摘要:

ObjectivesTo evaluate both the frequency and route of endotracheal colonization of intubated children by pathogens and to assess the usefulness of Pediatric Risk of Mortality scoring and measurement of gastric pH in predicting this colonization.DesignProspective data collection.SettingA multidisciplinary pediatric ICU.PatientsNineteen children with medical/surgical problems who were intubated for at least 4 days.InterventionsBuccal mucosa, and endotracheal and gastric aspirates were cultured for pathogens immediately after endotracheal intubation and daily for 4 to 5 days. Pediatric Risk of Mortality scores were calculated at the time of endotracheal intubation; gastric pH was measured each time that the cultures were obtained.Measurements and Main ResultsThe buccal mucosae of ten (53%) of 19 children were colonized with Candida species at the time of endotracheal intubation. This colonization correlated with the degree of physiologic instability as measured by Pediatric Risk of Mortality scores (12.9 ± 2.8 SEM for those patients colonized vs. 4.9 ± 1.0 for those patients not colonized;p= .01), but not with preintubation antibiotic therapy. Eleven (58%) children acquired 27 endotracheal pathogens after the day of intubation. The buccal mucosa was the initial site of colonization of 19 (70%) of 27 of the acquired pathogens. A gastric pH of >3.0 at the time of intubation correctly predicted colonization in nine of 11 children (p< .025, Fisher's exact test); a Pediatrick Risk of Mortality score of >8 at the time of endotracheal intubation correctly predicted colonization in eight of 11 patients (p< .05, Fisher's exact test).ConclusionsColonization of the buccal mucosa appears to be the crucial antecedent to endotracheal colonization in children. In children, gastric pH and Pediatric Risk of Mortality scores at the time of endotracheal intubation can predict pathogenic endotracheal colonization within 4 days of intubation. Selective decontamination regimes may be appropriate for these patients, especially those regimes that are directed to the buccal mucosa.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo determine the oxygen consumption (Vo2), resting energy expenditure, and substrate utilization after cardiac surgery in children.DesignProspective, observational, cross-sectional study with factorial design.SettingPediatric ICU at a university hospital.PatientsTwenty-six consecutive children during the first 3 days after open-heart surgery.InterventionsPatients were mechanically ventilated and received routine therapeutic interventions.Measurements and Main ResultsVo2, resting energy expenditure, and substrate utilization were determined by indirect calorimetry. Cardiac index was calculated using the Fick equation from the measured Vo2and the arterial-mixed venous oxygen content difference, and this cardiac index value was compared with a simultaneous cardiac index value that was measured by thermodilution whenever possible. There were excellent correlation and agreement between cardiac index measurements by Fick equation and thermodilution, indicating accurate Vo2measurements. Vo2was consistent with predicted values in healthy resting children. Resting energy expenditure was consistent with the predicted basal metabolic rate. The mean caloric intake was 19% of the mean energy expenditure. The respiratory quotient was 0.74 ± 0.05. The substrate utilization showed a shift toward fat oxidation and either gluconeogenesis or impaired carbohydrate utilization.ConclusionsCardiovascular surgery in children does not significantly alter resting energy expenditure but influences the substrate utilization. Perioperative hormonal stress responses and therapeutically administered catecholamines may explain the shift toward fat oxidation.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectivesTo determine the factors predicting mortality from bleeding esophageal varices and to examine the possibility of an association between the development of adult respiratory distress syndrome (ARDS) and the use of ethanolamine oleate as an esophageal variceal sclerosant.DesignRetrospective review.SettingICU in a teaching hospital.PatientsA total of 101 patients with endoscopically confirmed bleeding esophageal varices were admitted on 124 occasions from 1985 to 1990. Mean age was 50 ± 13.5 (SD) yrs. There were 62 males and 39 females. Using the Child-Pugh classification, 21.8% patients were class A, 38.6% class B, and 39.6% class C. Mean ICU and hospital lengths of stay were 5.4 ± 5.1 and 19.6 ± 16.1 days, respectively. Mean Acute Physiology and Chronic Health Evaluation (APACHE II) score on admission was 16.5 ± 7.6.InterventionsEndoscopic variceal sclerotherapy was performed in 99 (79.8%) of 124 ICU admissions in the 101 patients. Esophageal balloon tamponade was performed in 64 (51.6%) and a vasopressin infusion was administered in 47 (37.9%) of the 124 ICU admissions. A variety of factors was studied to find predictors of mortality and the development of ARDS.ResultsForty-eight (48.5%) of the 101 patients died during the hospital stay. Independent predictors of mortality (by stepdown logistic regression) were total volume of ethanolamine oleate injected during sclerotherapy, multiple blood transfusions, Glasgow Coma Scale score, International normalized ratio for prothrombin test, and the presence of circulatory shock on ICU admission. Age, sex, Child-Pugh score, APACHE II score, serum bilirubin, albumin, and creatinine concentrations, use of esophageal balloon tamponade or vasopressin infusion, sepsis, pneumonia, congestive cardiac failure, aspiration, and ARDS were not statistically independent predictors of outcome. There was no difference in the mortality rates for the various causes of liver disease. Pulmonary complications occurred in 44 (43.6%) patients; sepsis occurred in 31 (25%) patients. ARDS developed in 14 patients (11.3% admissions, 13.9% patients). Statistically independent predictors of ARDS were sepsis, low plasma albumin concentration, use of esophageal balloon tamponade, and more than one sclerotherapy session. The volume and type of sclerosant used were not statistically independent predictors.ConclusionsOutcome is poor for patients with bleeding esophageal varices requiring ICU admission and is related to the severity of liver failure, the degree of blood loss, and failure of therapy to stop the bleeding. The findings do not support an association between the use of the sclerosant ethanolamine and the development of ARDS.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo assess the efficacy of bulk diffusion in maintaining oxygenation during apnea testing for brain death.DesignCase series.SettingICU in a primary care hospital.PatientsTwenty-four consecutive patients with suspected brain death. Most patients suffered cerebral trauma from vehicular accidents.InterventionPatients were preoxygenated with an FIO2of 1.0 and were maintained during apnea testing with bulk flow of an FIO2of 1.0 at 40 to 60 L/min in adults and 15 L/min in children. The pre-apnea Paco2was between 35 to 45 torr (4.7 to 6.0 kPa) in all patients.Main Outcome MeasuresTwenty-three patients completed the test. Five patients had a Pao2< 100 torr (Main ResultsNo patient breathed spontaneously during the apnea test. Twenty-two patients achieved a Paco2>60 torr (>8 kPa). One patient had a postapnea Paco2of 59 torr (7.8 kPa). The test was stopped in one patient who became hypotensive.ConclusionsThe bulk diffusion technique has several advantages, including ease of performance over other methods of supplying oxygen during apnea testing, but this method does not prevent hypoxemia in patients with lung disease.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Background and PurposeNeurologic injury caused by changes in cerebral blood flow is a concern in infants treated with extracorporeal membrane oxygenation (ECMO). To investigate the hypothesis that cerebral hemodynamics would be influenced by bypass flow rates, eight ketamine anesthetized lambs (age range 1 to 8 days) had measurements of cerebral hemodynamics before and after institution of venoarterial bypass.MethodsCerebral blood flow (whole brain and regional) were measured using the radiola-beled microsphere technique. A left carotid artery catheter (placed without sacrificing the vessel) reference sample was used for calculation of brain blood flows. Arterial and venous (sagittal sinus) oxygen contents and blood gases were measured across the cerebral circulation. Cerebral oxygen consumption, oxygen delivery, and fractional oxygen extraction were calculated. Measurements were made pre-ECMO and after placement on venoarterial ECMO at flow rates of 50 and 100 mL/kg/min. In addition, four other lambs were studied at a flow rate of 150 mU kg/min, and seven additional animals were used to address methodologic issues with the micro-sphere technique in this model.ResultsCerebral blood flow and oxygen delivery significantly decreased, compared with control at both flow rates of 100 and 50 mL/kg/min (87.8 ± 5.2 vs. 36.4 ± 6.2; and 35.1 ± 5.8 mL/100 g/min; 5.82 ± 0.37 vs. 2.14 ± 0.35; and 2.19 ± 0.39 μM/100 g/min, respectively). Cerebral fractional oxygen extraction increased significantly at a flow of 50 mL/kg, and cerebral oxygen consumption decreased significantly at a flow of 100 mL/kg. At a flow rate of 150 mL/kg/min, cerebral hemodynamic variables did not differ from control measurements.ConclusionsThese findings demonstrate that changes in cerebral blood flow and cerebral oxygen metabolism can occur in the newborn lamb with the initiation of ECMO, and that these changes are dependent on bypass flow rate.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Background and MethodsEmergency endotracheal drug administration has become an acceptable route for drug delivery during cardiopulmonary resuscitation. The purpose of the present study was to determine whether the site of endotracheal epinephrine injection is an important factor in its absorption. Epinephrine (1:1000), in a dose of 0.02 mg/kg diluted in 2 mL of saline, was given to ten anesthetized mongrel dogs. Each dog was studied twice: once when the epinephrine was injected into the endotracheal tube, and on another day, through the endotracheal tube via a flexible catheter wedged into a peripheral bronchus. Arterial blood samples for plasma epinephrine concentration determinations were collected, before and at 1, 2, 5, 10, 15, and 30 mins after each intratracheal drug administration.ResultsBoth routes of epinephrine administration significantly increased plasma concentrations within 1 min of injection. Higher plasma epinephrine concentrations were achieved after peripheral bronchial epinephrine administration (maximal concentration 8.9 ± 3.2 vs. 2.0 ± 0.4 ng/mL), and the total dose absorbed was significantly (76.5 ± 13.5 vs. 36.7 ± 6.5 ng/min/mL,p< .05) higher. The time interval to reach maximal concentration was significantly shorter with the peripheral bronchial dosing than with the endotracheal route (1.3 ± 0.2 vs. 2.7 ± 0.5 min,p< .05). Neither group demonstrated a significant change in heart rate, and both had similar, minor decreases in BP for >2 to 5 mins. There were no significant differences between the arterial blood gases of the two groups at various stages of the experimentConclusionsIn dogs, epinephrine administered via the peripheral bronchial route has a clear pharmacologic advantage over the endotracheal route. This advantage may be more important during cardiopulmonary resuscitation conditions and other low flow states, and may account for the failure observed with the endotracheal route in recently published clinical reports.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo review the current status and future needs of medical students with respect to education in critical care medicine.Data SourcesLiterature review and questionnaire administered at the 1990 Educational and Scientific Symposium of the Society of Critical Care Medicine.Measurements and Main ResultsMedical students are presently not required to master even the basic aspects of critical care medicine before licensing. The results of the questionnaire demonstrated that critical care medicine professionals believe a critical care core curriculum should be established and its completion should be made a requirement for graduation from medical school A reference set of critical care medicine learning objectives and a strategy for their implementation are presented.>ConclusionsThere is a gap between what student physicians are required to learn and what they need to know to effectively initiate critical care interventions and to appropriately refer patients to ICUs. This gap can and should be remedied with wide implementation of a critical care core curriculum.

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID