ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo more clearly define the relationships between plasma proinflammatory cytokine concentrations, physiologic disturbance, and survival in severely ill patients.DesignProspective, longitudinal, cohort analytic study.SettingTeaching hospital intensive care unit (ICU).PatientsTwo hundred fifty-one consecutive nonselected patients admitted to the ICU.InterventionsNone.Measurements and Main Resultsor=to10 days, and of these 19 patients, 16 patients had prolonged increases of plasma cytokines. Two patients with persistently increased plasma TNF concentrations died. Otherwise, persistently increased plasma cytokine concentrations had a variable relation to daily APACHE scores and to mortality.ConclusionsPlasma cytokine concentrations fluctuate in serious illness and have a poor correlation with derangement of whole body physiology in seriously ill patients. Only the presence of bioactive TNF in plasma was an independent predictor of mortality. Daily measurement of plasma proinflammatory cytokine concentrations is unlikely to have clinical application in the ICU setting, except possibly in specific subgroups of patients.(Crit Care Med 1996; 24:1775-1781)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveThe endothelial cell produces many bioactive compounds that are presumed to play important roles in the pathogenesis of the adult respiratory distress syndrome (ARDS). We postulated that individuals with sepsis and trauma--two at-risk diagnoses for the development of ARDS--might demonstrate differences in the degree of endothelial cell activity.DesignProspective cohort study.SettingIntensive care unit patients in a tertiary, university-affiliated, city hospital.PatientsFifty-five intensive care unit patients (19 with sepsis and 36 trauma patients).InterventionsPlasma measurements of three endothelial cell products--von Willebrand factor antigen, soluble intercellular adhesion molecule-1 (ICAM-1), and soluble E-selectin--were performed within 8 hrs of patients meeting our inclusion criteria, and at the clinical onset of ARDS.Measurements and Main ResultsTwenty-six percent of the septic patients and 25% of the trauma patients developed ARDS. The median (and 25% to 75% quartiles) concentrations of all three mediators measured in the sepsis patients (von Willebrand factor antigen 399% [375% to 452%], ICAM-1 573 ng/mL [470 to 980], and soluble E-selectin 180 ng/mL [81 to 340]) were significantly higher (p < .001 for each individual analysis) than in the trauma patients (von Willebrand factor antigen 256% [217% to 310%], ICAM-1 148 ng/mL [113 to 210], and soluble E-selectin 42 ng/mL [31 to 65 ng/mL]). In addition, neither the ICAM-1 nor soluble E-selectin concentrations measured in the trauma patients were different (p = .17 and p = .24, respectively) from normal controls. In those patients who developed ARDS, the differences in the concentrations of all three endothelial cell mediators between the sepsis and trauma patients persisted (p = .008 for von Willebrand factor antigen, p = .003 for ICAM-1, and p = .003 for E-selectin).ConclusionThese findings suggest that differences in endothelial cell activity exist between sepsis and trauma patients who are at risk for the development of ARDS.(Crit Care Med 1996; 24:1782-1786)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo study the immunomodulatory effect of the histamine receptor antagonist, ranitidine, in patients admitted to the intensive care unit after severe head injury.DesignRandomized, prospective, double-blind study.SettingSurgical intensive care unit of a university Level I trauma center.PatientsTwenty patients admitted with a Glasgow Coma Scale score of <10 who were enrolled as part of a prospective, multicenter trial to assess the impact of multiple risk factors and ranitidine prophylaxis on the development of stress-related upper gastrointestinal bleeding.InterventionsContinuous infusion of ranitidine at 6.25 mg/hr (n = 9) or placebo (n = 11) for a maximum of 5 days.Measurements and Main ResultsBefore the patients were enrolled in the study and on completion of treatment, lymphocyte cell-surface antigen expression was determined by flow cytometry (n = 14 patients); mitogen-stimulated interferon-gamma and interleukin-2 production were measured by enzyme-linked immunosorbent assay (n = 19 patients). Treatment with ranitidine, but not placebo, was associated with a significant increase in CD4+ lymphocytes (33% to 49%; p < .05) and a significant decrease in CD8+ lymphocytes (41% to 27%; p < .05). Also, the mitogen-stimulated interferon-gamma production increased from 121 to 269 pg/mL (p < .05) in patients treated with ranitidine, but not in patients treated with placebo. There were no significant differences in interleukin-2 production or circulating B-cell concentrations between both groups.ConclusionThis study demonstrates an immunostimulatory effect of the histamine-2-receptor antagonist, ranitidine, both at the cellular and mediator levels in patients after head injury.(Crit Care Med 1996; 24:1787-1792)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo determine the efficacy, safety, and cost of simplified omeprazole suspension in mechanically ventilated critically ill patients who have at least one additional risk factor for stress-related mucosal damage.DesignProspective, open-label study.SettingSurgical intensive care and burn unit at a university tertiary care center.PatientsSeventy-five adult, mechanically ventilated patients with at least one additional risk factor for stress-related mucosal damage.InterventionsPatients received 20 mL of simplified omeprazole suspension (containing 40 mg of omeprazole) initially, followed by a second 20-mL dose 6 to 8 hrs later, then 10 mL (20 mg) daily. Simplified omeprazole suspension was administered through a nasogastric tube, followed by 5 to 10 mL of tap water. The nasogastric tube was clamped for 1 to 2 hrs after each administration.Measurements and Main ResultsThe primary outcome measure was clinically significant gastrointestinal bleeding determined by endoscopic evaluation, nasogastric aspirate examination, or heme-positive coffee ground material that did not clear with lavage, which was associated with at least a 5% decrease in hematocrit. Secondary efficacy measures were gastric pH measured 4 hrs after omeprazole was first administered, mean gastric pH after omeprazole was started, and the lowest gastric pH during omeprazole therapy. Safety-related outcomes included the occurrence rate of adverse events and pneumonia. No patient experienced clinically significant upper gastrointestinal bleeding after receiving omeprazole suspension. The 4-hr postomeprazole mean gastric pH was 7.1, the mean gastric pH after starting omeprazole was 6.8, and the mean lowest pH after starting omeprazole was 5.6. The occurrence rate of pneumonia was 12%. No patient in this high-risk population experienced an adverse event or a drug interaction that was attributable to omeprazole.Conclusions5.5 in mechanically ventilated critical care patients without producing toxicity.(Crit Care Med 1996;24:1793-1800)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo determine the pattern of the soluble interleukin (IL)-6 receptor during acute meningococcal infections and recovery phase, and to measure the effect of plasma or whole blood exchange on the plasma concentrations of these mediators.DesignProspective, descriptive patient study.SettingUniversity hospital intensive care unit.PatientsPatients with bacteriologically proven meningococcal infections were entered in the study. Three group were formed: a) patients with meningitis without shock (group A); b) patients with meningitis and shock (group B); and c) patients with shock only (group C).InterventionsPart (n = 9) of the patients with shock underwent plasma or whole blood exchange.Measurements and Main ResultsSerum concentrations of interleukin-6 and soluble IL-6 receptors were determined sequentially during the acute and recovery phases. Peak concentrations of IL-6 were highest in group C, followed by group B and group A. Soluble IL-6 receptor concentrations showed an opposite pattern and were all below normal. Soluble IL-6 receptor concentrations were negatively correlated with the IL-6 concentrations. During recovery, IL-6 rapidly decreased and soluble IL-6 receptors increased to supranormal concentrations, after which concentrations returned to normal. Plasma or whole blood exchange did not significantly influence IL-6 concentrations but did increase the soluble IL-6 receptor concentration directly after an exchange session followed by a rapid decrease.ConclusionsSoluble IL-6 receptor concentrations are low in acute meningococcal infections. Plasma or whole blood exchange temporarily increases these concentrations. It needs to be determined whether the effect of this therapy is beneficial to the patient.(Crit Care Med 1996; 24:1801-1805)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo analyze the mechanism of vasodilation and circulatory shock occurring in patients who are treated with isolated limb perfusion with melphalan and recombinant tumor necrosis factor (TNF)-alpha for locally advanced malignant tumors. To determine the role of nitric oxide, if any, by measuring plasma nitrite and nitrate concentrations.DesignObservational survey.SettingA 12-bed surgical intensive care unit in a university referral hospital.PatientsEight patients treated with hyperthermic isolated limb perfusion.InterventionsNinety minutes of hyperthermic isolated limb perfusion with recombinant TNF-alpha (3 or 4 mg) and melphalan (10 to 13 mg/L limb volume).Measurements and Main ResultsAll patients developed sepsis syndrome due to leakage of recombinant TNF-alpha from the perfusion circuit to the systemic circulation. Despite the presence of very high systemic TNF-alpha concentrations during and immediately after perfusion, and despite definite signs of hyperdynamic circulatory shock (increased heart rate, increased cardiac index, decreased systemic vascular resistance), nitrite and nitrate concentrations, as measured in plasma at several time points, were not increased.ConclusionsThe hypothesis that in humans, TNF-alpha induces vasodilation and shock through activation of inducible nitric-oxide synthase and subsequent formation of excessive quantities of nitric oxide is not substantiated by our results. Normal nitric oxide metabolite concentrations were found in the presence of high TNF-alpha concentrations and shock. Other mechanisms that do not involve the nitric oxide pathway are likely to play a role in the generation of hypotension and septic shock in this setting.(Crit Care Med 1996; 24:1806-1810)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesEthicists advise that life-sustaining treatment decisions should be made in keeping with patient preferences. Until recently, there has been little systematic study of the impact of patient preferences on the use of various life-sustaining treatments or the consequent cost of hospital care. This prospective study was designed to answer the following questions: a) Do patient treatment preferences about the use of life-sustaining treatment influence the treatments they receive? and b) Do patient treatment preferences influence the total cost of their hospitalization?DesignA prospective, cohort study.SettingA university teaching hospital.PatientsHospitalized patients, at least 50 yrs of age, with short life expectancy due to end-stage heart, lung, or liver disease, metastatic cancer, or lymphoma.InterventionsNone.Measurements and Main ResultsPatients were interviewed to determine their desire for life-sustaining treatment and other characteristics and then were followed for 6 months to determine life-sustaining treatment use and costs during hospitalization.Two hundred forty-four patients were interviewed. Fifty-eight percent of patients expressed a desire for life-sustaining treatments to prolong life for 1 wk. During 245 subsequent hospitalizations, there were 20 episodes of mechanical ventilation, 63 episodes of intensive care, and 66 cancer treatments given. Bivariate and multivariate analyses showed no significant association between patient desire to receive treatment to prolong life and either life-sustaining treatment use (p = .59) or hospital costs (p = .20).ConclusionIn a university teaching hospital setting, there is no systematic evidence that patient preferences determine life-sustaining treatment use or hospital costs.(Crit Care Med 1996; 24:1811-1817)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo compare the efficacy of a newly available antiseptic solution (composed of 0.25% chlorhexidine gluconate, 0.025% benzalkonium chloride, and 4% benzyl alcohol), with 10% povidone iodine, on the prevention of central venous or arterial catheter colonization and infection.DesignProspective, randomized clinical trial.SettingSurgical-trauma intensive care unit (ICU) in a university hospital.PatientsAll patients admitted to the ICU and requiring the insertion of a central venous and/or an arterial catheter from July 1, 1992 to October 31, 1993.InterventionsPatients were randomly assigned to one of two groups according to the antiseptic solution used for insertion and catheter care. The same solution was used for skin disinfection from the time of catheter insertion to the time of removal of each catheter.Measurements and Main Resultsor=to103colony-forming units [cfu]/mL by quantitative culture), and catheter-related sepsis (as defined by sepsis abating following catheter removal per 1,000 catheter-days), were significantly lower in the chlorhexidine group (12 vs. 31 [relative risk 0.4, 95% confidence interval 0.1 to 0.9, p < .01] and 6 vs. 16 [relative risk 0.4, 95% confidence interval 0.1 to 1, p = .05], respectively). The rate of central venous catheter colonization and central venous catheter-related sepsis per 1,000 catheter-days were also significantly lower in the chlorhexidine group (8 vs. 31 [relative risk 0.3, 95% confidence interval 0.1 to 1, p = .03] and 5 vs. 19 [relative risk 0.3, 95% confidence interval 0.1 to 1, p = .02], respectively). Finally, the rate of arterial catheter colonization per 1,000 catheter-days was significantly lower in the chlorhexidine group (15 vs. 32 [relative risk 0.5, 95% confidence interval 0.1 to 1, p = .05]), whereas the rate of arterial catheter-related sepsis per 1,000 catheter-days was similar for the two study groups (8 in the chlorhexidine group vs. 10 in the povidone iodine group [relative risk 0.8, 95% confidence interval 0.1 to 2.2, p = .6]). The 0.25% chlorhexidine solution was superior to the 10% povidone iodine solution in preventing catheter colonizations and catheter-related sepsis due to Gram-positive bacteria (5 vs. 20 [p < .001], and 2 vs. 10 [p < .001], respectively), whereas the activity of the 0.25% chlorhexidine solution was nonsignificantly superior in preventing Gram-negative infections (7 vs. 4 [p = .5], and 4 vs. 2 [p = .8], respectively).ConclusionsThe 4% alcohol-based solution of 0.25% chlorhexidine gluconate and 0.025% benzalkonium chloride was more effective than 10% povidone iodine for insertion site care of short-term central venous and arterial catheters. This effect appeared related to a more efficacious prevention of infections with Gram-positive bacteria.(Crit Care Med 1996; 24:1818-1823)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID