摘要:

ObjectiveTo examine the influence of genetic variations in heat shock proteins on trauma outcome.DesignProspective, noninterventional, single-center study.SettingLevel I trauma center.SubjectsEighty consecutive severe multiple trauma patients.InterventionsNone.Measurements and Main ResultsPlasma concentrations of interleukin-6 and tumor necrosis factor-&agr; were measured over a 5-day course by chemiluminescence-immunoassay. The genotypes of the polymorphisms HSPA1B (HSP70-2) G1538A and HSPA1L (HSP70-Hom) C2437T were determined by polymerase chain reaction and restriction cleavage withPstI orNcoI, respectively. Allele frequency of the HSPA1B 1538 G allele was 0.569, and that of the HSPA1L 2437 T allele was 0.821. Interleukin-6 concentrations rapidly increased and dropped to almost normal after 5 days, whereas tumor necrosis factor-&agr; concentrations increased until day 5. Patients carrying the genotypes HSPA1B AG or HSPA1L CT had significantly higher plasma concentrations of tumor necrosis factor-&agr; and interleukin-6 compared with those with genotype GG or TT. Presence of the HSPA1L genotype CT also was a significant risk factor to develop liver failure (odds ratio, 4.6; 95% confidence interval, 1.5–14.1) and to acquire at least one complication severe enough to score three points according to the Denver multiple organ failure score (odds ratio, 3.0; 95% confidence interval, 1.1–9.2).ConclusionThe data indicate that genetic variations of the heat shock proteins HSPA1B and HSPA1L may contribute to clinical outcome after severe injury.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo describe the incidence of clinical deep venous thrombosis associated with femoral central venous catheters (CVC-DVT) in children with diabetic ketoacidosis (DKA).DesignRetrospective case-matched control series.SettingPediatric intensive care units of two university-affiliated hospitals.PatientsAll eight pediatric DKA patients with femoral central venous catheters between 1998 and 2001, and 16 age-matched control patients with femoral central venous catheters and circulatory shock.InterventionsNone.Measurements and Main ResultsThe records of all children with DKA and the control patients were reviewed. CVC-DVT was defined as persistent ipsilateral leg swelling after removal of a femoral central venous catheter. Control patients with coagulopathies, thrombocytopenia, cancer, and hyperglycemia were excluded. Four of eight patients with DKA developed CVC-DVT compared with none of the 16 control patients (p= .007, Fisher’s exact test). All four patients with DKA and CVC-DVT were <3 yrs old. Doppler ultrasound examination was performed on three of the four patients with clinical CVC-DVT, confirming the diagnosis in each case.ConclusionsThis study suggests that young children with DKA have an increased incidence of clinical DVT associated with the placement of femoral central venous catheters.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveWe investigated the role of right-to-left shunt with standardized transcranial Doppler ultrasonography in a large population of divers referred for symptoms of decompression illness.DesignCase series compared with a control group.SettingMilitary teaching hospital, hyperbaric unit.PatientsPatients were 101 consecutive divers with clinical evidence of decompression illness and a control group of 101 healthy divers.InterventionSpecification of the type of decompression illness involved and detection/evaluation of right-to-left shunt by standardized transcranial Doppler. The degree of right-to-left shunt was defined as major if the number of high-intensity transient signals in the middle cerebral artery was >20.Measurements and Main ResultsWe evaluated the odds ratios by logistic regression analysis with vs. without right-to-left shunt for subjects with cochleovestibular symptoms, cerebral decompression illness, spinal decompression illness, and Caisson sickness. Of the 101 divers presenting with decompression illness, transcranial Doppler detected a right-to-left shunt in 59 (58.4%), whereas control subjects demonstrated a right-to-left shunt in 25 cases (24.8%; odds ratio, 4.3; 95% confidence interval, 2.3–7.8;p= .09). When a right-to-left shunt was detected, the right-to-left shunt was major in 12 of 25 patients in the control group and in 49 of 59 patients in the decompression illness group (odds ratio, 8.7; 95% confidence interval, 4.2–18.0;p< .001). Within the decompression illness group, the proportion of major right-to-left shunt was 24 of 34 (odds ratio, 29.7; 95% confidence interval, 10.0–87.2;p< .0001) in the cochleovestibular subgroup, 13 of 21 (odds ratio, 24.1, 95% confidence interval, 6.8–86.0,p< 0.0001) in the cerebral decompression illness subgroup, ten of 31 (odds ratio, 3.9; 95% confidence interval, 1.5–10.3;p< .01) in the spinal decompression illness subgroup, and two of two (odds ratio, 1.1; 95% confidence interval, 0.2–5.7;p= .9) in the subgroup of divers with Caisson sickness.ConclusionBased on our results, we conclude that major right-to-left shunt was associated with an increased incidence of cochleovestibular and cerebral decompression illness, suggesting paradoxical embolism as a potential mechanism.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveA low tidal volume can induce alveolar derecruitment in patients with acute lung injury. This study was undertaken to evaluate whether this resulted mainly from the decrease in tidal volumeper seor from the reduction in end-inspiratory plateau pressure and whether there is any benefit in raising the level of positive end-expiratory pressure (PEEP) while plateau pressure is kept constant.DesignProspective crossover study.SettingMedical intensive care unit of a university teaching hospital.PatientsFifteen adult patients ventilated for acute lung injury (Pao2/Fio2, 158 ± 34 mm Hg; lung injury score, 2.7 ± 0.6).InterventionsThree combinations were tested: PEEP at the lower inflection point with 6 mL/kg tidal volume, PEEP at the lower inflection point with 10 mL/kg tidal volume, and high PEEP with tidal volume at 6 mL/kg, keeping the plateau pressure similar to the preceding condition.Measurements and Main ResultsPressure-volume curves at zero PEEP and at set PEEP were recorded, and recruitment was calculated as the volume difference between both curves for pressures ranging from 15 to 30 cm H2O. Arterial blood gases were measured for all patients. For a similar PEEP at the lower inflection point (10 ± 3 cm H2O), tidal volume reduction (10 to 6 mL/kg) led to a significant derecruitment. A low tidal volume (6 mL/kg) with high PEEP (14 ± 3 cm H2O), however, induced a significantly greater recruitment and a higher Pao2than the two other strategies.ConclusionAt a given plateau pressure (i.e., similar end-inspiratory distension), lowering tidal volume and increasing PEEP increase recruitment and Pao2.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate partial occlusion in patients with pulmonary hypertension with regard to a) the degree to which it leads to overestimation of pulmonary artery occlusion pressure (Ppao) and b) identification of factors that could enhance its recognition.DesignObservational descriptive study.SettingMedical intensive care unit.PatientsFourteen patients with pulmonary hypertension and an increased pulmonary artery diastolic pressure (Ppad) − Ppao gradient (≥10 mm Hg).InterventionsNone.Measurements and Main ResultsThe Ppao was recorded during partial occlusion (partial Ppao) and after catheter repositioning to obtain a lower, more accurate value (best Ppao). The error due to partial occlusion, defined as the difference between the partial Ppao and the best Ppao, was 13 ± 5 mm Hg (range, 6–21 mm Hg). The previously widened Ppad − Ppao gradient invariably narrowed during partial occlusion and then increased by 13 ± 5 mm Hg (range, 5–23) during the best Ppao measurement. There was a moderate correlation between the error due to partial occlusion (partial Ppao − best Ppao) and both the mean pulmonary artery pressure (r = .77,p< .01) and the Ppad − Ppao gradient (r = .79,p< .01).ConclusionsPartial occlusion in patients with pulmonary hypertension may lead to significant overestimation of the Ppao and should be suspected when there is a substantial increase in the Ppao without a concomitant increase in the Ppad, as reflected by a marked narrowing of a previously widened Ppad − Ppao gradient.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo compare low level albumin excretion (microalbuminuria), a marker of systemic capillary permeability, with mortality, Acute Physiologic And Chronic Health Evaluation (APACHE II) score, the Simplified Acute Physiologic (SAP II) score, and their derived mortality probabilities in patients admitted to a general intensive care unit.DesignProspective observational study.SettingA 14-bed intensive care unit in a university teaching hospital.PatientsA total of 140 consecutive patients (59 surgical, 48 medical, 22 trauma, and 11 burns).InterventionsUrine collection within 15 mins of intensive care unit admission for assessment of microalbuminuria.Measurements and Main ResultsMicroalbuminuria, expressed as the albumin-creatinine ratio (ACR: normal, <2.3 mg/mmol), was compared with mortality, APACHE II and SAP II scores and their derived mortality probabilities after 24 hrs, intensive care unit stay, and markers of organ function and inflammation. Median (95% confidence interval) ACR at admission for survivors (n = 115) and nonsurvivors (n = 25) were 4.2 (3.6–6.5) and 17.8 (8.0–40.8) mg/mmol, respectively (p= .0002 Mann Whitney). For 92 surgical, trauma, and burn patients, of whom 81 survived, ACR of >5.9 mg/mmol gave a sensitivity for death of 100%, specificity of 59%, positive predictive value of 25%, and negative predictive value of 100%. Mortality probability receiver operator characteristic curve areas for ACR, APACHE II, and SAP II were 0.843 (p< .0001), 0.793 (p= .0004), and 0.770 (p= .0017), respectively. ACR was associated with intensive care unit stay (p= .0021) and highest serum C-reactive protein (p= .0002), serum creatinine (p< .0001), and bilirubin (p= .0009). For 48 medical patients, of whom 34 survived, admission ACRs for survivors and nonsurvivors were 8.3 (5.7–10.8) and 10.7 (4.1–48.2) mg/mmol, respectively (p= .32). SAP II, but not APACHE II, score was significantly higher for nonsurvivors.ConclusionsFor surgical, trauma, and burn patients, but not medical patients, microalbuminuria within 15 mins of intensive care unit admission predicted death as well as APACHE II and SAP II scores calculated after 24 hrs, and it shows promise as a predictor of outcome.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivesTo assess the outcome and to identify early prognostic indicators in a global population of patients with hematologic malignancy admitted to the intensive care unit for a life-threatening complication.DesignRetrospective observational study.SettingMedical intensive care unit at a tertiary university hospital.PatientsA total of 124 consecutive critically ill patients with a hematologic malignancy admitted to the intensive care unit during a 3.5-yr period.MeasurementsWe collected variables at admission and during admission and identified predictors of in-hospital mortality by stepwise logistic regression analysis.Main ResultsMean Acute Physiology and Chronic Health Evaluation II score was 26 ± 7.7. Sixty-one percent had a high-grade malignancy, and 27% had active disease. Thirty-five percent were leukopenic (leukocyte count, <1.0 × 109/L) at admission. Respiratory failure (48%), sepsis (18.5%), and neurologic impairment (17%) were the major reasons for admission at the intensive care unit. Seventy-one percent of the patients required ventilatory support for a median duration of 6 (3–17) days, 46% received vasopressors at admission, and 26.6% needed renal replacement therapy during their intensive care unit stay. A recent bacteremia precipitating intensive care unit admission was found in 21.8% of the patients. Crude intensive care unit, in-hospital, and 6-month mortality rates were 42%, 54%, and 66%, respectively. Four variables were independently associated with outcome in a multivariate logistic regression analysis: leukopenia (odds ratio, 2.9; 95% confidence interval, 1.1–7.7), vasopressors (odds ratio, 3.74; 95% confidence interval, 1.4–9.8), and urea of >0.75 g/L (>12 mmol/L) (odds ratio, 9.4; 95% confidence interval, 4.2–26) at admission were associated with poor outcome, whereas recent bacteremia (odds ratio, 0.17; 95% confidence interval, 0.05–0.58) was associated with better prognosis. Using these variables, we arbitrarily categorized our population into three groups for survival analysis: a low-risk group (low urea with or without either leukopenia or vasopressors, n = 60), an intermediate-risk group (high urea or a combination of leukopenia and vasopressors, n = 34), and a high-risk group (high urea in combination with leukopenia or vasopressors, n = 27). Patients with a bacteremia prompting intensive care unit admission were allocated to a one-step-lower risk group. Survival probabilities at 30 days and 6 months were 75% and 55% in the first group, 35% and 21% in the second group, and 4% and 0%, respectively, in the third group (p< .001).ConclusionThe general reluctance to admit patients with a hematologic malignancy to the intensive care unit, even with severe critical illness, is unjustified. However, we identified four early predictors of outcome that may be of value in deciding in which patients advanced or prolonged support should not be continued.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo measure and describe hospital noise and determine whether noise can be correlated with nursing stress measured by questionnaire, salivary amylase, and heart rate.DesignCohort observational study.SettingTertiary care center pediatric intensive care unit.SubjectsRegistered nurses working in the unit.InterventionsNone.Measurements and Main ResultsEleven nurse volunteers were recruited. An audiogram, questionnaire data, salivary amylase, and heart rate were collected in a quiet room. Each nurse was observed for a 3-hr period during patient care. Heart rate and sound level were recorded continuously; saliva samples and stress/annoyance ratings were collected every 30 mins. Variables assessed as potential confounders were years of nursing experience, caffeine intake, patients’ Pediatric Risk of Mortality Score, shift assignment, and room assignment. Data were analyzed by random effects multiple linear regression using Stata 6.0. The average daytime sound level was 61 dB(A), nighttime 59 dB(A). Higher average sound levels significantly predicted higher heart rates (p= .014). Other significant predictors of tachycardia were higher caffeine intake, less nursing experience, and daytime shift. Ninety percent of the variability in heart rate was explained by the regression equation. Amylase measurements showed a large variability and were not significantly affected by noise levels. Higher average sound levels were also predictive of greater subjective stress (p= .021) and annoyance (p= .016).ConclusionsIn this small study, noise was shown to correlate with several measures of stress including tachycardia and annoyance ratings. Further studies of interventions to reduce noise are essential.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThis study was performed to quantify the quality benefits and staff perceptions of a computerized clinical information system implementation in an intensive care unit. Although clinical information systems have been available and implemented in many intensive care units for more than a decade, there is little objective evidence of their impact on the quality of care and staff perceptions.DesignA longitudinal observational study before and after clinical information system implementation.SettingA 12-bed adult general intensive care unit in a large Australian tertiary referral teaching hospital.InterventionImplementation of a fully featured clinical information system to replace paper-based charts of patient observations, clinical records, results reporting, and drug prescribing.Measurements and Main ResultsThe frequency of clinical adverse events over a 4-yr period using an established reporting system was examined. Pre- and postimplementation staff questionnaires were distributed and analyzed. There were significant reductions in the rates of medication, intravenous therapy, and ventilator incidents. There was a trend toward a reduction in pressure sores. The survey, utilizing a validated questionnaire, demonstrated a positive perception of the clinical information system by nursing staff, with less time spent in documentation and more time in patient care. Nursing staff recruitment and retention improved after clinical information system implementation.ConclusionsImplementation of a fully featured clinical information system was associated with significant improvements in key quality indicators, positive nursing staff perceptions, and some positive resource implications.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundAcute mediastinitis is a serious complication; it occurs after esophageal perforation and thoracic surgery and is rarely due to infections. Clinical and computed tomographic scan signs may be nonspecific, especially in postoperative patients.DesignWe prospectively evaluated the value of transesophageal endosonography with guided fine-needle aspiration in the diagnosis and identification of etiologic agents in critically ill patients with suspected posterior mediastinitis.SettingUniversity hospital.Patients and MethodsTransesophageal endosonography/fine-needle aspiration was performed at the bedside in the intensive care unit with a Pentax 34UX echo-endoscope and a portable Hitachi console (EUB 525). Eighteen patients with clinically suspected mediastinitis were examined with intensive care team support.ResultsComputed tomography was performed before transesophageal endosonography in all 18 patients and was inconclusive in 9. Transesophageal endosonography detected mediastinal lesions in 16 (89%) of 18 patients and was more accurately diagnostic than computed tomography (p= .0082). Fifteen patients had undergone surgery (11 esophagectomy, 1 other esophageal surgery, 1 head/neck cancer surgery, 1 complication after dilatational tracheostomy, and 1 with intervention after polytrauma). Three patients were suspected to have nonpostoperative mediastinitis. In 16 patients, infectious organisms were detected (bacterial, n = 14; fungal, n = 1; tuberculosis, n = 1). Culture and sensitivity of transesophageal endosonography/fine-needle aspiration specimens led to appropriate drug therapy. In two patients, methicillin-resistantStaphylococcus aureuswas detected, leading to isolation care. Twelve patients improved; six died. Of the two patients in whom transesophageal endosonography did not detect a mediastinitis, one was false negative on autopsy. There were no complications.ConclusionBedside transesophageal endosonography/fine-needle aspiration of posterior mediastinal lesions in critically ill patients was an effective and relatively noninvasive way to detect mediastinitis and provide material to identify the etiologic agent. It was particularly useful in postesophagectomy patients.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID