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Biomedical subjects

Jaap E Tulleken

Publications and source records attributed to Jaap E Tulleken.

At least 19 recordsLinked to original sources
PubMed2006

Hyperglycaemia in critically ill patients: marker or mediator of mortality?

Acute hyperglycaemia has been associated with complications, prolonged intensive care unit and hospital stay, and increased mortality. We made an inventory of the prevalence and prognostic value of hyperglycaemia, and of the effects of glucose control in different groups of critically ill patients. The prevalence of hyperglycaemia in critically ill patients, using stringent criteria, approaches 100%. An unambiguous negative correlation between hyperglycaemia and mortality has been described in various groups of critically ill patients. Although the available evidence remains inconsistent, there appears to be a favourable effect of glucose regulation. This effect on morbidity and mortality depends on patient characteristics. To be able to compare results of future studies involving glucose regulation, better definitions of hyperglycaemia (and consequently of normoglycaemia) and patient populations are needed.

Biomarkers↗
PubMed2006

Automated erythrocytapheresis in severe falciparum malaria: A critical appraisal.

Imported falciparum malaria is increasing in Western countries. In patients with severe disease, exchange transfusion has been added to antimalarial and conventional supportive therapy to increase removal of parasitized erythrocytes, but hemodynamic compromise limits its use; automated erythrocytapheresis may be advantageous. We review published reports of patients with severe falciparum malaria treated by automated erythrocytapheresis combined with standard therapy and add three more cases to the literature. No studies have been conducted to evaluate its clinical efficacy, and this adjunct therapy should therefore be considered as salvage therapy. Apheresis of red cells appears feasible, safe and effective in rapidly reducing parasite count.

Erythrocytes↗
PubMed2006

A good death.

We describe the cases of two patients discharged home directly from the ICU. Both patients had the strong wish to die at home after being told that there were no therapeutic options. Sometimes discharge is feasible and can mean very much for patients and their family. Taking measures to ensure a "good deathbed" is an obligation for doctors and nursing staff. However, due to the focus on cure this palliative goal is not always pursued.

Death↗
PubMed2006

Mean glucose level is not an independent risk factor for mortality in mixed ICU patients.

OBJECTIVE: To find out if there is an association between hyperglycaemia and mortality in mixed ICU patients. DESIGN AND SETTING: Retrospective cohort study over a 2-year period at the medical ICU of a university hospital. MEASUREMENTS: Admission glucose, maximum and mean glucose, length of stay, mortality, insulin therapy and Apache-II score. RESULTS: In 1085 consecutive patients, ICU- and hospital mortality were 20 and 25%, respectively. The total number of blood glucose measurements was 10.012. Admission glucose was 7.9 +/- 4.5 mmol/l (mean +/- SD), mean glucose 7.5 +/- 2.9 and maximum glucose 10.0 +/- 5.4 mmol/l. Median ICU length of stay (LOS) was 3.0 days (range 2.0-6.0 days, IQR), and hospital LOS was 16 days (range 7-32 days). In 28% of patients insulin treatment was started. Median Apache-II score was 13. 68% of patients were mechanically ventilated. Univariate analysis showed an association with ICU mortality for mean glucose (non-survivors 8.6 +/- 4.3 vs 7.2 +/- 2.4 survivors), maximum glucose (11.7 +/- 5.9 vs 9.6 +/- 5.2, non-survivors vs survivors, respectively), use of insulin (mortality 29 vs 17% in patients not using insulin) and age (61 vs 55.7 years). Gender and a history of diabetes mellitus were not associated with mortality. In a multivariate model, the Apache-II score was the only variable associated with mortality independent of other variables, including mean blood glucose. CONCLUSION: In this retrospective study mean glucose level was not an independent risk factor for mortality in mixed ICU patients.

Aged↗
PubMed2006

Brugada electrocardiographic pattern elicited by cyclic antidepressants overdose.

OBJECTIVE: The Brugada syndrome is a clinical and electrocardiographic familial entity, which may lead to sudden cardiac death. A Brugada pattern ECG may occasionally be caused by conditions such as an overdose of tricyclic antidepressants (TCA). Toxicity of TCA frequently results in the need for critical care support. We retrospectively studied characteristics and electrocardiographic indicators of toxicity of all TCA poisoned patients. SETTING: All patients admitted from 1/1/2000 to 1/11/2004 to our ICU after an act of deliberate self-poisoning were included. The ECG's were analysed retrospectively by a cardiologist. Patients with an overdose of TCA were divided in three groups; I. without ECG abnormalities, II. Presence of ECG abnormalities but without Brugada signs, III patients with a Brugada pattern ECG. RESULTS: 134 patients were admitted. In 35 patients a TCA was the main toxic substance. In 12 (34%) TCA patients no ECG abnormalities were found. An increase in QRS duration (>100 ms) was seen in 13 (37%) cases. Six (17%) of them demonstrated a Brugada like pattern. The ECG abnormalities resolved quickly after administration of sodium bicarbonate. Length of stay did not differ between groups. APACHE II and the amount of sodium bicarbonate administered were the highest in the Brugada pattern group. Two patients died. CONCLUSIONS: in TCA poisoning the Brugada pattern ECG is a particular manifestation of the frequently occurring intraventricular conduction disturbances. In intoxicated patients in whom the substance is unknown early recognition of the conduction disturbances is important for suspecting a poisoning with TCA.

Adult↗
PubMed2006

Towards a feasible algorithm for tight glycaemic control in critically ill patients: a systematic review of the literature.

INTRODUCTION: Tight glycaemic control is an important issue in the management of intensive care unit (ICU) patients. The glycaemic goals described by Van Den Berghe and colleagues in their landmark study of intensive insulin therapy appear difficult to achieve in a real life ICU setting. Most clinicians and nurses are concerned about a potentially increased frequency of severe hypoglycaemic episodes with more stringent glycaemic control. One of the steps we took before we implemented a glucose regulation protocol was to review published trials employing insulin/glucose algorithms in critically ill patients. METHODS: We conducted a search of the PubMed, Embase and Cochrane databases using the following terms: 'glucose', 'insulin', 'protocol', 'algorithm', 'nomogram', 'scheme', 'critically ill' and 'intensive care'. Our search was limited to clinical trials conducted in humans. The aim of the papers selected was required to be glycaemic control in critically ill patients; the blood glucose target was required to be 10 mmol/l or under (or use of a protocol that resulted in a mean blood glucose = 10 mmol/l). The studies were categorized according to patient type, desired range of blood glucose values, method of insulin administration, frequency of blood glucose control, time taken to achieve the desired range for glucose, proportion of patients with glucose in the desired range, mean blood glucose and frequency of hypoglycaemic episodes. RESULTS: A total of twenty-four reports satisfied our inclusion criteria. Most recent studies (nine) were conducted in an ICU; nine others were conducted in a perioperative setting and six were conducted in patients with acute myocardial infarction or stroke. Studies conducted before 2001 did not include normoglycaemia among their aims, which changed after publication of the study by Van Den Berghe and coworkers in 2001; glycaemic goals became tighter, with a target range between 4 and 8 mmol/l in most studies. CONCLUSION: Studies using a dynamic scale protocol combining a tight glucose target and the last two blood glucose values to determine the insulin infusion rate yielded the best results in terms of glycaemic control and reported low frequencies of hypoglycaemic episodes.

Algorithms↗
PubMed2006

Accuracy and feasibility of point-of-care and continuous blood glucose analysis in critically ill ICU patients.

INTRODUCTION: To obtain strict glucose regulation, an accurate and feasible bedside glucometry method is essential. We evaluated three different types of point-of-care glucometry in seriously ill intensive care unit (ICU) patients. The study was performed as a single-centre, prospective, observational study in a 12-bed medical ICU of a university hospital. METHODS: Patients with an expected ICU stay of more than 48 hours were included. Because the reference laboratory delivers glucose values after approximately 30 to 60 minutes, which is too slow to use in a glucose regulation protocol and for calibration of the subcutaneous continuous glucose monitoring system (CGMS) (CGMS System Gold), we first validated the ICU-based blood gas/glucose analyser ABL715 (part 1 of the study). Subsequently, part 2 was performed: after inserting (and calibrating) the subcutaneous CGMS, heparinised arterial blood samples were drawn from an arterial line every 6 hours and analysed on both the Precision PCx point-of-care meter using test strips and on the blood gas/glucose analyser ABL715. CGMS glucose data were downloaded after 24 to 72 hours. The results of the paired measurements were analysed as a scatter plot by the method of Bland and Altman and were expressed as a correlation coefficient. RESULTS: Part 1: Four hundred and twenty-four blood samples were drawn from 45 critically ill ICU patients. The ICU-based blood gas/glucose analyser ABL715 provided a good estimate of conventional laboratory glucose assessment: the correlation coefficient was 0.95. In the Clarke error grid, 96.8% of the paired measurements were in the clinically acceptable zones A and B. Part 2: One hundred sixty-five paired samples were drawn from 19 ICU patients. The Precision PCx point-of-care meter showed a correlation coefficient of 0.89. Ninety-eight point seven percent of measurements were within zones A and B. The correlation coefficient for the subcutaneous CGMS System Gold was 0.89. One hundred percent of measurements were within zones A and B. CONCLUSION: The ICU-based blood glucose analyser ABL715 is a rapid and accurate alternative for laboratory glucose determination and can serve as a standard for ICU blood glucose measurements. The Precision PCx is a good alternative, but feasibility may be limited because of the blood sample handling. The subcutaneous CGMS System Gold is promising, but real-time glucose level reporting is necessary before it can be of clinical use in the ICU. When implementing a glucose-insulin algorithm in patient care or research, one should realise that the absolute glucose level may differ systematically among various measuring methods, influencing targeted glucose levels.

Adult↗
PubMed2005

Quality of interhospital transport of critically ill patients: a prospective audit.

INTRODUCTION: The aim of transferring a critically ill patient to the intensive care unit (ICU) of a tertiary referral centre is to improve prognosis. The transport itself must be as safe as possible and should not pose additional risks. We performed a prospective audit of the quality of interhospital transports to our university hospital-based medical ICU. METHODS: Transfers were undertaken using standard ambulances. On departure and immediately after arrival, the following data were collected: blood pressure, heart rate, body temperature, oxygen saturation, arterial blood gas analysis, serum lactic acid, plasma haemoglobin concentration, blood glucose, mechanical ventilation settings, use of vasopressor/inotropic drugs, and presence of venous and arterial catheters. Ambulance personnel completed forms describing haemodynamic and ventilatory data during transport. Data were collected by our research nurse and analyzed. RESULTS: A total of 100 consecutive transfers of ICU patients over a 14-month period were evaluated. Sixty-five per cent of patients were mechanically ventilated; 38% were on vasoactive drugs. Thirty-seven per cent exhibited an increased number of vital variables beyond predefined thresholds after transport compared with before transport; 34% had an equal number; and 29% had a lower number of vital variables beyond thresholds after transport. The distance of transport did not correlate with the condition on arrival. Six patients died within 24 hours after arrival; vital variables in these patients were not significantly different from those in patients who survived the first 24 hours. ICU mortality was 27%. Adverse events occurred in 34% of transfers; in 50% of these transports, pretransport recommendations given by the intensivist of our ICU were ignored. Approximately 30% of events may be attributed to technical problems. CONCLUSION: On aggregate, the quality of transport in our catchment area carried out using standard ambulances appeared to be satisfactory. However, examination of the data in greater detail revealed a number of preventable events. Further improvement must be achieved by better communication between referring and receiving hospitals, and by strict adherence to checklists and to published protocols. Patients transported between ICUs are still critically ill and should be treated as such.

Ambulances↗
PubMed2004

Endotoxin increases plasma soluble tumor necrosis factor-related apoptosis-inducing ligand level mediated by the p38 mitogen-activated protein kinase signaling pathway.

Despite extensive knowledge about the mechanisms behind sepsis, this syndrome still caries a large morbidity and mortality rate. Dysregulated immune and coagulation systems are held responsible. However, additional pathophysiological mechanisms such as uncontrolled apoptosis induced by death receptor ligands might well play a role. P38 mitogen-activated protein (MAP) kinase inhibitors are considered as potential drugs in inflammatory diseases. Therefore, the effect of endotoxin administration on the response of soluble(s) tumor necrosis factor-related apoptosis-inducing ligand (sTRAIL), a death receptor ligand, and the role of p38 MAP kinase inhibition was studied in 21 human volunteers. The volunteers received 30 min before the endotoxin infusion a single oral dose of placebo or the selective p38 MAP kinase inhibitor drug, RWJ-67657. Plasma sTRAIL increased 10-fold to 6564 +/- 511 pg/mL after 2.5 h. This increase was blocked completely by the highest dose of RW-J6765. This is the first report showing that endotoxin increases sTRAIL where the p38 MAP kinase signaling pathway is involved.

Adult↗
PubMed2004

p38-MAPK inhibition and endotoxin induced tubular dysfunction in men.

BACKGROUND: To evaluate the possibility of preventing endotoxin induced renal damage by p38-MAPK inhibition in a human model. DESIGN AND METHODS: Twenty-one healthy young male volunteers received 4 ng/kg Escherichia coli endotoxin as a single dose. Four groups of volunteers received an oral dose of placebo or 350, 700 or 1400 mg RWJ-67657, a p38-MAPK inhibitor, 20 min before endotoxin infusion. Urine samples were collected at set time intervals. The urinary excretion rate of beta(2)-microglobulin and N-acetyl-beta-D-glucosaminidase, as indicators of tubular dysfunction was determined. RESULTS: There was a significant increase of beta(2)-microglobulin and N-acetyl-beta-D-glucosaminidase urine excretion rate after endotoxin infusion in the placebo group. p38-MAPK inhibition prevented the increase of markers for tubulopathy. CONCLUSIONS: Endotoxin infusion induces measurable tubular damage. Blocking the p38-MAPK may prevent this damage. The mechanism is unclear, but blocking TNF-alpha release is a possible explanation.

Adult↗