilation

Sleep in Critically III Chemically Paralyzed Patients Requiring Mechanical VentilationSleep deprivation is a well-documented problem among patients in the ICU and may impair physiologic and psychological well-being. Initial investigations using polysomnography reveal decreased total sleep time (TST), as well as abnormal sleep architecture with increased stage 1 and stage 2 non-rapid eye movement sleep, decreased slow wave sleep (SWS), and decreased rapid eye movement (REM) sleep. However, these studies are limited to only 8-h nighttime data collection and excluded patients receiving mechanical ventilation. add comment
Twenty-four-hour polysomnography in ICU patients receiving mechanical ventilation demonstrated inconsistent results in TST and sleep architecture. Cooper and coworkers report a subset of patients with > 50% delta activity and considered this to be “unidentifiable electrophysiologic sleep” consistent with encephalopathy or coma, although no specific source for encephalopathy could be determined. Gabor and colleagues, in contrast to prior ICU studies, determined REM sleep time (14.3%) to be normal.
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A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Recommendation

Lymph nodes in these patients have histologic changes typical for Wegener granulomatosus. Sixty-seven percent of Wegener granulomatosus patients will have musculoskeletal symptoms at some time during their disease course. These usually consist of arthralgias and myalgias. However, 28% of these patients will have arthritis. The various patterns include monoarticular arthritis, migratory oligoarthritis, and asymmetrical polyarthritis involving both large and small joints. The arthritis is usually nonerosive and nondeforming; the knee is the most frequently involved joint. Ninety percent of patients with active Wegener granulomatosus have a positive anti-neutrophil cytoplasmic antibody test result. Of course, these patients typically present with a necrotizing granulomatous vasculitis involving the upper airway, lungs, and/or kidneys. The chest radiographs usually reveal multiple nodular infiltrates with cavitation.
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A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Conclusions

A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: ConclusionsSome but not all lymphoid cells have Epstein-Barr virus-encoded RNA. Adult-onset Still disease affects women and men in the age range of 30 to 50 years. Fever can be present before the arthritis. The arthritis is often polyarticular and involves the knees, wrists, and ankles. Salmon-colored or pink macules appear on the trunk and extremities and become more prominent when patients are febrile. Patients have normal or high serum complement levels, and serum ferritin levels can be extremely high. Mediastinal adenopathy has been reported in association with Still disease. The lymph nodes in patients with Still disease have four distinct histologic patterns. These include paracortical hyperplasia with vascular proliferation and reactive lymphocytes, paracortical hyperplasia with massive sinus histiocytosis, patchy infiltration of large T-immunoblasts with high mitotic activity, and distinct follicular hyperplasia. comments

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A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Discussion

Diarrhea, weight loss, arthritis, and generalized lymphadenopathy were the most frequent initial manifestations in patients with Whipple disease seen at the Mayo Clinic. Biopsy reveals tissue infiltration with foamy macrophages with periodic acid Schiff-positive granular inclusions containing bacteria. Patients with Whipple disease may have granulomas on biopsy. Case reports have linked Ureaplasma urealyticum, Chlamydia pneumoniae, and Yersinia pseudotuberculosis infections with simultaneous or subsequent development of classic Lofgren syndrome. The lymphadenopathy in these infectious diseases discussed in this paragraph may reflect either direct involvement of the lymph node by the infectious pathogen or a reactive systemic response to infection. Link
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A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Treatment

A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: TreatmentThe presence of at least three of these criteria had a sensitivity of 93% and a specificity of 99% (Table 2). However, some authors have published case reports describing unusual difficulty with this diagnosis. Patients with sarcoidosis may have positive rheumatoid factor, and/or positive an-tinuclear antibody assays, and/or elevated uric acid levels, and these laboratory results can lead to confusion. Most patients with sarcoidosis (> 90%) have intrathoracic lymphadenopathy. Biopsies reveal non-caseating granulomas. However, similar results occur in patients with granulomatous infection and malignancy. Most patients with Lofgren syndrome have complete resolution of their symptoms, and this syndrome represents a benign acute presentation of sarcoidosis with a good prognosis. In the series of Lofgren, 102 patients (91.9%) had complete resolution of hilar adenopathy and infiltrates, if present, by 2 years. comments

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