ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Objectivesa) To examine the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Glasgow Coma Scores as predictors of the outcome of patients following resuscitation from cardiac arrest; b) to study the impact of the components of APACHE II on the prediction.DesignA nationwide study in Finland with prospectively collected data on all patients admitted to intensive care after cardiac arrest during a 14-month period. Two thirds of the cardiac arrest patients included in the study were randomly selected to derive predictive models, and the remaining one third constituted the validation sample.SettingA total of 25 medical and surgical ICUs in Finland (13 in tertiary referral centers).PatientsSix-hundred nineteen consecutive cardiac arrest patients. Fifteen patientsMain Outcome MeasuresVariables included in the APACHE II or Glasgow Coma Scores were collected at the time of ICU admission and then three times after admission, at 24-hr intervals. ICU- and hospital-mortality rates and a 6-month mortality rate after ICU admission were studied.ResultsOf 604 study patients, 370 (61.3%) patients died in the hospital. The most accurate prediction of hospital outcome was based on data collected after the first day of ICU care, not on the admission values. Twenty-one (21.9%) of 96 patients with a low APACHE II score (<9) died compared with 66 (84.6%) of 78 patients with a high APACHE II score (>25) (p< .001). Of 160 patients with a normal Glasgow Coma Score (14 to 15), 45 (28.1%) died, whereas there were 114 (81.4%) nonsurvivors among 140 patients with a low Glasgow Coma Score of 3 (p< .001). The performance of predictive models, including age, the Chronic Health Evaluation, and either the Acute Physiology Score (Acute Physiology Score model) or the Glasgow Coma Score (Glasgow-Coma Score model) were compared with the prediction according to the APACHE II in the validation sample. When using 80% probability of death as a decision rule, the Acute Physiology Score model determined 35 of 153 patients to have high risk of death, 29 of whom died (the positive predictive value being 82.9%). The Glasgow Coma Score model predicted 34 patients to die, 26 of whom died (positive predictive value 76.5%), and the APACHE II score predicted seven deaths, five of whom actually died (positive predictive value 71.4%).ConclusionsThe APACHE II scoring system cannot be recommended as a prognostic tool to support clinical judgment in cardiac arrest patients, but by modifying it, a more accurate prediction of poor outcome could be achieved. The Glasgow Coma Score explained to a great extent the predictive power of the APACHE II. (Crit Care Med 1991; 19:1465)

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that preoperative lumbar epidural morphine improves postoperative pain control and ventilatory function after transsternal thymectomy in patients with myasthenia gravis.DesignThe study design was randomized, placebo-controlled, and double-blind.SettingAfter surgery, all patients were admitted to the Neuroscience Critical Care Unit for evaluation and treatment.PatientsAll patients with myasthenia gravis who presented to the hospital for thymectomy were asked to participate in the study. Twenty patients were randomized to either the placebo or epidural morphine groups.InterventionsPatients received either epidural morphine (7 mg in 14 mL of sterile saline) or saline (14 mL) before induction of anesthesia. Supplemental iv opioids were administered intraoperatively, with need determined by the anesthesiologist.Main Outcome MeasuresThe main outcome measures were indicators of postoperative pain (e.g., Visual Analog Pain Score, requirement for supplemental opioid administration, respiratory rate) and ventilatory function (e.g., forced vital capacity, negative inspiratory pressure).ResultsImmediately after surgery, the Visual Analog Pain Score in the placebo group was twice as high as the score in the epidural morphine group (placebo 7.0 ±PT 1.3; epidural morphine 3.5 ±PT 1.2,p< .05). During the first eight postoperative hours, the placebo group required more opioids (0.22 ±PT 0.03 vs. 0.12 ±PT 0.04 mg/kg morphine equivalents,p< .06) than the epidural morphine group. Later, both groups received similar amounts of opioids. Patients receiving epidural morphine had better initial recovery of forced vital capacity (at 8 hrs: 55 ±PT 6% [epidural morphinel vs. 34 ±PT 5% [placebo] of preoperative value,p< .05). Respiratory rate was lower for the first 12 postoperative hours in the epidural morphine group, without a difference in Paco2. There was no difference between groups for the duration of postoperative intubation or ventilation.ConclusionsPreoperative lumbar epidural morphine facilitates postoperative analgesia and improves initial postoperative ventilatory performance.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo study the effect of individualized pharmacokinetic dosing of aminoglycosides on patient outcome.DesignProspective, randomized study.SettingTertiary care hospital.PatientsNinety-five patients with documented Gram-negative infections received 97 courses of aminoglycoside therapy.InterventionsPatients were randomized between pharmacokinetic dose adjustment and monitoring or traditional physician-directed techniques. Patients were stratified by severity of underlying illness before randomization.Measurement and Main ResultsSixty-two courses of treatment were satisfactorily completed. Patients in the severely ill group (eight kinetic, eight traditional) had significantly (p< .05) better survival (7 kinetic, 3 traditional) when managed with pharmacokinetic consultation. The kinetic arm received greater doses (156 ±PT 59 mg/dose; 2.4 ±PT 0.6 mg/kg) than the traditional arm (81 ±PT 27 mg/dose; 1.5 ±PT 0.6 mg/kg) (p< .001). In addition, the dose per day (mg/kg) was greater in the kinetic arm (4.1 ±PT 1.5) than the traditional arm (3.2 ±PT 1.3) (p< .001). The improved survival was achieved by attaining therapeutic peak serum concentrations earlier in the course of the infection and by administering more total aminoglycoside without increasing toxicity.ConclusionsWe conclude that pharmacokinetic management of aminoglycoside dosing may improve the outcome of severely ill patients.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that selective decontamination of the digestive tract improves outcome in cardiac surgical patients.DesignProspective, consecutive, controlled trial over two 4-month periods.SettingEight-bed, open-plan postcardiac surgery ICU.PatientsAll patients undergoing cardiac bypass surgery were eligible. Patients requiring endotracheal intubation for >4 days were included in the analysis. In the initial 4 months, 12 (8.5%) of 141 patients required >4 days of intubation. These 12 patients werenottreated with selective decontamination of the digestive tract. We therefore used these patients as the control group. In the second 4-month period, 12 (6.6%) of 180 patientsweretreated with selective decontamination of the digestive tract and formed the study group.Main Outcome MeasuresThe primary measure was mortality. Secondary measures included oropharyngeal decontamination and the presence of lower airway infection.InterventionsCephradine prophylaxis. The study group received every 6 hrs 4 mL orally and 20 mL intragastrically a suspension of antimicrobial agents (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg), starting on postoperative day 1. The control group did not receive any oral antimicrobial agents.ResultsMortality rate was significantly (p< .05) reduced from eight (66%) of 12 patients in the control group to two (16.7%) of 12 patients in the selective decontamination of the digestive tract group. No differences in oropharyngeal decontamination or lower airway infection rates between the two groups were found.ConclusionsThere is a reduced mortality rate in patients receiving selective decontamination of the digestive tract. However, the reader should recognize the small sample size studied. A simple suspension of the antimicrobial agents failed to rid the oropharynx of bacteria.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo compare the frequency of acute stress ulceration and secondary pneumonia caused by aerobic Gram-negative bacilli in ICU patients treated with either sucralfate or ranitidine.DesignProspective, randomized study.SettingICU, university hospital.PatientsSixty adult patients who were mechanically ventilated and at risk of developing stress ulceration.InterventionThe patients were randomized to receive either sucralfate (1 g every 6 hrs) via the nasogastric tube or iv ranitidine (50 mg every 6 hrs). If the gastric pH wasMeasurements and Main ResultsOn admission, the frequency rate of erosion/ulceration (assessed with the endoscope) was 13.5%. After 4 days, this rate had increased to 18% in sucralfate-treated patients and 36% in ranitidine-treated patients (NS). Mean gastric pH was more alkaline in the ranitidine-treated patients (5.50) compared with the sucralfate-treated patients (4.26) (p< .01). This pH permitted a higher occurrence rate of gastric colonization by aerobic Gram-negative bacilli in ranitidine-treated patients (64.3%) compared with sucralfate-treated patients (23.8%) (p< .01). Retrograde bacterial colonization from the stomach to oropharynx and trachea occurred more frequently in ranitidine-treated patients compared with sucralfate-treated patients. Ultimately, the occurrence rate of pneumonia was greater in the ranitidine-treated (35.7%) than in the sucralfate-treated patients (10.3%) (p< .05).ConclusionBased on our findings, we recommend the adoption of sucralfate for routine prophylaxis against stress ulceration. (Crit Care Med 1991; 19:1491)

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

ObjectiveTo determine circulating atrial natriuretic factor (ANF) concentrations in the postoperative state and to define potential hemodynamic determinants of regional plasma ANF concentrations.DesignCohort study.SettingPediatric ICU in a university hospital.PatientsTwenty-two children, mean age 4.2 yrs (range 0.9 to 13.5), were studied 18 hrs after corrective surgery on cardiopulmonary bypass. The underlying cardiac malformations were ventricular septum defect (n = 5), transposition of great arteries (n = 5), tetralogy of Fallot (n = 4), pulmonary stenosis (n = 3), and miscellaneous (n = 5).InterventionsIn addition to the commonly monitored variables in postoperative cardiac patients, blood volume was estimated by the125I albumin method, and plasma samples for radioimmunoassay determination of ANF concentrations were taken simultaneously from indwelling catheters.Measurements and Main ResultsCompared with normal age-matched values, plasma ANF concentrations were increased in all patients, with values tending to be highest in the left atrium, followed by systemic artery, superior vena cava, and pulmonary artery (345 ±PT 158, 333 ±PT 169, 311 ±PT 154, and 272 ±PT 160 pg/mL, respectively [mean ±PT SD; NS]). Simple regression analysis demonstrated a moderate correlation between blood volume and the concentration of ANF in the superior vena cava (p< .05). Stepwise multivariate analysis showed no significant independent predictor of plasma ANF concentrations.ConclusionsPlasma ANF concentrations are increased after open-heart surgery in children, with moderate direct correlation to blood volume. The wide scatter of increased hormone concentrations may be explained by the many factors known to influence circulating ANF concentrations, such as age, underlying disease, cardiovascular state, and drugs.

ISSN:0090-3493    

出版商:OVID    

年代:1991

数据来源: OVID