摘要:

Objective:To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration.Design:Randomized, controlled clinical trial.Setting:Medical intensive care unit (19 beds) in an urban teaching hospital.Patients:Patients requiring mechanical ventilation (n = 321).Interventions:Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159).Measurements and Main Results:The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00,p= .008, log rank test; chi-square = 8.54,p= .004, Wilcoxon's test; chi-square = 9.18,p= .003, −2 log test). Lengths of stay in the intensive care unit (5.7 ± 5.9 days vs. 7.5 ± 6.5 days;p= .013) and hospital (14.0 ± 17.3 days vs. 19.9 ± 24.2 days;p< .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5 ± 4.0 days vs. 5.6 ± 6.4 days;p= .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%],p= .038).Conclusions:The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives:To determine the effect of a ventilation strategy to prevent barotrauma on long-term outcome in survivors of acute lung injury.Design:Prospective blinded cohort analysis.Setting:Three university-affiliated medical-surgical intensive care units.Patients:A total of 28 survivors of acute lung injury, 1-2 yrs after diagnosis, from a multicenter prospective randomized controlled trial comparing pressure (peak inflation pressure ≤30 cm H2O) and volume (tidal volume ≤8 mL/kg) limited ventilation to a conventional (peak inflation pressure ≤50 cm H2O, tidal volume 10-15 mL/kg) ventilation strategy.Measurements and Main Results:Physicians blinded as to treatment group evaluated 20 of 28 survivors (treatment group, 7; control group, 13). Exercise tolerance in the 6-minute walk test was comparable to patients with chronic respiratory disease and equivalent between groups (treatment group, 373 ± 171 m vs. control group, 375 ± 129 m;p= .84). Pulmonary function testing showed reduced diffusing capacity (treatment group, 64 ± 29% predicted vs. control group, 74 ± 14% predicted;p= .68) and normal volumes, flows, and blood gases. Two domains of disease-specific Health Related Quality of Life assessed by the Chronic Respiratory Questionnaire were worse for patients in the treatment group compared with the control group (Emotional Function 3.8 ± 1.4 vs. 5.1 ± 0.08;p= .05, Mastery 4.7 ± 1.7 vs. 6.2 ± 0.8;p= .03). There were no between-group differences in the scores of the Spitzer Quality of Life Index (a generic Health Related Quality of Life instrument), although they were reduced (7.5 ± 1.9) and comparable to patients with chronic disease.Conclusions:We found that 1-2 yrs after the onset of their illness, survivors of acute lung injury have reductions in quality of life and exercise tolerance which are similar to patients with chronic diseases. We were unable to show that a limited ventilation strategy improves either long-term pulmonary function or quality of life in survivors of acute lung injury.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To study the rate of elimination of ethanol after a major burn trauma.Design:Prospective, controlled study.Setting:National burns unit in a Swedish university hospital.Patients and Subjects:Eight consecutive patients suffering from 18%-72% total burned surface area and nine healthy male control subjects.Interventions:The patients received ethanol, 0.35-0.60 g/kg body weight intravenously, during 1 hr. This was repeated daily during the first week postburn. The control subjects received the same amount of ethanol once.Measurements and Main Results:Blood samples were drawn at 20- to 30-min intervals during 5 hrs after the start of the infusion. Serum ethanol was determined by headspace gas chromatography. The rate of elimination of ethanol was calculated from the concentration time profile. In the control subjects, the median elimination rate was 0.074 g/kg/hr (range, 0.059-0.083 g/kg/hr). In the patients, it was already 0.138 g/kg/hr (range, 0.111-0.201 g/kg/hr) on the first day; this increased even further over the following 6 days, reaching 0.183 g/kg/hr (range, 0.150-0.218 g/kg/hr) on the seventh day.Conclusions:Ethanol elimination is augmented postburn. A more effective reoxidation of reduced nicotinamide adenine dinucleotide seems the most likely explanation for the increased rate of ethanol elimination in these hypermetabolic trauma patients. This finding suggests that the oxidative capacity of the liver may be assessed by studying the rate of ethanol elimination in burn victims.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine the frequency of central venous catheter-induced thrombosis of the axillary vein.Design:Prospective, controlled study.Setting:Tertiary care university center.Patients:Sixty patients in a medical-surgical intensive care unit who required central venous catheterization via the axillary vein.Interventions:Single-lumen, silicone elastomer or polyurethane catheters were inserted for a mean duration of 14.7± 7.4 days (range, 4-33 days). On catheter removal, bilateral upper-extremity phlebographic examination was performed in each patient. The incidence of deep vein thrombosis in catheterized arms was compared with that in uncatheterized arms.Measurements and Main Results:Of the 60 patients who underwent axillary vein cannulation, one patient had clinical signs of arm vein thrombosis, but no patient had clinical sign of pulmonary embolism. There were 35 patients (58.3%) who developed positive phlebographic examinations homolateral to the catheter. Fibrin sleeves that developed around the catheters were observed in 28 patients (47%). Five patients (8.3%) had phlebographic signs of partial axillary vein thrombosis: nonobstructive clots adherent to the vessel wall and/or the catheter. Two patients (3.3%) had phlebographic signs of complete axillary vein thrombosis. No thrombosis was observed in patients with catheterizations lasting ≤6 days, two cases were observed for duration of 7-14 days, and five cases were observed for duration of ≥15 days (p< .01). In the seven patients with axillary vein thrombosis, the vessel was cannulated with fewer than three puncture attempts, and the mean duration for catheter insertion (10 ± 2.5 min) was not different from that of patients with no axillary vein thrombosis (14 ± 9 min).Conclusions:Based on the data from the present study, we conclude that axillary vein catheterization is associated with a 11.6% frequency of upper-extremity deep vein thrombosis. This rate of vein thrombosis is similar to that observed after internal jugular or subclavian vein cannulation. Given the acceptable rate of this clinically important complication, axillary vein cannulation offers an attractive alternative site for catheter insertion to the internal jugular or subclavian vein in the critically ill. Because thrombosis is rare or absent in catheterizations lasting <15 days, it seems wise to withdraw axillary catheters after a maximum of 2 wks.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To determine incidence, severity, characteristics, and causes of anemia and transfusion requirements in medical intensive care patients.Design and Setting:Open prospective clinical study in a 24-bed medical intensive care unit in a tertiary-care university hospital.Patients:Patients (N = 96) treated in the intensive care unit for >3 days.Interventions:None.Measurements:Parameters of erythropoiesis and red blood cell metabolism, including hemoglobin, reticulocyte counts, serum iron, transferrin, ferritin, haptoglobin, vitamin B12, folic acid, and erythropoietin concentrations were determined serially. Diagnostic blood loss and red blood cell transfusions were recorded, and the total blood loss was estimated from changes in hemoglobin concentrations and the amount of hemoglobin transfused.Main Results:The median hemoglobin concentration was 12.1 g/dL at admission and 11.2 g/dL at the end of the intensive care unit stay. A total of 74 patients (77%) suffered from anemia and received 257 red blood cell units, approximately half of which were given within the first 5 days. Three patients who received 19 red blood cell units were admitted with acute gastrointestinal bleeding, but in the remainder, a median total blood loss of 128 mL/d was not (n = 60) or not solely (n = 11) a result of overt bleeding. Diagnostic blood loss declined from a median of 41 mL on day 1 to <20 mL after 3 wks and contributed 17% (median) to total blood loss. Acute renal failure, fatal outcome, and simplified acute physiology score >38 on admission were associated with a 5.8-, 7.0-, and 2.8-fold increase in total blood loss. Reticulocyte counts and erythropoietin concentrations were inappropriately low for the degree of anemia, and plasma transferrin saturation was mostly <20%.Conclusions:Anemia is frequent and results in a high requirement for red blood cell transfusions in the medical intensive care setting. A major proportion of blood loss is not caused by overt bleeding or diagnostic blood sampling but, rather, may result from various other reasons, e.g., occult gastrointestinal bleeding and renal replacement therapy. The erythropoietic response to anemia is blunted, probably as a consequence of an inappropriate increase in erythropoietin production and diminished iron availability.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To analyze the costs and discharge status for patients with prolonged mechanical ventilation undergoing tracheostomy.Design:Retrospective analysis of a statewide database.Patients:All patients (n = 37,573) >18 yrs of age who had prolonged mechanical ventilation (procedure code 96.72) and were discharged from the hospital between 1992 and 1996 with a final DRG code of 483.Interventions:None.Measurements and Main Results:Rates of change in discharges and hospital reimbursements and the cost per survivor were examined by case payment groups and discharge year. A direct relation between volume and reimbursement rate was seen over time, although the patient age distributions remained relatively stable. The greatest increase in volume was from 1995 to 1996. For most years, there was a consistent inverse relation between age and survival, with older survivors being more likely to be discharged to residential healthcare facilities and younger patients more likely to be discharged home. There was a consistent direct relation between age and cost per survivor, mainly the result of improved survival rather than decreased reimbursements in later years.Conclusions:More controlled reimbursements and improved overall survival rates for DRG 483 have contributed to the improved cost per survivor among all age groups over the period. Given the greater proportion of elderly that do not survive or who are placed into residential healthcare facilities, more scrutiny is needed concerning the use of DRG 483 resources so that care is better coordinated for these patients in the inpatient and post-acute care settings.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives:To compare recovery times from neuromuscular blockade between two groups of critically ill patients in whom pancuronium was administered by continuous infusion or intermittent bolus injection. To compare the mean pancuronium requirements (milligrams per kilogram per hour) and to assess the incidence of prolonged recovery times (>12 hrs) and residual muscle weakness.Design:Prospective, observational cohort.Setting:Intensive care unit in a university-affiliated hospital.Patients:A total of 30 mechanically ventilated patients who required pharmacologic paralysis. Patients were excluded if they had renal failure (creatinine clearance <30 mL/min), heart rate >130 beats/min, hepatic failure, peripheral nerve disease or myopathy, stroke, spinal cord damage, or myasthenia gravis.Interventions:Patients were assigned to receive pancuronium either by continuous infusion (n = 14) or intermittent bolus (n = 16). Depth of paralysis was titrated to maintain one or two responses to Train-of-Four stimulation with an accelerograph and desired clinical goals. Recovery time was defined as time from discontinuation of muscle relaxant until the amplitude of the fourth twitch, measured every 15-30 min using an accelerograph, was 70% the amplitude of the first twitch (Train-of-Four ≥ 0.7).Measurements and Main Results:These patients included the only three patients with status asthmaticus in our study. The groups were similar with respect to age, sex, weight, Acute Physiology and Chronic Health Evaluation II score, mode of ventilation, creatinine clearance, indications for paralysis, and duration of pancuronium administration. The median time for patients to recover from paralysis was 3.5 hrs (95% confidence interval, 1.82-5.18) in the infusion group vs. 6.3 hrs (95% confidence interval, 3.40-9.19) in the intermittent bolus group (p= .10). Less drug was administered in the intermittent group (mean, 0.02 ± 0.01mg/kg/hr) than by infusion (mean, 0.04 ± 0.01 mg/kg/hr;p< .001). Six patients (five in the infusion group and one in the intermittent group) developed persistent severe muscle weakness. In addition, six different patients (three from each group) had prolonged recovery >12 hrs.Conclusions:Our study suggests that recovery time after paralysis with continuous infusion is faster than that after intermittent bolus injection. Although more pancuronium was administered in the continuous-infusion group, recovery time was not prolonged as a consequence. It is uncertain whether pancuronium given by infusion increases the risk of persistent muscle weakness.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To investigate whether endotoxin, interleukin-6, and circulating adhesion molecules, measured sequentially in blood, can predict mortality and organ dysfunction in sepsis.Design:Inception cohort study with follow-up for 28 days.Setting:Surgical intensive care unit at a university hospital.Patients:A total of 14 consecutive patients were enrolled in the study within the first 24 hrs after onset of septic shock. Seven healthy subjects were studied as controls.Interventions:Patients were analyzed for mortality and development of organ dysfunction.Measurements and Main Results:At the end of the 28-day follow-up period, seven of the patients were still alive (survivors) but the other seven (nonsurvivors) had died. At the time of enrollment in the study (day 0), the Acute Physiology and Chronic Health Evaluation II score was 28.4 in survivors (n = 7) and 28.7 in nonsurvivors (n = 7). In contrast, circulating intercellular adhesion molecule-1 (ICAM-1) was significantly higher in nonsurvivors than in survivors. Circulating ICAM-1 predicted mortality in patients with septic shock with a sensitivity and a specificity of 71.4% each. Endotoxin, interleukin-6, circulating L-selectin, P-selectin, E-selectin, and platelet endothelial cell adhesion molecule-1, however, did not distinguish between survivors and nonsurvivors. In addition, circulating ICAM-1 at day 0 showed a significant correlation with the highest serum bilirubin observed during the entire study period (r2= 0.963).Conclusions:Because only circulating ICAM-1 was higher in nonsurvivors than in survivors at day 0, circulating ICAM-1 may serve as an early prognostic marker for outcome in septic shock. In addition, measurement of circulating ICAM-1 facilitates identification of those patients with the highest risk of developing liver dysfunction.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective:To test the hypothesis that elevated interleukin (IL)-10 plasma concentration relative to IL-6 and IL-8 in patients with acute pancreatitis is associated with improved clinical outcome.Design:Case series.Setting:University hospital surgical and intensive care unit.Patients:Patients with mild (n = 18) and severe (n = 14) acute pancreatitis were recruited within 12 hrs of admission and studied for 5 days.Interventions:None.Measurements and Main Results:The plasma concentration of IL-10 was significantly elevated in patients with severe pancreatitis during the 5 days and especially so in those who died compared with survivors on day 5 (p<.03). The ratio of IL-10/IL-6 was decreased in patients with severe pancreatitis on day 5 (p< .01). There was a significant decrease in the ratio of IL-10/IL-8, but not of IL-10/IL-6, during the first 5 days (p< .014).Conclusions:The findings are consistent with the hypothesis that an increase in plasma IL-10 relative to IL-6 or IL-8 is associated with improved clinical outcome.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives:To determine the effect of breathing helium-oxygen (HELIOX) mixtures on pulmonary gas exchange during severe asthma.Design:A retrospective case-match control design was used to compare the changes in alveolar to arterial gradient [(A-a)gradient] in the first 2 hrs of mechanical ventilation (MV) for status asthmaticus (SA) in patients who received HELIOX with those who did not. Patients were matched for diagnosis of asthma, ventilatory failure, ventilator mode and settings, and equivalent pharmacologic therapy.Setting:The adult and pediatric intensive care units of a tertiary-care hospital.Subjects:Adult and pediatric patients undergoing MV for SA.Interventions:Use of HELIOX or standard nitrogen-oxygen mixtures during MV.Measurements and Main Results:A total of 11 patients receiving HELIOX in the first 2 hrs of MV for SA were compared with 11 case-matched controls who did not. At baseline, the HELIOX and control groups had similar (A-a)gradients (216 ± 92 torr and 226 ± 82 torr, respectively). The (A-a)gradient decreased significantly to 85 ± 44 torr after initiation of ventilation with HELIOX (p< .0003), whereas it did not change significantly in the control group in a similar time frame and during identical treatment without HELIOX. The reduction in (A-a)gradient in the HELIOX group facilitated a reduction in FIO2from 0.8 ± 0.2 initially to 0.4 ± 0.1 at the time of the second blood gas determination, thus permitting greater concentrations of helium to be administered.Conclusions:MV with HELIOX improves (A-a)gradient in patients with SA. Although this improvement adds little to routine therapy with supplemental oxygen, it does permit reduction in concentration of inspired oxygen to levels that maximize helium concentration and thus permit full benefits of HELIOX on lung mechanics to be realized in even the most severely ill asthmatics.

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID