摘要:

ObjectiveTo evaluate the effects of short-term, high-volume hemofiltration (STHVH) on hemodynamic and metabolic status and 28-day survival in patients with refractory septic shock.DesignProspective, interventional.SettingIntensive care unit (ICU), tertiary institution.PatientsTwenty patients with intractable cardiocirculatory failure complicating septic shock, who had failed to respond to conventional therapy.InterventionsSTHVH, followed by conventional continuous venovenous hemofiltration. STHVH consisted of a 4-hr period during which 35 L of ultrafiltrate is removed and neutral fluid balance is maintained. Subsequent conventional continuous venovenous hemofiltration continued for at least 4 days.Measurements and Main ResultsCardiac index, systemic vascular resistance, pulmonary vascular resistance, oxygen delivery, mixed venous oxygen saturation, arterial pH, and lactate were measured serially. Fluid and inotropic support were managed by protocol. Therapeutic endpoints were as follows during STHVH: a) by 2 hrs, a ≥50% increase in cardiac index; b) by 2 hrs, a ≥25% increase in mixed venous saturation; c) by 4 hrs, an increase in arterial pH to >7.3; d) by 4 hrs, a ≥50% reduction in epinephrine dose. Patients who attained all four goals (11 of 20) were considered hemodynamic “responders”; patients who did not (9 of 20) were considered hemodynamic “nonresponders.” There were no differences in baseline hemodynamic, metabolic, and Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Scores between responders and nonresponders. Survival to 28 days was better among responders (9 of 11 patients) than among nonresponders (0 of 9). Factors associated with survival were hemodynamic-metabolic response status, time interval from ICU admission to initiation of STHVH, and body weight.ConclusionsThese data suggest that STHVH may be of major therapeutic value in the treatment of intractable cardiocirculatory failure complicating septic shock. Early initiation of therapy and adequate dose may improve hemodynamic and metabolic responses and 28-day survival.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveIn acute massive pulmonary embolism with hemodynamic instability, monitoring of pulmonary artery pressure can be used to assess the efficacy of thrombolytic therapy. As a noninvasive alternative to pulmonary artery catheterization, we investigated the efficacy of continuous monitoring of end-tidal CO2tension.DesignIn 12 patients with massive pulmonary embolism who required mechanical ventilation, mean pulmonary arterial pressure (MPAP) and end-tidal carbon dioxide tension (ETco2) were registered continuously during thrombolytic therapy. Paco2, cardiac index as estimated by thermodilution catheter and respiratory ratio of arterial oxygen tension and inhaled oxygen concentration (Pao2/Fio2) were determined every 60 mins.Measurements and Main ResultsBefore thrombolysis, MPAP (34.5 ± 9.8 mm Hg) and the difference between Paco2and ETco2(10.1 ± 4.7 mm Hg) were markedly increased compared with normal values. Continuously monitored MPAP was related to ETco2for both all patients (r2= .42;p< .001) and individually (mean r2= .92; range, .79-.98;p< .001). In ten survivors, the mean cardiac index and Pao2/Fio2increased during therapy from 1.7 ± 0.4 to 2.8 ± 0.6 L/min·m2and 125 ± 27 to 285 ± 50 mm Hg (p< .01, respectively). In these patients, the difference between Paco2and ETco2decreased from 9.8 ± 4.5 to 2.8 ± 0.9 mm Hg (p< .001). Recurrent embolism was detected in two patients by sudden reduction of ETco2.ConclusionsAnalysis of ETco2allows monitoring of the efficacy of thrombolysis and may reflect recurrent embolism. Thus, on the basis of this small study, analysis of ETco2appears to be useful for noninvasive monitoring in mechanically ventilated patients with massive pulmonary embolism.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives&bgr;-Adrenergic receptor agonists such as isoproterenol inhibit production of tumor necrosis factor (TNF)-&agr; in a number of cell types. Because the heart is a source of TNF-&agr;, we hypothesized that isoproterenol would inhibit cardiac production of the cytokine.DesignAnalysis of cardiac release of TNF-&agr;.SettingMedical research laboratory.SubjectsRats.InterventionsNone.Measurements and Main ResultsWith the approval of the Institutional Animal Care and Use Committee, rats were anesthetized and hearts were removed and perfused. After 30 mins, bacterial lipopolysaccharide (LPS) with or without isoproterenol was infused for 60 mins. At 30, 60, 90, 120, and 150 mins, coronary flow was measured and coronary effluent was analyzed for TNF-&agr;. Cardiac production of TNF-&agr; was expressed as pg/min. Cyclic adenosine monophosphate (AMP) in the coronary effluent was measured. TNF-&agr; messenger RNA was determined in ventricular tissue. After 30 mins, TNF-&agr; was undetectable in the coronary effluent. However, 60 mins after the initiation of LPS infusion, TNF-&agr; release was 875 ± 255 pg/min and increased to 2164 ± 721 pg/min at 150 mins. Simultaneous infusion of isoproterenol with LPS stimulated cyclic AMP release and inhibited TNF-&agr; production. For instance, at 60 and 150 mins, TNF-&agr; release was 75 ± 38 and 58 ± 29 pg/min, respectively (p< .05 vs. LPS alone). Simultaneous infusion of isoproterenol with LPS blocked the induction of TNF-&agr; messenger RNA by LPS. Isoproterenol, begun 30 mins after the initiation of LPS infusion, still suppressed LPS-stimulated TNF-&agr; release by 95% at 150 mins. Similar results were obtained with norepinephrine.ConclusionsActivation of &bgr;-adrenergic receptors inhibits cardiac TNF-&agr; release. This implies that cytokine production by the heart is inhibited by the sympathetic nervous system. In heart failure, the cardiac response to the sympathetic nervous system is impaired. This impairment may play a role in the high plasma levels of TNF-&agr; found in heart failure.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo describe the long-term health-related quality of life (HRQL) of survivors of sepsis and to evaluate the reliability and validity of the medical outcomes study Short Form-36 (SF-36) in this population.Study DesignCross-sectional survey.SettingUniversity intensive care unit.PatientsSurviving patients over the age of 17 yrs who met the criteria for the Society of Critical Care Medicine/American College of Chest Physicians definition of sepsis identified through a review of patients admitted to the intensive care unit from 1994 to 1998.InterventionsNone.Measurements and Main ResultsBaseline demographics and clinical characteristics were abstracted from the medical chart. After hospital discharge, the SF-36 and Patrick’s Perceived Quality of Life scale were administered by telephone. The SF-36 was readministered 2 wks later. We screened the charts of 109 patients; 78 had a diagnosis of sepsis. Of these, 31 had died, 3 had severe communication problems, 9 refused to participate, and 5 patients could not be located. A total of 30 patients completed the first interview; 26 completed the second. Compared with established norms for the U.S. general population, survivors of sepsis scored significantly lower on the physical functioning, role physical, general health, vitality, and social functioning domains, as well as on the Physical Health Summary Scale. Mean scores on the Mental Health Summary Scale were very similar between the survivors of sepsis and U.S. norms. The SF-36 demonstrated high internal consistency (Cronbach’s alpha ranged from 0.65 to 0.94) and excellent test-retest stability (intraclass correlation coefficient ranged from 0.75 to 0.97). Both the Physical Health Summary Scale and the Mental Health Summary Scale correlated well with overall Perceived Quality of Life scores (Pearson correlation coefficients 0.45 and 0.56, respectively).ConclusionsThe long-term HRQL of survivors of sepsis is significantly lower than that of the general U.S. population. The SF-36 demonstrated good reliability and validity when used to measure HRQL in survivors of sepsis.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo determine whether the frequency rate of hyperglycemia and infectious complications can be reduced by an underfeeding strategy in patients requiring total parenteral nutrition (TPN), without deleterious effects on nitrogen balance.DesignProspective, randomized, controlled nonblinded trial.SettingA university-affiliated teaching hospital with a dedicated TPN service.PatientsTPN was initiated in 40 adult patients and continued for ≥5 days.InterventionTwo different TPN feeding strategies were compared: hypocaloric feeding (1 L containing 70 g protein and 1000 kcal) and standard weight-based regimen, begun in similar amounts initially, but advanced in increments toward 25 kcal and 1.5 g protein/kg dry (or adjusted ideal) weight.Measurements and Main ResultsWe evaluated the frequency rate of hyperglycemia, average blood glucose, numbers and types of infections while receiving nutritional support, and nitrogen balance after 5 days of TPN. There were significant differences between the quantities of calories, dextrose, fat, and protein provided to the two groups. However, average blood glucose, frequency rate of hyperglycemia, and infection rates (from intravenous catheter, pneumonia, and wound/abdominal collection) were similar in each group. The control group showed a trend toward a higher insulin requirement. Nitrogen balance, only available as a subset, was significantly more negative in the hypocaloric group.ConclusionsProvision of TPN to a goal of 25 kcal/kg was not associated with more hyperglycemia or infections than a deliberate underfeeding strategy. A regimen of 1.5 g/kg protein in conjunction with 25 kcal/kg did, however, provide significant nutritional benefit in terms of nitrogen balance in comparison with hypocaloric TPN.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveWe proposed to compare the efficacy and safety of midazolam and propofol in its new preparation (2% propofol) when used for prolonged, deep sedation in traumatized, critically ill patients. We also retrospectively compared 2% propofol with its original preparation, 1% propofol, used in a previous study in a similar and contemporary set of patients.DesignA prospective, randomized, unblinded trial (midazolam and 2% propofol) and a retrospective, contemporary trial (2% propofol and 1% propofol).SettingsA trauma intensive care unit in a tertiary university hospital.PatientsA total of 63 consecutive trauma patients, admitted within a period of 5 months and requiring mechanical ventilatory support for >48 hrs, 43 of whom (73%) suffered severe head trauma. We also retrospectively compared the 2% propofol group with a series of patients in whom 1% propofol was used.InterventionsFor the prospective trial, we randomized two groups—a midazolam group with continuous administration of midazolam at dosages 0.1–0.35 mg/kg/hr, and a 2% propofol group with continuous infusion at dosages 1.5–6 mg/kg/hr. Equal dosages of analgesics were administered. Similar management protocols were applied in the 1% propofol group, used in the retrospective analysis with 2% propofol.Measurements and Main ResultsEpidemiologic and efficacy variables were recorded. Hemodynamic and biochemical variables were also monitored on a regular basis. Neuromonitoring was also performed on those patients with head trauma. Sedation adequacy was similar and patient behavior after drug discontinuation was not different in either prospective group (midazolam and 2% propofol). Hemodynamic or neuromonitoring variables were also similar for both groups. Triglyceride levels were significantly higher in the 2% propofol group compared with the midazolam group. A higher number of therapeutic failures because of sedative inefficacy was seen in the 2% propofol group compared with the midazolam group, especially during the first sedation days. When comparing 2% propofol and 1% propofol, a significantly higher number of therapeutic failures because of hypertriglyceridemia were found in the 1% propofol group, as opposed to a major number of therapeutic failures because of inefficacy, found in the 2% propofol group.ConclusionsPropofol’s new preparation is safe when used in severely traumatized patients. Its more concentrated formula improves the lipid overload problem seen with the prolonged use of the previous preparation. Nevertheless, a major number of therapeutic failures were detected with 2% propofol because of the need for dosage increase. This fact could be caused by a different disposition and tissue distribution pattern of both propofol preparations. New studies will be needed to confirm these results.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID