摘要:

ObjectiveTo evaluate the efficacy of a commercial immunoglobulin (Ig) A- and IgM-enriched immunoglobulin preparation containing high antibody titers against various human pathogens in the prevention of postoperative infections in anergic patients undergoing cardiac surgery.DesignA single-center, prospective, double-blind, randomized study comparing the effect of a polyvalent intravenous human immunoglobulin (IVIG) preparation vs. placebo.Location of the StudyInstitute of Anesthesiology and Department of Thoracic and Cardiovascular Surgery, University Hospital, Wurzburg, Germany.PatientsA total of 515 patients awaiting elective open-heart surgery with the aid of cardiopulmonary bypass were tested for their in vivo immune response to intradermally administered recall antigens. Forty patients who were preoperatively shown to be anergic in this skin test, and therefore at high risk of developing serious postoperative infections, were selected from this group. Twenty patients with normal immune responses, and thus having a normal risk of infection, were randomly selected from the same patient group to serve as an immunoreactive control group.InterventionsAfter obtaining approval from the local institutional review board and informed consent from patients, the 40 anergic patients were randomized and assigned either to the IVIG group (n = 19), to receive a commercially available human IgA- and IgM-enriched immunoglobulin preparation (dose, 20 g), or to the placebo group (n = 21), to receive physiologic saline. These treatments were started 4 hrs after surgery as a 400-mL continuous infusion over a period of 53 hrs. Patients were observed for the development of postoperative infection for the next 2 wks. Group comparisons were made using repeated-measures analysis of variance and Fisher's exact test. A p value < .05 was considered statistically significant.Measurements and Main ResultsPostoperative infections were detected in nine of 21 patients (43%) in the placebo group but in only one of 19 patients (5%) in the IVIG-treated group (p = .007; Fisher's exact test). Three of the 20 patients (15%) with normal immune response who received standard postoperative treatment developed postoperative infections.ConclusionsA commercially available IgA- and IgM-enriched intravenous immunoglobulin preparation administered immediately after cardiac surgery significantly reduced the incidence of postoperative infections in preoperatively anergic patients. (Crit Care Med;:)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo compare esophageal Doppler ultrasonography with standard hemodynamic variables used in postoperative care for the prediction of postoperative complications after cardiac surgery.DesignProspective, observational pilot study.SettingUniversity hospital, multidisciplinary intensive care unit.PatientsPostoperative cardiac surgical patients.InterventionsStandard postoperative management as guided by routinely measured hemodynamic variables.MeasurementsAn esophageal Doppler ultrasound probe was inserted for measurement of stroke volume (SV), cardiac output (CO), and other flow-related variables. Both these and routine hemodynamic variables (mean arterial pressure, central venous pressure, heart rate, arterial base deficit, urine output, core-toe temperature difference) were recorded at half-hourly intervals for the first 4 postoperative hrs. The incidence of systemic inflammatory response syndrome at 24 hrs, Acute Physiology and Chronic Health Evaluation II, and multiple organ failure scores, postoperative complications, and length of ICU and hospital stays were recorded.Main ResultsTwenty consecutively admitted patients were studied: eight after emergency bypass grafting and 12 after elective bypass grafts and/or valve replacement. Of the nine patients who developed postoperative complications, two died. At admission, significant differences were seen between patients with a complicated and those with an uncomplicated surgical procedure for SV, heart rate, and standard base excess, but not for cardiac output. By using receiver operator characteristic curves, SV was the best marker for predicting postoperative complications during the initial postoperative period.ConclusionsA low SV and a high heart rate, both at ICU admission and during the subsequent 4 hrs, were the best prognostic factors for development of complications after cardiac surgery. Cardiac output values were not useful. This pilot study suggests that the minimally invasive technique of esophageal Doppler ultrasonography may be a useful tool to assist early prognostication. (Crit Care Med 1999; 27:1288-1294)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo obtain accurate values for the components of energy expenditure in critically ill patients with sepsis or trauma during the first 2 wks after admission to the intensive care unit.DesignProspective study.SettingCritical care unit and university department of surgery in a single tertiary care center.PatientsTwelve severely septic (median Acute Physiology and Chronic Health Evaluation II Score, 23; range, 15 to 34) and 12 major trauma patients (median Injury Severity Score, 33.5; range, 26 to 50).InterventionsTotal body fat, total body protein, and total body glycogen were measured as soon as hemodynamic stability had been reached and repeated 5 and 10 days later. Resting energy expenditure (REE) was measured daily by indirect calorimetry.Measurements and Main ResultsChanges in total body fat, total body protein, and total body glycogen in critically ill patients provide data for the accurate construction of an energy balance. Energy intake minus energy balance gives a direct measurement of total energy expenditure (TEE) and, when combined with measurements of REE, activity energy expenditure can be obtained. TEE, REE, and activity energy expenditure were calculated for two sequential 5-day study periods. REE progressively increased during the first week after the onset of severe sepsis or major trauma, peaking during the second week at 37 +/- 6% (SEM) and 60 +/- 13% greater than predicted, respectively. For both the sepsis and trauma patients, TEE was significantly higher during the second week than during the first week (3257 +/- 370 vs. 1927 +/- 370 kcal/day, p < .05, in sepsis; 4123 +/- 518 vs. 2380 +/- 422 kcal/day, p < .05, in trauma). During the first week after admission to the hospital, TEE in sepsis and trauma patients, respectively, averaged 25 +/- 5 and 31 +/- 6 kcal/kg of body weight/day, and during the second week, 47 +/- 6 and 59 +/- 7 kcal/kg/day (p < .03, for comparison of first and second weeks). For the first week, the ratio of TEE to REE was 1.0 +/- 0.2 and 1.1 +/- 0.2 but during the second week rose to 1.7 +/- 0.2 and 1.8 +/- 0.2 in patients with sepsis (p < .05, for comparison of weeks) and trauma (p = .09), respectively.ConclusionsTotal energy expenditure is maximal during the second week after admission to the critical care unit, reaching 50 to 60 kcal/kg/day. (Crit Care Med 1999; 27:1295-1302)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectivesTo describe the time course and prognostic significance of tumor necrosis factor-alpha (TNF-alpha) levels and hemostatic abnormalities in clinical sepsis.DesignProspective, observational study with sequential measurements in an inception cohort.SettingAn emergency department in a university teaching hospital. Patients were followed up until they either left the hospital or died.PatientsDuring a 1-yr period, 43 adult patients were selected from all emergency department patients who met the established criteria for sepsis. Excluded were patients with either organ dysfunction or septic shock at the time of admission.InterventionsNone.Measurements and Main ResultsBlood samples were collected serially (day of admission and on days 3, 5, and 7) to determine TNF-alpha, platelet count, fibrinogen, factor VII, antithrombin III, tissue-type plasminogen activator activity, plasminogen activator inhibitor activity, plasminogen, and alpha 2-antiplasmin. Fibrinopeptide A was measured only on the day of admission. Data were analyzed to determine whether admission values or serially obtained values within 7 days were useful in predicting outcome. Thirteen patients died and 30 survived. On admission, assay values indicated that platelet count and antithrombin III were significantly lower than normal (as observed in 50 healthy adults). Fibrinogen, plasminogen activator inhibitor type 1, tissue-type plasminogen activator, fibrinopeptide A, and TNF-alpha were higher than normal, whereas concentrations of factor VII, plasminogen, and alpha 2-antiplasmin were in the normal range. No differences were detected in the admission values between survivors and nonsurvivors, except for antithrombin III. However, subsequent values of some variables demonstrated a difference between survivors and nonsurvivors. Survivors showed increasing platelet count and antithrombin III values compared with nonsurvivors, in whom the values remained low, with no significant changes during the study period. High TNF-alpha levels were found in both groups, but only survivors experienced progressive decrease during the observation period.ConclusionsEarly clinical sepsis is characterized by high plasma levels of TNF-alpha and by activation of the coagulation and fibrinolysis systems. Longitudinal analysis of some variables (antithrombin III, platelet count, and TNF-alpha) showed some differences with time between the survivor and nonsurvivor groups, but we feel that such differences were not large enough to be predictive in individual patients. (Crit Care Med 1999; 27:1303-1308)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveProinflammatory cytokines such as tumor necrosis factor (TNF)-alpha and interleukin (IL)-1 beta have been implicated in the pathogenesis of myocardial dysfunction in ischemia-reperfusion injury, sepsis, chronic heart failure, viral myocarditis, and cardiac allograft rejection. Although circulating TNF-alpha and IL-1 beta are both often elevated in septic shock, it remains unknown whether TNF-alpha or IL-1 beta are the factors induced during sepsis that directly depress human myocardial function, and if so, whether the combination synergistically depresses myocardial function. Furthermore, the mechanism(s) by which these cytokines induce human myocardial depression remain unknown. We hypothesized the following: a) TNF-alpha and IL-1 beta directly depress human myocardial function; b) together, TNF-alpha and IL-1 beta act synergistically to depress human myocardial function; and c) inhibition of ceramidase or nitric oxide synthase attenuates myocardial depression induced by TNF-alpha or IL-1 beta by limiting proximal cytokine signaling or production of myocardial nitric oxide (NO).DesignProspective, randomized, controlled study.SettingExperimental laboratory in a university hospital.SubjectsFreshly obtained human myocardial trabeculae.InterventionsHuman atrial trabeculae were obtained at the time of cardiac surgery, suspended in organ baths, and field simulated at 1 Hz, and the developed force was recorded. After a 90-min equilibration, TNF-alpha (1.25, 12.5, 125, or 250 pg/mL for 20 mins), IL-1 beta (6.25, 12.5, 50, or 200 pg/mL for 20 mins), or TNF-alpha (1.25 pg/mL) plus IL-1 beta (6.25 pg/mL) were added to the bath, and function was measured for the subsequent 100 mins after the 20-min exposure. To assess the roles of the sphingomyelin and NO pathways in TNF-alpha and IL-1 beta cross-signaling, the ceramidase inhibitor N-oleoyl ethanolamine (1 [micro sign]M) or the NO synthase inhibitor NG-monomethyl-L-arginine(10 [micro sign]M) was added before TNF-alpha (125 pg/mL) or IL-1 beta (50 pg/mL).Measurements and Main Results.05 vs. control) resulted in contractile depression (p < .05 vs. control). Inhibition of myocardial sphingosine or NO release abolished the myocardial depressive effects of either TNF-alpha or IL-1 beta.ConclusionsTNF-alpha and IL-1 beta separately and synergistically depress human myocardial function. Sphingosine likely participates in the TNF-alpha and IL-1 beta signal leading to human myocardial functional depression. Therapeutic strategies to reduce production or signaling of either TNF-alpha or IL-1 beta may limit myocardial dysfunction in sepsis. (Crit Care Med 1999; 27:1309-1318)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectivesTo analyze the utilization of intensive care unit (ICU) days in a Canadian medical-surgical ICU and to identify ICU patients with prolonged ICU length of stay (LOS).DesignProspective descriptive study.SettingA Canadian tertiary care medical-surgical ICU.PatientsConsecutive patients admitted to an adult medical-surgical ICU. Neurosurgical, cardiac surgical, and coronary care unit patients were excluded.Measurementsor=to14 days. Among the four LOS groups, the number of ICU days and observed and predicted death rates were compared. Admissions were also stratified by risk of death into five probability range quintiles. Among the five risk groups, ICU LOS was compared between survivors and nonsurvivors.Results0.8 (predicted to die) or <0.2 (predicted to live) whose outcomes were opposite to that predicted had twice the ICU LOS compared with patients whose outcomes were consistent with prediction.Conclusionor=to14 days accounted for 7.3% of total admissions but consumed 43.5% of total ICU days. Identification of patients with prolonged ICU LOS who would ultimately die in the ICU may lead to earlier withdrawal of therapy in these patients, resulting in a substantial reduction in suffering and cost savings. In our study population, outcome prediction using the APACHE II Equation didnot provide sufficient power to accurately discriminate between nonsurvivors and survivors. (Crit Care Med 1999; 27:1319-1324)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID