ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Objective:To evaluate the effectiveness of a polyclonal immunoglobulin (Ig) preparation containing IgG, IgM, and IgA as an adjunctive therapy for septic shock.Design:Prospective, randomized clinical trial.Setting:A clinical immunology ward at the center for internal medicine in a university hospital.Patients:Fifty-five patients with septic shock were randomly allocated to two groups according to criteria of septic shock.Intervention:One group of patients (n = 27) received a commercially available immunoglobulin preparation (containing high titers of antibodies specific for determinants to bacterial endotoxin) during the first 3 days after inclusion in the study. The other randomized group (n = 28) did not receive any immunoglobulin preparation.Measurements and Main Results:During the period of ≤6 wks after the beginning of clinically apparent septic shock, death related to the septic process occurred in one (4%) of 27 patients who received immunoglobulin. By comparison, nine (32%) of 28 control group patients died during this period (p<.01 ). Within the first 48 hrs after onset of the clinically apparent septic process, significantly increased activity of circulating endotoxin and simultaneously decreased specific IgG serum titers to lipid A were detected in the group of nonsurvivors.Conclusions:Administration of a polyclonal immunoglobulin preparation in the early phase of septic shock was associated with significantly improved survival.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Objective:To determine whether plasma lipid hydroperoxides may be a useful marker for sepsis.Design:Exploratory, open-labeled study.Setting:Critical care unit at a university medical center.Patients:Twelve patients with sepsis syndrome requiring hemodynamic monitoring with pulmonary artery catheters. Seven patients were diagnosed with pulmonary infections and five patients had intra-abdominal infections.Interventions:Fatty acid hydroperoxide was measured in the fresh arterial plasma (radial artery) and mixed venous plasma (pulmonary artery) from each patient. Hydroperoxide was determined using a sensitive assay based on activating the cyclooxygenase reaction of prostaglandin H synthase.Measurements and Main Results:The mean difference between the amount of fatty acid hydroperoxide measured in the plasma draining involved regions (arterial plasma for pulmonary sepsis, mixed venous plasma for intra-abdominal sepsis) compared with the paired, uninvolved regions was 0.45 ± 0.14 μM (mean ± SEM;p< .005).Conclusions:Increased lipid hydroperoxides in blood-draining septic foci are markers of oxyradical release associated with severe infection, although they are not specific for infectious conditions, being released also from nonseptic regions of surgical trauma. Assays for hydroperoxides may be useful when relatively free of other tissue trauma.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Objective:To evaluate the impact of respiratory alkalosis on the elimination of intravenously infused lactate.Design:Prospective, randomized, crossover study.Setting:Medical ICU of a university hospital.Patients:Eight patients treated by ventilatory support for neurologic or neuromuscular diseases.Interventions:Patients were investigated on two occasions: during normoventilation (pH7.42±0.1, Pco241 ± 2torr[5.5 ± 0.2kPa])and during respiratory alkalosis (pH 7.59 ± 0.1, Pco227 ± 2 torr [3.6 ± 0.2 kPa]) induced by controlled hyperventilation. To evaluate lactate elimination kinetics, 1 mmol/kg body weight of L-lactic acid was infused over 5 mins.Measurements and Main Results:Arterial lactate concentrations and blood gas values were determined before and repeatedly after the infusion. Lactate elimination variables were calculated from the plasma curve by using a two-compartment model. Respiratory alkalosis increased plasma lactate from 1.56 ± 0.1 to 2.49 ± 0.2 mmol/L (p< .001). The lactate elimination half-life increased from 4.57 ± 0.2 mins at pH 7.42, to 9.96 ± 1.1 mins during pH 7.59 (p< .01), and β half-life increased from 12.2 ± 1.9 to 44.1 ± 1 mins (p< .01). Whole-body clearance decreased 40% from 24.2 ± 2.9 to 14.3 ± 2.0 mL/kg body weight-min (p< .01).Conclusions:Respiratory alkalosis increases the basal concentration of plasma lactate and decreases clearance of infused lactic acid. These findings provide further evidence of the adverse effects of alkalosis.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectivesPrevious reports have described prolonged paralysis after treatment with neuromuscular junction blocking agents in critically ill patients. The purpose of this study was to further describe a group of patients who developed prolonged weakness after treatment with these agents.DesignClinical information, electrodiagnostic and muscle pathology results are described in this group of patients. Clinical information includes diagnoses, dosage of neuromuscular junction blocker, other medications affecting the neuromuscular system, and neuromuscular examination and clinical course.SettingAll patients were seen in the ICUs of three local hospitals.PatientsIncluded were critically ill patients with a variety of diagnoses, all of whom developed severe weakness after discontinuation of neuromuscular junction blocking agents.InterventionsElectrodiagnostic studies and muscle biopsies were performed on several of the patients.Measurements and Main ResultsAll patients had pronounced weakness without sensory loss. Electrodiagnostic and muscle pathology findings were consistent with failed neuromuscular transmission. Although many patients had disorders or were taking medications that can injure the neuromuscular system, no disorder or medication was common to all. Recovery of strength often took several months and most patients were slow to wean from mechanical ventilator support.ConclusionsAlthough alternative explanations cannot be excluded with certainty, the use of neuromuscular junction blocking agents may lead to neurogenic atrophy and care must be taken when using them.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo confirm whether the descending aortic blood flow velocity waveform variable of flow time corrected for heart rate, measured using an esophageal Doppler transducer, can be used for noninvasive optimization of left ventricular (LV) filling.SettingICU and operating theater.SubjectsForty-three mechanically ventilated patients in the ICU or undergoing cardiothoracic surgery in whom a pulmonary arterial catheter was in situ.InterventionsLV preload was a) increased from hypovolemic states (pulmonary arterial occlusion pressure [PAOP] <8 mm Hg) by fluid challenge, b) decreased from normovolemic states (PAOP 10 to 15 mm Hg) by either iv nitrates or intravascular fluid loss, and c) decreased from heart failure or fluid overload states (PAOP <20 mm Hg) by iv nitrates. No other maneuver was performed concurrently.Measurements and Main ResultsDescending aortic blood flow was measured by an esophageal Doppler transducer. Corrected flow time was calculated by dividing systolic flow time by the square root of the cycle time. PAOP and corrected flow time increased after fluid challenges in hypovolemic states, and decreased when LV preload was decreased from normovolemic states. However, when preload was decreased from overload states, PAOP always decreased, but the corrected flow time usually increased before any subsequent decrease. The greatest value of corrected flow time corresponded with the maximal stroke volume seen.ConclusionsEsophageal Doppler measurement of aortic blood flow can be used for rapid, noninvasive optimization of LV filling in mechanically ventilated patients.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo confirm the consistent effects on Doppler-measured aortic blood flow velocity waveform variables of alterations in left ventricular preload, afterload, and inotropy using pharmacologic and physiologic maneuvers.SettingMedical school laboratory.SubjectsHealthy volunteers.InterventionsIncreasing infusion rates of dobutamine (1.25 to 5 μg/kg·min), esmolol (1.25 to 5 mg/min), phentolamine (1.25 to 5 mg/min), methoxamine (1.25 to 5 mg/min), metaraminol (1.25 to 5 mg/min), and placebo (1.25 to 5 mL of 0.9% saline/min) and increasing plasma removal (0.5 to 1 L) in awake, rested, supine subjects.Measurements and Main ResultsAscending aortic blood flow was measured by the suprasternal Doppler approach allowing calculation of waveform variables of stroke distance and minute distance (linear measures of stroke volume and cardiac output), peak velocity, mean acceleration and flow time corrected for heart rate. An index of systemic vascular resistance was obtained by dividing mean systemic BP by the minute distance. Inotropic changes predominantly affected peak velocity and mean acceleration. Changes in preload mainly affected the flow time corrected for heart rate, whereas afterload changes had an intermediate effect. Unsuspected but subsequently confirmed hemodynamic effects were seen with esmolol and metaraminol.ConclusionsAortic blood flow velocity waveform variables measured by Doppler ultrasound can be used to noninvasively follow changes in left ventricular preload, afterload, and inotropy.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo assess the frequency and mortality rates of septic shock in ICU patients and the clinical course of multiple organ failure associated with septic shock.DesignRetrospective case survey.SettingTertiary care center.PatientsDuring a 2-yr period, 2,469 consecutive intensive care patients were studied regarding the frequency and hospital mortality rates of septic shock. A subset of 1,311 patients was further analyzed for the occurrence of organ system failures within 48 hrs of the onset of septic shock and again 4 to 7 days later.Measurements and Main ResultsThe frequency rate of septic shock was 1.9% (n = 48), with a mortality rate of 72.9% (n = 35) in patients with septic shock. Deaths due to septic shock represented 14.6% of all deaths in the ICU during the study period. Eighteen patients died within 72 hrs of the onset of septic shock. Refractory hypotension was the cause of death in 15 of these 18 patients. Beyond 72 hrs, multiple organ failure accounted for eight of 17 deaths. The mean ± SD number of organ systems failing at 48 hrs was 3.3 ± 1.3 in survivors and 4.0 ± 1.1 in nonsurvivors, and at 4 to 7 days was 2.1 ± 1.5 in survivors and 4.0 ± 1.5 in nonsurvivors (p< .05). None of the specific organ system failures had prognostic value. The number of organ system failures was not related to the duration of hypotension, but had a weak correlation (r2= .26,p< .05) with the duration of vasoactive treatment at 4 to 7 days. The prolonged need for norepinephrine therapy was associated with an increased occurrence of renal failure. Thirty (62.5%) patients had positive blood cultures and a mortality rate similar to the mortality rate of patients with negative blood cultures. Patients with negative blood cultures died more often with hypotension (p< .02).ConclusionsSeptic shock is a major cause of death in intensive care patients. Refractory hypotension is a main cause of early deaths. Later on, multiple organ failure becomes the primary clinical problem and cause of mortality.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Study ObjectiveTo determine types of respiratory complications encountered in critically ill patients with serious acute upper gastrointestinal (GI) bleeding, and to identify associated risk factors.DesignRetrospective chart review.SettingA university hospital medical ICU.Patients and MethodsWe reviewed medical records of 86 patients admitted to the medical ICU over a 21/2-yr period of time, for 107 consecutive episodes of serious acute upper GI bleeding. Clinical features of patients who developed respiratory complications of pneumonia, witnessed aspiration of gastric contents, or who required intubation and mechanical ventilation for other reasons were compared with those features of patients without respiratory complications.Main ResultsRespiratory complications occurred during 23 (22%) serious upper GI bleeding episodes (mean transfusion requirement, 7 units of packed RBCs). Twelve patients developed pneumonia and all had evidence of advanced liver disease. Five patients were observed to aspirate gastric contents and six patients required intubation and mechanical ventilation for reasons other than pneumonia or aspiration. Esophageal sites of bleeding (esophagitis, esophageal ulcers and esophageal varices), advanced liver disease, age >70 yrs, and an Acute Physiology and Chronic Health Evaluation (APACHE) II score >13 appeared to be risk factors. Mortality rate was increased in patients with respiratory complications: 70% of patients with respiratory complications died, compared with 4% of those patients without such problems (p< .001).ConclusionsRespiratory complications are common in critically ill medical patients with serious acute upper GI bleeding, and are associated with a poor outcome. Risk factors include advanced liver disease, esophageal site of bleeding, age >70 yrs, and higher APACHE II score.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID