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

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveThe expression of proinflammatory cytokines is rapidly increased in experimental models of the acute respiratory distress syndrome (ARDS), in patients at risk for ARDS, and in patients with established ARDS. Because multiple cytokines are present in bronchoalveolar lavage fluid, a common, proximal activation mechanism may operate in these settings. The proinflammatory cytokines whose expression is increased in the lungs of patients with ARDS have binding sequences in their enhancer/promoter regions for transcriptional regulatory proteins, such as nuclear factor-kappa B (NF-kappa B), nuclear factor-IL6 (NF-IL6), cyclic adenosine monophosphate responsive element binding protein, serum protein-1, and activating protein-1. To test the hypothesis that activation of one or more of these nuclear transcriptional regulatory factors might provide a common mechanism for the simultaneous expression of multiple cytokine genes in the setting of ARDS, we measured activation of these factors in alveolar macrophages from patients with ARDS and from controls.DesignProspective, clinical study.SettingMedical and surgical intensive care units at a university hospital and a county hospital.PatientsTwelve patients, six with established ARDS and six control patients without lung injury.InterventionsPatients with ARDS and controls underwent fiberoptic bronchoscopy and bronchoalveolar lavage. Alveolar macrophages were isolated from lavage fluid and the nuclear proteins were extracted. Activation of transcriptional factors NF-kappa B, NF-IL6, cyclic adenosine monophosphate responsive element binding protein, activating protein-1, and serum protein-1 was determined using an electrophoretic mobility shift assay, followed by densitometry of the autoradiographed gels.Measurements and Main ResultsThere were no significant differences in gender, age, tobacco smoking, Acute Physiology and Chronic Health Evaluation II score, quantity of lavage fluid, or number of alveolar macrophages in lavage specimens in the patient groups. Acute Lung Injury score and the PaO2/FIO2ratio differed significantly between controls and ARDS patients: 0.46 +/- 0.17 vs. 2.74 +/- 0.14 (p < .0001) and 310 +/- 45 torr (41.3 +/- 6.0 kPa) vs. 150 +/- 11 torr (21.3 +/- 1.5 kPa) (p <.006), respectively. The mean FIO2of the control patients was not significantly different from the mean FIO2of ARDS patients: 0.47 +/- 0.11 vs. 0.55 +/- 0.6 (p = .53). Patients with ARDS had significantly (p < .02) increased activation of NF-kappa B in alveolar macrophages compared with patients without the syndrome. There was no evidence of increased activation of the transcriptional factors activating protein-1, serum protein-1, NF-IL6, or cyclic adenosine monophosphate responsive element binding protein in alveolar macrophages from ARDS vs. control patients.ConclusionsThese experiments demonstrated increased in vivo activation of the nuclear transcriptional regulatory factor NF-kappa B (but not NF-IL6, cyclic adenosine monophosphate responsive element binding protein, activating protein-1, or serum protein-1) in alveolar macrophages from patients with ARDS. Because binding sequences for NF-kappa B are present in the enhancer/promoter sequences of multiple proinflammatory cytokines, activation of NF-kappa B may contribute to the increased expression of multiple cytokines in the lung in the setting of established ARDS.(Crit Care Med 1996; 24:1285-1292)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo investigate the potential role of endogenous prostacyclin (PGI sub 2) released after mesenteric traction during major abdominal surgery on perioperative endotoxemia and bacterial translocation.DesignProspective, randomized, double-blind clinical study.SettingOperating room and surgical intensive care unit in a university hospital.PatientsFifty consecutive patients scheduled for major abdominal surgery (pancreas resection, abdominal aortic surgery).InterventionsFifteen minutes before skin incision, either 400 mg of ibuprofen or a placebo equivalent were administered intravenously. Immediately after peritoneal incision, eventration and traction of the small bowel was intentionally performed in a uniform fashion.Measurements and Main ResultsBaseline values were obtained before induction of anesthesia. Additional measurements, along with assessments of hemodynamics and gas exchange, were performed before incision of the peritoneum and at 5, 30, and 45 mins and 3, 6, and 24 hrs after mesenteric traction. Arterial plasma concentrations of 6-keto-prostaglandin F1alpha and thromboxane B2(stable metabolites of PGI2and thromboxane A2) were determined by radioimmunoassay. Endotoxin was measured by limulus amebocyte lysate test. Mesenteric lymph nodes were sampled in 31 patients (ibuprofen n = 14, placebo n = 17) and sent for culture under sterile conditions. Transient hypotension and a marked increase of plasma 6-keto-prostaglandin F1alpha concentrations occurred up to 6 hrs after mesenteric traction in untreated patients with median peak concentrations (2243 vs. 72 ng/L [p < .0001, placebo vs. ibuprofen], observed 5 mins after mesenteric traction). Endotoxemia occurred in both study groups. However, after mesenteric traction, plasma endotoxin concentrations were significantly higher in the ibuprofen group. Median peak concentrations (0.12 vs. 0.27 EU/mL [p < .001, placebo vs. ibuprofen]) were observed 3 hrs after mesenteric traction. Gram-negative bacteria in mesenteric lymph nodes were detected exclusively in the ibuprofen group (n = 5, p < .01).ConclusionsIn ibuprofen-pretreated patients, significantly higher endotoxin concentrations as well as bacterial translocation to mesenteric lymph nodes occurred, despite the absence of a transient decrease in mean arterial pressure that had been associated with PGI2release. Therefore, we hypothesized that during major abdominal surgery, endogenous PGI2released in response to mesenteric traction may play a crucial role in maintaining splanchnic microcirculation and thus preserving gut mucosal barrier function.(Crit Care Med 1996; 24:1293-1301)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo investigate the effects of adjunctive therapy with parenteral N-acetyl-L-cysteine in patients with newly diagnosed septic shock.DesignProspective, randomized, double-blind, placebo-controlled study.SettingMultidisciplinary intensive care unit at a university teaching hospital.PatientsTwenty patients (N-acetyl-L-cysteine group [n = 10], placebo group [n = 10]), 15 male and five female, of mean age 64 +/- 15 (SD) yrs and Acute Physiology and Chronic health Evaluation (APACHE) II score 33 +/- 6, with septic shock within 24 hrs of diagnosis.InterventionsAfter a 2-hr stabilization period (time-zero minus 2 hrs to time-zero), patients received either N-acetyl-L-cysteine in 5% dextrose (150 mg/kg in 100 mL over 15 mins, followed by 50 mg/kg in 250 mL over 4 hrs, and then 100 mg/kg/24 hrs in 500 mL for 44 hrs; N-acetyl-L-cysteine group) or the equivalent volume of 5% dextrose (placebo group).Measurements and Main ResultsHemodynamic and oxygen transport indices were measured at time-zero minus 2 hrs and time-zero, and at multiple time points thereafter until completion of the trial infusion (time-zero plus 48 hrs). A daily Organ Failure Score was recorded for 14 days. Treatment group demographics and hemodynamic variables did not differ significantly between the two groups at time-zero. Mean (SD), pooled mean arterial pressure (MAP), and cardiac index were 75 +/- 15 mm Hg and 3.9 +/- 1.2 L/min/m2, respectively. Over the next 48 hrs, in the N-acetyl-L-cysteine group, there was a progressive decrease, relative to both time-zero and the placebo group, in MAP, cardiac index, and left ventricular stroke work index (p < .01, repeated-measures analysis of variance). Percentage reductions in these values relative to the placebo group at 48 hrs were 23%, 18%, and 43%, respectively. Oxygen transport indices, arterial blood gas analyses, PaO2/FIO2.1, logistic regression) between the two groups.ConclusionAdjunctive therapy with N-acetyl-L-cysteine in newly diagnosed septic shock was associated with a depression in cardiovascular performance, as indicated by progressive reductions in cardiac index, left ventricular stroke work index, and MAP.(Crit Care Med 1996; 24:1302-1310)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo evaluate the differences in efficacy and in clinical and biochemical tolerance to amphotericin B administered in a lipid emulsion compared with amphotericin B administered in 5% dextrose in water in the treatment of Candida albicans infection in intensive care unit (ICU) patients.DesignProspective, controlled, randomized study, conducted during a 2.5-yr period, comparing the two treatment protocols.SettingGeneral ICU of a university-affiliated municipal hospital.PatientsSixty consecutive critically ill patients with confirmed or suspected Candida infection.InterventionsPatients received amphotericin B (1 mg/kg/24 hrs), administered randomly in 5% dextrose in water (group A), or in lipid emulsion (20% Intralipid Registered Trademark) (group B).Measurements and Main ResultsClinical tolerance (fever, chills, hemodynamics), hepatorenal tolerance, and biological tolerance (serum electrolytes and coagulation profile) were evaluated. Patients receiving amphotericin B in lipid emulsion experienced a lower frequency rate of drug-associated fever (61.4% vs. 5.8%, p < .003) rigors (54% vs. 8.5%, p < .004), hypotension (17% vs. 0%), and nephrotoxicity (increase of serum creatinine concentration, 66.7% vs. 20%, p < .0002). Significant (264,500 +/- 71,460 to 163,570 +/- 34,450 mm3, p < .01) thrombocytopenia, not associated with active bleeding, occurred in patients receiving amphotericin B lipid in emulsion but not in patients receiving the drug in dextrose.ConclusionsTreatment with amphotericin B in a lipid emulsion when given to critically ill patients with Candida sepsis seems to be safer and as effective as the conventional mode of administration.(Crit Care Med 1996; 24:1311-1315)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveOpen-label trial of the safety and short-term efficacy of calf's lung surfactant in pediatric respiratory failure.DesignMulti-institutional, uncontrolled, observational trial.SettingSix pediatric intensive care units of tertiary medical centers.Patientsor=to7.InterventionsUp to four doses of intratracheal surfactant (80 mL/m2).Measurements and Main ResultsVentilator parameters, arterial blood gases, and derived oxygenation and ventilation indices were recorded before, and at intervals after, surfactant administration. Complications and outcome measures were also noted. There was immediate improvement in oxygenation and moderation of ventilator support associated with surfactant administration in 24 of 29 patients. A modest but statistically insignificant effect was seen with subsequent doses. The only complications occurred in three patients who developed airleaks, two of which were coincident with surfactant administration. The overall mortality rate was 14%, which compares favorably with other published series.ConclusionsAdministration of calf's lung surfactant appears to be safe and is associated with rapid improvement in oxygenation and moderation of ventilator support in children with acute hypoxemic respiratory failure. These results set the stage for a randomized, controlled study.(Crit Care Med 1996; 24:1316-1322)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Objectivesa) To determine the need for intensive monitoring on the first operative night of surgery in children undergoing adenotonsillectomy for mild obstructive sleep apnea; b) to examine the effect of narcotics on postoperative obstructive sleep apnea.DesignRandomized, prospective study.SettingUniversity hospital.PatientsChildren, ranging in age between 1 and 18 yrs, presented to the Pediatric Otolaryngology Clinic for adenotonsillectomy for mild obstructive sleep apnea defined as from one to 15 obstructive apnea events per hour on preoperative polysomnogram.InterventionsPatients were assigned to receive either a narcotic- or a halothane-based anesthetic for adenotonsillectomy. A postoperative polysomnogram was performed in the pediatric intensive care unit on the first operative night.Measurements and Main ResultsEighteen patients were recruited, 15 of whom met inclusion criteria: nine patients received a halothane-based anesthetic and six patients received a fentanyl-based anesthetic. When the data were analyzed by pooling both groups, the differences between pre- and postoperative sleep studies demonstrated a reduction in the number of obstructive events and less severe oxygen desaturations on the operative night. Total sleep time between the two sleep studies decreased from 371 +/- 13 to 304 +/- 14 mins. The number of obstructive apnea events/hr decreased as well. The lowest oxygen saturation measured during rapid eye movement sleep was 78 +/- 5% preoperatively and 92 +/- 1% postoperatively.ConclusionsOur data suggest that children without underlying medical conditions, neuromotor diseases, or craniofacial abnormalities, 1 to 18 yrs of age, who suffer from mild obstructive sleep apnea, have improvements documented by polysomnography on the night of surgery following adenotonsillectomy and do not necessarily need to be monitored intensively. These findings were not significantly affected by the choice of intraoperative anesthetic.(Crit Care Med 1996; 24:1323-1327)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo describe clinical and electrophysiologic features and outcomes of critically ill patients with neuromuscular causes of failure to wean from mechanical ventilator support.DesignA prospective, consecutive, case series.SettingNeurological, neurosurgical, and medical intensive care units in a university hospital.PatientsSeven patients during a 3-yr period with failure to wean from mechanical ventilation not explained by pulmonary complications.InterventionsMuscle and nerve biopsy in three patients.Measurements and Main ResultsDetailed electrodiagnostic studies were done in all patients 3 to 6 wks (median 4.5) after the onset of the acute illness and were repeated 3 months to 3.5 yrs later in those patients who survived. Primary illnesses included various intracranial and medical conditions. All patients had moderate-to-severe limb weakness with marked muscle atrophy. Tendon reflexes were decreased in three patients, exaggerated in two patients with intracranial lesions, and absent in two patients. Electromyography demonstrated severe acute denervation, with striking involvement of proximal muscles. Muscle and nerve biopsies showed severe neurogenic atrophy and axonal degeneration without inflammation. There was no evidence of primary myopathy. Two patients died of complications of sepsis. Of the survivors, three patients had no further weakness at the time of reexamination, except for peroneal nerve palsy in one patient. Two patients, still in the recovery period, showed markedly improved conditions but still showed slight weakness of the proximal muscles. By electrophysiology, signs of chronic neurogenic damage were demonstrable in all survivors at follow-up.ConclusionsCritical illness polyneuropathy is a frequent cause of neuromuscular weaning failure in critically ill patients, regardless of the type of primary illness. Involvement of proximal (including facial and paraspinal) muscles is striking. Tendon reflexes are often preserved. Patients with central nervous system injury may likewise develop critical illness polyneuropathy. In these latter patients, tendon reflexes may even be exaggerated. Recovery from critical illness polyneuropathy is usually rapid and clinically complete, although incomplete on electrodiagnostic study. Residual peripheral nerve lesion, generally of the peroneal nerve, is the most frequent feature of incomplete recovery. The need for careful electrophysiologic testing is emphasized to clarify the nature and extent of neuromuscular disturbances in critically ill patients. Failure to recognize the development of neuropathy in these patients may lead to erroneous conclusions about the ability to wean them from the ventilator.(Crit Care Med 1996; 24:1328-1333)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID