摘要:

ObjectiveTo study the effect of decline in blood pressure on mortality in patients with spontaneous intracerebral hemorrhage (ICH).DesignRetrospective chart review.SettingUniversity-affiliated teaching hospital.PatientsConsecutive patients admitted with spontaneous ICH over a 3-year period.MeasuresBlood pressure recordings were obtained from the first 24 hrs. Patients (n = 105) with more than five blood pressure recordings and on average greater than one measurement per 2 hrs were included (mean measurements per patient = 20.3). Mean arterial pressure (MAP) recordings over the first 24 hrs after presentation were regressed on time for each patient. Each patient's MAP was calculated as a slope (change mm Hg/hr). We performed logistic regression analyses to determine the effect of MAP slope on mortality and functional outcome, adjusting for other predictive factors including Glasgow Coma Scale (GCS) score and hematoma volume. The effect of MAP slope on mortality was also evaluated in subsets of patients based on age, gender, initial GCS score, initial MAP, treatment status, hematoma volume, and presence of ventricular blood.Main ResultsMean slope of change in MAP was -2.0 mm Hg/hr (+/- 1.9, range -8.5 to +0.6). The slope of MAP (faster rate of decline) within the first 24 hrs was significantly associated with higher mortality (p = .04), independent of initial GCS score and hematoma volume. In subgroup analyses, MAP slope was significantly associated with mortality in men (p = .08), patients with hematoma volume <50 mm (3or=to10 (p = .07). MAP slope did not predict functional outcome among survivors.ConclusionsA rapid decline in MAP within 24 hrs after presentation is independently associated with increased mortality in patients with ICH. A large, prospective, randomized trial is required to confirm these findings. (Crit Care Med; 1999 27:480-485)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveAlthough a benefit of vasopressin when compared with epinephrine was shown during cardiopulmonary resuscitation (CPR) after a short duration of ventricular fibrillation cardiac arrest, the effect of vasopressin during prolonged cardiac arrest with pulseless electrical activity is currently unknown.DesignProspective, randomized laboratory investigation using an established porcine model with instrumentation for measurement of hemodynamic variables, vital organ blood flow, blood gases, and return of spontaneous circulation.SettingUniversity hospital laboratory.SubjectsEighteen domestic pigs.InterventionsAfter 15 mins of cardiac arrest and 3 mins of chest compressions, 18 animals were randomly treated with either 0.8 units/kg vasopressin (n = 9) or 200 [micro sign]g/kg epinephrine (n = 9).Measurements and Main ResultsCompared with epinephrine, vasopressin resulted, at both 90 secs and 5 mins after drug administration, in significantly higher (p < .05) median (25th-75th percentiles) left ventricular myocardial blood flow (120 [range, 96-193] vs. 54 [range, 11-92] and 56 [range, 41-80] vs. 21 [range, 11-40] mL/min/100 g, respectively) and total cerebral blood flow (85 [78-102] vs. 24 [18-41] and 50 [44-52] vs. 8 [5-23] mL/min/100 g, respectively). Spontaneous circulation was restored in eight of nine animals in the vasopressin group and in one of nine animals in the epinephrine group (p = .003).ConclusionsCompared with a maximum dose of epinephrine, vasopressin significantly increased left ventricular myocardial and total cerebral blood flow during CPR and return of spontaneous circulation in a porcine model of prolonged cardiac arrest with postcountershock pulseless electrical activity. (Crit Care Med 1999; 27:486-492)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo measure quinolinic acid, a macrophage-derived neurotoxin, in the cerebrospinal fluid (CSF) of children after traumatic brain injury (TBI) and to correlate CSF quinolinic acid concentrations to clinically important variables.DesignA prospective, observational study.SettingThe pediatric intensive care unit in Children's Hospital of Pittsburgh, a tertiary care, university-based children's hospital.PatientsSeventeen critically ill children following severe TBI (Glasgow Coma Scale score <8) whose care required the placement of an intraventricular catheter for continuous drainage of CSF.InterventionsNone.Measurements and Main ResultsPatients ranged in age from 2 mos to 16 yrs (mean 6.0 yrs). CSF was collected immediately on placement of the ventricular catheter and daily thereafter. Quinolinic acid concentration was measured by gas chromatography/mass spectroscopy in 69 samples (4.0 +/- 0.4 [SEM] samples per patient). CSF quinolinic acid concentration progressively increased after injury (p = .034, multivariate analysis) and was increased in nonsurvivors vs. survivors (p = .002, multivariate analysis). CSF quinolinic acid concentration was not associated with age. Although overall CSF quinolinic acid concentration was not associated with shaken injury (p = .16, multivariate analysis), infants suffering with shaken infant syndrome had increased admission CSF quinolinic acid concentrations compared with children with accidental mechanisms of injury (p = .027, Mann-Whitney Rank Sum test).ConclusionsA large and progressive increase in the macrophage-derived neurotoxin quinolinic acid is seen following severe TBI in children. The increase is strongly associated with increased mortality. Increased CSF quinolinic acid concentration on admission in children with shaken infant syndrome could reflect a delay in presentation to medical attention or age-related differences in quinolinic acid production. These findings raise the possibility that quinolinic acid may play a role in secondary injury after TBI in children and suggest an interaction between inflammatory and excitotoxic mechanisms of injury following TBI. (Crit Care Med 1999; 27:493-497)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine the value of procalcitonin (ProCT) as a marker of infection in critically ill patients.DesignProspective, observational study.SettingMedicosurgical department of intensive care (31 beds).PatientsOne hundred eleven infected and 79 noninfected patients.InterventionsNone.Measurements and Main ResultsProCT and C-reactive protein (CRP) concentrations were monitored daily. The best cutoff values for ProCT and CRP were 0.6 ng/mL and 7.9 mg/dL, respectively. Compared with CRP, ProCT had a lower sensitivity (67.6 vs. 71.8), specificity (61.3 vs. 66.6), and area under the receiver operating characteristic curve (0.66 vs. 0.78, p < .05). The combination of ProCT and CRP increased the specificity for infection to 82.3%. In the infected patients, plasma ProCT, but not CRP, values were higher in nonsurvivors than in survivors. Infected patients with bacteremia had higher ProCT concentrations than those without bacteremia, but similar CRP concentrations. ProCT levels were particularly high in septic shock patients.ConclusionsProCT is not a better marker of infection than CRP in critically ill patients, but it can represent a useful adjunctive parameter to identify infection and is a useful marker of the severity of infection. (Crit Care Med 1999; 27:498-504)

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:

ObjectiveTo analyze the influence of extracerebral organ system dysfunction after aneurysmal subarachnoid hemorrhage (SAH) on mortality and neurologic outcome.DesignObservational study with retrospective data extraction.SettingNeurosurgical intensive care unit (NICU) at a primary level university hospital, supervised and staffed by both members of the Clinic of Neurosurgery and the Clinic of Anesthesiology and General Intensive Care.PatientsTwo hundred forty-two patients treated for intracranial aneurysm rupture within 7 days of the most recent SAH.InterventionsRoutine neurosurgical interventions for obliteration of the ruptured aneurysm (microsurgery, Guglielmi Detachable Coils embolization) and for treatment of posthemorrhagic hydrocephalus (ventriculostomy, cerebrospinal fluid shunt implantation).Measurements and Main ResultsRespiratory, renal, hepatic, cardiovascular, and hematologic organ system functions were evaluated both individually and in aggregate by using a modified version of the Multiple Organ Dysfunction (mMOD) score. Of 1,452 organ system functions assessed in 242 patients during their NICU stay, 714 organ system functions were intact (cerebral: 0, extracerebral: 714), 556 organ systems had mild-to-moderate dysfunctions (mMOD scoremax1-2 for the affected organ system; cerebral: 153, extracerebral: 403), and 182 organ systems failed (mMOD score (max) 3 for the affected organ system; cerebral: 89, extracerebral: 93). Severity of extracerebral organ system dysfunctions correlated with the degree of neurologic impairment (Hunt and Hess [H&H] score) in a graded fashion. Similarly, the chance to develop systemic inflammatory response syndrome (SIRS) during the NICU stay increased with increasing admission H&H grade. The incidence of SIRS and septic shock was 29% and 10.3%, respectively. The mortality rate was 40.2% in patients with SIRS and 80% for patients suffering septic shock. Seventy-seven percent of extracerebral organ system failures (OSFs) occurred in conjunction with SIRS: 51% of respiratory OSFs, 97% of renal OSFs, 100% of hepatic OSFs, 96% of cardiovascular OSFs, and 73% of hematopoietic OSFs. Both CNS dysfunction and extracerebral organ system dysfunctions were significantly related to neurologic outcome. The probability of unfavorable neurologic outcome significantly increased with both decreasing cerebral perfusion pressure (CPP) and increasing severity of extracerebral organ dysfunction.ConclusionAneurysmal SAH and its neurologic sequelae accounted for the principal morbidity and mortality in the current series. Development of extracerebral organ system dysfunction was associated with a higher probability of unfavorable neurologic outcome. Systemic inflammation (SIRS) and secondary organ dysfunction were the principal non-neurologic causes of death. (Crit Care Med 1999; 27:505-514)

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:

ObjectiveTo compare silver-coated and uncoated central venous catheters regarding bacterial colonization. To assess the relative contribution of catheter hub and skin colonization to catheter tip colonization.DesignProspective, randomized clinical trial.SettingIntensive care unit in a university hospital.PatientsPatients after cardiac surgery who required a central venous double-lumen catheter (DLC).InterventionsSixty-seven adult patients were prospectively randomized to receive either a silver-coated (S group, n = 34) or an uncoated control (C group, n = 33) DLC. Blood cultures were drawn at catheter removal, and removed catheters were analyzed with quantitative cultures. Typing of microorganisms included DNA fingerprinting.Measurements and Main ResultsCatheters were removed if no longer necessary and aseptically divided into three segments: segment A, the catheter tip; segment B, an intermediate section; and segment C, the subcutaneous portion. Bacterial catheter colonization was quantitatively measured using sonication to detach adherent bacteria from the catheter segments in the broth and subsequent culture of an aliquot. Selected isolates of coagulase-negative staphylococci and other bacteria from catheter segments were examined by means of pulsed-field gel electrophoresis (PFGE) after macrorestriction digestion of bacterial DNA to study colonization pathogenesis.Quantitatively lower bacterial colonization could be demonstrated on the silver-coated catheters (200 +/- 550 colony forming units [CFUs]/cm catheter segment; mean +/- SD). The difference in the control catheters (1120 +/- 5350 CFUs/cm catheter segment; mean +/- SD) was not, however, significant (p = .25).The frequency of colonization of at least one catheter segment was 52.9% for the silver-coated catheters and 57.6% for the control catheters (p = .44), without any significant differences in the colonization of corresponding catheter segments.or=to103or=to103CFUs/mL by luminal flush) was nine in the silver group and seven in the control group, a difference that failed to reach significance (p = .41). Two patients in both groups developed catheter-related bacteremia.Pattern analysis after PFGE demonstrated that about 70% of the isolates found on the catheter tip were identical with those on the skin at the insertion site, whereas about 75% were identical with those recovered from the hub.In 29% of colonized catheters, identical bacteria were found on the hub and the skin at the insertion site.ConclusionsSilver-coating of DLCs did not significantly reduce bacterial catheter colonization compared with the control catheters. PFGE analysis of coagulase-negative staphylococci and other bacteria demonstrated various pathogenic routes of catheter-related colonization, whereby the microorganisms of the skin flora around the insertion site must be regarded as the main source of catheter-related infections. (Crit Care Med 1999; 27:515-521)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveThis study evaluates the somatic, socioeconomic, and psychiatric long-term results, as well as the factors for adverse outcome, in a significant subset of patients with severe multiple injuries resulting from attempted suicide.DesignThe follow-up study 6.1 +/- 3 (SD) yrs after trauma was based on prospectively documented data of patients with multiple injuries.SettingLevel I universlty trauma center in a major German city.Measurements and Main ResultsData derived from thorough physical and psychiatric evaluations. The Brief Psychiatric Rating Scale and the Global Assessment of Functioning Scale served to describe psychiatric outcome.Patientsor=to3), 65 (12%) attempted suicides were reported (Injury Severity Score, 40 +/- 15; age, 38 +/- 18 yrs). Twenty-one patients of the study cohort died during the hospital stay, and six subjects died thereafter, none because of suicide. Three patients were lost to follow-up, resulting in 35 individuals eligible for examination. None of the latter had reattempted suicide. Seventeen (48%) had good or satisfactory outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings (Brief Psychiatric Rating Scale), and good psychosocial ability (Global Assessment of Functioning Scale). For eight patients (24%), the result was indeterminate. The adverse outcomes in ten patients (28%) were mainly influenced by the presence of chronic schizophrenia (n = 4), affective disorder (n = 2), or severe traumatic brain injury (n = 3).ConclusionsDespite the parasuicidal origin, the long-term results after severe trauma were good or satisfactory in approximately half the cases and without further suicide attempts in any of the patients. Good recovery of the parasuicidal patients in our study is approximately 20% lower than in an unselected group of patients with multiple injuries and may be attributed mainly to the underlying chronic psychiatric disease. (Crit Care Med 1999; 27:522-530)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo evaluate the effect of acute changes in minute ventilation (VE) on oxygen consumption (VO2), carbon dioxide production (VCO2), respiratory quotient, and energy expenditure during volume-controlled mechanical ventilation in the critically ill surgical patient. The effects on some oxygen transport variables were assessed as well.DesignProspective, randomized clinical studySettingAdult surgical intensive care unit of a university teaching hospital.PatientsTwenty adult critically ill surgical patients were studied during volume-controlled mechanical ventilation.InterventionsAfter a basal period of stability (no changes over time in body temperature, energy expenditure, blood gases, acid-base status, cardiac output, and ventilatory parameters), VE was then randomly either increased or reduced (+/- 35%) by a change in tidal volume (VT), while respiratory rate and inspiratory/expiratory ratio were kept constant. Settings were then maintained for 120 mins. During the study, patients were sedated and paralyzed.Measurements and Main ResultsVO2, VCO2, and respiratory quotient were measured continuously by a Nellcor Puritan Bennett 7250 metabolic monitor (Nellcor Puritan Bennett, Carlsbad, CA). Hemodynamic and oxygen transport parameters were obtained every 15 mins during the study. Despite large changes in VE, VO2and energy expenditure did not change significantly either in the increased or in the reduced VE groups. After 15 mins, VCO2and respiratory quotient changed significantly after ventilator resetting. VCO2increased by 10.5 +/- 1.1% (from 2.5 +/- 0.10 to 2.8 +/- 0.12 mL/min/kg, p < .01) in the increased VE group and decreased by 12.4 +/- 2.1% (from 2.7 +/- 0.17 to 2.4 +/- 0.16 mL/min/kg, p < .01) in the reduced VE group. Similarly, respiratory quotient increased by 16.2% +/- 2.2% (from 0.87 +/- 0.02 to 1.02 +/- 0.02, p < .01) and decreased by 17.2% +/- 1.8% (from 0.88 +/- 0.02 to 0.73 +/- 0.02, p < .01). VCO2normalized in the reduced VE group, but remained higher than baseline in the increased VE group. Respiratory quotient did not normalize in both groups and remained significantly different from baseline at the end of the study. Cardiac Index, oxygen delivery, and mixed venous oxygen saturation increased, while oxygen extraction index decreased significantly in the reduced VE group. Neither of the mentioned parameters changed significantly in the increased VE group.ConclusionsWe conclude that, during controlled mechanical ventilation, the time course and the magnitude of the effect on gas exchange and energy expenditure measurements caused by acute changes in VE suggest that VO2and energy expenditure measurements can be used reliably to evaluate and quantify metabolic events and that VCO2and respiratory quotient measurements are useless for metabolic purposes at least for 120 mins after ventilator resetting. (Crit Care Med 1999; 27:531-539)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID