摘要:

ObjectiveTo evaluate the adequacy, tolerance, and complications of enteral nutrition, compared with parenteral nutrition, in pediatric patients requiring extracorporeal membrane oxygenation (ECMO).DesignA retrospective chart review of all patients placed on extracorporeal life support from January 1991 through December 1995.SettingMedical/surgical pediatric intensive care unit at Egleston Children's Hospital, a tertiary care pediatric center.PatientsTwenty-nine consecutive pediatric patients who required ECMO and were provided nutritional support, either enterally or parenterally. Group A consisted of 14 patients who were provided nutritional support using total parenteral nutrition. Group B consisted of 15 patients. Two patients were excluded from group B because their ECMO run was <36 hrs, leaving insufficient data for analysis. The remaining 13 patients were provided total enteral nutrition during ECMO.InterventionsNone.Measurements and Main ResultsBoth groups were similar in age, weight, pre-ECMO oxygenation index, alveolar-arterial oxygen difference, type, and duration of ECMO (p = NS). Comparison of percent ideal body weight on admission did not show a statistical difference between groups A and B (p = .883). There was no difference between the two groups in the time needed to achieve caloric goal (p = .536) from the initiation of ECMO. No complications were associated with the utilization of enteral feedings. Savings for the nutritional supplement was estimated to be $170 per day for the enterally fed group. The percentage of patients surviving was higher in the enterally fed patients compared with the parenterally fed group (79% vs. 100%), although this difference was not statistically significant (p = .47).ConclusionsEnteral nutrition in patients receiving either venoarterial or venovenous ECMO is well tolerated, provides adequate nutrition, is cost effective, and is without complications, as compared with parenteral nutrition. These data suggest that total enteral nutrition can be safely administered for nutritional support in pediatric patients undergoing either venoarterial or venovenous ECMO. (Crit Care Med 1998; 26:358-363)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectivesWhen ventilating a nonintubated patient in cardiac arrest, the European Resuscitation Council has recently recommended a decrease in the tidal volume from 0.8 to 1.2 L to 0.5 L, partly in an effort to decrease peak flow rate, and therefore, to minimize stomach inflation. The purpose of the present study was to examine the validity of the European Resuscitation Council's recommendation in terms of gas distribution between lungs and stomach in a bench model that simulates ventilation of a nonintubated patient with a self-inflatable bag representing tidal volumes of 0.5 and 0.75 L.DesignA bench model of a patient with a nonintubated airway was used consisting of face mask, manikin head, training lung (lung compliance, 50 mL/cm H2O; airway resistance, 5 cm H2O/L/sec), adjustable lower esophageal sphincter pressure (LESP) and simulated stomach.SettingUniversity hospital laboratory.SubjectsThirty healthcare professionals.InterventionsHealthcare professionals performed 1-min bag-mask ventilation at each LESP level of 5, 10, and 15 cm H2O at a rate of 12 breaths/min, using an adult and pediatric self-inflating bag, respectively. Volunteers were blinded to the LESP, which was randomly varied.Measurements and Main ResultsBoth types of self-inflating bags induced stomach inflation, with higher stomach and lower lung tidal volumes when the LESP was decreased. Lung tidal volume with the pediatric bag was significantly (p < .05) lower at all LESP levels when compared with the adult bag, and ranged between 240 mL at an LESP of 15 cm H2O and 120 mL at an LESP of 5 cm H2O. Stomach tidal volume with the adult bag ranged between 250 mL at an LESP of 15 cm H2O and increased to 550 mL at an LESP of 5 cm H2O. Stomach tidal volume with the pediatric bag was significantly lower (p < .05) at all LESP levels when compared with the adult bag and ranged between 70 mL at an LESP of 15 cm H2O and 300 mL at an LESP of 5 cm H2O.ConclusionsOur data support the recommendation of the European Resuscitation Council to decrease tidal volumes to 0.5 L when ventilating a cardiac arrest victim with an unprotected airway. A small tidal volume may be a better trade-off in the basic life support phase, as this may provide reasonable ventilation while avoiding massive stomach inflation. (Crit Care Med 1998; 26:364-368)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo review acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) in light of recent information about the definitions, epidemiology, pathophysiology, management, and outcome of these conditions.Data SourcesThe author's personal files as well as the computerized MEDLINE database.Study SolutionStudies were selected for their relevance to the conditions of ALI and ARDS.Data ExtractionThe author extracted all applicable data.Data SynthesisThe diagnostic criteria for ALI and ARDS include a) acute onset; b) bilateral chest radiographic infiltrates; c) a pulmonary artery occlusion pressure of <or=to18 mm Hg or no evidence of left atrial hypertension; and d) impaired oxygenation manifested by a PaO2/FIO2ratio of <or=to300 torr (<or=to40 kPa) for ALI and <or=to200 torr (<or=to27 kPa) for ARDS. The incidence of ALI and ARDS are [approximately]70 and 7 patients out of 100,000 of the total U.S. population per year, respectively. The conditions result from direct or indirect injury to the pulmonary epithelium and endothelium that causes edema, atelectasis, inflammation, and fibrosis. This "diffuse alveolar damage" is actually patchy in many patients. Therapy of ALI and ARDS is largely supportive, although new approaches in mechanical ventilation, patient positioning, and pharmacologic therapy have been introduced. The mortality rate of ARDS has improved to <50%, but the reasons for this improvement are unclear.ConclusionALI and ARDS are better defined and understood than ever before, and their outcome has improved for unclear reasons. (Crit Care Med 1998; 26:369-376)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo develop practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice.ParticipantsA task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine, and the Infectious Disease Society of America.EvidenceThe task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four categories, according to study design and scientific value.Consensus ProcessThe task force met several times in person and twice monthly by teleconference over a 1-yr period of time to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts' opinions. Draft documents were composed and debated by the task force until consensus was reached by nominal group process.ConclusionsThe panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if it is indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether or not infection is present, so additional testing can be avoided and therapeutic options can be made. (Crit Care Med 1998; 26:392-408)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo describe our experience with the use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy in adult patients with severe cardiopulmonary failure from Hantavirus pulmonary syndrome.DesignCase series.SettingTertiary referral center.PatientsPatients with confirmed Hantavirus infection, who developed severe cardiopulmonary failure in which conventional therapy was assessed as being unsuccessful.InterventionsRecords of previous patients treated for Hantavirus pulmonary syndrome were reviewed and findings consistent with 100% mortality were found.Measurements and Main ResultsFindings associated with a 100% mortality rate were a) cardiac index of <2.5 L/min/m24.0 mmol/L (normal range 0.0 to 2.2); c) pulseless electrical activity or ventricular fibrillation or ventricular tachycardia; and d) refractory shock despite fluid resuscitation, and vasoactive medications. From 1994 to 1996, seven patients were admitted with confirmed Hantavirus pulmonary syndrome and severe cardiopulmonary failure. Three of the seven patients had at least two of the four criteria for a 100% morality rate listed above, and appeared to be failing optimal conventional therapy. These three patients received support with venoarterial ECMO. The first patient was placed on ECMO during cardiac arrest and died. The next two patients who received ECMO for Hantavirus pulmonary syndrome survived after relatively short, uncomplicated ECMO runs, and were discharged without complications.ConclusionsECMO successfully provided cardiopulmonary support in two patients with severe Hantavirus pulmonary syndrome who survived with a good outcome. Our experience suggests that ECMO is a beneficial therapy for patients critically ill with Hantavirus [ulmonary syndrome. (Crit Care Med 1998; 26:409-414)

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1998

数据来源: OVID