摘要:

Objective:To demonstrate that by using the knowledge and skills of the primary care provider and by applying statistical and scientific principles of quality improvement, outcomes can be improved and costs significantly reduced.Design:A before and after quasi-experimentally designed trial using historical controls plus an analysis of costs in areas not influenced by intensive care unit (ICU) practice to control for possible secular changes.Setting:A tertiary ICU.Patients:All patients admitted to the above-mentioned ICU from January 1, 1991, through December 31, 1995.Interventions:a) A focused program that applied statistical and scientific quality improvement processes to the practice of intensive care. b) An organized effort to modify the culture, thinking, and behavior of the personnel who practice in the ICU.Measurements:Severity of illness, ICU and hospital lengths of stay, ICU and hospital mortality rates, total hospital costs as analyzed by the cost center, and measures of improvement in specific areas of care.Main Results:Significant improvement in glucose control, use of enteral feeding, antibiotic use, adult respiratory distress syndrome survival, laboratory use, blood gases use, radiograph use, and appropriate use of sedation. A severity adjusted total hospital cost reduction of $2,580,981 in 1991 dollars when comparing 1995 with the control year of 1991, with 87% of the reduction in those cost centers directly influenced by the intervention.Conclusions:A focused quality improvement program in the ICU can have a beneficial impact on care and simultaneously reduce costs.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine the presence of otherwise undetected myocardial cell injury in patients with septic shock using daily measurements of cardiac troponin I (cTN I).Design:Prospective observational study.Setting:Intensive care unit of a tertiary institution.Patients:Fifteen consecutive patients with septic shock and six mechanically ventilated patients without septic shock.Interventions:Daily collection of blood for the measurement of cTN I serum levels. Regular biochemical and hemodynamic assessment. Illness severity assessment and collection of demographic data.Measurements and Main Results:Fifteen patients were studied for a median period of 3 days (range, 1 to 9 days). Serum cTN I concentrations were elevated to values otherwise considered diagnostic of acute myocardial infarction in 12 patients and were significantly higher than in critically ill controls (p= .01). All three patients who died in the intensive care unit and all four patients who did not survive beyond 28 days had elevated levels of cTN I. Survivors tended to lower levels of cTN I while in septic shock than nonsurvivors, and all three patients without increased cTN I survived. There was a significant positive correlation between vasoactive drug requirements and cTN I level (p= .04) and a significant negative correlation between cTN I concentration and left ventricular stroke work index (p= .01).Conclusion:Myocardial cell injury appears to be common in patients with septic shock and correlates with cardiac dysfunction.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:LipophilicMalasseziaspecies may induce catheter-associated sepsis in newborns and immunocompromised patients receiving parenteral lipids. Therefore, we tested whetherM. furfurand six otherMalasseziaspecies can use commercially available infusions as a lipid source.Design:Prospectivein vitrostudy.Setting:Research laboratory in a university hospital.Interventions:None.Measurements and Main Results:With the exception ofM. restricta,allMalasseziaspecies grow on lipid infusions. There are no substantial differences among the different brands. The most rapid growth is shown byM. furfur,which grows better on agar containing a 20% rather than a 10% lipid infusion. Growth ofM. furfurandM. sympodialiscan be reduced by infusions containing medium-chain triglycerides. Incubated in triglycerides,M. furfuris strongly suppressed by 50% medium-chain triglycerides andM. sympodialisby 8% medium-chain triglycerides. When medium-chain free fatty acids are added to triglycerides, both species can be suppressed by about 1% free fatty acids.Conclusion:Medium-chain triglycerides and medium-chain free fatty acids are toxic forMalasseziaspecies. Commercially available infusions containing medium-chain triglycerides might be used to prevent systemicMalasseziainfections.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To evaluate the effect of dopexamine on the incidence of acute inflammation in the stomach/duodenum in patients undergoing abdominal surgery ≥1.5 hrs with a minimum of one high-risk criterion.Design:Prospective, randomized, double-blind, placebo-controlled study. This study was conducted as a side arm to a multicenter, multinational study.Setting:University hospital in an adult intensive care unit.Patients:Thirty-eight patients.Interventions:Patients were stabilized with fluid, blood products, and supplementary oxygen to achieve predetermined goals: cardiac index > 2.5 L/min/m2, mean arterial blood pressure of 70 mm Hg, pulmonary arterial occlusion pressure of 10 mm Hg, hemoglobin of 100 g/L, and arterial saturation of 94%. After stabilization, the study drug (either placebo [group A], dopexamine 0.5 μg/kg/min [group B], or dopexamine 2.0 μg/kg/min [group C]) was commenced. The study drug infusion was started 2 to 12 hrs before surgery and infused for 24 hrs after surgery. Estimation of upper gut blood flow was assessed using a gastric tonometer, and gastroscopy with biopsy was performed before surgery (after induction of anesthesia) and 72 hrs after surgery. Comparisons were made between endoscopic findings and histologic proof of acute inflammatory changes. In addition, biopsies were assessed for the presence in the mucosa of mast cells, myeloperoxidase activity, and inducible nitric oxide synthase.Measurements and Main Results:Intramucosal pH decreased significantly with time in all three groups (p< .001), reaching the lowest point at the end of surgery. There was no difference among the groups. Endoscopy visualized acute inflammatory changes in 58.3% of group A patients, 46.2% of group B patients, and 53.9% of group C patients after hemodynamic optimization. At 72 hrs, dopexamine-treated patients compared with placebo-treated patients had a significantly lower incidence of gastric and duodenal acute inflammatory changes, as defined by myeloperoxidase activity (37.5% in groups B and C vs. 86% in group A;p< .05).Conclusion:Dopexamine in doses of 0.5 and 2.0 μg/kg/min affords significant histologic protection to the upper gastrointestinal tract mucosa 72 hrs after operation in high-risk surgical patients undergoing abdominal surgery.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine the impact ofAcinetobacter baumannii(AB) acquisition in intensive care unit (ICU) patients on mortality and length of stay (LOS).Design:Pairwise matched 1:1 case-control study.Setting:Medical-surgical ICU in a tertiary health care institution.Patients:During 16 months, all patients admitted to the ICU were eligible. Case patients were defined as every patient with an AB isolation 48 hrs after ICU admission. Control patients were retrospectively selected from ICU patients without any AB isolation, according to seven matching variables.Measurements and Main Results:Attributable mortality and excess LOS in the ICU were measured. Eighty-seven patients were included, with 75 pairs successfully matched. Infection was defined in 48 patients (23 respiratory). The attributable mortality rate for AB acquisition was 30% (49% vs. 19%) (95% confidence interval [CI] = 23%, 37%): 43% (CI = 34%, 52%) in patients with infection (58% vs. 15%) and 53% (CI = 41%, 65%) in patients with respiratory infections (70% vs. 17%). The estimated risk rates for death were 2.6 (CI = 1.6, 4.5;p< .001), 4.0 (CI = 1.9, 8.3;p< .001), and 4.0 (CI = 1.6, 10.2;p< .01), respectively. The attributable excess LOS was 13 days for both AB acquisition and infection (23 vs. 10 days;p< .001) and respiratory infections (23 vs. 10 days;p< .01). In noninfected patients, no significant excess of mortality was found (33% vs. 26%), but LOS increased in 15 days.Conclusion:AB acquisition involved an excess LOS in ICU patients and increased risk of death, but the latter could be found only in patients with proven infection.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine whether idiopathic pneumonia syndrome (IPS), a form of noninfectious lung injury that follows bone marrow transplantation, is associated with cytokine activation and increased susceptibility to lipopolysaccharide (LPS).Design:Case series.Setting:Tertiary referral center for marrow transplantation.Patients:Recipients with biopsy-confirmed IPS; normal volunteers and marrow transplant recipients without IPS were analyzed as controls.Measurements and Main Results:Levels of lymphocyte and macrophage-derived cytokines as well as components of the LPS, LPS-binding protein (LBP), and CD14 system in bronchoalveolar lavage (BAL) fluid were determined. We found evidence of increased vascular permeability (BAL protein) and inflammatory cytokine activation (interleukin-1, interleukin-2, interleukin-6, and tumor necrosis factor-α) in patients with IPS. Patients without IPS had BAL fluid cytokine and protein levels that were similar to levels in BAL fluid from normal volunteers. Moreover, components of the LPS amplification system (LBP and soluble CD14) were increased in patients with IPS but not in patients without IPS.Conclusions:These results provide direct evidence for proinflammatory cytokine activation in IPS and suggest that these patients might be at increased risk for LPS-mediated injury through the LBP amplification pathway.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine the effect of selenium replacement on morbidity and mortality in patients with systemic inflammatory response syndrome (SIRS).Design:Controlled, randomized prospective open-label pilot study comparing patients with and without selenium replacement.Setting:Intensive care unit of a university hospital for internal medicine.Patients:Forty-two patients with SIRS caused by infection and a minimal Acute Physiology and Chronic Health Evaluation (APACHE) II score of 15 points on the day of admission were included. The selenium replacement group of patients (Se+; n = 21) received sodium selenite for 9 days (535 μg [6.77 μmol] for 3 days, 285 μg [3.61 μmol] for 3 days, and 155 μg [1.96 μmol] for 3 days) and thereafter, 35 μg (0.44 μmol) per day iv. The control group (Se−, n = 21) received 35 μg of sodium selenite throughout the total treatment period.Interventions:Morbidity and clinical outcome was monitored by scoring using the APACHE III score, occurrence of acute renal failure, need and length of mechanical ventilation, and hospital mortality. Blood samples on days 0, 3, 7, and 14 were analyzed for serum selenium concentration and glutathione peroxidase (GSH-Px) activity.Measurements and Main Results:The median APACHE II score at admission, age, gender, underlying diseases, serum selenium levels, and GSH-Px activities at admission were identical in both groups. In Se+ patients, serum selenium levels and GSH-Px activity normalized within 3 days, whereas in controls, both variables remained significantly low (p< .0001). The APACHE III score decreased significantly in both groups but was significantly lower in the Se+ group (day 3,p> .05; day 7,p= .018; and day 14,p= .045 Se+ compared with Se−). Hemodialysis with continuous veno-venous hemodialysis because of acute renal failure was necessary in nine Se− compared with three Se+ patients (p= .035). Overall mortality in the Se− group was 52% vs. 33.5% in the Se+ group (p= .13).Conclusions:Selenium replacement in patients with SIRS seems to improve clinical outcome and to reduce the incidence of acute renal failure requiring hemodialysis.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives:To determine correlations and predictive strength of surrogate markers (body temperature, leukocyte count, C-reactive protein [CRP], and procalcitonin [PCT]) with elevated levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in septic patients.Design:Prospective consecutive case series.Setting:Surgical intensive care unit (ICU) of a university hospital.Patients:A total of 175 patients experiencing intensive care unit stays >48 hrs categorized for sepsis according to ACCP/SCCM Consensus Conference criteria.Measurements and Main Results:CRP and PCT were both significantly correlated with TNF-α and IL-6. Based on the area-under-the-curve of the receiver operating characteristics curves, predicting capability was highest for PCT (0.814 for TNF-α >40 pg/mL and 0.794 for IL-6 >500 pg/mL), moderate with CRP (0.732 and 0.716, respectively), and lowest for leukocyte count (0.493 and 0.483, respectively) and body temperature (0.587 and 0.589, respectively). Sensitivity, specificity, positive, and negative predictive values and test effectiveness all followed this same pattern of being highest for PCT followed by CRP, with leukocyte count and body temperature being lowest.Conclusion:PCT may be an early and better marker of elevated cytokines than the more classic criteria of inflammation.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives:To determine whether clinical features can be used in a decision rule to prospectively identify a subgroup of internal jugular catheter placements that are correctly positioned and free from mechanical complications, thus obviating the need for routine postprocedural chest radiographs in selected patients.Design:Prospective cohort study.Setting:Tertiary care teaching hospital.Patients:A total of 107 consecutive patients who presented to our catheter service for internal jugular catheter insertion because of clinical indications between November 1995 and April 1996. Exclusion criteria were mechanical ventilation, an altered mental status, an age of <15 years, and a height of <152 cm.Interventions:Right or left internal jugular vein catheter placement followed by a postprocedural chest radiograph.Measurements:The operating physician completed a detailed questionnaire for each catheter insertion, designed to detect potential complications and to predict the necessity, or lack of necessity, for a postprocedural chest radiograph. The questionnaire documented patient characteristics, the number of needle passes, difficulty establishing access, operator experience, poor anatomical landmarks, number of previous catheter placements, resistance to wire or catheter advancement, resistance to aspiration of blood or flushing of the catheter ports, sensations in the ear, chest, or arm, and development of signs or symptoms suggestive of pneumothorax. After catheter insertion, chest radiographs were obtained to assess for mechanical complications and malpositioned catheters.Main Results:In 46 cases, the decision rule predicted either a complication or a malposition and, thus, the need for a chest radiograph. In 61 cases, neither was predicted (no chest radiograph was needed). Radiographs confirmed one complication (pneumothorax) and 15 catheter tip malpositions (nine in the right atrium and six in the right axillary vein). Among the 46 cases predicted to have a potential complication or malposition, there were one actual complication (pneumothorax) and six actual malpositions (three axillary vein malpositions and three right atrial malpositions). The positive predictive value of this decision rule is 15%. Among the 61 cases predicted to be free from complications or malpositions and not to require a postprocedural chest radiograph, there were nine unexpected malpositions (three axillary vein malpositions and six right atrial malpositions). The negative predictive value is 85%. The overall sensitivity of the decision rule for detecting complications and malpositions is 44%, and the specificity is 55%.Conclusions:In experienced hands, internal jugular venous catheterization is a safe procedure. However, the incidence of axillary vein or right atrial catheter malposition is 14%, and clinical factors alone will not reliably identify malpositioned catheters. Chest radiographs are necessary to ensure correct internal jugular catheter position.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives:To assess the value of using intramucosal pH (pHi) measurements to evaluate the viability of the gastric tube after thoracic esophagectomy, and to determine whether these measurements may be used for early prediction of anastomotic insufficiency.Design:Prospective, observational study.Setting:University hospital in Japan.Patients:Thirty-nine patients who had undergone thoracic esophagectomy as a treatment for esophageal cancer.Interventions:The blood flow within the gastric tube was measured using a laser Doppler flowmeter during surgery. Periodic measurement of the pHi within the gastric tube (gastric pHi) began during surgery and continued until the second postoperative day. In 30 patients, the pHi within the rectum (rectal pHi) was measured simultaneously with the gastric pHi. The patients were divided into two groups: those patients who experienced anastomotic insufficiency constituted the leakage(+) group (n = 13); those patients who did not experience these complications were designated the leakage(−) group (n = 26).Measurements and Main Results:The gastric pHi values correlated significantly with simultaneous measurements of the blood flow at the anastomotic site (p< .01). The postoperative gastric pHi values increased gradually in the leakage(−) group but stopped increasing after surgery in the leakage(+) group. The rectal pHi values increased gradually after surgery in both groups. Furthermore, there was a significant difference between the two groups when their gastric pHi values were subtracted from their rectal pHi values from the morning of the first postoperative day until the morning of the second postoperative day (p< .05).Conclusions:The gastric pHi values well reflected the viability of the gastric tube, especially when combined with the rectal pHi values. By measuring pHi, we can more accurately predict the risk of anastomotic insufficiency earlier after surgery and therefore give those patients who need it additional care to improve the viability of the gastric tube.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID