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

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 the duration of antimicrobial activity and the efficacy of indwelling catheters coated with minocycline and rifampin in preventing ultrastructural colonization.DesignMulticenter, prospective, randomized, clinical trial.SettingFive university-based medical centersPatientsCohort 1 consisted of 40 randomized patients in whom an equal number of minocycline- and rifampin-coated and uncoated catheters were inserted and studied using scanning electron microscopy. Cohort 2 consisted of 118 patients who received coated catheters that were tested for the antimicrobial activity and levels of the antibiotics at the time of removal.InterventionsCatheters pretreated with tridodecylmethylammonium chloride and subsequently coated with minocycline and rifampin; uncoated catheters (control).Measurements and Main ResultsQuantitative scanning electron microscopy was utilized to determine both the ultrastructural colonization in biofilm on coated and uncoated catheters. The zones of inhibition of coated catheters from studied patients against Staphylococcus epidermidis was used to determine the antimicrobial durability. High-performance liquid chromatography was used to determine antibiotic levels on indwelling coated catheters and in serum. Mild-to-heavy ultrastructural colonization was detected in 7 (35%) of 20 coated catheters and in 16 (80%) of 20 uncoated catheters (p = .004). Significant antimicrobial inhibitory activity against S. epidermidis was maintained for 16 days. Rifampin and minocycline continued to be detected on the surfaces of coated catheters for at least 2 wks after placement. Neither antibiotic was detected in the 60 serum samples obtained from 15 patients during catheterization.ConclusionCoating catheters with minocycline and rifampin inhibits ultrastructural colonization of indwelling catheters and maintains effective antimicrobial activity for at least 2 wks. (Crit Care Med 1998; 26:219-224)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Objectiveor=to75 yrs of age after cardiac surgery.DesignInception cohort study.SettingA tertiary care, 54-bed cardiothoracic intensive care unit (ICU).Patientsor=to75 yrs admitted over a 30-month period for cardiac surgery.InterventionCollection of data on preoperative factors, operative factors, postoperative hemodynamics, and laboratory data obtained on admission and during the ICU stay.Measurements and Main ResultsPostoperative death, frequency rate of organ dysfunction, nosocomial infections, length of mechanical ventilation, and ICU stay were recorded.15 mm Hg, stroke volume index of <30 mL/min/m2300 mg/dL after surgery, and anemia beyond the second postoperative day. During the study period, the study cohort used 6,859 (21.5%) ICU patient-days out of a total 31,867 ICU patient-days. Nonsurvivors used 2,023 (30%) ICU patient-days and patients with morbidity used 5,903 (86%) ICU patient-days.ConclusionsSevere underlying cardiac disease (including shock, requirement for mechanical circulatory support, hypoalbuminemia, and hepatic dysfunction), intraoperative blood loss, surgical reexploration, long ischemic times, immediate postoperative cardiovascular dysfunction, global ischemia and metabolic dysfunction, and anemia beyond the second postoperative day predicted poor outcome in the elderly after cardiac surgery. Postoperative morbidity and mortality disproportionately increased the utilization of intensive care resources in elderly patients. Future efforts should focus on preoperative selection criteria, improvement in surgical techniques, perioperative therapy to ameliorate splanchnic and global ischemia, and avoidance of anemia to improve the outcome in the elderly after cardiac surgery. (Crit Care Med 1998; 26:225-235)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine whether the diagnostic accuracy of bronchoscopy samples in patients with suspected ventilator-associated pneumonia is affected by prior antibiotic treatment given for a previous infection, and/or by antibiotic treatment recently started to treat suspected ventilator-associated pneumonia.DesignStudy of critically ill patients.SettingIntensive care unit in a university hospital.Patients72 hrs earlier), n = 31; and recent antibiotic group (new antibiotic treatment class started within the last 24 hrs), n = 20.InterventionsFiberoptic bronchoscopy with quantitative protected specimen brush cultures, bronchoalveolar lavage cultures, and intracellular organism counts of bronchoalveolar lavage cells.Measurements and Main Resultsor=to0.85) in both current antibiotic treatment and recent antibiotic treatment patients. Sensitivities for a 5% intracellular organism count of bronchoalveolar lavage cells, a protected specimen brush culture threshold of 103colony-forming units (cfu)/mL, and a bronchoalveolar lavage culture threshold of 105or=to0.9. In the recent antibiotic group, protected specimen brush and bronchoalveolar lavage cultures had lower sensitivities (p < .05), and the best threshold values for these two tests were 102cfu/mL and 103cfu/mL, respectively.ConclusionsAfter recent introduction of an antibiotic treatment for suspected ventilator-associated pneumonia, protected specimen brush and bronchoalveolar lavage culture thresholds must be decreased to maintain good accuracy. In contrast, current antibiotic treatment prescribed for a prior infectious disease does not modify the diagnostic accuracy of protected specimen brush or bronchoalveolar lavage. (Crit Care Med 1998; 26:236-244)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectivesTo compare the incidence of withdrawal or withholding of life support (WD/WHLS), and to identify similarities and differences in the process of the withdrawal of life support (WDLS) between teaching and community hospitals' intensive care units (ICUs).DesignProspective cohort study, with some data obtained by retrospective chart review.SettingThe ICUs of three teaching hospitals and six community hospitals.PatientsAll patients who died in these nine ICUs over a 6-mo period.InterventionsNone.Measurements and Main ResultsData on admitting diagnosis, cause of death, mode of death (death despite active treatment, withdrawal or withholding of life support), those initiating and involved in WDLS, and modalities of life support withdrawn were gathered for patients dying in the ICU over a 6-mo period. One hundred sixty patients in community hospitals and 292 in teaching hospitals died in their respective ICUs over the 6-mo period. We found a difference in the distribution of mode of death between community hospitals and teaching hospitals, resulting from a greater proportion of patients dying as a result of withholding life support in community hospitals (11.9% vs. 3.8% withheld, respectively, p = .004). Among the six community hospitals and three teaching hospitals, we found a difference in the proportion of patients dying despite active treatment compared with those dying as a result of WD/WHLS (p = .042 and p = .044, respectively). Initiation of WDLS by physicians was more frequent at teaching hospitals (81% vs. 61%, p = .0005), while families more commonly initiated WDLS at community hospitals (34% vs. 19%, p = .005). A greater proportion of patients in teaching hospitals were receiving mechanical ventilation (99% vs. 89%) and vasopressors (76% vs. 65%) before WDLS. Similar proportions had mechanical ventilation withdrawn (68% and 74%, community hospitals and teaching hospitals, respectively), while there was a trend for fewer patients in community hospitals to have vasopressors withdrawn (56% vs. 70%, p = .082). The time to death after WDLS had begun was longer in community hospitals compared with teaching hospitals (0.74 +/- 1.38 days vs. 0.27 +/- 0.79 [SD] days, p = .0028).ConclusionsThe incidence of WD/WHLS was similar in community hospitals and teaching hospitals; however, withholding of life support was more common in community hospitals. The process of WDLS appears to differ between community hospitals and teaching hospitals. (Crit Care Med 1998; 26:245-251)

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 assess the effect of proactive ethics consultation on documented patient care communications and on declsions regarding high-risk intensive care unit (ICU) patients.DesignProspective, controlled study.Patients96 hrs of continuous mechanical ventilation.Interventions96 hrs of continuous mechanical ventilation. Patient care planning, for subjects in the proactive group, was reviewed with physicians and with the care team using a standardized set of prompting questions designed to focus discussion of key decision-making and communication issues for critically and terminally ill patients. Issues and concerns were identified and action strategies were suggested to those in charge of the patient's care. Formal ethics consultation, using a patient care conference model, was made available upon request.Measurements and Main ResultsPost discharge chart reviews of the three groups indicated no statistically significant differences on important demographic variables including age, gender, and acuity. Comparisons of survivors and nonsurvivors for the three groups indicated, at statistically significant levels, more frequent and documented communications, more frequent decisions to forgo life-sustaining treatment, and reduced length of stay in the ICU for the proactive consultation group.ConclusionProactive ethics consultation for high-risk patient populations offers a promising approach to improving decision-making and communication and reducing length of ICU stay for dying patients. (Crit Care Med 1998; 26:252-259)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID