摘要:

Objective:To determine whether bronchoalveolar lavage fluid (BALF) from patients either at risk for the acute respiratory distress syndrome (ARDS) or with sustained ARDS modulates neutrophil apoptosis; to measure the BALF concentrations of the apoptosis inhibitors granulocyte colony-stimulating factor (G-CSF) and granulocyte/macrophage colony-stimulating factor (GM-CSF) before and after the onset of ARDS; and to determine whether the BALF concentrations of G-CSF and/or GM-CSF are associated with clinical outcome.Design:Prospective cohort study.Setting:Tertiary university hospital.Patients:Twenty patients at risk for ARDS and 45 patients with established ARDS.Interventions:Patients at risk for ARDS underwent bronchoalveolar lavage within 24 hrs of being identified, then again 72 hrs later. Patients with ARDS underwent bronchoalveolar lavage within 24 hrs of meeting ARDS criteria, then again on days 3, 7, and 14 of the disease.Measurements and Main Results:Normal peripheral blood neutrophil were incubated overnight in BALF from normal volunteers, from patients at risk for ARDS, or from patients with ARDS. neutrophil apoptosis was determined by flow cytometric analysis of annexin V binding. G-CSF and GM-CSF were measured in BALF by immunoassays. Compared with normal BALF, BALF from patients on days 1 and 3 of ARDS inhibited neutrophil apoptosis, but BALF from patients at later stages of ARDS, or from patients at risk for ARDS, did not. The BALF concentrations of both G-CSF and GM-CSF were elevated early in ARDS and decreased toward later stages. Patients who lived had significantly higher concentrations of GM-CSF in the BALF than those who died.Conclusions:We conclude that the antiapoptotic effect of ARDS BALF on normal neutrophil is highest during early ARDS, and decreases during late ARDS. G-CSF and GM-CSF are present in BALF from patients with ARDS, and their concentrations parallel the antiapoptotic effect of ARDS BALF. These data support the concept that the life-span of neutrophil in the air spaces is modulated during acute inflammation. GM-CSF in the air spaces is associated with improved survival in patients with ARDS.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To investigate the activity of intravenous immunoglobulin (IVIG) as a prophylactic agent against infection in trauma victims.Design:Prospective, randomized, double-blind, placebo-controlled study.Setting:A 20-bed university intensive care unit.Patients:Thirty-nine trauma patients with injury severity scores (ISSs) of 16-50.Interventions:Penicillin was given at the time of admission and continued at least until day 4. Twenty-one patients received IVIG and 18 patients received human albumin at 1 g/kg in four divided doses (days 1, 2, 3, and 6). The two groups had similarities in age, gender, Acute Physiology and Chronic Health Evaluation II score, risk of death, and Glasgow Coma Scale score, but differing ISSs (p= .02), at the time of admission. Blood was collected on days 1, 4, and 7.Measurements and Main Results:Clinical variables related to infection were recorded. The complement components C3c, C4 and CH50, IgG, and the fractions of IgG were measured. The serum bactericidal activity (SBA) was assessed at 37°C (98.6°F) and 40°C (104.0°F) at the time of admission and during the course of IVIG administration.Controlling for ISS, IVIG-treated patients had fewer pneumonias (p= .003) and total non-catheter-related infections (p= .04). Catheter-related infections (p= .76), length of stay in the intensive care unit, antibiotic days, and infection-related mortality did not differ between the two groups. A significantly increased trend in IgG and its subclasses was shown on days 4 and 7 in the IVIG group but not in the control group (p< .000001). No important differences were noted in complement fractions. The SBA of the groups was similar on day 1, but significantly higher on days 4 and 7 (p< .000001) in the IVIG group, remaining so controlling for complement and ISS. SBA was higher at 40°C (104.0°F) compared with 37°C (98.6°F) (p< .0001) under all three conditions. In both groups, low SBA (on days 1, 4, and 7) was associated with increased risk of pneumonia (p< .01) and non-catheter-related infections (p= .06 for day 1;p< .01 for days 4 and 7).Conclusions:Trauma patients receiving high doses of IVIG exhibit a reduction of septic complications and an improvement of SBA. Early SBA measurement may represent an index of susceptibility to infection.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To survey the management of head-injured patients in 1997 and to identify differences compared with a survey conducted in 1991.Design:A two-page questionnaire was mailed to all neurosurgeons in North America certified by the American Board of Neurologic Surgeons, asking their views regarding the most appropriate acute care of patients with severe traumatic brain injury (TBI).Setting:North American neurosurgical practices.Patients:Not applicable.Interventions:None.Measurements and Main Results:Compared with a 1991 survey, there was a significant increase in the proportion of neurosurgeons who felt these patients should have intracranial pressure monitoring (28% vs. 83%) and a decrease in the proportion who used prophylactic hyperventilation therapy (83% vs. 36%) and steroids (64% vs. 19%). Ninety-seven percent of respondents felt that the cerebral perfusion pressure should be maintained at >70 mm Hg, and 44% indicated that patients with severe TBI should be treated at Level I trauma centers.Conclusions:There have been significant changes in the acute management of patients with severe TBI since 1991. Current practices more closely reflect the recommendations of evidence-based guidelines.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To describe outcomes of adult survivors of prolonged critical illness after direct transfer to extended care facilities.Design:A retrospective cohort study.Setting:All adult intensive care units (ICUs) in a tertiary care university hospital.Patients:A consecutive series of 97 adult survivors with an ICU stay of ≥7 days transferred directly from intensive care to extended care facilities between 1990 and 1996.Interventions:None.Methods and Main Results:Hospital and extended care facility charts were reviewed for patient characteristics, resource utilization, and survival. Survivors were for a minimum of 1 yr and a maximum of 6 yrs, and were interviewed to assess quality of life and functionality. The mean age of the patients was 66 ± 16 (range, 19-93) yrs. The median length of ICU stay for these patients was 39 (range, 7-276) days. Only 18 of the 71 ventilator-assisted patients were weaned from mechanical ventilation after transfer to the extended care facility. Survival for the study period, at 1 yr after discharge from the ICU, was 49.5%. One year after discharge from the ICU, 11.5% of all patients had returned home, were breathing spontaneously, had a fair or better quality of life, and had good physical functionality. Each successive year, an increasing proportion of patients underwent direct transfer to an extended care facility. This strategy decreased the patients' length of stay (p< .002) in the ICU from year to year, but was significantly associated with an increase in readmissions to acute care hospitals (p< .002).Conclusions:Survivors of catastrophic illness who are so debilitated that they require transfer to an extended care facility have a low likelihood of achieving both survival and functional independence 1 yr after discharge from the ICU. Aggressive cost-conscious strategies to accelerate the transfer of these patients successfully reduced the length of ICU stay and hospital costs, but were associated with a high rate of readmission to tertiary care facilities.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To evaluate the ability of three scoring systems to predict hospital mortality in adult patients of an interdisciplinary intensive care unit in Germany.Design:A prospective cohort study.Setting:A mixed medical and surgical intensive care unit at a teaching hospital in Germany.Patients:From a total of 3,108 patients, 2,795 patients (89.9%) for Acute Physiology and Chronic Health Evaluation (APACHE) II and 2,661 patients (85.6%) for APACHE III and Simplified Acute Physiology Score (SAPS) II could be enrolled to the study because of defined exclusion criteria.Interventions:None.Measurements and Main Results:Probabilities of hospital death for patients were estimated by applying APACHE II and III and SAPS II and compared with observed outcomes. The overall goodness-of-fit of the three models was assessed. Hospital death rates were equivalent to those predicted by APACHE II but higher than those predicted by APACHE III and SAPS II. Calibration was good for APACHE II. For the other systems, it was insufficient, but better for SAPS II than for APACHE III. The overall correct classification rate, applying a decision criterion of 50%, was 84% for APACHE II and 85% for APACHE III and SAPS II. The areas under the receiver operating characteristic curve were 0.832 for APACHE II and 0.846 for APACHE III and SAPS II. Risk estimates for surgical and medical admissions differed between the three systems. For all systems, risk predictions for diagnostic categories did not fit uniformly across the spectrum of disease categories.Conclusions:Our data more closely resemble those of the APACHE II database, demonstrating a higher degree of overall goodness-of-fit of APACHE II than APACHE III and SAPS II. Although discrimination was slightly better for the two new systems, calibration was good with a close fit for APACHE II only. Hospital mortality was higher than predicted for both new models but was underestimated to a greater degree by APACHE III. Both score systems demonstrated a considerable variation across the spectrum of diagnostic categories, which also differed between the two models.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:Long-term treatment with nondepolarizing neuromuscular blocking agents and corticosteroids in the intensive care unit is not benign, and an increasing number of patients with acute quadriplegic myopathy have been reported with increased use of these drugs. The purpose of this study was to investigate the mechanisms underlying acute quadriplegic myopathy.Design:Percutaneous muscle biopsy samples were obtained, and electrophysiologic examinations were performed during the acute phase and during recovery in patients with acute quadriplegic myopathy. Regulation of muscle contraction and myofibrillar protein synthesis was studied using cell physiologic techniques, ultrasensitive electrophoresis,in situhybridization, and histopathologic techniques.Setting:All patients were seen in the intensive care unit of different university hospitals.Patients:All patients were critically ill with sepsis. They had been given massive doses of corticosteroids in combination with variable doses of neuromuscular blocking agents. All patients developed paralysis of spinal nerve-innervated muscles. On the other hand, cranial nerve-innervated muscle and sensory and cognitive functions were well maintained after discontinuation of treatment with neuromuscular blocking agents.Intervention:Muscle biopsy samples were obtained and electrophysiologic examinations were performed in all patients.Measurements and Main Results:The major observations in patients with acute quadriplegic myopathy were, as follows: a) a general decrease in myofibrillar protein content; b) specific but highly variable partial or complete loss of myosin and myosin-associated proteins; c) very low thick-filament/thin-filament protein ratios; d) absence of myosin messenger RNA; and e) a dramatically impaired muscle cell force-generating capacity in the acute phase of acute quadriplegic myopathy. During clinical improvement, normal expression of myosin messenger RNAs, reexpression of thick-filament proteins, and increased specific tension were observed.Conclusions:Acute quadriplegic myopathy is associated with a specific decrease in thick-filament proteins related to an altered transcription rate. Although the decreased content of thick-filament proteins is important for prolonged muscle weakness, it is not the primary cause of muscle paralysis in the acute stage, during which impaired muscle membrane excitability probably plays a more significant role. Several factors contribute to this condition, but the action of corticosteroids seems to be the predominant one, along with potentiation by neuromuscular blocking agents, immobilization, and probably also concurrent sepsis.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To characterize the source of bleeding and the prognosis in critically ill patients with upper gastrointestinal hemorrhage that developed while in the hospital.Setting:Intensive care units of a large academic tertiary-care center.Design:Retrospective cohort study.Subjects:Patients undergoing endoscopy in intensive care units for gastrointestinal bleeding that developed while in the hospital.Measurements and Main Results:Medical records were available for 142 patients. Of these, 66 met the criteria for in-hospital bleeding. Peptic ulcer disease, present in 56% of patients, was the most common bleeding source identified. Of patients with peptic ulcer disease, nine of 37 (24%) had stigmata of recent hemorrhage. Ten patients (15%) received endoscopic hemostasis interventions (eight receiving therapy for bleeding ulcers, two receiving therapy for esophageal varices). The in-hospital mortality rate was 42%. The cause of death was sepsis and/or multiple system organ failure in 21 patients (75%); the gastrointestinal bleeding may have contributed to the onset of sepsis in one of these patients. No patients died directly of gastrointestinal bleeding.Conclusions:Critically ill patients who bleed while in the hospital have similar sources of bleeding and rates of endoscopically directed therapy as patients admitted to hospital with bleeding. The mortality rate is very high in patients with bleeding that develops in the hospital, and this is usually a result of systemic disease. These data may help clinicians and patients to estimate the potential benefit of urgent endoscopy in critically ill patients.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To compare measurements of the effective pulmonary blood flow (&OV0422;ep, i.e., nonshunted fraction of cardiac output, &OV0422;t) by the inert gas rebreathing (RB) method and the thermodilution (TD) technique in critically ill patients.Design:Prospective, comparative study of a noninvasive method and an established invasive technique.Setting:An 11-bed general intensive care unit in a university hospital.Patients:A total of 14 critically ill patients, all mechanically ventilated and monitored with systemic and pulmonary artery catheters.Measurements and Main Results:&OV0422;epwas determined in duplicate by RB using a mass spectrometer for gas analysis. For each determination, &OV0422;twas measured in triplicate by the cold water bolus TD technique and averaged. Simultaneously mixed venous and arterial blood samples were analyzed to calculate the intrapulmonary shunt fraction and thereby convert estimates of &OV0422;tto &OV0422;ep. Mean difference between paired estimates (RB - TD) was 0.01 L/min, so for differences was 1.19 L/min, and 95% confidence interval for the bias was −0.45 to 0.47 L/min. Coefficients of variation for repeated &OV0422;epestimates were 8% (RB) and 12% (TD), respectively. Coefficients of variation for RB estimates of functional residual capacity and lung tissue volume were 6% and 17%, respectively.Conclusions:The RB method is a promising method for simultaneous noninvasive estimation of &OV0422;epand functional residual capacity in mechanically ventilated patients. However, further investigations are needed to evaluate potential problems of the method before it can be recommended for clinical purposes.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective:To compare the evolution of plasma concentrations of leukotriene (LT) B4, LTC4, LTD4, and interleukin (IL)-8 in patients with acute respiratory distress syndrome (ARDS) and in patients at risk of ARDS and to assess the value of these mediators in predicting mortality rate from ARDS.Design:A case-control study comparing ARDS patients and patients at risk of ARDS as well as survivors and nonsurvivors with ARDS.Setting:Hospital intensive care unit, laboratory, and department of hematology.Patients:Twenty-one patients with ARDS and 14 patients at risk of ARDS.Intervention:Arterial blood samples were collected on days 0, 1, and 5 after admission to the intensive care unit.Measurements and Main Results:LTs were extracted, separated by high-pressure liquid chromatography and quantified by enzyme immunoassay. IL-8 was analyzed by ELISA. Plasma concentrations of LTB4and LTC4plus LTD4were significantly higher in ARDS patients than in patients at risk of ARDS during the first 24 hrs. Concentrations of IL-8 were also higher in ARDS patients than in patients at risk throughout the study, although the differences between the two groups were only significant on day 5. Only the plasma concentration of LTB4on day 1 was a marker of ARDS (72.2% sensitivity, 84.6% specificity). A logistic regression analysis showed that LTB4and IL-8, on day 1, were markers of mortality rate in patients with ARDS (70.0% sensitivity, 87.5% specificity).Conclusions:LTs are elevated during the early phases of ARDS, whereas IL-8 increases throughout the study. The evaluation of LTB4and IL-8 may be useful prognostic indices in patients with early phase ARDS after admission to the intensive care unit.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives:To characterize the rates of accidental removal of endotracheal tubes, nasogastric tubes, central venous catheters, and arterial catheters. To assess the efficacy of corrective measures aimed at reducing the accidental removal of these devices.Design:Prospective, observational, and interventional study.Setting:Eighteen-bed medical-surgical intensive care unit of a 650-bed tertiary care hospital.Patients:Patients admitted to the intensive care unit who had any of the following devices in place for more than 24 hrs: endotracheal tube, nasogastric tube, central venous catheter, arterial catheter.Measurements and Interventions:Data were collected on the date of placement of tubes and catheters, position of vascular catheters, date of removal, and reason for removal. The study involved three consecutive 6-month periods. At the end of the first and the second periods, information about rates of accidental removal was provided to the physicians and nurses. In addition, the personnel were instructed to be more vigilant and specific measures aimed at reducing the accidental removal were introduced.Main Results:In the first period, 289 endotracheal tubes were placed and 13.1% (24.7 per 1000 days) were removed accidentally. In the second and third periods, 17.1% (25.5 per 1000 days) and 11.4% (15.1 per 1000 days) were removed accidentally, respectively.In the first period, 368 nasogastric tubes were placed and 41% (73.9 per 1000 days) were removed accidentally. In both the second and the third period, a significant reduction in the rate of accidental removal was observed (32.4% or 41.2 per 1000 days and 25.8% or 29.8 per 1000 days, respectively).A significant decrease was observed in the rates of accidental removal of central venous catheters from 7.5% (12.4 per 1000 days) in the first period to 3.6% (5.4 per 1000 days) in the second period.The rate of arterial catheters accidentally removed expressed according to the time at risk significantly decreased from 46.5 per 1000 days in the first period to 19.1 per 1000 days in the second period and 25.3 per 1000 days in the third period.Conclusions:The information provided by the rates of accidental removal expressed by patient-days is helpful to compare results obtained in populations with different times of follow-up. Education of medical personnel and limiting upper-extremity access to within 20 cm from any catheter or tube resulted in a significant reduction of patient-related removal of tubes and catheters.

ISSN:0090-3493    

出版商:OVID    

年代:2000

数据来源: OVID