摘要:

ObjectiveTo assess physician decision-making in triage for intensive care and how judgments impact on patient survival.DesignProspective, descriptive study.SettingGeneral intensive care unit, university medical center.InterventionsAll patients triaged for admission to a general intensive care unit were studied. Information was collected for the patient's age, diagnoses, surgical status, admission purpose, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mortality. The number of available beds at the time of triage and reasons for refused admission were obtained.Measurements and Main ResultsOf 382 patients, 290 were admitted, 92 (24%) were refused admission, and 31 were admitted at a later time. Differences between admission diagnoses were found between patients admitted or not admitted (p < .001). Patients refused admission had higher APACHE II scores (15.6 +/- 1.5 admitted later and 15.8 +/- 1.4 never admitted) than did admitted patients (12.1 +/-.4; p < .001). The frequency of admitting patients decreased when the intensive care unit was full (p < .001). Multivariate analysis revealed that triage to intensive care correlated with age, a full unit, surgical status, and diagnoses. Hospital mortality was lower in admitted (14%) than in refused patients (36% admitted later and 46% never admitted; p < .01) and in admitted patients with APACHE II scores of 11 to 20 (p = .02). The 28-day survival of patients was greater for admitted patients compared with patients never admitted (p = .01).ConclusionsPhysicians triage patients to intensive care based on the number of beds available, the admission diagnosis, severity of disease, age, and operative status. Admitting patients to intensive care is associated with a lower mortality rate, especially in patients with APACHE scores of 11 to 20. (Crit Care Med 1999;27:1073-1079)

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 the extent of the potentially protective heat shock protein 70 response in peripheral blood lymphocytes of patients with severe sepsis after ex vivo lipopolysaccharide stimulation.DesignEntry study of consecutive patients with severe sepsis, those who were critically ill or nonseptic after major surgery, and healthy blood donors.SettingSurgical intensive care unit in a university hospital.PatientsTen patients with diagnoses of severe sepsis; ten critically ill, nonseptic patients after major surgery; and ten healthy blood donors.InterventionsNone.Measurements and Main ResultsWe investigated the ex vivo endotoxin-inducible expression of heat shock protein 70 in peripheral blood lymphocytes of patients with severe sepsis by means of flow cytometry. Only negligible amounts of inducible intracellular heat shock protein 70 accumulation (<4.2% of lymphocytes) could be detected in peripheral blood lymphocytes without lipopolysaccharide stimulation. The proportion of cells accumulating heat shock protein 70 after treatment with lipopolysaccharide was distinctly lower in patients with severe sepsis (p < .05) than in critically ill, nonseptic patients after major surgery and healthy blood donors (38.3 +/- 3.3%, 82.2 +/- 4.5%, and 70.9 +/- 3.9%, respectively; mean +/- SEM; n = 10). Patients with clinical signs of recovery from severe sepsis showed an increase in heat shock protein 70 expression.ConclusionsInducibility of ex vivo heat shock protein 70 was impaired in peripheral blood lymphocytes of patients with severe sepsis. The impaired expression of the potentially protective heat shock protein 70 may contribute in vivo to immune dysfunction, because intact functioning of T and B lymphocyte responses is of central importance in resisting infection in severe sepsis. Monitoring of inducible heat shock protein 70 in peripheral blood lymphocytes may contribute to the evaluation of the immune consequences of severe sepsis. (Crit Care Med 1999; 27:1080-1084)

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:

ObjectivesTo evaluate the usefulness of a novel qualitative, rapid, bedside immunoassay device for the detection of elevated creatine kinase MBmass(CK-MB) and myoglobin as a supportive tool for decision-making by the physician who is evaluating patients who present with chest pain.DesignProspective study.SettingPrehospital (mobile intensive care units).PatientsThree hundred twenty-eight consecutive patients, age 71 +/- 13 yrs (64% males), who were admitted to the hospital via Shahal's mobile intensive care units.InterventionDuring a 6-month period, based on clinical presentations and electrocardiograms, the mobile's physicians classified patients into groups of high or low probability of having an acute myocardial infarction and, thereafter, used a rapid bedside STATus kit[registered sign] (Spectral Diagnostics, Toronto, Ontario, Canada) to determine blood creatine kinase/MB and myoglobin.Measurements and Main Results2 hrs after onset, diagnostic sensitivities, specificities, and positive and negative predictive values for physicians were as follows: 71%, 90%, 46%, and 96%, respectively, compared with 100%, 85%, 44%, and 100%, respectively, if assessed by the kit.ConclusionsIf used 2 to 12 hrs from the onset of symptoms, this device is a convenient diagnostic aid to prevent a misdiagnosis of acute myocardial infarction or unnecessary hospitalization to exclude infarction. This tool may be a promising cost-cutting factor in these days of escalating expenses and dwindling resources. (Crit Care Med 1999; 27:1085-1089)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo define the epidemiology of broad-spectrum cephalosporin-resistant Gram-negative bacilli in intensive care units (ICUs) during a nonoutbreak period, including the prevalence, the risk factors for colonization, the frequency of acquisition, and the rate of infection.DesignProspective cohort study.SettingTertiary care hospital.PatientsConsecutive patients admitted to two surgical ICUs.Main Outcome MeasurementsSerial patient surveillance cultures screened for ceftazidime (CAZ) resistance, antibiotic and hospital exposure, and infections.Resultsor=to3 days, 26% acquired a CAZ-RGN. Of the 14 infections caused by CAZ-RGN, 11 (79%) were attributable to the same species present in surveillance cultures at admission to the surgical ICU.ConclusionsColonization with CAZ-RGN was common and was usually not recognized by clinical cultures. Most patients colonized or infected with CAZ-RGN had positive surveillance cultures at the time of admission to the surgical ICU, suggesting that acquisition frequently occurred in other wards and institutions. Patients exposed to first-generation cephalosporins, as well as broad-spectrum cephalosporins/penicillins, were at high risk of colonization with CAZ-RGN. Empirical treatment of nosocomial Gram-negative infections with broad-spectrum cephalosporins, especially in the critically ill patient, should be reconsidered. (Crit Care Med 1999; 27:1090-1095)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectivesTo characterize the decreases in pulmonary artery temperature that coincide with the inflation cycle of pneumatic calf compression stockings and to examine their effects on the thermodilution measurement of cardiac output.DesignThree-part observational study.SettingUniversity hospital surgical intensive care unit.PatientsPostoperative patients with indwelling pulmonary artery catheters.InterventionThermodilution cardiac output measurements with and without pneumatic calf compression.Measurements and Main ResultsPhase 1 (n = 18) examined the effects of pneumatic compression on pulmonary artery temperature. There was no effect on pulmonary artery temperature (device off, 37.468 +/- 0.008[degree sign]C; device on, 37.458 +/- 0.014[degree sign]C), but the difference between the maximum and minimum pulmonary artery temperatures was increased (off, 0.031 +/- 0.006[degree sign]C; on, 0.055 +/- 0.012[degree sign]C [p < .001]). Phase 2 (n = 12) found that the mean thermodilution cardiac output with 10 mL of cold (0-5[degree sign]C) injectate was unchanged by pneumatic compression (off, 7.00 +/- 2.28 L/min; on, 6.89 +/- 2.22 L/min). However, when the compression devices were operating, the variability between the individual measurements was increased, as reflected by larger coefficients of variation (off, 3.19 +/- 1.96; on, 8.72 +/- 6.56 [p < .02]). Similar results were obtained during phase 3 (n = 5), when cardiac output was measured with room temperature Injectate.ConclusionsIntermittent pneumatic calf compression increased lower limb venous return, causing acute but transient decreases in pulmonary artery blood temperature. This did not affect the accuracy of thermodilution cardiac output measurements that were made using 10 mL of either cold or room temperature injectate. (Crit Care Med 1999; 27:1096-1099)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectivesTo investigate whether prolonged infusion of N-acetylcysteine (NAC) that is commenced immediately after admission to the intensive care unit could ameliorate the development or progression of multisystem organ failure and improve mortality.DesignProspective, randomized, double-blinded clinical trial.SettingSix-bed intensive care unit in a teaching hospital.PatientsOf the 100 patients recruited (14 withdrew), 86 patients were studied.InterventionsAfter randomization, the treatment group (n = 41) received NAC (150 mg/kg bolus followed by a continuous infusion of 12 mg/kg/hr) and the placebo group (n = 45) received 5% dextrose, from a minimum of 3 days up to a maximum of 5 days.Measurements and Main ResultsThere was no statistically significant difference between the two groups regarding outcome as indicated by mortality and the required days of inotropic support, mechanical ventilation, and intensive care. The time interval between hospital and intensive care unit admission showed great variability, with a median of 24 hrs for the whole sample. By splitting the groups with this median value, the effect of NAC was examined on patients admitted within 24 hrs and after 24 hrs of arrival to the hospital. There was a nonsignificant difference in mortality in favor of NAC. Patients admitted after 24 hrs of hospital admission had a significantly worse mortality in the NAC-treated group (61% vs. 32% for controls; p = .05).Conclusions24 hrs after hospital admission may potentially be harmful, and further studies should be undertaken to investigate the clinical use of the early application of NAC in critically ill patients. (Crit Care Med 1999; 27:1100-1104)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo assess the frequency of hypernatremia in patients who were admitted to an intensive care unit (ICU) and to determine the correlation of hypernatremia with the clinical outcomes, durations of the patients' stays in the ICU, and other clinical variables.DesignRetrospective survey.SettingUniversity teaching hospital.PatientsAll patients (total, 389) who were admitted to the medical ICU of the department of internal medicine during 1 yr.Measurementsor=to150 mmol/L or more) were determined; the correlation of hypernatremia with clinical outcome, duration of ICU stay, Acute Physiology and Chronic Health Evaluation II scores, and other clinical variables were evaluated; and changes in fluid administration in response to hypernatremia and fluid regimens in the period preceding hypernatremia were examined.Main ResultsOf a total of 389 patients who were admitted in 1995, hypernatremia was present at admission in 34 patients (8.9%). The average duration of hypernatremia in these patients was 16.2 (range, 4-56) hrs. A total of 22 patients (5.7%) developed hypernatremia in the course of their stay in the ICU. The average duration of hypernatremia in this group was 34.7 (range, 4-89) hrs. Moderately elevated levels of sodium had been detected in most of these patients (n = 21) in the days before the development of severe hypernatremia; however, adjustments in fluid infusion aimed at preventing the occurrence of hypernatremia were either lacking (n = 7) or inadequate (n = 11). Hospital-acquired hypernatremia vs. hypernatremia present at admission to the ICU was associated with a higher mortality rate (32% vs. 20.3%, respectively; p < .01).ConclusionsDespite frequent measurement of sodium levels in patients in the ICU, hypernatremia is a relatively common occurrence. Initial treatment of hypernatremia is often inadequate, and sometimes treatment is delayed. The development of hypernatremia is associated with adverse outcomes for patients developing hypernatremia in the ICU. Hypernatremia could potentially be used as an indicator of quality of care in the medical ICU. (Crit Care Med 1999; 27:1105-1108)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo perform a descriptive study of patients with acute respiratory failure secondary to acquired immunodeficiency syndrome-related Pneumocystis carinii pneumonia and to identify variables that are predictive of death within 3 months.DesignCase series study.SettingInfectious disease intensive care unit (ICU) in a university hospital.PatientsDetailed clinical, laboratory, and ventilatory data were collected prospectively within 48 hrs of admission and during the ICU stay in 110 consecutive human immunodeficiency virus-infected patients requiring ICU management with or without mechanical ventilation for P. carinii pneumonia-related acute respiratory failure.Measurements and Main Resultsor=to5 days (OR, 2.8; 95% CI, 1.1-6.9), nosocomial infection (OR, 5.2; 95% CI, 2.1-12.9), and pneumothorax (OR, 5; 95% CI, 1.7-14.7) were predictive of death within 3 months of ICU admission. Among patients with delayed mechanical ventilation on day 3 or later and with a pneumothorax associated or not associated with a nosocomial infection, the predicted probability of 3-month death was close to 100%.ConclusionsOur data suggest that the most significant predictive factors of death were identifiable during the course of P. carinii pneumonia-related acute respiratory failure rather than at admission and can help in bedside decisions to withdraw intensive care support in such patients. (Crit Care Med 1999; 27: 1109-1115)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID