ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectivesTo determine the safety of a ``humanized'' antibody to human anti-tumor necrosis factor-alpha (TNF-alpha) in patients with septic shock, and to examine the pharmacokinetics, immune response, and influence of the antibody on cytokine concentrations in this patient group.DesignProspective, randomized, placebocontrolled, phase II multicenter clinical trial, with escalating doses of a fully humanized anti-TNF-alpha antibody (CDP571).SettingSeven academic intensive care units in Europe.PatientsForty-two patients with rapidly evolving septic shock who received CDP571 in addition to standard supportive care.InterventionsPatients received intravenously either placebo or one of four single doses of CDP571: 0.1, 0.3, 1.0, or 3.0 mg/kg.Measurements and Main ResultsThe humanized anti-TNF-alpha antibody was well tolerated. The overall all-cause 28-day mortality rate was 62%. Mortality rate was similar in the placebo and treatment groups, except that all six patients who received 0.3 mg/kg of CDP571 died within 7 days. This outcome, which was not dose-related, is consistent with the poorer prognostic characteristics of this group at baseline. The peak CDP571 concentrations and area under the curve increased proportionately with the dose. The low level of the immune response detected had little effect on the ability of circulating CDP571 to bind TNF-alpha and on the pharmacokinetics of the antibody. An abrupt reduction in circulating TNF-alpha concentration was observed 30 mins after CDP571 administration at all active dosage levels. While interleukin-1 beta and interleukin-6 plasma concentrations decreased with time in all dosage groups, these cytokine concentrations decreased more rapidly during the initial 24 hrs in the treatment groups than in the placebo group.ConclusionsThe humanized anti-TNF-alpha antibody, CDP571, is well tolerated and able to cause a dose-dependent reduction in circulating TNF-alpha concentrations in patients with septic shock. Further studies are needed to determine the efficacy of this antibody to improve the survival rates of critically ill patients with severe sepsis.(Crit Care Med 1995; 23:1461-1469)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo assess the validity and potential clinical utility of cardiac output monitoring using Doppler echocardiography in patients treated with volume expansion after subarachnoid hemorrhage.DesignObservational study of patients in a randomized, clinical trial.SettingNeurologic intensive care unit.PatientsSimultaneous, blinded measurements of cardiac output by thermodilution and Doppler echocardiography were performed in 48 patients 1 or 2 days after aneurysmal clipping. Follow-up Doppler echocardiography was performed an average of 3.9 days later (range 3 to 6) in 15 patients assigned to normovolemia and 24 patients assigned to hypervolemia.InterventionPatients received supplemental 5% albumin in order to maintain increased (hypervolemia) or normal (normovolemia) cardiac filling pressures.Measurements and Main ResultsThe overall degree of correlation between the two measures was moderate (r equals .67, r2equals .45, p less than .0001). Bias and precision calculations (minus 0.75 plus minus 1.34 L/min) showed a tendency for Doppler echocardiography to underestimate thermodilution, particularly when cardiac output was very high. Although hypervolemia patients received more 5% albumin than normovolemia patients, mean percent change in Doppler echocardiography cardiac output did not differ between the two groups. Multiple regression analysis showed that the percent change in Doppler echocardiography cardiac output correlated strongly with changes in heart rate (p less than .0001), but not with daily net fluid balance or 5% albumin administration.ConclusionsAgreement was poor between Doppler echocardiography and thermodilution measurements of cardiac output, and trends reflected variations in heart rate rather than fluid status. Monitoring of cardiac output by this technique cannot be recommended in patients treated with volume expansion after subarachnoid hemorrhage.(Crit Care Med 1995; 23:1470-1474)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo determine if myocardial ischemia, as detected by continuous electrocardiographic monitoring, is correlated with continued ventilator dependence in patients who have had difficulties weaning from mechanical ventilation.DesignA prospective, observational study.SettingA university, tertiary care hospital.PatientsSeventeen medical and postsurgical patients (age 70 plus minus 9 yrs; range 54 to 84) who had received mechanical ventilation for 5 to 67 days at the time of entry into the study.InterventionsNone.Measurements and Main ResultsPatients wore a calibrated, frequency-modulated, two-channel electrocardiographic recorder with two bipolar chest leads attached to exploring electrodes for 24 hrs. We recorded the following data: a) electrocardiographic evidence of myocardial ischemia; b) eventual separation from mechanical ventilation; c) whether the patient survived to be discharged from the hospital; d) duration of tracheal intubation and mechanical ventilation; and e) length of hospital stay. The key outcome variable tested was successful weaning, which was defined as breathing without mechanical ventilatory assistance on discharge from the hospital. Six (35%) of 17 patients had electrocardiographic evidence of myocardial ischemia at the time of entry into the study. The presence of ischemia was associated with failure to wean from mechanical ventilation (p less than .05; relative risk 3.05).ConclusionsMyocardial ischemia (as detected by a 24-hr, continuous Holter monitor) occurs frequently in ventilator-dependent patients. The occurrence of ischemia was associated with failure to wean from mechanical ventilation in this patient population.(Crit Care Med 1995; 23:1475-1480)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo assess the pulmonary artery (PA) diastolic-occlusion (wedge) pressure gradient in patients with acute pulmonary embolism and to evaluate this variable's diagnostic utility.DesignRetrospective, clinical review.SettingIntensive care and cardiac catheterization units of a university medical center.InterventionsNone.PatientsA series of 19 acute pulmonary embolism patients with concurrent right heart catheterization. Control groups consisted of 19 age-, sex-, and heart rate-matched critically ill controls who also underwent right heart catheterization, eight patients suspected of having pulmonary embolism who had negative pulmonary angiography and concurrent right heart catheterization, and 255 patients with a primary diagnosis of coronary artery disease who underwent right heart catheterization at the time of left heart catheterization.Measurements and Main ResultsInitial hemodynamics (systolic, diastolic, and mean systemic and pulmonary arterial pressures, occlusion pressure, PA diastolic-occlusion pressure gradient, cardiac output, systemic and pulmonary vascular resistances) were compared between cohorts. Other than differences in the PA diastolic-occlusion pressure gradients, no significant differences were identified between cohorts. Pulmonary embolism patients were found to have increased PA diastolic-occlusion pressure gradients (10 plus minus 5 vs. 3 plus minus 2 mm Hg for the critically ill controls [p less than .0002], and 4 plus minus 4 mm Hg for the coronary artery disease cohort [p less than .0005]). However, no significant difference in PA diastolic-occlusion pressure gradient values was identified when patients with proven pulmonary embolism were compared with patients in whom pulmonary embolism was clinically suspected yet not confirmed by angiograms (10 plus minus 9 mm Hg; NS). For three of 19 pulmonary embolism patients, no occlusion pressure could be obtained due to an inability to wedge the balloon tip; 13 of 16 patients had PA diastolic-occlusion pressure gradients of more than equals 8 mm Hg. In the pulmonary embolism cohort, PA diastolic-occlusion pressure gradient correlated well with pulmonary vascular resistance (r2equals .50; p less than .05), but not with cardiac output or heart rate.ConclusionIn the large number of patients with right heart catheters in whom the question of pulmonary embolism is raised, an increased PA diastolic-occlusion pressure gradient (especially more than equals 8 mm Hg) may provide a clue to the diagnosis of pulmonary embolism, but is not specific for this diagnosis.(Crit Care Med 1995; 23:1481-1484)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo assess the mortality rate and complications in a population of surgical patients with severe adult respiratory distress syndrome (ARDS) treated with positive endexpiratory pressure (PEEP) of more than 15 cm H2O in an attempt to reduce intrapulmonary shunt to approximate 0.20 and reduce FIO2to less than 0.50.DesignRetrospective review of patients treated by a standardized ventilatory support protocol at the time of their illness.SettingA 24-bed surgical intensive care unit in a university medical center.PatientsAll patients admitted to the surgical intensive care unit during a 34-month period who met the criteria for severe ARDS (Pao2of less than equals 70 torr [less than equals 9.3 kPa] on an FIO2of more than equals 0.50, diffuse interstitial and/or alveolar infiltrates on chest radiograph, decreased lung compliance, no evidence of congestive heart failure, and a likely predisposing etiology) were evaluated. Patients treated with PEEP of more than 15 cm H2O were selected for this review.InterventionsPatients were treated by a protocol to achieve oxygenation end points, which consisted of maintaining arterial oxyhemoglobin saturation (as determined by pulse oximetry of more than equals 0.92), while reducing FIO2to less than 0.50 and decreasing intrapulmonary shunt fraction to less than equals 0.20 by adding PEEP. With the exception of patients with suspected intracranial hypertension related to closed-head injury, low-rate intermittent mandatory ventilation was the primary mode of ventilation. Pressure-support ventilation was added, when needed, to improve patient comfort, enhance spontaneous tidal volume, or improve CO2excretion.Measurements and Main ResultsEighty-six patients with severe ARDS were treated with a PEEP of more than 15 cm H2O. Nineteen of these patients died early of severe closed-head injury or massive uncontrollable hemorrhage and were excluded from the evaluation. The remaining 67 patients had a mean Lung Injury Score of 3.3 during their treatment with high PEEP. Twenty (30%) of 67 patients died. Eight of the deaths occurred after decrease of ventilatory support and with acceptable blood gases. The other 12 patients who died had continued oxygenation deficits and received increased levels of ventilatory support at the time of death. Twenty-six (39%) of 67 patients had radiographic manifestations of barotrauma (pneumothorax, subcutaneous emphysema, etc.) related to their primary injuries or to complications related to central venous catheter placement. Seven (17%) of 41 patients developed clinical or radiographic signs of barotrauma while receiving high-level PEEP. The hemodynamic effects of increased airway pressure were managed with fluids and inotropic agents, when necessary, and did not limit the application of PEEP to reach the defined end point of treatment.ConclusionsThis subset of patients with severe ARDS treated with high-level PEEP had a mortality rate lower than those rates previously reported by other researchers using more conventional ventilatory support and resuscitation techniques. FIO2may be significantly reduced and PaO2may be maintained at acceptable values by decreasing intrapulmonary shunt fraction using high-level PEEP.(Crit Care Med 1995; 23:1485-1496)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo determine how much information concerning resuscitation and outcome is provided by the end-tidal CO2and derived variables obtained during surgery.DesignRetrospective chart review.SettingEmergency hospital operating room.PatientsOne hundred critically ill or injured patients requiring major surgery and having a mortality rate of 41%.InterventionsStandard intraoperative monitoring, including continuous capnography, plus arterial blood gas analyses every 1 to 1.5 hrs during surgery.Measurements and Main ResultsThere was only a fair correlation between the PaCO2and end-tidal CO2(r2equals .14). The mortality rates in these patients were highest in those patients who had the lowest end-tidal CO2values, the highest arterial to end-tidal CO2differences, and the highest estimated alveolar deadspace fraction. A persistent end-tidal CO2of less than equals 28 torr (less than equals 3.8 kPa) was associated with a mortality rate of 55% (vs. 17% in those patients with a higher end-tidal CO2). The mortality rate was also increased in patients with a persistent arterial to end-tidal CO2difference of more than equals 8 torr (more than equals 1.1 kPa) (58% vs. 23%).ConclusionsEnd-tidal CO2and derived values should be monitored closely in critically ill or injured patients. Efforts should be made--by increasing cardiac output and core temperature and by adjusting ventilation as needed--to maintain the end-tidal CO2at more than equals 29 torr (more than equals 3.9 kPa) and the arterial to end-tidal CO2difference at less than equals 7 torr (less than equals 1.0 kPa).(Crit Care Med 1995; 23:1497-1503)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

ObjectiveTo determine the safety and efficacy of a graduated dosing scheme of phosphorus replacement therapy in patients with hypophosphatemia receiving specialized nutrition support.DesignProspective clinical trial.SettingA 455-bed tertiary care institution, with Level I trauma designation.PatientsSeventy-eight adult patients, followed and co-managed by a multidisciplinary Nutrition Support Service, with a serum phosphorus concentration of less than 3 mg/dL (less than 0.97 mmol/L) and no evidence of renal insufficiency, calcium or parathyroid disorders, or obesity.InterventionsPatients were enrolled into one of three categories based on their serum phosphorus concentration: mild hypophosphatemia (2.3 to 3 mg/dL [0.74 to 0.97 mmol/L]), moderate hypophosphatemia (1.6 to 2.2 mg/dL [0.52 to 0.71 mmol/L]), or severe hypophosphatemia (less than 1.5 mg/dL [less than 0.48 mmol/L]). Each patient received one intravenous phosphorus bolus dose, based on the assigned category of hypophosphatemia, according to a graduated dosing scheme: 0.16 mM/kg (mild), 0.32 mM/kg (moderate), or 0.64 mM/kg (severe). Serum/blood concentrations of phosphorus, calcium, albumin, magnesium, urea nitrogen, and creatinine were measured for three consecutive days.Measurements and Main ResultsSixtyseven patients completed the protocol. There were 31 patients with mild hypophosphatemia, 22 patients with moderate hypophosphatemia, and 14 patients with severe hypophosphatemia. Serum phosphorus concentrations increased significantly (p less than .001) in all groups after the phosphorus bolus: 2.6 plus minus 0.6 to 3.3 plus minus 0.6 mg/dL (0.84 plus minus 0.19 to 1.1 plus minus 0.19 mmol/L) for the mild group; 1.9 plus minus 0.6 to 2.7 plus minus 0.6 mg/dL (0.61 plus minus 0.19 to 0.87 plus minus 0.19 mmol/L) for the moderate group; 1.3 plus minus 0.8 to 2.3 plus minus 0.8 mg/dL (0.42 plus minus 0.26 to 0.74 plus minus 0.26 mmol/L) for the severe group. There were no clinically significant changes in serum/blood calcium, albumin, urea nitrogen, or creatinine concentrations and no adverse reactions to the phosphorus regimens throughout the 3-day study period.ConclusionThe graduated dosing scheme of phosphorus replacement therapy is both safe and efficacious in patients receiving specialized nutrition support.(Crit Care Med 1995; 23:1504-1511)

ISSN:0090-3493    

出版商:OVID    

年代:1995

数据来源: OVID