ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivesOur objectives were a) to identify univariate correlates of death in emergency department patients at risk for infection; b) to perform multivariate analyses and identify independent predictors of death; and c) to develop and internally validate a prediction rule that may be used in the emergency department to risk stratify patients into different risk groups to predict their mortality rate.DesignProspective cohort study.SettingEmergency department of an urban university referral center.PatientsConsecutive emergency department patients, aged 18 or older, who were at risk for infection, as indicated by the emergency department physician ordering a blood culture between February 1, 2000, and February 1, 2001. Of 3,301 eligible patient visits, 3,179 (96%) were enrolled.InterventionsNone.Measurements and Main ResultsThe primary outcome was 28-day in-hospital mortality rate. There were 2,070 visits in the derivation set, with 110 deaths (5.3%), and 1,109 visits in the validation set, with 63 deaths (5.7%). Independent multivariate predictors of death were terminal illness (odds ratio, 6.1; 95% confidence interval, 3.6–10.2), tachypnea or hypoxia (2.7, 1.6–4.3), septic shock (2.7, 1.2–5.7), platelet count <150,000 (2.5, 1.5–4.3), band proportion >5% (2.3, 1.5–3.5), age >65 (2.2, 1.3–3.6), lower respiratory infection (1.9, 1.2–3.0), nursing home residence (1.9, 1.2–3.0), and altered mental status (1.6, 1.0–2.6). The clinical prediction rule stratified patients into mortality risk groups of very low, 0.9% (95% confidence interval, 0.2–1.5%); low, 2.0% (0.8–3.2%); moderate, 7.8% (5.6–10%); high, 20% (13–27%); and very high, 50% (36.1–64%) in the derivation set. Mortality rates for the corresponding risk groups in the validation set were 1.1%, 4.4%, 9.3%, 16%, and 39%, respectively. The receiver operating characteristic area for the rule was 0.82 in the derivation set and 0.78 in the validation set.ConclusionsIn patients with suspected infection, this model identifies significant correlates of death and allows stratification of patients according to mortality risk. As new therapies become available for patients with sepsis syndromes, the ability to predict mortality risk may be helpful in triage and treatment decisions.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivesTo prospectively evaluate the performance of the Clinical Pulmonary Infection Score (CPIS) and its components to identify early in the hospital course of ventilator-associated pneumonia (VAP) which patients are responding to therapy.DesignProspective, multicenter, in a cohort of mechanically ventilated patients.SettingThe intensive care unit of six hospitals located in the metropolitan area of Buenos Aires, Argentina.PatientsSixty-three patients, from a cohort of 472 mechanically ventilated patients hospitalized for >72 hrs, had clinical evidence of VAP and bacteriologic confirmation by bronchoalveolar lavage (BAL) or blood cultures.InterventionsBronchoscopy with BAL fluid culture and blood cultures after establishing a clinical diagnosis of VAP. All patients received antibiotics, 46 before bronchoscopy and 17 immediately after bronchoscopy.Measurements and ResultsCPIS was measured at 3 days before VAP (VAP-3); at the onset of VAP (VAP); and at 3 (VAP+3), 5 (VAP+5), and 7 (VAP+7) days after onset. CPIS rose from VAP-3 to VAP and then fell progressively in the population as a whole (p< .001), and the fall in CPIS was significant in 31 survivors, but not in 32 nonsurvivors. From the individual components of the CPIS, only the Pao2/Fio2ratio distinguished survivors from nonsurvivors, beginning at VAP+3. When CPIS was <6 at 3 or 5 days after VAP onset, mortality was lower than in the remaining patients (p= .018). These differences also related to the finding that those receiving adequate therapy had a slight fall in CPIS and a significant increase of Pao2/Fio2at VAP+3, whereas those getting inadequate therapy did not.ConclusionsSerial measurements of CPIS can define the clinical course of VAP resolution, identifying those with good outcome as early as day 3, and could possibly be of help to define strategies to shorten the duration of therapy.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveEscherichia colihemolysin has been implicated as an important pathogenic factor in extraintestinalE. coliinfections including sepsis. We investigated the effects of coronary administration ofE. colihemolysin on cardiac function in isolated rat hearts perfused at constant flow.DesignProspective, experimental study.SettingResearch laboratory at a university hospital.SubjectsIsolated hearts from male Wistar rats.InterventionsIsolated hearts were perfused with purifiedE. colihemolysin for 60 min.Measurements and Main ResultsLow concentrations of the toxin in the perfusate (0.1–0.2 hemolytic units/mL) caused a dose-dependent coronary vasoconstriction with a marked increase in coronary perfusion pressure, which was paralleled by a decrease in left ventricular developed pressure (and the maximum rate of left ventricular pressure increase). Moreover, 0.2 hemolytic units/mLE. colihemolysin evoked ventricular fibrillation within 10 mins of toxin application. These events were accompanied by the liberation of leukotrienes (LTC4, LTD4, LTE4, and LTB4), thromboxane A2, prostaglandin I2, and the cell necrosis markers lactate dehydrogenase and creatine kinase into the recirculating perfusate. The lipoxygenase inhibitor MK-886 fully blocked the toxin-induced coronary vasoconstrictor response and the loss of myocardial contractility and reduced the release of lactate dehydrogenase and creatine kinase. In contrast to this, the cyclooxygenase inhibitor indomethacin was entirely ineffective. In addition,E. colihemolysin elicited an increase in heart weight and left ventricular end-diastolic pressure, the latter again being suppressed by MK-886.ConclusionsLow doses ofE. colihemolysin cause strong coronary vasoconstriction, linked with loss of myocardial performance, release of cell injury enzymes, and electrical instability, with all events being largely attributable to toxin-elicited leukotriene generation in the coronary vasculature. Bacterial exotoxins such asE. colihemolysin thus may be implicated in the cardiac abnormalities encountered in septic shock.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

BackgroundPrevalence and causes of sex-based differences in morbidity and mortality secondary to cardiovascular disease remain controversial. Cardiac troponin I (cTnI) is a sensitive and specific marker for myocardial injury. Serial cTnI measurements have been used to identify perioperative myocardial cell injury.ObjectiveTo determine whether sex influences the extent of myocardial injury during cardiac surgery, we measured perioperative cTnI in male and female patients.DesignA total of 17 male and 17 female patients were prospectively studied in an age- and case-matched manner. Arterial cTnI were obtained preinduction, 30 mins after the application of the aortic cross-clamp, at arrival to the intensive care unit, and on postoperative day 1.SettingTertiary cardiac surgery center at a major teaching hospital.ResultsThere was no difference between men and women in body mass index (kg/m2), duration of cardiopulmonary bypass, and aortic cross-clamp times. Preoperative cTnI measurements were similar in men (0.24 ± 0.15 ng/mL) and women (0.25 ± 0.13 ng/mL, mean ± sem). The maximum serum cTnI occurred on postoperative day 1 in all patients, and it was 3-fold higher in men (18.5 ± 5.7 ng/mL) compared with women (6.4 ± 1.0 ng/mL).ConclusionsMen had markedly higher serum cTnI compared with women, although they were case matched with respect to age and cardiac risk factors. Our results may suggest there may be sex-related differences in the myocardial response to ischemia and reperfusion injury or intrinsic differences between the male and female myocardium.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the frequency of adverse drug reactions in surgical intensive care units and evaluate their effect on the length of stay.DesignProspective cohort study. Between May 1997 and December 1999, while the patients were staying in the surgical intensive care unit, data were gathered regarding suspected adverse drug reactions and on different variables related to the length of stay.SettingSurgical intensive care units of our hospital.PatientsA total of 401 patients hospitalized in the surgical intensive care unit.Main ResultsIn 37 of the 401 patients seen (9.2%; 95% confidence interval, 6.6–12.5), 39 different adverse drug reactions were detected. The adverse drug reactions were most frequently caused by the following drugs: morphine hydrochloride (n = 13), meperidine hydrochloride (n = 9), and metamizole (n = 7). Five adverse drug reactions were severe, the suspected medication had to be discontinued in 14 cases, and new drugs were necessary to manage the adverse drug reaction in 28 cases. The crude estimation of the effect of adverse drug reactions performed on the length of stay with a bivariant regression model indicated that each adverse drug reaction was related to an increase of 3.39 days (95% confidence interval, 1.47–5.31) in the length of stay. This estimation was reduced to 2.31 days (95% confidence interval, 0.64–3.99) when considering other variables that might cause confusion for analysis, although it is still important.ConclusionsAdverse drug reactions are a significant clinical and economic problem in surgical intensive care units.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether use of a hygroscopic and hydrophobic heat and moisture exchanger (HME) for 7 days without change affects its efficiency in long-term, mechanically ventilated, chronic obstructive pulmonary disease (COPD) patients.DesignProspective, randomized, controlled clinical study comparing two combined HMEs.SettingMedical intensive care unit at a university teaching hospital.PatientsLong-term, mechanically ventilated, COPD patients compared with non-COPD patients.InterventionsIn the first part of the study, COPD patients were studied with the Hygroster HME changed once a week. For the second part, the Hygroster was assessed in non-COPD patients and compared with the Hygrobac HME used in COPD and non-COPD patients for 1 wk without change. Devices could be changed if hygrometric measurements indicated insufficient humidity delivery.Measurements and Main ResultsDaily measurements were recorded for inspired gas temperature and relative and absolute humidity. Ventilatory variables, clinical indicators of efficient humidification, were also recorded. No tracheal tube occlusion occurred. However, contrary to the manufacturer advertisement, the Hygroster experienced surprisingly low values for absolute humidity in both COPD and non-COPD patients. Such events did not occur with the Hygrobac. Absolute humidity with the Hygroster was constantly and significantly lower during the 7-day study period than with the Hygrobac. Absolute humidity measured in COPD patients was identical to that measured in the rest of the study population with both HMEs.ConclusionsManufacturer specifications and bedside measurements of absolute humidity differed considerably for the Hygroster, which in certain instances did not achieve efficient humidification in both COPD and non-COPD patients. This did not occur with the Hygrobac, which performed well throughout the 7-day period in both COPD and non-COPD patients. Our results speak for independent andin vivoevaluation of HMEs.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the prognostic value of lactate clearance and lactate production in severely ill septic patients with normal or mildly elevated blood lactate concentration.DesignProspective, observational study.SettingNineteen-bed mixed medicosurgical intensive care unit.PatientsFifty-six patients with severe sepsis and blood lactate concentration <3 mmol/L.Measurements and Main ResultsLactate metabolism was evaluated in all patients. Lactate clearance was measured by modeling the change in arterial blood lactate over time induced by an infusion of 1 mmol/kg sodium lactate for 15 mins. Lactate production was calculated as the product of lactate clearance times the blood lactate concentration before the infusion. Outcome was taken to be mortality at 28 days after the beginning of the septic episode. A logistic regression model taking into account different risk factors was constructed. Among the 56 patients, 17 (30.3%) died before the 28th day. Basal blood lactate concentration was not different between survivors and nonsurvivors, whereas lactate clearance and production were higher in survivors (0.86 ± 0.32 vs. 0.58 ± 0.18 L/hr/kg,p< .005, and 1.19 ± 0.63 vs. 0.89 ± 0.24 mmol/hr/kg,p= .055, respectively). An increase in blood lactate 45 mins after the end of the lactate infusion (&Dgr;lact-T60) ≥0.6 mmol/L was predictive of 28-day mortality with 53% sensitivity and 90% specificity. Multivariate analysis showed that only three factors were independently and significantly correlated with 28-day mortality: presence of more than two organ failures (odds ratio, 27;p= .04), age >70 yrs (odds ratio, 5.7;p= .032), and &Dgr;lact-T60 ≥0.6 mmol/L (odds ratio, 14.2;p= .042).ConclusionLow lactate clearance in severely ill septic patients with normal or mildly elevated blood lactate is predictive of poor outcome independently of other known risk factors such as age and number of organ failures.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe aim of the study was to compare the safety concerning cerebral hemodynamics of ketamine and sufentanil used for sedation of severe head injury patients, both drugs being used in combination with midazolam.DesignProspective, randomized, double-blind study.SettingIntensive care unit in a trauma center.PatientsTwenty-five patients with severe head injury.InterventionsTwelve patients received sedation with a continuous infusion of ketamine-midazolam and 13 with a continuous infusion of sufentanil-midazolam. All patients were mechanically ventilated with moderate hyperventilation.Measurements and Main ResultsPrognostic indicators (age, Glasgow Coma Scale scores, computed tomography diagnosis, and Injury Severity Scale score) were similar in the two groups at study entry. Measurements were carried out during the first 4 days of sedation. The average infusion rates during this time were 82 ± 25 &mgr;g·kg−1·min−1ketamine and 1.64 ± 0.5 &mgr;g·kg−1·min−1midazolam in the ketamine group and 0.008 ± 0.002 &mgr;g·kg−1·min−1sufentanil and 1.63 ± 0.37 &mgr;g·kg−1·min−1midazolam in the sufentanil group. No significant differences were observed between the two groups in the mean daily values of intracranial pressure and cerebral perfusion pressure. The numbers of intracranial pressure elevations were similar in both groups. The requirements of neuromuscular blocking agents, propofol, and thiopental were similar. Heart rate values were significantly higher in the ketamine group on therapy days 3 and 4 (p< .05). With regard to arterial pressure control, more fluids were given on the first therapy day and there was a trend toward greater use of vasopressors in the sufentanil group. Sedative costs were similar in the two groups.ConclusionThe results of this study suggest that ketamine in combination with midazolam is comparable with a combination of midazolam-sufentanil in maintaining intracranial pressure and cerebral perfusion pressure of severe head injury patients placed under controlled mechanical ventilation.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveConcentrations of group IIA secretory phospholipase A2, an inflammatory response mediator, are increased in the plasma of patients with sepsis and septic shock, and the extent of elevation is correlated with mortality. LY315920Na/S-5920 is a selective inhibitor of group IIA secretory phospholipase A2that has been shown to inhibit serum group IIA secretory phospholipase A2enzyme activity in patients with severe sepsis. The primary objectives of this study were to determine whether there was a dose-response relationship between two doses of LY315920Na/S-5920 compared with placebo in the reduction of 28-day all-cause mortality in patients with severe sepsis and to determine whether LY315920Na/S-5920 had an acceptable safety profile.DesignMulticenter, double-blind, placebo-controlled trial of two doses of LY315920Na/S-5920 in a parallel design.PatientsA total of 586 patients with severe sepsis at 72 institutions in the United States.InterventionsPatients enrolled within 72 hrs from onset of first sepsis-induced organ failure were randomized (1:1:1) to low-dose LY315920Na/S-5920 (target plasma concentration of 200 ng/mL, n = 196), high-dose LY315920Na/S-5920 (800 ng/mL, n = 194), or placebo (n = 196). Study medication was administered as a constant-rate intravenous infusion for 168 hrs.Measurements and Main ResultsThe study was stopped prematurely because it was unlikely that a statistically significant difference in mortality between LY315920Na/S-5920 and placebo would be found. There was no effect of LY315920Na/S-5920 on the primary end point of 28-day all-cause mortality across the entire study population. The 28-day all-cause mortality was distributed as follows: placebo group, 33.2% (65/196 patients); low-dose LY315920Na/S-5920, 37.2% (73/196); and high-dose LY315920Na/S-5920, 36.1% (70/194);p= .525. However, in a prospectively planned analysis, there was a favorable overall dose-response effect on 28-day all-cause mortality in patients administered LY315920Na/S-5920 within 18 hrs of onset of the first sepsis-induced organ failure. Among these patients, 28-day all-cause mortality was distributed as follows: placebo group, 43.5% (20/46 patients); low-dose LY315920Na/S-5920, 31.4% (16/51); and high-dose LY315920Na/S-5920, 20.8% (10/48);p= .018.ConclusionsAdministration of LY315920Na/S-5920 had an acceptable safety profile in patients with severe sepsis. There was no overall survival benefit associated with the use of LY315920Na/S-5920 in this study. However, prospectively planned secondary analyses suggested that treatment with LY315920Na/S-5920 was associated with an improvement in survival in patients treated within 18 hrs of the first sepsis-induced organ failure.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID