摘要:

ObjectivesTo compare in the same patient with septic shock, respective effects of epinephrine, norepinephrine, and the combination of norepinephrine and dobutamine (5 [micro sign]g/kg/min) on systemic hemodynamic parameters and gastric mucosal perfusion using gastric tonometry and laser-Doppler flowmetry techniques.DesignProspective, controlled, randomized, crossover study.SettingUniversity hospital intensive care unit.PatientsTwelve patients with septic shock.InterventionsEach patient received in a random succession epinephrine, norepinephrine, and norepinephrine plus dobutamine. Dosages of epinephrine and norepinephrine were adjusted to achieve a mean arterial pressure between 70 and 80 mm Hg. A laser-Doppler probe and a tonometer were introduced into the gastric lumen.Measurements and Main ResultsThe increase in gastric mucosal perfusion detected by laser-Doppler flowmetry was higher with epinephrine and the combination of norepinephrine and dobutamine than with norepinephrine alone (p < .05). In addition, the ratio of gastric mucosal perfusion (local oxygen delivery) to systemic oxygen delivery was increased after norepinephrine plus dobutamine as compared with norepinephrine alone and epinephrine (p < .05). Although values of intramucosal pH and gastroarterial PCO2tended to be higher with norepinephrine plus dobutamine compared with those obtained with norepinephrine and epinephrine, differences were not statistically significant.ConclusionsFor the same mean arterial pressure in patients with septic shock, our study showed that administration of epinephrine increased gastric mucosal perfusion more than norepinephrine administration alone. Addition of dobutamine (5 [micro sign]g/kg/min) to norepinephrine improved gastric mucosal perfusion. This result could be explained by a vasodilating effect of dobutamine on gastric mucosal microcirculation. (Crit Care Med 1999; 27:893-900)

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 prognostic scoring systems in a retrospective series of patients with severe acute pancreatitis admitted to a surgical intensive care unit (ICU).MethodBetween January 1992 and December 1996, the charts of all patients with a discharge code of acute pancreatitis were reviewed. There were 273 charts reviewed. Of these, 12 were admitted to the surgical ICU with a diagnosis of severe acute pancreatitis. A preliminary analysis of the data considers descriptive summary statistics, such as the mean and the range. The Spearman's rank-correlation test was computed to assess concordance between the following: a) length of stay and Ranson criteria; b) length of stay and Acute Physiology and Chronic Health Evaluation (APACHE) III score; and c) length of stay and modified Glasgow Coma score. Also, an unpaired t-test was used to obtain concordance between the following: a) death and Ranson; b) death and APACHE III; and c) death and modified Glasgow Coma score.Results30 at 96 hrs (mean 71 +/- 16 [SD]; p < .0) subsequently died. These two patients were excluded from the Spearman's rank-correlation tests. The mean length of stay in our sample was 61.8 (range, 7-201) days. The mean Ransom criteria was 4.3 (range, 1-9). The mean 96-hr APACHE III score was 33.3 (range, 0-83). The Spearman's rank-correlation between length of stay and Ranson criteria was 0.68, with a corresponding p value of .03. Similar results were observed for the length of stay and APACHE III at 96 hrs (correlation, 0.77; p = .0098) and the length of stay and the modified (correlation, 0.78; p = .007). These data reveal that the magnitude of correlation between the length of stay and the 96-hr APACHE III and modified Imrie is larger than that between length of stay and Ranson criteria.Conclusions60 days. These patients had major pancreatic complications that included pancreatic necrosis, pancreatic abscess, pseudocyst, hemorrhagic pancreatitis, and pancreatic ascites. (Crit Care Med 1999; 27:901-907)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine the effect of the nitric oxide synthase inhibitor, L-NG-monomethylarginine, on interleukin-6 and interleukin-8 accumulation, and nuclear factor-kappa B expression in an endothelial cell model of sepsis.DesignControlled cell culture experiments examining the immunomodulatory effects of nitric oxide synthase inhibition.SubjectsA human endothelial cell line (EA.hy926).Measurements and ResultsCells were incubated with tumor necrosis factor-alpha and interleukin (IL)-1 beta in the presence of L-NG-monomethylarginine(L-NMMA). IL-6 and IL-8 were measured in culture supernatants using enzyme immunoassay. Nuclear factor-kappa B was measured using electrophoretic mobility shift assay and was quantified using phosphorimaging. IL-6 accumulation was decreased (p < .05) and IL-8 accumulation increased (p < .01) with L-NMMA. Increased nuclear factor-kappa B expression in stimulated cells was unaltered on exposure to L-NMMA. Cell viability was unaffected.ConclusionsExcessive production of nitric oxide has been implicated in septic shock, and the use of nitric oxide synthase inhibitors has been suggested. The immunoregulatory actions of nitric oxide synthase inhibitors affects the profile of cytokine release. This effect is not mediated through modulation of nuclear factor-kappa B. These findings have implications for the use of nitric oxide synthase inhibiting agents in septic shock. (Crit Care Med 1999; 27:908-912)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectiveor=to70 mmHg.DesignMulticenter, open-label, uncontrolled, dose range finding study.SettingTen intensive care units in Europe and the United States.PatientsThirty-two patients with septic shock diagnosed within <24 hrs.InterventionsPatients received a fixed dose rate of 546C88 at either 1 (n = 6), 2.5 (n = 6), 5 (n = 4), 10 (n = 5), or 20 mg/kg/hr (n = 11) by intravenous infusion for up to 8 hrs. Conventional vasoactive therapy was restricted to noreplnephrine and/or dobutamine. During 546C88 therapy, MAP was to be maintained between 70 and 90 mm Hg, while attempting to withdraw any concurrent norepinephrine.Measurements and Main Results70 mm Hg. There was an increase in vascular tone and a decrease in cardiac index within the 1st hr of therapy. Systemic vascular resistance returned toward baseline with reduction of concomitant administration of norepinephrine. The decline in oxygen delivery was associated with an increase in extraction and, therefore, the maintenance of oxygen consumption. There was a sustained reduction of venous admixture within the 1st hr of therapy. 546C88 was not associated with any major or dose-dependent adverse effect on pulmonary, hepatic, or renal function.ConclusionsTreatment with the nitric oxide synthase inhibitor, 546C88, can restore the balance of vasomotor tone, thereby, maintaining blood pressure and reducing or eliminating the requirement for norepinephrine therapy in patients with septic shock. Infusion of 546C88 (1-20 mg/kg/hr) appears to have a satisfactory overall safety profile. (Crit Care Med 1999; 27:913-922)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectivesTo compare the efficiency of two heat and moisture exchange filters (HMEFs) of different compositions of the humidifying capacity and the rate of bronchial colonization and ventilator-associated pneumonia in patients in the intensive care unit (ICU).DesignProspective, randomized study.SettingICU of a university hospital.PatientsAll patients who required mechanical ventilation for 24 hrs or more during the study period.InterventionsAt admission to the ICU, patients were randomly assigned to one of two groups. In one group, the patients were ventilated with Humid-Vent Filter Light HMEF. The condensation surface was made of paper impregnated with CaCl2. The filter membrane was made of polypropylene. In the other group, the patients were ventilated with the Clear ThermAl HMEF (Intersurgical, France). The condensation surface was made of plastic foam impregnated with AlCl2. The filter membrane was made of two polymer fibers (modacrylic and polypropylene). In both groups, HMEFs were changed daily.Measurements and Main ResultsSeventy-seven patients were ventilated for 19 +/- 7 days with the Humid-Vent Filter Light HMEF and 63 patients for 17 +/- 6 days with the Clear ThermAl HMEF. Patients ventilated with the Humid-Vent Filter Light underwent 8.7 +/- 3.7 tracheal aspirations and 1.2 +/- 2.0 instillations per day and those with the Clear ThermAl, 8.2 +/- 3.9 and 1.5 +/- 2.4 per day, respectively (NS). The abundance of tracheal secretions and the presence of blood and viscosity, as evaluated by semiquantitative scales, were similar in both groups. One episode of tracheal tube occlusion was observed with the Humid-Vent Filter Light HMEF and none with the other HMEF (NS). Tracheal colonization was observed at a rate of 91% with the Humid-Vent Filter Light and 97% with the Clear ThermAl (NS). The rate of ventilator-associated pneumonia was similar in both groups (35%). Bacteria responsible for tracheal colonization and pneumonia were similar in both groups.ConclusionsDespite differences in their components, the two HMEFs that were tested achieved similar performances in terms of humidification and heating of inspired gases. Only one episode of endotracheal tube occlusion was detected, and very few patients (three in each group) had to be switched to an active heated humidifier. No difference was observed either in the rate of tracheal colonization or of ventilator-associated pneumonia. These data show that the Humid-Vent Filter Light and the Clear ThermAl HMEFs are suited for use with ICU patients. (Crit Care Med 1999; 27: 923-928)

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 determine changes in the production of inflammatory cytokines and acute-phase proteins, and in the priming of peripheral blood mononuclear cells (PBMC), as mechanisms for the high incidence of postoperative complications in patients who have undergone hepatectomy simultaneously with resection of the gastrointestinal tract.DesignProspective, clinical study for 3 wks after operation.SettingA surgical department in a university hospital.PatientsTwenty-one consecutive adult patients with synchronous and metachronous hepatic metastases from gastrointestinal malignancies, curatively resected by simultaneous resection (group A, n = 9) or by hepatectomy alone (group B, n = 12), and 15 patients with gastrointestinal malignancies undergoing curative resection (group C).InterventionPeripheral venous blood samples collected before operation and on days 1, 3, 5, 7, 10, 14, and 21 after operation.Measurements and Main ResultsThe serum and plasma levels of acute-phase proteins, interleukin (IL)-1 beta, IL-6, tumor necrosis factor (TNF)-alpha, and endotoxin were measured. The in vitro production of IL-1 beta and TNF-alpha by PBMC was also determined by the stimulation of lipopolysaccharide. The incidence of postoperative complications was significantly higher in group A than in groups B and C. The serum levels of IL-6 increased significantly, with a peak at postoperative day 1 in all groups, and the peak levels of IL-6 in groups A and B were significantly higher than that in group C. The serum levels of all acute-phase proteins measured in this study (alpha1-antitrypsin, haptoglobin, and C-reactive protein) increased markedly after operation in group C (p < .05). In group A, only C-reactive protein increased after operation, but its peak level was lower than in groups B and C (p < .05). Although IL-1 beta and TNF-alpha in the serum were not detectable in any of the groups during the entire study period, the lipopolysaccharide-induced in vitro production of IL-1 beta and TNF-alpha by PBMC in all groups was significantly elevated after operation, with a peak at days 1 and 3 after operation, respectively. In addition, the elevation of the in vitro production of IL-1 beta and TNF-alpha in group A was significantly greater than that in group C, lasting until postoperative day 5 (IL-1 beta) and postoperative day 10 (TNF-alpha). The levels of plasma endotoxin increased significantly in all groups, with a peak at day 1 after operation, and the peak levels were significantly higher in group A than in groups B and C. There was a significant correlation between the peak levels of in vitro TNF-alpha production and the peak levels of plasma endotoxin (r2= .331, p < .01).ConclusionsThe augmented enhancement of the priming of PBMC as a result of surgery in patients undergoing simultaneous resection of the liver and gastrointestinal tract, together with the reduced synthesis of the acute-phase reactants and impaired host defense mechanisms, might be responsible for the high incidence of postoperative complications, possibly because subsequent exposure of primed macrophages/monocytes to triggering substances such as endotoxin and bacterial components after operation results in inappropriate production of inflammatory cytokines. (Crit Care Med 1999; 27:929-936)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo describe the use of bacterial DNA amplification of conserved bacterial 16S ribosomal DNA nucleotide sequences by polymerase chain reaction (PCR) to detect the presence of septicemia in critically ill septic patients.DesignCase series of blood samples from septic patients comparing the PCR results with conventional blood culture results.SettingA general intensive care unit in a tertiary referral hospital.PatientsTwo sets of samples (n = 101 and n = 55) from patients diagnosed as clinically septic and requiring blood cultures. They were classified by internationally accepted criteria into systemic inflammatory response syndrome, severe sepsis, and septic shock groups.InterventionsBlood samples taken in a sterile fashion concurrently for blood culture, and PCR of the bacterial 16S ribosomal RNA gene in leukocytes and plasma. Two different DNA extraction techniques for PCR were tried sequentially.Measurements and Main ResultsBlood culture and PCR positivity were measured in relation to the clinical classification of severity of sepsis. Using the initial extraction method (n = 101), ten patients were positive by both PCR and blood culture, eight patients were PCR positive and blood culture negative, and seven patients were blood culture positive and PCR negative. From the clinical criteria, PCR detected at least six true positives that had been missed on blood culture and missed four true Gram-positive bacteremias. When the initial code was broken, this deficiency was rectified using the improved extraction technique (n = 55), in which ten patients were positive by PCR and blood culture, 29 patients were PCR positive and blood culture negative, and two patients were PCR negative and PCR positive.ConclusionsWe conclude that the use of PCR (for the 16S ribosomal DNA in the plasma) was significantly more sensitive than the use of conventional blood culturing techniques for the detection of bacteremia in seriously ill patients. This could prove to be a valuable adjunct to conventional blood cultures. (Crit Care Med 1999; 27:937-940)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo date, studies of partial liquid ventilation (PLV) have examined its effects acutely in anesthetized and mechanically ventilated subjects. We set out to develop a model of prolonged PLV in awake, spontaneously breathing animals.DesignAnimal case seriesSettingCardiopulmonary physiology laboratory.SubjectsFifteen New Zealand white rabbits (3.2 +/- 0.39 kg).InterventionsAnimals were anesthetized and instrumented with a novel technique allowing percutaneously assisted placement of an intratracheal catheter with a subcutaneously tunneled externalized free end. After anesthetic recovery, PLV was performed in spontaneously breathing unsedated animals.Measurements and Main ResultsEvaporative losses were determined using a single 10 mL/kg perflubron dose (n = 5); hourly radiographs were obtained until residual perflubron was minimal. For prolonged PLV (n = 10), a 10-mL/kg initial perflubron dose was followed every 4 hrs with 5-mL/kg supplements. Radiographs were obtained immediately before and after perflubron administration and were scored (0-5) by a radiologist blinded to dosing regimen and time Interval. Data were analyzed with ANOVA and Student's t-test with correction for multiple comparisons. Initial filling was nearly complete (score = 4.8 +/- 0.42); lungs were maintained approximately half-filled through 4 hrs (score = 2.53 +/- 0.71). By 6 hrs, the majority of perflubron had evaporated (score = 1.75 +/- 0.53). Over 24 hrs, radiographs documented continuous perflubron exposure (postfill = 4.53 +/- 0.64, prefill = 3.40 +/- 0.71, average = 3.97 +/- 0.43); scores were comparatively higher after filling (after = 4.53 +/- 0.64, before = 3.4 +/- 0.71, p < .001). Left and right lung volumes were equivalent (left = 4.06 +/- 0.47, right = 3.89 +/- 0.39, p = .027). All animals survived the 24 hrs of PLV.ConclusionsPercutaneously assisted intratracheal cannulation with catheter exteriorization permits prolonged PLV in spontaneously breathing, unsedated animals. Continuous perfluorocarbon exposure with this method is reproducible, consistent, and well tolerated for 24 hrs in uninjured animals. (Crit Care Med 1999; 27:941-945)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID