RESUMEN
UNLABELLED: Prolonged use of sedative drugs frequently leads to oversedation of intensive care patients. Clinical assessment scales are not reliable in deeply sedated patients. Parameters obtained from spectral and bispectral analysis of electroencephalogram (EEG) records have been combined to create an index (BIS) to monitor anesthesia depth. The role of such parameters in monitoring the depth of the sedation in intensive care unit (ICU) patients has yet to be determined. We designed the present prospective study to redefine and calculate available spectral and bispectral parameters from raw EEG records and estimate their clinical relevance for the diagnosis of under- or oversedation levels in ICU patients. Forty adult patients receiving continuous midazolam and morphine sedation were included. We obtained 167 clinical evaluations of sedation level using Ramsay and COMFORT scales along with an EEG record of 300 s. Six spectral parameters-relative power of 4 frequency bands (beta, alpha, Theta, and delta), 95th percentile of the power spectrum (SEF95), and 50th percentile of the power spectrum (SEF50) and four bispectral parameters, real triple product, bispectrum (Bispectrum), bicoherence, and ratio 10-were calculated. The relevance of each of these parameters and combinations in predicting too light (Ramsay 1 and 2) or deep (Ramsay 5 and 6) sedation levels was assessed. These calculations were performed before and after exclusion of the agitated patients, whose COMFORT 4 score was above 2. The most relevant parameters for predicting levels of deep sedation (Ramsay 5 and 6) were ratio 10 (area under the curve = 0.763; 95% confidence interval, 0.679-0.833) and SEF95 (area under the curve = 0.687; 95% confidence interval, 0.597-0.767). The most relevant parameters for predicting light levels of sedation (Ramsay 1 and 2) were also ratio 10 (area under the curve = 0.829; 95% confidence interval, 0.695-0.917) and SEF95 (area under the curve = 0.798; 95% confidence interval, 0.650-0.898). There is a modest improvement in relevance of their linear combination in predicting sedation level. Results were similar after exclusion of agitated patients. We conclude that various calculated EEG descriptive parameters exhibited large interindividual variability. There was a strong correlation between EEG spectral and bispectral parameters. Bispectral analysis slightly improves the predictive power of simple spectral analysis in distinguishing too light or deep sedation levels in ICU patients. IMPLICATIONS: Spectral edge frequency 95 and Ratio 10 are the most relevant electroencephalogram (EEG) indexes for monitoring the level of sedation in intensive care unit patients but calculated EEG values exhibited large interindividual variability. Bispectral analysis of EEG provides a slight improvement over simple spectral analysis.
Asunto(s)
Enfermedad Crítica , Electroencefalografía , Hipnóticos y Sedantes/farmacología , Adulto , Anciano , Área Bajo la Curva , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Little is known regarding malignant thymoma and thymic carcinoma optimal therapy, and a multimodality approach could therefore be proposed in an attempt to improve the survival of patients. We report our experience with 8 cases of malignant thymoma or thymic carcinoma. These patients took part in a multimodality treatment program including neoadjuvant chemotherapy, surgery, and postoperative radiotherapy in our center between December 1995 and June 2001. The induction chemotherapy consisted of 4 courses of the CAP regimen (cyclophosphamide 600 mg/m2 day 1, doxorubicin 50 mg/m2 day 1, and cisplatin 80 mg/m2 day 2), every 3 weeks. Patients underwent surgical resection after complete hematological recovery pending sufficient tumor response with a postchemotherapy resectable status. Adjuvant radiotherapy up to 60 Gy in 30 fractions was attempted postsurgically or after best chemotherapeutic response in nonsurgical patients. Among the 8 patients, 3 had a thymic carcinoma and 5 a malignant thymoma; 5 had a stage IV and 3 a stage III disease (Masaoka). Six patients partially responded to the chemotherapy regimen. Three patients were operated upon, and complete resection was performed in 2 cases. Finally, 4 patients achieved the planned radiotherapy. Four patients are still alive without evidence of tumor activity (23-77 months from the diagnosis) and 1 patient is alive with relapse at 56 months. The low compliance with the program led us to an early discontinuation. The high proportion of thymic carcinoma and advanced disease in our limited series might be an explanation for this unsatisfactory result. Optimal multimodality treatment of epithelial thymic tumor remains to be defined in multicenter trials.
Asunto(s)
Carcinoma/terapia , Timoma/terapia , Neoplasias del Timo/terapia , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma/patología , Cisplatino/uso terapéutico , Terapia Combinada , Ciclofosfamida/uso terapéutico , Fraccionamiento de la Dosis de Radiación , Doxorrubicina/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Timectomía , Timoma/patología , Neoplasias del Timo/patología , Resultado del TratamientoRESUMEN
In vitro, steroids down-regulate the expression of cell adhesion molecules (CAMs) in endothelial cells stimulated by lipopolysaccharide. Low-dose hydrocortisone is a new treatment of patients with septic shock, a state that is characterized by an endothelial injury. The aim of the present study was to investigate whether the plasma levels of soluble CAMs, reflecting in vivo endothelial activation, could be modulated in patients with septic shock treated by hydrocortisone. This was a prospective and observational study conducted in the intensive care unit at a university hospital. The subjects included 40 patients with septic shock (American College of Chest Physicians Consensus Conference/Society of Critical Care Medicine definition); 45 healthy blood donors served as controls. The patients receiving the standard care ("reference group") during the first 6 months were compared with the patients receiving the hydrocortisone therapy ("hydrocortisone group") for the next 6 months. Measurements of sCAMs were performed on days 1 and 3 of the disease. On day 1, sE-selectin, sP-selectin, sVCAM-1, and sICAM-1 were significantly elevated in patients with septic shock compared with healthy donors. sE-selectin levels significantly decreased between days 1 and 3 in the "hydrocortisone group," whereas there was no significant change in the "reference group". Surprisingly, sICAM-1 levels significantly increased between days 1 and 3 only in patients treated by hydrocortisone. No significant changes were observed for sP-selectin and sVCAM-1 levels in the two groups. In patients with septic shock, glucocorticoids differently affected the pattern of evolution of sCAMs, with sE-selectin being decreased and sICAM-1 being increased. Expression of sP-selectin and sVCAM-1 was not affected.