摘要:

Cross-brain oxygen extraction may be altered by coma, hyperventilation, hypothermia, or barbiturates, and has been demonstrated in adults and more recently in children to be related to functional neurologic recovery after a variety of brain injuries. However, measurement of cross-brain oxygen extraction in children is currently not a part of routine clinical care, partly because there have been no published attempts relating the technique of jugular venous bulb (JVB) catheterization and its complication in children. We catheterized the JVB to measure cerebral venous oxygen content and calculate cross-brain oxygen extraction in 26 deeply comatose neonates and children ranging in age from a few hours to 14 yr. Bedside catheterization using the Seldinger technique was successful in 25 children, with standard venous cutdown necessary in the remaining child. All JVB catheterizations were performed with parental consent and during continuous monitoring of the intracranial (ICP) or fontanelle, as well as arterial, pressure. ICP was not significantly altered by the cannulation procedure in any of the children studied, although the cannulation occurred early in the child's course when ICP was well controlled. Inadvertent carotid artery puncture with bleeding con-trolled by local pressure occurred in four children, and catheter malposition was confirmed on lateral skull x-ray in two others. Jugular venous bulb catheters remained in place for 2 to 7 days (average 3) and malfunction or obstruction of the catheter did not occur. Organisms were grown from three of 26 catheter tips submitted for culture, with peripheral blood cultures also positive for the same organisms in two of these. We conclude that JVB catheterization in neonates, infants, and children can be carried out successfully at the bedside in the pediatric ICU without significantly increasing ICP. The incidence of catheter-related sepsis is similar to that seen with other invasive vascular catheters.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The sepsis syndrome represents a systemic response to infection and is defined as hypothermia (temperature0F) or hypothermia (>101090 beat/min), tachypnea (>20 breath/min), clinical evidence of an infection site and with at least one end-organ demonstrating inadequate perfusion or dysfunction expressed as poor or altered cerebral function, hypoxemia (Pao2

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Twenty consecutive patients with severe sepsis were randomized to fluid challenge with 5% albumin or 10% low MW hydroxyethyl starch (pentastarch) solutions. Fluid challenge was administered iv as 250 ml of test colloid every 15 min until the pulmonary artery wedge pressure (WP) was 15 mm Hg or a maximum dose of 2000 ml was infused. Hemodynamic, respiratory, and coagulation profiles were measured before and after fluid infusion. The amount of colloid required to achieve a WP of 15 mm Hg was comparable between groups. Both colloid infusions resulted in similar increases in cardiac output, stroke output, and stroke work. The effect of fluid infusion with pentastarch on coagulation was not significantly different from albumin, although pentastarch was associated with a 45% decrease in factor VIII:c. We conclude that pentastarch is equivalent to albumin for fluid resuscitation of patients with severe sepsis.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The relationship between sepsis-induced CNS dysfunction and changes in brain blood flow remains unknown, and animal studies examining the influence of sepsis on cerebral blood flow (CBF) do not satisfactorily address that relationship. We measured CBF and cerebrovascular reactivity to CO2in nine patients with sepsis syndrome using the133Xe clearance technique. Mean CBF was 29.6 ± 15.8 (SD) ml/100 g. min, significantly lower than the normal age-matched value in this laboratory of 44.9 ± 6.2 ml/100 g. min (p < .02). This depression did not correlate with changes in mean arterial pressure. Despite the reduction in CBF, the specific reactivity of the cerebral vasculature to changes in CO2was normal, 1.3 ± 0.9 ml/100g. min/mm Hg. Brain blood flow is reduced in septic humans; the contribution of this reduction to the metabolic and functional changes observed in sepsis requires further study.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The specific ECG characteristics of metabolic acidosis have not been satisfactorily defined in man. We addressed this question by prospectively studying 14 consecutive patients admitted with metabolic acidosis and without hyperkalemia. Arterial blood gas analysis and serum potassium determinations were performed during acidosis and after its correction. ECGs were recorded at the same times. Mean pHa increased from 7.11 ± 0.05 to 7.40 ± 0.01 (p < .001) in response to an increase in total CO2content from 6.8 ± 1.4 to 21.2 ± 0.7 mmol/L (p < .001). Serum potassium concentration decreased only slightly after correction of the acidosis from 4.2 ± 0.1 to 3.9 ± 0.14 mmol/L (p< .05). T waves were taller during acidosis than after correction (0.68 ± 0.1 vs. 0.28 ± 0.04 mV.p< .001 and 0.64 ± 0.08 vs. 0.38 ± 0.04,p< .005, in precordial leads V2and V3, respectively). Moreover, the amplitude of T waves in V2was correlated positively with the arterial concentration of H+(r = 786,p< .001) and negatively with the arterial total CO2content (r = -.71,p< .005). In addition to their augmented amplitude, T waves were peaked and symmetrical with a narrow base (“tent-shaped”). Thus, metabolic acidosis may be accompanied by an increase in the amplitude of T waves, even in the absence of hyperkalemia.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The Simplified Acute Physiology Score (SAPS), the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Acute Physiology Score (APS), and the Coronary Prognostic Index (CPI), calculated within the first 24 h of ICU admission, were compared in 76 patients with acute myocardial infarction (AMI). Sixteen (21%) patients subsequently died in the ICU. The nonsurvivors had significantly higher SAPS, APACHE II, and CPI scores than the survivors. ROC curves drawn for each severity index were in a discriminating position. There were no significant differences either between the areas under the ROC curves drawn for SAPS, APACHE II, and CPI, or between the overall accuracies of these indices. APS provided less homogeneous information. We conclude that SAPS and APACHE II, two severity indices which are easy to use, assess accurately the short-term prognosis, i.e., the ICU outcome, of patients with AMI.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

We followed prospectively over 5 months all medical and surgical ICU patients placed on total parenteral nutrition (TPN) and recorded their Acute Physiology and Chronic Health Evaluation II (APACHE II) scores on the day of admission, on the day TPN was started, length of time in ICU before TPN was started, and the number of days TPN was administered. Sixty-one patients (15 to 82 yr) had an inhospital mortality of 47%. The APACHE II score was significantly higher for nonsurvivors vs. survivors both on the day of admission (24.4 ± 9.6 vs. 18.4 ± 6.5; p < .003) and also on the day TPN was started (21 ± 8.6 vs. 16.4 ± 5.6; p < .002). However, at a 60% risk of dying, specificity was 96.9% and sensitivity 27.6%. The mean number of days before TPN was started was 3.2 and mean number of days on TPN was 9.2 (p= NS). We conclude that calculation of APACHE II score either on ICU admission or on the day TPN is considered does not seem useful in identifying patients who will not benefit from TPN.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

We studied 432 admissions to two Danish ICUs by using a standard severity of illness classification system to assess utilization and outcome. Substantial differences in utilization were found. The patients in Hospital 2 were younger, had better previous health records, and were admitted significantly more often for active treatment as opposed to monitoring than the patients in Hospital 1. Although their measured severity of illness was similar, patients at Hospital 2 received significantly more therapy and their mortality exceeded that of the patients at Hospital 1. The mortality rate of Hospital 2 also exceeded that predicted from a recent survey of U.S. hospitals. We found, however, that 35% of the patients at Hospital 2 had been transferred to the ICU from other ICUs. This created the possibility of an adverse selection and lead-time bias for the patients at Hospital 2. These findings indicate that although national and international comparisons of intensive care are now possible using common classification systems, this progress has created a new need for more precise measurement of potential confounding biases, such as the duration of intensive care services received before formal ICU admission.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

A retrospective review of all patients cared for who met Loe's criteria for extracorporeal membrane oxygenation (ECMO) was conducted covering the 3-yr period 1983 through 1985. There were five out of 3,726 admissions who met criteria for ECMO (three of 127 outborn admissions). All infants were >2 kg birth weight and met criteria based on alveolar-arterial oxygen pressure difference (P[A-a]O2), barotrauma criteria, or both P(A-a)O2and barotrauma criteria. All infants had persistent pulmonary hypertension. Two patients also had hyaline membrane disease and one also had asphyxia and meconium aspiration. All patients were treated with conventional therapy and all survived. There were no patients who met criteria for ECMO and died and there were no patients referred for ECMO during this period. Published criteria for ECMO estimate a control group mortality rate of 80% to 94%. Mortality for this series was 0%. (Ninety-five percent confidence interval for mortality in a group of five survivors is 0% to 45%) Controlled trials of ECMO were not done initially because it was considered unethical. This series shows that historical mortality rates are no longer valid and that controlled trials must be done.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

We investigated 25 patients (aged 20 to 70 yr) in septic shock with low systemic vascular resistance in order to assess the effects on renal function of prolonged (24 to 240 h) norepinephrine (NE) infusion (range 0.5 to 1.5 μg/kg-min). Two sets of renal function tests were made: a) control study before NE therapy after the initial intravascular loading and on dopamine infusion (mean dosage 14 ± 2 μg/kg-min); b) in the last 24 h of NE infusion associated with dopamine (2 to 3, μ/kg-min). The following renal function tests were measured: urine flow rate, creatinine, osmolar and free water clearances, and fractional excretion of sodium (Fena). Data were collected only in 22 nonanuric patients: urine flow rate, creatinine, and osmolar clearance increased (p < .001), and free water clearance (p < .001) and Fena (p < .02) decreased. These results suggest that NE (0.5 to 1.5 μg/kg-min) may be used in the treatment of human septic shock without deleterious renal effects.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID