摘要:

ObjectiveDetermine variables in the acute care period associated with survival and pediatric intensive care unit (PICU) length of stay (LOS) for children with severe traumatic brain injury.DesignRetrospective cohort.SettingLevel 1 pediatric trauma center.PatientsChildren (0–17 yrs) admitted 1991 to 1995 with nonpenetrating traumatic brain injury and admission Glasgow Coma Scale score of ≤8.InterventionsNone.Measurements and Main ResultsThe first 72 hrs of hospitalization were analyzed in detail for 136 patients. The primary end point was survival; secondary end points were PICU LOS, cost, and day at which Glasgow Coma Scale score was ≥14. Predictors of outcome were abstracted, including Pediatric Trauma Score, Glasgow Coma Scale score, Pediatric Risk of Mortality, physiologic variables, computed tomography evidence of brain injury, and neuroresuscitative medications. The fatality rate was 24%. Age and gender were similar between groups (p≥ .1). Survival was independently predicted by 6-hr Glasgow Coma Scale score (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.06–11.9;p< .001) and maximum systolic blood pressure (OR 1.05; 95% CI 1.01–1.09;p< .02). Odds of survival increased 19-fold when maximum systolic blood pressure was ≥135 mm Hg (OR 18.8; 95% CI 2.0–178.0;p< .01). By discharge, 67% of patients had an age-appropriate Glasgow Coma Scale score. Median hospital costs were $8,798 for survivors: only mannitol use independently predicted high cost (odds ratio 4.9; 95% CI 1.2–19.1;p< .01). For survivors, median PICU LOS was 2 days, although 25% had LOS >6 days. Six-hour Glasgow Coma Scale score (OR 0.62; 95% CI 0.48–0.80;p< .001) and mannitol (OR 7.9; 95% CI 2.3–27.3;p< .001) were each independently associated with a prolonged LOS among survivors.ConclusionsPatients with higher 6-hr Glasgow Coma Scale scores were more likely to survive. Adjusting for severity of injury, survival was associated with maximum systolic blood pressure ≥135 mm Hg, suggesting that supranormal blood pressures are associated with improved outcome. Mannitol administration was associated with prolonged LOS, yet conferred no survival advantage. We suggest reevaluation of blood pressure targets and mannitol use in children with severe traumatic brain injury.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo assess the occurrence of active human cytomegalovirus (HCMV) infection and HCMV disease and to evaluate potential risk factors in immunocompetent intensive care patients after major surgery or trauma.DesignA prospective clinical study.SettingAn anesthesiological intensive care unit (ICU) in a university hospital.PatientsFifty-six anti-HCMV immunoglobulin G (IgG) seropositive patients without manifest immunodeficiency whose simplified acute physiology score (SAPS II) value rose to ≥41 points during their ICU stay.InterventionsOnce a week, the patients were examined for active HCMV infection by polymerase chain reaction and by viral cultures from blood and lower respiratory tract secretions. Three times a week, detailed clinical examination for signs of HCMV disease was carried out.Measurements and Main ResultsTwenty of the 56 ICU patients (35.6%) who met the study criteria of a SAPS II score >40 points and anti-HCMV IgG seropositivity developed an active HCMV infection as diagnosed by the detection of HCMV DNA in leukocytes, plasma, or respiratory tract secretions. In seven patients, the virus was isolated in the respiratory tract secretions. Severe HCMV disease appeared in two patients with pneumonia or encephalitis respectively. In patients with active HCMV infection, the mortality tended to be higher (55%) than in those without (36%); the duration of intensive care treatment of the survivors was significantly longer in the patients with active HCMV infection (median 30 vs. 23 days;p= .0375). Univariate testing for factors associated with active HCMV infection showed the importance of sepsis at admission (p= .011) and prolonged pretreatment on the ward or in an external ICU (p= .002); the relevance of underlying malignant disease was borderline (p= .059). Multiple regression analysis identified only sepsis to be independently associated with active HCMV infection (p= .02; odds ratio, 4.62).ConclusionsEven in a group of ICU patients without manifest immunodeficit who were anti-HCMV IgG seropositive and had reached a SAPS II score of ≥41 points, active HCMV infection occurred frequently (35.6%). Septic patients were affected twice as often as the total study population. In 2 of the 20 cases, active HCMV infection progressed to severe HCMV disease. Proper diagnosis demands special clinical attention combined with extended virological examinations. Further studies in a larger patient group should evaluate the influence of HCMV on ICU mortality.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo describe the clinical characteristics and outcomes of patients with acquired immunodeficiency syndrome (AIDS) admitted to the intensive care unit (ICU).DesignAn observational cohort study with retrospective chart review.SettingICU of an urban university medical center.PatientsConsecutive ICU admissions of patients with AIDS at an urban university medical center between December 1993 and June 1996.InterventionsNone.Measurements and Main ResultsFor each patient, we recorded ICU admission diagnosis, clinical characteristics, and outcome. Among 129 ICU admissions of patients with AIDS, 102 (79%) were admitted for infections, of which (45%) had infections caused by bacteria.Pseudomonas aeruginosa,Staphylococcus aureus, and other enteric pathogens were the most frequent isolates. Pneumonia accounted for 65% of 102 admissions for infections. Overall hospital mortality was 54%, but mortality was higher (68%) for patients with bacterial sepsis. Neutropenia was associated with differences in unadjusted survival rates, whereas CD4 counts were not. Independent predictors of hospital mortality included increasing acute physiology scores and severity of sepsis.ConclusionsIn our ICU, among patients with AIDS, sepsis resulting from bacterial infection is now a more frequent cause of admission thanPneumocystis cariniipneumonia. Severity of illness and the presence of severe sepsis were the clinical predictors most associated with increased mortality. Patients who are not receiving or responding to highly active antiretroviral therapy may become as likely to be admitted to an ICU with a treatable bacterial infection as with classic opportunistic infections. Therefore, broad-spectrum empirical antibacterial therapy is particularly important when the etiology of infection is uncertain.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectivesTo determine whether the genotype frequencies of the five bi-allelic polymorphisms in the bactericidal/permeability increasing protein (BPI) (Lys216→ Glu;PstI polymorphism in intron 5; silent mutation G545→ C) and the lipopolysaccharide binding protein (LBP) (Cys98→ Gly; Pro436→ Leu) are associated with the incidence and lethality of sepsis.DesignCase control study of patients with sepsis.SettingIntensive care units within university hospitals.PatientsA total of 204 patients diagnosed with sepsis and 250 healthy blood donors.InterventionsNone.Measurements and Main ResultsShort DNA fragments containing the polymorphic sites of the LBP and BPI locus were amplified by the polymerase chain reaction or mismatched polymerase chain reaction. The individual polymorphisms were determined with the appropriate restriction enzyme digestions and subsequent agarose gel electrophoresis. The presence of LBP genotypes with the less frequent Gly98allele was found to be associated with sepsis (p< .02) in male patients, but not in females. Patients which were homozygote for either of the rare Gly98(n = 6) and/or Leu436(n = 5) LBP alleles, furthermore, exclusively were nonsurvivors of sepsis. The genotype frequencies in the BPI gene did not differ between patients and control individuals.ConclusionsOur findings suggest that common polymorphisms in the gene for LBP in combination with male gender are associated with an increased risk for the development of sepsis and, furthermore, may be linked to an unfavorable outcome. These data support the important immunomodulatory role of LBP in Gram-negative sepsis and suggest that genetic testing may be helpful for the identification of patients with an unfavorable response to Gram-negative infection.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo assess the possibility that acute respiratory distress syndrome (ARDS) of pulmonary and nonpulmonary origins represent two distinct syndromes.DesignAnalysis of data collected prospectively from an inception cohort of 117 patients with ARDS.SettingAdult intensive care unit (ICU), university/postgraduate hospital.Measurements and Main ResultsDifferences were sought in mortality and 6-month functional outcome between patients developing ARDS due to pulmonary (group 1) and nonpulmonary (group 2) pathology. Group 1 patients displayed a trend toward increased ICU and in-hospital mortality (42.1% vs. 23.2%,p= .10, and 47.4% vs. 27.9%,p= .11, respectively). No difference was found in ICU length of stay (46.3 ± 4.9 vs. 39.0 ± 4.8 days for groups 1 and 2, respectively) nor in duration of positive-pressure ventilation (26.2 ± 4.3 vs. 20.6 ± 3.2 days). However, the need for pressure-controlled inverse ratio ventilation was significantly greater in group 1 (16.9 ± 3.2 vs. 9.1 ± 1.3 days;p= .033). In survivors, reductions in total lung capacity at 6 months (68.1 ± 4.6 vs. 61.8 ± 4.6% predicted for groups 1 and 2, respectively;p= .4), accessible lung volume (74.4 ± 4.4 vs. 68.9 ± 4.9% predicted;p= .56), and forced expiratory volume (77.8 ± 2.9 vs. 80.3 ± 2.4% predicted;p= .57) did not differ between groups. Gas transfer coefficient was well preserved (84.5 ± 4.6 vs. 86.6 ± 4.7% predicted;p= .80).ConclusionsThese data suggest a trend toward higher mortality and ventilatory requirements in ARDS of direct etiology, generating a hypothesis worthy of further exploration.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveThe development of organ dysfunction is the principal determinant of outcome in acute pancreatitis and is mediated through a systemic inflammatory response characterized by leukocyte and endothelial cell activation. Up-regulation of the endothelial cell adhesion molecules, E-selectin and P-selectin, is important for endothelial/leukocyte interactions. Levels of serum-soluble E-selectin and P-selectin have been suggested as markers of endothelial activation. This study examines the kinetics of serum-soluble selectins in patients with acute pancreatitis complicated by organ dysfunction.DesignProspective observational study.SettingUniversity teaching hospital with a specialist hepato-pancreatico-biliary service.PatientsEighteen patients with acute pancreatitis were studied, nine of whom had organ dysfunction.Measurements and Main ResultsSerial venous blood samples were collected on the first 3 days after admission for measurement of soluble E-selectin and P-selectin by enzyme-linked immunosorbent assay. In all patients, soluble P-selectin concentrations decreased significantly during the study period. Nonsurvivors had significantly higher levels of soluble P-selectin than survivors. In contrast, soluble E-selectin increased significantly during the study period in patients with organ dysfunction, whereas it remained constant in patients without evidence of organ dysfunction.ConclusionsThese results suggest a role for endothelial-derived selectins in the development of organ dysfunction in patients with acute pancreatitis. The observed temporal differences in serum selectin concentrations is in keeping within vitroobservations of endothelial selectin expression.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo examine prospectively the relationship between memories of intensive care (ICU) and levels of anxiety after ICU discharge, the stability of these memories with time, and their relationship to the development of acute posttraumatic stress disorder (PTSD)-related symptoms.DesignCase series cohort assessed by interview at 2 and 8 wks after ICU discharge.SettingDistrict general hospital (serving a population of 350,000) general intensive care unit.PatientsMemories of ICU and anxiety levels were studied in 45 patients after ICU discharge. Thirty patients were examined again at 8 wks to assess memory stability and development of acute PTSD-related symptoms.Measurements and Main ResultsStandardized interviews and questionnaires were used to assess memory for ICU, anxiety, and depression 2 wks after ICU discharge. In addition, PTSD-related symptoms and panic were assessed 8 wks after ICU discharge. A total of 33 of 45 patients had delusional memories from ICU at 2 wks; nine of the patients with delusional memories had no factual memories, and these patients had higher anxiety levels 2 wks after ICU discharge (p< .0001). Thirty patients had paired assessments at 2 and 8 wks. Those patients who had no factual recall of ICU but had delusional memories at 2 wks scored highly for PTSD-related symptoms and panic attacks at 8 wks (p= .023 and .014, respectively). The only predictors of possible acute PTSD-related symptoms at the 8-wk assessment were trait anxiety (p= .006) and having delusional memories without recall of factual events in the ICU at 2 wks (p< .0001). Only delusional memories were retained over time, whereas the recall of factual events in the ICU declined.ConclusionsWe propose that the development of acute PTSD-related symptoms may be related more to recall of delusions alone. This study suggests that even relatively unpleasant memories for real events during critical illness may give some protection from anxiety and the later development of PTSD-related symptoms when memories of delusions are prominent.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo examine the effects of adrenergic stimulation on hepatosplanchnic perfusion, oxygen extraction, and tumor necrosis factor-&agr; production during endotoxic shock.DesignIn vivo, prospective, randomized, controlled, repeated-measures, experimental study.SettingExperimental physiology laboratory in a university teaching hospital.SubjectsTwenty-one anesthetized and mechanically ventilated dogs.InterventionsAn intrapericardial catheter was positioned. Catheters for blood sampling were inserted into the right femoral artery, hepatic vein, portal vein, and pulmonary artery. Ultrasonic flow probes were placed around the portal vein, the hepatic artery, the mesenteric artery, the left renal artery, and the left femoral artery. Animals received 2 mg/kg ofEscherichia coliendotoxin, followed by fluid resuscitation. Seven dogs received intravenous isoproterenol (0.1 &mgr;g/kg·min-1), seven received phenylephrine (1 &mgr;g/kg·min-1), and seven served as controls. Thirty minutes later, cardiac tamponade was introduced to study organ perfusion and tissue oxygen extraction capabilities.Main ResultsThe isoproterenol group had a higher cardiac index and stroke index and lower systemic vascular resistance than the other groups. The phenylephrine group had a higher arterial pressure but a lower cardiac index than the isoproterenol group. The isoproterenol group had a higher hepatic artery blood flow than the other groups and a higher portal and mesenteric flow than the control group. Liver and gut mucosal blood flow was greater in the isoproterenol than in the phenylephrine group. The isoproterenol group had a lower global critical oxygen delivery than the other groups (8.8 ± 1.3 vs. 13.1 ± 2.0 (control) and 11.8 ± 3.3 mL/kg·min-1(phenylephrine); bothp< .05) and a higher liver critical oxygen extraction ratio than the control group. Isoproterenol tended to attenuate, but phenylephrine significantly increased, blood tumor necrosis factor levels.ConclusionsDuring endotoxic shock, &bgr;-stimulation can improve hepatosplanchnic perfusion and enhance tissue oxygen extraction capabilities, whereas &agr;-stimulation does not. In addition, &agr;-adrenergic stimulation can increase tumor necrosis factor levels.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID