摘要:

ObjectiveTo compare a restrictive red blood cell transfusion strategy with a more liberal strategy in volume-resuscitated critically ill patients with cardiovascular disease.SettingTwenty-two academic and three community critical care units across Canada.Study DesignRandomized controlled clinical trial.Study PopulationThree hundred fifty-seven critically ill patients with cardiovascular diseases from the Transfusion Requirements in Critical Care trial who had a hemoglobin concentration of <90 g/L within 72 hrs of admission to the intensive care unit.InterventionsPatients were randomized to a restrictive strategy to receive allogeneic red blood cell transfusions at a hemoglobin concentration of 70 g/L (and maintained between 70 and 90 g/L) or a liberal strategy to receive red blood cells at 100 g/L (and maintained between 100 and 120 g/L).ResultsBaseline characteristics in the restrictive (n = 160) and the liberal group (n = 197) were comparable, except for the use of cardiac and anesthetic drugs (p< .02). Average hemoglobin concentrations (85 ± 6.2 vs. 103 ± 6.7 g/L;p< .01) and red blood cell units transfused (2.4 ± 4.1 vs. 5.2 ± 5.0 red blood cell units;p< .01) were significantly lower in the restrictive compared with the liberal group. Overall, all mortality rates were similar in both study groups, including 30-day (23% vs. 23%;p= 1.00), 60-day, hospital, and intensive care unit rates. Changes in multiple organ dysfunction from baseline scores were significantly less in the restrictive transfusion group overall (0.2 ± 4.2 vs. 1.3 ± 4.4;p= .02). In the 257 patients with severe ischemic heart disease, there were no statistically significant differences in all survival measures, but this is the only subgroup where the restrictive group had lower but nonsignificant absolute survival rates compared with the patients in the liberal group.ConclusionA restrictive red blood cell transfusion strategy generally appears to be safe in most critically ill patients with cardiovascular disease, with the possible exception of patients with acute myocardial infarcts and unstable angina.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

BackgroundInstitutional review boards (IRBs) are given discretion to interpret and apply the federal regulations governing the protection of human subjects in research.ObjectiveTo determine the extent of the variability among different IRBs on their approved research practices and informed consent forms within the context of a multicenter trial that used a common protocol.DesignDescriptive analysis of survey information and informed consent forms.Setting and ParticipantsSixteen IRBs from the institutions participating in a multicenter trial comparing lower vs. traditional tidal volume ventilation in patients with acute lung injury.MeasurementsAnalysis of survey information on IRBs’ approved research practices. Analysis of informed consent forms for the presence and the adequacy of description of each basic element of informed consent specified in the federal regulations. Reading levels of informed consent forms.Main ResultsSurveys and IRB-approved consent forms were obtained from all of the contacted IRBs (n = 16). Variability was observed among several of the research practices; one IRB waived the requirement for informed consent, five IRBs permitted telephone consent, and three IRBs allowed prisoners to be enrolled. Three consent forms contained all of the basic elements of informed consent outlined in the federal regulations, and 13 forms had varying numbers of these elements absent (six forms without one element, four without two, one without three, and two without four). Reading levels of the consent forms ranged from grades 8.2 to 13.4 (mean ± sd was 11.6 ± 1.2 grade level).ConclusionsWithin a multicenter trial, IRBs reviewing a common protocol varied in several of their approved research practices and in the extent to which the basic elements of informed consent were included in their consent forms.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo evaluate the potential clinical, metabolic, and economic advantages of enteral nutrition over total parenteral nutrition.DesignProspective, randomized clinical trial.SettingDepartment of surgery in a university hospital.PatientsTwo hundred and fifty-seven patients with cancer of the stomach (n = 121), pancreas (n = 110), or esophagus (n = 26) were randomized to receive postoperative total parenteral nutrition (TPN group, n = 131) or early enteral nutrition (EEN group, n = 126). The nutritional goal was 25 kcal/kg/day. The two nutritional formulas were isocaloric and isonitrogenous, and they were continued until oral intake was at least 800 kcal/day.MeasurementsMorbidity, mortality, length of hospital stay, and treatment costs were evaluated in all patients. In 40 consecutive patients, selected nutritional, immunologic and inflammatory variables were studied. Moreover, intestinal oxygen tension was evaluated by micropolarographic implantable probes.Main ResultsThe nutritional goal was reached in 100/126 (79.3%) patients in the EEN group and in 128/131 (97.7%) patients in the TPN group (p< .001). In the EEN group, hyperglycemia (serum glucose, >200 mg/dL) was observed in 4.7% of the patients vs. 9.1% in the TPN group (p= NS). Alteration of serum electrolyte levels was 3.9% in the EEN group vs. 13.7% in the TPN group (p< .01). No significant difference was found in nutritional, immunologic, and inflammatory variables between the two groups. The overall complication rate was similar (40.4% for TPN vs. 35.7%, for EEN;p= .52). No difference was detected for either infectious or noninfectious complications, length of hospital stay, and mortality. From postoperative day 5, intestinal oxygen tension recovered faster in the EEN group than in the TPN group (43 ± 5 mm Hg vs. 31 ± 4 mm Hg at day 7;p< .001). EEN was four-fold less expensive than TPN ($25 vs. $90.60/day, respectively).ConclusionEEN represents a rational alternative to TPN in patients who undergo upper gastrointestinal tract surgery for cancer and who clinically require postoperative artificial nutrition.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveFiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) are major tools in the diagnosis of pulmonary complications in immunocompromised patients. Nevertheless, severe hypoxemia is an accepted contraindication to FOB in nonintubated patients. The purpose of this study was to evaluate the feasibility and safety of laryngeal mask airway (LMA)-supported FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia.DesignProspective, clinical investigation.SettingMedical intensive care unit of a university hospital.PatientsForty-six immunosuppressed patients admitted to our intensive care unit with suspected pneumonia and Pao2/Fio2≤ 125.InterventionsAfter the administration of 0.3 mg·kg−1of etomidate, the patients were ventilated manually while receiving 1.0 Fio2. After the administration of 2.5 mg·kg−1of propofol, followed by an infusion of 9.1 ± 2.3 mg·kg−1·hr−1of propofol, the LMA (size 3 or 4) was placed and connected to a bag-valve unit to allow manual ventilation with 1.0 Fio2. The FOB was introduced through a T-adapter attached to the LMA, and BAL was carried out with 150 mL of sterile 0.9% saline solution by sequential instillation and aspiration of 50-mL aliquots.Measurements and Main ResultsThree patients developed transient laryngospasm during passage of the bronchoscope via the LMA, which resolved with deepening of anesthesia. Changes in mean blood pressure, heart rate, Pao2/Fio2, and Paco2values induced by the procedure did not reach significance. Seven patients (15%) presented hypotension (mean blood pressure, <60 mm Hg) maintained for 120 ± 40 secs, which required plasma expanders in three cases. Oxygen desaturation to <90% occurred in six patients (13%) during BAL. Nevertheless, the lowest Sao2during the procedure was significantly higher than the initial Sao2(94% ± 4% vs. 90% ± 2%). No patient required tracheal intubation during the 8 hrs after the procedure. BAL had an overall diagnostic yield of 65%. Because of the results obtained by using the BAL analysis, treatment was modified in 33 (72%) cases.ConclusionApplication of the LMA appears to be a safe and effective alternative to intubation for accomplishing FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo investigate the role of the splanchnic region in the hyperlactatemia of septic patients.DesignProspective, observational study.SettingThirty-one-bed mixed medicosurgical intensive care unit.PatientsNinety invasively monitored and mechanically ventilated patients with severe sepsis.Measurements and Main ResultsSplanchnic lactate balance was measured in all patients. Splanchnic blood flow was determined by using the primed continuous indocyanine green infusion technique in 69 patients. In 71 patients, gastric mucosal Pco2and the Pco2gap (the difference between gastric and arterial Pco2) also were determined by using gas tonometry with an automated gas analyzer. In each patient, arterial, mixed-venous, and hepatic venous blood samples were obtained to determine hemoglobin oxygen saturations and lactate concentrations. Arterial and hepatic venous lactate concentrations were determined in triplicate and were averaged, and the arterial hepatic venous difference in lactate and lactate consumption were calculated. The splanchnic region produced lactate in only six of the 90 patients. Mean arterial pressure, cardiac index, arterial lactate, hepatic venous oxygen saturation, and catecholamine use were similar in the six patients with splanchnic lactate production and in the 84 others. The arterial hepatic venous differences in lactate and splanchnic lactate consumption were related directly to arterial lactate concentrations (y = 0.073x + 0.209, r2= .06,p< .05, and y = 0.06x + 0.183, r2= .08,p< .05, respectively) but were not related to Pco2gap, to the gradient between mixed-venous and hepatic venous oxygen saturations, or to bilirubin concentrations.ConclusionsSplanchnic lactate release is uncommon in septic patients, even when hyperlactatemia is severe.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo determine the precise relationship between tissue factor and tissue factor pathway inhibitor (TFPI) after trauma, as well as to test the hypothesis that low TFPI levels are not sufficient to prevent tissue factor-dependent intravascular coagulation, leading to multiple organ dysfunction syndrome (MODS).DesignProspective, observational cohort study.SettingEmergency room and intensive care unit in a university hospital.PatientsThirty-three trauma patients, 18 with disseminated intravascular coagulation (DIC) and 15 without DIC were studied. Ten normal, healthy volunteers served as control subjects.InterventionsNone.Measurements and Main ResultsAntigen concentration of tissue factor and TFPI, and global parameters of coagulation and fibrinolysis were measured on the day of admission, and on days 1–4 after admission. The number of systemic inflammatory response syndrome (SIRS) criteria that patients met and the DIC score were determined, simultaneously. The results of these measurements, incidence of MODS, and outcome were compared between the DIC patients and those without DIC. In the DIC patients, significantly higher tissue factor levels (p= .0049) and lower platelet counts (p= .0016) were found compared with the non-DIC patients and control subjects. However, the TFPI values remained at normal levels during the study period. No correlation was found between the peak levels of tissue factor and TFPI. The mean duration of SIRS and the maximum number of the SIRS criteria being met by the patients in the DIC group were statistically longer and higher than those in the non-DIC patients. The incidence of MODS and the number of the dysfunctioning organs were higher in the DIC patients compared with those in the non-DIC patients, and the DIC patients had a poor outcome.ConclusionsWe systematically elucidated the relationship between tissue factor and TFPI in post-trauma patients. Highly activated tissue factor-dependent coagulation pathway is not sufficiently prevented by the normal TFPI levels in patients with DIC. The DIC associated with thrombotic and inflammatory responses causes MODS, and leads to poor outcome in post-trauma patients.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo investigate plasma aluminum levels in critically ill patients requiring continuous venovenous hemofiltration (CVVH), while receiving sucralfate for stress ulcer prophylaxis.DesignRandomized, controlled study.SettingCardiothoracic intensive care unit.PatientsTwenty postoperative cardiac surgical patientsInterventionsTwenty patients requiring CVVH support for acute renal failure were randomized into two groups for concurrent stress ulcer prophylaxis. Group 1 (n = 10) received nasogastric sucralfate, and group 2 patients received intravenous ranitidine. Plasma aluminum samples were analyzed at baseline and on days 1, 4, 8, and 14.Measurements and Main ResultsIn both the sucralfate and ranitidine groups, clinical characteristics, number of days the patients were on CVVH support (median, 5.5 [range, 2–32] days, and median, 3 [range, 2–18] days, respectively) and duration of prophylaxis (median, 12 [range, 4–42] days, and median, 16 [range, 3–62] days, respectively) were similar. There were no significant differences in the baseline aluminum concentrations (median, 0.37 [range, 0.15–1.63] &mgr;mol/L, vs. median, 0.32 [range, 0.11–1.0] &mgr;mol/L;p= .79). On initiation of therapy, aluminum levels in the sucralfate group increased dramatically on day 1 (median, 0.87 [range, 0.26–4.4] &mgr;mol/L) and peaked on day 4 (median, 2.84 [range, 1.52–4.44] &mgr;mol/L) with seven of the ten patients exhibiting levels of >2 &mgr;mol/L. In the ranitidine group, there were no significant elevations in aluminum levels above baseline. Analysis of the two groups at the four time points revealed that aluminum levels in the sucralfate group were up to 14 times higher, with the confidence intervals suggesting that the true value may be 2–27 times higher (p< .0001). On cessation of CVVH, a rapid decline in aluminum levels was observed. No clinical manifestations of these potentially toxic levels were observed.ConclusionsThe use of sucralfate for stress ulcer prophylaxis in patients requiring CVVH results in toxic elevations in plasma aluminum levels. Alternative agents should be considered for prophylaxis in these patients.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveThe antioxidantN-acetylcysteine (NAC) has been shown to attenuate septic tissue injury. To evaluate whether NAC affects host defense mechanisms in critically ill patients, thus predisposing to increased risk of infection, the current study focuses on neutrophil phagocytotic and burst activity after treatment with NAC.DesignProspective, randomized, clinical trial.SettingTwelve-bed operative intensive care unit in a university hospital.PatientsThirty patients diagnosed with sepsis/systemic inflammatory response syndrome, or multiple trauma.InterventionsPatients were randomly assigned to receive either NAC (n = 15) for 4 days in increasing dosages (day 1: 6 g; day 2: 12 g; days 3 and 4: 18 g) or a mucolytic basis dosage of NAC (3 × 300 mg/day [control]; n = 15), respectively.Measurements and Main ResultsBlood samples were taken before NAC high-dose infusion (day 1), after increasing doses of NAC (days 3 and 5) and 4 days after the last high-dose treatment (day 8). Neutrophil oxidative burst activity after stimulation withEscherichia coliand polymorphonuclear phagocytosis were determined in a flow cytometric assay. Baseline values of polymorphonuclear functions were comparable in both groups. NAC high-dose treatment resulted in a significantly improved phagocytosis activity compared with control patients. In contrast to this, polymorphonuclear burst activity was significantly reduced in the NAC high-dose treated group on day 3.ConclusionThese findings suggest that infusion of NAC in high doses affects granulocyte functions in critically ill patients. Antimicrobial host defense requires the effective sequence of cell adhesion, phagocytosis, and bactericidal respiratory burst. The enhanced phagocytotic activity might be a compensatory mechanism in states of impaired respiratory burst to maintain tissue sterility. For certain mechanisms of disease, the effects observed might be favorable (e.g., ischemia/reperfusion, endothelial cell activation), for others (infection) this might be detrimental.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo characterize the symptom experience of a cohort of intensive care unit (ICU) patients at high risk for hospital death.DesignProspective analysis of patients with a present or past diagnosis of cancer who were consecutively admitted to a medical ICU during an 8-month period.SettingAcademic, university-affiliated, tertiary-care, urban medical center.PatientsOne hundred cancer patients treated in a medical ICU.InterventionAssessment of symptoms.MeasurementsPatients’ self-reports of symptoms using the Edmonton Symptom Assessment Scale (ESAS), and ratings of pain or discomfort associated with ICU diagnostic/therapeutic procedures and of stress associated with conditions in the ICU.Main ResultsHospital mortality for the group was 56%. Fifty patients had the capacity to respond to the ESAS, among whom 100% provided symptom reports. Between 55% and 75% of ESAS responders reported experiencing pain, discomfort, anxiety, sleep disturbance, or unsatisfied hunger or thirst that they rated as moderate or severe, whereas depression and dyspnea at these levels were reported by approximately 40% and 33% of responders, respectively. Significant pain, discomfort, or both were associated with common ICU procedures, but most procedure-related symptoms were controlled adequately for a majority of patients. Inability to communicate, sleep disruption, and limitations on visiting were particularly stressful among ICU conditions studied.ConclusionsAmong critically ill cancer patients, multiple distressing symptoms were common in the ICU, often at significant levels of severity. Symptom assessment may suggest more effective strategies for symptom control and may direct decisions about appropriate use of ICU therapies.

ISSN:0090-3493    

出版商:OVID    

年代:2001

数据来源: OVID