ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate in Gram-negative sepsis patients the human monoclonal immunoglobulin M antibody (MAB-T88) directed at the enterobacterial common antigen which is a specific surface antigen closely linked to lipopolysaccharide and shared by all members of the Enterobacteriaceae family of Gram-negative bacteria.DesignProspective, randomized, double-blinded, placebo-controlled, multicenter trial.SettingThirty-three academic medical centers in the United States.PatientsPatients were entered with a clinical diagnosis of sepsis, the presence of either shock or multiple organ dysfunction, and presumptive evidence for Gram-negative infection.InterventionsPatients received a single intravenous infusion, over 30 mins, of either 300 mg of MAB-T88 formulated in albumin, or placebo (albumin).Measurements and Main ResultsThe primary analysis group was prospectively identified as those patients with documented evidence of an infection with bacteria of the family Enterobacteriaceae at any site. The primary end point was survival within the first 28 days. A total of 826 patients were enrolled with 55% (n = 455) in the primary analysis group. There were no significant differences between the intervention and control primary analysis group study groups for sites of infection, severity of illness, underlying medical conditions, adequacy of antibiotic or surgical treatment, or other baseline variables except for a higher frequency of chronic renal failure in the MAB-T88 group (4.4% vs. 1.3%,p= .051). The average Acute Physiology and Chronic Health Evaluation II scores were 26.8 ± 8.6 (mean ± sd) in the MAB-T88-treated group and 26.5 ± 8.3 in the placebo-treated group (p= .72). There was no significant difference between MAB-T88- and placebo-treated groups during the first 28-day all-cause mortality in the primary analysis group (34.2% vs. 30.8%,p= .44) or in all 826 patients enrolled (37.0% vs. 34.0%,p= .36). On subset analysis, the use of MAB-T88 was not associated with significant mortality trends. More adverse events were seen with the use of MAB-T88 in the bacteremic enterobacterial common antigen group (p< .05).ConclusionsUse of the human monoclonal antibody, MAB-T88, did not improve the mortality in patients with presumed Gram-negative sepsis or in those patients with proven enterobacterial common antigen infections. No subset trends were identified that would support further investigation of this agent in sepsis.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveSix to 25 percent of patients discharged alive from the intensive care unit (ICU) die before hospital discharge. Although this post-ICU mortality may indicate premature discharge from a full ICU or suboptimal management in the ICU or ward, another factor may be discharge from the ICU as part of a decision to limit treatment of hopelessly ill patients. We investigated determinants of post-ICU mortality, with special attention to this factor.DesignProspective, multicenter, database study.SettingSeven ICUs in or near Paris, France.PatientsA total of 1,385 patients who were discharged alive from an ICU after a stay of ≥48 hrs; 150 (10.8%) died before hospital discharge. Decisions to withhold or withdraw life-sustaining treatments were implemented in the ICUs in 80 patients, including 47 (58.7%) who died before hospital discharge.InterventionsNone.Measurements and Main ResultsIn the univariate analysis, post-ICU mortality was associated with advanced age, poor chronic health status, severe comorbidities, severity and organ failure scores (Simplified Acute Physiology Score II, sepsis-related organ failure assessment, and Logistic Organ Dysfunction at admission and at ICU discharge), decisions to withhold or withdraw life-sustaining treatments, and Omega score (reflecting ICU resource utilization and length of ICU stay). Multivariate stepwise logistic regression identified five independent determinants of post-ICU mortality: McCabe class 1 (odds ratio, 0.388 [95% confidence interval, 0.26–0.58]), transfer from a ward (odds ratio, 1.89 [95% confidence interval, 1.27–2.80]), Simplified Acute Physiology Score II score at admission >36 (odds ratio, 1.57 [95% confidence interval, 1.6–2.33]), decisions to withhold or withdraw life-sustaining treatments (odds ratio, 9.64 [95% confidence interval, 5.75–16.6]), and worse sepsis-related organ failure assessment score at discharge (odds ratio, 1.11 [95% confidence interval, 1.03–1.18] per point).ConclusionsMore than 10% of ICU survivors died before hospital discharge. Determinants of post-ICU mortality included variables reflecting patient status before and during the ICU stay. However, the most powerful predictor of post-ICU mortality was the decision to withhold or withdraw life-sustaining treatments in the ICU, suggesting that the decision has been made not to use the unique services of the ICU for these patients.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo describe a real-time, continuous physiologic data acquisition system for the study of disease dynamics in the intensive care unit.DesignDescriptive report.SettingA 16-bed pediatric intensive care unit in a tertiary care children’s hospital.PatientsA total of 170 critically ill or injured pediatric patients.InterventionsNone.Main Outcome MeasuresNone.ResultsWe describe a computerized data acquisition and analysis system for the study of critical illness and injury from the perspective of complex dynamic systems. Both parametric (1 Hz) and waveform (125–500 Hz) signals are recorded and analyzed. Waveform data include electrocardiogram, respiration, systemic arterial pressure (invasive and noninvasive), central venous pressure, pulmonary arterial pressure, left and right atrial pressures, intracranial pressure, body temperature, and oxygen saturation. Details of the system components are explained and examples are given from the resultant physiologic database of signal processing algorithms and signal analyses using linear and nonlinear metrics.ConclusionsWe have successfully developed a real-time, continuous physiologic data acquisition system that can capture, store, and archive data from pediatric intensive care unit patients for subsequent time series analysis of dynamic changes in physiologic state. The physiologic signal database generated from this system is available for analysis of dynamic changes caused by critical illness and injury.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivePostoperative hyponatremia is a frequent metabolic disturbance that may cause life-threatening complications. It results from both a positive electrolyte-free water (EFW) balance and an antidiuretic hormone release. During surgery, intracellular solutes may leak out of cells because of an increased membrane permeability leading to increased osmolality, cellular water shift, and redistribution hyponatremia, a concept coined the sick cell syndrome. Because of release of osmotically active solutes, plasma or urinary osmolar gap should increase. Therefore, we tested the hypothesis that postoperative hyponatremia may be related to a translocational mechanism evidenced by a postoperative increase of the osmolar gap rather than to a positive EFW balance.SettingAn anesthesiology department in a 1,200-bed university hospital.DesignA 5-month prospective observational study.SubjectsThirty-three consecutive patients undergoing elective hip arthroplasty under general anesthesia. They were divided into two groups whether the postoperative plasma sodium concentration decrease was ≥2 mmol/L (group 1) or <2 mmol/L (group 2).MeasurementsPlasma sodium concentration ([Na+]p) and plasma osmolality were measured before induction of anesthesia and at skin closure. Osmolality was calculated at the same times. Plasma osmolar gap (OGp) was calculated as the difference between measured and calculated osmolality. Postoperative urinary osmolar gap (OGu) was calculated in the same way. EFW balance was calculated as the ratio of (infused EFW − excreted urinary EFW) to total body water.ResultsIn 33 patients, a significant [Na+]pdecrease of −2.0 was observed. No relationship was demonstrated between EFW balance and perioperative [Na+]pvariation (r= .28;p= .12). A relationship was observed between perioperative OGpvariation and perioperative [Na+]pvariation (r= .74;p< .0001). In the 19 group 1 patients, [Na+]pdecreased by −3.0 mmol/L. EFW balance did not differ between group 1 and group 2 patients. No statistical relationship was observed between EFW balance and perioperative [Na+]pvariation in group 1 (r= .20;p= .40) and in group 2 (r= .43;p= .14). OGpincreased only in group 1 but not in group 2 patients, and postoperative OGuwas greater in group 1 than in group 2 patients. A relationship was observed between perioperative OGpvariation and perioperative [Na+]pvariation in group 1 (r= .53;p= .02) but not in group 2 (r= .32;p= .26).ConclusionHyponatremia after hip arthroplasty may not be related to a positive EFW balance. The postoperative increase of the OGpand the greater postoperative OGuin patients developing postoperative hyponatremia suggest the release of osmotically active solutes leading to cellular water shift from intracellular to extracellular spaces. These data may support the clinical relevance of the sick cell syndrome in the postoperative context.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveAcute renal failure can be treated with continuous renal replacement therapy (CRRT) or intermittent hemodialysis. There is no difference in mortality, although patients treated with CRRT may have a higher rate of renal recovery. Given these considerations, an estimate of the costs by modality may help in choosing the method of dialysis. As such, the objective of this study was to estimate the cost of CRRT and intermittent hemodialysis in the intensive care unit and to explore the impact of renal recovery on subsequent clinical outcomes and costs among survivors.DesignRetrospective cohort study of all patients who developed acute renal failure and required dialysis between April 1, 1996, and March 31, 1999.SettingTwo tertiary care intensive care units in Calgary, Canada.PatientsA total of 261 critically ill patients.InterventionsNone.MeasurementsAll patients were followed to determine in-hospital and subsequent clinical outcomes (survival and frequency of renal recovery). The immediate and potential long-term costs of CRRT and intermittent hemodialysis were measured.Main ResultsThe cost of performing CRRT ranged from Can $3,486 to Can $5,117 per week, depending on the modality and the anticoagulant used, and it was significantly more expensive than intermittent hemodialysis (Can $1,342 per week). Survivors with renal recovery spent significantly fewer days in hospital (11.3 vs. 22.5 days,p< .001) and incurred less healthcare costs ($11,192 vs. $73,273,p< .001) over the year after hospital discharge compared with survivors who remained on dialysis.ConclusionsImmediate cost savings could be achieved by increasing the use of intermittent hemodialysis rather than CRRT for patients with acute renal failure in the intensive care unit. Because of the high cost of ongoing dialysis, CRRT may still be an economically efficient treatment if it improves renal recovery among survivors; further study in this area is required.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveFirst, to assess the pattern of the prediction of intensive care unit patients’ outcome with regard to survival and quality of life by nurses and doctors and, second, to compare these predictions with the quality of life reported by the surviving patients.DesignProspective opinion survey of critical care providers; comparison with follow-up for survival, functional status, and quality of life.SettingSix-bed medical intensive care unit subunit of a 1,000-bed tertiary care, university hospital.PatientsAll patients older than 18 yrs, admitted to the medical intensive care unit for >24 hrs over a 1-yr period (December 1997 to November 1998).InterventionsDaily judgment of eventual futility of medical interventions by nurses and doctors with respect to survival and future quality of life. Telephone interviews with discharged patients for quality of life and functional status 6 months after intensive care unit admission.Measurements and Main ResultsData regarding 521 patients including 1,932 daily judgments by nurses and doctors were analyzed. Disagreement on at least one of the daily judgments by nurses and doctors was found in 21% of all patients and in 63% of the dying patients. The disagreements more frequently concerned quality of life than survival. The higher the Simplified Acute Physiology Score and the longer the intensive care unit stay, the more divergent judgments were observed (p< .001). In surviving and dying patients, nurses gave more pessimistic judgment and considered withdrawal more often than did doctors (p< .001). Patients only rarely indicated bad quality of life (6%) and severe physical disability (2%) 6 months after intensive care unit admission. Compared with patients’ own assessment, neither nurses nor doctors correctly predicted quality of life; false pessimistic and false optimistic appreciation was given.ConclusionsDisagreement between nurses and doctors was frequent with respect to their judgment of futility of medical interventions. Disagreements most often concerned the most severely ill patients. Nurses, being more pessimistic in general, were more often correct than doctors in the judgment of dying patients but proposed treatment withdrawal in some very sick patients who survived. Future quality of life cannot reliably be predicted either by doctors or by nurses.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess the adequacy of empirical antimicrobial therapy prescribed in septic shock patients and to evaluate the relationship between inadequate antimicrobial therapy and 30-day mortality.DesignProspective observational study.SettingMedical-surgical (16-bed) intensive care unit in an urban teaching hospital.PatientsA total of 107 patients requiring intensive care admission were prospectively evaluated during the 3-yr period of the study.InterventionsProspective patient surveillance and data collection and assessment of antimicrobial therapy according to microbiological documentation.Measurements and Main ResultsA source of infection associated with a microbiological documentation was identified in 78 of the 107 patients (72%). Empirical antimicrobial therapy consisted of a pivotal antibiotic (&bgr;-lactam) associated with an aminoglycoside (59 patients) or a fluoroquinolone (21 patients). Vancomycin was added in 14 patients. Sixty-nine of the 78 patients (89%) received an adequate antimicrobial therapy. The mortality rate of patients receiving an adequate antimicrobial therapy was 56%, and seven of the nine patients (78%) receiving an inadequate antimicrobial therapy died (p= .2). Among the 81 patients who were alive on day 3, antimicrobial therapy was modified in agreement to clinical status and microbiological documentation in 80% of cases, with de-escalation in 64% of cases. De-escalation consisted of withdrawing the nonpivotal antibiotic in 42% of patients or switching to a narrow-spectrum &bgr;-lactam antibiotic (22% of cases).ConclusionThe prescription of empirical antimicrobial therapy by a senior physician in agreement with practice guidelines made it possible to achieve a crude rate of 89% of adequate antimicrobial therapy in study patients. Inadequate antimicrobial therapy was associated with a 39% excess of mortality. A de-escalation of the empirical therapy was possible in 64% of patients.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveNoninvasive positive pressure techniques such as continuous and bilevel positive airway pressure avoid intubation and its attendant complications in selected patients with acute respiratory failure. However, mask intolerance remains a common cause for failure of noninvasive ventilatory techniques. The aim of our study was to assess patient tolerance of oronasal vs. nasal mask ventilation in acute respiratory failure.DesignRandomized, controlled trial.SettingEmergency department or intensive care units at a university hospital.PatientsSeventy patients with acute respiratory failure as evidenced by clinical or blood gas criteria.InterventionsPatients randomly received either a disposable nasal or an oronasal mask (Respironics, Pittsburgh, PA) when they met study criteria.Measurements and Main ResultsThirty-five patients were randomized into each arm of the study; most of the patients had acute cardiogenic pulmonary edema (48.6% of the nasal mask group and 42.8% of the facial mask group) or chronic obstructive airway disease (34.3% of the nasal mask group and 31.4% of the facial mask group). Baseline clinical characteristics of the two groups of patients were similar. Heart and respiratory rates and blood gases improved similarly for patients in both mask groups. Rates of intubation were also similar (eight in each group). However, mask intolerance was significantly higher in the nasal than the oronasal mask group (12 vs. 4, respectively,p= .023). Four patients in the nasal (11.4%) and two in the oronasal mask group (5.7%) died later during the hospitalization. The overall success rate tended to be greater in the oronasal (65.7%) than the nasal group (48.6%), but the difference was not statistically significant.ConclusionAlthough both masks performed similarly with regard to improving vital signs and gas exchange and avoiding intubation, the nasal mask was less well tolerated than the oronasal mask in patients with acute respiratory failure.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ContextContrary to tonometer gastric intramucosal pH, there is currently no validated threshold prognostic value for Pco2gap (tonometer gastric mucosal Pco2minus arterial Pco2) in the critically ill patient.ObjectiveTo demonstrate a relationship between Pco2gap and mortality in mechanically ventilated patients.Design and SettingInception cohort study from a 9-month prospective survey of 95 consecutively ventilated critically ill patients in a teaching hospital.PatientsAll the ventilated patients of the intensive care unit were included at their admission.Measurements and Main ResultsGastric Pco2using regional capnometry with air-automated tonometry, arterial gas, lactate, and organ system failure score were measured at admission and after 6, 12, 24, 48, 72, 96, and 120 hrs. For the entire population, the 28-day mortality was 44%. In multivariate analysis, independent predictors of death were organ system failure score (odds ratio, 2.12; 95% confidence interval, 1.02–3.14), 24-hr Pco2gap (odds ratio, 1.57; 95% confidence interval, 1.10–2.24), and 24-hr lactate (odds ratio, 1.48; 95% confidence interval, 1.06–2.05). We found a threshold value of 20 mm Hg for Pco2gap and 2.5 mmol/L for lactate, which was associated with a sensitivity of 0.70 and 0.72, respectively, and a specificity of 0.72 and 0.73, respectively.ConclusionThe Pco2gap is a marker of mortality in ventilated patients in the intensive care unit.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID