ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo determine the allele frequency and genotype distribution of a bi-allelic tumor necrosis factor (TNF) gene polymorphism and plasma TNF-alpha concentrations in postoperative intensive care unit (ICU) patients suffering from severe sepsis.DesignProspective, consecutive entry study of patients with severe sepsis in a postoperative ICU.SettingUniversity hospital.PatientsForty patients with diagnosis of severe sepsis, admitted to the ICU between June 1993 and December 1994.InterventionsNone.Measurements and Main ResultsA 782 basepairs fragment of genomic DNA, including the polymorphic site of the restriction enzyme Ncol within the TNF locus, was amplified by means of polymerase chain reaction. The genotype of each patient was determined after Ncol digestion of the amplified product and subsequent agarose gel electrophoresis. Reading the size of the resulting DNA bands from the agarose gel demonstrated the genotype, as defined by the two alleles TNFB1 and TNFB2. Serial blood samples were drawn every sixth hour during the first 48 hrs and every 12th hour thereafter, for less than equals 96 hrs after diagnosis. TNF-alpha plasma concentrations were detected by an enzyme-linked immunosorbent assay. Assessment of organ dysfunction was performed by calculating a Multiple Organ Failure score.The overall allele frequency (TNFB1 0.35; TNFB2 0.65) and genotype distribution (TNFB1 homozygotes 10%; TNFB1/TNFB2 heterozygotes 48%; TNFB2 homozygotes 42%) in 40 patients with severe sepsis were comparable with those values found in normal individuals. Development of multiple organ failure occurred in 33 (82.5%) of 40 patients, whereas 23 (57.5%) of 40 patients did not survive. In contrast to the overall allele frequency, nonsurvivors showed a significantly higher prevalence of the allele TNFB2 (p less than .005). Patients homozygous for the allele TNFB2 demonstrated a higher mortality rate than heterozygous (TNFB1/TNFB2) patients (p equals .0022). In addition, patients with TNFB2 homozygotes displayed higher circulating TNF-alpha concentrations as well as higher Multiple Organ Failure scores compared with heterozygous (TNFB1/TNFB2) patients.ConclusionsThe bi-allelic Ncol polymorphism within the TNF locus is a genomic marker for patients with increased TNF-alpha response and poor prognosis in severe sepsis. The amount of TNF released in situations of severe infection and sepsis appears to be influenced genetically. TNFB2 homozygous individuals displaying increased circulating TNF plasma concentrations combined with high mortality rate may be included in future studies testing anti-TNF strategies in severe sepsis.(Crit Care Med 1996; 24:381-384)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo study the influence of long-term volume therapy with different solutions and continuous administration of pentoxifylline on plasma concentrations of circulating adhesion molecules.DesignProspective, randomized study.SettingA surgical intensive care unit (ICU) of a university hospital.PatientsForty-two patients with sepsis secondary to major surgery were included.InterventionsThe patients were randomly separated into three groups. In group 1 (n equals 14), volume therapy was exclusively carried out with 10% low-molecular-weight hydroxyethyl starch solution. In group 2 (n equals 14), patients exclusively received 20% human albumin for volume therapy. In group 3 (n equals 14), volume therapy was not defined and pentoxifylline was continuously given (1.4 mg/kg/hr iv).Measurements and Main ResultsFrom arterial blood samples, plasma concentrations of soluble adhesion molecules (endothelial leukocyte adhesion molecule-1 [soluble ELAM-1], intercellular adhesion molecule-1 [soluble ICAM-1], vascular cell adhesion molecule-1 [soluble VCAM-1], and soluble granule membrane protein-140) were serially measured on the day of admission to the ICU (``baseline'' value) and during the next 5 days at noon.No significant differences between the three groups were found for macrohemodynamics.Soluble ELAM-1, soluble ICAM-1, and soluble VCAM-1 plasma concentrations were markedly higher than normal values at baseline in all groups. In the hydroxyethyl starch group, soluble ELAM-1 plasma concentration decreased to the normal range, whereas it further increased in the human albumin group and was almost unchanged in the pentoxifylline group.During the study period, soluble ICAM-1 and soluble VCAM-1 plasma concentrations remained unchanged in the hydroxyethyl starch group. However, these concentrations increased in the other groups. Soluble granule membrane protein-140 increased significantly only in the human albumin group (483 plus minus 103 to 683 plus minus 94 ng/mL). In the hydroxyethyl starch-treated patients, Acute Physiology and Chronic Health Evaluation II score decreased significantly (from 24.3 plus minus 3.4 at baseline to 17.0 plus minus 3.3 at the end of the study period). Only PaO2/FIO2was correlated to plasma concentrations of adhesion molecules.ConclusionsSepsis is associated with markedly increased plasma concentrations of adhesion molecules, indicating endothelial activation or damage. By long-term volume therapy with hydroxyethyl starch solution, these concentrations remained unchanged or even decreased, whereas in patients in whom human albumin was infused or pentoxifylline was given continuously, plasma concentration of soluble adhesion molecules further increased.(Crit Care Med 1996; 24:385-391)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesThe aims of this study were: a) to evaluate plasma concentrations of cytokines and their soluble receptors, as well as antioxidant substances in patients at high risk of developing multiple organ failure; b) to investigate early change; and c) to examine the possible prognostic value of these elements.DesignProspective analysis.SettingSurgical intensive care unit (ICU) of a university hospital.PatientsSixteen patients at risk for multiple organ failure.Measurements and Main ResultsTen patients developed multiple organ failure and five of them died. Whereas tumor necrosis factor-alpha (TNF-alpha) plasma concentrations were only borderline higher in patients developing multiple organ failure, TNF-soluble receptors 55 and 75 were significantly increased during all ICU days compared with patients not going into organ failure. Interleukin-6 plasma concentrations were higher in patients developing multiple organ failure during the first 2 days after ICU admission. The antioxidant vitamin C was significantly decreased in patients going into multiple organ failure during all ICU days. Other biochemical markers of antioxidant activity, such as vitamin E, copper, and zinc plasma concentrations, did not differ between the two groups.ConclusionsOur data suggest that there is a marked increase in anti-TNF activity and a decrease of antioxidant defense in patients at risk of developing multiple organ failure. The predictive value of plasma concentrations of circulating TNF-soluble receptors and vitamin C in this type of patient needs further evaluation.(Crit Care Med 1996; 24:392-397)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo study the acute hemodynamic effects of furosemide in critically ill pediatric patients, the temporal relationship between hemodynamic changes and changes in neuroendocrine axis, and the temporal relationship between hemodynamic changes and urine output.DesignProspective study.SettingPediatric intensive care unit in a tertiary care university center.PatientsFourteen critically ill pediatric patients who clinically required diuretic therapy.InterventionsBefore and after furosemide administration, hemodynamic and neurohormonal measurements were taken.Measurements and Main ResultsHemodynamic and neurohormonal responses to acute diuretic therapy were measured in 14 pediatric patients treated with furosemide (1 mg/kg/dose). Cardiac index deteriorated by 10 mins after drug administration (minus 9.4 plus minus 3.9%, p less than .05) and was associated with an increase in systemic vascular resistance (17.1 plus minus 4.8%, p less than .05). There was a subsequent increase in cardiac index (20 plus minus 4.9%, p less than .05) at 30 mins, with a decrease in systemic vascular resistance (minus 11.5 plus minus 5.2%, p less than .05). These hemodynamic changes were associated with marked increases in renin and norepinephrine concentrations and an increase in urinary prostaglandin release. The hemodynamic and neurohormonal effects had their onset before maximum diuresis.ConclusionIntravenous furosemide administration in acutely ill pediatric patients results in an acute but transient deterioration in cardiac function that appears to parallel the neuroendocrine changes rather than the acute diuresis.(Crit Care Med 1996; 24:398-402)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo evaluate the benefit of recombinant human growth hormone administration on muscle strength and duration of weaning in critically ill patients undergoing prolonged mechanical ventilation.DesignProspective, randomized, controlled, single-blind study.SettingIntensive care unit.PatientsTwenty patients requiring more than equals 7 days of mechanical ventilation for acute respiratory failure.InterventionRandom assignment to receive either 0.43 IU (approximate 0.14 mg) recombinant growth hormone/kg body weight/day (treated group), or saline (nontreated group) for 12 days.Measurements and Main ResultsNutritional support was guided by indirect calorimetry. Cumulative nitrogen balance was positive throughout the study period in the treated group (44.9 plus minus 17.3 [SEM] g/12 days) vs. the nontreated group (minus 65.8 plus minus 11.8 g/12 days) (p less than .0001). Despite similar initial plasma concentrations, recombinant growth hormone supplementation resulted in marked increases in growth hormone, insulin like growth factor-1, and insulin concentrations (p less than .05, .02, and .0001, respectively, vs. nontreated group). Body impedance determined net fat-free mass increased in the treated group (0.8 plus minus 0.6 kg) vs. the nontreated group (minus 1.1 plus minus 0.5 kg) (p less than .03). Initial peripheral muscle function, assessed by computer-controlled electrical stimulation of the adductor pollicis, was similarly lower in treated and nontreated groups than sex and age-matched normal controls, and decreased further during the study period. Arterial blood gases, cumulative total mechanical ventilation time, and number of hrs/day of mechanical ventilation during weaning were similar in both patient groups. Only three of the ten patients in each group were weaned from mechanical ventilation by day 12.ConclusionsDaily administration of recombinant growth hormone in mechanically ventilated patients with acute respiratory failure promotes a marked nitrogen retention. However, this action is accompanied neither by an improvement in muscle strength nor by a shorter duration of ventilatory suppport.(Crit Care Med 1996; 24:403-413)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo assess the effect of three different alcohol withdrawal therapy regimens in traumatized chronic alcoholic patients with respect to the duration of mechanical ventilation and the frequency of pneumonia and cardiac disorders during their intensive care unit (ICU) stay.DesignA prospective, randomized, blinded, controlled clinical trial.SettingA university hospital ICU.PatientsMultiple-injured alcohol-dependent patients (n equals 180) transferred to the ICU after admission to the emergency room and operative management. A total of 180 patients were included in the study; however, 21 patients were excluded from the study after assignment.InterventionsPatients who developed actual alcohol withdrawal syndrome were randomized to one of the following treatment regimens: flunitrazepam/clonidine (n equals 54); chlormethiazole/haloperidol (n equals 50); or flunitrazepam/haloperidol (n equals 55). The need for administration of medication was determined, using a validated measure of the severity of alcohol withdrawal (Revised Clinical Institute Withdrawal Assessment for Alcohol Scale).Measurements and Main ResultsThe duration of mechanical ventilation and major intercurrent complications, such as pneumonia, sepsis, cardiac disorders, bleeding disorders, and death, were documented. Patients did not differ significantly between groups regarding age, Revised Trauma and Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II score on admission. In all except four patients in the flunitrazepam/clonidine group, who continued to hallucinate, the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale decreased to less than 20 after initiation of therapy. ICU stay did not significantly differ between groups (p equals .1669). However, mechanical ventilation was significantly prolonged in the chlormethiazole/haloperidol group (p equals .0315) due to an increased frequency of pneumonia (p equals .0414). Cardiac complications were significantly (p equals .0047) increased in the flunitrazepam/clonidine group.ConclusionsThere was some advantage in the flunitrazepam/clonidine regimen with respect to pneumonia and the necessity for mechanical ventilation. However, four (7%) patients had to be excluded from the study due to ongoing hallucinations during therapy. Also, cardiac complications were increased in this group. Thus, flunitrazepam/haloperidol should be preferred in patients with cardiac or pulmonary risk. Further studies are required to determine which therapy suits individual patients. A symptom-orientated patient approach rather than one standard therapy should be considered.(Crit Care Med 1996; 24:414-422)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo characterize the sequential plasma concentrations of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) and their relationship with the clinical outcome in patients with intra-abdominal infection who underwent surgical intervention.DesignA prospective, comparative study.SettingSurgical intensive care unit of a university hospital.PatientsFifteen patients with surgically proved intra-abdominal infection were included as the infected group. The comparative noninfected group consisted of ten patients who underwent major abdominal surgery without infection.InterventionsBlood samples were obtained from the indwelling arterial catheter before induction of general anesthesia, and 1, 1.5, 2, 3, 4, 6, and 24 hrs after skin incision.Measurements and Main ResultsPlasma cytokine concentrations were measured using radioimmunoassay. The hemodynamic and physiologic parameters were recorded for comparison with cytokine concentrations. In the noninfected group, the TNF-alpha concentration was very low throughout the observation period, and the IL-6 concentration increased 4 hrs after skin incision. The infected group had significantly higher TNF-alpha and IL-6 concentrations than the noninfected group. The TNF-alpha concentration increased from 129.2 plus minus 46.4 to 1196.0 plus minus 445.8 pg/mL and the IL-6 concentration increased from 54.2 plus minus 24.3 to 560.3 plus minus 187.5 pg/mL 2 hrs after skin incision in the infected group. The postoperative APACHE II score correlated significantly with both peak IL-6 (r2equals .39) and peak TNF-alpha (r2equals .32) concentrations.ConclusionsBoth TNF-alpha and IL-6 concentrations increased significantly after surgical intervention in patients with intra-abdominal infection. The pulse increase in TNF-alpha concentration and the persistent increase in IL-6 concentration were related to the poor postoperative clinical condition in infected patients.(Crit Care Med 1996; 24:423-428)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID