ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectivesThe difficult decision to forgo (withhold or withdraw) life-sustaining treatment has received extensive commentary. Little attention has been paid to how physicians do, and should, care for dying patients once this decision is made. This study describes the characteristics of patients who forgo treatment, determines the range and sequential process of forgoing treatment, and suggests ethical and public policy implications.DesignThe charts of all patients who died at the University of Minnesota Hospital during a 2-month period were reviewed. The patient information that was collected included age and sex, diagnoses, mental status, location in the hospital, length of hospital stay, method of payment, the timing of the first decision to forgo treatment, and the range and sequence of interventions forgone.SettingAll ICUs and general wards in a 586-bed tertiary care university hospital.PatientsAll patients who died at the University of Minnesota Hospital during May and June 1989.Main ResultsA total of 52 (74%) of 70 patients who died had some intervention withheld or withdrawn before death. Those patients in whom treatment was forgone were more likely to have an underlying malignancy or impaired mental status and longer hospital stays. Thirty-two (62%) of 52 patients who declined some treatment were in an ICU; 26 (50%) of 52 patients required mechanical ventilation. On average, 5.4 separate interventions were forgone per patient. Resuscitation and/or endotracheal intubation were generally the first measures withheld; once a patient required a ventilator, withdrawing the ventilator was a late decision. Precise methods of ventilatory and vasopressor withdrawal varied considerably among patients.ConclusionsForgoing life-sustaining treatment is not a single decision but it often occurs in a sequential manner over several days. A strict analysis of the benefits and burdens of various interventions may be inadequate in deciding what interventions are appropriate in the care of the dying patient. (Crit Care Med 1992; 20:570–577)

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo determine a correlation between serial brainstem auditory-evoked response measurements and ultimate neurologic outcome in pediatric patients who suffered a cardiac arrest resulting from a submersion accident.DesignInception cohort, prospective correlational study.SettingA 15-bed pediatric ICU (within a 150-bed tertiary care pediatric hospital) admitting patients of all ages except nonsurgical neonates.PatientsAll previously normal pediatric patients who suffered a cardiac arrest after a submersion accident. Patients evaluated: 111; patients studied: 89.MethodsPatients received serial brainstem auditory-evoked response testing within 6 hrs of resuscitation and then once daily for up to 10 days. Brainstem auditory-evoked response measurements included wave I-V interpeak latency, wave V amplitude, and wave I/V amplitude ratio. Upon discharge, patients were evaluated and classified into one of four neurologic outcome groups: normal, handicapped, vegetative, or dead. Patients classified into the handicapped group exhibited mild neurologic deficits after discharge. Vegetative patients were noninteractive with their environment and required full-time caretaker support. Serial brainstem auditory-evoked response measurements from the four outcome groups were compared with brainstem auditory-evoked response measurements obtained from a group of 39 healthy children of comparable age.Main ResultsPatients who recovered neurologically intact manifested brainstem auditory-evoked response measurements that were similar to controls. Brainstem auditory-evoked response measurements in the handicapped outcome group were also normal after resuscitation but showed significant reduction in wave V amplitudes over the ensuing days. When compared with controls, patients with a vegetative outcome manifested abnormally prolonged wave I-V interpeak latencies, diminished wave V amplitudes, and large-wave I/V amplitude ratios following resuscitation. However, I-V interpeak latencies normalized within 24 hrs after resuscitation. I-V interpeak latencies were no different than controls until hospital day 3, at which time they became significantly prolonged. Patients who were declared brain dead or died from cardiovascular collapse exhibited very abnormal brainstem auditory-evoked response measurements on admission and until death. Wave V could not be detected on admission in 19/31 patients within this group.ConclusionsBrainstem auditory-evoked response testing is useful as an aid in the assessment of neurologic outcome following submersion-induced cardiac arrest. However, standardization of brainstem auditory-evoked response testing and production of normative data are required before this modality can be more widely studied and applied. (Crit Care Med 1992; 20:578–585)

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo investigate the feasibility of predicting gentamicin dosing requirements during continuous arteriovenous hemodiafiltration (CAVHD).DesignProspective study.SettingGeneral intensive therapy unit in a university teaching hospital.PatientsFive adult patients with acute renal failure in whom both dialytic and gentamicin therapy were indicated.Measurements and Main ResultsCAVHD clearance and total body clearance of gentamicin were estimated from serial gentamicin concentrations in the blood and the combined ultrafiltrate and dialysate. Results (mean ±PT SD) were: CAVHD clearance of gentamicin 5.2 ±PT 1.8 mL/min; total body clearance of gentamicin 20.5 ±PT 6.9 mL/min; ultrafiltrate flow rate 7.0 ±PT 2.4 mL/min (420 ±PT 146 mL/hr). CAVHD clearance of gentamicin was small and represented approximately 25% of total body clearance of gentamicin, although significant interpatient variation existed in these measurements and in the proportion of total gentamicin clearance attributable to CAVHD. CAVHD clearance of gentamicin was related to the ultrafiltrate flow rate (r2= .81).ConclusionsCAVHD clearance of gentamicin may be predicted for variable ultrafiltrate flow rates. However, due to its minor and variable contribution to total body clearance of gentamicin, prediction of gentamicin dosing requirements based on estimates of CAVHD clearance of gentamicin would be precluded and close monitoring of circulating gentamicin concentrations during CAVHD is necessary. (Crit Care Med 1992; 20:586–589)

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo study the effects of pharmacologically increasing gastric pH on gastric colonization and the development of pneumonia in intubated critically ill patients.DesignRandomized, controlled trial.SettingMedical ICU in a university hospital.PatientsThirty-four tracheotomized patients with tetanus.InterventionsSixteen patients received iv ranitidine to increase gastric pH >4 (ranitidine group), while 18 patients received no prophylaxis for upper gastrointestinal bleeding (control group).Measurements and Main ResultsMean gastric pH was higher in the ranitidine group (median 4.7, range 3.6 to 6.1) than in the control group (median 2.1, range 1.2 to 4.9;p< .05). Gastric colonization occurred in 15 (94%) of 16 patients who received ranitidine, 2 days (median; range 1 to 5) after intubation; gastric colonization also occurred in all control patients (median 4 days, range 1 to 9;p< .05). Pneumonia occurred in 13 (81%) of 16 patients who received ranitidine, 3 days (median, range 1 to 5) after intubation and in nine (50%) of 18 control patients (p< .01) 5 days after tracheal intubation (median, range 3 to 14;p< .01). Prior gastric colonization by the pathogen that caused pneumonia was demonstrable in nine (56%) of 16 patients who received ranitidine vs. eight (44%) of 18 control patients (p> .05). The risk for developing pneumonia in the ranitidine-treated group was highest in the first 4 days after tracheal intubation. There was no difference in the frequency of upper gastrointestinal hemorrhage in the two groups.ConclusionsPharmacologically increasing gastric pH increases the risk for developing pneumonia in intubated critically ill patients. The pneumonia occurs earlier than in untreated control patients. (Crit Care Med 1992; 20:590–593)

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo determine the effects of disseminated intravascular coagulation (DIC) and headinjury on posttrauma coagulation and fibrinolysis.DesignCase-control study.SettingGeneral ICU (tertiary care center) in a city hospital serving a population of 150 million people.PatientsForty trauma victims: 15 with DIC; 25 without DIC.InterventionsMeasurement of six types of coagulation and fibrinolytic molecular markers (fibrinopeptide A, fibrinopeptide Bβ15–42, plasmin antiplasmin complex, D-dimer, tissue plasminogen activator antigen concentration, tissue plasminogen activator activity) immediately after trauma, 3 days later, and 6 days later. Anticoagulant treatment with gabexate mesilate at 1.45 ±PT 0.06 mg/kg/hr.Measurements and Main ResultsFibrinopeptide A, fibrinopeptide Bβ15–42, plasmin antiplasmin complex, and D-dimer showed high values immediately after trauma and exceeded normal activity for the first 6 days. When trauma was complicated with DIC, the molecular markers showed significantly higher values than those for non-DIC patients on all days. In the head-injured patients, such effect was not noted. Tissue plasminogen activator antigen concentration and tissue plasminogen activator activity were within a normal physiologic range of variation. By contrast, tissue plasminogen activator antigen concentration increased significantly after trauma in patients with DIC. When anticoagulant treatment was found effective, it caused a reduction in fibrinopeptide A.Conclusionsa) Fibrinolytic shut-down and its reactivation cannot be confirmed after trauma. b) Head injury does not lead to an increase in posttrauma coagulation or fibrinolytic activity. c) DIC enhances posttrauma coagulation and fibrinolytic activity and plasminogen activator inhibitor activity can be inferred in DIC patients. d) Increase in tissue plasminogen activator antigen concentration without tissue plasminogen activator activation may be a prognostic factor indicative of DIC and its chances of improvement, and fibrinopeptide A as an assessment criterion for the effectiveness of anticoagulant treatment. (Crit Care Med 1992; 20:594–600)

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

ObjectiveTo evaluate the pharmacokinetics and pharmacodynamics of dobutamine in critically ill children.DesignA prospective study of pediatric patients receiving continuous infusions of dobutamine in a stepwise format from 2.5 to 10.0 μg/kg/min.SettingA pediatric critical care unit.PatientsTwelve children ranging in age from 1 month to 17 yrs with primary medical conditions.MeasurementsPlasma dobutamine concentrations and hemodynamic responses were measured at each infusion rate at steady state. Dose response data were analyzed to determine the threshold or minimum plasma dobutamine concentration necessary for discernible hemodynamic effects.Main ResultsDobutamine plasma clearance rates ranged from 40 to 130 mL/kg/min. Each patient presented a linear increase in the plasma dobutamine concentration at each infusion rate (r2=.97,p< .001). Plasma clearance rate vs. actual dobutamine concentration did not vary. Cardiac output, BP, and heart rate increased 30%, 17%, and 7%, respectively, at maximal dose. The dobutamine concentration thresholds for changes in cardiac output, BP, and heart rate were 13 ±PT 6, 23 ±PT 14, and 65 ±PT 30 ng/mL, respectively.ConclusionsThere was no effect of plasma dobutamine concentration or infusion rate on plasma clearance rate. For this group of patients, over the range of the intravenous doses studied, dobutamine pharmacokinetics followed a first-order kinetic model. Threshold values for dobutamine usually show increases in cardiac output before changes in heart rate. These data demonstrate that dobutamine is an effective inotropic agent in critically ill pediatric patients and has minimal chronotropic action. (Crit Care Med 1992; 20:601–608)

ISSN:0090-3493    

出版商:OVID    

年代:1992

数据来源: OVID