摘要:

ObjectivesTo determine if age, previous functional status, or acute severity of illness affect the acute and long-term mortality rates and functional status of the very elderly (≥85 yrs) after an ICU admission.DesignCohort study (retrospective entry for the first year of the study and prospective entry thereafter with prospective follow-up throughout).SettingAn ICU in a community teaching hospital with follow-up at home or at a skilled nursing facility.PatientsAll (n = 105) patients ≥85 yrs admitted to the ICU over a 2-yr period.Main Outcome MeasuresICU, 30-day post-hospital discharge, and 1-yr mortality rates, activities of daily living scores, organ system failure score at the time of ICU admission.ResultsThe ICU, 30-day posthospital discharge, and the 1-yr mortality rates were 30%, 43%, and 64%, respectively. Mortality rates significantly increased between the ICU stay or 30 days posthospital discharge and 1-yr follow-up periods. Of those patients who lived up to 6 months after hospital discharge, 86% survived to 1 yr with little change in functional status from baseline. In the patients with ≥2 organ system failures, there were 88% 30-day posthospital discharge and 100% 1-yr mortality rates. Severity of illness, as measured by the number of organ system failures, was associated with increased ICU (odds ratio 3.38; 95% confidence interval, 1.51 to 7.60;p< .005) and 1 yr (odds ratio 5.76; 95% confidence interval, 2.49 to 13.29;p< .0001) mortality rates, while age within this group and preadmission functional status were not.ConclusionsWithin the very elderly population, acute severity of illness is the most significant predictor of mortality after an ICU admission. For most very elderly patients, surviving 1 yr after an ICU admission, there is little change in functional status.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectivesTo quantitate insulin losses and glucose absorption during acute continuous hemofiltration with dialysis and to assess the clinical importance of these changes.DesignProspective collection of serum and ultradiafiltrate fluid in patients receiving acute continuous hemofiltration with dialysis. Measurements of serum and ultradiafiltrate insulin and glucose concentrations. Calculations of insulin excretion and glucose absorption. Correlation of findings with patient outcome.SettingUniversity medical center.PatientsSixteen ICU patients with acute renal failure.Measurements and Main ResultsThe mean serum glucose concentration before acute continuous hemofiltration with dialysis was 178 mg/ dL (9.9 mmol/L) (95% confidence interval 112 to 244 mg/dL [6.2 to 13.6 mmol/L]), increasing to 257 mg/dL (14.3 mmol/L) (95% confidence interval 167 to 347 mg/dL [9.3 to 19.3 mmol/L]) after 4 hrs of acute continuous hemofiltration with dialysis, and stabilizing at 207 mg/dL (11.5 mmol/L) (95% confidence interval 160 to 254 mg/dL [8.9 to 14.1 mmol/L]) at 24 hrs. Mean plasma insulin concentration before acute continuous hemofiltration with dialysis was 34.4 mU/L (95% confidence interval 8.6 to 60.2 mU/L), increasing to 54.4 mU/L at 4 hrs (95% confidence interval 25 to 83.8 mU/L; NS). There was no significant decrease in mean insulin concentration across the filter (51.8 mU/L before filtration vs. 51.9 mU/L after filtration). Insulin was detected in the ultradiafiltrate but its overall mean clearance rate was only 6.2 mL/min, with mean daily losses of 689 mU/day (95% confidence interval 325 to 1053 mU/day). During acute continuous hemofiltration with dialysis, glucose absorption through the filter averaged 134 g/day (95% confidence interval 96.2 to 171.8 g/day). Plasma insulin concentrations were significantly (p< .05) lower in survivors than nonsurvivors (51.7 vs. 123.6 mU/L).ConclusionsSignificant glucose absorption occurs during acute continuous hemofiltration with dialysis and is coupled with minor insulin losses (<1 U/day) through the filter. These events do not appear to have major clinical impact. A low plasma insulin concentration is associated with diminished mortality rates in this group of patients.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo determine whether or not the presence of a nasogastric tube causes a change in the bacterial flora in the oropharynx.Study DesignCohort (prospective) design with concurrent control.SettingGeneral Surgical and Ear, Nose, and Throat Units of a tertiary care hospital.PatientsSixteen patients with and 14 patients without a nasogastric tube.InterventionsPatients scheduled to undergo surgery under general anesthesia with endotracheal intubation were eligible for inclusion in the study. From these patients, a study cohort of 16 consecutive patients who were to have nasogastric tube intubation and 14 patients who were not to have nasogastric intubation were enrolled. All patients had a high oropharyngeal swab taken for bacteriologie culture just before surgery. The swab of the oropharynx for culture was repeated after 48 to 72 hrs. The type of organism grown was identified and compared between and within the two groups.ResultsThere was a significant increase in the frequency of colonization of the oropharynx by pathogenic Gram-negative bacteria after 48 to 72 hrs of nasogastric intubation in comparison with the preintubation level (p< .01) as well as in comparison with the group that did not have nasogastric intubation (p< .001). The pathogens included Pseudomonas, Klebsiella, Proteus andEscherichia coli.There was also a tendency for suppression of normal flora. There was no significant change in the flora of the control group of patients who did not have nasogastric intubation. The two groups were comparable with respect to age, gender, severity of underlying illness, and use of prophylactic perioperative antibiotics.ConclusionsThe presence of nasogastric tubes in patients predisposes to colonization by Gram-negative pathogenic bacteria within 48 to 72 hrs.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectivesTo determine the applicability of the Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system in a Swiss ICU, and to evaluate its utility in evaluating data from 2 yrs of consecutive admissions to show that the predictability of outcome is similar to that predictability observed by Knaus et al. in 1985 (in 5,815 patients), with the provision that large numbers of patients are studied.DesignProspective clinical trial over 2 yrs, with statistical analysis of the Swiss patients, and between the Swiss patients and the patients studied by Knaus et al. Receiver operating characteristic curves were calculated.SettingSurgical ICU in a Swiss university hospital.PatientsA total of 2,061 consecutive patients admitted to the surgical ICU who were classified as postoperative (elective or emergency) and nonoperative. Hospital mortality rate was considered.ResultsPatients were 53 ± 16 yrs of age. Mean APACHE II score was 10.5 ± 7.0. The mean APACHE H score was significantly (p< .001) lower in the 1,813 survivors (9.0 ± 5.2) than in the 248 nonsurvivors (21.5 ± 8.5). The mortality rate was higher among the Swiss patients when compared with the patients studied by Knaus et al. who had postoperative scores of 20 to 29 and nonoperative scores of >24. The distribution of the scores and mortality rates were stable during the two study periods, as were the differences in mortality rates between the Swiss population and that population studied by Knaus et al. Sensitivity and specificity of the scores were highest in the emergency surgery group (87% and 78%), and lowest in the elective surgery group (76% and 73%). The APACHE equation underestimated the risk of death.ConclusionsThe APACHE n score, because of its consistency over time and the stability of the mortality rates, can be used in our surgical ICU without modification. The calculated risk of death gives no additional information. (Crit Care Med 1992; 20:1681–1687)

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectivesTo determine the interobserver reliability of residents and nurses collecting Acute Physiology and Chronic Health Evaluation (APACHE H) data and the subsequent effect of these data collections on individual patient mortality prediction.DesignIn a prospective study, residents and nurses independently collected data to derive APACHE H scores. When their scores differed, a standard score was determined by one of the investigators.SettingA general medical and surgical ICU.PatientsA total of 120 consecutive patients were included; of these patients, 79 had standard scores determined because resident and nurse scores differed.Main ResultsThere was overall agreement between the residents and nurses with no significant difference between mean APACHE II scores or mean predicted mortality rates. Intraclass correlation coefficients confirmed good overall agreement between observer groups for predicted mortality rate: resident vs. nurse r2= .94, resident vs. standard r2= .94, and nurse vs. standard r2= .90. However, clinically significant lack of agreement was demonstrated in 5% of the patients by the 95% confidence limits of agreement: resident vs. nurse −14 to +14%, resident vs. standard −10 to +14%, and nurse vs. standard −14 to +20%.ConclusionsWhile interobserver variability between resident and nurse data collection has minimal effect on derived predicted mortality rate with large patient groups, significant variability may occur in individual patients. Residents were more accurate data collectors than nurses.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Background and MethodsRats rapidly develop respiratory distress when exposed to 100% oxygen and die within a few days. Autopsy of the lung shows severe histologie damage characteristic of the adult respiratory distress syndrome. The purpose of this study was to evaluate the effects of magnesium sulfate loading in a rat model of acute oxygen toxicity. Thirty-four rats were divided into three groups. Group 1 (n = 18) served as a control (no magnesium therapy), while group 2 (n = 8) and group 3 (n = 8) received varying amounts of magnesium sulfate. All animals were exposed to 100% oxygen for 96 hrs or until death. Lung damage was quantitated by measuring the lung injury score on histologie examination.ResultsAdministering magnesium sulfate in moderate doses at infrequent intervals to rats (group 2) resulted in less severe oxygen-induced lung damage than that which occurred in rats not receiving magnesium (control group). However, the difference was not statistically significant. Rats (group 3) given doses of magnesium sulfate in amount and frequency adequate to maintain a serum magnesium concentration recognized as therapeutic in eclampsia significantly reduced oxygen-induced lung damage.ConclusionHigh-dose magnesium sulfate therapy can reduce lung injury caused by acute oxygen toxicity in rats.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Background and MethodsThis study was undertaken to find out whether translocation of bacteria to the abdominal cavity and endotoxemia in rats with sterile peritonitis could be prevented by selective decontamination of the digestive tract. Sterile peritonitis was caused by the intraperitoneal injection of either 100, 150, 200, or 300 mg of zymosan suspended in paraffin.ResultsThe frequency of infection of the abdominal cavity depended on the dose of zymosan given, ranging from 20% in rats receiving 100 mg to 89% in rats receiving 300 mg of zymosan. In rats not receiving antibiotics for selective decontamination of the digestive tract (the control group), Gram-negative bacilli were isolated from the digestive tract in all rats, and Gram-negative bacilli were isolated from the abdominal cavity in ten of 19 rats. In rats receiving antibiotics for selective decontamination of the digestive tract, Gram-negative bacilli were isolated from the digestive tract in none of the 14 rats, and likewise, Gram-negative bacilli were isolated from the abdominal cavity in none of the 14 rats (p < .005). Moreover, in rats receiving antibiotics for selective decontamination of the digestive tract, endotoxin levels in feces and plasma were significantly lower, as compared with rats not receiving antibiotics for selective decontamination of the digestive tract.ConclusionSelective decontamination of the digestive tract prevents translocation of Gram-negative bacilli to the abdominal cavity, and endotoxemia and mortality in rats with sterile peritonitis.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo evaluate whether current criteria for the diagnosis of brain death fulfill the requirement for the “irreversible cessation of all functions of the entire brain, including the brainstem.”Data SourcesClinical, philosophical, legal, and public policy literature on the subject of brain death.Data Extraction/SynthesisWe advance four arguments to support the view that patients who meet the current clinical criteria for brain death do not necessarily have the irreversible loss of all brain function. First, many clinically brain-dead patients maintain hypothalamic-endocrine function. Second, many maintain cerebral electrical activity. Third, some retain evidence of environmental responsiveness. Fourth, the brain is physiologically defined as the central nervous system, and many clinically brain-dead patients retain central nervous system activity in the form of spinal reflexes. We explore options for resolving these inconsistencies between the conceptual definition and the clinical criteria used to make the diagnosis of brain death.ConclusionsBrain death is a valid conception of death because it signifies the permanent loss of consciousness. Brain death criteria should therefore be based on the diagnosis of the permanent loss of consciousness rather than that of the loss of vegetative brain functions. Revision of our current “whole brain” definition of brain death to a “higher brain” standard should be considered.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveReview of the history and accomplishments of the Society of Critical Care Medicine (SCCM) to determine appropriate directions for the future.Data SourcesHistorical documents of the SCCM,Critical Care Medicine, bioethics and healthcare financing literature, Instant Library of Quotations.Study SelectionIdentified (by the author) material containing specific statements concerning goals and objectives at the time of the founding of the SCCM and at intervals. Material supporting and criticizing predictive indices were identified and bioethical treatises concerning patient autonomy and quality-of-life decisions were chosen.Data ExtractionPresidential addresses of the first three SCCM presidents, material relevant to preservation of life and alleviation of suffering from bioethical and healthcare financing perspectives. Relevant quotations.Data SynthesisInitial goals and objectives were identified. Societal and economic factors changing critical care were analyzed for their effect on current and future SCCM directions and objectives.ConclusionsThe founding members set important goals for critical care and patient care, research, education, and organization. From a perspective of what was foreseeable, these goals have been accomplished to an admirable degree. The SCCM has responded to these goals by providing educational programs and fostering research, especially in its annual meetings and through the publication of guidelines in Critical Care Medicine. The SCCM members would do well to read the first three presidential addresses to experience the eloquence and foresight firsthand, particularly with respect to the founders' spirit, considerations of training, scope of care, humanism, organization and relations within and outside of critical care, integration of care, and development of the scientific process at the bedside. There have been major changes in society since the SCCM was founded: the maturation of the concept of patient's autonomy; recognition of quality-of-life values; healthcare financing; and legal and ethical aspects of care. The critical care profession in general, and the SCCM specifically, should seek to develop effective cost-containment strategies and severity of illness or predictive indices. The SCCM should also educate the professions with respect to ethical issues and provide information directly to the public, especially in the areas of advance directives and withholding and withdrawing care. Through these contributions, the SCCM can assume its proper leadership role within medicine, but, of greater importance, in society. In doing so, societal myths and misunderstandings of the capabilities, futility, role, and limitations of critical care can be corrected. The organization and structure of the SCCM are well developed to accomplish these ends. The SCCM leaders are both able and willing. The objectives seem reasonable and should be attainable.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID