摘要:

ObjectiveBaseline patient functional status as assessed by providers is correlated with mortality after intensive care unit (ICU) admission. We wanted to see if patient self-perception of health status before admission to an ICU correlated with functional outcome.DesignProspective survey on a convenience sample.SettingSingle urban university-affiliated Veterans Affairs Medial Center.PatientsOne hundred ninety-nine patients in surgical and medical/coronary ICUs.InterventionsNone.MeasurementsPatient-assessed baseline health status was monitored with the Medical Outcome Survey Short-Form 36 (SF-36), consisting of 36 questions that evaluate eight health status concepts. In addition, baseline functional status (Zubrod scale) was determined and severity of illness (Acute Physiology and Chronic Health Evaluation [APACHE] II) data were collected. Zubrod functional status, which includes mortality, was determined 6 wks and 6 months after ICU admission, and correlation coefficients were calculated.Main ResultsWe found it feasible to collect SF-36 health status data on a 9% sample in this setting. Less than 1% of responses were completed by proxy. The SF-36 data were internally consistent, and several of its scales including general health perception and physical functioning correlated with patient Zubrod functional status (r2= .08, p < .001; r2= .14, p < .001) at 6 wks as did vitality (r2= .04, p < .01), social function (r2= .03, p < .05), and physical role function (r2= .02, p = .053), although to a lesser extent. Similar correlations were also found with 6-month functional status.ConclusionsWe conclude that use of the SF-36 is time efficient in an ICU setting and correlates with 6-wk and 6-month functional outcome. It correlates as well with functional outcome as either the baseline Zubrod functional status or the APACHE II severity of illness measurement. The five-question general health evaluation portion correlated almost as well with outcome as the more extensive 36-item questionnaire. Use of the SF-36 may define patient populations for comparison across hospitals. It may also target individuals with needs for additional posthospitalization care, including rehabilitation services or nursing home placement. (Crit Care Med 1999; 27:1466-1471)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo investigate the relationship between single-frequency bioimpedance at 50 kHz (both total body impedance and segmental impedance) and total body water, measured using tritiated water in the presence of the severe fluid retention seen in multiple organ failure.DesignProspective, controlled study.SettingGeneral intensive care unit.SubjectsTwenty patients with multiple organ failure and 30 normal volunteers, of whom a subgroup of ten had total body water measured.InterventionsNone.Measurements and Main ResultsTotal body water and total and segmental bioimpedance values at 50 kHz were measured using tritiated water and a Holtain body composition analyzer in 20 patients with multiple organ failure and in ten normal volunteers. An additional 20 normal volunteers also had segmental and total body impedance measured. There was no difference in the linear regression lines constructed for the patients and the volunteers, but the SEM in the patients (7.6 L) was four times that seen in the normal subjects (1.9 L). In a further seven patients, the impedance technique overestimated the change in total body water, deduced from acute changes in weight, by between 0% and 46% (median, 12%). In the patients, who were supine, the knee-ankle segment contributed significantly more to total body impedance than it did in the normal volunteers (42.5% vs. 34.4%; p < .001), who were upright and mobile immediately before the measurement.ConclusionsAlthough single-frequency bioimpedance does give an indication of total body water and change in total body water, it is neither precise nor accurate enough to be the sole guide to fluid therapy. The proportion of total impedance contributed by the knee-ankle segment, which contains relatively little water, was significantly greater in the patients than in the controls, probably reflecting better drainage of fluid from the lower limb in the supine position. (Crit Care Med 1999; 27:1472-1477)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo evaluate the safety and efficacy of an intravenous liposomal dispersion of prostaglandin E1as TLC C-53 in the treatment of patients with acute respiratory distress syndrome (ARDS).DesignRandomized, prospective, multicenter, double-blind, placebo-controlled, phase III clinical trial.SettingForty-seven community and university-affiliated hospitals in the United States.PatientsA total of 350 patients with ARDS were enrolled in this clinical trial.InterventionPatients were prospectively randomized in a 1:1 ratio to receive either liposomal prostaglandin E1or placebo. The study drug was infused intravenously for 60 mins every 6 hrs for 7 days starting with a dosage of 0.15 [micro sign]g/kg/hr. The dose was increased every 12 hrs until the maximal dose (3.6 [micro sign]g/kg/hr) was attained or intolerance to further increases developed. Patients received standard aggressive medical/surgical care during the infusion period.Outcome MeasuresThe primary outcome measure was the time it took to wean the patient from the ventilator. Secondary end points included time to improvement of the PaO2/FIO2ratio (defined as first PaO2/FIO2300 mm Hg), day 28 mortality, ventilator dependence at day 8, changes in PaO2/FIO2, incidence of and time to development/resolution of organ failure other than ARDS.ResultsA total of 348 patients could be evaluated for efficacy. The distribution of variables at baseline describing gender, lung injury scores, Acute Physiology and Chronic Health Evaluation II scores, PaO2/FIO2, pulmonary compliance, and time from onset of ARDS or from institution of mechanical ventilation to the first dose of study drug was similar among patients in the liposomal prostaglandin E1(n = 177) and the placebo (n = 171) treatment arms. There was no significant difference in the number of days to the discontinuation of ventilation in the liposomal prostaglandin E1group compared with the placebo group (median number of days to off mechanical ventilation, 16.9 in patients receiving liposomal prostaglandin E1and 19.6 in those administered placebo; p = .94). Similarly, mortality at day 28 was not significantly different in the two groups (day 28 mortality, 57 of 176 (32%) in the liposomal prostaglandin E1group and 50 of 170 (29%) in patients receiving placebo; p = .55). In contrast, treatment with liposomal prostaglandin E1was associated with a significantly shorter time to reach a PaO2/FIO(2300 mm Hg (median number of days to reaching a PaO2/FIO2300 mm Hg: 9.8 days in the liposomal prostaglandin E145.9 [micro sign]g/kg) of liposomal prostaglandin E1(median number of days to discontinuation of ventilation, 10.3 in the liposomal prostaglandin E1group and 16.3 days in patients receiving placebo; p = .05). The overall incidence of serious adverse events was not significantly different in the liposomal prostaglandin E1(40%) or placebo-treated (37%) groups. Drug-related adverse events of all kinds were reported in 69% of the patients receiving liposomal prostaglandin E1compared with 33% of the placebo group, with hypotension and hypoxia (occurring in 52% and 24% of the liposomal prostaglandin E1-treatedpatients, respectively, and 17% and 5% of the placebo-treated patients, respectively) being noted most frequently.ConclusionsIn the intent-to-treat population of patients with ARDS, treatment with liposomal prostaglandin E1accelerated improvement in indexes of oxygenation but did not decrease the duration of mechanical ventilation and did not improve day 28 survival. (Crit Care Med 1999; 27:1478-1485)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectivesTo evaluate the ability of an interdisciplinary data set (recently defined by the Austrian Working Group for the Standardization of a Documentation System for Intensive Care [ASDI]) to assess intensive care units (ICUs) by means of the Simplified Acute Physiology Score II (SAPS II) for the severity of illness and the simplified Therapeutic Intervention Scoring System (TISS-28) for the level of provided care.DesignA prospective, multicentric study.SettingNine adult medical, surgical, and mixed ICUs in Austria.PatientsA total of 1234 patients consecutively admitted to the ICUs.InterventionsCollection of data for the ASDI data set.Measurements and Main ResultsThe overall mean SAPS II score was 33.1 +/- 2.1 points. SAPS II overestimated hospital mortality by predicting mortality of 22.2% +/- 2.9%, whereas observed mortality was only 16.8% +/- 2.2%. The Hosmer-Lemeshow goodness-of-fit test for SAPS II scores showed lacking uniformity of fit (H = 53.78, 8 degrees of freedom; p < .0001). TISS-28 scores were recorded on 8616 days (30.6 +/- 1.5 points). TISS-28 scores were higher in nonsurvivors than in survivors (30.4 +/- 0.9 vs. 25.7 +/- 0.4, respectively; p < .05). No significant correlation between mean TISS-28 per patient per unit on the day of admission and mean predicted hospital mortality (r2= .23; p < .54) or standardized mortality ratio per unit (r2= -.22; p < .56) was found.ConclusionsImplementation of an interdisciplinary data set for ICUs provided data with which to evaluate performance in terms of severity of illness and provided care. The SAPS II did not accurately predict outcomes in Austrian ICUs and must, therefore, be customized for this population. A combination of indicators for both severity of illness and amount of provided care is necessary to evaluate ICU performance. Further data acquisition is needed to customize the SAPS II and to validate the TISS-28. (Crit Care Med 1999; 27:1486-1491)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo assess the safety and potential efficacy of a mechanical ventilation strategy designed to reduce stretch-induced lung injury in acute respiratory distress syndrome.DesignProspective, randomized, controlled clinical trial.SettingEight intensive care units in four teaching hospitals.PatientsFifty-two patients with acute respiratory distress syndrome.Interventions55 cm H2O (7.3 kPa). Small tidal volume patients: tidal volume 5-8 mL/kg ideal body weight, to keep plateau pressure < 30 cm H2O (4.0 kPa).Measurements and Main ResultsMean tidal volumes during the first 5 days in traditional and small tidal volume patients were 10.2 and 7.3 mL/kg, respectively (p < .001), with mean plateau pressure = 30.6 and 24.9 cmH2O (3.3 kPa), respectively (p < .001). There were no significant differences in requirements for positive end-expiratory pressure or FIO2, fluid intakes/outputs, requirements for vasopressors, sedatives, or neuromuscular blocking agents, percentage of patients that achieved unassisted breathing, ventilator days, or mortality.ConclusionsThe reduced tidal volume strategy used in this study was safe. Failure to observe beneficial effects of small tidal volume ventilation treatment in important clinical outcome variables may have occurred because a) the sample size was too small to discern small treatment effects; b) the differences in tidal volumes and plateau pressures were modest; or c) reduced tidal volume ventilation is not beneficial. (Crit Care Med 1999; 27:1492-1498)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo describe the level of sedation for a cohort of mechanically ventilated adult intensive care unit (ICU) patients using validated subjective and objective tools.DesignProspective convenience sample.SettingMultidisciplinary 34-bed ICU at Maine Medical Center, a 599-bed nonuniversity, academic medical center.PatientsSixty-three adult ICU patients were monitored during 64 episodes of ventilatory support.Measurements and Main ResultsPatients were prospectively evaluated by one trained investigator using the revised Sedation-Agitation Scale (SAS) and were simultaneously monitored for 1 to 5 hrs using the Bispectral Index (BIS), a numeric scale from 0 to 100 derived from the electroencephalogram. BIS values were assigned to baseline, stimulated, and average conditions for each patient by a separate investigator blinded to SAS scores. Ventilator settings, medications, and the lung injury severity (LIS) score were also recorded. Sedation levels varied from very deep sedation (SAS score = 1, BIS score = 43) to mild agitation (SAS score = 5, BIS score = 100). Heavily sedated patients (SAS score = 1-2, n = 20) had higher FIO2(0.52 vs. 0.42, p = .008), oxygenation index (9.4 vs. 5.4, p = .03), and LIS scores (1.3 vs. 0.7, p = .004) and lower baseline (66 vs. 78, p = .01), average (66 vs. 81, p < .001), and stimulated (89 vs. 96, p = .016) BIS scores compared with more awake patients. Patients with intermittent neuromuscular blockade use (n = 4) had higher FIO2(0.65 vs. 0.44, p = .006), minute ventilation (14.6 vs. 9.9 L/min, p = .005), positive end-expiratory pressure (7.5 vs. 4.8 cm H2O, p = .05), oxygenation index (15.7 vs. 6.0, p < .001), and LIS scores (3.3 vs. 1.0, p = .036) and were more sedated, with higher suppression ratios (3.5 vs. 0.6, p = .05) and lower SAS scores (1.5 vs. 4, p = .035). The average BIS values correlated well with SAS (r2= .21, p < .001).ConclusionsSAS and BIS work well to describe the depth of sedation for ventilated ICU patients. Deeper sedation and intermittent neuromuscular blockade were used for patients with greater ventilatory requirements and more severe lung disease. The correlation between subjective and objective scales varied in medical, surgical, and trauma patients. Further research with SAS and BIS may facilitate the development of quantitative sedation guidelines for the ICU. (Crit Care Med 1999; 27:1499-1504)

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:

ObjectivesThis study compared 2-mL bolus thermodilution cardiac output measurements with standard 10-mL bolus measurements.DesignCardiac output was measured with the new 2-mL bolus technique and the 10-mL standard thermodilution technique in a perspective series. We describe a system that automatically cools and injects 2-mL boluses of saline into a standard pulmonary artery catheter. It uses a Peltier effect solid-state cooler and pneumatically driven syringe injector to measure cardiac output once per minute.SettingAnimal laboratory.AnimalsEight adult Duroc swine weighing between 38.0 and 57.5 kg.InterventionsOnce each minute, 2 mL of cooled 5% dextrose was injected through the pulmonary catheter. Once every 8 mins, four sequential measurements of cardiac output were made using 10-mL injections.Measurements and Main ResultsA total of 1249 paired waveforms were processed with both a conventional algorithm and with a neural network. For the conventional algorithm, the correlation coefficient was r2= .92 and the SD of the difference was 1.30 L/min. For the neural network, the correlation coefficient was r2= .94 and the SD of the difference was 0.88 L/min. Output filtering improved the results in both cases.ConclusionNeural networks accurately derive cardiac output from 2-mL bolus thermodilution injections, allowing cardiac output to be monitored automatically once per minute in many patients. The technique is convenient and uses standard low-cost catheters. (Crit Care Med 1999; 27:1505-1510)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo study the pathogenesis of the host response during bacterial translocation, a rat model was designed for prolonged follow-up after injury.DesignA prospective, controlled animal study.SettingAnimal laboratory.SubjectsYoung male Wistar rats.InterventionsAntibiotic decontamination of rats was performed 4 days before intragastric inoculation with a selected Escherichia coli strain (1010bacteria/kg of body weight). Two days later, the rats received a lipopolysaccharide injection or not (control group) and were observed for 3 days. They were then killed. A reference group (pair-fed healthy animals) was studied in parallel.Measurements and Main ResultsDuring observations, urinary total nitrogen loss and 3-methylhistidine excretion were determined daily. When the rats were killed, mesenteric lymph nodes (MLNs), spleen, and liver were aseptically removed and cultured. Colonies identified as translocated E. coli were counted in each organ. Intracellular amino acid free pools were measured in extensor digitorum longus and anterior tibialis. Endotoxin induces bacterial translocation of bacteria from gut lumen to MLNs (100% vs. 59% in the lipopolysaccharide-untreated control group; p < .05) and dissemination to spleen and liver (65% and 45% of positive cultures after endotoxemia, respectively, vs. 6% and 12% in the control groups). No translocation occurred in the reference group. Evidence for the hypermetabolic response was seen in lipopolysaccharide-treated and infected rats, but protein catabolism was more closely related to the occurrence of bacterial dissemination to spleen and liver than to translocation alone (e.g., the cumulative 3-methylhistidine excretion during the observation period was 4.07 +/- 0.18 [micro sign]mol in uninfected rats, 4.48 +/- 0.29 in rats with positive MLN cultures alone and 6.17 +/- 0.30 in MLN, spleen, or liver infected rats; 1 vs. 2, NS; 3 vs. 1, and 3 vs. 2, p < .05).ConclusionsGut barrier failure is associated with a deep excessive catabolic response in the host. The mechanism by which the metabolic state affects the resistance to infection apparently involves amino acid metabolism. (Crit Care Med 1999; 27:1511-1516)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background and MethodsIn the present study, we tested the hypothesis that peroxynitrite and subsequent activation of the nuclear enzyme poly(ADP-ribose) synthetase (PARS) play a role in the pathogenesis of multiple organ failure induced by peritoneal injection of zymosan in the rat.Animals were randomly divided into six groups (ten rats for each group).The first group was treated with ip administration of saline solution (0.9% NaCl) and served as the sham group. The second group was treated with ip administration of zymosan (500 mg/kg suspended in saline solution). In the third and fourth groups, rats received ip administration of 3-aminobenzamide (10 mg/kg) 1 and 6 hrs after zymosan or saline administration, respectively. In the fifth and sixth groups, rats received ip administration of nicotinamide (50 mg/kg) 1 and 6 hrs after zymosan or saline administration, respectively. After zymosan or saline injection, animals were monitored for 72 hrs to evaluate systemic toxicity (conjunctivitis, ruffled fur, diarrhea, and lethargy), loss of body weight, and mortality.ResultsA severe inflammatory response, characterized by peritoneal exudation, high plasma and peritoneal levels of nitrate/nitrite (the breakdown products of nitric oxide), and leukocyte infiltration into peritoneal exudate, was induced by zymosan administration. This inflammatory process coincided with the damage of lung, small intestine, and liver as assessed by histologic examination and by an increase of myeloperoxidase activity, which is indicative of neutrophil infiltration. Zymosan-treated rats showed signs of systemic illness, significant loss of body weight, and high mortality rates.Peritoneal administration of zymosan in the rat also induced a significant increase in the plasma levels of peroxynitrite as measured by the oxidation of the fluorescent dihydrorhodamine 123.Immunohistochemical examination demonstrated a marked increase in the immunoreactivity to nitrotyrosine, a specific "footprint" of peroxynitrite, in the lung of zymosan-shocked rats. In vivo treatment with ip administration of 3-aminobenzamide (10 mg/kg, 1 and 6 hrs after zymosan injection) or nicotinamide (50 mg/kg, 1 and 6 hrs after zymosan injection) significantly decreased mortality, inhibited the development of peritonitis, and reduced peroxynitrite formation. In addition, PARS inhibitors were effective in preventing the development of organ failure because tissue injury and neutrophil infiltration, by myeloperoxidase evaluation, were reduced in the lung, small intestine, and liver.ConclusionsIn conclusion, the major findings of our study are that peroxynitrite and the consequent PARS activation exert a role in the development of multiple organ failure and that PARS inhibition is an effective anti-inflammatory therapeutic tool.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID