摘要:

ObjectiveTreatment of preterm infants with respiratory distress syndrome (RDS) with exogenous surfactant has greatly improved clinical outcome. Some infants require multiple doses, and it has not been studied whether these large amounts of exogenous surfactant disturb endogenous surfactant metabolism in humans. We studied endogenous surfactant metabolism in relation to different amounts of exogenous surfactant, administered as rescue therapy for RDS.DesignProspective clinical study.SettingNeonatal intensive care unit in a university hospital.PatientsA total of 27 preterm infants intubated and mechanically ventilated for respiratory insufficiency.InterventionsInfants received a 24-hr infusion with the stable isotope [U-13C]glucose starting 5.3 ± 0.5 hrs after birth. The13C-incorporation into palmitic acid in surfactant phosphatidylcholine (PC) isolated from serial tracheal aspirates was measured. Infants received either zero (n = 5), one (n = 4), two (n = 15), or three (n = 3) doses of Survanta (100 mg/kg) when clinically indicated.Measurements and Main ResultsUsing multiple regression analysis, the absolute synthesis rate (ASR) of surfactant PC from plasma glucose increased with 1.3 ± 0.4 mg/kg/day per dose of Survanta (p= .007) (mean ± sem). The ASR of surfactant PC from glucose was increased by prenatal corticosteroid treatment with 1.3 ± 0.4 mg/kg/day per dose corticosteroid (p= .004), and by the presence of a patent ductus arteriosus with 2.1 ± 0.7 mg/kg/day (p= .01).ConclusionThese data are reassuring and show for the first time in preterm infants that multiple doses of exogenous surfactant for RDS are tolerated well by the developing lung and stimulate endogenous surfactant synthesis.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo examine the outcome, functional autonomy, and quality of life of elderly patients (≥70 yrs old) hospitalized for >30 days in an intensive care unit (ICU).DesignProspective cohort study.SettingA ten-bed, medical-surgical ICU in a 460-bed, acute care, tertiary, university hospital.PatientsA consecutive cohort of 75 patients, >70 yrs old, admitted to the ICU from January 1, 1993, to August 1, 1998, for >30 days.InterventionsNone.Measurements and Main ResultsSeverity at admission and of the underlying disease was estimated according to the Simplified Acute Physiologic Score (SAPS II), the Organ Dysfunction and/or Infection (ODIN) score, the McCabe score, and the Knaus classification. Therapeutic intensity was measured through the French Omega scoring system. All patients were mechanically ventilated during their ICU stay. Outcome measurements were made by two cross-sectional studies using telephone interviews on the first week of September 1996 and 1998 with a questionnaire including measures of functional capacity by Katz’s Activities of Daily Living, modified Patrick’s Perceived Quality of Life score, and the Nottingham Health Profile. The survival rate was 67% in the ICU and 47% in the hospital. A total of 30 patients were alive and able to participate in at least one of the cross-sectional studies. Independence in activities of daily living was decreased significantly after the ICU stay, except for feeding. However, most of the 30 patients remained independent (class A of the Activities of Daily Living index) with the possibility of going home. Perceived Quality of Life scores remained good, even if the patients estimated a decrease in their quality of life for health and memory. Return to society appeared promising regarding patient self respect and happiness with life. The estimated cost by survivor was of 55,272 EUR ($60,246 US).ConclusionsThis study suggests that persistent high levels of ICU therapeutic intensity were associated with a reasonable hospital survival in elderly patients experiencing prolonged mechanical ventilatory support. These patients presented a moderate disability that influenced somewhat their perceived quality of life. These results are sufficient to justify prolonged ICU stays for elderly patients.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo evaluate the effects of maximizing the oxygen delivery on morbidity and mortality in patients >60 yrs of age and/or with chronic diseases of vital organs who underwent major elective surgery.DesignProspective, randomized, controlled trial.SettingA 24-bed general intensive care unit of a teaching hospital.PatientsThirty-seven high-risk patients who underwent major surgery.InterventionsThe hemodynamic and oxygen transport variables and outcomes in 18 patients (control group) treated to maintain normal values of oxygen delivery were compared with 19 patients (protocol group) treated to maintain “supranormal” values. Therapy in both groups consisted of volume expansion and, when necessary, dobutamine to reach target values, during the surgery and 24 hrs postoperatively.Measurements and Main ResultsWe interrupted the study because of a significant difference in the 60-day mortality rate. The mortality rate in the control group was significantly higher when compared with the protocol group (9/18 [50%] vs. 3/19 [15.7%],p< .05). The prevalence of clinical and infectious complications was higher in the control group than in the protocol group (67% and 31% respectively; relative risk, 0.47; 95% confidence interval, 0.226–0.991;p< .05) and there was a trend toward more severe organ dysfunction in nonachievers patients (17/24 [71%] vs. 6/13 [46%], relative risk, 0.65; 95% confidence interval, 0.343–1.237; NS).ConclusionOlder patients with existing cardiorespiratory illness undergoing major surgery have a reduced morbidity and mortality when dobutamine is used to maximize oxygen transport.

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:

ObjectiveWe examined the pattern of organ system dysfunction, the evolution of this pattern over time, and the relationship of these features to mortality in patients who had sepsis syndrome.DesignProspective, multicenter, observational study.SettingIntensive care units in tertiary referral teaching hospitals.PatientsA total of 287 patients who had sepsis syndrome were prospectively identified in intensive care units.Materials and MeasurementsCardiovascular, pulmonary, neurologic, coagulation, renal, and hepatic dysfunction were assessed at onset and on day 3 of sepsis syndrome. Organ dysfunction was classified as normal, mild, moderate, severe, and extreme dysfunction. We calculated the occurrence rate and associated 30-day mortality rate of organ dysfunction at the onset of sepsis syndrome. We then measured the change in organ dysfunction from onset to day 3 of sepsis syndrome and determined, for individual organ systems, the associated 30-day mortality rate.ResultsAt the onset of sepsis syndrome, clinically significant pulmonary dysfunction was the most common organ failure, but was not related to 30-day mortality. Clinically significant cardiovascular, neurologic, coagulation, renal, and hepatic dysfunction were less common at the onset of sepsis syndrome but were significantly associated with the 30-day mortality rate. Worsening neurologic, coagulation, and renal dysfunction from onset to day 3 of sepsis syndrome were associated with significantly higher 30-day mortality than with improvement or no change in organ dysfunction.ConclusionsIncreased mortality rate in sepsis syndrome is associated with a pattern characterized by failure of nonpulmonary organ systems and, in particular, worsening neurologic, coagulation, and renal dysfunction over the first 3 days. Although initial pulmonary dysfunction is common in patients with sepsis syndrome, it is not associated with an increased mortality rate.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo study the pharmacokinetics of meropenem in critically ill patients with acute renal failure receiving continuous venovenous hemofiltration (CVVHF).DesignProspective, open-labeled study.SettingMedical intensive care unit of the University Medical Center Utrecht.PatientsFive critically ill patients receiving CVVHF for acute renal failure treated with meropenem for documented or suspected bacterial infection.InterventionAll patients received meropenem (500 mg) administered intravenously every 12 hrs. Plasma samples and ultrafiltrate aliquots were collected during one dosing interval.Measurements and ResultsMean age and body weight of the patients studied were 46.6 yrs (range, 28–61 yrs) and 85.8 kg (range, 70–100 kg), respectively. The following pharmacokinetic variables for meropenem were obtained: mean peak plasma concentration was 24.5 ± 7.2 mg/L, mean trough plasma concentration was 3.0 ± 0.9 mg/L, mean terminal elimination half-life was 6.37 ± 1.96 hrs, mean total plasma clearance was 4.57 ± 0.89 L/hr, mean CVVHF clearance was 1.03 ± 0.42 L/hr, mean nonrenal clearance was 3.54 ± 1.06 L/hr, and mean volume of distribution was 0.37 ± 0.15 L/kg.ConclusionIn critically ill patients with acute renal failure, nonrenal clearance became the main elimination route. CVVHF substantially contributed to the clearance of meropenem (23% of mean total plasma clearance). We recommend meropenem to be dosed at 500 mg intravenously every 12 hrs in patients receiving CVVHF, according to our operational characteristics. This dosing regimen resulted in adequate trough plasma levels for susceptible microorganisms.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that dopexamine reduces postoperative mortality and morbidity in high-risk, major abdominal surgery patients, when given to fluid-resuscitated patients starting before the operation and continued for 24 hrs after surgery.DesignProspective, randomized, controlled, double-blind multicenter trial.SettingIntensive care units in 13 hospitals from six European countries.PatientsA total of 412 patients with predefined high-risk criteria, undergoing major abdominal surgery with an expected duration of at least 1.5 hrs.InterventionsThe patients received placebo (n = 140), dopexamine at 0.5 &mgr;g/kg/min (n = 135), or dopexamine at 2.0 &mgr;g/kg/min (n = 137) starting after preoperative hemodynamic stabilization and continued for 24 hrs after surgery.Measurements and Main ResultsThe primary outcome variable was mortality at 28 days. Analysis was by intention to treat. Dopexamine had no effect on mortality (at 28 days, 13%, 7%, and 15%, for the groups receiving placebo, dopexamine at 0.5 &mgr;g/kg/min, and dopexamine at 2.0 &mgr;g/kg/min, respectively), despite the expected dose-dependent hemodynamic responses. No effect was observed on the occurrence of organ dysfunction, duration of intensive care unit stay, or length of hospital stay.ConclusionWe conclude that dopexamine in doses that result in increased cardiac output and oxygen delivery after preoperative stabilization with fluids does not improve outcome after major abdominal surgery compared with fluids alone. Based onpost hocsubgroup analysis and stratification according to the number of risk factors, we suggest that the concept should be further tested in patients at higher risk of complications or undergoing emergency surgery.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo evaluate the impact of case mix variation on the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II using measures of calibration and discrimination.DesignAPACHE II data were collected prospectively at the surgical intensive care unit of the University of Vermont on all adult admissions over an 8-yr period (excluding cardiac surgical patients, burn patients, and patients <16 yrs of age). The original case mix was systematically varied to create 2,000 different case mixes ranging in mortality between 5% and 18% using a computer-intensive resampling algorithm. The area under the receiver operating characteristic curve and the Hosmer-Lemeshow C statistic were derived for each of the simulated case mixes with bootstrapping.SettingThe surgical intensive care unit at a 450-bed teaching hospital.PatientsA group of 6,806 adult surgical patients excluding cardiac surgical patients and burn patients.Measurements and ResultsSimulated data sets were created from a database of patients treated at a single institution to test the hypothesis that the performance of APACHE II is stable across a clinically reasonable range of mortality rates. The discrimination and calibration of APACHE II varied with case mix.ConclusionThe discrimination of APACHE II is not independent of case mix. However, the variability of the Hosmer-Lemeshow statistic as a function of the case mix may simply reflect the limitations of this goodness of fit statistic to assess model calibration. Because the discrimination of APACHE II is a function of case mix, caution should be exercised when using APACHE II-based adjusted mortality rates to compare intensive care units with widely divergent case mixes.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveTo investigate whether inhaled nitric oxide (NO) enhances pulmonary lipid peroxidation as indicated by arterial blood levels of malondialdehyde, hexanal, and pentanal in patients with acute respiratory distress syndrome (ARDS).DesignProspective, nonrandomized, controlled trial.SettingSurgical intensive care unit in a university hospital.PatientsTwenty-five patients with ARDS, as defined by the American-European Consensus Conference, and a Pao2/Fio2≤170 mm Hg were enrolled in the study. Four healthy subjects were studied as controls.InterventionsOn enrollment of the patients in the study, a dose-response test with increasing concentrations of inhaled NO (0, 2, 10, 40, 0 ppm) was performed. Patients who showed an increase of >20% in Pao2were designated as responders and all others as nonresponders. In responders, this dose-response test was followed by 24 hrs of continuous treatment with inhaled NO at the best NO concentration determined during the dose-response test, whereas nonresponders received standard care. For healthy volunteers, the dose-response test took the form of spontaneous breathing of the same NO concentrations.Measurements and Main ResultsEighteen patients (72%) showed an increase of >20% in Pao2during the dose-response test. This significant improvement in arterial oxygenation in responders led to a significant reduction in Fio2(responders, 0.73 ± 0.05 vs. nonresponders, 0.89 ± 0.05) after 24 hrs of therapy. On enrollment, arterial blood concentrations of malondialdehyde, hexanal, and pentanal were significantly higher than those of healthy volunteers. In addition, arterial concentrations of hexanal and pentanal exceeded mixed venous levels two- to ten-fold. Inhalation of NO did not significantly alter these blood concentrations either during the dose response test or during 24 hrs of therapy.ConclusionsIn patients with ARDS, malondialdehyde, hexanal, and pentanal were significantly elevated, indicating lipid peroxidation. Lipid peroxidation was not further affected by inhalation of NO.

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