摘要:

Objective:To determine whether additional therapy aimed at correcting low gastric intramucosal pH (pHi) improves outcome in conventionally resuscitated, critically ill patients.Design:Prospective, randomized, controlled study.Setting:General intensive care unit (ICU) of a university teaching hospital.Patients:A total of 210 adult patients, with a median Acute Physiology and Chronic Health Evaluation II score of 24 (range, 8-51).Interventions:All patients were resuscitated according to standard guidelines. After resuscitation, those patients in the intervention group with a pHi of <7.35 were treated with additional colloid and then dobutamine (5 μg/kg/min then 10 μg/kg/min) until 24 hrs after enrollment.Measurements and Main Results:There were no significant differences (p> .05) in ICU mortality (39.6% in the control group vs. 38.5% in the intervention group), hospital mortality (45.3% in the control group vs. 42.3% in the intervention group), and 30-day mortality (43.7% in the control group vs. 40.2 in the intervention group); survival curves; median modified maximal multiorgan dysfunction score (10 points in the control group vs. 13 points in the intervention group); median modified duration of ICU stay (12 days in the control group vs. 11.5 days in the intervention group); or median modified duration of hospital stay (60 days in the control group vs. 42 days in the intervention group). A subgroup analysis of those patients with gastric mucosal pH of ≥7.35 at admission revealed no difference in ICU mortality (10.3% in the control group vs. 14.8% in the intervention group), hospital mortality (13.8% in the control group vs. 29.6% in the intervention group), or 30-day mortality (10.3% in the control group vs. 26.9% in the intervention group).Conclusions:The routine use of treatment titrated against pHi in the management of critically ill patients cannot be supported. Failure to improve outcome may be caused by an inability to produce a clinically significant change in pHi or because pHi is simply a marker of disease rather than a factor in the pathogenesis of multiorgan failure.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Introduction:The impact of pulmonary artery (PA) catheters on patient outcome has been questioned and their usage has become controversial. Meta-analysis on mortality has shown a trend for improved survival with PA catheter-guided therapy. We now perform a meta-analysis on morbidity from PA catheters in the published literature.Methods:We did a search of the medical database (Medline) from 1970 through 1996, using the headings "pulmonary artery catheterization," "Swan-Ganz catheterization" and "right heart catheterization," and restricting the results to "effectiveness" and "usefulness." We also consulted with other experts regarding published randomized controlled trials (RCTs). This yielded 16 RCTs addressing the question of effectiveness of PA catheter-guided treatment. Of these, 12 were found to include data on morbidity. Major morbidity, defined as organ failures as per the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria, from these trials was entered into a formal meta-analysis.Results:A total of 1,610 patients from the 12 trials were analyzed. Morbidity events were observed in 62.77% of the PA catheter treatment group, and in 74.34% of the control group. A relative risk ratio of 0.78074 was obtained, with a 95% confidence interval of 0.6459-0.94374 and a correspondingpof .0168, a lower morbidity in the PA catheter treatment group. Those with PA catheter-guided treatment had a mean protective effect of 21.9% for risk of morbidity. Other important covariates such as acuity of illness, quality score of trials, year of publication, type of PA catheter-guided treatment used (PA catheter vs. no PA catheter, or PA catheter vs. PA catheter for supranormal hemodynamic values), and surgical or mixed patient population, all increased variability and were not statistically significant predictors for risk ratio of morbidity.Conclusions:Meta-analysis of RCTs included in this study shows that there is a statistically significant reduction in morbidity using PA catheter-guided strategies.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To determine whether indocyanine green (ICG) and glucose dilutions can detect generalized capillary protein leakage in septic patients without requiring repeated measurements.Design:Prospective, clinical study.Setting:General intensive care unit.Patients:Twelve consecutive patients who met the criteria of sepsis and 16 consecutive acute myocardial infarction (AMI) patients without any underlying pathology inducing generalized protein capillary leakage.Interventions:Both ICG 25 mg and glucose 5 g were administered simultaneously, to calculate the plasma volume determined by the ICG dilution method (PV-ICG) and the initial distribution volume of glucose (IDVG), on day 1 of sepsis or on day 1 of hospitalization for the AMI patients. The relationship between these two volumes and the PV-ICG/IDVG ratio was evaluated in two patient groups.Measurements and Main Results:Although the IDVG of the two patient groups was not statistically different, the PV-ICG in the septic patients was higher than that in the AMI patients (p< .01). Consequently, the PV-ICG/IDVG ratio in the septic patients was higher than that in the AMI patients (p< .01). Eight of the 12 septic patients had a PV-ICG/IDVG ratio of >0.45, which was not observed in any of the AMI patients. The PV-ICG/IDVG ratio in the septic patients correlated inversely with the total plasma protein concentration (r2= .46,p< .025) and mean arterial pressure (r2= .42,p< .05).Conclusions:Our results indicate that overestimation of the PV-ICG can occur in septic patients and, further, suggest that simultaneous measurement of the two distribution volumes would help predict generalized capillary protein leakage in septic patients without repeated measurement.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives:To develop and evaluate a method for measuring blood volume using the dilution of a fluorescent-labeled hydroxyethyl starch.Design:Laboratory and clinical investigation.Setting:Biochemistry laboratory at the University of Cardiff. Hematology clinic, surgical ward and intensive care unit of the University Hospital of Wales.Patients:Seventeen patients with suspected polycythemia. Eight patients who had undergone major surgery and/or were receiving intensive postoperative care.Interventions:All surgical and postoperative care was provided by clinicians not involved in the study. Patients with suspected polycythemia were referred for blood volume measurement using labeled albumin and red blood cells.Measurement and Main Results:A proprietary brand of hydroxyethyl starch (Elohaes) was labeled with fluorescein isothiocyanate. Dilution of this compoundin vivowas used for measuring blood volume, and the results were compared with those obtained using radiolabeled albumin and the considered criterion, radiolabeled red cells. The elimination of the labeled starch follows the same progress as that of the parent compound, indicating that the fluorescent tag is stable in vivo. The volume of distribution of the labeled starch is 2.5 mL/kg lower than that for labeled albumin (p= .05). Blood volume, measured from the dilution of fluorescent starch, is lower (4.9 mL/kg) than that measured with albumin (p= .048) but higher (6.61 mL/kg) than that measured with red blood cells (p= .0007). This latter difference may be even smaller at marginally higher doses of the fluorescent starch.Conclusion:These data support the view that hydroxyethyl starch provides a valid alternative to red cell labels as a means of calculating blood volume in patients. Labeling the starch with a fluorescent marker makes the assay procedure more sensitive and infinitely easier. The dose required is not high enough to affect the hemodynamic status of the patient.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To evaluate an intravenous meropenem dosage regimen in adult intensive care patients with acute renal failure treated by continuous renal replacement therapy.Design:A prospective, clinical study.Setting:General intensive care unit of a university hospital.Patients:Ten critically ill adult patients being treated with meropenem and receiving continuous veno-venous hemofiltration (hemofiltration rates, 1-2 L/hr) (n = 5) or continuous veno-venous hemodiafiltration (hemofiltration rates, 1-1.5 L/hr; dialysis rates, 1-1.5 L/hr) (n = 5) via a polyacrylonitrile hollow fiber 0.9-m2filter.Interventions:Patients received a meropenem dose of 1 g iv every 12 hrs as a 5-min bolus.Measurements and Main Results:Meropenem concentrations were measured by high-performance liquid chromatography in serum taken at timed intervals and in ultrafiltrate/dialysate to determine serum concentration-time profiles, derive pharmacokinetic variable estimates, and determine sieving coefficients and filter clearances. The serum concentrations were examined to see whether they were above the minimum inhibitory concentrations (MICs) for pathogens that may be encountered in intensive care patients. Serum concentrations exceeded 4 mg/L (MIC90forPseudomonas aeruginosa) during 67% of the dosage period in all patients. Sub-MIC90concentrations were obtained in three patients immediately before treatment and in one patient 12 hrs after treatment. Mean (SD) (n = 10) pharmacokinetic variable estimates were as follows: elimination half-life, 5.16 hrs (1.83 hrs); volume of distribution, 0.35 L/kg (0.10 L/kg); and total clearance, 4.30 L/hr (1.38 L/hr). A sieving coefficient of 0.93 (0.06) (n = 9) indicated free flow across the filter. The fraction cleared by the extracorporeal route was 48% (13%) (n = 9), which is clinically important.Conclusions:A meropenem dose of 1 g iv every 12 hrs provides adequate serum concentrations in the majority of patients receiving continuous veno-venous hemofiltration or continuous veno-venous hemofiltration with a 0.9-m2polyacrylonitrile filter at combined ultrafiltrate/dialysate flow rates of up to 3 L/hr. A lower dose would not be sufficient for the empirical treatment of potentially life-threatening infections in all patients.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To evaluate the safety and efficacy of the platelet-activating factor receptor antagonist BB-882 in the treatment of patients with sepsis.Design:Double-blind, placebo-controlled, randomized, multi-centered study.Setting:Thirty-four European intensive care units.Patients:One hundred fifty-two patients with clinical suspicion of infection and a mean APACHE II score between 15 and 35 in the 24 hrs before entry into the trial.Interventions:Patients received either a loading dose of 4 mg of BB-882 on the first day, followed by an intravenous infusion of 96 mg/24 hrs for up to 120 hrs, or placebo.Measurements:Hemodynamic, respiratory and oxygen transport variables, blood lactate concentrations, interleukin-6, interleukin-8, tumor necrosis factor (TNF)-α, soluble TNF receptor concentrations, organ failure score, 28-day mortality rate, Acute Physiology And Chronic Health Evaluation (APACHE) II score within 24 hrs of entry.Results:Sixty-nine patients (42 male, 27 female) received placebo and 83 (59 male, 24 female) received BB-882. Patients ranged in age from 16 to 89 yrs (mean, 60 yrs). No important differences existed between the two groups in terms of gender distribution, age, or initial APACHE II score. Sepsis was identified as Gram-positive in 49 patients, Gram-negative in 40, mixed in 37, and unknown in 26. No important differences were shown in hemodynamic, respiratory, or oxygen transport variables between groups during the study. Organ failure scores were similar in the two groups throughout the study. Cytokine concentrations were not significantly different in the two groups. Within 28 days of entering the study, 75 patients died, including 31 (45%) in the placebo group and 44 (53%) in the treatment group,p= .32. The median time to death in the placebo group was 6.0 days, and in the treatment group, it was 4.5 days (p= .30).Conclusion:Treatment of sepsis with the platelet-activating factor antagonist BB-882 offers no advantage over placebo on survival, hemodynamic status, respiratory function, or organ failure scores.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To determine whether early enteral feeding in a septic intensive care unit (ICU) population, using a formula supplemented with arginine, mRNA, and ω-3 fatty acids from fish oil (Impact), improves clinical outcomes, when compared with a common use, high protein enteral feed without these nutrients.Design:A prospective, randomized, multicentered trial.Setting:ICUs of six hospitals in Spain.Patients:One hundred eighty-one septic patients (122 males, 59 females) presenting for enteral nutrition in an ICU.Interventions:Septic ICU patients with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of ≥10 received either an enteral feed enriched with arginine, mRNA, and ω-3 fatty acids from fish oil (Impact), or a common use, high protein control feed (Precitene Hiperproteico).Measurements and Main Results:One hundred seventy-six (89 Impact patients, 87 control subjects) were eligible for intention-to-treat analysis. The mortality rate was reduced for the treatment group compared with the control group (17 of 89 vs. 28 of 87;p< .05). Bacteremias were reduced in the treatment group (7 of 89 vs. 19 of 87;p= .01) as well as the number of patients with more than one nosocomial infection (5 of 89 vs. 17 of 87;p= .01). The benefit in mortality rate for the treatment group was more pronounced for patients with APACHE II scores between 10 and 15 (1 of 26 vs. 8 of 29;p= .02).Conclusions:Immune-enhancing enteral nutrition resulted in a significant reduction in the mortality rate and infection rate in septic patients admitted to the ICU. These reductions were greater for patients with less severe illness.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To determine energy expenditure in critically ill patients suffering from acetaminophen-induced fulminant hepatic failure and compare it with values obtained in matched, healthy control subjects and in patients studied during the anhepatic period of elective liver transplantation.Design:Prospective, controlled, observational study.Setting:A ten-bed intensive therapy unit and a liver transplant unit at a University teaching hospital.Patients and Subjects:Sixteen patients suffering from acetaminophen-induced fulminant hepatic failure who were sedated, paralyzed, and mechanically ventilated; 16 age-, gender-, and weight-matched, awake, healthy control subjects; and 16 patients with chronic liver disease, undergoing elective liver transplantation, who were studied during the anhepatic period of surgery.Interventions:None.Measurements and Main Results:The mean energy expenditure was calculated in each case for a 30-min period, using indirect calorimetry. In the patients undergoing liver transplantation, measurements were performed after clamping the hepatic veins and recipient hepatectomy. Energy expenditure was markedly increased in the fulminant hepatic failure group (mean energy expenditure, 4.05 [SD 0.52] kJ·kg−1·hr−1), in comparison with healthy control subjects (mean, 3.44 [0.27] kJ·kg−1·hr−1; mean difference, 18%;p< .001) and in comparison with patients during the anhepatic period of liver transplantation (mean, 3.15 [0.61] kJ·kg−1·hr−1; mean difference, 29%;p< .001). These differences were even more pronounced when a correction factor for differences in core temperature was included in the calculation. Harris-Benedict predictions of energy expenditure were unreliable in the patients with acute liver failure. No correlations were found among energy expenditure and hemodynamic variables, the requirement for vasoconstrictors, or the presence of renal failure.Conclusions:Despite the loss of functioning liver cell mass, the metabolic rate is substantially increased in patients with acetaminophen-induced fulminant hepatic failure. This finding is consistent with the marked systemic inflammatory response, which accompanies acute hepatic failure. The Harris-Benedict equation is unreliable when an estimation of energy expenditure is required in patients with this condition.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To evaluate carbamezapine (CBZ) for neuritic pain relief in Guillain-Barré syndrome (GBS) patients in the intensive care unit (ICU).Design:Prospective, double-blind, randomly allocated crossover study days.Setting:ICU in a tertiary care university hospital.Participants:Twelve consecutive, conscious adult (22-54 yrs) patients with GBS during recovery from the muscular weakness and receiving pressure-support ventilation in the ICU. All patients complained of severe backache and/or leg cramps and tenderness in muscles, and they required opioids for pain relief.Interventions:CBZ (100 mg every 8 hrs) or equivalent placebo was given to nursing staff in coded powder form. Medication was given to patients through a nasogastric feeding tube. The same coded medicine was given for 3 days, and after a 1-day omission, a second set of coded powder was given for the next 3 days in a randomized, double-blind, crossover fashion. Pethidine (1 mg·kg−1) was given intravenously in between, if the pain score was >2. Group 1 (n = 6) patients were given a placebo on the first 3 days, followed by CBZ. Group 2 (n = 6) patients were given CBZ on the first 3 days, followed by a placebo.Measurements and Main Results:In these two study periods of different medications, we observed and scored pain (1, no pain; 5, severe pain), sedation (1, alert; 6, asleep, does not respond to verbal command), and total pethidine requirement per day. In group 1 patients, a significant (p< .001) improvement in the sedation score and a low requirement for pethidine was observed 3 days later, when CBZ was started. However, in group 2 patients, a gradual increase in the pethidine requirement and a high sedation score were noteworthy in the later days of placebo medication. Observations were also analyzed for CBZ days vs. placebo days. Overall, the pain score (1.7 ± 0.8) during the CBZ period of both regimens was significantly (p< .001) lower than during the placebo days (3.1 ± 0.9). Significantly higher doses of pethidine (3.7 ± 0.9 mg/kg/day) were used on the placebo days than on the CBZ days (1.7 ± 1.0 mg/kg/day).Conclusion:The pain in GBS has a dual origin, and we recommend CBZ as an adjuvant to treat pain in GBS patients, during the recovery phase in the ICU, to reduce the narcotic requirement.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To assess the rate of occurrence and nature of airway accidents in intubated patients.Design:Prospective recording of all airway accidents in a 16-bed multidisciplinary intensive care unit.Patients:A total of 5,046 ventilated patients intubated for 9,289 days during 4 yrs.Measurements and Main Results:We determined the number and diagnoses of intubated and ventilated patients, the number and timing of airway accidents, the type of tracheal tube used and duration for which the tube wasin situ,the description of the type of accident, the severity of the accident, and its impact on the course of the patient's illness, whether the patient needed reintubation, and whether the accident was preventable. The total accident rate was 36 of 5,046 patients during 9,289 intubated patient days; 26 occurred in 5,043 endotracheally intubated patients during 8,446 patient endotracheal tube days. There were 10 tracheostomy-related accidents from a total of 79 patients with tracheostomies during 843 tracheostomy patient days. Six had severe consequences and one resulted in death. Eleven were completely preventable, 17 partly preventable, and 8 were considered unpreventable. Self-extubation was the most common accident. Seven of 13 self extubations occurred in patients due for elective extubation in the next few hours. Twelve of 15 patients with self- or accidental extubation of an endotracheal tube accidents did not require reintubation.Conclusions:Airway accidents occurred at low levels with even lower rates of resultant morbidity and mortality. Tracheostomy accidents are more common than those with an endotracheal tube.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID