摘要:

ObjectiveTo evaluate the safety and relative effectiveness of two diuretic protocols in the intensive care unit (ICU).DesignProspective, randomized comparative study.PatientsThirty-three cardiac and medical ICU patients with pulmonary edema or fluid overload for which aggressive diuresis was intended.InterventionsEnrolled patients were randomized to fluid management strategies combining fluid restriction and individually adjusted diuretic therapy by either continuous or bolus infusions of furosemide, titrated to achieve negative hourly fluid balance.Measurements and Main ResultsCumulative intake minus output (primary endpoint); change in serum creatinine, and length of ICU and hospital stay (secondary endpoints). Diuresis by either protocol was feasible, safe, and effective. The main outcome measures were not significantly different for either group managed with a standardized protocol.ConclusionsProtocol-guided diuretic management, with individualized titration of dosage to defined physiologic endpoints can be readily and safely implemented in the ICU. Both continuous and bolus diuretic regimens appear equally effective in achieving negative fluid balance. Larger studies with a randomized control arm are needed before these protocols can be recommended as routine practice. (Crit Care Med 1997; 25:1969-1975)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo investigate the concentrations of triglyceride, cholesterol, and high-density lipoprotein during a 50-hr infusion of 2% propofol, starting within 24 hrs of admission to the intensive care unit (ICU).DesignProspective, clinical study.SettingICU, university hospitalPatients2 days, were studied for 50 hrs, begining at 1800 hrs on the first day of ICU admission.Measurements and Main Results1000 pg/mL, but there was no relationship between concentrations of cytokines and triglycerides in plasma.ConclusionsInfusion of 2% propofol to critically ill patients over a 50-hr period does not result in a significant increase in triglyceride concentrations. Mean cholesterol and high-density lipoprotein concentrations were low throughout the study period. There was a significant direct correlation between triglyceride and C-reactive protein and an inverse correlation between cholesterol and C-reactive protein, suggesting that the changes in lipids in critically ill patients may be partly attributable to the acute-phase response. (Crit Care Med 1997; 25:1976-1981)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectivesTo determine the rate of lower extremity deep vein thrombosis after the use of femoral catheters in intensive care unit (ICU) comatose or sedated adults. Results were then compared with results of patients undergoing superior vena cava catheterization.DesignProspective, randomized, controlled, unblinded study.SettingA mixed medical/surgical ICU in a university hospital.PatientsSixty-one comatose or sedated patients admitted to the ICU who underwent central venous catheterization.InterventionsPatients were monitored for signs of thrombotic complications. On catheter removal, a lower-extremity bilateral phlebographic examination was performed in each patient.Measurements and Main ResultsAfter randomization, 31 patients underwent femoral vein catheterization and 30 patients underwent superior vena cava catheterization, either by axillary (21 patients) or internal jugular vein (10 patients) cannulation. Single lumen polyurethane catheters were inserted for a mean duration of 7.1 +/- 4.6 (SD) days in the femoral vein group and 9.9 +/- 5.5 days in the superior vena cava group (p=NS). No patient had clinical signs of leg venous thrombosis or pulmonary embolism during the study period. In each patient, lower extremity bilateral phlebography was performed at the time of catheter removal. Leg phlebographies were normal in 18 (60%) patients in the femoral vein group and 26 (84%) patients in the superior vena cava group. Fibrin sleeves which developed around the femoral catheters were seen in seven (23.3%) patients in the femoral vein group and in no patients in the superior vena cava cannulation group. Three patients had femoral vein thrombosis, two (6.6%) patients in the femoral vein group (two nonobstructive thromboses, adherent to the common femoral vein wall) and one (3.0%) patient in the superior vena cava group (nonobstructive thrombosis which developed in the superficial femoral vein) (p = NS). Lower deep extremities thrombosis developed in five (16.7%) patients in the femoral vein group and in five (16%) patients in the superior vena cava group (p=NS).ConclusionsFemoral vein catheterization with a polyurethane catheter is associated with a lower rate of extremity deep vein thrombosis which is similar to the rate observed after superior vena cannulation in comatose or sedated patients. Femoral vein thrombosis was observed at a rate of 6.6% after femoral vein cannulation and a rate of 3% after superior vena cava cannulation. Given the acceptable rate of this clinically important complication, femoral vein cannulation offers an attractive alternative to insertion via the vena cava in the critically ill. (Crit Care Med 1997; 25:1982-1985)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine the rate of complications following the use of femoral catheters in adults.DesignProspective survey of major and minor complications.SettingA mixed medical/surgical intensive care unit (ICU) in a university hospital.PatientsEighty consecutive patients admitted to the ICU who underwent right femoral venous catheterization over a 13-month period.InterventionsPatients were carefully monitored for mechanical, infectious, and thrombotic complications. On catheter removal, a lower extremity bilateral phlebographic examination was performed in each patient.Measurements and Main ResultsThere were 80 polyurethrane catheters inserted for a mean duration of 8.8 +/- 4.4 (SD) days. Catheters were inserted by interns or residents (75%) or by critical care fellows (25%). Minor complications consisted of arterial puncture (15%), local hematoma (4.4%), local bleeding (3%), and local inflammation (5%). After insertion, 17% of catheter tips were in the right atrium, 13% in the abdominal vena cava, 63% in the thoracic inferior vena cava (correct position), and 8% in aberrant abdominal intravascular positions. After repositioning, 80% of catheter tips were in the thoracic inferior vena cava. One patient developed a catheter-related bacteremia. Catheter-related sepsis were seen in three (3.7%) patients and catheter colonization in 11 (13.7%) patients.No patient had clinical signs of deep vein thrombosis or pulmonary embolism. Bilateral phlebography was performed in 70 patients at the time of catheter removal and was normal in 45 (64%) patients. Fibrin sleeves were seen in 11 (15.7%) patients. Lower extremity deep vein thrombosis developed in 24 (34%) patients. Six (8.5%) patients had femoral vein thrombosis (common femoral vein in two patients, and superficial femoral vein in four patients).Eighteen (25.7%) patients developed popliteal vein or posterior tibial vein thrombosis that was either bilateral (n = 16) or homolateral (n = 2) to the femoral catheter.ConclusionsBased on the data from this study, we conclude that femoral vein catheterization with a polyurethane catheter is associated with an 8.5% frequency rate of femoral vein thrombosis. Thrombosis in the popliteal vein or posterior tibial vein is higher (25.7%), but is homolateral to the catheter with only a 2.8% frequency rate. Infectious complications are low and similar to those of other central venous routes. Given the acceptable rate of clinically important complications, femoral venous catheterization offers an attractive alternate site of insertion to the jugular and subclavian veins for central venous access in the critically ill. (Crit Care Med 1997; 25:1986-1989)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine the sympathetic response during cardiopulmonary bypass at mild (34[degree sign]C) and moderate (28[degree sign]C) hypothermia.DesignA randomized study.SettingTertiary university hospital.PatientsAdults undergoing elective coronary artery bypass graft surgery.InterventionsNone.Measurements and Main ResultsPlasma norepinephrine, eplnephrine, and neuropeptide Y concentrations were measured. Moderate, but not mild, hypothermic cardiopulmonary bypass evoked a significant sympathetic response with increases in plasma norepinephrine and neuropeptide Y concentrations. A significantly higher incidence of postoperative atrial fibrillation was also observed in the moderate hypothermic compared with the mild hypothermic group.ConclusionsOur results indicate that the degree of hypothermia significantly influences the sympathetic response during cardiopulmonary bypass. The higher incidence of postoperative atrial fibrillation in the moderate hypothermic group suggests that the enhanced sympathetic response might be one contributing factor in the development of atrial fibrillation. (Crit Care Med 1997; 25:1990-1993)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectivesProgression from systemic inflammatory response syndrome (SIRS) to sepsis, severe sepsis, and septic shock has been demonstrated in a variety of patients. However, the presence of SIRS alone was not helpful in predicting the development of multiple organ dysfunction syndrome (MODS) since SIRS includes many nonprogressive conditions. This study was conducted to investigate the clinical significance of SIRS in postoperative patients.DesignRetrospective study.SettingThe surgical department of a university hospital.PatientsTwo hundred ninety-two consecutive patients who received elective common gastrointestinal surgery (esophagectomy, pancreatoduodenectomy, hepatectomy, gastrectomy, colorectal resection, and laparoscopic cholecystectomy) between 1992 and 1995.InterventionsPatients were analyzed for preoperative physiologic status, surgical stress parameters, and postoperative status of SIRS, complications, and end-organ dysfunction.Measurements and Main Results30 days developed severe MODS, and three of them died.ConclusionsSIRS is a useful criterion for the recognition of postoperative complications and end-organ dysfunctions. Early recovery from SIRS may arrest the progression of organ dysfunction. (Crit Care Med 1997; 25:1994-2000)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo compare the impact of two different customization strategies in the performance of the admission Mortality Probability Model II (MPM II0) using formal statistical assessment.DesignAnalysis of the database of a multicenter, multinational, prospective cohort study, EURICUS-1, involving 89 intensive care units (ICUs) from 12 European countries.SettingEighty-nine ICUs from 12 European countries.PatientsData from 16,060 patients consecutively admitted to 89 ICUs from 12 European countries were collected during a 4-month period. In accordance with original MPM II0criteria, the following patients were excluded from analysis: patients <18 yrs of age; patients considered readmissions; patients with acute myocardial infarction or burns; and patients in the postoperative period recovering from coronary artery bypass surgery. A total of 10,397 patients were analyzed.InterventionsCollection of the data necessary for the calculation of MPM II0and basic demographic statistics. Vital status at hospital discharge was registered. Two new logistic regression equations were developed to relate MPM II sub 0 to mortallty after splitting the database into development and validation samples, the first with the original logit of MPM II0as an independent variable (first-level customization), and the second with all 15 original variables (second-level customization). Discrimination (area under the receiver operating curve), Hosmer-Lemeshow goodness-of-fit tests H and C, and observed/expected mortality ratios were evaluated in both samples and within relevant subgroups.Measurements and Main ResultsThe discriminative capability of the models was only slightly affected by customization (0.810 vs. 0.803), remaining lower than in the original description of the MPM II0(0.824). Calibration improved, with Hosmer-Lemeshow goodness-of-fit tests H and C showing a good fit of the models. However, the formal evaluation of discrimination, calibration, and observed/expected mortality ratios across relevant subgroups appeared to be poor in some groups.ConclusionsIn this ICU patient database, second-level customization was more effective than first-level customization in improving the overall goodness-of-fit of MPM II0and should probably be chosen as the preferential strategy to improve the fit of a model when the sample size is large enough. However, second level customization had only a slight impact on discrimination. Its effects on the uniformity of fit are insufficlent to overcome the problems that can arise when the model is applied in populations in which the case-mix is distinct from the population where it was originally developed. (Crit Care Med 1997; 25:2001-2008)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine the incidence, predisposing factors, and outcome of early bloodstream infection after cardiopulmonary bypass.DesignA case control study.SettingA 54-bed cardiac surgical intensive care in a tertiary referral center.PatientsPatients from a 30-month period with preoperative hospital stay of <48 hrs and subsequent bloodstream infection within 96 hrs of cardiopulmonary bypass were included in a case group. The control group consisted of patients who had cardiac surgery on the same day as the case group.Measurements and Main ResultsPatient demographics, history of comorbidity, preoperative laboratory testing, details of surgery, transfusion requirement, inotropic infusions, hemodynamics, and arterial blood gases on admission to intensive care were compared in the two groups. Measures of outcome were duration of mechanical ventilation and intensive care stay, serum creatinine on the first postoperative day, highest creatinine and bilirubin concentrations, and hospital mortality.During the study period, 7,928 patients had cardiac surgery. Sixteen (0.2%) patients had early bloodstream infection; the control group consisted of 95 patients. Thirteen of the patients with bloodstream infection had Gram-negative bacilli on blood culture, two had Candida species, and two had Gram-positive bacteria. On multivariate logistic regression analysis, greater prevalence of preoperative pulmonary hypertension (odds ratio 9; 95% confidence interval 2 to 41.8; p = .004), diabetes (odds ratio 4.6; 95% confidence interval 1.4 to 15.8; p = .01), number of blood products transfused (odds ratio 1.09; 95% confidence interval 1.04 to 1.17; p = .005), and infusion of inotropes (odds ratio 4.7; 95% confidence interval 1.3 to 16.4; p = .02) or vasopressors (odds ratio 4.1; 95% confidence interval 1.3 to 15.6; p = .02) were associated with postoperative bloodstream infection.Early bloods tream infection was associated with significantly prolonged duration of mechanical ventilation (117.2 +/- 21.5 vs. 18 +/- 8.8 hrs; p = .0001), intensive care stay (213 +/- 27.5 vs. 53 +/- 11.0 hrs; p < .0001), greater creatinine concentrations on the first posroperative day (1.6 +/- 0.1 vs. 1.2 +/- 0.04 mg/dL; p = .0002), greater maximum creatinine concentration (2.4 +/- 0.2 vs. 1.3 +/- 0.1 mg/dL; p < .0001), and greater maximum bilirubin concentration (4.7 +/- 0.6 vs. 1.3 +/- 0.2 mg/dL; p < .0001) when compared with the control group. Five (32%) of 16 bacteremic patients died vs. none of the 95 control patients (p < .0001).ConclusionsEarly bloodstream infection after cardiac surgery is uncommon and involves predominantly Gram-negative bacteria. The risk factors associated with bloodstream infection were preoperative morbidity and more complex surgery. Bloodstream infection was associated with a significantly adverse impact on outcome after cardiac surgery. (Crit Care Med 1997; 25:2009-2014)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo investigate protein complement 3a (C3a) and protein complement 3 (C3) plasma levels in trauma patients directly after the injury, in relation to the patients' outcome, the development of sepsis, or the injury severity, as determined by either the Polytrauma Score (PTS), the Injury Severity Score (ISS), or the Trauma and Injury Severity Score (TRISS).DesignProspective study.SettingSurgical intensive care unit in a university hospital.PatientsThirty-four patients with multiple trauma.InterventionsNone.Measurements and Main ResultsC3a and C3 concentrations, as well as the C3a/C3 ratio, were determined at the time of the accident (T0), at the emergency admission (T1), 8 hrs after the accident (T2), and every 8 hrs until day 3, every 12 hrs until day 6, and once daily on days 7 and 8. The C3a plasma concentrations and the C3a/C3 ratios of nonsurvivors were significantly greater at T0 or T1 as compared with those survivors (p = .008 or .033). Patients who developed sepsis had higher C3a plasma levels at the scene of accident than patients without complications. However, these differences did not reach statistical significance (p = .051), although a clear trend was apparent.Patients were grouped according to the severity of injury, as determined by either the PTS, ISS, or TRISS. We found significant differences in the both the mean C3a values and the C3a/C3 ratio among the different groups, during the first 8 hrs after the injury. In addition, a significant correlation was observed between the C3a concentration or the C3a/C3 ratio at T0 to T2 and either the ISS (r2= .49), PTS (r2= .22) or the TRISS (r2= .45), which was similar to correlations between injury severity scores themselves (r2= .36 to .58).ConclusionsComplement activation occurs immediately after the injury. The degree of activation is a hallmark for the outcome of a patient. Determination of C3a concentrations, at the scene of the accident, may prove helpful to assess the severity of the injury and to determine the prognosis. The amount of C3a and the C3a/C3 ratio may be useful as additional parameters to the existing trauma scoring systems, such as, PTS, ISS, and TRISS. (Crit Care Med 1997; 25:2015-2024)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine whether intratracheal pulmonary ventilation (ITPV) allows for effective oxygenation and ventilation at lower mean airway pressures and peak inspiratory pressures than conventional ventilation in a piglet model of meconium aspiration syndrome.DesignProspective, interventional study.SettingThe animal research laboratory at Children's National Medical Center, Washington, DC.SubjectsTwenty newborn piglets, 2 to 7 days of age, weighing 1.8 to 2.8 kg.InterventionAnimals were anesthetized, paralyzed, intubated, and ventilated. Femoral arterial and venous catheters were inserted; 5 mL/kg of 20% meconium in normal saline was instilled into the endotracheal tube. Animals were randomized to either ITPV or conventional ventilation, and settings were adjusted to maintain ideal blood gases, i.e., pH 7.35 to 7.45, PCO240 to 45 torr (5.3 to 6 kPa), PO280 to 100 torr (10.7 to 13.3 kPa), and SaO2or=to90%. Ventilatory settings were adjusted as needed to a maximum of: FIO21.0, peak inspiratory pressure 40 cm H2O, positive end-expiratory pressure 5 cm H2O, and respiratory rate 80 breaths/min.Measurements and Main ResultsArterial blood gases were taken every 30 mins for 4 hrs and ventilatory settings were adjusted to maintain optimal blood gases. Heart rate, mean arterial blood pressure, and arterial saturation were monitored continuously. The animals in the ITPV group had significantly lower peak inspiratory pressure at 1, 2, 3, and 4 hrs after meconium instillation (p < .018) and significantly lower mean airway pressure at 2, 3, and 4 hrs after meconium instillation (p < .03). The mean peak inspiratory pressure in the ITPV animals ranged from 17 +/- 2.7 cm H2O at baseline to 16.6 +/- 5.7 cm H2O at 4 hrs compared with 16.5 +/- 2.7 cm H2O at baseline to 31.8 +/- 9.1 cm H2O at 4 hrs in the conventionally ventilated animals (p < .04). The mean airway pressure ranged from 6.3 +/- 1.1 mm Hg at baseline to 6.8 +/- 2.5 mm Hg at 4 hrs in the ITPV group compared with 5.5 +/- 1.2 mm Hg at baseline to 10.7 +/- 3.4 mm Hg at 4 hrs in the conventional ventilation group (p < .03). The lungs of the ITPV animals were less hemorrhagic and had less pathologic evidence of injury than the lungs of the conventionally ventilated animals.ConclusionsThese results indicate that ITPV can be used to effectively ventilate and oxygenate piglets with meconium aspiration syndrome at lower mean airway pressures and peak inspiratory pressures than conventional ventilation. This lower pressure causes less injury to the lungs of the animals. (Crit Care Med 1997; 25:2025-2030)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID