ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo assess the accuracy and validity of Acute Physiology and Chronic Health Evaluation (APACHE) III hospital mortality predictions in an independent sample of U.S. intensive care unit (ICU) admissions.DesignNonrandomized, observational, cohort study.SettingTwo hundred eighty-five ICUs in 161 U.S. hospitals, including 65 members of the Council of Teaching Hospitals and 64 nonteaching hospitals.Patientsor=to400 beds and 1,074 admissions at hospitals with <200 beds.InterventionsNone.Measurements and Main ResultsWe used demographic, clinical, and physiologic information recorded during ICU day 1 and the APACHE III Equation topredict the probability of hospital mortality for each patient. We compared observed and predicted mortality for all admissions and across patient subgroups and assessed predictive accuracy using tests of discrimination and calibration. Aggregate hospital death rate was 12.35% and predicted hospital death rate was 12.27% (p = .541). The model discriminated between survivors and nonsurvivors well (area under receiver operating curve = 0.89). A calibration curve showed that the observed number of hospital deaths was close to the number of deaths predicted by the model, but when tested across deciles of risk, goodness-of-fit (Hosmer-Lemeshow statistic, chi-square = 48.71, 8 degrees of freedom, p < .0001) was not perfect. Observed and predicted hospital mortality rates were not significantly (p < .01) different for 55 (84.6%) of APACHE III's 65 specific ICU admission diagnoses and for 11 (84.6%) of the 13 residual organ system-related categories. The most frequent diagnoses with significant (p < .01) differences between observed and predicted hospital mortality rates included acute myocardial infarction, drug overdose, nonoperative head trauma, and nonoperative multiple trauma.ConclusionsAPACHE III accurately predicted aggregate hospital mortality in an independent sample of U.S. ICU admissions. Further improvements in calibration can be achieved by more precise disease labeling, improved acquisition and weighting of neurologic abnormalities, adjustments that reflect changes in treatment outcomes over time, and a larger national database. (Crit Care Med 1998; 26:1317-1326)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo assess diaphragmatic function in vitro during experimental cerulein-induced acute pancreatitis.DesignProspective, randomized, controlled animal trial.SettingResearch laboratory at a large university medical center.SubjectsTwenty male Sprague-Dawley rats, weighing 180 to 200 g.InterventionsSodium chloride 0.9% or cerulein (5 [micro sign]g/kg/hr) was infused for 6 hrs.Measurements and Main ResultsIsometric force generated during electrical stimulation of costal diaphragmatic strips was measured 6 hrs after the end of infusion. Diaphragmatic strength was assessed at different frequencies (10, 20, 30, 50, and 100 Hz). Endurance index was the time until the force generated during the 30 Hz repetitive stimulation decreased to 50% of the initial value (T50%). Histologic examination of the diaphragm was performed. A decrease averaging 40% in diaphragmatic strength generation was observed for all frequencies of stimulation in the pancreatitis group. Compared with the control group, this decrease was associated with a reduction in T50% (30.9 +/- 12.5 [SD] and 46.4 +/- 10.8 secs in pancreatitis and control, respectively; p < .05). No histologic alteration of the diaphragm was observed.ConclusionsAcute pancreatitis induced marked diaphragmatic dysfunction. Although the precise mechanisms responsible for this alteration are not precisely determined, diaphragmatic dysfunction may play a role in pancreatitis-associated respiratory failure. (Crit Care Med 1998; 26:1327-1331)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine if autopsies performed on patients who die in the medical intensive care unit (ICU) provide clinically important new information.DesignRetrospective review.SettingA 16-bed medical-coronary ICU.PatientsPatients who underwent autopsy during a 1-yr period.InterventionsPre mortem diagnoses were determined from the medical record. Autopsy results were obtained from the final pathology report. A panel of three physicians with certification of added qualifications in critical care medicine reviewed the findings.Measurements and Main ResultsThese questions were asked: a) Is the primary clinical diagnosis confirmed? b) Are the clinical and pathologic causes of death the same? c) Are new active diagnoses revealed? and d) If the new findings had been known before death, would the clinical management have differed?Forty-one autopsies (31% of deaths) were done that showed: a) the same primary clinical diagnosis and post mortem diagnosis in 34 (83%) patients; b) the same clinical and pathologic cause of death in 27 (66%) patients; c) new active diagnoses in 37 (90%) patients; and d) findings that would have changed medical ICU therapy had the findings been known in 11 (27%) patients.ConclusionsAlthough the primary clinical diagnosis was accurate in most cases before death, the cause of death was frequently unknown. Almost all autopsies demonstrated new diagnoses, and knowledge of these new findings would have changed medical ICU therapy in many cases. In the critical care setting, autopsies continue to provide information that could be important for education and quality patient care. (Crit Care Med 1998; 26:1332-1336)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo identify priorities for intensive care unit (ICU) intervention and research.DesignAnalysis of a large intensive care database.SettingTwenty-four ICUs in the North Thames region of the United Kingdom.PatientsAll patients admitted to an ICU between January 1, 1992, and April 31, 1996, on whom data had been entered into the database. Patients who were admitted after cardiac surgery, who had burns, or were <16 yrs of age were excluded from the study, as were data from patients with a previous ICU admission within 6 mos or where ICU or hospital outcome was unknown. Data were excluded from units that had entered <300 patients into the database.InterventionsNone.Measurements and Main Results2 days, and they accounted for nearly 81% of bed days.ConclusionsEarly identification of patients at risk, both before admission and after discharge from the ICU, may allow treatment to decrease mortality. Research and resources may be best directed at patients who die, despite a relatively low predicted mortality. Although these patients are a small percentage of the low-risk admissions, they constitute a large number of ICU deaths. Many patients die after discharge from ICU and this mortality may be decreased by minimizing inappropriate early discharge to the ward, by the provision of high-dependency and step-down units, and by continuing advice and follow-up by the ICU team after the patient has been discharged. Intervention before ICU admission and support of patients after discharge from the ICU should be part of the effort to decrease mortality for ICU patients. Inadequate provision of resources for critically ill patients may result in excess intensive care mortality that is not detected with ICU outcome prediction methods. (Crit Care Med 1998; 26:1337-1345)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo validate a new system of continuous cardiac output monitoring.DesignMulticenter, prospective, nonrandomized clinical study.SettingFour university hospitals.PatientsForty-seven adult intensive care unit patients.InterventionsPulmonary artery catheterization.Measurements and Main Results7.5 L/min) or low (<4.5 L/min) cardiac output values, or duration (72 hrs) of the study.ConclusionsThis continuous cardiac output system provides a reliable estimate of cardiac output for clinical use if applied in conditions similar to this study. The combination of a continuous measure of cardiac output with other continuous physiologic monitoring (arterial and mixed venous oxygen saturation, oxygen consumption, etc.) may provide important information that no single parameter could achieve. (Crit Care Med 1998; 26:1346-1350)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine if a difference exists in the circadian rhythm entrainment between patients with and without intensive care unit (ICU) psychosis.DesignRetrospective chart reviews from 149 consecutive patients admitted to our ICU during the period of January 1993 to August 1993. Twelve patients with a history of mental illness or alcohol or substance abuse were excluded from the study.SettingA 20-bed surgical ICU at a large teaching hospital.PatientsPatients who remained in the ICU for a minimum of 2 days after undergoing thoracic or vascular operations.InterventionsNone.Measurements and Main ResultsHourly temperature and urine output were ascertained from the patient records. The time of temperature and urine output nadir was used as a marker of circadian rhythm. Of the 137 patients included in the study, 17 (12.4%) developed ICU psychosis as defined by standard criteria. The time of temperature nadir was randomly distributed around the clock for each group. Cosinar rhythmometry analysis of temperature data showed a lack of circadian rhythm entrainment in most patients up to the third postoperative day. No statistically significant difference exists in the deviation of such impairment between the groups.ConclusionEither patients who develop ICU psychosis have an increased sensitivity to an alteration of their circadian rhythm, or ICU psychosis develops independent of circadian rhythm abnormalities. (Crit Care Med 1998; 26:1351-1355)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectivesTo determine if oxyhemoglobin saturation in blood samples taken from the superior vena cava or right atrium can be substituted for oxyhemoglobin saturation in blood taken from the proximal pulmonary artery (SvO2) in patients in shock.DesignProspective clinical investigation.SettingMixed surgical/medical intensive care unit in a university hospital.PatientsThirty consecutive patients in severe circulatory shock who required insertion of a pulmonary artery flotation catheter (PAFC) immediately on intensive care unit admission. All patients fulfilled the criteria described below which were established in advance.Measurements and Main ResultsOxyhemoglobin saturation in the superior vena cava, right atrium, and pulmonary artery (SvO2) was measured by cooximetry in consecutive blood samples from each site during initial insertion of the PAFC. The mean standard deviation of values from these sites was similar: 74 +/- 12.5%, 70.6 +/- 13%, and 71.3 +/- 12.7%, respectively. However, when superior vena cava and right atrial oxyhemoglobin saturations and SvO2were compared, the ranges and 95% confidence limits were found to be clinically unacceptable. The ranges were -19.3 to 23.1% and -19.7 to 16.7%, respectively, and the 95% confidence limits were -18.4 to 24.2% and -18.6 to +17.3%, respectively.ConclusionsThese wide range differences and confidence limits would lead to large errors if superior vena cava or right atrial oxyhemoglobin saturations were substituted for true mixed venous blood in oxygen transport or pulmonary venous admixture calculations, or if clinical decision making was based on individual results. In patients in shock in whom clinical decisions may be based on the value of mixed venous oxyhemoglobin, oxyhemoglobin saturation is only reliably measured in samples taken from the pulmonary artery. (Crit Care Med 1998; 26:1356-1360)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID