摘要:

ObjectivesTo evaluate the safety and physiologic response of inhaled nitric oxide (NO) in patients with acute respiratory distress syndrome (ARDS). In addition, the effect of various doses of inhaled NO on clinical outcome parameters was assessed.DesignProspective, multicenter, randomized, double-blind, placebo-controlled study.SettingIntensive care units of 30 academic, teaching, and community hospitals in the United States.PatientsPatients with ARDS, as defined by the American-European Consensus Conference, were enrolled into the study if the onset of disease was within 72 hrs of randomization.InterventionsPatients were randomized to receive placebo (nitrogen gas) or inhaled NO at concentrations of 1.25, 5, 20, 40, or 80 ppm.Measurements and Main ResultsAcute Increases in PaO2, decreases in mean pulmonary arterial pressure, Intensity of mechanical ventilation, and oxygenation index were examined. Clinical outcomes examined were the dose effects of inhaled NO on mortality, the number of days alive and off mechanical ventilation, and the number of days alive after meeting oxygenation criteria for extubation.A total of 177 patients were enrolled over a 14-month period. An acute response to treatment gas, defined as a PaO2or=to20%, was seen in 60% of the patients receiving inhaled NO with no significant differences between dose groups. Twenty-four percent of placebo patients also had an acute response to treatment gas during the first 4 hrs. The initial increase in oxygenation translated into a reduction in the FIO2over the first day and in the intensity of mechanical ventilation over the first 4 days of treatment, as measured by the oxygenation index. There were no differences among the pooled inhaled NO groups and placebo with respect to mortality rate, the number of days alive and off mechanical ventilation, or the number of days alive after meeting oxygenation criteria for extubation. However, patients receiving 5 ppm inhaled NO showed an improvement in these parameters. In this dose group, the percentage of patients alive and off mechanical ventilation at day 28 (a post hoc analysis) was higher (62% vs. 44%) than the placebo group.5%. The mean inspired nitrogen dioxide concentration in inhaled NO patients was 1.5 ppm.ConclusionsFrom this placebo-controlled study, inhaled NO appears to be well tolerated in the population of ARDS patients studied. With mechanical ventilation held constant, inhaled NO is associated with a significant improvement in oxygenation compared with placebo over the first 4 hrs of treatment. An improvement in oxygenation index was observed over the first 4 days. Larger phase III studies are needed to ascertain if these acute physiologic improvements can lead to altered clinical outcome. (Crit Care Med 1998; 26:15-23)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo evaluate the impact of the route of administration of artificial nutrition and the composition of the diet on outcome.DesignProspective, randomized, clinical trial.SettingDepartment of surgery, university hospital.PatientsOne hundred sixty-six consecutive patients undergoing curative surgery for gastric or pancreatic cancer.InterventionsAt operation, the patients were randomized into three groups to receive: a) a standard enteral formula (control group; n = 55); b) the same enteral formula enriched with arginine, RNA, and omega-3 fatty acids (enriched group; n = 55); and c) total parenteral nutrition (TPN group; n = 56). The three regimens were isocaloric and isonitrogenous. Enteral nutrition was started within 12 hrs following surgery. The infusion rate was progressively increased to reach the nutritional goal (25 kcal/kg/day) on postoperative day 4.Measurements and Main ResultsTolerance of enteral feeding, rate and severity of postoperative complications, and length of hospital stay were recorded.Early enteral infusion was well tolerated.Side effects were recorded in 22.7% of the patients, but only 6.3% did not reach the nutritional goal. The enriched group had a lower severity of infection than the parenteral group (4.0 vs. 8.6; p < .05). In subgroups of malnourished (n = 78) and homologous transfused patients (n = 42), the administration of the enriched formula significantly reduced both severity of infection and length of stay compared with the parenteral group (p < .05). Moreover, in transfused patients, the rate of septic complications was 20.0% in the enriched group, 38.4% in the control group, and 42.8% in the TPN group.ConclusionsEarly enteral feeding is a suitable alternative to TPN after major abdominal surgery. The use of the enriched diet appears to be more beneficial in malnourished and transfused patients. (Crit Care Med 1998; 26:24-30)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectivesTo determine whether aerosolized antibiotics can be delivered efficiently to the lower respiratory tract in mechanically ventilated patients and to define possible clinical responses to these agents.DesignProspective serial study with cases as their own control.SettingA 10-bed respiratory care unit for patients with chronic respiratory failure in a tertiary university hospital.PatientsVentilator dependent patients who are otherwise medically stable. All subjects had a tracheostomy in place, were colonized with Gram-negative organisms, and produced purulent secretions which could be sampled daily.InterventionsSix patients received nine courses of nebulized therapy, which consisted of treatments every 8 hrs of gentamicin (80 mg) or amikacin (400 mg) for 14 to 21 days.Measurements and Main ResultsDoses to the lung were measured using radiolabeled aerosols and antibiotic concentrations in sputum. The response was assessed by a) changes in the volume of respiratory secretions; b) effect on bacterial cultures; and c) changes in the inflammatory cells and mediators of inflammation of the respiratory secretions (interleukin-1 beta [IL-1 beta], tumor necrosis factor-alpha [TNF-alpha], soluble intercellular adhesion molecule-1 [sICAM-1], and human leukocyte elastase). On average, patients inhaled 35.4 +/- 5.08% (SD) of the initial drug placed in the nebulizer (neb-charge). Of this neb-charge, 9.50 +/- 2.78% was found on the respirator tubing and tracheostomy tube and 21.9 +/- 7.15% was actually deposited in the lungs. The remainder of the neb-charge was sequestered in the nebulizer or exhaled. Trough sputum concentrations averaged 4.3 +/- 3.2 micro g/mL/mg neb-charge (range 234 to 520 micro g/mL) and increased to 16.6 +/- 8.1 micro g/mL/mg neb-charge (range 1005 to 5839 micro g/mL) immediately after therapy (p = .011). Serum concentrations were undetectable in most determinations except for a single patient who was in renal failure (8.7 micro g/mL amikacin). Treatment caused a significant reduction in the volume of secretions (p = .002). Weekly cultures revealed eradication of Pseudomonas species, Serratia marcescens, and Enterobacter aerogenes in most of the trials. Before antibiotic treatment, concentrations of IL-1 beta were higher than those reported in acute respiratory distress syndrome. Throughout the duration of the study, IL-1 beta correlated significantly with the absolute number of macrophages, neutrophils, and lymphocytes, respectively (r2= .55, p = .002; r2= .50, p < .0004, r2= .36, p = .005). TNF-alpha concentrations correlated with lymphocytes and neutrophils, respectively (r2= .27, p = .013, r2= .21, p = .033). sICAM-1 concentrations increased twofold (p < .001) during treatment and then returned to baseline. The volume of secretions was related to neutrophil and IL-1 beta concentrations, respectively (r2= .25, p = .008, r2= .35, p = .006).ConclusionsNebulizer delivery of aerosolized aminoglycosides is efficient and predictable. In our clinical model, aerosolized antibiotics can make a significant impact on respiratory secretions. Their efficacy in treatment of critically ill patients remains to be determined. (Crit Care Med 1998; 26:31-39)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo report the indications and adverse events associated with administration of the oral N-acetylcysteine preparation by the intravenous route.DesignRetrospective consecutive case series analysis of 226,720 Toxic Exposure Surveillance System data sheets from a certified regional poison center during the period January 1, 1992 through December 31, 1993.SettingA regional poison center certified by the American Association of Poison Control Centers.PatientsSeventy-six patients treated with the oral N-acetylcysteine solution by the intravenous route.InterventionsNone.Measurements and Main ResultsWe report the indications and adverse events associated with the intravenous administration of the oral N-acetylcysteine preparation.Four (4/76, 5.3%) patients developed adverse events attributable to N-acetylcysteine. None of these events involved hemodynamic, cardiovascular, or pulmonary effects. All reactions occurred during infusion of the initial N-acetylcysteine dose. There were three (3/76, 3.9%) deaths overall; however, they were not attributable to the intravenous administration of the oral N-acetylcysteine preparation.ConclusionsIntravenous administration of the oral N-acetylcysteine preparation appears to have limited adverse effects and offers another mechanism of delivery of the potentially lifesaving N-acetylcysteine when oral administration is not possible. (Crit Care Med 1998; 26:40-43)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo examine the relationship between intensive care unit (ICU) healthcare workers' confidence and their decision to withdraw life support.DesignCross-sectional survey of Canadian intensivists, ICU housestaff, and bedside nurses. Respondents chose the level of care (from comfort measures only to full aggressive care) for 12 patients described in clinical scenarios, and rated their confidence in their decisions.SettingThirty-seven Canadian university-affiliated hospitals.PatientsNone.InterventionsWe used discrete data analysis models to examine the association between the chosen level of care, confidence in the decisions, the clinical scenario, and healthcare worker group.Measurements and Main ResultsThe response rate was 1,361 (76%)/1,795; for this analysis, we used data from 1,306 respondents with completed questionnaires. Responses for each scenario varied widely among respondents. The level of care chosen was dependent on the scenario, the healthcare worker group, and the confidence with which the decisions were made (p < .001 for each). Intensivists were less aggressive than the ICU nurses, who were less aggressive than the housestaff, but the magnitude of effect was small. Overall, respondents were very confident about their decisions 34% of the time. After adjustment for clinical scenario and chosen level of care, intensivists were more confident than nurses, who were more confident than housestaff (40% of intensivists, 29% of nurses, and 23% of housestaff were very confident). In general, healthcare workers tended to be more confident when they chose extreme levels of care than when they chose intermediate levels of care. Considerable variability in responses to scenarios remained even when we considered only those responses made with the highest level of confidence.ConclusionsWhile confidence in decisions about withdrawal of life support increases with seniority and authority, consistency of decisions may not. When given standard information, healthcare workers can make contradictory decisions yet still be very confident about the level of care they would administer. (Crit Care Med 1998; 26:44-49)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo evaluate the performance of the New Simplified Acute Physiology Score (SAPS II) and the admission Mortality Probability Model (MPM0) in a large independent database, using formal statistical assessment.DesignAnalysis of the database of a multicenter, multinational, prospective cohort study, EURICUS-I.SettingEighty nine intensive care units (ICUs) from 13 European areas.PatientsData of 16,060 patients consecutively admitted to the participating ICUs were collected during a period of 4 months. Following the original SAPS II and MPM0criteria, the analysis excluded: patients <18 ys of age; readmissions; patients admitted with acute myocardial infarction; burns; and patients in the post-operative period after coronary artery bypass surgery. All patients with a length of stay <8 hrs were excluded from the study to keep comparability between both systems. A total of 10,027 patients were analyzed.InterventionsCollection of the first 24 hrs' admission data necessary for the calculation of SAPS II and MPM0and basic demographic statistics. Vital status at discharge from the hospital was registered.Measurements and Main ResultsDespite having a good discriminative capability, as measured by the area under the receiver operating characteristic (ROC) curves (SAPS II: ROC = 0.822 +/- 0.005 SEM; MPM040%) and MPM030%) overestimated the risk of death. The evaluation of the uniformity of fit of SAPS II and MPM0demonstrated large variations across the various subgroups of patients.ConclusionsThe original SAPS II and MPM0models did not accurately predict mortality on an independent large international multicenter ICU patient database. Results of studies utilizing general outcome prediction models without previous validation in the target population should be interpreted with prudence. (Crit Care Med 1998; 26:50-61)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectivesTo describe the clinical and laboratory parameters of patients with septic shock following infection with Coccidioides immitis, estimate the incidence of septic shock from coccidioidomycosis, and outline clues that may be helpful in early diagnosis of this syndrome.DesignRetrospective, descriptive case series.SettingA 250-bed general public hospital In Kern County, CA.PatientsEight patients diagnosed with septic shock from infection with C. immitis from September 1991 to December 1993. Five were Hispanic, two were Filipino, and one was African-American. The diagnosis of C. immitis was made by microscopic examination and culture of the organism from sputum or other sites. Septic shock was diagnosed using criteria formulated by the American College of Chest Physicians Consensus Conference/Soclety of Critical Care Medicine.Measurements and Main ResultsNo patient had traditional immunocompromising conditions. All patients had pulmonary symptoms and were symptomatic for a mean duration of 19.4 +/- 19.8 days before admission. One patient presented with septic shock and the remaining seven developed shock during their hospital course. Serology for coccidioidomycosis was positive in six patients. The mean cardiac index was 5.8 +/- 1.9 (SD) L/min/m (2), the mean arterial pressure was 71.0 +/- 16.7 mm Hg, the mean pulmonary artery occlusion pressure was 16.9 +/- 3.5 mm Hg, and the mean systemic volume resistance index was 846.6 +/- 224.1 dyne[center dot]sec/cm5[center dot]m2. All patients developed acute respiratory distress syndrome. Coccidioidomycosis was recognized or considered in only five of eight patients before they developed septic shock. Despite therapy with amphotericin B, all patients died. One patient died of progressive pulmonary disease, two patients suffered an acute arrest, and five patients developed progressive multiple organ system failure and died with additional organ involvement.ConclusionsSeptic shock following infection with C. immitis is an ominous yet underrecognized condition. Hemodynamic parameters and cytokine concentrations were not significantly different from values seen in Gram-negative septic shock. Clinical clues to the diagnosis include duration of illness and conspicuous pulmonary involvement. Patient outcome in this series was poor but may improve with increased recognition of septic shock in infections from C. immitis. (Crit Care Med 1998; 26:62-65)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine if a program to educate referring physicians as to the poor outcome of mechanically ventilated bone marrow transplant patients would result in a change in intensive care unit (ICU) utilization.DesignRetrospective chart review.SettingMedical ICU at an urban university hospital.PatientsPatients undergoing bone marrow transplantation in the interval before (n = 236) vs. the interval after (n = 144) a physician education program.InterventionsTwo separate educational programs were conducted for oncologists and intensivists to review the findings of an earlier study demonstrating the outcome of bone marrow transplant patients in the ICU.Measurements and Main ResultsThe results demonstrated that this physician education intervention did not result in a change in the utilization of medical ICU resources by these patients. Comparing the time periods before and after the intervention, there were no statistically significant differences in the proportion of patients who were admitted to the medical ICU, the proportion who received mechanical ventilation, or the medical ICU lengths of stay. Similarly, the two groups did not differ regarding the 100-day survival rate of all bone marrow transplant patients studied, all bone marrow transplant patients admitted to the medical ICU, or all bone marrow transplant patients intubated.ConclusionSimple educational interventions are not a powerful mechanism by which to alter the practice of physicians regarding the utilization of scarce and expensive resources, even when the physicians generally agree that the use of those resources results in dismal patient outcomes. (Crit Care Med 1998; 26:66-70)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo review the intensive care unit (ICU) experience of patients admitted with acute exacerbations of chronic obstructive pulmonary disease.DesignRetrospective case series.SettingUniversity teaching hospital.PatientsWe reviewed the records of 100 consecutive ICU admissions of patients with acute exacerbations of chronic obstructive pulmonary disease over a period of 4.25 yrs.InterventionsNone.Measurements and Main ResultsPatients were characterized using a computerized prospective database and case note review. Multivariate analysis identified variables predicting ICU and hospital length of stay. The Cox proportional hazards model was used to analyze survival after hospital discharge. Seventy-five patients (24 female and 51 male, mean age 68.5 +/- 7 [SD] yrs) with 100 ICU admissions were identified. Premorbid airway obstruction was severe, with forced expiratory volume in 1 sec (FEV (1))/forced vital capacity (FVC) of 0.7 +/- 0.34 L and FEV1/FVC of 39 +/- 16%. Thirty-two percent received home-administered oxygen and 42% were housebound. The pre-ICU admission PaCO2was 86 +/- 28 torr (11.5 +/- 3.7 kPa), with a pH of 7.24 +/- 0.11 and a PaO2/FIO2of 190 +/- 66. ICU admission Acute Physiology and Chronic Health Evaluation II score was 18 +/- 5. Forty-three patients were mechanically ventilated for a median of 4 days (range 0.08 to 30). Tracheostomy, in seven patients, was maintained for 21 +/- 7 days. Ventilation time and tracheostomy frequency predicted length of ICU stay (median 3 days; range 1 to 40) and hospital stay (17 days; 4 to 97), respectively. ICU and hospital case-fatality rates were 1% and 11%. Out-of-hospital (24-month) probability of survival was predicted by plasma albumin concentration at the time of ICU admission; this probability of survival was.64 at an albumin concentration of 38 g/L.ConclusionsICU admission of severely ill chronic obstructive pulmonary disease patients results in acceptable outcomes. Survival of <or=to2 yrs is not affected by mechanical ventilation or tracheostomy requirement. (Crit Care Med 1998; 26:71-78)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveThis study examined, using nonlnvaslve means, the changes in breathing pattern and inspiratory muscle pressure-time indices during difficult progressive withdrawal of pressure-support ventilation.DesignA prospective analysis of the temporal evolution of several respiratory variables in difficult-to-wean patients.SettingA university hospital intensive care unit.PatientsA heterogeneous group of 17 patients receiving prolonged mechanical ventilation.InterventionsDaily measurements of breathing pattern and respiratory muscle performance parameters in difficult-to-wean patients.Measurements and Main ResultsWe examined breathing pattern variables, rapid shallow breathing (respiratory rate/tidal volume), tracheal occlusion pressure, maximal Inspiratory pressure (PImax), and the tension-time index of the inspiratory muscles (TTmus = PI/PImax x Ti/Ttot) (where Ti/Ttot is inspiratory fraction of the cycle). All measurements were repeated at 24-hr intervals throughout the difficult weaning period. The patients were extubated on satisfying ten of 12 classical weaning criteria.Eleven patients were successfully weaned from mechanical ventilation while six patients were not.Weaning failure was associated with the following: a) longer periods of mechanical ventilation before weaning; b) high values of tracheal occlusion pressure, respiratory rate, minute ventilation, and effective impedance maintained throughout the difficult weaning period; and c) persistent high PaCO2and intrinsic positive end-expiratory pressure values. As the weaning failure patients' inspiratory muscles confronted an increasing inspiratory load, values of the tension-time index of the inspiratory muscles entered or remained in the fatigue zone. In contrast, weaning success patients normalized their breathing pattern and decreased their tracheal occlusion pressure, effective impedance, and tension-time index values.ConclusionsBreathing pattern alterations and respiratory muscle performance impairments lead to ventilator dependency after prolonged mechanical ventilation. The measurement of variables such as the noninvasive tracheal occlusion pressure, inspiratory power of breathing, and tension-time index of the inspiratory muscles facilitate the management of difficult-to-wean patients. (Crit Care Med 1998; 26:79-87)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID