摘要:

ObjectiveHeat shock protein (HSP)70-2 is an important immunomodulatory protein induced in response to inflammatory stimuli. We assessed whether HSP70-2+1267 genotype influenced the risk of septic shock in a prospective cohort study of community-acquired pneumonia and whether HSP70-2+1267 genotype is a better predictor of septic shock than the genotype at lymphotoxin-&agr; +250.DesignProspective cohort study.SettingA large, nonprofit, private hospital system in Memphis, TN.PatientsAdults admitted with community-acquired pneumonia between 1998 and 2001. Septic shock was defined according to consensus criteria (American College of Chest Physicians/Society of Critical Care Medicine, 1992).InterventionsBlood sampling.Measurements and Main ResultsA total of 343 subjects were enrolled; 30 had septic shock. HSP70-2+1267 and lymphotoxin-&agr; +250 genotype was determined using polymerase chain reaction and restriction enzyme digestion. HSP70-2+1267 AA genotype was the strongest predictor of septic shock (p= .0005; relative risk, 3.5). Lymphotoxin-&agr; +250 AA genotype was also associated with an increased risk of septic shock (p= .002; relative risk, 2.7). Logistic regression analysis found only age (p= .04) and HSP70-2+1267 genotype (p= .006) were predictors of septic shock. The greatest risk of septic shock was associated with carriage of the HSP70-2+1267 A/lymphotoxin-&agr; +250 A haplotype (p< .0001).ConclusionsHSP70-2+1267 genotype is a stronger predictor of septic shock in patients with community-acquired pneumonia than lymphotoxin-&agr; +250 genotype.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the outcome and health-related quality of life of patients requiring ≥14 days of mechanical ventilation in the intensive care unit (ICU).DesignProspective cohort study with post-ICU, cross-sectional, health-related quality-of-life survey.SettingA 17-bed ICU in a university hospital.PatientsA consecutive cohort of 347 patients receiving mechanical ventilation for ≥14 days.InterventionsNone.Measurements and Main ResultsOf the patients enrolled in the study, 150 (44%) died in the ICU and 197 were discharged (58 of 197 died 1–57 months after discharge). Factors associated with ICU death according to multivariate logistic regression analysis were age ≥65 yrs, preadmission New York Heart Association functional class of ≥3, a preadmission immunocompromised status, septic shock at ICU admission, renal replacement therapy in the ICU, and nosocomial septicemia. Cox proportional hazards multivariate analysis identified age of ≥65, a preadmission immunocompromised status, and duration of mechanical ventilation for >35 days as independent predictors of death after ICU discharge. By contrast, postcardiac surgery patients had a better outcome. Health-related quality of life was evaluated for 87 of the 99 long-term survivors after a median follow-up of 3 yrs by using the Nottingham Health Profile and St. George’s Respiratory questionnaires. Compared with those of a general French population, their scores were significantly worse for each of the Nottingham Health Profile domains, except social isolation. Nottingham Health Profile scores did not significantly differ between postcardiac and nonpostcardiac surgery patients, men and women (except that women felt more socially isolated), and patients with and without acute respiratory distress syndrome (except for more sleep disorders in those with acute respiratory distress syndrome). Finally, pulmonary-specific St. George’s Respiratory Questionnaire global score was worse for acute respiratory distress syndrome survivors.ConclusionsProlonged mechanical ventilation is associated with impaired health-related quality of life compared with that of a matched general population. Despite these handicaps, 99% of the patients evaluated were independent and living at home 3 yrs after ICU discharge. Future studies should focus on physical or psychosocial rehabilitation that could lead to improved management of patients after their ICU stay.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveActivation and suppression of immune responses are crucial events during sepsis. Based on substantial new data, a complex picture of differential immune-enhancing and immunosuppressive actions of adrenocortical steroids is emerging. The adrenal androgen dehydroepiandrosterone and its precursor, dehydroepiandrosterone-sulfate, show a considerable decrease with increasing age and serve as functional antagonists to endogenous glucocorticoids. Therefore, we examined time-dependent changes in dehydroepiandrosterone, dehydroepiandrosterone-sulfate, cortisol, adrenocorticotropin, and inflammatory variables in surviving and nonsurviving patients with severe sepsis.DesignProspective observational study in consecutive patients.SettingMedical and interdisciplinary intensive care units in two university hospitals and one city hospital.PatientsThirty nonsurgical patients (25 men and 5 women) with severe sepsis (American College of Chest Physicians/Society of Critical Care Medicine criteria); 15 survivors (mean age, 54 ± 14 yrs; Acute Physiology and Chronic Health Evaluation III score, 59 ± 35) and 15 nonsurvivors (mean age, 63 ± 15 yrs; Acute Physiology and Chronic Health Evaluation III score, 67 ± 24) were included. Hormones were compared individually and between survivors/nonsurvivors by sequential blood drawings from early sepsis till time of recovery/death.InterventionsNone.Measurements and Main ResultsDuring early sepsis, cortisol (nmol/L) was not significantly higher in survivors than nonsurvivors (750 ± 121 vs. 454 ± 92,p< .08) and decreased in survivors (p< .01) during late sepsis. During early sepsis, dehydroepiandrosterone-sulfate (percentage of age-matched normal levels) was higher in survivors than nonsurvivors (85 ± 19 vs. 22 ± 7,p< .01). Dehydroepiandrosterone-sulfate decreased in survivors (p= .0001) but remained low in nonsurvivors during late sepsis. Dehydroepiandrosterone (percentage of age-matched normal levels) was not significantly elevated in survivors compared to nonsurvivors during early sepsis (282 ± 42 vs. 214 ± 63,p< .08). Dehydroepiandrosterone decreased in survivors (p< .01) but not in nonsurvivors during late sepsis. Linear regression for dehydroepiandrosterone levels showed a reconstitution of age dependence only in survivors during recovery. Adrenocorticotropin levels did not change. The dehydroepiandrosterone-sulfate/cortisol ratio decreased significantly in both survivors and nonsurvivors, whereas dehydroepiandrosterone/cortisol ratio only decreased in survivors during course of sepsis.ConclusionsDuring sepsis, adrenal androgens and glucocorticoids show a diverse time-dependent course in survivors and nonsurvivors.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate whether calcium adjusted for albumin can be used to monitor calcium homeostasis in critically ill patients.DesignProspective single-single center observational study.SettingClinical laboratory and critical care unit of a regional teaching hospital.PatientsFifty-three paired samples were from 36 patients requiring intensive care treatment.InterventionsNone.Measurements and Main ResultsTotal calcium, albumin-adjusted calcium, and ionized calcium were measured in critically ill patients during an 8-wk period. Calcium was adjusted for albumin using the formula that is most frequently used in The Netherlands. Using ionized calcium as the gold standard, albumin-adjusted calcium overestimated hypercalcemia and totally missed hypocalcemia. The same seemed to be true for other formulas used for albumin or protein adjustment of calcium concentrations.ConclusionsAlbumin-adjusted calcium cannot be used in an intensive care setting to monitor reliably the calcium levels in critically ill patients and should be replaced by measurement of ionized calcium.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo report on the incidence and risk factors associated with the development of ischemic skin lesions (ISL) in critically ill patients with catecholamine-resistant vasodilatory shock treated with a continuous infusion of arginine-vasopressin (AVP).DesignRetrospective analysis.SettingTwelve-bed general and surgical intensive care unit in a university hospital.PatientsA total of 63 critically ill patients with catecholamine-resistant vasodilatory shock.InterventionsContinuous AVP infusion.Measurements and Main ResultsDemographic, hemodynamic, laboratory data, and skin status were evaluated 24 hrs before and during AVP therapy (24 and 48 hrs). Patients were grouped according to development of new ISL during AVP therapy. A mixed-effects model was used to compare groups. A multiple logistic regression analysis was used to identify independent risk factors for the development of ISL. ISL developed in 19 of 63 patients (30.2%). Thirteen of 19 patients (68%) developed ISL in distal limbs, two patients (10.5%) developed ISL of the trunk, four patients (21%) developed ISL in distal limbs and in the trunk. Five patients (26%) had additional ischemia of the tongue. Body mass index, preexistent peripheral arterial occlusive disease, presence of septic shock, and norepinephrine requirements were significantly higher in patients developing ISL. ISL patients received significantly more units of fresh frozen plasma and thrombocyte concentrates than patients without ISL. Preexistent peripheral arterial occlusive disease and presence of septic shock were independently associated with the development of ISL during AVP therapy.ConclusionsISLs are a common complication during continuous AVP infusion in patients with catecholamine-resistant vasodilatory shock. The presence of septic shock and a history of peripheral arterial occlusive disease are independent risk factors for the development of ISL.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveStroke volume variation as measured by the analysis of the arterial pressure waveform enables prediction of volume responsiveness in ventilated patients with normal cardiac function. The aim of this study was to investigate the ability of monitoring stroke volume variation to predict volume responsiveness and to assess changes in preload in patients with reduced left ventricular function after cardiac surgery.DesignProspective study.SettingUniversity hospital.PatientsFifteen mechanically ventilated patients with a left ventricular ejection fraction <0.35 (study group) and 15 patients with an ejection fraction >0.50 (control group) after coronary artery bypass grafting following admission to the intensive care unit.InterventionsVolume loading with 10 mL of hetastarch 6% times body mass index. If stroke volume index increased >5%, successive volume loading was performed until no further increase in stroke volume index was reached.Measurements and Main ResultsStroke volume variation, central venous pressure, pulmonary artery occlusion pressure (PAOP), and left ventricular end-diastolic area index (LVEDAI) were measured at baseline and immediately after each volume loading step. In both groups, stroke volume variation at baseline correlated significantly with changes in stroke volume index caused by volume loading (p< .01). Further, changes in stroke volume variation as a result of volume loading correlated significantly with the concomitant changes in stroke volume index in both groups (p< .01). Using receiver operating characteristic analysis, in the study group areas under the curve for stroke volume variation, PAOP, central venous pressure, and LVEDAI did not differ significantly. In the control group, the area under the curve for stroke volume variation was statistically larger than for PAOP, central venous pressure, and LVEDAI.ConclusionsContinuous and real-time monitoring of stroke volume variation by pulse contour analysis can predict volume responsiveness and allows real-time assessment of the hemodynamic effect of volume expansion in patients with reduced left ventricular function after cardiac surgery.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundSubcutaneously administered low-molecular-weight heparins are widely used for prevention of venous thromboembolism. The appropriateness of the subcutaneous route in critically ill patients has never been established.ObjectiveTo determine anti-Xa activities in critically ill patients and in noncritically ill patients receiving prophylactic doses of subcutaneous enoxaparin.DesignProspective, controlled, open-labeled study.SettingTertiary medical-cardiologic-postoperative intensive care unit and a general medical ward at a university hospital.PatientsA total of 16 intensive care unit patients (group 1; age, 61.1 ± 16 yrs; male/female ratio, 7/9; Acute Physiology and Chronic Health Evaluation II score, 20.9 ± 7; mechanical ventilation, n = 15; vasopressors, n = 13) and 13 noncritically ill medical patients (group 2; age, 61.7 ± 9 yrs; male/female ratio, 7/6) were studied. Body mass index (25.7 ± 5 vs. 24 ± 6 kg/m2,p= not significant) was comparable and serum creatinine levels (0.83 ± 0.25 vs. 1.07 ± 0.3 mg/dL, group 1 vs. 2) were within the normal range in both groups. Patients with impaired renal function, receiving hemofiltration, or requiring therapeutic anticoagulation were not eligible.InterventionsNone.Measurements and Main ResultsAnti-Xa activities were determined at 0, 1, 3, 6, and 12 hrs after a single daily subcutaneous dose of 40 mg enoxaparin on day 1 and at 3 hrs after 40 mg of enoxaparin on days 2–5. Mean anti-Xa levels at 0 to 12 hrs were consistently lower in group 1 compared with group 2 by analysis of variance (p= .001 between groups and over time), as was the area under the curve at 0 to 12 hrs (2.6 ± 1 vs. 4.2 ± 1.7 units·mL−1·hr−1, group 1 vs. 2,p= .008). Significant differences in anti-Xa activity were also found on days 2–5 (p= .001). Peak anti-Xa activities at 3 hrs after administration were negatively correlated with the body mass index (r= −.41,p< .03). No correlation was found between the anti-Xa activity at 3 hrs and the dose of norepinephrine (r= .12,p= .7).ConclusionCritically ill patients with normal renal function demonstrated significantly lower anti-Xa levels in response to a single daily dose of subcutaneous enoxaparin when compared with medical patients in the normal ward.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo describe our experience with the implementation of intensive care in the setting of a field hospital, deployed to the site of a major urban disaster.DesignDescription of our experience during mission to Turkey; conclusions regarding implementation of intensive care at disaster sites.SettingMilitary Field Hospital at Adapazari in Turkey.PatientsCivilian patients admitted for care at the field hospital.InterventionsNone.Measurements and Main ResultsOn August 17, 1999 a major earthquake occurred in western Turkey, causing approximately 16,000 fatalities and leaving >44,000 injured. Approximately 66,000 buildings were severely damaged or destroyed. A medical unit of the Israeli Defense Forces Medical Corps, consisting of 23 physicians, 13 nurses, nine paramedics, 13 medics, laboratory and roentgen technicians, pharmacists, and associated support personnel, were sent to Adapazari in Turkey. The field hospital treated approximately 1,200 patients over a period of 2 wks, 70 surgical operations were performed, 20 babies were delivered, and a variety of medical, surgical, orthopedic, and pediatric/neonatal care was provided. The 12-bed intensive care unit operated by the unit, was staffed by three physicians and eight nursing/paramedic personnel. Patient mix was: a total of 63 patients, among them five with major trauma, 20 with acute cardiac disease, 15 patients with various acute medical conditions, and 11 surgical and postoperative patients. Three patients were intubated and mechanically ventilated (one cardiogenic pulmonary edema and two major trauma). The intensive care unit provided the following functions to the field hospital: care of the critically ill and injured, preparation for and implementation of transportation of such patients, pre- and postoperative care for major surgical procedures, expertise, and equipment for the care of very ill patients throughout the field hospital.ConclusionsIn suitable circumstances, an intensive care capability should be an integral part of medical expeditions to major disasters.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that helium/oxygen mixture can reduce the work of breathing at the end of the weaning process in patients with chronic obstructive pulmonary disease.DesignProspective, randomized, crossover study.SettingTwo medical intensive care units at two university tertiary care centers.PatientsThirteen patients with chronic obstructive pulmonary disease evaluated just before and after extubation.InterventionsHelium/oxygen and air/oxygen mixtures were administered sequentially, for 20 mins each, in a randomized order, just before extubation. It was possible to repeat the study after extubation in five patients.Measurements and Main ResultsBefore extubation, the helium/oxygen mixture induced no significant variation in the breathing pattern. By contrast, it reduced the work of breathing from 1.442 ± 0.718 J/L (mean ± sd) to 1.133 ± 0.500 J/L (p< .05). This reduction was explained mainly by a reduction in the resistive component of the work of breathing from 0.662 ± 0.376 to 0.459 ± 0.256 J/L (p< .01). We also observed a slight reduction in the intrinsic positive end-expiratory pressure from 2.9 ± 2.1 cm H2O to 2.1 ± 1.8 cm H2O (p< .05). Similar results were also observed after extubation in five patients in whom the repetition of the study was possible.ConclusionsIn spontaneously breathing intubated patients with chronic obstructive pulmonary disease recovering from an acute exacerbation, helium/oxygen mixture reduces the work of breathing as well as intrinsic positive end-expiratory pressure without modifying the breathing pattern.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveAngiotensin-converting enzyme inhibitors are an effective therapy for all stages of heart failure due to reduced systolic left ventricular function. Because sufficient data on intravenous angiotensin-converting enzyme inhibitors following coronary artery bypass surgery complicated by postoperative left ventricular dysfunction are unavailable, the efficacy and safety of intravenously administered enalaprilat were evaluated.DesignA placebo-controlled, randomized, double-blind protocol.SettingPostoperative intensive care unit at the German Heart Institute Berlin.PatientsForty patients with a left ventricular ejection fraction <35% following coronary artery bypass surgery on the second postoperative day or after weaning from intra-aortic balloon counterpulsation.InterventionsA loading dose of enalaprilat 0.625 mg infused over 1 hr was followed by 5 mg/24 hrs administered continuously for up to 72 hrs.Measurements and Main ResultsSystemic and pulmonary hemodynamic variables, blood gases, hormonal variables, renal function, and electrolytes were measured before and repeatedly during therapy. Acute effects were as follows: At 1 hr, enalaprilat increased the cardiac index (p< .001), stroke volume index (p< .001), and right ventricular stroke work index (p< .03) compared with placebo, whereas mean arterial pressure (p< .008) and both systemic (p< .001) and pulmonary (p< .02) vascular resistance decreased. Continuous effects were as follows: Over 72 hrs, enalaprilat decreased diastolic pulmonary artery pressure (p< .019), pulmonary artery occlusion pressure (p< .02), and central venous pressure (p< .02). The cardiac and stroke volume indexes were consistently higher in the enalaprilat group, whereas systemic and pulmonary vascular resistances were lower. The arterial blood-pressure lowering effect was blunted and heart rate remained unchanged. Mixed venous oxygenation (p< .02) was higher and arterial oxygenation was not modified. Finally, enalaprilat increased creatinine clearance (p< .002) and decreased creatinine (p< .02) and urea (p< .03).ConclusionsIntravenous enalaprilat safely and effectively improves cardiac and renal function following coronary artery bypass surgery complicated by postoperative left ventricular dysfunction.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID