摘要:

We investigated prospectively clinical bleeding in 1,328 consecutive patients admitted to a medical/surgical ICU over 1 yr. One hundred thirty-eight (10.4%) patients bled after ICU admission, and an additional 388 (29.2%) bled coincident with admission. The upper GI tract was the site of bleeding in 34.8% of patients whose bleeds commenced in the ICU, and accounted for 22% of total sites. Patients with clinical bleeding after ICU admission had a significantly (p< .001) higher likelihood of death than those who did not bleed, and those with multiple bleeding sites had a higher mortality (54.9%) than those with single sites (31%) (p< .006). Multiple logistic regression analyses revealed that risk ratios (RR) for bleeding after ICU admission were mechanical ventilation (RR = 1.82), nutritional failure (RR = 3.45), acute renal failure (RR = 3.36), antiulcer medication (RR = 3.36), and anticoagulants (RR = 4.19). No antibiotics could be specifically incriminated. This study defines the scope, characteristics, and importance of bleeding in ICU patients and establishes risk factors.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

Because several studies have shown a significant inverse correlation between depressed serum concentrations of albumin and hospital morbidity, a study with central total parenteral nutrition (TPN) with normal serum albumin (NSA) in hypoalbuminemic patients was conducted. Sixty-one patients who required central TPN were randomized into one of two groups: group 1 (n = 31) received TPN plus NSA (25 to 37.5 g/day) until their measured serum albumin was >3 g/dl, and group 2 (n = 30), who received TPN alone. AH patients were followed for hospital complications until discharge or death. The groups were well matched for age, sex, major diagnoses, initial serum albumin concentrations, hospital complications before TPN, and number of operative procedures. Both groups received comparable doses of energy (37.2 ± 8.9 vs. 33.0 ± 6.2 kcal/kg·day) and protein (1.6 ± 0.4 vs. 1.6 ± 0.3 g/kg·day). After initiation of TPN, there were significantly more hospital complications in group 2 (1 = 1.1 ± 1.4, n = 33; 2 = 2.6 ± 3.0, n = 80,p< .01). When complications in the patient groups were stratified, significantly more patients in group 2 developed pneumonia (18 vs. 9,p< .05) and septicemia (11 vs. 2,p< .05). Increasing serum albumin concentrations with NSA in hypoalbuminemic patients receiving central TPN appears to be associated with a reduction in hospital morbidity.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

There has been much interest in the parenteral use of medium-chain triglycerides (MCT) as a noncarbohydrate energy source. This study examines the effects of infusion iv into postabsorptive normal subjects with three doses (0.5, 1.0, 1.5 g/kg·15 h) of an emulsion containing 56% MCT and 44% long-chain triglyceride (LCT) and comparing its metabolic effect with infusions of normal saline (NS) and an emulsion containing LCT alone. There were significant increases in serum β-hydroxybutyrate and acetoacetate 5 and 15 h after the start of the MCT-LCT infusions. Increases were seen only after 15 h of NS, while none was observed during LCT alone. Triglycerides were increased in a doserelated fashion with MCT-LCT and were increased even further with LCT alone. Glycerol increased in a dose-related fashion both during the MCT-LCT and LCT infusion beginning immediately (0.5 h) after the start of the infusion. With NS infusion, glycerol increased significantly only after 15 h of infusion. The MCT-LCT mixture and the highest LCT dose resulted in a significant (12%) increase in oxygen consumption after 5 h of infusion. There was no difference in oral glucose tolerance between the various infusions. Infusion of MCT results in significant ketogenesis and more study is needed to determine its clinical utility.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

The major aim was to develop a branch-chain decision tree for penetrating truncal injury and to subject this to a prospective trial of its feasibility to track management decisions. In contrast to the conventional trauma study which focuses on highly selected, well-defined surgical problems, this algorithmic approach was designed to look at the whole gamut of problems of unselected patients with penetrating injury as they enter the ED. The branch-chain algorithm primarily focuses on priorities, order of procedures, and the immediate therapeutic options. The algorithm was used to track clinical management of 280 consecutive patients with penetrating truncal injuries; 31 were dead on arrival, 12 were alive on admission but died during their hospitalization. Of 209 patients whose management was in satisfactory compliance, four (2%) died; eight (20%) of 40 patients who had major deviations from the algorithm died (p <.01).

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

The aim of the present study was to examine the essential problems in a retrospective study of 381 organ injuries in 260 patients, to identify problems, to define criteria, to describe decision rules, and to organize these rules into branch-chain decision trees or clinical algorithms. The basic hypothesis of this study is that criteria organized into a prioritized decision tree can provide objective standards to evaluate the quality of trauma care and to compare alternative approaches. The algorithm was designed to provide prompt therapy for the most life-threatening problems: respiratory and cardiac arrest, shock, head injury, tamponade, lacerations of the great vessels, cardiac contusion, ruptured parenchymal organs, lacerated viscera, and injury to other intraperitoneal organs. Resuscitation from shock, correction of circulatory problems, and monitoring of physiologic variables were prioritized to evaluate the presence of circulatory deficits and the adequacy of specific therapy to correct them. Concomitantly, diagnosis of the underlying problems was approached using peritoneal lavage, abdominal and chest x-rays, iv urograms, cystograms, endoscopy, upper and lower GI barium or hypaque studies, ultrasound, scintograms, and CT scans. In emergency conditions these are limited to a large extent by time factors. The diagnostic accuracy, priorities, and limitations of each of these were evaluated in emergency conditions. The algorithm was used to track management decisions in a prospective series; the mortality of 51 patients with satisfactory compliance was 4% and 44% in nine patients with major deviations from the algorithm.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

Hepatic hypoperfusion can result in ischemic hepatitis, a clinical syndrome characterized by a sudden rise in serum transaminases followed by resolution to near normal levels within 7 to 10 days. Although described in adults, this syndrome has not been well defined in pediatric patients. We report 22 children who developed ischemic hepatitis during an acute illness. Fifteen of 22 patients had a documented hypotensive episode or no cardiac output before the onset of the ischemic hepatitis episode. Four of the seven patients without documented hypotension required pressor therapy to maintain their BP. SGOT showed a marked rise (mean 2294 IU/L, range 438 to 6652) from admission to 96 h (mean 34) with a rapid decline to near normal levels within 9 days (mean 5.1). Serum bilirubin levels also rose transiently, but generally not to the extent of transaminase levels. A clinically significant coagulopathy occurred in six patients. Although nine patients expired, none died as a direct result of the hepatic damage. Ischemic hepatitis can occur during illnesses associated with diminished hepatic blood flow and follows a characteristic course that usually can be differentiated from viral or drug-induced hepatitis on clinical and biochemical criteria.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

A retrospective case-control study involving 99 premature infants requiring vigorous respiratory support was conducted to investigate the relative contribution of various etiologic factors in the development of chronic lung disease (CLD). Nineteen of the 99 developed CLD. Background and management factors up to the development of CLD, with attention to mode of ventilation (tube, or face mask/nasal prongs) were investigated. Infants in the CLD group had significantly lower birth weights (BW) (p< .001) and gestational ages (p< .01) than those in the non-CLD group. There was no difference in the incidence of intrathoracic airleak or symptomatic patent ductus arteriosus. Of the CLD group, 74% were intubated compared with 35% in the non-CLD group (p< .002). There was no difference between the group's in the morbidity score of initial pulmonary disease or in the duration of ventilation with various pressures and oxygen concentrations. Multiple logistic regression analysis revealed that intubated infants were 4.8 times more likely to develop CLD than nonintubated infants, and infants with low BW had a 3.2-fold greater risk of developing the disease.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

We reviewed retrospectively 88 patients to assess whether the APACHE II severity of disease classification system can predict mortality in patients with respiratory failure due to cardiac pulmonary edema. Mean score for survivors was higher than for nonsurvivors (24.5 ± 6.7 vs. 20.7 ± 5.7, p < .01), and increasing APACHE II scores were not associated with increasing mortality. Mortality was 54% for APACHE II scores ± 18,43% for scores >18 andp< .001. The presence of myocardial infarction (MI) was associated with a high mortality. Mortality in the 51 MI patients was 52.9% vs. 13.5% in the 37 patients without MI (p< .001), but APACHE II scores were similar (22.6 ± 6.6 and 23.7 ± 6.4, respectively). The relationship between APACHE II scores and mortality did not improve if patients with and without MI are analyzed separately. For patients with MI, mortality was 78.6% for scores between 12 and 17, 56.2% for scores between 18 and 23,33.3% for scores between 24 and 29, and 33.3% for scores >29. For patients without MI, mortality was 0% for scores between 12 and 17, 30.7% for scores between 18 and 23, 9.1% for scores between 24 and 29, and 0% for scores >29. Patients with MI had lower initial mean arterial pressure than those without MI (86 ± 31 vs. 120 ± 25 mm Hg,p< .001), and more frequently required vasoactive medication (63% vs. 5.5%,p< .001), suggesting that significant myocardial injury from infarction is related to the higher mortality observed. These results suggest the APACHE II scores might not provide accurate prognostic information in an ICU population with a large proportion of patients with cardiogenic pulmonary edema, and confirm the APACHE II authors' warning that the index should be assessed critically in disease states in which it has not been previously validated

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

Gastric intramural pH (pHi), which has been shown to reflect the adequacy of oxygenation in peripheral tissue beds, was measured in acutely ill surgical patients in order to evaluate its value as a prognostic factor and its relation to the sepsis score. Fifty-nine surgical patients were studied on ICU admission. The stomach wall pH was calculated from the Pco2in gastric juice and arterial bicarbonate concentration using the Henderson-Hasselbach equation. A fall in tissue pH < 7.32 was taken as an indication of inadequate tissue oxygenation. Patients with sepsis scores >10 were considered septic.Hospital and short-term (within 72 h of admission) mortality rates were determined. A significantly higher short-term mortality rate was observed in patients having a pHi <7.32 (37% vs. 0%,p< .005). Most (90%) of the septic patients had a pHi <7.32. The short-term mortality rate was the highest (50%) in the septic group. In this group also, a linear correlation was found between pHi and the sepsis score (r = -.43,p< .01). Gastric pHi, however, offered no prediction for the long-term outcome.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID

摘要:

Mechanically induced respiratory alkalosis decreases pulmonary arterial pressure in infants with persistent pulmonary hypertension of the newborn and in newborn lambs with hypoxia-induced pulmonary hypertension. Since thromboxane A2may mediate the pulmonary hypertension in infants with Group B β-hemolytic streptococci andEscherichia colipneumonia, we studied the effect of respiratory alkalosis on thromboxane-induced pulmonary‘ hypertension. A specific thromboxane A2-mimetic, U46619, was infused into six normoxic, sedated, mechanically ventilated lambs. U46619 produced pulmonary hypertension which was significantly attenuated during respiratory alkalosis. These results support the use of respiratory alkalosis to treat infants and children with pulmonary hypertension regardless of the presumed etiology.

ISSN:0090-3493    

出版商:OVID    

年代:1988

数据来源: OVID