ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveQuality assurance techniques applied within the healthcare industry have been widely used and are intended to improve patient outcomes. Two methods that have been utilized are incident reporting and medical chart review (MCR). The objectives for this study were to evaluate facilitated incident monitoring (FIM) and MCR in the intensive care setting.DesignCross-sectional comparison of prospective FIM and retrospective MCR.SettingTertiary, 12-bed, closed intensive care unit (ICU) in Australia providing adult and pediatric intensive care to surgical, medical, trauma, and retrieval patients.PatientsPatients present or admitted to the ICU during the 2-month study period.Measurement and Main ResultsDuring the study period, there were 176 admissions involving 164 patients. A total of 100 FIM reports, of which 70 related to care provided by the ICU team, identified 221 incidents. There were 30 FIM reports that described adverse events, of which only one related to ICU team care. Potential of harm was estimated to be minimal in 49% and significant in 51%; 84% of incidents were considered preventable. Important contextual information was provided, including evidence for the importance of system factors. MCR identified 132 adverse events involving 48% of charts, and 47 related to ICU team care. Common adverse events included nosocomial infections, aspiration, neurologic compromise, respiratory arrest, delayed diagnosis, and treatment. Twenty percent of adverse events were considered preventable, and in 41%, there was evidence of system causation.ConclusionFIM provided more contextual information about incidents and identified a larger number and higher proportion of preventable problems than MCR, but FIM identified few iatrogenic infections, problems with pain management, or problems leading to ICU admission. FIM is easily incorporated into the clinical routine. This study suggests that incident monitoring may be more useful for identifying quality problems, and it could be supplemented by selective audits and focused MCR to detect problems not reported well by FIM.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo establish the prevalence, clinical characteristics, and electrophysiologic features of residual neuromuscular dysfunction after prolonged critical illness.DesignProspective follow-up study of survivors of prolonged critical illness.SettingA university hospital and two district general hospitals in the UK.PatientsThe study occurred for a period of 5 yrs. All patients during that time who were in the intensive care unit for >28 days were entered in the study.Measurements and Main ResultsAt follow-up, length of intensive care unit and hospital stay, duration of mechanical ventilation and admission Acute Physiology and Chronic Health Evaluation II score were recorded from the case notes. A clinical history was obtained, a Barthel Index disability score was calculated, and a full neurologic examination was performed. Nerve conduction studies, needle electromyography, single-fiber electromyography and thermal thresholds were performed. A total of 195 patients were identified. There were 86 survivors, of whom 47 could be contacted and 22 consented to be studied. The median time from intensive care unit discharge to follow-up was 43 months (range, 12–57 months). All gave a clear history of severe weakness and functional impairment after hospital discharge and, in all, recovery was prolonged. Motor or sensory deficits were present on clinical examination in 59% of the patients studied. Common peroneal nerve palsy was present in two patients. A total of 21 of 22 (95%) patients had electromyographic evidence of chronic partial denervation at follow-up, findings indicative of a preceding axonal neuropathy. The single-fiber electromyographic studies were also consistent with a preceding motor neuropathy.ConclusionSevere weakness requiring prolonged rehabilitation and abnormal clinical neurologic findings are extremely common in survivors of protracted critical illness. Neurophysiologic evidence of chronic partial denervation of muscle consistent with previous critical illness polyneuropathy is almost invariable and can be found up to 5 yrs after intensive care unit discharge in >90% of these long-stay patients. Evidence of myopathy is unusual. These findings have important implications for the management and rehabilitation of intensive care survivors.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe purpose of this study was to investigate the effect of recombinant adeno-associated viral (rAAV) vector-mediated human vascular endothelial growth factor (VEGF165) transfer on experimental burn wounds.DesignRandomized experiment.SettingResearch laboratory.SubjectsC57BL/6 male mice weighing 25–30 g.InterventionsMice were immersed in 80°C water for 10 secs to achieve a partial-thickness scald burn. Animals were randomized to receive at two injection sites on the edge of the burn either 1011copies of the rAAV-VEGF165 or the vector carrying the control and inert gene &bgr;-galactosidase (rAAV-LacZ). On day 14 the animals were killed. Burn areas were used for histologic examination, evaluation of VEGF expression (immunohistochemistry) and VEGF wound content (enzyme-linked immunosorbent assay), determination of wound nitrite, and measurement of messenger RNA (mRNA) for endothelial and inducible nitric oxide synthase (eNOS and iNOS).Measurements and Main ResultsrAAV-VEGF165 increased epithelial proliferation, angiogenesis, and maturation of the extracellular matrix. Furthermore, gene transfer enhanced VEGF expression, studied by immunohistochemistry, and the wound content of the mature protein (rAAV-LacZ, 11 ± 5 pg/wound; rAAV-VEGF165, 104 ± 7 pg/wound). Moreover, VEGF165 gene transfer increased wound content of nitrate. Finally, rAAV-VEGF165 administration enhanced the messenger RNA for eNOS (rAAV-VEGF165, 1.1 ± 0.2 relative amount of eNOS mRNA; rAAV-LacZ, 0.66 ± 0.3 relative amount of eNOS mRNA) and iNOS (rAAV-VEGF165, 0.8 ± 0.09 relative amount of iNOS mRNA; rAAV-LacZ, 0.45 ± 0.05 relative amount of iNOS mRNA).ConclusionOur study suggests that rAAV-VEGF gene transfer may be an effective therapeutic approach to improve clinical outcomes after thermal injury.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess the value of clinical and/or radiographic prognostic indices in predicting the clinical course and outcome of patients with acute pancreatitis, in the intensive care unit.DesignRetrospective, single institution review.SettingAn adult medical and surgical intensive care unit in a public, urban teaching hospital.PatientsPatients with acute pancreatitis requiring intensive care unit admission between January 1, 1997 and June 30, 2000.InterventionsStandard care.Measurements and Main ResultsA total of 477 patients were hospitalized with the diagnosis of acute pancreatitis. Of these, 28 patients (6%) were admitted to the intensive care unit. Ranson’s, Imrie scores, Acute Physiologic and Chronic Health Evaluation (APACHE) II and III scores, simplified acute physiology scores, and multiple organ dysfunction scores were tabulated at 1, 2, 3, 7, and 14 days after intensive care unit admission. Abdominal computed tomography was available for review for 24 of the 28 patients (86%), where the mean Balthazar’s computed tomography index was 4.5 ± 0.4 (range = 2 to 10). Hospital mortality rate for the intensive care unit patients was 14% (4 of 28). The intensive care unit length of stay ranged from 1 to 79 days (mean 15 days, median 5 days). Fifty-seven percent of the patients developed organ dysfunction, and 36% of the patients required mechanical ventilatory support, ranging in duration from 1 to 70 days. Infectious morbidity occurred in 43% of patients. Thirty-six percent of the patients required operative intervention for intraabdominal complications. APACHE II scores at 7 days after intensive care unit admission correlated closely with ventilator days (r2= .90;p= .003) and correlated with the occurrence of infectious complications (r2= .71;p= .02). Patient age, APACHE III, simplified acute physiology scores, multiple organ dysfunction scores, Ranson, Imrie, computed tomography, and APACHE II scores before day 7 did not closely correlate with the occurrence of adverse clinical outcome.ConclusionsThe clinical course and outcomes of intensive care unit patients with acute pancreatitis can be highly variable. An APACHE II score <10 during the initial 48 hrs correlated with mild pancreatitis and uncomplicated intensive care unit course; however, multifactorial prognosticators were not useful for the early identification of patients who developed complications or required extended intensive care unit care.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveIbutilide, a class III antiarrhythmic drug, has been shown to convert atrial fibrillation to sinus rhythm more rapidly than procainamide or sotalol. Our objective was to compare the efficacy and safety of ibutilide and amiodarone in patients after cardiac surgery.DesignProspective, randomized, double-blinded study.SettingIntensive care unit of a university hospital.PatientsForty adults with an onset of atrial fibrillation within 3 hrs after admission.InterventionsBefore the administration of antiarrhythmic drugs, a 24-hr Holter electrocardiograph was attached. Patients in the ibutilide group received ibutilide 0.008 mg/kg body weight over 10 mins; treatment was repeated if atrial fibrillation or flutter persisted. If sinus rhythm was not achieved within 4 hrs, amiodarone 5 mg/kg was administered over 30 mins, followed by amiodarone 15 mg/kg over 24 hrs. Patients in the amiodarone group received amiodarone 5 mg/kg over 30 mins, followed by amiodarone 15 mg/kg over 24 hrs if atrial fibrillation or flutter continued.Measurements and Main ResultsWithin the first 4 hrs, atrial fibrillation was converted in nine of 20 patients (45%) in group ibutilide and in ten of 20 patients (50%) in group amiodarone (not significant). Mean time for conversion overall was 385 mins in group ibutilide and 495 mins in group amiodarone (not significant). In group amiodarone, the protocol was discontinued in two patients because of severe arterial hypotension. Atrial fibrillation recurred in 11 of 20 patients (55%) in group ibutilide and in seven of 20 patients (35%) in group amiodarone (not significant). Ventricular arrhythmia did not occur during the first 24 hrs of the protocol.ConclusionsIbutilide has no significant advantage over amiodarone for the conversion of atrial fibrillation to sinus rhythm in either time to conversion or conversion overall, but severe hypotension was not seen with ibutilide.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe impact of resistant (vs. nonresistant) Gram-negative infections on mortality remains unclear. We sought to define risk factors for and excess mortality from these infections.DesignProspective cohort study.SettingInpatient surgical wards at a university hospital.PatientsAll patients in the general, transplant, and trauma surgery services diagnosed with Gram-negative rod (GNR) infection.Measurements and Main ResultsAll culture-proven GNR infections (n = 924) from December 1996 to September 2000 were studied. Characteristics and outcomes were compared between GNR infections with and without antibiotic resistance. Univariate and logistic regression analysis identified factors associated with antibiotic-resistant GNR (rGNR) infection and mortality. rGNR infection (n = 203) was associated with increased Acute Physiology and Chronic Health Evaluation (APACHE) II scores (17.8 ± 0.5), multiple comorbidities, pneumonia and catheter infection, coexistent infection with antibiotic-resistant Gram-positive cocci and fungi, and high mortality (27.1%). Only seven isolates were resistantin vitroto all available antibiotics. Logistic regression demonstrated that rGNR infection was an independent predictor of mortality (odds ratio, 2.23; 95% confidence interval, 1.35–3.67;p= .002). Analysis of rGNR infection with controls matched by organism, age, APACHE II score, and site of infection, however, revealed that antibiotic resistance was not associated with increased mortality (23.6% vs. 29.2%,p= .35). Furthermore, analysis of allPseudomonas aeruginosainfections demonstrated no significant difference in mortality between resistant and sensitive strains (18.9% vs. 20.0%,p= .85).ConclusionrGNRs are associated with prolonged hospital stay and increased mortality. Infection with rGNRs independently predicts mortality; however, this may be more closely related to selection of certain bacterial species with a high frequency of resistance rather than actual resistance to antibiotic therapy. Therefore, altering infection-control practices to limit the dissemination of certain bacterial species may be more effective than attempts to control only antibiotic-resistant isolates.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveOur first objective was to determine a blood lactate threshold predictive of survival in human immunodeficiency virus patients experiencing lactic acidosis related to nucleoside analogs, and second, to test l-carnitine for the treatment of patients exceeding that threshold.Designa) Retrospective study using data from personal and published observations to determine the lactate threshold between survivors and nonsurvivors in human immunodeficiency virus patients being treated with nucleoside analogs. b) Prospective multicenter open trial to test l-carnitine treatment of human immunodeficiency virus patients receiving nucleoside analogs.SettingMedical intensive care units of four teaching hospitals and one general hospital.PatientsRetrospective analysis of data from 39 human immunodeficiency virus patients (five personal cases and 34 patients from the literature) receiving nucleoside-analog treatment from which lactate values were available. An additional six patients with high lactate values were included as a pilot study testing the use of l-carnitine therapy.Measurements and Main ResultsAn initial lactate level of 9 mmol/L, which gave good positive and negative predictive values, was determined as a threshold between survivors and nonsurvivors for the patients receiving nucleoside-analog treatment. Six patients with initial lactate levels >10 mmol/L were prospectively treated with l-carnitine; three survived beyond the end of the study.ConclusionsThe blood lactate levels in human immunodeficiency virus patients receiving nucleoside-analog therapy can predict mortality in these patients. The preliminary data from this pilot study suggest that l-carnitine may be helpful for patients who have nucleoside-analog-related lactic acidosis with blood lactate levels >10 mmol/L. Further studies will be necessary to affirm the therapeutic efficacy of l-carnitine in this setting.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveHost response to infection and other forms of tissue injury have been termed systemic inflammatory response syndrome (SIRS). This inflammatory response can frequently be accompanied by oxidative injury in one or more organ systems in the body. The objective of this report was to clarify the possible role of oxidative stress in the development of multiple organ failure (MOF) in patients with SIRS.DesignProspective clinical study.SettingIntensive care unit in a university hospital.PatientsA total of 214 consecutive patients (mean age, 57.1 ± 17.4 yrs; range, 13 to 84 yrs; 148 men and 66 women). At the time of admission, 139 patients fulfilled the clinical criteria for SIRS.InterventionsNone.Measurements and Main ResultsWe measured plasma concentrations of thiobarbituric acid reactant substances (TBARS), as an index of oxidative stress, every day from the point of admission to the intensive care unit until discharge or death. Furthermore, all variables of the SIRS score and the Sequential Organ Failure Assessment score were collected every day. At the time of admission, plasma TBARS concentrations in SIRS patients with MOF were significantly higher than those in SIRS patients without MOF (2.3 ± 0.9 vs. 1.9 ± 0.6 nmol/mL,p< .01), and there was a significant correlation between plasma TBARS concentration and Sequential Organ Failure Assessment score (r2= .18,p< .001). Furthermore, the duration of SIRS persistence was significantly associated with the percentage increase in plasma TBARS concentration during SIRS persistence in those patients in whom the duration of SIRS was confirmed (r2= .73,p< .001). The duration of SIRS was significantly higher in patients who developed MOF than in patients who did not develop MOF (6.9 vs. 3.2 days,p< .001). The percentage increase in plasma TBARS concentration during SIRS was also significantly higher in patients who developed MOF than in patients who did not develop MOF (57.1% vs. 15.8%,p< .001).ConclusionsIt can be concluded that processes of oxidative stress in connection with continued SIRS may promote the development of MOF.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo investigate the pathophysiology underlying raised lactate levels after cardiac surgery with cardiopulmonary bypass (CPB).DesignProspective observational study.SettingMedical and surgical intensive care unit of a tertiary hospital.PatientsA total of 40 patients undergoing first-time coronary artery bypass grafting with CPB.InterventionsThe prothrombotic response to cardiac surgery with CPB was assessed by measuring plasma levels of prothrombin fragment 1 + 2 and plasminogen activator inhibitor (PAI) activity. The hemodynamic responses to cardiac surgery with CPB were also measured using standard techniques.Measurements and Main ResultsAfter cardiac surgery, prothrombin fragment 1 + 2 levels increased 6-fold and PAI activity increase 2- to 3-fold (p< .0001). Lactate levels were not associated with prothrombin fragment 1 + 2 and PAI activity levels after CPB. Lactate levels were associated with baseline PAI activity (p= .006), a history of hypertension (p= .02), raised baseline lactate levels (p= .02), an early increase in body temperature after CPB (p= .05), a late increase in oxygen consumption after CPB (p= .03), and a raised white cell count after CPB (p= .06). Lactate levels were inversely associated with the maximum activated clotting time level reached during CPB (p= .02). Multivariate linear regression demonstrated lactate levels were independently associated with baseline PAI activity.ConclusionWe found cardiac surgery with CPB was associated with a marked prothrombotic response. Lactate levels were associated with elevated baseline PAI activity and evidence of an amplified inflammatory response to cardiac surgery with CPB. Our findings implicate aspects of the inflammatory response, including microvascular thrombosis, in the development of raised lactate levels after cardiac surgery with CPB.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID