摘要:

Because it is difficult to diagnose, acalculous cholecystitis in critically ill patients is treated frequently in an advanced stage. Three of 1600 cardiac surgery ICU admission cases and five of 500 general surgical ICU admission cases were analyzed retrospectively to determine which variables expedited diagnosis and might have encouraged earlier surgery. Vague right upper quadrant physical findings and nonspecific changes in liver function chemistries led frequently to radiologic evaluations. Noninvasive diagnostic procedures such as ultrasound and hepatobiliary scans were helpful but frequently inconclusive. Of the eight patients, the five survivors were diagnosed while still in the hyperdynamic hemodynamic state of early sepsis. Cholecystostomy performed early under local anesthesia was the safest procedure in this group of critically ill patients. After other sources of sepsis such as suppurative phlebitis, yeast septicemia, catheter sepsis, and other extra-abdominal sources such as soft-tissue, urinary, and pulmonary infections have been ruled out, hemodynamic data obtained from pulmonary artery catheters inserted during the early phase of sepsis increase diagnostic accuracy and should expedite surgical exploration.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

Demographic characteristics, severity of illness, resource utilization, and outcome were compared for 351 medical ICU (MICU) and 329 ward patients of a large, urban, tertiary care hospital. Patients were similar in age, race, sex, and insurance coverage. Both MICU and ward patients had similar health status distrubutions 3 to 6 months before hospitalization. Severity of illness, as measured by the Acute Physiology Score was significantly higher in the MICU patients, although there was considerable overlap in the distributions. Resource utilization, as measured by the Therapeutic Intervention Scoring System (TISS), was also significantly higher in the MICU; again, the distributions of the two groups overlapped, although mostly for low values of TISS. Of the MICU sample, 28% to 30% never required active therapeutic interventions; 11% of the ward sample received active treatment. The significant overlap between MICU and ward distributions of severity of illness and resource utilization has implications for admission and discharge policies.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

A retrospective review of 64 patients receiving more than 10 units of red cell concentrate plus crystalloid within 12 h revealed two consecutive patterns of elevation of the partial thromboplastin time (PTT). The PTT at 3 to 4 h (PTT3–4) correlated with the number of liters of crystalloid (LC) infused over the first 3 h (PTT3–4= 37 + 7 LC, r = .7643,p< .001); the PTT thereafter (PTT4+) correlated with the number of hours of closely antecedent hypotension (AH) (PTT4+= 37 + 21 AH, r = .8680,p< .001). These data indicate a transient dilutional coagulopathy, followed by coagulopathy related to the duration of closely AH. Whether this latter is due to impaired production, disseminated intravas-cular coagulation, or dilution due to internal shifts of fluids and/or proteins, remains to be clarified. Therapeutic implications of these data are discussed.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

The effect of positive end-expiratory pressure (PEEP) on PaO2during collapse of a single pulmonary lobe was investigated in seven dogs. Increasing PEEP to the ventilated region of lung increased the proportion of cardiac output flowing to the collapsed lobe and decreased PaO2and pH. PaCO2increased at the onset of lobar collapse but was not significantly altered by changes in PEEP. In impaired lungs, the benefits of PEEP may be offset by an increase in blood flow to the unventilated region and hence lead to a decrease in PaO2.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

A variety of frequencies and percent inspiratory times (%Ti) may be used for high-frequency jet ventilation (HFJV). Five physiologic criteria were used to evaluate various combinations of frequency and %Ti: mean airway pressure (Paw), cardiac output, Paco2, Pao2, and intrapulmonary shunt (Qsp/Qt). At a constant drive pressure, the effects of frequencies of 100, 200, 300, 450, 600, 750, and 900 cycle/min at %Ti values of 20%, 30%, and 40% of the respiratory cycle were evaluated and compared with the effects of controlled mechanical ventilation (CMV) at 8 to 12 breath/min. Only at 200 cycle/min and 20% Ti, were Paw, cardiac output, Paco2, Pao2, and Qsp/Qt all the same as the CMV values. At 100 cycle/min and 20% Ti, Co2elimination increased without significantly affecting Paw, cardiac output, Pach, or Qsp/Qt. These data suggest that HFJV might compromise one or more physiologic variables at certain combinations of frequency and %Ti. Therefore, at a fixed drive pressure, there appears to be a narrow range of HFJV ventilator settings that should be considered.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

Transcutaneous cardiac pacing is a rapid technique for pacing the heart using skin electrodes to pass repetitive electrical impulses through the thorax. This paper reports the results of transcutaneous pacing in a series of 52 emergency department patients. Patients were selected for pacing if they were unconscious and in asystole (30 patients) or unconscious with a pulseless or hemodynamically ineffective bradycardia (22 patients). In all cases, transcutaneous pacing was attempted after initial resuscitative drug therapy failed. Of the 26 patients with successful ECG capture, 14 were initially in asystole, 11 were initially in a pulseless bradycardia, and one had a hemodynamically ineffective bradycardia. Of the eight patients developing a pulse, four developed a measurable BP. The four patients who developed a measurable BP were young (ages 22 to 39 yr) and only one had an underlying cardiac etiology for his cardiac arrest. No patient survived to be discharged from the hospital. Twenty-five of the 52 patients also had a transvenous pacemaker inserted, with successful electrical capture in five of the patients. Only one of the transvenously paced asystolic patients subsequently developed a BP. There were no patients successfully paced transvenously who were not successfully paced transcutaneously.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

Poisoning by cytotoxic mushrooms (Amanita phalloidesand related species) is associated with severe morbidity and a high mortality rate. Due to the difficulty of performing controlled studies and to the poor knowledge of the pharmacodynamics of toxins in human poisoning, there is considerable debate about appropriate treatment, particularly the feasibility and the efficacy of detoxification.Because circulating amatoxins can be detected in the serum of poisoned patients as long as 30 h after ingestion, a detoxification treatment should ideally increase the rate of toxin elimination in order to minimize the toxic exposure of highly susceptible cells, such as hepatocytes. We found forced diuresis to be the most effective procedure for toxin removal. Other techniques, such as plasmapheresis and peritoneal dialysis, proved much less useful for this purpose.The administration of cathartics, adsorbent agents, and gastroduodenal lavage, are indicated for preventing further absorption of toxins from the gut. An important part of therapy is early and vigorous volume replacement, to correct the severe hypovolemia which results from massive fluid loss during the cholera-like phase of intoxication.Use of this therapeutic approach in 53 patients with amatoxin poisoning resulted in a high survival rate and a low incidence of severe liver injury.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

Hypertonic saline (2400 mOsm/L) has been used successfully for fluid resuscitation of dogs subjected to severe hemorrhagic shock. This study compared the effects of resuscitation with hypertonic saline vs. lactated Ringer's solution on intracranial pressure (ICP) in dogs subjected to 30 min of sustained hypovolemic shock. Hypotension was produced by rapid withdrawal of blood until mean arterial pressure was 50 mm Hg, maintained at that level by withdrawal or infusion of blood over the next 30 min as necessary. Eight animals were resuscitated with hypertonic saline solution and nine with lactated Ringer's solution. Both solutions restored systolic blood pressure and cardiac output to control values. However, diastolic blood pressure and mean arterial pressure did not return to control values. The most prominent difference between the two groups was in ICP measured after resuscitation. ICP was lower in dogs resuscitated with hypertonic saline than in dogs resuscitated with lactated Ringer's solution (p= .029). Hypertonic saline fluid resuscitation may represent a potential alternative when aggravation of intracranial hypertension during resuscitation would place a patient at greater risk.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

We infused starch microemboli (63 to 74-μn diameter) into the external jugular vein of 28 dogs, to observe the effects of continuous positive-pressure ventilation (CPPV) on gas exchange and hemodynamics during hypoxemia (Pao253 ± 3 torr). CPPV at both 10 and 15 cm H2O end-tidal pressure improved Pao2. CPPV 15 returned Pao2and pulmonary shunt to control values but reduced cardiac output, O2transport, and O2consumption. In spite of these changes suggesting inadequate tissue oxygenation with CPPV 15, mixed venous oxygenation was not reduced. We conclude that: (a) hypoxemia after microemboli infusion is improved by CPPV and therefore likely caused by ventilation/per-fusion abnormalities; (b) the improvement in Pao2produced by CPPV after microemboli is not beneficial if CPPV reduces perfusion and O2transport; and (c) mixed venous oxygenation does not appear to be an adequate measure of oxygen transport to tissues when CPPV is applied in this high pulmonary vascular resistance setting.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID

摘要:

The resolution time of pneumothorax in neonates requiring tube thoracotomy is not known. We found that 28%, 50%, and 83% of 54 pneumothoraces in 40 neonates resolved within 24, 96, and 168 h of tube thoracotomy, respectively. Pneumothoraces that persisted beyond 168 h were in infants requiring ventilatory assistance. Moreover, a significantly (p< .05) greater number of preterm infants with persistent pneumothorax developed chronic lung disease compared to preterm infants in whom pneumothorax resolved by 168 h.

ISSN:0090-3493    

出版商:OVID    

年代:1985

数据来源: OVID