ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundTracheal aspirate Gram's stains are used to guide antibiotic selection in empiric pneumonia treatment in the surgical intensive care unit (SICU). We questioned whether Gram's stains predict the organism cultured.MethodsA retrospective review of prospectively collected data.ResultsGram's stains correlated with the cultured organism in 284 of 543 (52%) SICU cultures and in 226 of 403 (56%) trauma intensive care unit (TICU) cultures. Gram-negative rod (GNR) stains yielded GNR organisms in 182 of 205 (89%) SICU cultures and in 160 of 176 (91%) TICU cultures. Gram-positive coccus (GPC) stains yielded GPC organisms in 75 of 228 (33%) SICU cultures and in 52 of 149 (35%) TICU cultures. Noncorrelates in the GPC group were predominantly GNRs (185 of 250 (74%)).ConclusionWhen the clinical decision has been made that empiric antibiotic coverage is necessary, GNR coverage should be instituted regardless of Gram's stain result. The decision to institute GPC coverage needs to be supported by clinical data other than the Gram's stain.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo evaluate the effects of maintaining increased levels of preload on cardiopulmonary function and visceral perfusion during resuscitation.Methodsor=to 120 mL/m2during resuscitation. The INO group had inotropes added according to a prospectively determined protocol and was maintained at a RVEDVI of 90 to 100 mL/m2. Systemic perfusion was assessed using oxygen transport and acid-base parameters, and pulmonary function was evaluated with PaO2/FiO2ratio, dynamic compliance, ventilator days, and incidence of adult respiratory distress syndrome. Gut perfusion was assessed by measuring gastric intramucosal pH (pHi). Data are expressed as means +/- SD.ResultsThe mean RVEDVI was significantly higher in the PL group (n = 19) than in the INO group (n = 20) during resuscitation (119 +/- 18 vs. 103 +/- 22 mL/m sup 2, p = 0.01). There was no difference in oxygen delivery, mixed venous oxygen saturation, lactate, PaO2/FiO20.1). In the patients who had pHi measured sequentially during resuscitation (PL = 13, INO = 17), the final pHi was significantly higher in the PL group (7.31 +/- 0.1 vs. 7.16 +/- 0.2, p = 0.03).ConclusionPatients resuscitated at higher levels of preload have significantly better visceral perfusion than those resuscitated at normal preload with addition of inotropes. This higher preload does not adversely affect pulmonary function.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveThis study was done to evaluate the differences in base deficit (BD) clearance, pH normalization, and the occurrence of complications between survivors and nonsurvivors after trauma.DesignConcurrent data entry with retrospective review.MethodsTrauma patients meeting registry criteria from July 1990 through August 1995 with arterial blood gases performed within 1 hour of admission and admission BD <or=to -6 were included. Data was grouped by BD category (moderate, -6 to -9; severe, <or=to-10). Group means +/- SEM were compared with a two-tailed t test.Measurements and Main Results-6 had an increased frequency of adult respiratory distress syndrome, multiple organ failure, and mortality.ConclusionBase deficit reveals differences in metabolic acidosis between survivors and nonsurvivors not shown by pH determinations and is clearly a better marker of acidosis clearance after shock.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo test fiber-optic PO2, PCO2, and pH sensors placed in skeletal muscle as monitors of hemorrhage, shock, and resuscitation, compared with mean arterial blood pressure, cardiac output, and blood gas variables.DesignObservational study in physiology laboratory, using a canine controlled hemorrhagic shock model.Materials and MethodsMongrel dogs (20-35 kg; n = 10) were monitored with arterial, venous, and pulmonary artery catheters. A probe (0.5 mm in diameter) with fiber-optic PO2, PCO2, and pH sensors was placed percutaneously in the adductor muscle of the right medial thigh. Mean arterial blood pressure of 45 to 50 mm Hg was maintained for 1 hour with controlled hemorrhage, after which shed blood was reinfused. The animals were monitored for 4 hours after reinfusion.Measurements and Main ResultsSkeletal muscle PO2(PmO2) decreased from 31 +/- 9 to 5 +/- 4 mm Hg during shock and recovered with reinfusion. Skeletal muscle pH (pHm) decreased from 7.24 +/- 0.10 to 6.94 +/- 0.12 during shock, to 6.90 +/- 0.13 with reinfusion, and recovered to near baseline 2 hours after reinfusion. PmCO2increased from 48 +/- 14 to 134 +/- 86 mm Hg during shock, to 138 +/- 92 mm Hg with a time course inverse to pHm, and recovered to near baseline 30 minutes after reinfusion. On average, skeletal muscle PCO2(PmCO2) and pHm did not recover to baseline, possibly indicating persistent anaerobic metabolic effects. O2delivery, mixed venous PO2, mixed venous O2saturation and PmO sub 2 responded with similar time courses.ConclusionPmO2, PmCO2, and pHm can be monitored simultaneously for several hours with fiber-optic sensors in a single, small probe. PmO2may provide information comparable to O2delivery. PmCO2may reflect adequacy of perfusion. pHm may indicate success of resuscitation. This technology may offer new insight into the extent of injury and refinement of shock resuscitation and monitoring.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectivesTo compare the effects of simulated and mild actual hemorrhage on parameters used traditionally to assess hemorrhaging patients: heart rate (HR), blood pressure (BP), and Shock Index (SI = HR/systolic BP), with stroke distance (SD) measured ultrasonically as an index of cardiac stroke volume.Materials and MethodsHemorrhage was simulated in 19 healthy volunteers by the application of graded lower-body negative pressure (LBNP) (0, -20, -40, and -60 mm Hg) to pool blood in the lower body and reduce venous return. Measurements were also made before and after a standard blood donation (450 mL) in nine healthy volunteers.Measurements and main ResultsSD decreased significantly and progressively from the baseline level of 23.8 +/- 5.7 cm (mean +/- SD) at each level of LBNP: by 3.4 +/- 1.9, 7.4 +/- 2.5, and 11.8 +/- 3.2 cm at LBNP of -20, -40, and -60 mm Hg, respectively. Neither HR nor SI changed significantly at the lowest level of LBNP (-20 mm Hg), but they showed progressive, significant increases thereafter. Mean BP did not change significantly at any level of LBNP. Similarly, after a controlled hemorrhage of 450 mL, SD decreased significantly by 3.3 +/- 1.6 cm from 22.2 +/- 2.8 cm, whereas HR and SI remained unchanged and mean BP increased slightly.ConclusionChanges in SD may provide an earlier indication of progressive blood loss than either HR or BP alone or in combination.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo study the significance of a geographic hyperechoic liver parenchyma pattern on ultrasound (US) examination of patients with blunt abdominal injury.DesignProspective clinical study with double-blind evaluation of images and clinical data.Methods and Main ResultsWe performed US examinations in 831 consecutive patients admitted to our hospital for blunt abdominal trauma and identified 33 with a geographic hyperechoic pattern in the liver. We correlated the appearance with computed tomographic images and with clinical, angiographic, and scintigraphic data. All patients with a geographic hyperechoic pattern showed mild computed tomographic evidence of hepatic injury (Mirvis grade 2, 69%; Mirvis grade 3, 31%). Excluding patients who required urgent surgery for other reasons and patients in shock, patients with the geographic hyperechoic pattern were managed conservatively with no complications.ConclusionThe geographic hyperechoic pattern of liver parenchyma on US examination of trauma patients is a mild injury that, of itself, does not require surgical therapy.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

Critically injured patients occasionally present with indicators that they do not want resuscitation.What should clinicians do if these indicators come to light during resuscitations? This question is explored in the case of an unconscious and unresponsive adult woman with life-threatening injuries from a motor vehicle crash who was wearing a "DNR" medical necklace. The normal use of standard advance directives, including the use of prehospital advance directives, is discussed and contrasted with that of nonstandard directives, including verbal directives. The differing standards required to withhold and withdraw treatments in acutely injured patients are discussed, as are methods for assessing a patient's decision-making capacity at the bedside and a process to rapidly determine ethical courses of action in crisis situations. This discussion emphasizes that patients in life-threatening situations should normally be treated if the only available instructions are nonstandard directives. The patient gives her perspective on why she wore the directive and on the surgeons' actions.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundThe thymus plays important roles in host defense, which may be impaired after burn injury. The effects of thermal injury on thymocytes were investigated in male Wistar rats.MethodsChanges in thymus weight and content of glutathione and corticosterone were determined after burn injury. Apoptosis of thymocytes was detected by electrophoresis of DNA, and lymphocyte subsets were characterized by flow cytometry. The effects of adrenalectomy and the glucocorticoid receptor antagonist RU486 in burned animals were also studied.ResultsThe weight of the thymus decreased progressively after burn injury, and this effect was accompanied by increases in the corticosterone concentration in plasma and the thymus and apoptosis of CD4 sup + CD8 sup + thymocytes. Administration of RU486 or adrenalectomy inhibited burn-induced thymocyte apoptosis.ConclusionThermal injury increases the corticosterone concentration in plasma and the thymus and triggers thymocyte apoptosis.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo evaluate the clinical characteristics and neurologic outcome of children with carbon monoxide poisoning treated with normobaric oxygen therapy.Methods25%; (2) toxic, carboxyhemoglobin level 10.1 to 25%; (3) suspected toxic, carboxyhemoglobin level <or=to10% with acute neurologic manifestations; or (4) nontoxic, carboxyhemoglobin <or=to10% without acute neurologic manifestations.ResultsOne hundred six patients (median age, 3.5 years; range, 0.1-14.9 years) were identified, 37 with severe toxic, 37 with toxic, 13 with suspected toxic, and 19 with nontoxic exposures. The most common presenting signs or symptoms included altered level of consciousness, metabolic acidosis, tachycardia, and hypertension. All patients received normobaric oxygen for 5.5 hours (range, 0.6-44 hours). Carboxyhemoglobin levels decreased to less than 3% in 3.6 hours (range, 0-15.5 hours). Fifteen patients died, three from massive burn injury, eight from hypoxic-ischemic encephalopathy after cardiopulmonary arrest at presentation, and four from late complications of burn injury. Seven survivors did not recover their premorbid neurologic state, four of whom had respiratory arrest when rescued. Two patients had initial neurologic recovery followed by transient deterioration at 4 and 14 days after exposure. One patient developed seizures and was found to have bilateral occipital lobe infarctions 51 days after exposure.ConclusionAcute neurologic manifestations after carbon monoxide exposure are common in children. These resolve rapidly with normobaric oxygen, however. Persistent sequelae are primarily related to asphyxia. Delayed neurologic syndromes are uncommon in children treated with normobaric oxygen.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID