摘要:

ObjectiveComparison of oscillometric blood pressure measurement with two different devices (M3000A using a new algorithm and M1008A using an established algorithm, both Hewlett Packard) and evaluation of current recommendations concerning the relation between cuff size and upper arm circumference in critically ill patients.DesignProspective data collection.SettingEmergency department in a 2000-bed inner-city hospital.PatientsA total of 30 patients categorized into three groups according to their upper arm circumference (I, 18–25 cm; II, 25.1–33 cm; III, 33.1–47.5 cm) were enrolled in the study protocol.InterventionsIn each patient, two noninvasive blood pressure devices with three different cuff sizes were used to perform oscillometric blood pressure measurement. Invasive mean arterial blood pressure measurement was done by cannulation of the radial artery.Measurement and Main ResultsOverall, 1,011 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 30 patients (group I, n = 10; group II, n = 10; group III, n = 10). The overall discrepancy between both methods with the M3000A was −2.4 ± 11.8 mm Hg (p< .0001) and, with the M1008A, −5.3 ± 11.6 mm Hg (p< .0001) if the recommended cuff size according to the upper arm circumference was used (352 measurements). If smaller cuff sizes than recommended were used (308 measurements performed in group II and III), the overall discrepancy between both methods with the M3000A was 1.3 ± 13.4 mm Hg (p< .024) and, with the M1008A, −2.3 ± 11.5 mm Hg (p< .0001).ConclusionThe new algorithm reduced the overall bias of the oscillometric method but still showed a significant discrepancy between both methods of blood pressure measurement, primarily due to the mismatch between upper arm circumference and cuff size. The improvement of the algorithm alone could not result in a sufficient improvement of oscillometric blood pressure measurement. A reevaluation of the recommendations concerning the relation between upper arm circumference and cuff size are urgently required if oscillometric blood pressure measurement should become a reasonable alternative to intra-arterial blood pressure measurement in critically ill patients.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveEndotracheal intubation is the gold standard for providing emergency ventilation, but acquiring and maintaining intubation skills may be difficult. Recent reports indicate that even in urban emergency medical services with a high call volume, esophageal intubations were observed, requiring either perfect intubation skills or development of alternatives for emergency ventilation.DesignSimulated emergency ventilation in apneic patients employing four different airway devices that used small tidal volumes.SettingUniversity hospital operating room.SubjectsForty-eight ASA I/II patients who signed written informed consent before being enrolled into the study.InterventionsIn healthy adult patients without underlying respiratory or cardiac disease who were breathing room air before undergoing routine induction of surgery, 12 experienced professional paramedics inserted either a laryngeal mask airway (n = 12), Combitube (n = 12), or cuffed oropharyngeal airway (n = 12) or placed a face mask (n = 12) before providing ventilation with a pediatric (maximum volume, 700 mL) self-inflating bag with 100% oxygen for 3 mins.Measurements and Main ResultsIn three of 12 cuffed oropharyngeal airway patients, two of 12 laryngeal mask airway patients, and one of 12 Combitube patients, oxygen saturation fell below 90% during airway device insertion, and the experiment was terminated; no oxygenation failures occurred with the bag-valve-mask. Oxygen saturation decreased significantly (p< .05) during insertion of the Combitube and laryngeal mask but not with the bag-valve-mask and cuffed oropharyngeal airway; however, oxygen saturation increased after 1 min of ventilation with 100% oxygen. No differences in tidal lung volumes were observed between airway devices.ConclusionsParamedics were able to employ the laryngeal mask airway, Combitube, and cuffed oropharyngeal airway in apneic patients with normal lung compliance and airways. In this population, bag-valve-mask ventilation was the most simple and successful strategy. Small tidal volumes applied with a pediatric self-inflating bag and 100% oxygen resulted in adequate oxygenation and ventilation.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveIschemia/reoxygenation following cardiopulmonary resuscitation might cause endothelial injury/activation that could contribute to an adverse outcome after cardiopulmonary resuscitation. We studied plasma concentrations of von Willebrand factor (vWF) antigen and soluble intracellular adhesion molecule (sICAM)-1 as markers of a generalized endothelial injury/activation in relation to outcome after cardiopulmonary resuscitation.DesignRetrospective study on stored plasma samples.SettingIntensive care unit at a university hospital.PatientsThirty-five patients who survived >24 hrs after in- or out-of-hospital cardiopulmonary resuscitation and 15 noncritically ill control patients.InterventionsBlood sampling.Measurements and Main ResultsPlasma concentrations of vWF antigen and sICAM-1 on day 2 after cardiopulmonary resuscitation were higher in patients than in controls (p< .001 andp= .001, respectively). In-hospital cardiopulmonary resuscitation, cardiopulmonary resuscitation duration ≥15 mins, severe cardiovascular failure, and renal dysfunction/failure at the time of blood sampling were associated with significant elevations in vWF antigen and sICAM-1 concentrations. Patients with an unfavorable outcome after cardiopulmonary resuscitation (cerebral performance category ≥3) exhibited higher vWF antigen and sICAM-1 concentrations than patients with good outcome (cerebral performance category 1–2;p< .001 andp= .097, respectively). Renal dysfunction/failure, severe cardiovascular failure, systemic inflammatory response syndrome, and cardiopulmonary resuscitation duration ≥15 mins were also associated with higher adverse outcome rates. Combination of these four variables into a cardiac arrest risk score (levels 0–4) showed adverse outcome rates of 100, 56, and 0% in patients with arrest scores of 4, 2–3, and 0–1, respectively. A vWF antigen concentration >166% was an independent predictor of outcome after cardiopulmonary resuscitation (p= .002) and was associated with increased adverse outcome rates in patients with cardiac arrest risk scores of 2–3. Furthermore, both vWF antigen concentrations >166% and sICAM-1 concentrations >500 ng/mL had 100% specificity for an adverse outcome in patients after out-of-hospital cardiopulmonary resuscitation but were less predictive in patients after in-hospital cardiopulmonary resuscitation.ConclusionsvWF antigen and sICAM-1 might be useful adjunctive variables for early determination of outcome in patients after successful out-of-hospital cardiopulmonary resuscitation.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess the relationship between concentrations of bronchoalveolar cytokines and bacterial burden (quantitative bacterial count) in intubated patients with a presumptive diagnosis of community-acquired pneumonia.DesignA cross-sectional and clinical investigation.SettingMedical/surgical and respiratory intensive care unit of a tertiary 1,200-bed medical center.PatientsAccording to the time course of community-acquired pneumonia at the time of study with bronchoalveolar lavage, 69 mechanically ventilated patients were divided into three subgroups: primary (n = 11), referral (n = 23), and treated (n = 35) community-acquired pneumonia.InterventionsBronchoalveolar lavage was performed in the most abnormal area on chest radiograph by fiberoptic bronchoscope. Bronchoalveolar lavage fluid was processed for quantitative bacterial culture. The concentrations of bronchoalveolar lavage cytokines (tumor necrosis factor-&agr;, interleukin-1&bgr;, interleukin-6, interleukin-8, and interleukin-10) also were measured.Measurements and Main ResultsThirty-two patients had a positive bacterial culture (bronchoalveolar lavage ≥103colony-forming units/mL).Pseudomonas aeruginosa,Acinetobacter baumannii,Staphylococcus aureus, andKlebsiella pneumoniaemade up 76% of pathogens recovered at high concentrations. The concentrations of bronchoalveolar lavage interleukin-1&bgr; were 199.1 ± 32.1 and 54.9 ± 13.0 pg/mL (mean ± se) in the patients with positive and negative bacterial culture, respectively (p< .001). Bronchoalveolar lavage interleukin-1&bgr; was significantly higher in the patients with a high bacterial burden (p< .001), with mixed bacterial infection (p< .001), and withP. aeruginosapneumonia (p< .001), compared with values in patients without these features. The relationship between bacterial load and concentrations of bronchoalveolar lavage interleukin-1&bgr; was very strong in the patients with primary and referral community-acquired pneumonia but was borderline in treated community-acquired pneumonia.ConclusionsThe common pathogens were similar to the core pathogens of hospital-acquired pneumonia, probably due to antibiotic effects, delayed sampling, and superimposed nosocomial infection. Since the concentration of bronchoalveolar lavage interleukin-1&bgr; was correlated with bacterial burden in the alveoli, it may be a marker for progressive and ongoing inflammation in patients who have not responded to pneumonia therapy and who have persistence of bacteria in the lung.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe purpose of this study was to determine the prognostic value of sublingual Pco2(PSLco2), lactate concentration, and mixed venous oxygen saturation (SMVo2) in hemodynamically unstable intensive care patients and, additionally, to compare the temporal changes of these variables in response to treatment.SettingMedical/surgical intensive care unit.SubjectsFifty-four patients, mean age 58 ± 8 yrs.InterventionsOxyhemodynamic variables, arterial lactate concentration, and PSLco2were recorded in unselected sequential intensive care patients undergoing pulmonary artery catheterization. A data set was obtained immediately after insertion of the pulmonary artery catheter and repeated 4 and 8 hrs later.Measurements and Main ResultsTwenty-one patients had severe sepsis or septic shock. Twenty-seven (50%) patients died. The initial PSLco2–Paco2gradient (PSLco2-diff) and the initial PSLco2were highly predictive of outcome (p= .0004 andp= .004, respectively); however, there was no difference in the arterial lactate concentration and SMVo2between the survivors and nonsurvivors. The PSLco2-diff had the best receiver operator characteristic characteristics (area under the curve, 0.75), with a PSLco2-diff >25 mm Hg being the best discriminator of outcome. With treatment, the PSLco2-diff decreased in both survivors and nonsurvivors; however, the lactate and SMVo2remained relatively unchanged during the study period.ConclusionsThe baseline PSLco2-diff and PSLco2were better predictors of outcome than traditional markers of tissue hypoxia and were more responsive to therapeutic interventions. The PSLco2-diff and/or PSLco2may prove to be a useful marker for goal-directed therapy and for assessing the response to clinical interventions aimed at improving tissue oxygenation.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether use of a hygroscopic heat and moisture exchanger (HME) for 48 hrs without change affects its efficiency and the level of bacterial colonization in long-term mechanically ventilated medical intensive care unit patients.DesignProspective, randomized clinical study evaluating two hygroscopic HMEs.SettingMedical intensive care unit at a university teaching hospital.PatientsLong-term mechanically ventilated medical intensive care unit patients, including chronic obstructive pulmonary disease patients.InterventionsPatients were randomly allocated to one of the two HMEs studied (Hygrolife and EdithFlex) and changed every 48 hrs. Devices in both groups could be changed if hygrometric measurements indicated insufficient humidity delivery.Measurements and Main ResultsDaily measurements of inspired gas temperature and relative and absolute humidity. In addition, cultures of tracheal aspirations and both patient and ventilator sides of the device were performed after 48 hrs of use. Ventilatory variables and clinical indicators of efficient humidification were also recorded. Prolonged use of both HMEs was safe and efficient (no tracheal tube occlusion occurred). Mean duration of mechanical ventilation was 20 days. Both clinical indicators and hygrometric measurements showed that both devices performed well during 48 hrs. Absolute humidity with EdithFlex was significantly higher on day 0 and day 1 than with Hygrolife. Absolute humidity measured in chronic obstructive pulmonary disease patients was identical to that measured in the rest of the study population. Tracheal colonization and HME colonization were similar with both HMEs. Bacterial contamination of the ventilator side of both devices was markedly low.ConclusionsThese two purely hygroscopic HMEs provided safe and efficient humidification during a 48-hr period of use in long-term mechanically ventilated medical intensive care unit patients, including chronic obstructive pulmonary disease patients. In addition, they maintained ventilatory circuits clean, despite the absence of filtering media. The cost of mechanical ventilation is consequently reduced.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo analyze quantitatively the relationship between sedation and resting energy expenditure or oxygen consumption in postoperative patients.DesignA prospective, clinical study.SettingAn eight-bed intensive care unit at a university hospital.PatientsThirty-two postoperative patients undergoing either esophagectomy or surgery of malignant tumors of the head and neck who required mechanical ventilation and sedation for ≥2 days postoperatively.InterventionsNone.Measurements and Main ResultsA total of 133 metabolic measurements were performed. Ramsay sedation scale (RSS), body temperature, and the dose of midazolam were evaluated at the time of the metabolic cart study. All patients received analgesia with buprenorphine at a fixed dose of 0.625 &mgr;g·kg−1·hr−1continuously. Midazolam was used for induction and maintenance of intravenous sedation after admission to the intensive care unit. The initial dose was 0.04 mg·kg−1·hr−1and was adjusted to achieve a desired depth of sedation at 3, 4, or 5 on the RSS every 4 hrs. The degree of sedation was classified into three states: light sedation (RSS 2–3; n = 49), moderate sedation (RSS 4; n = 39), and heavy sedation (RSS 5–6; n = 45).ResultsWith increasing the depth of sedation, oxygen consumption index (mL·min−1·m−2), resting energy expenditure index (REEI; kcal·day−1·m−2), and REE/basal energy expenditure (BEE) decreased significantly. Oxygen consumption index (mean ± sd), REEI, and REE/BEE were 151 ± 18, 1032 ± 120, and 1.29 ± 0.17 in the light sedation, 139 ± 22, 947 ± 143, and 1.20 ± 0.16 in the moderate sedation, and 125 ± 16, 865 ± 105, and 1.13 ± 0.12 in the heavy sedation, respectively.ConclusionAn increase in the depth of sedation progressively decreases in oxygen consumption index and REEI in postoperative patients.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess morbidity in patients with severe sepsis managed with and without drotrecogin alfa (activated).DesignAnalysis of secondary end points in a prospective, randomized, double-blind, placebo-controlled, multicenter, phase 3 trial (PROWESS).SettingA total of 164 medical institutions in 11 countries.PatientsA total of 1,690 consecutive adult patients with severe sepsis.InterventionsA 96-hr infusion of drotrecogin alfa (activated) (human recombinant activated protein C) or placebo.Measurements and Main ResultsSequential Organ Failure Assessment (SOFA) scores for cardiovascular, respiratory, renal, hematologic, and hepatic organ systems were measured for 28 days. Mean cardiovascular SOFA scores were significantly lower for patients treated with drotrecogin alfa (activated) compared with placebo patients over this time period (p= .022). Drotrecogin alfa (activated)–treated patients also showed significantly faster resolution of cardiovascular (p= .009) and respiratory (p= .009) dysfunction and significantly slower onset of hematologic organ dysfunction (p= .041) compared with placebo patients for days 1 to 7. No significant differences in morbidity were observed between treatment groups among 28-day survivors.ConclusionDrotrecogin alfa (activated) demonstrated significant improvements in organ function compared with placebo in a large phase 3 clinical trial that has shown a mortality benefit in patients with severe sepsis.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveWe evaluated the variable Kt/V, which has become established in the therapy of end-stage renal disease in acute renal failure, to assess the influence of the filtration volume of continuous venovenous hemofiltration on Kt/V. We measured the variables of acid-base balance and uremia control.DesignProspective interventional pilot study.SettingMedical intensive care unit of a university hospital.PatientsFifty-six patients with acute renal failure and continuous venovenous hemofiltration treatment.InterventionsThe patients were consecutively treated with a filtration volume of either 1 L/hr (group 1) or 1.5 L/hr (group 2).Measurements and Main ResultsPatients with a filtration volume of 1.5 L/hr achieved a Kt/V of 0.8 per day, which was significantly higher than in the patient group treated with 1 L/hr (0.53,p< .05). The filtration volume of 1.5 L/hr led to a markedly better control of blood urea nitrogen concentrations, 69.3 ± 6.6 mg/dL vs. 52.1 ± 5.2 (p< .05), and to a much quicker and longer lasting compensation of acidosis. Both groups had acidotic pH at the beginning of therapy (group 1, 7.29 ± 0.02; group 2, 7.29 ± 0.02, nonsignificant). In group 2, a significantly higher pH value than in group 1 was measured after 24 hrs of continuous venovenous hemofiltration (p< .001; 7.39 ± 0.02 vs. 7.31 ± 0.02). The pH values in group 1 did not normalize until after 4 days. The filtration volume of 1.5 L/hr led to a quicker increase in bicarbonate concentrations after 24 hrs of therapy (group 1, 2.8 ± 3.2 mmol/L; group 2, 6.5 ± 3.1 mmol/L,p< .001).ConclusionsThe standardized urea clearance Kt/V is a valuable tool in the treatment of acute renal failure. Higher Kt/V levels were associated with a better control of uremia and acid-base balance. However, there were no differences in the clinical course, patient survival, percentage of patients with or without renal failure who were transferred from the intensive care unit, or Acute Physiology and Chronic Health Evaluation III scores.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo compare the survival of patients in a teaching hospital pediatric intensive care unit in which residents provided after-hours in-house coverage with survival in the same unit with hospitalists providing this coverage.DesignRetrospective cohort study.SettingPediatric intensive care units in two teaching hospitals that are managed by the same group of academic pediatric intensivists, one of which transitioned from the traditional resident-staffed model to a hospitalist-staffed model for after-hours in-house coverage.PatientsAll pediatric patients admitted to the study pediatric intensive care unit and to the control pediatric intensive care unit from April 1997 through March 1998, the resident era, and from October 1998 through September 1999, the hospitalist era.InterventionsMultivariate analysis, with survival as the dependent variable and era (hospitalist vs. resident) as an independent variable, was used to compare odds of survival during the hospitalist era with that of the resident era, adjusted for severity of illness. Multivariate linear regression was used to compare length of stay during the hospitalist era with that of the resident era, adjusted for severity of illness. Pediatric Risk of Mortality scores and those diagnostic categories typically associated with higher mortality rates also were included as independent variables in both analyses to adjust for severity of illness.Measurements and Main ResultsMultivariate analysis yielded an estimated odds ratio of survival of 2.8 for the hospitalist era compared with the resident era (p= .013), and our analysis supported an independent association between survival and hospitalist era. Multivariate linear regression showed that length of stay, also adjusted for severity of illness, during the hospitalist era was 21.1 hrs shorter than during the resident era (p= .013). Neither survival nor length of stay was significantly associated with era at the control hospital.ConclusionImproved survival with hospitalists, rather than residents, providing after-hours care when an intensivist is not in house suggests that the quality of care of critically ill patients is improved when more experienced physicians are providing bedside care. Shorter length of stay with the hospitalist model also may reflect improved quality of care.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID