摘要:

ObjectiveTo investigate the numbers, clinical characteristics, resource use, and outcomes of admissions who met precise clinical and physiologic criteria for severe sepsis (as defined in the PROWESS trial) in the first 24 hrs in the intensive care unit.DesignObservational cohort study, with retrospective analysis of prospectively collected data.SettingNinety-one adult general intensive care units in England, Wales, and Northern Ireland between 1995 and 2000.PatientsPatients were 56,673 adult admissions.InterventionsNone.Measurements and Main ResultsWe found that 27.1% of adult intensive care unit admissions met severe sepsis criteria in the first 24 hrs in the intensive care unit. Most were nonsurgical (67%), and the most common organ system dysfunctions were seen in the cardiovascular (88%) and respiratory (81%) systems. Modeling the data for England and Wales for 1997 suggested that 51 (95% confidence interval, 46–58) per 100,000 population per year were admitted to intensive care units and met severe sepsis criteria in the first 24 hrs.Of the intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, 35% died before intensive care unit discharge and 47% died during their hospital stay. Hospital mortality rate ranged from 17% in the 16–19 age group to 64% in those >85 yrs. In England and Wales in 1997, an estimated 24 (95% confidence interval, 21–28) per 100,000 population per year died after intensive care unit admissions with severe sepsis in the first 24 hrs.For intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, median intensive care unit length of stay was 3.56 days (interquartile range, 1.50–9.32) and median hospital length of stay was 18 days (interquartile range, 8–36 days). These admissions used 45% of the intensive care unit and 33% of the hospital bed days used by all intensive care unit admissions.ConclusionsSevere sepsis is common and presents a major challenge for clinicians, managers, and healthcare policymakers. Intensive care unit admissions meeting severe sepsis criteria have a high mortality rate and high resource use.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveLevosimendan is a promising calcium sensitizer that potentially could be useful in settings of pulmonary vasoconstriction and right ventricular dysfunction. There is a shortage of information concerning its effects on right ventricular function and ventriculovascular coupling. The aim of the present study was to characterize the effects of levosimendan on right ventricular and pulmonary vascular function by means of pressure-volume and pulsatile flow analysis.DesignProspective laboratory investigation.SettingUniversity hospital laboratorySubjectsEight landrace pigs (mean weight, 37 kg).InterventionsFollowing instrumentation with biventricular conductance catheters, pulmonary and right coronary artery flow probes, a high-fidelity pulmonary pressure catheter, and a right coronary venous catheter, hemodynamic measurements were performed in baseline conditions and during levosimendan infusion at three increasing plasma concentrations (mean values, 27.5, 67.6, and 142.5 ng/mL).Measurements and Main ResultsLevosimendan increased heart rate and cardiac output, reduced systemic vascular resistance, and had a positive inotropic effect on the left ventricle and increased left ventricular mechanical efficiency. Moreover, levosimendan increased right ventricular contractility and hydraulic power. However, total pulmonary vascular resistance and characteristic impedance did not change throughout the protocol, and right ventricular mechanical efficiency decreased slightly at the highest concentration of levosimendan.ConclusionsAt clinical concentrations in the present model, levosimendan increases right ventricular contractility and performance without significantly influencing pulmonary vascular tone. Further studies are required in a model of pulmonary vasoconstriction to disclose possible pulmonary vasodilator effects of levosimendan.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo develop a valid, reliable, and responsive bedside instrument assessing Adaptation to the Intensive Care Environment (ATICE) in mechanically ventilated adult intensive care unit (ICU) patients.DesignInstrument development and prospective clinimetric evaluation.SettingUniversity-affiliated medical ICU.PatientsConsecutive patients with expected mechanical ventilation of ≥12 hrs.InterventionsAdministration of ATICE.Measurements and Main resultsItem generation for the ATICE involved focus groups and literature review. The ATICE consists of five items: Awakeness and Comprehension combined in a Consciousness domain, and Calmness, Ventilator Synchrony, and Face Relaxation combined in a Tolerance domain. Clinical sensibility of the ATICE assessed by ten ICU physicians and 20 ICU nurses not involved in the development of the ATICE was rated highly (median values 5–7 on a 7-point scale). The ATICE was administered to 80 patients during a total of 152 assessments. Each assessment was performed by three raters (ICU physician, ICU nurse, research nurse), concomitantly with independent scoring of four scales (Ramsay Scale, Riker Scale, Glasgow Coma Scale, and Comfort Scale) and six visual analog scales. Internal consistency was high, as reflected by Cronbach’s &agr; for the Consciousness and Tolerance domains of .87 and .67, respectively. Intraclass correlation coefficients for the Consciousness and the Tolerance domains ranged from .92 to .99, indicating high interrater reliability. Cross-sectional and longitudinal validity was confirmed for the overall ATICE and the Consciousness and Tolerance domains, as reflected by strong correlations between ATICE and the relevant items or domains of the Ramsay Scale, Riker Scale, Glasgow Coma Scale, Comfort Scale, each of the visual analog scales, and the amounts of sedatives and analgesics administered.ConclusionsThe ATICE measures the adaptation of mechanically ventilated patients to the ICU environment. After rigorous multidisciplinary development, we demonstrated high reliability, validity, and responsiveness of this instrument.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate novel indications for the use of human albumin solutions in the prevention and treatment of acute lung injury following shock/resuscitation and to test the hypothesis that 25% human albumin is an effective resuscitation fluid as well as an immunomodulatory agent protective against lung injury in our model.DesignA previously developed rodent model of acute lung injury in which resuscitated shock primes for increased lung injury in response to a small dose of intratracheal lipopolysaccharide.SettingUniversity-affiliated hospital.SubjectsSprague Dawley rats weighing 300–350 g.InterventionsAnimals were bled to a mean arterial pressure of 40 mm Hg and maintained in a shock phase for 1 hr. Animals then were resuscitated by transfusion of the shed blood plus an equal volume of Ringer’s lactate or their shed blood plus 3 mL/kg volume of 25% albumin or their shed blood plus 15 mL/kg of 5% human albumin over a period of 2 hrs. To test for the possible role of 25% albumin as an antioxidant, we also performed resuscitation with Ringer’s lactate supplemented with N-acetylcysteine or 25% albumin depleted of its antioxidant properties by N-ethylmaleimide. Mean arterial pressure was monitored continuously. One hour after resuscitation, 100 &mgr;g of lipopolysaccharide in 200 &mgr;L of saline was administered intratracheally.Measurements and Main ResultsResuscitation with 25% albumin significantly reduced transpulmonary protein flux, bronchoalveolar lavage fluid neutrophil counts, and the degree of histopathological injury compared with resuscitation with Ringer’s lactate or 5% albumin. To delineate the underlying mechanism of this beneficial effect, the production of cytokine-induced neutrophil chemoattractant as well as nuclear translocation of its critical transcription factor nuclear factor-&kgr;B was measured. Both cytokine-induced neutrophil chemoattractant messenger RNA concentrations and nuclear factor-&kgr;B translocation were diminished following 25% albumin resuscitation. Furthermore, 25% albumin significantly decreased lipid peroxidation in plasma as measured by 8-isoprostane concentrations. N-ethylmaleimide modified 25% albumin, possessing lesser antioxidant activity, exhibited an attenuated protection from lung injury.ConclusionsResuscitation with 25% albumin attenuates lung injury in this rat model. The beneficial effect was due to reduced neutrophil sequestration. The antioxidant properties of the 25% albumin preparation appeared to be partially responsible for the effects observed. These studies suggest a novel role for 25% albumin as an anti-inflammatory agent in neutrophil-mediated diseases, such as acute respiratory distress syndrome.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveWe investigated the evolution of lung injury in an animal model with multiple rib fractures, both with and without acute lung injury, and the influence of spontaneous breathing with continuous positive airway pressure (CPAP) therapy on the relative distributions of alveolar ventilation (&OV0312;a) and perfusion (&OV0422;).DesignProspective, randomized laboratory investigation using an established porcine model with instrumentation for measurement of ventilation/perfusion distribution, pulmonary mechanics and gas exchange, and cardiovascular variables.SettingUniversity experimental research laboratory.SubjectsTwenty-nine domestic swine.InterventionsAnesthetized pigs were assigned randomly to undergo chest wall dissection alone or chest wall dissection and bilateral fractures of ribs with or without oleic acid-induced acute lung injury.Measurements and Main ResultsGas exchange was evaluated by blood gas analysis and multiple inert gas elimination technique. After baseline data were collected, subsequent data were collected at 60 and 120 mins after experimental injuries, and at 180 mins, which was 60 mins after titration of CPAP therapy. The range of CPAP was 4–22 cm H2O. Shunt (&OV0312;a/&OV0422; < 0.005), venous admixture &OV0312;a/&OV0422; < 0.1), and functional deadspace (&OV0312;a/&OV0422; > 10) before injury were similar among all animals and ranged from 3.4% to 4.5%, 4.2% to 5.0%, and 54.4% to 56.5%, respectively. There were no changes, throughout the study, in lung regions with low &OV0312;a/&OV0422; (0.005 < &OV0312;a/&OV0422; ≤ 0.1) in any group of animals. Shunt of control animals increased to 10.5 ± 8.8% (p< .05) at 60 mins but demonstrated no further changes in &OV0312;a/&OV0422; at subsequent measurements. Shunt also increased after animals underwent bilateral rib fractures without (12.7%,p< .05) and with (19.9%,p< .05) acute lung injury; however, it decreased in both groups after the application of CPAP (4.6% and 6.6%, respectively,p< .05). All changes in venous admixture directly reflected the change in shunt at all intervals. Functional deadspace was unaffected by chest wall dissection, rib fractures, or subsequent lung injury but decreased after CPAP therapy in all animals.ConclusionsAcute lung injury exacerbated the right-to-left intrapulmonary shunt seen within the first hour after disruption of the chest wall. Application of CPAP decreased shunt, improved matching of &OV0312;a/&OV0422;, and reduced the requirement for supplemental oxygen, without any significant impairment in cardiovascular function.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveApolipoprotein E isoform (E4) has been posited to affect outcomes after central nervous system injury. This project sought to determine the relationship between the apoE4 allele and the recovery of amino acid neurotransmitters (aspartate, glutamate, and lactate/pyruvate ratio [L/P]) following a traumatic brain injury (TBI) after controlling for patient characteristics.DesignThis prospective clinical study examined neurotransmitters and L/P within the cerebrospinal fluid and compared the trends by apoE genotypes.SettingAdults with TBI were recruited from a neurotrauma intensive care unit within a trauma I university medical center.PatientsNinety-one patients were enrolled into the study after a severe TBI (Glasgow Coma Scale [GCS] score, ≤8). Cerebrospinal fluid was serially sampled from a ventriculostomy every 4 hrs for the first 24 hrs and every 6 hrs for 25–120 hrs after injury.Measurements and Main ResultsHierarchical linear modeling analyses were used to compare the change of glutamate, aspartate, and L/P over time by the presence or absence of the apoE4 allele, with GCS score, sex, race, and therapeutic hypothermias included as covariates. There was a significant apoE4 allele group effect on both the linear and quadratic slopes in aspartate. In glutamate, the rate of change in glutamate was statistically related to GCS score. There was no significant difference in the glutamate response over time by the presence of the apoE4 allele. There was a significant difference in the change in L/P across time, with faster recovery when the apoE4 allele was absent.ConclusionsRecovery of aspartate and L/P differed depending on the presence of the apoE4 allele. Patients with the allele had significant increased and sustained levels of aspartate and L/P after TBI. Changes in glutamate were related to severity of illness and were independent of the presence of the apoE4 allele.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe purpose of this study was to evaluate the long-term cardiopulmonary outcome at ages 10–15 yrs following neonatal extracorporeal membrane oxygenation (ECMO). The specific aims of the study were to assess baseline aerobic capacity, cardiac function, and pulmonary function in neonatal ECMO survivors using graded exercise testing, echocardiography, and pulmonary function tests.DesignCohort study.SettingExercise and pulmonary function laboratories of a large children’s hospital.PatientsSeventeen 10- to 15-yr-old children treated with ECMO as neonates for meconium aspiration syndrome and 17 age-matched healthy controls.InterventionsChildren were evaluated by use of physical exam, electrocardiogram, echocardiogram, treadmill stress test, and pulmonary function tests.Measurements and Main ResultsAverage weight, height, and age were similar between the groups. Both pre- and postexercise pulmonary function tests revealed air trapping and mild lower airway obstruction in the ECMO group, compared with mean pulmonary functions in the normal range for the control group. The mean forced expiratory volume in 1 sec, the forced expiratory flow between 25% and 75% of vital capacity, and the ratio between residual volume and total lung capacity were significantly different between the ECMO group and the control group. Although the ECMO group exhibited baseline and postexercise lung function abnormalities, there were no differences in maximal oxygen consumption between the two groups and all subjects reached anaerobic threshold.By regression analysis, the gestational age, duration of oxygen, and exercise score were significantly correlated with baseline lung function, using forced expiratory flow between 25% and 75% of vital capacity as the dependent variable.ConclusionsDespite abnormalities in baseline and postexercise pulmonary functions, ECMO graduates have similar aerobic capacity to age-matched healthy controls. The most significant factor in predicting long-term pulmonary outcome in ECMO graduates is the duration of oxygen use following decannulation.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveSince the introduction of multilumen central venous catheters two decades ago, there has been controversy whether the additional lumens place patients with these catheters at higher risk for infection. Our objective was to determine the risk of catheter-related bloodstream infection (CRBSI) and catheter colonization in multilumen catheters compared with single-lumen catheters.Data SourceStudies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter colonization among single-, double-, and triple-lumen central venous catheters were included. We excluded studies if they included central venous catheters that were long-term, cuffed, tunneled, or coated with antibiotic or antiseptic agents.Data AbstractionTwo independent reviewers abstracted data on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter colonization, and 4) study design and quality.Data SynthesisA total of 15 studies met inclusion criteria. Summary odds ratios were calculated using a random-effects model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00–4.66), catheter colonization was not (summary odds ratios, 1.78; 95% confidence interval, 0.92–3.47). Tests for heterogeneity, however, suggested substantial variation by study. When only studies of higher quality were included, multilumen catheters were found not to be associated with a significant increase in CRBSI prevalence (summary odds ratios, 1.30; 95% confidence interval, 0.50–3.41).ConclusionsMultilumen central venous catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient differences are considered. The slight increase in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

The “dead-donor rule” requires patients to be declared dead before the removal of life-sustaining organs for transplantation. The concept of brain death was developed, in part, to allow patients with devastating neurologic injury to be declared dead before the occurrence of cardiopulmonary arrest. Brain death is essential to current practices of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to the organs. The concept of brain death has long been recognized, however, to be plagued with serious inconsistencies and contradictions. Indeed, the concept fails to correspond to any coherent biological or philosophical understanding of death. We review the evidence and arguments that expose these problems and present an alternative ethical framework to guide the procurement of transplantable organs. This alternative is based not on brain death and the dead-donor rule, but on the ethical principles of nonmaleficence (the duty not to harm, orprimum non nocere) and respect for persons. We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead. Advantages of this approach are that (unlike the dead-donor rule) it focuses on the most salient ethical issues at stake, and (unlike the concept of brain death) it avoids conceptual confusion and inconsistencies. Finally, we point out parallel developments, both domestically and abroad, that reflect both implicit and explicit support for our proposal.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID