Combined therapy with antithrombin and recombinant human soluble thrombomodulin in patients with severe sepsis and disseminated intravascular coagulation 565

BackgroundAppropriate patient selection is very important when initiating mild therapeutic hypothermia (MTH) for patients following out-of-hospital cardiac arrest, and the extent of unconsciousness at implementation must be defined in such cases. However, there are no clear standards regarding the level of unconsciousness at which MTH would be beneficial. The effects of MTH in patients with different degrees of unconsciousness according to the motor response score of the Glasgow Coma Scale (GCS) were investigated.MethodsThe subjects consisted of witnessed non-traumatic adult out-of-hospital cardiac arrest patients admitted to our institute from April 2002 to August 2011. The patients were divided into six groups according to the GCS motor response score: 1 (GCS M1), 2 (GCS M2), 3 (GCS M3), 4 (GCS M4), 5 (GCS M5), and 6 (GCS M6). The neurological outcome was evaluated at 30 days after hospital admission using the Cerebral Performance Category. Chi-squared Automatic Interaction Detection (CHAID) analysis was performed to estimate the threshold GCS M level where therapeutic hypothermia is indicated. Odds ratios were then calculated by multiple logistic-regression analysis using factors including GCS M5–6 and MTH.ResultsA total of 289 patients were enrolled in this study. CHAID analysis demonstrated two points of significant increase in percentage of good recovery at 30 days after admission, dividing the GCS M categories into three groups. Patients classified with a GCS motor response score of 5 or higher had the highest percentage of good recovery. The odds ratio for good recovery (CPC1–2) was 2.901 (95 % CI 1.460–5.763, P = 0.002) for MTH, and that for GCS M5–6 was 159.835 (95 % CI 33.592–760.513, P < 0.001).ConclusionsMTH may be unnecessary in patients with a GCS motor response score of 5 or higher. Consequently, because there are post cardiac arrest patients with a GCS motor response score of 4 or lower who benefit from MTH, MTH may be limited to patients with a GCS motor response score of 4 or lower.

Effect of low non-protein calorie/nitrogen ratio enteral nutrition in critically ill patientsAiko Tanaka, Hirotaka Sawano, Yuichi Yoshinaga, Yusuke Ito, Tomoaki Natsukawa, Yasuyuki Hayashi, Tatsuro Kai Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital 1-1-6 Tsukumodai, Suita, Osaka 565-0862, JapanObjectives: The aim was to evaluate low non-protein calorie/nitrogen (NPC/N) ratio enteral nutrition compared to our conventional enteral nutrition in critically ill patients. Methods: An unblinded randomized control study was performed in a single tertiary emergency critical care center. Patients with mechanical ventilation were randomized to receive our conventional enteral diet (Group S, n=15) or low NPC/N enteral diet (Group A, n=13) and monitored for 28 days. The main outcomes measured were ventilator-free days (VFD) and ICU length of stay. The secondary outcomes were SOFA score, plasma albumin and prealbumin, adverse events and mortality. Results: The total calories delivered was similar in both groups, but protein delivery was significantly higher in patients in group A (P=0.02) who received low NPC/N enteral nutrition. There were also favorable trends in group A for VFD (P=0.10) and improved nutritional markers (plasma albumin and prealbumin) (P=0.13, P=0.10). There was no difference between the study groups in SOFA score change or survival. Conclusion: In critically ill patients, a higher provision of protein in enteral nutrition could be associated with decreased length of mechanical ventilation and improvement of nutritional markers.