摘要:

ObjectiveTo investigate the feasibility and predictive value of sublingual PCO2(PSLCO2) measurements as a noninvasive and early indicator of systemic perfusion failure.DesignA prospective, criterion study.SettingEmergency department and medical and surgical intensive care units of an urban community medical center.Participants and PatientsFive normal human volunteers and 46 patients with acutely life-threatening illness or injuries.InterventionsIntra-arterial or automated cuff blood pressure and arterial blood lactate (LAC) were measured concurrently with PSLCO2.ResultsPSLCO22.5 mmol/L had a PSLCO2of 81 +/- 24 mm Hg. This contrasted with patients admitted without clinical signs of shock and LAC of <2.5 mmol/L who had a PSLCO2of 53 +/- 8 mm Hg (p < .001). The initial PSLCO2of 12 patients who died before recovery from shock was 93 +/- 27 mm Hg, and this contrasted with 58 +/- 11 mm Hg (p < .001) in hospital survivors. Increases in PSLCO2were correlated with increases in LAC (r2= .84; p < .001). When PSLCO (2) exceeded a threshold of 70 mm Hg, its positive predictive value for the presence of physical signs of circulatory shock was 1.00. When it was <70 mm Hg, it predicted survival with a predictive value of 0.93.ConclusionPSLCO2may serve as a technically simple and noninvasive clinical measurement for the diagnosis and estimation of the severity of circulatory shock states. (Crit Care Med 1999; 27:1225-1229)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectivesThe purpose of this study was to determine whether apoptosis is a major mechanism of cell death in patients with sepsis. The activities of caspase-3 and the antiapoptotic protein, BCL-2, were investigated also.DesignA prospective study of 20 patients who died of sepsis and multiple organ dysfunction was performed. The control group of 16 patients consisted of critically ill, nonseptic patients who were evaluated either prospectively[7]or retrospectively[9]. In addition, normal colon sections from seven patients who had bowel resections were included. Apoptosis was evaluated in hematoxylin and eosin-stained specimens by deoxyuridine triphosphate nick end-labeling (TUNEL) and by DNA gel electrophoresis.SettingTwo academic medical centers.PatientsCritically ill patients.Measurements and Main Results25% to 50% of cells being positive focally in the splenic white pulp of six septic but in no nonseptic patients.ConclusionsWe conclude that caspase-3-mediated apoptosis causes extensive lymphocyte apoptosis in sepsis and may contribute to the impaired immune response that characterizes the disorder. (Crit Care Med 1999; 27:1230-1251)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo evaluate those factors that impact on the delivery of enteral tube feeding.DesignProspective study.SettingMedical intensive care units (ICU) and coronary care units at two university-based hospitals.PatientsForty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding.InterventionsRate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented.Measurements and Main Resultsor=to90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes.ConclusionsThe current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings. (Crit Care Med 1999; 27:1252-1256)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo compare two dosing regimens of acetazolamide for the reversal of metabolic alkalosis in mechanically ventilated patients with asthma or chronic obstructive pulmonary disease.DesignA randomized, double-blind, placebo-controlled trial.SettingA 35-bed medical intensive care unit in a tertiary care teaching hospital.Patientsor=to4 mEq/L) not receiving acetazolamide or sodium bicarbonate in the previous 72 hrs.InterventionsStratified by previous diuretic use and randomized to receive intravenous administration of acetazolamide, one dose of 500 mg or 250 mg every 6 hrs for a total of four doses.Measurements and Main ResultsSerum bicarbonate and potassium concentrations were drawn every 6 hrs for 72 hrs, arterial blood gases were drawn every 12 hrs for 72 hrs, and both urine chloride and pH were drawn at hours 0, 6, 12, 18, 24, 48, and 72. By using generalized estimating Equation techniques, no difference was found between the two dosing regimens at any point over the study period for serum bicarbonate, serum potassium, or urine chloride end points. Results did not differ between diuretic- and nondiuretic-treated patients. Serum bicarbonate concentrations remained significantly decreased in both treatment groups 72 hrs after administration of the first acetazolamide dose (31.8 +/- 4.9-25.3 +/- 3.8 mEq/L, p < .0001 [250 mg x 4]; 31.9 +/- 25.4-25.4 +/- 3.6 mEq/L, p < .0001 [500 mg x 1]).ConclusionsWe conclude that a single 500-mg dose of acetazolamide reverses nonchloride responsive metabolic alkaloses in medical intensive care unit patients as effectively as multiple doses of 250 mg. Studies to examine the prolonged duration of action of acetazolamide observed in this study as well as the effect of acetazolamide on clinical end points, such as duration of mechanical ventilation, are warranted. (Crit Care Med 1999; 27:1257-1261)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo examine whether changes in interleukin (IL)-6 and IL-10 concentrations in patients with systemic inflammatory response syndrome (SIRS) can predict a poor outcome.DesignProspective study.SettingEmergency and intensive care unit of a medical school hospital.PatientsTwenty-five patients who fulfilled the criteria for SIRS.InterventionsBlood samples were collected for cytokine determinations.Measurements and Main ResultsIL-6 and IL-10 concentrations were measured by enzyme-linked immunosorbent assay in plasma samples. Blood samples were obtained at 0, 1, 2, and 4 days from patients who fulfilled the criteria for SIRS. Of 25 patients, 19 survived and the other six patients died of multiple organ failure. Although IL-6 and IL-10 concentrations in survivors decreased gradually from 186.1 +/- 34.4 to 93.6 +/- 18.9 (SEM) pg/mL (p < .05) and from 77.4 +/- 21.2 to 32.0 +/- 11.8 pg/mL (p < .05), IL-6 concentrations in nonsurvivors did not. Although the ratio of IL-6 to IL-10 in survivors was almost stable, the ratio in nonsurvivors increased from 5.5 +/- 3.1 to 18.7 +/- 2.8 (p < .05). Multivariate analysis showed that when heart rate, mean arterial pressure, IL-6, IL-10, and the ratio of IL-6 to IL-10 were taken into account, there only remained a relationship between the ratio of IL-6 to IL-10 and outcome.ConclusionsIn nonsurvivors, IL-6 concentrations did not decrease, IL-10 concentration decreased, and the ratio of IL-6 to IL-10 increased. An increase in the ratio of IL-6 to IL-10 indicated a correlation with a poor outcome. (Crit Care Med 1999; 27:1262-1264)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine whether the genotype and allelic frequencies of two human leukocyte antigen-linked bi-allelic 70-kilodalton heat shock protein (HSP70) gene polymorphisms are associated with susceptibility to and outcome of severe sepsis. Furthermore, we investigated a possible linkage between HSP70 gene polymorphisms and the previously reported and mortality-related tumor necrosis factor-beta (TNF-beta) NcoI gene polymorphism.DesignConsecutive entry study of patients with severe sepsis.SettingSurgical intensive care unit in a university hospital.PatientsEighty-seven patients with a diagnosis of severe sepsis.InterventionsNone.Measurements and Main Results.05). Analysis of a possible linkage between HSP70 and TNF-beta genotypes resulted in a significant association (odds ratio, 4.15; p < .01) of the HSP70-2 A/A homozygous genotype and the TNFB2/B2 homozygous genotype, which is reported to be a genomic marker for a poor prognosis in severe sepsis.ConclusionsOur data show that the bi-allelic NcoI and PstI polymorphisms within the HSP70-HOM and HSP70-2 locus, respectively, are associated with neither susceptibility to nor outcome of severe sepsis. Moreover, we found a linkage between HSP70-2 A homozygotes and the previously reported and mortality-related homozygous genotype, TNFB2/B2, in patients suffering from severe sepsis. (Crit Care Med 1999; 27:1265-1270)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo establish the validity and reliability of a new sedation scale, the Motor Activity Assessment Scale (MAAS).DesignProspective, psychometric evaluation.SettingSixteen-bed surgical intensive care unit (SICU) of a 937-bed tertiary care, university-affiliated teaching hospital.Patientsor=to12 hrs after surgery and were not receiving neuromuscular blockers.InterventionFour hundred assessments (eight per patient) were completed consecutively but independently, in pairs, at standardized times (both day and night) by two nurses who were preselected for each assessment from a pool of 32 pretrained SICU nurses.Measurements and Main ResultsTo estimate validity, paired assessments (four/patient) compared the MAAS result with the subjective assessment using a 10-cm visual analog sedation scale, the percent change in blood pressure and heart rate from the previous 4-hr baselines, and the number of recent agitation-related sequelae. To estimate reliability, paired assessments (four/patient) measured correlation between assessments of the same type (e.g., MAAS-MAAS). Generalized estimating equations, which accounted for the four repeated measures in each patient, supported MAAS validity by finding a linear trend between MAAS and the visual analog scale (p < .001), blood pressure (p < .001), heart rate (p < .001), and agitation-related sequelae (p < .001) end points. The MAAS (kappa = 0.83 [95% confidence interval, 0.72 to 0.94]) was found to be more reliable than subjective assessment using the visual analog scale (intraclass correlation coefficient = 0.32 [95% confidence interval, 0.05 to 0.55]).ConclusionsThe MAAS is a valid and reliable sedation scale for use with mechanically ventilated patients in the SICU. Further studies are warranted regarding the effect of MAAS implementation in our SICU on patient outcomes, such as quality of sedation and length of mechanical ventilation, as well as the use of the MAAS in other patient populations (e.g., medical). (Crit Care Med 1999; 27:1271-1275)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveThe pathogenesis of acute gastric stress ulceration in the seriously ill is uncertain, and any role of Helicobacter pylori infection is unknown. We aimed to assess the relationship between H. pylori serological status and stress ulceration in seriously ill patients, as well as H. pylori serological status in intensive care nurses as a marker for nosocomial infection.DesignProspective epidemiologic survey.SettingAdult intensive care unit in a university teaching hospital.PatientsOne hundred patients, 100 nurses, and 500 blood donors as community controls.InterventionsH. pylori serological status was measured in patients, staff, and controls using a rapid whole blood test. Upper gastrointestinal bleeding and risk factors for acute stress ulceration were recorded.Measurements and Main ResultsIn seriously ill patients, H. pylori seropositivity (67%) was significantly higher than in the control group (39%) (p < .001). In patients, seropositivity was not related to age, country of birth, diagnostic category, severity of illness, or risk score for stress ulceration. There was a trend toward increased macroscopic gastric bleeding in seropositive patients. In intensive care nurses, H. pylori seropositivity (40%) was significantly higher than in age-matched controls (19%) (p < .001). Only duration of intensive care nursing was significantly associated with seropositivity (p = .02).ConclusionsThe unexpectedly high H. pylori seropositivity rate in this seriously ill cohort raises the possibility that under intensive care conditions, H. pylori infection may modulate responses to illness and injury, with consequent clinical implications. Furthermore, the elevated seropositivity rate in intensive care nurses suggests that H. pylori can be nosocomially transmitted. (Crit Care Med 1999; 27:1276-1280)

ISSN:0090-3493    

出版商:OVID    

年代:1999

数据来源: OVID