摘要:

Objectives:Measurement of the time elapsed from the decision to use a pulmonary artery catheter to the onset of the adapted treatment.Design:Prospective study.Setting:Critical care unit of a university hospital.Patients:A total of 104 critically ill patients.Interventions:The time elapsed from the decision to use a pulmonary artery catheter to the onset of the adapted treatment. Five time intervals (availability, preparation, catheterization, data collection, and therapeutic intervals) were individualized according to the times of decision of pulmonary artery catheter insertion, operator's hand washing, venipuncture, postoperative dressing, data collection, and the effective onset of subsequent therapy.Measurements and Main Results:Among 120 used pulmonary artery catheters, seven could not be inserted. The time to use the pulmonary artery catheter was never shorter than 45 mins (median value = 120 mins). For availability, preparation, catheterization, data collection, and therapeutic intervals, the median values were 30, 20, 20, 20, and 10 mins, respectively. The availability and data collection intervals were shortened during the night period and the fourth quarter of the study, respectively.Conclusions:The pulmonary artery catheter use is time consuming. However, the availability and data collection intervals could be shortened.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To describe global hemodynamics and splanchnic perfusion changes in response to acute modifications in PaCO2in hemodynamically stable patients.Design:Prospective, randomized crossover study.Setting:Medical-surgical intensive care unit at a community hospital (400,000 inhabitants).Patients:Ten critically III patients who were sedated, paralyzed, and mechanically ventilated.Interventions:Hypercapnia and hypocapnia were obtained by increasing and reducing instrumental deadspace in random order. After each intervention, patients returned to the basal condition. Each period lasted 80 min: 20 min to achieve stable PaCO2and 60 min for tonometer equilibration. In each period, global hemodynamic variables and tonometric data were collected. The periods were compared using analysis of variance.Measurements and Main Results:Acute hypercapnia (PaCO2from 40 ± 3 to 52 ± 3 torr,p< .05) increased cardiac index (3.43 ± 0.37 vs. 3.97 ± 0.43 mL/min/m2,p< .05), heart rate (95 ± 6 vs. 105 ± 3 beats/min,p< .05), and mean pulmonary artery pressure (21 ± 1 vs. 24 ± 1 mm Hg,p< .05) and reduced systemic vascular resistance (992 ± 98 vs. 813 ± 93 dyne-sec/cm5,p< .05) and oxygen extraction ratio (27 ± 3% vs. 22 ± 2%,p< .05). Standardized intramucosal PCO2increased from 49 ± 2 to 61 ± 3 torr (p< .05) with an associated decrease in calculated intramucosal pH ([pHi] 7.35 ± 0.03 vs. 7.25 ± 0.02,p< .05), but the gastro-arterial PCO2gradient (ΔPCO2) did not change. Acute hypocapnia (PaCO2from 41 ± 3 to 34 ± 3 torr,p< .05; pH 7.41 ± 0.01 to 7.47 ± 0.02,p< .05) induced slight increments in systemic vascular resistance (995 ± 117 vs. 1088 ± 160 dyne·sec/cm5,p< .05) and oxygen extraction ratio (28 ± 2% vs. 30 ± 2%,p< .05). Standardized intramucosal PCO2decreased (50 ± 4 vs. 44 ± 3 torr,p< .05), pHi increased (7.33 ± 0.03 vs. 7.36 ± 0.02;p< .05), but ΔPCO2did not change.Conclusions:In this small group of stable patients, moderate acute variations in PaCO2had a significant effect on global hemodynamics, but splanchnic perfusion, assessed by ΔPCO2, did not change. In these conditions, the use of pHi to evaluate gastric perfusion appears unreliable.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To evaluate a decrease in catheter-related bloodstream infection rate in patients with antiseptic triple-lumen catheters in an intensive care unit.Data Sources:Retrospective review of surveillance records, patient medical records, laboratory and microbiological reports, and antibiotic administration records.Study Selection:Patients admitted to the intensive care unit with triple-lumen catheters.Data Extraction:A subset of one entry per patient was extracted from 2 yrs of primary bloodstream infection surveillance data. Data collection included risk factors, laboratory and microbiological data, and insertion sites and dates of all intravascular catheters present during triple-lumen catheterization.Data Synthesis:The catheter-related bloodstream infection rate was 5.4 and 11.3 per 1000 catheter days in antiseptic and nonantiseptic triple-lumen catheter groups, respectively (p= .06). By multivariate analysis using a Cox Proportional Hazards Model, the antiseptic triple-lumen catheters were associated with a significant reduction in catheter-related bloodstream infection (p= .03). Model expansion to include intrajugular site was significant by a likelihood ratio test [2(log likelihood diff) = 4.26p< .05 χ21]Conclusions:The use of antiseptic triple-lumen catheters may substantially reduce catheter-related bloodstream infections in an intensive care population and may be subsequently associated with a decrease in length of stay.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To evaluate the accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients.Design:Prospective data collection.Setting:Emergency department in a 2,000-bed inner city hospital.Patients:Thirty-eight patients categorized into three groups according to their upper-arm circumference (group I: 18-25 cm; group II: 25.1-33 cm; and group III: 33.1-47.5 cm) were enrolled in the study protocol.Interventions:In each patient, all three cuff sizes (Hewlett-Packard Cuff 40401 B, C, and D) were used to perform an oscillometric blood pressure measurement at least within 3 mins until ten to 20 measurements for each cuff size were achieved. Invasive mean arterial blood pressure measurement was done by cannulation of the contralateral radial artery with direct transduction of the systemic arterial pressure waveform. The corresponding invasive blood pressure value was obtained at the end of each oscillometric measurement.Measurement and Main Results:Overall, 1,494 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 38 patients (group I, n = 5; group II, n = 23; and group III, n = 10) over a total time of 72.3 hrs. Mean arterial blood pressure ranged from 35 to 165 mm Hg. The overall discrepancy between oscillometric and invasive blood pressure measurement was −6.7 ± 9.7 mm Hg (p< .0001), if the recommended cuff size according to the upper-arm circumference was used (539 measurements). Of all the blood pressure measurements, 26.4% (n = 395) had a discrepancy of ≥10 mm Hg and 34.2% (n = 512) exhibited a discrepancy of ≥20 mm Hg. No differences between invasive and noninvasive blood pressure measurements were noted in patients either with or without inotropic support (−6.6 + 7.2 vs. −8.6 + 6.8 mm Hg; not significant).Conclusion:The oscillometric blood pressure measurement significantly underestimates arterial blood pressure and exhibits a high number of measurements out of the clinically acceptable range. The relation between cuff size and upper-arm circumference contributes substantially to the inaccuracy of the oscillometric blood pressure measurement. Therefore, oscillometric blood pressure measurement does not achieve adequate accuracy in critically ill patients.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives:To review the intensive care unit experience of patients with admitted or acquired nosocomial endocarditis (NE) defined according to the Duke criteria.Design:Prospective, cohort study.Setting:University teaching hospital.Patients:We reviewed the records of 22 patients documented with NE during a 6-yr period from 1992 to 1997.Interventions:None.Measurements and Main Results:Twenty-two patients (9 women/13 men) aged 38-83 yrs (mean 65 ± 9 yrs) had a NE (prevalence of 5 per 1,000 admissions). For six patients, NE was the reason for the admission to the intensive care unit. For 17 patients, the time elapsed between admission and diagnosis of NE was 39 ± 25 days. Sixteen patients were predisposed to infection and seven had underlying heart conditions that put them at risk for acute endocarditis: three prosthetic valves, two valvular diseases, and two cardiac pacemakers. In 21 cases (one unknown portal of entry), NE was the consequence of bacteremia related to a medical or surgical procedure: 11 intravascular devices, eight surgical wounds, one tracheal procedure, and one leg ulceration. The bacteriologic agents detected in blood cultures were: staphylococci (n = 17),Streptococcus(n = 2),Pseudomonas aeruginosa(n = 2), andCandida(n = 2). Fourteen patients underwent echocardiography according to cardiac signs (cardiac failure, new cardiac murmur, or embolic event). For the eight remainders, echocardiography was performed systematically because of fever and positive blood cultures. The lesions detected by 21 transthoracic and 17 transesophageal echocardiographs were the following: vegetations (n = 19), myocardial abscesses (n = 5), and valvular perforation (n = 1). On 16 surgical indications, only five patients underwent surgery because the others were in too poor of a condition. The overall mortality was 68% (n = 15) and was directly associated with NE in 36% of cases (n = 8). Seven patients (28%) were discharged 34 days after the diagnosis of endocarditis.Conclusions:NE is a frequent nosocomial infection that occurs late during hospitalization. Persistent fever with positive blood cultures is sufficient symptomology to promptly perform an echocardiogram. The poor prognosis is related to the poor condition of those patients who cannot be referred for surgical treatment.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To evaluate the use of bedside chest radiography and patient outcome before and after implementation of a cardiac surgery critical care pathway that included guidelines for bedside radiography.Design:A cohort observational study.Setting:A university hospital in the midwest.Patients:Three groups, of 100 patients each, undergoing cardiac surgery in 1990, 1991, and 1995.Intervention:Introduction of a critical care pathway.Measurements:Medical records were retrospectively reviewed in three groups of 100 patients each: before the introduction of the critical care pathway; 2 months after introduction of the pathway in 1991; and 4 yrs after introduction in 1995. Data were analyzed to determine operative risk for each group. Subsequent analyses determined bedside radiography use, total length of hospital stay, and patient outcome (mortality rate, complications requiring intervention, and reoperation) during hospitalization and at outpatient follow-up 15-30 days postdischarge.Results:Total length of hospital stay was shorter for the 1995 group (7.6 ± 6.6 days) compared with other groups (prepathway, 11.1 ± 10.3 days; 1991 postpathway, 10.2 ± 9.6 days;p< .05). The mean numbers of radiographs per patient were as follows: prepathway, 5.1; 1991 postpathway, 5.2; and 1995 postpathway, 3.3. The mean number of radiographs in the 1995 group was significantly lower (p= .02). More patients had the proposed number of two bedside radiographs described in the pathway in the 1995 group compared with the other groups (prepathway,p< .0001; the two-month postpathway group,p= .01). Twenty-three malpositioned catheters/tubes were found in the prepathway and 1991 groups compared with 11 in the 1995 group (p= .02). No statistically significant difference was found in inpatient complications (mediastinal bleeding, pneumothoraces, and pleural effusions), postdischarge complications, reoperations, or mortality rate.Conclusion:Introduction of a critical care pathway can decrease the use of bedside radiography without adversely affecting near-term patient outcomes.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To assess the effect on the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III of two different approaches to scoring the Glasgow Coma Scale (GCS) in sedated patients. The first approach was to assume that the GCS score was normal, and the second was to use the GCS value recorded before the patient was sedated.Design:Prospective cohort study over 2 yrs.Setting:Twenty-two general adult intensive care units in Scotland.Patients:13,291 consecutive admissions to the participating intensive care units.Measurements and Main Results:After exclusion of patients according to standard, predefined criteria, the Acute Physiology and Chronic Health Evaluation II and III systems were used to calculate the probability of hospital mortality for patients included in the study. In patients whose GCS scores could not be assessed accurately during the first 24 hrs, the APACHE II and III predictions were calculated twice: first, assuming that the GCS score was normal; and second, substituting the GCS score recorded before sedation. This generated two different databases for each system, and the predictions for both were compared with the observed hospital mortality rate. The effect of the two different approaches to the GCS on the performance of both APACHE II and APACHE III was assessed using measures of discrimination (area under the receiver operating characteristic curve) and goodness of fit (calibration curves and the Hosmer-Lemeshow statistic). Analysis was undertaken for both the entire cohort and for the group of patients whose APACHE scores were altered.There was a wide variation in the number of patients who had their scores altered between participating units. There were also differences between diagnostic groups. Overall, however, 50% of the patients were sedated and 22% had their scores altered. Using the presedation GCS score increased the discrimination of both APACHE II and APACHE III. The calibration of APACHE III was also improved but that of APACHE II deteriorated. The calibration improved, however, in those patients with altered scores, suggesting that the overall deterioration is attributable to other limitations in the fit of the model to these data. Although changes had the greatest effect in patients with a neurologic or trauma diagnosis, the changes were important in most diagnostic groups.Conclusions:The GCS is an important component of both APACHE II and APACHE III. It should be assessed directly whenever possible. When patients are sedated, using the GCS score recorded before sedation is preferable to the assumption of normality. The variations between different units and different diagnostic groups highlight the possible effects of case mix on the performance of prognostic scoring systems.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To determine the patterns of oxygen consumption (&OV0312;O2) using indirect calorimetry (IC) for the first 24 hrs after serious blunt traumatic injury.Design:Prospective, observational study.Setting:Surgical intensive care unit of a Level 1 trauma center.Patients:Sixty-six mechanically ventilated patients with blunt traumatic injury and Injury Severity Score >15.Interventions:IC for 24 hrs postinjury. Patients were resuscitated to standard parameters of perfusion.Measurements and Main Results:Mean patient age was 50.1 ± 18.7 yrs with a mean Injury Severity Score 30.7 ± 11.3). Mean &OV0312;O2for all patients for the 24-hr study period was 168.5 ± 29.5 mL/min/m2. The level of &OV0312;O2was not related to Injury Severity Score, the number or combination of organ systems injured, or to the use of vasoactive agents. Patients >65 yrs of age had significantly lower &OV0312;O2(p= .0038) compared with patients ≤50 yrs. &OV0312;O2did not change over time after resuscitation to normal parameters of perfusion. Mean &OV0312;O2was 156.5 ± 63.2 mL/min/m2in patients who developed multiple organ dysfunction, and 172.4 ± 33.3 mL/min/m2in those who did not develop multiple organ dysfunction (p= .16).Conclusions:Seriously injured patients are hypermetabolic in the early postinjury period. The level of &OV0312;O2is unrelated to injury severity or number of organ systems involved. Elderly patients can be expected to have lower levels of &OV0312;O2. &OV0312;O2does not change significantly in response to resuscitation to normal parameters of perfusion. &OV0312;O2measured by IC did not predict the development of multiple organ dysfunction.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives:We noticed that in some patients after cardiac surgery, when flow triggering was used, cardiogenic oscillation might be autotriggering the ventilatory support. In a prospective study, we evaluated the degree of cardiogenic oscillation and the frequency rate of autotriggering. We suspected that autotriggering caused by cardiogenic oscillation was more common than clinically appreciated.Design:Prospective, nonrandomized, clinical study.Setting:Surgical intensive care unit in a national heart institute.Patients:A total of 104 adult patients were enrolled after cardiac surgery.Interventions:During the study period, patients were paralyzed and ventilated with intermittent mandatory ventilation at a rate of 10 breaths/min, pressure support of 10 cm H2O, and flow triggering with a sensitivity of 1 L/min.Measurements and Main Results:Because the patients would not be able to breathe spontaneously, we counted pressure-support (PS) breaths as instances of autotriggering. Then, we classified the patients into two groups according to the number of PS breaths: an "AT group" (PS breaths of >5/min) and a "non-AT group" (PS breaths of ≤5/min). If autotriggering occurred, we decreased the sensitivity so autotriggering disappeared (threshold triggering sensitivity). The intensity of cardiogenic oscillation was assessed as the flow and airway pressure at the airway opening. A total of 23 patients (22%) demonstrated more than five autotriggered breaths/min. During mechanical ventilation, the inspiratory flow fluctuation caused by cardiogenic oscillation was significantly greater in the AT group than in the non-AT group (4.67 ± 1.26 L/min vs. 2.03 ± 0.86 L/min;p< .01). The AT group also showed larger cardiac output, higher ventricular filling pressures, larger heart size, and lower respiratory system resistance than the non-AT group. As the inspiratory flow fluctuation caused by cardiogenic oscillation increased, the level of triggering sensitivity also was increased to avoid autotriggering. In the AT group with 1 L/min of sensitivity, the respiratory rate increased (19.9 ± 2.7 vs. 10 ± 0 breaths/min,p< .01), PaCO2decreased (30.8 ± 4.0 torr [4.11 ± 0.36 kPa] vs. 37.6 ± 4.3 torr [5.01 ± 0.57 kPa];p< .01), and mean esophageal pressure increased (7.7 ± 3.0 vs. 6.9 ± 3.0 cm H2O;p< .01) compared with the threshold triggering sensitivity.Conclusions:Autotriggering caused by cardiogenic oscillation is common in postcardiac surgery patients when flow triggering is used. Autotriggering occurred more often in patients with more dynamic circulation. Autotriggering caused respiratory alkalosis and hyperinflation of the lungs.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives:To delineate the costs of care of patients with Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure and to compare them with those of other mechanically ventilated patients.Design:Apost hocanalysis of a prospective investigation.Setting:Medical and coronary intensive care units (ICUs) of an 804-bed, university-based hospital.Patients:A total of 300 mechanically ventilated patients, 44 with COPD and 256 others, were included.Measurements and Main Results:Despite similar lengths of ICU stay (9 days) and mechanical ventilation (5.5 days COPD vs. 5 days other,p= .11), ICU respiratory care costs for patients with COPD were $2,422 ($1,157-$6,110) [median U.S. dollars (interquartile range)] vs. $1,580 ($738-$3,322) for the others (p= .01). Ventilator costs for COPD patients were $1,795 ($943-$5,782) vs. $1,574 ($613-$3,112) (p= .12). Total hospitalization respiratory care costs for COPD patients were higher, $4,064 ($2,422-$9,572) vs. $2,342 ($1,186-$4,591), (p= .0001), and 74.4% of the median difference in cost between COPD patients and others was accounted for by spontaneous nebulizers (p= .001), metered dose inhalers (p= .01), and pulse oximetry (p= .02). By using multiple linear regression analyses, we found that COPD remained associated with higher respiratory costs (p< .05). Respiratory Care was the third largest category of hospital costs after beds (27%) and pharmacy expenses (25%), and it comprised ∼14% of total cost. Total hospital costs were large for both groups, but did not differ between COPD and the others [$24,217 ($16,211-$58,834) vs. $27,672 ($15,692-$53,766), respectively (p= .96)]. Linear regression analyses showed that only Acute Lung Injury score was significantly related to total ICU and hospital costs of care (p< .05).Conclusions:Costs of ICU and non-ICU respiratory care for patients with COPD are higher than costs of care for other mechanically ventilated patients. Although the increased cost of bronchodilators and oximetry in these patients may serve as target areas for reductions in respiratory care costs, it may also be true that these modalities of therapy and management are necessary and need to be used with even greater intensity to achieve better outcomes. The predominant contributions of bed and pharmacy costs in all of our patients with respiratory failure support research efforts addressing these aspects of care.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID