摘要:

ObjectiveThe role of family interests in medical decision making is controversial. Physicians who routinely treat incompetent patients may have preferred strategies for addressing family interests as they are encountered in surrogate medical decision making. We sought to determine how physicians view the role of family interests in surrogate medical decision making.DesignCross-sectional mail survey.SettingRemote study.PatientsSurveyed were neonatologists, pediatric intensivists, and medical intensivists affiliated with American medical schools.Measurements and Main ResultsA total of 327 (55%) of 596 surveys were returned; 35% of respondents were pediatric intensivists, 39% were neonatologists, and 26% were medical intensivists. The majority of respondents believed that family interests should be considered in decisions for incompetent patients, even if those interests are not necessarily important interests of the patient. Less than 10% preferred the traditional model in which the physician-patient relationship is exclusive and family interests are excluded. Medical intensivists, and those who described themselves as more religious, more opposed to healthcare rationing, and more protective of patients, tended to prefer patient-centered surrogate decision-making models. Physicians who treat children, especially neonatologists, were more accepting of family-centered surrogate decision-making models than were physicians who exclusively treat adults.ConclusionsA majority of the academic intensivists in our study believed that family interests should play an important role in medical decision making for incompetent patients. Our findings suggest that the traditional view of the physician-patient relationship may represent an overly simplistic model for medical decision making.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether gender-related differences exist in the provided level of care and outcome in a large cohort of critically ill patients.DesignProspective, observational cohort study with data collection from January 1, 1998, to December 31, 2000.SettingThirty-one intensive care units in Austria.PatientsA total of 25,998 adult patients, consecutively admitted to 31 intensive care units in Austria..InterventionsWe assessed severity of illness, level of provided care, and vital status at hospital discharge.Measurements and Main ResultsOf 25,998 patients, 58.3% were male and 41.7% were female. Hospital mortality rate was slightly higher in women (18.1%) than in men (17.2%), but severity of illness-adjusted mortality rate was not different. Men received an overall increased level of care and had a significantly higher probability of receiving invasive procedures, such as mechanical ventilation (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.16–1.28), single vasoactive medication (OR, 1.18; 95% CI, 1.12–1.24), multiple vasoactive medication (OR, 1.21; 95% CI, 1.15–1.28), intravenous replacement of large fluid losses (OR, 1.14; 95% CI, 1.08–1.20), central venous catheter (OR, 1.06; 95% CI, 1.01–1.12), peripheral arterial catheter (OR, 1.15; 95% CI, 1.10–1.22), pulmonary artery catheter (OR, 1.48; 95% CI, 1.34–1.62), renal replacement therapy (OR, 1.28; 95% CI, 1.16–1.42), and intracranial pressure measurement (OR, 1.34; 95% CI, 1.18–1.53).ConclusionsIn a large cohort of critically ill patients, no differences in severity of illness-adjusted mortality rate between men and women were found. Despite a higher severity of illness in women, men received an increased level of care and underwent more invasive procedures. This different therapeutic approach in men did not translate into a better outcome.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the long-term effect of a program of rotating antibiotics on the incidence of ventilator-associated pneumonia and the susceptibilities of Gram-negative bacilli responsible for ventilator-associated pneumonia.DesignProspective program for the surveillance of antibiotic susceptibilities of microorganisms responsible for ventilator-associated pneumonia.SettingAcademic, university-based, medical intensive care unit (16 beds).Subjects2,856 mechanically ventilated patients.InterventionsA new program of antibiotic use was introduced at the end of 1996 that involved the rotation of antibiotics in empirical and therapeutic use of the treatment of ventilator-associated pneumonia. The rotation concerned the &bgr;-lactam and aminoglycoside classes, with a rotation interval of 1 month. The use of antibiotics was monitored monthly. No preference was given to any particular antibiotic. In a previous study, the period before the introduction of this protocol (1995–1996) was compared with the period 2 yrs after (1997–1998): The results indicated a decreased incidence of ventilator-associated pneumonia, a lower incidence of potentially resistant Gram-negative bacilli, and increased sensitivities of Gram-negative bacilli, especiallyPseudomonas aeruginosaandBurkholderia cepacia. After 1998, we decided to continue a routine for this rotation. The long-term effect of this program was studied by comparing the incidence of Gram-negative bacilli responsible for ventilator-associated pneumonia and their susceptibilities obtained in a third period: 1999–2001. The long-term effect (5 yrs) of such a strategy—2-yr protocol period (1997–1998) and 3-yr routine period (1999–2001)—could be evaluated.Measurements and Main ResultsDuring the 7-yr study period, 2,856 patients were mechanically ventilated for >48 hrs. The incidence of ventilator-associated pneumonia remained significantly lower in period 3 (1999–2001): 23% (period 1, 1995–1996) vs. 15.7% (period 2, 1997–1998) vs. 16.3% (period 3, 1999–2001;p= .002). Late-onset ventilator-associated pneumonia occurred in 86.6% and 94% of cases, respectively, in periods 1 and 3 (p= .02). The decrease of the incidence of early-onset ventilator-associated pneumonia was statistically significant during the 7-yr study period: 13% vs. 9% vs. 5.9% (p= .02). Combined with a higher incidence of late-onset ventilator-associated pneumonia, the incidence of potentially resistant Gram-negative bacilli increased in period 3: 42.2% vs. 34.5% vs. 41.7% (nonsignificant), except forB. cepacia: 11.7% vs. 7.4% vs. 3.7% (p= .005). Nevertheless, the potential antibiotic-resistant Gram-negative bacilli were more sensitive to most of the &bgr;-lactams, especially piperacillin-tazobactam and cefepime.ConclusionsRotation of antibiotics could help to avoid ventilator-associated pneumonia. It could greatly improve the susceptibilities of the potentially antibiotic-resistant Gram-negative bacilli responsible for late-onset ventilator-associated pneumonia. This program could be applied in routine with good results 5 yrs after its introduction. Further studies, especially multiple-center trials, are necessary to confirm this result and better define the rotation type and intervals.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo compare the effectiveness of normal saline, dextran, hypertonic, and hypertonic-hyperoncotic solutions in hemorrhagic shock.DesignLaboratory investigation.SettingUniversity hospital, Emergency Surgery and Intensive Care staff.SubjectsThirty-two large white female pigs.InterventionsRoutine care included: anesthesia and sedation (ketamine 10 mg/kg, droperidol 0.25 mg/kg, diazepam 0.7 mg/kg, fentanyl 0.006 mg/kg, 2% enflurane, 20% nitrous oxide, pancuronium bromide 0.13 mg/kg); volume-controlled ventilation (Paco235–40 torr; 4.7–5.4 kPa); cannulation of right carotid artery and pulmonary artery. Three flow probes (subdiaphragmatic aorta, superior mesenteric artery, right renal artery) and regional venous catheters (superior mesenteric vein, right renal vein) were positioned. Animals were bled to 45 mm Hg for 1 hr and resuscitated with four different fluids and blood to normal aortic blood flow and hemoglobin.Measurements and Main ResultsMean arterial pressure and blood flow through abdominal aorta (&OV0312;aor), mesenteric artery (&OV0312;mes), and renal artery (&OV0312;ren) were continuously monitored. Cardiac output, systemic and regional oxygen delivery (&U1E0A;o2, &U1E0A;o2mes, &U1E0A;o2ren), and consumption (&OV0312;o2, &OV0312;o2mes, &OV0312;o2ren) were recorded every 30 mins. Baseline &OV0312;aorwas restored with different amounts of fluids in the four groups: normal saline (91.35 ± 22.18 mL/kg); dextran (16.24 ± 4.42 mL/kg); hypertonic (13.70 ± 1.44 mL/kg); and hypertonic-hyperoncotic (9.11 ± 1.20 mL/kg). The amount of sodium load was less using dextran and hypertonic-hyperoncotic and sodium levels were only transiently increased after hypertonic infusion. Mean arterial pressure and cardiac output were normalized in all groups. Animals resuscitated with normal saline and dextran showed increased pulmonary artery pressures. &U1E0A;o2was significantly higher after hypertonic-hyperoncotic infusion, because of reduced hemodilution. Hypertonic and hypertonic-hyperoncotic normalized &OV0312;mes, &U1E0A;o2mes, &OV0312;o2mes, &OV0312;ren, and &U1E0A;o2ren, whereas normal saline and dextran did not achieve this result. At the end of the experiment, hypertonic-hyperoncotic maintained mean arterial pressure, cardiac output, and &U1E0A;o2until the end of observation in contrast to normal saline, dextran, and hypertonic.ConclusionsResuscitation with a small volume of hypertonic-hyperoncotic solution allows systemic and splanchnic hemodynamic and oxygen transport recovery, without an increase in pulmonary artery pressure. It only transiently increased sodium concentration.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveHerpes family viruses have been recognized as pathogens for many years in immunosuppressed transplant or human immunodeficiency virus patients, but they have garnered little attention as potential pathogens in the nonimmunosuppressed critically ill. The objective of this study was to define the prevalence of and risk factors for development of herpes family virus infection in chronic critically ill surgical patients.DesignProspective epidemiologic study.SettingA 38-bed surgical intensive care unit in a major university hospital.PatientsNonimmunosuppressed intensive care unit patients in intensive care unit for ≥5 days.InterventionsNone; patients received no antiviral treatment during the study.Measurements and Main ResultsWeekly cultures for cytomegalovirus (CMV) and herpes simplex virus, viral serologies, and T-cell counts were performed. The prevalence (95% confidence interval) of positive respiratory cultures for herpes simplex or CMV was 35% (22–49%); 15% (5–25%) cultured positive for CMV, 23% (11–35%) cultured positive for herpes simplex virus, and one patient’s respiratory secretions culturing positive for both CMV and herpes simplex virus. The prevalence of CMV viremia was only 5.8% (1–10%). CMV+ patients had longer hospital admissions, intensive care unit admissions, and periods of ventilator dependence than CMV− patients, despite having comparable severity of illness scores. CMV+ patients also had significantly higher numbers of blood transfusions, prevalence of steroid exposure, and prevalence of hepatic dysfunction, and all were immunoglobulin G positive at the beginning of the study. In contrast, herpes simplex virus–positive patients had lengths of hospital admissions, lengths of intensive care unit admissions, and periods of ventilator dependence comparable with patients without viral infections (p> .05).ConclusionsThere is a significant prevalence (22–49%) of occult active herpes family viruses in chronic critically ill surgical patients. The clinical significance of these viral infections is unknown, although CMV+ patients have significantly higher morbidity rates than CMV− patients. Several factors suggest pathogenicity, but further study is needed to define causality.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe epidemiology of aspiration pneumonia and its impact on clinical and economic outcomes in surgical patients are poorly defined. We sought to identify preoperative patient characteristics and surgical procedures that are associated with an increased risk for aspiration pneumonia and to determine the clinical and economic impact in hospitalized surgical patients.DesignObservational study using a state discharge database.SettingAll hospitals in Maryland.PatientsWe obtained discharge data for 318,880 adult surgical patients in 52 Maryland hospitals from January 1, 1999, through December 31, 2000.Measurements and Main ResultsThe primary outcome variable was a discharge diagnosis of aspiration pneumonia. Unadjusted and adjusted analyses were performed to identify patient characteristics and surgical procedures associated with an increased risk for aspiration pneumonia and to determine the impact on intensive care unit admission, in-hospital mortality, hospital length of stay, and total hospital charges. The overall prevalence of aspiration pneumonia was 0.8%. The prevalence varied among hospitals (range, 0% to 1.9%) and by surgical procedure (range, <0.1% to 19.1%). Patient characteristics independently associated with an increased risk included: male sex, nonwhite race, age of >60 yrs vs. 18–29 yrs, dementia, chronic obstructive pulmonary disease, renal disease, malignancy, moderate to severe liver disease, and emergency room admission. In patients undergoing procedures other than tracheostomy, aspiration pneumonia was independently associated with an increased risk for admission to the intensive care unit (odds ratio, 4.0; 95% confidence interval, 3.0–5.1), in-hospital mortality (odds ratio, 7.6; 95% confidence interval, 6.5–8.9), longer hospital length of stay (estimated mean increase of 9 days; 95% confidence interval, 8–10), and increased total hospital charges (estimated mean increase of $22,000; 95% confidence interval, $19,000–$25,000).ConclusionsAspiration pneumonia occurs in approximately 1% of surgical patients and is associated with significant morbidity, mortality, and costs of care. Given that the rate of aspiration pneumonia varies among hospitals, we can improve the quality and reduce the costs of care by implementing strategies to reduce the rate of aspiration pneumonia.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo demonstrate whether fluconazole reduces multiple organ failure and mortality in early septic shock (<24 hrs).DesignA prospective randomized double-blind study.SettingA medical and surgical adult intensive care unit in a tertiary referral center.PatientsValues were obtained from 71 general adult intensive care unit patients.InterventionsDuring a 2.5-yr period, December 1998–June 2001, 71 patients with septic shock attributed to either nosocomial pneumonia (n = 37) or intra-abdominal sepsis (n = 34) were admitted to our intensive care unit and met the criteria of early septic shock and were entered into this study. All patients were randomized by our clinical pharmacist to receive daily either 200 mg of fluconazole in isotonic saline (fluconazole group = 32) or isotonic saline alone (placebo group = 39) intravenously during the course of their septic shock.Measurements and Main ResultsAll patients were closely monitored with pulmonary artery catheters and parameters to calculate daily organ dysfunction and Acute Physiology and Chronic Health Evaluation II scores. There was a highly significant increase in 30-day survival in the fluconazole-treated patients compared with the placebo patients (78% vs. 46%). However, fluconazole was found to be more effective in patients with septic shock attributed to intra-abdominal sepsis than to nosocomial pneumonia. Increased survival in the intra-abdominal sepsis clinical category was mirrored by a significantly lower number of organ failures in the treated group compared with the placebo group whereas the number of organ failures in the fluconazole group attributed to nosocomial pneumonia were not significantly increased compared with the control group. The septic shock state was considered in all cases to be attributed to bacterial and not to disseminated yeast infection with the exception of one patient in the control group who was admitted with candidemia. The mechanisms by which fluconazole exerts its protective effect against septic shock in patients is far from clear. However, fluconazole has been shown to enhance bactericidal activity of neutrophils and also to inhibit transmigration and adhesion of neutrophils in capillaries of distant organs.ConclusionsThe development of organ failure and mortality in septic shock was significantly reduced by fluconazole given intravenously. The mechanism of action of fluconazole in reducing multiple organ dysfunction in this group of patients may be attributed to the ability of fluconazole to increase recruitment, improve bactericidal activity of neutrophils, and to contain microorganisms locally.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveMultiple organ dysfunction syndrome is a frequent complication of severe sepsis and septic shock and has a high mortality. We hypothesized that extensive apoptosis of cells might constitute the cellular basis for this complication.DesignRetrospective study.SettingMedical and surgical wards or intensive care units of two university hospitals.PatientsFourteen patients with fever, 15 with systemic inflammatory response syndrome, 32 with severe sepsis, and eight with septic shock.InterventionsNone.Measurements and Main ResultsWe assessed circulating levels of nucleosomes, specific markers released by cells during the later stages of apoptosis, with a previously described enzyme-linked immunosorbent assay in these 69 patients with fever, systemic inflammatory response syndrome, severe sepsis, or septic shock. Severity of multiple organ dysfunction syndrome was assessed with sepsis scores, and clinical and laboratory variables. Elevated nucleosome levels were found in 64%, 60%, 94%, and 100% of patients with fever, systemic inflammatory response syndrome, severe sepsis, or septic shock, respectively. These levels were significantly higher in patients with septic shock as compared with patients with severe sepsis, systemic inflammatory response syndrome, or fever, and in nonsurvivors as compared with survivors. In patients with advanced multiple organ dysfunction syndrome, nucleosome levels correlated with cytokine plasma levels as well as with variables predictive for outcome.ConclusionsPatients with severe sepsis and septic shock have elevated plasma levels of nucleosomes. We suggest that apoptosis, probably resulting from exposure of cells to excessive amounts of inflammatory mediators, might by involved in the pathogenesis of multiple organ dysfunction syndrome.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine the pharmacokinetics and metabolism of midazolam in pediatric intensive care patients.DesignProspective population pharmacokinetic study.SettingPediatric intensive care unit.PatientsTwenty-one pediatric intensive care patients aged between 2 days and 17 yrs.InterventionsThe pharmacokinetics of midazolam and metabolites were determined during and after a continuous infusion of midazolam (0.05–0.4 mg/kg/hr) for 3.8 hrs to 25 days administered for conscious sedation.Measurements and Main ResultsBlood samples were taken at different times during and after midazolam infusion for determination of midazolam, 1-OH-midazolam, and 1-OH-midazolam-glucuronide concentrations via high-performance liquid chromatography–ultraviolet detection. A population analysis was conducted via a two-compartment pharmacokinetic model by the NPEM program. The final population model was used to generate individual Bayesian posterior pharmacokinetic parameter estimates. Total body clearance, apparent volume distribution in terminal phase, and plasma elimination half-life were (mean ± sd, n = 18): 5.0 ± 3.9 mL/kg/min, 1.7 ± 1.1 L/kg, and 5.5 ± 3.5 hrs, respectively. The mean 1-OH-midazolam/midazolam ratio and (1-OH-midazolam + 1-OH-midazolam-glucuronide)/midazolam ratio were 0.14 ± 0.21 and 1.4 ± 1.1, respectively. Data from three patients with renal failure, hepatic failure, and concomitant erythromycin-fentanyl therapy were excluded from the final pharmacokinetic analysis.ConclusionsWe describe population and individual midazolam pharmacokinetic parameter estimates in pediatric intensive care patients by using a population modeling approach. Lower midazolam elimination was observed in comparison to other studies in pediatric intensive care patients, probably as a result of differences in study design and patient differences such as age and disease state. Covariates such as renal failure, hepatic failure, and concomitant administration of CYP3A inhibitors are important predictors of altered midazolam and metabolite pharmacokinetics in pediatric intensive care patients. The derived population model can be useful for future dose optimization and Bayesian individualization.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate the effectiveness of an evidence-based intervention to prevent catheter-associated bloodstream infections among intensive care unit patients at a nonteaching, community hospital.DesignNonrandomized pre/post observational trial.SettingTwo intensive care units at Missouri Baptist Medical Center, Saint Louis, MO.ParticipantsNurses and critical care physicians.InterventionA ten-page, self-study module on the prevention of catheter-associated bloodstream infections, lectures, and posters given between July and September 1999.MeasurementsThe incidence of nosocomial catheter-associated bloodstream infection and patient demographics were measured for patients admitted between March 1998 and July 2000.Main ResultsThirty cases of catheter-associated bloodstream infections during 6110 catheter-days were noted in the preintervention period (4.9 cases/1000 catheter-days) vs. 11 cases during the 5210 catheter-days in the postintervention period (2.1 cases/1000 catheter-days). The relative risk for catheter-associated infection in the postintervention period was 0.43 (95% confidence interval, 0.22–0.84). Among catheterized patients, Acute Physiology and Chronic Health Evaluation II score (25.2 preintervention vs. 25.1 postintervention;p= .86), hemodialysis (91 of 647 [14%] patients vs. 69 of 541 [13%];p= .70), and the mean number of catheter days per patient (9.1 vs. 9.6 days;p= .46) did not differ between the pre- and postintervention periods.ConclusionsA focused, educational intervention among nurses and physicians in a nonteaching community hospital resulted in a significant, sustained reduction in the incidence of catheter-associated bloodstream infection.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID