ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveIncubation with interferon-gamma has been shown to increase the permeability of cultured monolayers of intestinal epithelial cells. We sought to determine whether this phenomenon is mediated, at least in part, by increased production of nitric oxide.DesignProspective, controlled, laboratory study. Human intestinal epithelial (Caco-2BBe) cells were grown as monolayers on permeable supports mounted in bicameral chambers. Permeability was assessed by adding fluorescein sulfonic acid (molecular weight = 478 daltons) to the apical compartment and determining the apical-to-basolateral clearance of the probe over a 24-hr period of incubation.SettingBasic science laboratory.Measurements and Main ResultsThe permeability of monolayers to fluorescein sulfonic acid was significantly increased after incubation in the presence of interferon-gamma (250 to 1000 U/mL). The effect of interferon-gamma on permeability was dependent on both the concentration of the cytokine and the duration of exposure to it. Concentrations of nitric oxide oxidation products, nitrite and nitrate, in incubation media were increased after exposure of cells to interferon-gamma. When intestinal epithelial (Caco-2BBe) monolayers were incubated with interferon-gamma in the presence of inhibitors of nitric oxide synthase (NG-monomethyl-L-arginine, NG-nitro-L-arginine-methyl ester, or NG-nitro-L-arginine), both of the effects of the cytokine (i.e., increased epithelial permeability and increased production of nitrite/nitrate) were attenuated.ConclusionsThese results suggest that upregulation of nitric oxide biosynthesis plays a pivotal role in the increase in permeability of intestinal epithelial (Caco-2BBe) monolayers induced by interferon-gamma. Increased production of nitric oxide induced by proinflammatory cytokines, such as interferon-gamma, may be an important factor contributing to gut mucosal hyperpermeability in sepsis.(Crit Care Med 1995; 23:1170-1176)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectivesTo evaluate the ability of the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system to predict patient outcome in two Canadian intensive care units (ICUs). To compare the severity of illness and outcome of Canadian ICU patients with existing United States data.DesignProspective data collection on 1,724 Canadian ICU patients for validation of the APACHE II system. Comparison of the outcome of Canadian ICU patients to retrospective United States data on 4,087 patients from the 1985 APACHE II multicenter study.SettingCanadian data from two university teaching hospital ICUs. United States data from 13 ICUs, ten of which were in university teaching hospitals.PatientsConsecutive patients admitted to adult medical/surgical ICUs. Coronary care unit, neurosurgical and cardiac surgery patients were excluded.InterventionsNone.Measurements and Main ResultsFor each patient, demographic data, diagnosis, APACHE II score and hospital survival data were collected. The predicted risk of death was calculated for each patient using the APACHE II risk of death equation. The accuracy in outcome prediction of the APACHE II system was assessed by means of the receiver operating characteristic curve, 2 times 2 decision matrices and linear regression analysis. The severity of illness and hospital mortality for the Canadian patients was compared with that of United States patients from the 1985 APACHE II multicenter study.In 1,724 Canadian ICU patients, the mean +/- SEM APACHE II score was 16.5 +/- 0.2. The predicted death rate was 24.7% and the observed death rate was 24.8%. Using receiver operating curve analysis, good correlation was found between predicted outcome and observed outcome. The area under the curve was 0.86. From the 2 times 2 decision matrix constructed for a predicted risk of death of 0.5, 83% of patients were correctly classified. The sensitivity was 50.9% and the specificity was 93.6%. When observed death rate was plotted against predicted death rate, linear regression analysis gave an r2of.99.Canadian patients had a higher death rate and APACHE II score than the United States patients. After controlling for severity of illness using the APACHE II score, the Canadian and United States death rates were similar.ConclusionsThe ability of the APACHE II system in predicting group outcome is validated in this Canadian ICU population by receiver operating characteristic curve, 2 times 2 decision matrices and linear regression analysis. The Canadian patients had a higher overall hospital death rate than the United States patients. After controlling for severity of illness using APACHE II scores, the hospital death rate was comparable between the Canadian and United States patients.(Crit Care Med 1995; 23:1177-1183)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo compare the prognostic value of blood lactate concentrations, gastric intramucosal pH, and their combination in patients with severe sepsis.DesignProspective, noninterventional study.SettingMedical/surgical intensive care unit of a university hospital.Patients10 or <6 times 103cells/mm3), hypotension (systolic arterial pressure <90 mm Hg), and evidence of organ dysfunction (oliguria or deterioration of mental status).InterventionsArterial lactate concentration and intramucosal pH were measured at the time of study entry, and at 4 and 24 hrs later. Hemodynamic data and oxygen-derived variables were determined at the time of study entry and 24 hrs later. Arterial blood and balloon saline gases were also determined to obtain the pH gap (arterial pH - intramucosal pH) and the PCO2gap (intramural PCO2- PaCO2).Measurements and Main Results2 mEq/L) and 26 (74%) had a low intramucosal pH (<7.32). Initially, there were no significant differences in blood lactate concentrations between nonsurvivors and survivors (3.2 +/- 1.5 vs. 2.8 +/- 2.3 mEq/L). Lactate concentrations remained high in nonsurvivors and progressively decreased in survivors (4 hrs: 3.3 +/- 1.1 mEq/L in nonsurvivors vs. 2.2 +/- 0.9 mEq/L in survivors [p < .01]; 24 hrs: 3.5 +/- 2.0 mEq/L in nonsurvivors vs. 1.9 +/- 1.1 mEq/L in survivors [p < .05]). Intramucosal pH was lower in the nonsurvivors than in the survivors initially (7.19 +/- 0.15 in nonsurvivors vs. 7.30 +/- 0.14 in survivors [p < .05]), at 4 hrs (7.18 +/- 0.17 in nonsurvivors vs. 7.29 +/- 0.13 in survivors [p = .06]), and at 24 hrs (7.19 +/- 0.31 in nonsurvivors vs. 7.30 +/- 0.17 in survivors [p < .05]). Of the 23 patients with initially high lactate concentrations, 12 (60%) of the 20 patients with low intramucosal pH died, as compared with one (33%) of the three patients with normal intramucosal pH (p = .052). Of the 14 patients with persistently high lactate concentrations at 24 hrs, all nine (100%) patients with low intramucosal pH, but only two (40%) of five patients with normal intramucosal pH died (p < .001). No significant relationship was found between lactate or intramucosal pH and oxygen-derived variables. Intramucosal pH correlated better with gastric intramural PCO2(r2= .58) than with arterial bicarbonate or base deficit/excess. Intramural PCO2was a more specific predictor of mortality than intramucosal pH. When compared with patients with normal lactate concentrations, those patients with high lactate concentrations had a higher pH gap (0.22 +/- 0.22 vs. 0.07 +/- 0.13 [p < .01]) and PCO2gap [21.0 +/- 33.9 vs. 1.8 +/- 9.8 torr [2.79 +/- 4.5 vs. 0.24 +/- 1.34 kPa]; p < .01).ConclusionsBoth lactate concentrations and intramucosal pH represent reliable prognostic indicators in severe sepsis, and their combination improves the prognostic assessment in these patients. Both variables are better prognostic indicators than oxygenderived variables. Intramural PCO2appears to be a more specific variable than intramucosal pH, which partially reflects systemic metabolic acidosis. Combined determinations of blood lactate concentrations and intramucosal pH or intramural PCO2may help to predict outcome from severe sepsis.(Crit Care Med 1995; 23:1184-1193)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo determine the occurrence rate of bacteremia associated with transesophageal echocardiography in intensive care unit (ICU) patients.DesignA prospective study of 139 patients undergoing transesophageal echocardiography.SettingThe medical ICU of a tertiary referral teaching hospital.PatientsOne hundred thirty-nine ICU patients (mean age 58 yrs) who underwent transesophageal echocardiography.InterventionsBlood samples were systematically drawn for aerobic and anaerobic culture at the following times: before (blood culture 1), at the end of (blood culture 2), and 30 mins after (blood culture 3) transesophageal echocardiography examinations.Measurements and Main ResultsThe mean duration of transesophageal echocardiography was 35 mins (range 7 to 120). One hundred thirty-four patients received mechanical ventilation; 125 patients had a nasogastric tube. Fifty-one patients had one or more underlying conditions that usually justify antimicrobial prophylaxis of bacterial endocarditis before high-risk procedures. Fifty-six patients did not receive any antibiotic treatment at the time of transesophageal echocardiography. In 114 patients, the three blood cultures were negative. In six patients, transesophageal echocardiography was performed during a preexisting bacteremia. A contamination (only one positive blood culture of the three sampling times) with coagulase-negative staphylococci occurred in four patients at blood culture 1, five patients at blood culture 2, and six patients at blood culture 3. Contamination with Corynebacterium species occurred in two patients at blood culture 2. In one patient receiving cefotaxime and netilmicin, blood culture 1 was sterile and blood cultures 2 and 3 yielded coagulase-negative staphylococci. In one patient receiving no antibiotic treatment, blood culture 1 was sterile and blood cultures 2 and 3 yielded Enterococcus faecalis. None of these two patients received a specific antibiotic treatment or developed any secondary septic focus.ConclusionsThe overall frequency of bacteremia induced by transesophageal echocardiography in ICU patients was 1.4% (two of 139 patients) (95% confidence interval 0.2% to 5.1%). The frequency did not differ whether patients received antibiotics before transesophageal echocardiography (one [1.2%] of 83 patients) or not (one [1.8%] of 56 patients) (p = .96). Therefore, routine antimicrobial prophylaxis does not appear justified before transesophageal echocardiography in ICU patients.(Crit Care Med 1995; 23:1194-1199)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo determine whether the institution of a methicillin-resistant Staphylococcus aureus prevention protocol was associated with a decrease in methicillin-resistant S. aureus ventilator-associated pneumonia in long-term, acute care ventilator patients.DesignA retrospective chart review comparing the number of episodes of clinical pneumonia per patient ventilator day in the 12 months preceding and 24 months following the introduction of the protocol.SettingUniversity affiliated, long-term, acute care ventilator hospital.PatientsLong-term, acute care ventilated patients who presented with clinical pneumonia.InterventionsAddition of a methicillin-resistant S. aureus prevention protocol. In addition to universal precautions, the protocol consisted of mupirocin 2% ointment applied to the anterior nares, and whole body washing with chlorhexidine. All patients were given mupirocin and chlorhexidine twice weekly. Patients were cohorted in the same room if they were, or had been, infected or colonized with methicillin-resistant S. aureus in any anatomical location or at any time. This procedure replaced strict isolation of methicillin-resistant S. aureus-infected or colonized individuals.Measurements and Main ResultsClinical pneumonia was diagnosed when a patient developed fever, bronchorrhea, increased white blood cell count, methicillin-resistant S. aureus isolated from the tracheal aspirate, and new or increasing infiltrate on chest roentgenograph.During the 12 months preceding the protocol, there were 0.2% episodes of methicillin-resistant S. aureus ventilator-associated pneumonia per ventilated patient day compared with 0.026% in the 24 months after the protocol (p < .001). The relative and absolute risk reductions associated with the introduction of the protocol were 87% and 6, respectively.ConclusionsThe period following the institution of the protocol showed a significant reduction in episodes of clinical pneumonia compared with the 12-month period preceding the use of the protocol (p < .001). Thus, we conclude that the introduction of this protocol is associated with a significant decrease in methicillin-resistant S. aureus ventilator-associated pneumonia.(Crit Care Med 1995; 23:1200-1203)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo document the safety and efficacy of an intravenous phosphate repletion regimen that is more aggressive than recommended by previously published guidelines, in intensive care unit (ICU) patients with hypophosphatemia.DesignProspective evaluation of rapid, intravenous phosphate repletion in eligible patients.SettingSurgical ICU in a teaching hospital.PatientsPatients with a serum phosphorus concentration of <2 mg/dL (<0.65 mmol/L) while in the ICU.InterventionsEnrolled patients received 15 mmol of sodium phosphate in 100 mL of 0.9% sodium chloride, infused intravenously over a period of 2 hrs. Patients with a serum potassium concentration of <3.5 mmol/L received potassium phosphate, if no other potassium supplementation was ordered. The same dose could be repeated to a maximum of 45 mmol in a 24-hr period if either the 6-hr or follow-up (18- to 24-hr) postinfusion serum phosphorus remained <2 mg/dL (<0.65 mmol). Serum electrolytes, renal function, vital signs, and reflexes were closely monitored.Measurements and Main ResultsEleven patients enrolled had baseline serum phosphorus values of 1.6 to 1.9 mg/dL (0.51 to 0.61 mmol/L). The serum phosphorus value immediately postinfusion was 2.3 to 5.3 mg/dL (0.74 to 1.7 mmol/L). Only one patient had a 6-hr postinfusion serum phosphorus of <2 mg/dL (<0.65 mmol/L), requiring two additional doses. Two other patients each required a second dose. Serum phosphorus was corrected in other patients with a single dose. No significant changes were noted in serum calcium, magnesium, or potassium concentrations, urine output, vital signs, or reflexes throughout the repletion period.ConclusionsAll patients were successfully repleted using the described protocol without any significant adverse effects. This repletion regimen may have widespread applicability in the ICU setting.(Crit Care Med 1995; 23:1204-1210)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectivesTo determine whether a rigorous antiseptic hand washing of bare hands with 4% chlorhexidine and alcohol reduced fingertip microbial colonization as compared with the use of boxed, clean, nonsterile latex gloves. In addition, to investigate if aseptic donning technique and/or a prior hand washing would reduce the level of glove contamination.DesignProspective, randomized, crossover design, with each subject serving as his/her own control.SettingUniversity intensive care unit.SubjectsForty-three intensive care nurses.InterventionsThe fingertips of 20 nurses were cultured before and after a strict antiseptic hand washing and before and after the routine and aseptic donning of sterile gloves. Subsequently, the fingertips of 43 nurses were cultured before and after the casual donning of nonsterile gloves over unwashed hands and before and after a strict antiseptic hand washing. Fingertip cultures were plated directly on agar, incubated for 24 hrs, and counted and recorded as the number of colony-forming units (cfu) for each hand. Different colony types were then subcultured.Measurements and Main Resultsor=to200 cfu/hand was reduced from 30% to 9%. Aseptic or casual donning of sterile gloves, with or without prior antiseptic hand washing, resulted in consistently low glove counts between 0 and 1.25 cfu. Nonsterile gloves casually donned over washed or unwashed bare hands diminished the bioburden to 2.17 and 1.34 cfu, respectively. No qualitative difference was found in the microorganisms recovered from gloved or bare hands.ConclusionsAntiseptic hand washing and the use of nonsterile gloves over unwashed hands confer similar reductions in the number of microorganisms. There is no additional benefit with the use of aseptic donning technique, prior antiseptic hand washing, or the use of individually packaged sterile gloves.(Crit Care Med 1995; 23:1211-1216)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID