摘要:

ObjectiveStarling’s equation indicates that reduced oncotic pressure gradients will favor edema formation, and the current consensus definition of acute respiratory distress syndrome (ARDS) excludes only the hydrostatic pressure contribution. We hypothesized that low serum total protein levels might correlate with the likelihood of ARDS in at-risk patients because serum total protein is the chief determinant of oncotic pressure in humans.DesignRegression analysis to compare outcomes in patients with low serum total protein levels with outcomes in patients with normal serum total protein levels with respect to weight change, development of ARDS, and mortality.SettingIntensive care units (ICUs) of seven clinical centers in North America.PatientsA total of 455 ICU patients who met consensus criteria for severe sepsis (178 of whom developed ARDS) from a recently completed prospective clinical trial.InterventionNone.Measurements and Main ResultsWe found that 92% of the patients developing ARDS had low or borderline serum total protein levels (<6 g/dL). Logistic and multiple regression analyses confirmed that of 18 clinical variables, initial serum total protein level and protein change over time were the most statistically significant predictors of weight gain, prolonged mechanical ventilation, ARDS development, and mortality in the study population. This correlation remained significant after adjustment for the other major predictors of outcome present at baseline (ie, Acute Physiology and Chronic Health Evaluation II score).ConclusionsHypoproteinemia is significantly correlated with fluid retention and weight gain, development of ARDS and poor respiratory outcome, and mortality in patients with sepsis. Prospective, randomized trials of serum protein manipulation are needed to establish whether there is a cause-effect relationship to this association.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo martial arguments for listing simplified Advance Directives on the Medicare card.Design and Main ResultsLiterature review shows that 90% of patients do not have advance directives, that patients and doctors are both remiss in discussing end-of-life issues, and that Medicare, insurance companies, and hospitals do little to remedy this lapse.ConclusionA case is made for listing simplified Advance Directives on the Medicare card.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo determine the safety, pharmacokinetics, biological effects, and immunogenicity of recombinant soluble complement receptor 1 (TP10) in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).DesignOpen label, ascending dosage, phase I trial.SettingTwo academic teaching hospitals.PatientsA total of 24 patients diagnosed with ALI/ARDS.InterventionA single, 30-min intravenous infusion of 0.1, 0.3, 1, 3, or 10 mg/kg TP10.Measurements and Main ResultsSerum levels of TP10 increased in proportion to the dose. Mean variable estimates (± sd) were half-life of disposition 69.7 ± 39.7 hrs, plasma clearance 2.39 ± 1.32 mL/hr/kg, and volume of distribution 190.6 ± 135.0 mL/kg. Inhibition of complement activity, measured by CH50, was significant for the interaction of dose and time (p= .024). The C3a levels demonstrated a trend for dose which did not reach statistical significance (p= .090) and soluble C5b-9 levels were significant only for dose (p= .023). As expected by the proposed physiologic mechanism, C4a levels were not affected by TP10, dose, or time. The overall mortality rate was 33%. Neither the type nor the frequency rate of specific adverse events were substantially different between dose groups. Seven adverse events in four patients were thought to be possibly related to TP10.ConclusionsTP10 has a half-life of ∼70 hrs and at doses ≥1 mg/kg, significantly inhibits complement activity at the levels of C3 and C5 in patients with ALI/ARDS. Complement inhibition was more prolonged over time with TP10 doses of 3 and 10 mg/kg. TP10 appears to be safe at the doses tested. Further studies will be required to completely assess the impact of TP10 on pathophysiology and clinical outcome in patients with ALI/ARDS.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectivesTo determine whether the use of recombinant human granulocyte colony-stimulating factor (G-CSF, filgrastim) reduces the mortality rate and the frequency rate of nosocomial infections in neutropenic patients requiring intensive care unit (ICU) admission.DesignRetrospective consecutive case series analysis.SettingMedical ICU of a teaching hospital.PatientsWe compared two groups of patients, according to whether or not they received G-CSF. In the ICU, 28 leukopenic patients received filgrastim (5 &mgr;g of body weight per day intravenously). In all these patients, G-CSF was continued until recovery from leukopenia, defined as a leukocyte count >1000/mm3. A total of 33 ICU leukopenic patients did not receive G-CSF. End points included leukocyte count, bone marrow recovery, frequency of ICU nosocomial infections (pneumonia, urinary tract, and catheter-related infections), and mortality rate.Measurements and Main ResultsThere were no differences in number of patients who recovered from leukopenia or in whom blood leukocyte count increased. Nosocomial infections occurred in the same percentage in both groups. The percentage of patients who died was identical in both groups. The percentage of patients with and without filgrastim therapy who recovered from leukopenia but died, was 86% and 78%, respectively.ConclusionIn the ICU, clinical outcome of neutropenic patients was not changed by G-CSF therapy. It is possible that G-CSF therapy may not be helpful in improving the ICU clinical outcome of neutropenic patients. Additional controlled studies designed to address this question are warranted.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveEsophagogastrectomy is an established surgical treatment for esophageal malignancy. The postoperative period may be complicated by the development of acute lung injury syndromes and thus, may provide a useful model in which to study the early pathogenic mechanisms of inflammatory lung injury.DesignOpen, prospective study.SettingHigh dependency and intensive therapy units.PatientsEight healthy male volunteers and 20 patients in the early postoperative periodInterventionsNone.Measurements and Main ResultsThe lung protein accumulation index (PAI) of radiolabeled transferrin was determined by using a portable, double-isotope system. The following circulating inflammatory markers–thought to reflect neutrophil-endothelial activation and injury including circulating neutrophil elastase–soluble L-, E-, and P-selectins and thrombomodulin and von Willebrand factor antigen were assayed from venous blood samples The PAI for healthy volunteers was median −0.5 (range, −1.73 to 0.27) × 10−3/min and for patients undergoing esophagogastrectomy −0.005 (range, −1.53 to 2.28) × 10−3/min. There was no statistical difference between the two groups. In the postesophagogastrectomy group, a significant elevation in circulating levels of neutrophil elastase, soluble P- and E-selectin, thrombomodulin, and von Willebrand factor antigen were observed relative to the control group but only circulating plasma elastase demonstrated a significant correlation with the PAI (r2= .23,p=.03).ConclusionsThe data suggest patients undergoing esophagogastrectomy develop a inflammatory response but this is not a surrogate of permeability and other factors are likely to determine persistent injury to the alveolar-capillary barrier function in this patient group.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo examine whether surgical stress causes blood cells to lose their responsiveness to endotoxin during surgery.DesignProspective case series.SettingA university hospital.PatientsSixteen volunteers classified as American Society of Anesthesiologists physical status I–II who were scheduled for elective distal partial gastrectomy.InterventionsWe studied nine patients who underwent elective distal partial gastrectomy. Blood samples for tumor necrosis factor (TNF) and interleukin (IL)-10 assay were obtained before anesthesia, preincision, 2 hrs and 4 hrs postincision, postextubation, and 24 hrs postincision. The rest of each blood sample was diluted with 5 volumes of endotoxin-free saline, incubated for 4 hrs in the presence of lipopolysaccharide (LPS), centrifuged to remove cells, and assayed for TNF. In another seven patients, antihuman IL-10 antibody was added into the diluted whole blood sample before LPS stimulation.Measurements and Main ResultsTNF activity was not detected in the blood of any patient throughout the study. In contrast, plasma cortisol and IL-10 levels increased rapidly during surgery (p< .01,p< .05, respectively). LPS-induced TNF activity in whole blood decreased significantly during surgery (p< .01) and recovered to control levels by 24 hrs postincision. The peak suppression of LPS-induced TNF and the peak value of plasma IL-10 levels occurred postextubation. Treatment with anti-IL-10 antibody partially restored the ability of LPS to induce TNF activity postextubation (p< .05).ConclusionsSurgical trauma rapidly induces a transient hyporesponsiveness of blood cells to endotoxin. Plasma IL-10, which increases during surgery, participates in this hyporesponsiveness.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo determine the value of procalcitonin (PCT) as a marker of postoperative infection after cardiac surgery.DesignA prospective single institution three phase study.SettingUniversity cardiac surgical intensive care unit (31 beds).PatientsPhase 1: To determine the normal perioperative kinetics of PCT, 20 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass were included. Phase 2: To determine whether PCT may be useful for diagnosis of postoperative infection, 97 consecutive patients with suspected infection were included. Phase 3: To determine the ability of PCT to differentiate patients with septic shock from those with cardiogenic shock, 26 patients with postoperative circulatory failure were compared.Measurements and Main ResultsPhase 1: Serum samples were drawn for PCT determination after induction of anesthesia (baseline), at the end of surgery, and daily until postoperative day (POD) 8. Baseline serum PCT concentration was 0.17 ± 0.08 ng/mL (mean ± sd). Serum PCT increased after cardiac surgery with a peak on POD 1 (1.08 ± 1.36). Serum PCT returned to normal range on POD 3 and remained stable thereafter. Phase 2: In patients with suspected infection, serum PCT was measured at the same time of C-reactive protein (CRP) and bacteriologic samples. Among the 97 included patients, 54 were infected with pneumonia (n = 17), bacteremia (n = 16), mediastinitis (n = 9), or septic shock (n = 12). In the 43 remaining patients, infection was excluded by microbiological examinations. In noninfected patients, serum PCT concentration was 0.41 ± 0.36 ng/mL (range, 0.08–1.67 ng/mL). Serum PCT concentration was markedly higher in patients with septic shock (96.98 ± 119.61 ng/mL). Moderate increase in serum PCT concentration occurred during pneumonia (4.85 ± 3.31 ng/mL) and bacteremia (3.57 ± 2.98 ng/mL). Serum PCT concentration remained low during mediastinitis (0.80 ± 0.58 ng/mL). Five patients with mediastinitis, two patients with bacteremia, and one patient with pneumonia had serum PCT concentrations of <1 ng/mL. These eight patients were administered antibiotics previously and serum PCT was measured during a therapeutic antibiotic window. For prediction of infection by PCT, the best cutoff value was 1 ng/mL, with sensitivity 85%, specificity 95%, positive predictive value 96%, and negative predictive value 84%. Serum CRP was high in all patients without intergroup difference. For prediction of infection by CRP, a value of 50 mg/L was sensitive (84%) but poorly specific (40%). Comparing the area under the receiver operating characteristic curves, PCT was better than CRP for diagnosis of postoperative sepsis (0.82 for PCT vs. 0.68 for CRP). Phase 3: Serum PCT concentration was significantly higher in patients with septic shock than in those with cardiogenic shock (96.98 ± 119.61 ng/mL vs. 11.30 ± 12.3 ng/mL). For discrimination between septic and cardiogenic shock, the best cutoff value was 10 ng/mL, with sensitivity of 100% and specificity of 62%.ConclusionCardiac surgery with cardiopulmonary bypass influences serum PCT concentration with a peak on POD 1. In the presence of fever, PCT is a reliable marker for diagnosis of infection after cardiac surgery, except in patients who previously received antibiotics. PCT was more relevant than CRP for diagnosis of postoperative infection. During a postoperative circulatory failure, a serum PCT concentration >10 ng/mL is highly indicative of a septic shock.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo determine whether the bronchodilator effects of albuterol and ipratropium bromide are greater if updraft nebulization is driven by 80% helium and 20% oxygen (HELIOX) than if driven by compressed room air (AIR) during the treatment of an acute exacerbations of chronic obstructive pulmonary disease (COPD).SettingThe emergency department of a 750-bed inner-city community hospital.MethodsOver a 12-month period, a convenience sample of 50 normoxic patients presenting with signs and symptoms of an acute exacerbation of COPD were prospectively randomized to receive either HELIOX or AIR as the driving gas for updraft nebulization of a mixture of albuterol 2.5 mg and ipratropium bromide 0.5 mg. Additional aerosol treatments with albuterol 2.5 mg were given at 20, 40, and 120 mins after randomization using the assigned gas. Spirometry was obtained while breathing room air before the first treatment (baseline) and at 1 hr and 2 hrs after the initiation of treatment. The primary measure of efficacy was the change in percent of predicted forced expiratory volume in 1 sec (Fev1) over the treatment period. A secondary measure of efficacy was the change in percentage of predicted forced expiratory flow after 25% to 75% of vital capacity had been expelled (Fef25–75).ResultsTwenty-five patients were randomized to each treatment group. Three patients (1 HELIOX, 2 AIR) were unable to complete the study. The baseline Fev1was 44% (95% confidence interval, 35% to 52%) of predicted in the HELIOX group and 39 (31% to 46%) of predicted in the AIR group. There were no adverse outcomes observed in either the HELIOX group or the AIR group. There were no significant differences in the change of Fev1between the two groups by either the 1 hr or 2 hr time point (1 hr, HELIOX + 10% [7% to 13%], AIR + 9% [5% to 13%]; 2 hr HELIOX + 10% [6% to 15%], AIR + 10% [6% to 14%]). The improvement in Fef25–75was significantly greater in the HELIOX group than in the AIR group at both the 1 hr time point (HELIOX + 14% [7% to 22%] vs. AIR + 7% [3% to 10%],p= .05) and at the 2 hr time point (HELIOX + 15% [8% to 21%] vs. AIR + 7% [4% to 11%],p= .05).ConclusionUse of HELIOX as a driving gas for the updraft nebulization of bronchodilators during the first 2 hrs of treatment of an acute COPD exacerbation failed to improve Fev1faster than the use of AIR. The faster improvement in Fef25–75during the first 2 hrs of treatment was small and of uncertain clinical significance.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo evaluate a method of measuring venous blood flowin vitroby using the Fick principle and change in saturation of venous blood and to apply the method to the clinical measurement of hepatic blood flow.DesignExperimental study using anin vitromodel and clinical study for critically ill patients.SettingDepartment of Anesthesiology and Intensive Care Medicine in Osaka City University Medical School.ModelHuman blood deoxygenated by bubbling of nitrogen was circulated in a closed circuit at 10–120 mL/min by a roller pump. A fiber optic sensor was attached to the circuit for continuous monitoring of hemoglobin saturation.PatientsEight critically ill patients, aged 54.3 ± 15.1 yrs, were studied.InterventionsHemoglobin saturation was changed in thein vitrostudy by the injection of 0.2 mL of oxygenated blood. Signals from the optical fiber were analogue-digital converted and recorded in a computer. In the clinical study, an oximetry catheter was inserted into the inferior vena cava (IVC) via the femoral vein. Arterial blood (10 mL) was drawn from the radial artery, and injected into the IVC. The changes in oxygen saturation in the venous blood were recorded.Measurements and Main ResultsBlood flow was calculated using the Fick principle, assuming that all the injected blood passes through the sensor.In vitroestimation of blood flow was well correlated with the actual flow (r2= .94). IVC blood flow was measured above and below the merging point of the hepatic vein. The difference of the two values was assumed to represent hepatic blood flow. IVC blood flow was calculated by the same method as for thein vitrostudy. The blood flows in the IVC above and below the anastomosis with the hepatic vein were 2.82 ± 0.56 (sd) L/min and 1.96 ± 0.61 (sd) L/min. Average estimated hepatic blood flow was 0.86 L/min (range, 0.34–1.75 L/min).ConclusionWe examined the accuracy and reliability of this new method in the presentin vitrostudy. This method may be clinically useful for measuring hepatic blood flow.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID