摘要:

ObjectiveTo review the outcome of bone marrow transplant (BMT) recipients admitted to a pediatric intensive care unit (ICU) and attempt to identify admission characteristics that might accurately predict a poor outcome.DesignRetrospective case-note review.SettingPediatric ICU of a tertiary teaching hospital.PatientsA total of 40 BMT recipients, accounting for 57 admissions to the ICU, in the 5 yrs between 1994 and 1998 were identified.Measurements and Main ResultsMedian time to ICU admission after BMT was 42 days. Of the 40 patients admitted to ICU, 11 (22.5%) are still alive, with a median time of follow-up since their most recent ICU admission of 587 days (absolute range, 308–1803 days). A total of 32 of 57 admissions (56.1%) resulted in the patient’s discharge from the ICU, and 21 admissions (36.8%) resulted in survival to at least 30 days after discharge. There was no difference between the survivors and nonsurvivors in terms of underlying diagnoses, age at BMT, or time to ICU admission after BMT. Type of BMT, conditioning regimen, and presence of significant graft vs. host disease was not found to influence outcome. Although patients who died in the ICU had a significantly longer length of stay compared with the survivors (median, 7.9 days, vs. 2.1 days,p= .02), 11 of 21 admissions (52.4%) associated with survival to 30 days post-ICU discharge were of ≥2 days of duration, the longest being 22.8 days. Thirty-one of 40 patients (77.5%) required intubation and mechanical ventilation during 36 of the 57 admissions, and 15 of these episodes (41.6%) ended with the patient’s discharge from the ICU. Of ten patients with respiratory failure associated with pulmonary infection, there were no survivors among those who remained ventilated at 48 hrs (n = 8). Four patients who required mechanical ventilation (12.9%) were alive at the 6-month follow-up. The majority of patients who died in the ICU did so after either withdrawal (65%) or limitation (22%) of treatment.ConclusionsDespite the generally poor prognosis for pediatric patients admitted to the ICU after BMT, intensive care continues to play an important role in the care of these patients. Although it is clear that patients who require mechanical ventilation have a worse prognosis, we were unable to identify factors that accurately predict with 100% sensitivity which patients will not survive. Those patients requiring mechanical ventilation due to pneumonitis have a particularly poor outcome, and our findings support the limitation of intensive care in certain circumstances. Decisions regarding treatment options and limitation of care in this group of patients should be based on ongoing outcome research in this field.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the influence of airway humidification devices on the efficacy of ventilation in difficult to wean patients.DesignA prospective, randomized, controlled physiologic study.SettingA 22-bed medical intensive care unit in a university hospital.PatientsChronic respiratory failure patients.InterventionsPerformances of a heated humidifier and a heat and moisture exchanger were evaluated on diaphragmatic muscle activity, breathing pattern, gas exchange, and respiratory comfort during weaning from mechanical ventilation by using pressure support ventilation. Eleven patients with chronic respiratory failure were submitted to four pressure support ventilation sequences by using the heated humidifier and the heat and moisture exchanger at two different levels of pressure support ventilation (7 and 15 cm H2O).Measurement and Main ResultsCompared with the heated humidifier and regardless of the pressure support ventilation level used, the heat and moisture exchanger significantly increased all of the inspiratory effort variables (inspiratory work of breathing expressed in J/L and J/min, pressure time product, changes in esophageal pressure, and transdiaphragmatic pressure;p< .05) and dynamic intrinsic positive end-expiratory pressure (p< .05). Similarly, the heat and moisture exchanger produced a significant increase in Paco2(p< .01) responsible for severe respiratory acidosis (p< .05), which was insufficiently compensated for despite a significant increase in minute ventilation (p< .05). This resulted in respiratory discomfort for all patients with the heat and moisture exchanger (p< .01). Adverse effects were partially counterbalanced by increasing the pressure support ventilation level with the heat and moisture exchanger by ≥8 cm H2O.ConclusionsThe type of airway humidification device used may negatively influence the mechanical efficacy of ventilation and, unless the pressure support ventilation level is considerably increased, the use of a heat and moisture exchanger should not be recommended in difficult or potentially difficult to wean patients with chronic respiratory failure.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the attributable cost of ventilator-associated pneumonia from a hospital-based cost perspective, after adjusting for potential confounders.DesignPatients admitted between January 19, 1998, and December 31, 1999, were followed prospectively for the occurrence of ventilator-associated pneumonia. Hospital costs were defined by using the hospital cost accounting database.SettingThe medical and surgical intensive care units at a suburban, tertiary care hospital.PatientsPatients requiring >24 hrs of mechanical ventilation.InterventionsNone.Measurements and Main ResultsWe measured occurrence of ventilator-associated pneumonia, in-hospital mortality rate, total intensive care unit (ICU) and hospital lengths of stay (LOS), and total hospital cost per patient. Ventilator-associated pneumonia occurred in 127 of 819 patients (15.5%). Compared with uninfected, ventilated patients, patients with ventilator-associated pneumonia had a higher Acute Physiology and Chronic Health Evaluation II score on admission (p< .001) and were more likely to require multiple intubations (p< .001), hemodialysis (p< .001), tracheostomy (p< .001), central venous catheters (p< .001), and corticosteroids (p< .001). Patients with ventilator-associated pneumonia were more likely to be bacteremic during their ICU stay (36 [28%] vs. 22 [3%];p< .001). Patients with ventilator-associated pneumonia had significantly higher unadjusted ICU LOS (26 vs. 4 days;p< .001), hospital LOS (38 vs. 13 days;p< .001), mortality rate (64 [50%] vs. 237 [34%];p< .001), and hospital costs ($70,568 vs. $21,620,p< .001). Multiple linear regression, controlling for other factors that may affect costs, estimated the attributable cost of ventilator-associated pneumonia to be $11,897 (95% confidence interval = $5,265–$26,214;p< .001).ConclusionsPatients with ventilator-associated pneumonia had significantly longer ICU and hospital LOS, with higher crude hospital cost and mortality rate compared with uninfected patients. After we adjusted for underlying severity of illness, the attributable cost of ventilator-associated pneumonia was approximately $11,897.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe hub connecting the catheter and the infusion equipment is a common portal of entry for bacteria causing catheter-related sepsis. We assessed the efficacy of a new hub model (Segur-Lock) that incorporates an antiseptic chamber filled with 3% iodinated alcohol in preventing endoluminal catheter contamination and catheter-related bloodstream infection arising at the hub.DesignProspective, randomized, multicenter study.SettingSeven medical and surgical adult intensive care units in Spain.PatientsA total of 230 patients aged 18 yrs or older requiring the insertion of a nontunneled central venous catheter for ≥6 days from January 1, 1998, to April 30, 1999.InterventionsPatients were randomized at the time of catheter insertion to receive catheters with standard Luer-lock connector (control group, n = 114) or catheters with the new hub model (n = 116).Measurements and Main ResultsSkin, catheter tip, and hub cultures were performed at the time the catheter was withdrawn because therapy was terminated or due to suspicion of sepsis, in which case peripheral blood and infusate cultures were simultaneously taken. Catheter-related bloodstream infection was diagnosed in 19 (8.3%) patients. Catheters were more often withdrawn because of suspicion of infection in the control group (43.8%) than in the new hub model group (30.1%,p< .035). The prevalence of culture-positive catheter hubs without associated bacteremia (colonization) was higher in the control group (14.4% vs. 4.3%,p< .001). Catheter-related bloodstream infection from the catheter hub also occurred more frequently in controls than in patients assigned to the new hub model (7% vs. 1.7%;p< .049; relative risk, 4.14; 95% confidence interval, 0.8–19).ConclusionsThis new antiseptic chamber–containing hub has proved to be effective in preventing endoluminal bacterial colonization and catheter-related bloodstream infection from hub contamination in intensive care unit patients with central venous catheters inserted for ≥6 days.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the rate of the acute respiratory distress syndrome (ARDS) after kidney transplantation and to identify risk factors associated with the development of ARDS after kidney transplantation and outcomes for patients diagnosed with ARDS in this setting.DesignRetrospective analysis of the national registry for end-stage renal disease in the United States.PatientsWe studied all patients who underwent kidney transplantation between July 1, 1994 and June 30, 1998 and identified patients diagnosed with ARDS. The diagnosis of ARDS was based on coding of patients records. We also compared the rate of ARDS after kidney transplantation with the rate of ARDS in the remainder of the U.S. population based on the results of the National Hospital Discharge Survey for 1997.Measurements and Main ResultsDuring the study period, 42,190 kidney transplantations were performed in the United States and ARDS was diagnosed in 86 of these subjects (0.2%) resulting in an annualized rate of ARDS of 51.0 cases per 100,000 patients per year. The rate of ARDS after kidney transplantation was significantly higher than the reported rate of ARDS in the U.S. population (p< .050). Demographic factors, indications for transplantation, comorbid illness, antigen mismatch, cytomegalovirus status, and development of rejection did not correlate with the development of ARDS. Of the immunosuppressive agents (e.g., cyclosporine, FK-506, mycophenolate mofetil, azathioprine, OKT-3, antilymphocyte globulin), only the use of antilymphocyte globulin when used to treat rejection was linked with an increased risk for ARDS (odds ratio: 3.85; 95% confidence interval: 1.36 to 10.87). Subjects with graft failure were 2.70 (95% confidence interval: 1.33 to 5.52) times more likely to develop ARDS. The 28-day mortality in subjects with ARDS was 52.1%. The 3-yr survival after kidney transplantation was 88.9% in those without ARDS compared with 57.8% in persons with ARDS (p< .001).ConclusionsAlthough ARDS is a rare event after kidney transplantation, undergoing renal transplantation increases the risk for ARDS. Among patients receiving kidney transplants, graft failure and the use of antilymphocyte globulin for rejection are associated with the development of ARDS. Patients who develop ARDS after kidney transplantation face significant mortality.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the incidence of critically ill patients displaying endogenous digitalis-like-immunoreactive substances (DLIS) and to examine the relationship of these hormones to routine laboratory variables, the underlying disease, myocardial function, hemodynamic status, severity of illness, systemic inflammation, and mortality rate.DesignSera of 401 consecutive critically ill patients, not treated with cardiac glycosides, were analyzed for DLIS (digitoxin and digoxin, TDx; Abbott Diagnostics, North Chicago, IL) and endogenous ouabain. Normal values of endogenous ouabain were determined in 62 healthy volunteers. We measured pro- and anti-inflammatory mediators (L-selectin, tumor necrosis factor-&agr;, interleukin-1&bgr;, interleukin-2, interleukin-6, interleukin-10), C-reactive protein, and serum amyloid A protein as well as patients’ Acute Physiology and Chronic Health Evaluation II and Goris scores. In a subgroup of patients with a pulmonary artery catheter (n = 95), we determined cardiac output, pulmonary artery occlusion pressure, systemic and pulmonary vascular resistance, left ventricular stroke volume, and right and left stroke work.SettingTwo surgical intensive care units of an university hospital.SubjectsSera of 401 consecutive critically ill patients.InterventionsBlood sampling.Measurements and Main ResultsOf the 401 patients tested, 343 had nonmeasurable DLIS concentrations (DLIS-negative), and 58 (14.5%) had positive digoxin (n = 18) or digitoxin (n = 34) concentrations (DLIS-positive) or were positive in both tests (n = 6). Mean endogenous ouabain concentrations were nine-fold increased in DLIS-positive (3.59 ± 1.43 nmol/L) and three-fold increased in DLIS-negative (1.34 ± .81 nmol/L) patients compared with controls (0.38 ± 0.31 nmol/L). DLIS and ouabain concentrations closely correlated with the Acute Physiology and Chronic Health Evaluation II and Goris score and were associated with increased concentrations of transaminases, bilirubin, aldosterone, cortisol, serum creatinine, fractional sodium excretion, proinflammatory mediators, C-reactive protein, and serum amyloid A (p≤ .009). The hospital mortality rates of DLIS-positive and DLIS-negative patients were 12% and 3.2%, respectively, and for patients with ouabain concentrations above and below 2 nmol/L 38.6% and 0.6%, respectively. In DLIS-positive patients with pulmonary artery catheter (n = 23), cardiac output, stroke volume, and left ventricular stroke work were decreased, and pulmonary artery occlusion pressure and central venous pressure were increased (p≤ .009).ConclusionsDifferent types of endogenous glycosides including endogenous ouabain are elevated in a significant proportion of critically ill patients. The occurrence of these substances is associated with increased morbidity and hospital mortality rates, possibly due to systemic inflammatory processes. DLIS but not endogenous ouabain concentrations were found to be related to left ventricular function.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the relationship between the acute inflammatory response after surgical trauma and changes in hepatic cytochrome P450 3A4 activity, compare changes in cytochrome P450 3A4 activity after procedures with varying degrees of surgical stress, and to explore the time course of any potential drug-cytokine interaction after surgery.DesignProspective, open-label study with each patient serving as his or her own control.SettingUniversity-affiliated, acute care, general hospital.PatientsA total of 16 patients scheduled for elective repair of an abdominal aortic aneurysm (n = 5), complete or partial colectomy (n = 6), or peripheral vascular surgery with graft (n = 5).InterventionsCytochrome P450 3A4 activity was estimated using the carbon-14 [14C]erythromycin breath test (ERMBT) before surgery and 24, 48, and 72 hrs after surgery. Abdominal aortic aneurysm and colectomy patients also had an ERMBT performed at discharge. Blood samples were obtained before surgery, immediately after surgery, and 6, 24, 32, 48, and 72 hrs after surgery for determination of plasma concentrations of interleukin-6, interleukin-1&bgr;, and tumor necrosis factor-&agr;. Clinical markers of surgical stress that were collected included duration of surgery, estimated blood loss, and volume of fluids administered in the operating room.Measurements and Main ResultsERMBT results significantly declined in all three surgical groups, with the lowest value at the time of the 72-hr study in all three groups. There was a trend toward differences in ERMBT results among groups that did not reach statistical significance (p= .06). The nadir ERMBT result was significantly and negatively correlated with both peak interleukin-6 concentration (rs= −.541,p= .03) and log interleukin-6 area under the curve from 0 to 72 hrs (rs= −.597,p= .014). Subjects with a peak interleukin-6 of >100 pg/mL had a significantly lower nadir ERMBT compared with subjects with a peak interleukin-6 of <100 pg/mL (35.5% ± 5.2% vs. 74.7% ± 5.1%,p< .001).ConclusionsAcute inflammation after elective surgery was associated with a significant decline in cytochrome P450 3A4 activity, which is predictive of clinically important changes in the metabolism of commonly used drugs that are substrates for this enzyme.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveSequential intravenous-to-oral antimicrobial therapy with highly bioavailable antiinfective agents such as the fluoroquinolones may improve patient safety and decrease cost of infection management. However, physiologic changes associated with critical illness may alter drug absorption, distribution, and clearance, and concomitant enteral feeding may decrease fluoroquinolone bioavailability. We evaluated the effect of critical illness and concomitant gastric tube feeding on gatifloxacin bioavailability.DesignProspective, randomized, single-dose, two-way crossover, pharmacokinetic study.SettingA tertiary, level-one, trauma center.PatientsSixteen critically ill patients (baseline Acute Physiology and Chronic Health Evaluation II score ≥16) tolerating enteral nutrition administered by gastric tube (NG) for ≥12 hrs were randomized to receive gatifloxacin concurrently with continuous tube feeding or with interrupted tube feeds. Patients with renal insufficiency or those receiving concomitant fluoroquinolone therapy or postpyloric feeding were excluded. Patients received gatifloxacin 400 mg either by the intravenous or NG route followed by the alternative dosage form after a 72-hr washout period.Measurements and Main ResultsSerial serum gatifloxacin concentrations (from 5 mins to 24 hrs) were analyzed using a validated high-performance liquid chromatography method. Bioavailability was determined as the ratio of NG/intravenous area under the concentration-time curve (AUC∞) measured by the trapezoidal method. Although there was no difference in the bioavailability between NG (AUC∞: 38.0 [range 20.1 to 48.5] &mgr;g·h/mL) and intravenous (AUC∞: 39.5 [range 24.1 to 63.1] &mgr;g·h/mL,p= .60) gatifloxacin (bioavailability: 98.5% [range 61.1% to 119.7%]), a wide variability was observed in three of eight patients (>30% reduction in bioavailability). Concomitant gastric tube feeding did not affect gatifloxacin bioavailability (interrupted tube feeds: 98.5% [range 61.1% to 119.7%]; continuous tube feeding: 109.0% [range 86.2% to 142.1%];p= .42). Neither a period nor differential carryover effect was observed.ConclusionsAlthough concomitant tube feeding did not affect gatifloxacin bioavailability, critical illness resulted in significant variability that may complicate the role of gatifloxacin in sequential intravenous-to-oral therapy. More research is needed to identify those patients in whom gatifloxacin bioavailability is reduced and for whom an empirical increase in gatifloxacin dose should be considered.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo compare the relationship between the time of pulmonary artery catheter replacement (4 days or 7 days after insertion) and the occurrence of catheter-associated infections.DesignOne-year prospective, randomized, controlled clinical trial.SettingSurgical and medical intensive care units at a 2,700-bed medical center.PatientsA total of 258 patients in critical condition who underwent pulmonary artery catheter insertion were recruited.InterventionsAll patients were randomized into two groups (4 days or 7 days) according to the length of time before the pulmonary artery catheter and pressure monitoring system were replaced.Measurements and Main ResultsOver a 12-month period, 331 catheters were inserted in 258 patients. In the per-protocol analysis, 98 patients (73.7%) in the 4-day group and 85 patients (68%) in the 7-day group were enrolled. Twelve patients (14.1%) in the 7-day group and 5 patients (5.1%) in the 4-day group (odds ratio, 3.06; 95% confidence interval, 0.94–10.48) had pulmonary artery catheter-tip colonization. Nine patients (10.5%) in the 7-day group and 7 patients (7.1%) in the 4-day group (odds ratio, 1.54; 95% confidence interval, 0.50–4.85) had bacteremia. In the 7-day group, pulmonary artery catheter-related bacteremia was found in only one patient (1.1%, 1.1 episodes per 1,000 catheter-days) compared with no patients in the 4-day group. The frequency of positive cultures from different sources between the 4-day and 7-day groups was not significantly different in the intention-to-treat analysis (p> .05).ConclusionsNo statistically significant difference was found for pulmonary artery catheter-associated infection when intervals of 4 or 7 days between insertion and replacement were compared. Patients with prolonged pulmonary artery catheterization must be carefully examined for signs or symptoms of infection. The time until pulmonary artery catheter replacement can be extended to 7 days if there is no evidence of catheter-related infection.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveLipoproteins have been implicated to play a role in innate immunity. Changes in lipoprotein levels have been reported in a variety of inflammatory disorders. Not much is known about lipoprotein metabolism in patients with severe sepsis. We conducted an ancillary study in a multiple-center phase III sepsis trial to investigate the dynamics of plasma lipoproteins in patients with severe sepsis.DesignProspective analysis in patients meeting criteria for severe sepsis as part of a multiple-center sepsis study (KyberSept) with antithrombin III (Kybernin P).SettingUniversity hospital intensive care unit.PatientsSeventeen patients were included in the study.InterventionsRandomized patients received a loading dose of 6000 IU of antithrombin III (Kybernin P) or placebo followed by a 96-hr continuous infusion of 250 IU/hr antithrombin III (Kybernin P) or placebo. In each patient, serial blood samples for total cholesterol, lipoprotein cholesterol, triglycerides, apolipoprotein A-1, apolipoprotein B, and C-reactive protein determination as well as clinical data were collected over 28 days.Measurements and Main ResultsPlasma cholesterol levels rapidly decreased from 2.67 ± 2.02 mmol/L on day 0 to a nadir of 1.41 ± 0.70 mmol/L on day 3, followed by a slow increase to 4.18 ± 1.94 mmol/L on day 28. High-density lipoprotein (HDL) cholesterol concentrations decreased rapidly from 0.84 ± 0.92 mmol/L to a nadir of 0.42 ± 0.35 mmol/L on day 3, to show a slow increase during the following 4 wks to 0.84 ± 0.42 mmol/L. The low-density lipoprotein (LDL) cholesterol concentrations were already low (0.94 ± 0.81 mmol/L) at study entry, to show a progressive increase to subnormal values (2.01 ± 0.94 mmol/L) at 4 wks. Nadir and recovery lipoprotein concentrations were significantly different (paired Student’st-test,p< .05). A significant correlation was found between HDL cholesterol and apolipoprotein A-1 (r = .714,p< .05) and between LDL cholesterol and apolipoprotein B (r = .733,p< .05). There was no statistical difference in lipoprotein concentrations either between survivors and nonsurvivors or between patients receiving antithrombin III or placebo.Serum amyloid A was a major apoprotein (45%) in HDL at the start of the sepsis and was slowly replaced by apolipoprotein A-1 during recovery. A positive correlation was found between plasma C-reactive protein concentrations and serum amyloid A concentrations in HDL (r = .684,p< .05). No other relevant correlations were found between inflammatory and lipoprotein parameters.ConclusionsIn patients with severe sepsis, lipoprotein concentrations rapidly change and can be reduced to 50% of recovery concentrations. The pattern of early rapid decline is found primarily in the HDL and a slow recovery in both HDL and LDL fractions. The correlation between apolipoprotein and lipoprotein cholesterol concentrations suggests a decline in lipoprotein particles. During severe sepsis, HDL is shifted to acute phase HDL, which is enriched in serum amyloid A and depleted of cholesterol and apolipoprotein A-1. Lipoprotein concentrations are unable to discriminate between survivors and nonsurvivors.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID