ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo investigate the relationship between oxygen transport patterns and outcome in patients with sepsis syndrome or septic shock managed according to two different treatment regimens.DesignRetrospective study of a subgroup of patients with sepsis syndrome or septic shock taken from a randomized, prospective, controlled trial.SettingGeneral intensive care units in a teaching and a district general hospital.PatientsSeventy-eight patients classified according to predetermined criteria as having sepsis syndrome or septic shock were drawn retrospectively from a larger study group of 109 consecutive patients considered to be at risk for developing multiple organ failure.Interventions4.5 L/min/m sup 2, oxygen delivery [DO2600 mL/min/m2, and oxygen consumption [VO2170 mL/min/m2) were not achieved with fluids alone, patients were randomized to either a control group or a treatment group. In the treatment group, dobutamine (5 to 200 micro g/kg/min) was administered to increase cardiac index and DO2until all three goals were simultaneously achieved. In the control group, dobutamine was administered only if the cardiac index was <2.8 L/min/m2. In both groups, norepinephrine was infused to maintain mean arterial pressure at 80 mm Hg.Measurements and Main ResultsHemodynamic, oxygen transport, and lactate measurements were made at the time of admission to the study, at the time of optimal volume administration, at 1, 2, 4, 8, 12, 16, 20, and 24 hrs, then every 6 hrs for the next 24 hrs, and at least every 8 hrs thereafter. The time at which all therapeutic goals were first achieved simultaneously or the time of maximal DO2was identified and termed "tmax."Survivors from both the control and treatment groups significantly (p < .001) increased cardiac index and DO2in response to maximal resuscitation, and despite an associated decrease in oxygen extraction (p < .01), there was a significant (p < .01) increase in VO2. In nonsurvivors from both groups, despite significant increases in cardiac index (p < .05) and DO2(p < .01) at tmax, oxygen extraction decreased (p < .01) and VO2remained unchanged. DO2and VO2were significantly lower (p < .05) at tmax in nonsurvivors than in survivors from both groups. Persistently high lactate concentrations were characteristic of nonsurvivors.ConclusionsSurvivors of sepsis syndrome or septic shock are characterized by an ability to increase both DO2and VO2. In contrast, nonsurvivors typically have reduced cardiac reserve, they fail to increase VO2following resuscitation, and when delivery is enhanced with aggressive inotropic support, oxygen extraction falls. These patterns of response were similar in both treatment and control groups, although the magnitude of the changes was exaggerated in the treatment group. These observations may help to explain the findings by some investigators that treatment aimed at achieving survivor values of cardiac index, DO2, and VO2fails to improve outcome when instituted following admission to intensive care. (Crit Care Med 1997; 25:926-936)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo evaluate the safety and effectiveness of high-frequency oscillatory ventilation using a protocol designed to recruit and maintain optimal lung volume in patients with severe adult respiratory distress syndrome (ARDS).SettingSurgical and medical intensive care units in a tertiary care, military teaching hospital.DesignA prospective, clinical study.PatientsSeventeen patients, 17 yrs to 83 yrs of age, with severe ARDS (Lung injury Score of 3.81 +/- 0.23) failing inverse ratio mechanical conventional ventilation (PaO2/FIO2ratio of 68.6 +/- 21.6, peak inspiratory pressure of 54.3 +/- 12.7 cm H2O, positive end-expiratory pressure of 18.2 +/- 6.9 cm H2O).InterventionsHigh-frequency oscillatory ventilation was instituted after varying periods of conventional ventilation (5.12 +/- 4.3 days). We employed a lung volume recruitment strategy that consisted of incremental increases in mean airway pressure to achieve a PaO2or=to8.0 kPa), with an FIO2of <or=to0.6.Measurements and Main ResultsHigh-frequency oscillator ventilator settings (FIO2, mean airway pressure, pressure amplitude of oscillation [Delta P] frequency) and hemodynamic parameters (cardiac output, oxygen delivery [DO2]), mean systemic and pulmonary arterial pressures, and the oxygenation index (oxygenation index = [FIO2x mean airway pressure x 100]/PaO2) were monitored during the transition to high-frequency oscillatory ventilation and throughout the course of the high-frequency protocol. Thirteen patients demonstrated improved gas exchange and an overall improvement in PaO2/FIO2ratio (p < .02). Reductions in the oxygenation index (p < .01) and FIO2(p < .02) at 12, 24, and 48 hrs after starting high-frequency oscillatory ventilation were observed. No significant compromise in cardiac output or DO2was observed, despite a significant increase in mean airway pressure (31.2 +/- 10.3 to 34.0 +/- 6.7 cm H247 (sensitivity 100%, specificity 100%) were associated with mortality.ConclusionsHigh-frequency oscillatory ventilation is both safe and effective in adult patients with severe ARDS failing conventional ventilation. A lung volume recruitment strategy during high-frequency oscillatory ventilation produced improved gas exchange without a compromise in DO2. These results are encouraging and support the need for a prospective, randomized trial of algorithm-controlled conventional ventilation vs. high-frequency oscillatory ventilation for adults with severe ARDS. (Crit Care Med 1997; 25:937-947)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo compare the detection rate of Pneumocystis carinii in endotracheal aspirates with that rate in bronchoalveolar lavage fluid, using calcofluor-white (Fungi-Fluor[R]) and immunofluorescence antibody (Genetic Systems) staining methods.DesignProspective, consecutive cases.SettingMedical intensive care unit at Ben Taub General Hospital.PatientsThirty-one intubated patients admitted with respiratory failure and suspected P. carinii pneumonia.InterventionsAn endotracheal aspirate specimen was obtained after maximally advancing a closed-system suction catheter, instilling aliquot portions of saline, and suctioning the lavage fluid. This procedure was followed within 30 mins by fiberoptic bronchoscopy and bronchoalveolar lavage.Measurements and Main ResultsEndotracheal aspirate and bronchoalveolar lavage specimens from each patient were mixed with Saccomano's fixative, blended, and centrifuged. Using a modified method for P. carinii cysts, the sediment was stained with the test calcofluor-white stain Solution A and the test antibody stain. The test antibody stain on the bronchoalveolar lavage specimens was positive for P. carinii for 13 patients and was used as the standard for comparison. In the endotracheal aspirate specimens, the test antibody stain detected 12 (92%) P. carinii-positive patients while the test calcofluor-white stain detected ten (77%) P. carinii-positive patients.ConclusionsWe described a simple method for obtaining, processing, and staining endotracheal aspirate specimens for P. carinii. Obtaining an endotracheal aspirate specimen did not require specially trained personnel or a specialized and more expensive catheter, and was not associated with any complications. (Crit Care Med 1997; 25:948-952)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo investigate plasma concentrations of adrenomedullin in patients with septic shock and the potential association of these concentrations with relaxation of vascular tone.DesignProspective, case series.SettingDepartment of Emergency and Critical Care Medicine, Nara Medical University.PatientsTwelve patients who fulfilled the clinical criteria for severe sepsis or septic shock (as defined by the Members of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee) and 13 healthy volunteers.InterventionsArterial blood samples were obtained via a 20-gauge cannula inserted into each patient's radial artery.Measurements and Main ResultsAfter extraction and purification, plasma adrenomedullin was measured by radioimmunoassay. Systemic vascular resistance index, pulmonary vascular resistance, cardiac index, and stroke volume index were determined with a thermodilution catheter.The mean plasma concentration of adrenomedullin was markedly higher in patients than in controls (226.1 +/- 66.4 [SEM] vs. 5.05 +/- 0.21 fmol/mL, p <.01). Moreover, these concentrations correlated significantly with cardiac index, stroke volume index, and heart rate values, and correlated significantly with decreases in diastolic blood pressure, systemic vascular resistance index, and pulmonary vascular resistance index values.ConclusionsEnhanced production of adrenomedullin in patients with septic shock may contribute to reduced vascular tone, hypotension, or both. More data are needed to clarify the role of adrenomedullin in the regulation of vascular tone in this patient population. (Crit Care Med 1997; 25:953-957)

ISSN:0090-3493    

出版商:OVID    

年代:1997

数据来源: OVID