摘要:

ObjectiveTo determine whether mortality rate after intracerebral hemorrhage (ICH) is lower in patients admitted to a neurologic or neurosurgical (neuro) intensive care unit (ICU) compared to those admitted to general ICUs.BackgroundThe utility of specialty ICUs is debated. From a cost perspective, having fewer larger ICUs is preferred. Alternatively, the impact of specialty ICUs on patient outcome is unknown. Patients with ICH are admitted routinely to both general and neuro ICUs and provide an opportunity to address this question.SettingForty-two neuro, medical, surgical, and medical-surgical ICUs.Measurements and Main ResultsThe study was an analysis of data prospectively collected by Project Impact over 3 yrs from 42 participating ICUs (including one neuro ICU) across the country. The records of 36,986 patients were merged with records of 3,298 patients from a second neuro ICU that collected the same data over the same period. The impact of clinical (age, race, gender, Glasgow Coma Scale score, reason for admission, insurance), ICU (size, number of ICH patients, full-time intensivist, clinical service, American College for Graduate Medical Education or Critical Care Medicine fellowship), and institutional (size, location, medical school affiliation) characteristics on hospital mortality rate of ICH patients was assessed by using a forward-enter multivariate analysis. Data from 1,038 patients were included. The 13 ICUs that admitted >20 patients accounted for 83% of the admissions with a mortality rate that ranged from 25% to 64%. Multivariate analysis adjusted for patient demographics, severity of ICH, and ICU and institutional characteristics indicated that not being in a neuro ICU was associated with an increase in hospital mortality rate (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.65–7.6). Other factors associated with higher mortality rate were greater age (OR, 1.03/year; 95% CI, 1.01–1.04), lower Glasgow Coma Scale score (OR, 0.6/point; 95% CI, 0.58–0.65), fewer ICH patients (OR, 1.01/patient; 95% CI, 1.00–1.01), and smaller ICU (OR, 1.1/bed; 95% CI, 1.02–1.13). Having a full time intensivist was associated with lower mortality rate (OR, 0.388; 95% CI, 0.22–0.67).ConclusionsFor patients with acute ICH, admission to a neuro vs. general ICU is associated with reduced mortality rate.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveGuglielmi detachable coil (GDC) embolization may be used to prevent early rebleeding after aneurysmal subarachnoid hemorrhage, but anticoagulation and induced hypertension may increase this risk. We sought to determine retrospectively the relationship between levels of induced hypertension and anticoagulation and incidence of rebleeding in GDC-treated patients.MethodsTwenty-five consecutive patients with acute (<14 days) subarachnoid hemorrhage who underwent GDC embolization were retrospectively analyzed with regard to percent obliteration of an aneurysm on postprocedure angiogram, the duration and intensity of anticoagulation, the duration and level of induced hypertension, and the frequency of thromboembolic and rebleeding complications.ResultsComplete angiographic obliteration of the aneurysm was achieved in five cases (20%). In some cases (n = 2), only the dome of the aneurysm was coiled to allow eventual surgical clipping. Heparin was given to 23 patients (92%) for an average of 6 days (range, 8 hrs to 22 days); the mean dose was 588 units/hr, and the mean partial thromboplastin time was 37 secs. Seven patients (28%) were treated with vasopressors for symptomatic vasospasm for a mean duration of 5 days (range, 8 hrs to 9 days); mean arterial blood pressure averaged 118 mm Hg, and peak systolic blood pressures ranged from 195 to 250 mm Hg. There were no episodes of aneurysm rebleeding. Three patients (12%) suffered intraoperative thromboembolic complications, which in one instance was fatal; two of these cases were associated with subtherapeutic partial thromboplastin time values.ConclusionInduced hypertension (mean arterial blood pressure, 120 mm Hg) and heparinization do not appear to increase the risk of early rebleeding after GDC embolization. In a select group of patients, use of anticoagulation in the immediate perioperative period to prevent thromboembolic complications appears to be safe.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo compare the efficacy of single, multiple, and continuous application of perfluorocarbon (PFC) FC-77 on gas exchange and lung pathology in a prolonged 24-hr study.DesignControlled animal trial.SettingResearch laboratory in a university setting.SubjectsTwenty-one newborn piglets (mean weight 1.94 kg).InterventionsAfter intubation and instrumentation, the anesthetized animals were randomized in three groups: a) animals receiving one 1-hr session of partial liquid ventilation (PLV) followed by 23 hrs of conventional ventilation (CV), designated as the single PLV (S-PLV) group; b) animals receiving multiple 1-hr sessions of PLV with intermittent CV, designated as the multiple PLV (M-PLV) group; and c) animals receiving continuous PLV over 24 hrs, designated as the continuous PLV (C-PLV) group. After lung injury was induced with repeated saline lavage, specific ventilatory treatment was initiated. The oxygenation index, Pao2/Fio2ratio, and ventilatory efficacy index were determined before and after lung injury and during the 24-hr course. After 24 hrs, the lungs were removed for histopathologic examination.Measurements and Main ResultsGas exchange variables improved within 60 mins in all groups after the initiation of the specific ventilatory treatment (p< .01). The best outcome was observed in the C-PLV group, which provided a continuously stable gas exchange over the 24-hr period. S-PLV initially improved gas exchange, but after 6 hrs all variables were impaired when compared with C-PLV (p< .01). M-PLV transiently improved gas exchange variables after each PFC application; however, M-PLV was associated with a significant deterioration of all pulmonary variables during the 24-hr course. The lungs of the animals in the M-PLV group demonstrated an increased lung injury score (p< .01) and increased morphometric values (p< .05) when compared with C-PLV.ConclusionsIn surfactant deficient lungs, single and multiple applications of PFC only transiently improved oxygenation. Multiple PFC fillings with intermittent gas ventilation led to a deterioration of gas exchange during the 24-hr study and severe lung damage. Continuous PLV provides the best gas exchange and the most favorable histopathologic outcome.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveLength of stay in the pediatric intensive care unit (PICU) is a reflection of patient severity of illness and health status, as well as PICU quality and performance. We determined the clinical profiles and relative resource use of long-stay patients (LSPs) and developed a prediction model to identify LSPs for early quality and cost saving interventions.DesignNonconcurrent cohort study.SettingA total of 16 randomly selected PICUs and 16 volunteer PICUs.PatientsA total of 11,165 consecutive admissions to the 32 PICUs.InterventionsNone.Measurements and Main ResultsLSPs were defined as patients having a length of stay greater than the 95thpercentile (>12 days). Logistic regression analysis was used to determine which clinical characteristics, available within the first 24 hrs after admission, were associated with LSPs and to create a predictive algorithm. Overall, LSPs were 4.7% of the population but represented 36.1% of the days of care. Multivariate analysis indicated that the following factors are predictive of long stays: age <12 months, previous ICU admission, emergency admission, no CPR before admission, admission from another ICU or intermediate care unit, chronic care requirements (total parenteral nutrition and tracheostomy), specific diagnoses including acquired cardiac disease, pneumonia, and other respiratory disorders, having never been discharged from the hospital, need for ventilatory support or an intracranial catheter, and a Pediatric Risk of Mortality III score between 10 and 33. The performance of the prediction algorithm in both the training and validation samples for identifying LSPs was good for both discrimination (area under the receiver operating characteristics curve of 0.83 and 0.85, respectively), and calibration (goodness of fit,p= .33 andp= .16, respectively). LSPs comprised from 2.1% to 8.1% of individual ICU patients and occupied from 15.2% to 57.8% of individual ICU bed days.ConclusionsLSPs have less favorable outcomes and use more resources than non-LSPs. The clinical profile of LSPs includes those who are younger and those that require chronic care devices. A predictive algorithm could help identify patients at high risk of prolonged stays appropriate for specific interventions.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care.DesignCross-sectional survey.SettingA random sample of clinicians at 31 pediatric hospitals in the United States.Measurements and Main ResultsThe survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p< .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%;p< .003); that ethical issues are discussed well within the team (92% vs. 59%;p< .0003), and that ethical issues are discussed well with the family (91% vs. 79%;p< .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care.ConclusionsNearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Malaria is one of the most common infectious diseases in the world, and severe respiratory complications have been described mainly in association withPlasmodium falciparum. We describe a case of acute respiratory distress syndrome complicating infection withP. vivaxin the setting of relatively low parasitemia in a 47-yr-old woman after a brief trip to Papua New Guinea. A review of the literature shows that pulmonary complications ofP. vivaxare rare but occur more frequently than generally acknowledged. Pathogenic mechanisms of these complications are discussed.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveWhereas the antifungal azole ketoconazole interferes with steroidogenesis and can cause adrenal insufficiency, fluconazole in standard doses is thought to not interfere with cortisol production. The objective was to evaluate the effect of high-dose fluconazole therapy on adrenal function in critically ill patients in an intensive care setting.DesignDescriptive case reports.SettingMedical intensive care unit in a university hospital.PatientsTwo patients, a 77-yr-old man (case 1) with esophageal cancer and a 66-yr-old woman (case 2) with multiple organ failure developed reversible adrenal insufficiency temporally related to the institution and withdrawal of high-dose fluconazole.InterventionsShort cosyntropin (adrenocorticotropic hormone; ACTH) stimulation tests.Measurements and Main ResultsTwo days after high-dose fluconazole in case 1, the serum ACTH level was 121 pg/mL (normal range is 9–52 pg/mL), and the peak cortisol after ACTH stimulation was 15.5 &mgr;g/dL (normal response is ≥18 &mgr;g/dL). Eleven days after discontinuation of fluconazole, the peak cortisol level after ACTH stimulation was 43.4 &mgr;g/dL. Twenty-four hours after high-dose fluconazole in case 2, an ACTH stimulation test had a low peak serum cortisol of 16.8 &mgr;g/dL. Fluconazole was withdrawn, and 5 days later, the peak stimulated cortisol was 20.6 &mgr;g/dL.ConclusionsAlthough fluconazole is the therapy of choice for patients in the intensive care setting withCandidainfections, two patients with multiple organ failure who received high-dose fluconazole appeared to develop adrenal insufficiency. Although preliminary and anecdotal, these data suggest a need to further investigate the possibility that high-dose fluconazole might cause adrenal insufficiency in already compromised critically ill patients.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID