摘要:

Two clinicians and the nursing sisters working in the ICU evaluated the chance of survival of ICU patients every day. Patients were assessed either as “outcome unknown or will die.” These predictions were compared with those made by computerized trend analysis of daily acute physiology and chronic health evaluation (APACHE II) scores corrected for the presence and duration of major organ system failure. The predictions were not acted upon during the study. Comparing the predictions with actual hospital outcome, the doctors and nurses had a false-positive diagnosis rate for dying of between 7.7% and 16.7%, while there were no false predictions by the computer model. The patients predicted to die by the doctors and nurses were not completely identical to those predicted by the computer. Predictions of doctors and nurses that were confirmed by the computer had a sensitivity of 20% and no false predictions of death.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The responses to therapy of 29 patients in septic shock are described. Patients received controlled plasma volume expansion followed by infusions of norepinephrine, dobutamine, and dopamine to achieve appropriate therapeutic goals. Increases in oxygen delivery (DO2) from 605 ± 40 (SEM) to 843 ± 27 ml/min ± m2(p< .001) were associated with increases in oxygen consumption (DO2) from 130 ± 6.8 to 169 ± 6.2 ml/min-m2(p< .001). The overall hospital survival rate was 52%. We suggest that the rational use of adrenergic agents and the achievement of appropriate physiologic end-points for therapy not only result in the reversal of hypotension, but also maintain or increase DO2and DO2, and may improve survival.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Effects of iv norepinephrine (NE) on renal function were investigated retrospectively in 15 patients with hyperdynamic septic shock. All patients had either a low systolic BP < 80 mm Hg, and/or oliguira < 0.5 ml/kg·h. We examined their serum creatinine level (SCr), daily urine flow (UF), 24-h creatinine clearance (Ccr), and hemodynamic indices before and during NE infusion. Before NE administration, the patients were divided into those with with a serum lactate level (Lac) < 20 mg/dl (group A, n = 9) and <20 mg/dl (group B, n = 6). NE was infused continuously at rates between 0.05 and 0.24 μg/kg·min which increased systolic BP by <20 mm Hg. Cardiac index was not significantly changed in either group. In group A, NE increased both UF (p< .05), and systemic vascular resistance index (SVRI) (p< .01), but did not affect Ccr. In group B, NE did not increase UF nor SVRI, and decreased Ccr significantly (p< .05). It is concluded that NE increased UF and SVRI only when Lac was in the normal range; otherwise, NE reduced renal function. Thus, when administering NE to increase UF, both Lac and renal function should be monitored carefully.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Continuous positive airway pressure (CPAP) breathing can be delivered using the demand-flow (DF) or continuous-flow (CF) system. A modified CF system, the flow-by (FB) system, operates with preset base-flow (BF) values between 5 and 20 L/min. The DF depends on changes in pressure for opening the pneumatic valve of the system (pressure sensitivity). In contrast, the FB depends on changes in flow (flow sensitivity). In six healthy male subjects, we determined the mechanical inspiratory work of breathing (WI, J/L) and the inspiratory work rate (J/min) on the DF and the FB systems at a BF of 5 and 20 L/min, at CPAP levels of 0, 5, and 10 cm H2O. In comparison to DF, on the FB system both WI and inspiratory work rate were significantly less at a CPAP of 10 cm H2O (p< .01). This was most likely due to the smaller drop in airway pressure at the onset of inspiration with the FB system. Varying the BF values in the FB system had no effect on WI or inspiratory work rate.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The aim of this study was to assess prospectively the variations of serum phosphorus concentration (P) after onset of mechanical ventilation (MV) in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory acidosis. In 14 COPD patients, we measured P, PaCO2, and pH, immediately before MV (H0), then one hour (H1), 4 (H4), 7 (H7), 12 (H12), and 24 h (H24) after starting MV. P at H0was in or above the normal range in ten patients and below normal range in four patients. P decreased significantly (p< .001) after MV at H1, H4, H7, H12, and H24. Hypophosphatemia was present in all patients after MV, but was severe (p< .3 mmol/L) in only two patients. There was a significant correlation (r = .56p< .01) between the decrease of P and the increase of pH after MV. Hypophosphatemia was a constant and early finding after institution of MV in COPD patients and was presumably related to an intracellular shift of P secondary to the correction of respiratory acidosis.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

The relationship between the respiratory index (RI = alveolar-arterial oxygen gradient [P(A-a)O2] normalized by PaO2) and the pulmonary shunt (Qsp/Qt) has been examined in 929 studies from 240 critically ill post-traumatic patients. Of these, 88 patients (443 studies) were individuals who developed post-traumatic adult respiratory distress syndrome (ARDS) and 152 were patients (486 studies) who did not develop ARDS. This study demonstrates that the RI to Qsp/Qt [RI/(Qsp/Qt)] relationship was significantly (p< .0001) increased in patients who developed fatal ARDS compared with those who did not develop ARDS, or with those whose ARDS resolved. Because of the increased oxygen consumption (QO2) in ARDS patients in association with their severe limitations in gas exchange (RI) and increased Qsp/Qt, surviving ARDS patients had a significant increase in the cardiac index which resulted in a higher oxygen delivery to QO2ratio. ARDS patients showed significant (p< .0001) evidence of increased pulmonary vascular tone, correlated with the increase in the RI/(Qsp/Qt) relationship. In addition, those patients with high RI/(Qsp/Qt) also had increased right ventricular (RVSW) to left ventricular work (LVSW) ratios which were shown to be a direct function of the rise in RI. This increase in both RVSW/LVSW and RI/(Qsp/Qt) ratios was significantly (p< .0001) correlated with an increased mortality. Thus, the RI/(Qsp/Qt) relationship, which can be obtained from arterial and mixed venous blood gases and saturations only, can be used to predict the severity of the ARDS process as well as important pulmonary vascular and right ventricular overload consequences.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

This study explores the value of combined high-frequency ventilation (CHFV) in a prospective clinical trial of 35 patients suffering from severe post-traumatic and/or septic adult respiratory distress syndrome (ARDS) who were refractory to conventional controlled mechanical ventilatory (CMV) support. The severity of ARDS was quantified by lung mechanics and gas exchange variables and the patients were classified on clinical grounds as well as on the basis of their respiratory index/pulmonary shunt relationship [RI/(Qsp/Qt)). During the same time period as the CHFV study, data from these patients were compared to those from 88 ARDS patients who had quantitatively similar degrees of respiratory insufficiency, but who were treated only with controlled mechanical ventilation (CMV). The use of CHFV in the 35 CMV refractor) patients resulted in an increase in expired tidal volume (VTE) by reducing the CMV inspired tidal volume (VTI) while increasing the volume component derived from high-frequency ventilation (HFV). This procedure appeared to reveal potentially salvageable ARDS patients who were refractory to CMV. In these patients, CHFV significantly reduced pulmonary mean airway pressure (Paw). The RI also decreased significantly and it was possible to reduce significantly the FIO2. In surviving ARDS patients treated with CHFV, an improvement in blood gases at reduced FIO2, without decreased cardiac output, was produced. The CHFV technique was used for ≤25 days and resulted in 23% survival of patients who were clinically and physiologically indistinguishable from the patients in the ARDS nonsurvivor group who were treated by CMV only. In surviving CHFV patients the decrease in Paw permitted a sustained, or increased, cardiac output with a rise in the oxygen delivery/oxygen consumption ratio, thus allowing for a higher PaO2for any given level of pulmonary shunt.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

We studied ICU patient blood loss as a result of diagnostic testing (DBL) and the effect of two measures to reduce it. A policy of using small volumes (pediatric phlebotomy tubes, reduced syringe volumes) for the most frequent laboratory tests was implemented in our medical ICU. We prospectively studied 151 patients admitted during two consecutive 10-wk periods. During period 2, DBL was displayed on each ICU flow sheet. The DBL/day (43.6 ± 3 [SEM] ml) was significantly lower (62.6 ± 4 ml) than it would have been if standard volume tubes had been used. This represented an average savings of 33%. During period 1 (n = 81), eight (10%) patients with no diagnosis involving blood loss had a decrease in Hct and received transfusion. DBL was significantly higher (316 ± 81 vs. 168 ± 18 ml,p< .001) for these patients and represented an average of 17% of transfusion requirements. During period 2 (n = 70), such transfusion requirements were significantly reduced (only one of 70,p< .001), as were tests ordered/day (7.8 ± 0.5 vs. 9.5 ± 0.6,p< .05). We conclude that DBL is a major health problem for the ICU patient. Routine use of small specimen volumes in this setting is warranted. Recording DBL for use in physician decision-making also significantly impacts this problem and should be considered an important part of the ICU database.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

Meeting the increased metabolic demands in the critically injured is a continuing challenge. Benefits of early enteral feeding after abdominal trauma have been previously reported, but the frequency of patient intolerance due to GI complaints remains unclear. One hundred twenty-three patients undergoing emergent laparotomy for major abdominal trauma with an abdominal trauma index ≤15 were prospectively randomized to either a control group (n = 52, no enteral nutrition during the first 5 days) or an enteral-fed group (n = 71). The enteral group had a needle catheter jejunostomy (NCI) placed at laparotomy and an elemental diet begun 12 h postoperatively, advanced in volume and concentration at 8-h intervals to 100–125 ml/h of full-strength diet. Symptoms of GI complaints (nausea, vomiting, cramping, distention, and diarrhea) were monitored daily and graded as minimal, moderate, or significant.Fifty percent of the control group had one or more GI complaints during the study period; six (12%) developed moderate discomfort. In the enteral group, 59 (83%) patients reported some GI discomfort; 11 had significant complaints (two nausea, seven cramping, six distention, two diarrhea). Nine (13%) of the enteral-fed patients ultimately required total parenteral nutrition supplementation due to GI complaints. The remaining 62 (87%) enteral patients were maintained on the elemental diet for a mean of 7 days (range 5 to 20). By postoperative day 5, patients received an average of 35 kcal/kg and 14.5 g N/day; 66% (41/62) were in positive N balance. Despite a high frequency of GI symptoms, with daily monitoring, adherence to a feeding schedule, and reassurance by the nutrition staff, the vast majority of patients sustaining major abdominal trauma tolerate full-scale NCJ feedings in the early postoperative period.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

NG tube feedings in hospitalized patients, whether in a ward or ICU, are considered a common etiology of diarrhea. To evaluate the accuracy of this assumption, 13 hospitalized postoperative patients with head and neck cancer, 11 ICU patients, and five healthy volunteers were given isotonic, low-residue, lactose-free tube feedings starting at 30 kcal/kg · day. There was no prior history of diarrhea in any patient studied. There was a significant difference in both albumin levels and diarrhea incidence in the three groups (analysis of variance,p< .05). Diarrhea occurred in four of 11 ICU patients while receiving feedings, but not in the healthy volunteers or non-ICU patients. The four patients with diarrhea had an average albumin level of 2.8 g/dL, while the other ICU patients had an average albumin of 2.6 g/dl. We conclude that isotonic NG tube feedings do not cause diarrhea in healthy volunteers or postoperative head and neck cancer patients. However, in some mechanically ventilated ICU patients, this regimen may cause diarrhea even though no risk factors can be clearly identified.

ISSN:0090-3493    

出版商:OVID    

年代:1989

数据来源: OVID