摘要:

ObjectiveTo present graphical procedures for prospectively monitoring outcomes in the intensive care unit.DesignObservational study: risk-adjusted control chart analysis of a case series.SettingTertiary referral adult intensive care unit: Princess Alexandra Hospital, Brisbane, Australia.PatientsA total of 3398 intensive care unit admissions from January 1, 1995, to January 1, 1998.ConclusionsRisk-adjusted process control charting procedures for continuous monitoring of intensive care unit outcomes are proposed as quality management tools. A modified Shewhartpchart and cumulative sum process control chart, using the Acute Physiology and Chronic Health Evaluation III model mortality prediction for risk adjustment, are presented. The risk-adjustedpchart summarizes performance at arbitrary intervals and plots observed against predicted mortality rate to detect large changes in risk-adjusted mortality. The risk-adjusted cumulative sum procedure is a likelihood-based scoring method that adjusts for estimated risk of death, accumulating evidence from outcomes of all previous patients. It formally tests the hypothesis of a change in the odds of death. In this application, we detected a decrease from above to predicted risk-adjusted mortality. This was temporally related to increased senior staffing levels and enhanced ongoing multidisciplinary review of practice, quality improvement, and educational activities. Formulas and analyses are provided as appendices.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the clinical benefit of increasing the osmotic load of the hypertonic solution administered for the treatment of refractory intracranial hypertension episodes in patients with severe head injury.DesignProspective, randomized study.SettingsA trauma center in a university hospital.PatientsTwenty consecutive patients with head trauma and persistent coma who required infusions of an osmotic agent to treat episodes of intracranial hypertension resistant to well-conducted standard modes of therapy were studied. Intracranial hypertension was considered refractory when it persisted despite deep sedation, optimal hemodynamic status, and, in some patients, drainage of cerebral spinal fluid.InterventionsPatients were randomly assigned to receive isovolume infusions of either 7.5% hypertonic saline solution (2400 mOsm/kg/H2O) or 20% mannitol (1160 mOsm/kg/H2O). The patients were given 2 mL/kg (body weight) of either solution, i.e., 361 ± 13 mOsm of saline or 175 ± 12 mOsm of mannitol per injection.Measurements and Main ResultsThe main variables studied were the number and the duration of episodes of intracranial hypertension per day during the study period, which was stopped after the last episode of intracranial hypertension was recorded from intracranial pressure monitoring or after the allocated treatment failure. Patients in the HHS group were monitored for 7 ± 5 days and those in the mannitol group for 7 ± 6 days (not significant). The rate of failure for each treatment was also evaluated. Failure was defined as the persistence of intracranial hypertension despite two successive infusions of the same osmotic agent. The mean number of osmotic solute infusions was 3.7 ± 5.3 in the mannitol group and 3.3 ± 4.1 in the hypertonic saline solution group (not significant). The mean number (6.9 ± 5.6 vs. 13.3 ± 14.6 episodes) of intracranial hypertension episodes per day and the daily duration (67 ± 85 vs. 131 ± 123 min) of intracranial hypertension episodes were significantly lower in the hypertonic saline solution group (p< .01). The rate of clinical failure was also significantly lower in the hypertonic saline solution group: 1 of 10 patients vs. 7 of 10 patients (p< .01).ConclusionIn this study, when a hypertonic solute was required for the treatment of refractory intracranial hypertension episodes in patients with severe head trauma, increasing the osmotic load by giving 2 mL/kg (body weight) of 7.5% saline (361 ± 13 mOsm) was more effective than giving 2 mL/kg (body weight) of 20% mannitol (175 ± 12 mOsm). Within the limitations of the present study, these data suggest that giving 2 mL/kg hypertonic saline solution (approximately 480 mOsm/70 kg body weight) is an effective and safe initial treatment for intracranial hypertension episodes in head-trauma patients when osmotherapy is indicated.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the relative rates of microbial colonization of individual lumens in triple-lumen central venous catheters (CVCs) and calculate the chance of detecting catheter-related blood stream infection (CRBSI) if only one lumen is sampled.DesignProspective evaluation of CVCs from suspected and nonsuspected CRBSI cases.SettingUniversity teaching hospital.PatientsTriple-lumen CVCs from 50 cases of suspected CRBSI (a raised peripheral white blood cell count, temperature >37°C, and/or local signs of infection at the catheter skin entry site) were evaluated. For comparison, 50 triple-lumen CVCs routinely removed at the end of use were evaluated.MeasurementsIn both groups, peripheral blood cultures were taken before CVC removal. After CVC removal, each lumen was sampledin vitrousing the endoluminal brush, and the tip was then cultured using the Maki roll technique.Main ResultsCVCs causing CRBSI had significant microbial colonization in one, two, or three lumens in ten (40%), ten (40%), or five (20%) cases, respectively. Overall, random sampling of only one lumen in CVCs causing CRBSI had a 60% chance of detecting significant colonization.ConclusionsIf only one CVC lumen is sampled, a negative result does not reliably rule out infection. Each lumen of multiple-lumen CVCs should be considered as a potential source of CRBSI.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveStudies of genetic associations with common diseases, such as between cytokine gene polymorphisms and severe bacterial sepsis, have reached conflicting conclusions. Failure to follow methodologic standards may have contributed to discordant findings. The −308 G→A transition in the tumor necrosis factor-&agr; promoter has been genotyped by a variety of methods. Based on our observation of genotyping inaccuracies, we sought to determine whether published studies followed a series of acceptable methodologic standards and whether failure to follow the standard of genotyping reproducibility could lead to erroneous conclusions about gene-disease associations.DesignSystematic review and reanalysis of banked genetic material. We applied a published series of seven methodologic standards to five reports of the association between this variant and bacterial sepsis. We then studied the accuracy of restriction fragment length polymorphism for the −308 site using DNA from a cohort of injury victims.SettingSurgery research laboratory.Measurements and Main ResultsWe observed that methodologic quality was not uniform and that reproducibility of genotyping was infrequently met. In our subjects, we found that 4 of 46 heterozygotes analyzed by restriction fragment length polymorphism were actually GG-homozygotes (9% misclassified) according to alternative genotyping methods.ConclusionsFailure to confirm genotype may have led to conclusions that this polymorphism is not associated with sepsis or outcome. Our observations have implications for the conduct and evaluation of studies of complex genetic disease.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

IntroductionIn addition to its effects on platelet function, recent studies suggest that inhaled nitric oxide (NO) also influences the function of circulating leukocytes. Therefore, the aim of this work was to investigate the formation of platelet-leukocyte aggregates (PLAs) and platelet and leukocyte cell surface receptor expression during NO therapy in patients with acute respiratory distress syndrome.MethodsIn 16 patients responding to NO therapy with an improvement in oxygenation (NO group) and in four nonresponders (control), platelet P-selectin expression, platelet fibrinogen binding, the expression CD11a on leukocytes, and the formation of PLAs were investigated at 0, 60, 120, and 180 mins of therapy or at corresponding time points by means of flow cytometry. In addition, PLA was investigated in 30 healthy volunteers during NO inhalation, in five mechanically ventilated patients without acute respiratory distress syndrome and without NO inhalation, and during NO incubation in platelet-rich plasma of ten healthy volunteersin vitro.ResultsNO therapy inhibited PLA formation at 60 (13% ± 4% in the NO group vs. 19% ± 7% in the control group,p< .01) and 120 mins (14% ± 4% vs. 18% ± 7%,p< .05) and slightly decreased CD11a expression at 60 mins (152 ± 22 arbitrary units vs. 187 ± 36 arbitrary units,p< .05). Furthermore, besides inhibiting platelet fibrinogen binding, NO also led to a significant inhibition of P-selectin expression at 120 (38% ± 4% vs. 43% ± 5%,p< .05) and 180 mins (34% ± 5% vs. 43% ± 6%,p< .01), demonstrating a significant correlation between changes in P-selectin expression and PLA formation. In contrast, PLA formation was not influenced by mechanical ventilation in patients without acute respiratory distress syndrome. These results were further supported by additional studies showing inhibition of PLA formation in healthy volunteers as well.ConclusionsNO-dependent inhibition of PLA formation in patients with acute respiratory distress syndrome can be explained by the inhibition in platelet P-selectin expression. Thus, this study provides rational evidence of systemic antileukocytic and antiplatelet properties of NO therapy in the clinical setting.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveAdequate oxygenation of the gastrointestinal mucosa to preserve its barrier function is a basic objective in the prevention of multiple organ failure. Sustaining a positive airway pressure during the entire respiratory cycle remains a cornerstone in the therapeutic regimen to improve systemic oxygenation. Whereas increased systemic oxygenation during breathing continuous positive airway pressure has been shown, the impact of continuous positive airway pressure on regional oxygenation in the gastrointestinal tract has not yet been evaluated. We hypothesized that continuous positive airway pressure decreases microvascular oxygen saturation in gastric mucosa.DesignProspective, randomized study.SettingUniversity department of anesthesiology.ParticipantsTwelve healthy volunteers.InterventionsIncremental increases of continuous positive airway pressure (0, 5, and 10 cm H2O) and subsequent release of continuous positive airway pressure.Measurements and Main ResultsWe continuously measured microvascular oxygen saturation in gastric mucosa by reflectance spectrophotometry. Systemic oxygen saturation, end-tidal Pco2, respiratory rate, heart rate, and arterial blood pressure were obtained noninvasively. In every volunteer, microvascular oxygen saturation in gastric mucosa was reduced corresponding to the level of continuous positive airway pressure, although systemic variables, especially systemic oxygen saturation, did not change. Continuous positive airway pressure reduced microvascular oxygen saturation in gastric mucosa from 59 ± 7% (baseline with 0 cm H2O continuous positive airway pressure, mean ± sd) to 54 ± 8% (p< .05) during 5 cm H2O continuous positive airway pressure and to 50 ± 9% (p< .05) during 10 cm H2O continuous positive airway pressure, returning to 59 ± 7% during spontaneous breathing with 0 cm H2O continuous positive airway pressure. End-tidal Pco2, respiratory rate, as well as hemodynamic variables, remained stable.ConclusionsReflectance spectrophotometry meticulously monitored changes in microvascular oxygen saturation in gastric mucosa during breathing continuous positive airway pressure. Microvascular oxygen saturation in gastric mucosa decreased with increasing levels of continuous positive airway pressure despite steady systemic variables. These results suggest that the impact of altering airway pressures on splanchnic oxygenation is not mirrored necessarily by concomitant changes in systemic circulation. Moreover, if these findings also apply to critically ill patients, monitoring microvascular oxygen saturation in gastric mucosa would be useful to further optimize the setting of ventilation variables.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveMany patients go through periods when they are too ill to give consent or to participate in decisions. When this occurs, patient autonomy is best maintained when a surrogate designated by the patient and familiar with his or her values can speak for the patient. The objective of this study was to determine whether people who are not yet ill are ready to accept surrogate designation. Attitudes toward family participation in care were explored also.DesignPopulation survey by telephone. Because refusal of life-sustaining treatment is a dramatic example of patient autonomy, the survey used questions about ICU admission.SettingGeneral population in France.SubjectsRepresentative random sample of 8000 residents of France aged 18 yrs or more.InterventionsNone.Main Outcome MeasuresThe survey investigated attitudes.ResultsMost respondents said they would like to designate a surrogate (7205 [90%]) and to have their family share in their care (6691 [84%] for bathing, 5629 [70%] for feeding, and 4139 [52%] for tracheal suctioning) and in decisions about their management (6120 [76%]). Among respondents with a spouse, 79% said they would designate the spouse to speak for them. The attitudes were not influenced by ethnicity, religion or education level.ConclusionsMost people living in France would want a surrogate to represent them should they be incompetent and admitted to an ICU. Primary care physicians should inform their patients about the benefits of discussing illness-related issues among friends and family.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveHematopoietic stem cell transplant (HSCT) recipients admitted to the intensive care unit (ICU) have high mortality. The prognostic importance of peripheral blood stem cell source in critically ill HSCT recipients and the performance of Acute Physiology and Chronic Health Evaluation (APACHE) III have not been well studied. In a previous study, the hospital mortality rate of HSCT recipients admitted to our ICU was 77%. The objectives of this study were to describe the clinical course of HSCT recipients admitted to the ICU and to determine the performance of APACHE III in predicting their mortality.DesignRetrospective cohort study.SettingAcademic medical center.PatientsHSCT recipients admitted to the ICU.MeasurementsDemographics, transplant type, stem cell source, APACHE II and III predicted mortality, development of sepsis and organ failure, use of mechanical ventilation, duration of hospital stay, and mortality.ResultsNinety-four percent of the 112 HSCT recipients were white and 64% male. The mean APACHE II and III scores were 25 and 44, respectively. The APACHE II and III hospital predicted mortality rates were 44% and 42%, respectively. Mechanical ventilation was provided to 63%. Organ failure developed in 94% and sepsis in 62%. The ICU, hospital, and 30-day mortality rates were 33%, 46%, and 52%, respectively. Allogeneic transplant and higher APACHE III scores, but not bone marrow stem cell source, were associated with increased mortality. Invasive mechanical ventilation, vasoactive medication use, sepsis, and organ failure during patients’ ICU course were also associated with increased mortality. The area under the receiver operating characteristic curve for APACHE III hospital mortality prediction was 0.704 (95% confidence interval, 0.610–0.786). For APACHE III hospital mortality prediction, the value of the Hosmer-Lemeshow statistic showed good model fit.ConclusionsCurrent mortality figures of HSCT recipients admitted to the ICU are better than previously reported. The APACHE III prognostic model has moderate discrimination and good calibration in predicting hospital mortality in these patients.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the effect of major trauma on the cytokine-producing activity of monocytes and CD4+T cells in a homogeneous cohort of patients as well as to determine the relationship between monocyte and T-lymphocyte responses and clinical outcome.SettingsSurgical intensive care units of a trauma center and flow cytometry and experimental laboratories at a teaching hospital.DesignProspective cohort clinical study with measurements of white cell cytokine-producing activity on days 2, 5, and 10 postinjury. The number of cytokine-producing CD14+monocytes, CD4+, and CD8+T cells were determined in whole blood using flow cytometry combined with the intracellular cytokine staining method. Basal and lipopolysaccharide-stimulated interleukin (IL)-12, tumor necrosis factor-&agr;, IL-6, and IL-1&agr; production by monocytes as well as basal and phorbol 12-myristate 13-acetate plus ionomycin-stimulated interferon-&ggr;, IL-4, and tumor necrosis factor-&agr; production by T cells were determined on days 2, 5, and 10 postinjury and compared with similar measurements made in healthy control subjects.PatientsTwelve randomly selected black, male patients were enrolled in the study: mean injury severity score, 26; mean age, 35 yrs; mean Glasgow Coma Scale score, 13; systemic inflammatory response syndrome, 92%; sepsis, 42%; bronchial infection, 42%; and adult respiratory distress syndrome 25%.Main ResultsAfter lipopolysaccharide stimulation, the number of IL-12-, tumor necrosis factor-&agr;-, IL-1&agr;-, and IL-6-producing CD14+monocytes was 40% to 70% lower in trauma patients on postinjury days 2, 5, and 10 than in healthy control subjects. After phorbol 12-myristate 13-acetate stimulation, the number of IL-4-producing CD4+cells increased three-fold in the trauma patients compared with healthy control subjects. In contrast, the number of interferon-&ggr;- or tumor necrosis factor-&agr;-producing CD4+and CD8+T cells was not different between the patients and control subjects. The Th1/Th2 ratio was significantly lower in patients on all postinjury days than in the control subjects. A statistically significant inverse correlation was found between the number of IL-12-producing monocytes and IL-4-producing CD4+T cells in trauma patients (p= .007, r2= .47). This correlation was absent in control subjects. The degree of depressed capacity of monocyte IL-12 production on day 2 postinjury showed a statistically significant correlation with the development of adult respiratory distress syndrome, sepsis, or infections and also with the duration of systemic inflammatory response syndrome and sepsis.ConclusionsMajor trauma results in an early and marked decrease in monocyte cytokine-producing activity. The trauma-induced depression in IL-12 production by the mononuclear phagocyte system may promote T-cell commitment toward a Th2 pattern early after trauma. The appearance of the Th2 pattern is the result of elevated numbers of IL-4-producing cells without major alterations in T-cell interferon-&ggr;-producing capacity. The degree of alterations in monocyte and T-cell responses on day 2 postinjury correlates with the development of adverse clinical outcomes and the subsequent duration of the inflammatory response.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo describe the outcome of using a rescue therapy including plasma exchange given to patients with a progressive acute disseminated intravascular coagulation and multiple organ dysfunction syndrome.Study DesignRetrospective study.SettingUniversity and county hospital.PatientsIncluded were 76 consecutive patients (41 men and 35 women) treated with plasma exchange as rescue therapy besides optimal conventional therapy during a progressive course of disseminated intravascular coagulation and multiple organ dysfunction syndrome, including acute renal failure. Of the 76 patients, 66% needed dialysis. The distribution was hemodialysis in 76%, continuous arteriovenous hemofiltration in 36%, continuous venovenous hemodialysis in 12%, and peritoneal dialysis in 24%. The median organ-failure score was 5 (range, 1–6). Seventy-two percent required mechanical ventilation; septic shock was present in 88%. The median septic shock score was 4 (range, 2–4). Nine patients had another reason than sepsis for the multiple organ dysfunction syndrome.InterventionPlasma exchange (centrifugation technique) was performed until disseminated intravascular coagulation was reversed (median, two times; range, 1–14). Besides antibiotics and fluid administration, most patients received heparin or low molecular weight heparin (77%), steroids (87%), and inotropes (88%). More than one vasoactive drug was used in 57% of the patients.Measurements and Main ResultsEighty-two percent of the patients survived and could leave the hospital. The previously observed survival rates by others for this category of patients would be <20%, and thus, the outcome in this study is significantly better.ConclusionPlasma exchange using plasma as replacement may, in addition to conventional intensive care, help to reverse severe progressive disseminated intravascular coagulation and multiple organ dysfunction syndrome and improve survival.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID