摘要:

One hundred twenty-five consecutive patients with a diagnosis of blunt chest trauma underwent T1–201 thallous chloride single photon-emission computed tomography (SPECT) scan, as well as physical examination, serial ECG and cardiac enzymes. A subset of patients had 24-h Holter monitoring. SPECT scan was performed within 24 h of injury. Seventy-five patients had positive scans and 48 had negative. Two studies could not be completed. Eleven patients with positive studies developed serious arrhythmias (multiple premature ventricular beats or atrial fibrillation). None of these patients had a prior history of cardiac disease. While three patients with negative SPECT scans had arrhythmias, each had a prior history of cardiac disease and two were on chronic antiarrhythmia therapy. Neither ECG findings, creatinine phosphokinase (CPK), nor CPK-isoenzymes distinguished between those patients who did and did not develop arrhythmias. We conclude that SPECT scan is useful in screening patients at risk of developing arrhythmias from cardiac contusion. Utilization of SPECT scan allows early discharge of a significant number of patients with blunt chest trauma who would otherwise require hospitalization for arrhythmia monitoring. (Crit Care Med 1990; 18:1)

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Vitamin E (Vit E) is an important component of the lung's defense against oxidant injury. The aim of this study was to determine a) if adult respiratory distress syndrome (ARDS) was associated with a decrease in Vit E plasma level linked to an enhancement of plasma lipoperoxidation, and b) if this Vit E deficiency might be explained by malnutrition and/or a consumption defect. Vit E, lipoperoxides (LP), total lipids, and fatty acid plasma levels were measured in 12 patients with ARDS (Pao2<60 torr with Fio20.6 on mechanical ventilation). At the onset of ARDS (T0), the decrease in Vit E plasma level was significant (p< .001) 7.73 ± 0.54 (n = 12) vs. 11.46 ± 0.55 mg/L (n = 7) in the control group (healthy subjects breathing room air). A significant (p< .05) increase in LP was simultaneously observed (4.12 ± 0.35 [In = 12] vs. 2.94 ± 0.30 nmol/ml [n = 17]) in the control group. At T0, LP were inversely correlated with Vit E plasma levels (r = .78,p< .01). Vit E deficiency was associated with low levels of total plasma lipids (3.68 ± 0.25 g/L) and plasma cholesterol (0.97 ± 0.07 g/L). Thus, the Vit E/total lipids ratio (2.18 ± 0.17 mg/g) was always above the accepted normal limit value for this ratio (0.8 mg/g). Significant decreases in essential fatty acid and linoleic acid (p< .01) and arachidonic acid (p< .05); and a significant (p< .05) increase in the oleic/linoleic acid ratio of 1.42 ± 0.16 vs. 0.91 ± 0.51 in the control group (n = 18) were simultaneously observed. During the 24 h after ARDS onset (n = 9), a significant decrease in LP was observed; i.e., −36% (p< .01) 6 h after ARDS onset, to −24% (p< .05) at 12 and 24 h, associated with a slight decrease in Vit E plotted against time, T0, 12, and 24 h after ARDS onset (Y = −0.03X + 7.34,p< .001) without any significant change in the oleic/linoleic acid ratio. We concluded that a) ARDS was associated with Vit E deficiency and enhancement of plasma lipoperoxidation; b) the low basal values of Vit E were linked to the low cholesterol and total lipid plasma levels, probably as a consequence of malnutrition; and c) during the course of ARDS, a significant Vit E plasma level decrease was observed, either as a consequence of increased utilization or as a consequence of decreased absorption.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Doppler ultrasound was used to study cerebral hemodynamics in the pericallosal artery of 21 newborn infants undergoing extracorporeal membrane oxygenation (ECMO) for intractable respiratory failure. Cerebral blood flow velocity waveforms were obtained pre-ECMO, after every major change in cardiopulmonary bypass flow during ECMO, and post-ECMO. The mean pulsatility index (PI) pre-ECMO was slightly higher than after decannulation, secondary to hypocarbia pre-ECMO. The PI decreased significantly at high (61 to 120 ml/min kg) cardiopulmonary bypass flows. This was associated with an increase in mean arterial pressure, but not with changes in Hct, Pao2. or Paco2. A negative curvilinear relationship between the amount of cardiopulmonary bypass flow and PI was found. These data suggest an increase in cerebral blood flow velocity and vasodilation of the cerebral vessels at high cardiopulmonary bypass flows, and may explain the occurrence of intracranial hemorrhage in infants undergoing ECMO.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Twenty patients (ten with mitral and/or aortic valve disease and ten with ischemic heart disease, all in the New York Heart Association class IV, aged between 18 and 74 yr, with cardiogenic pulmonary edema unresponsive to drug treatment) were treated with polysulphone membrane ultrafiltration (UF) in a veno-venous circuit. All patients had dyspnea, pulmonary rales, hypoxemia, tachycardia, hypotension, overhydration, radiologic evidence of engorged pulmonary vasculature, and Kerley-B lines.Systemic and pulmonary arterial pressures, cardiac output (by thermodilution), and intrapulmonary shunt fraction (Qsp/Qt) were determined and chest x-ray was obtained at the beginning and the end of UF. Average duration of the treatment was 150 ± 28 min; UF volume averaged 3000 ± 170 ml. UF reduced the Qsp/Qt by 58% from control condition, and did not significantly affect hemodynamic variables. Chest x-rays documented clearing of alveolar edema and venous congestion. These changes were associated with unequivocal clinical improvement and no mechanical ventilation was necessary to improve gas exchange. Short-term fluid subtraction did not result in undesired circulatory alterations. Because the ultrafiltrate composition is similar to plasmatic fluid, no modification in the plasma osmolarity was detected.In conclusion, UF may be considered an effective tool for the treatment of acute pulmonary edema refractory to drug therapy, as an alternative to mechanical ventilation, and as a remedy for excessive extravascular lung water.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Twenty-two pediatric patients with AIDS required assisted ventilation during 27 pediatric ICU (PICU) admissions. Patients were retrospectively divided on the basis of whether they required assisted ventilation for acute respiratory failure (ARF) or for another reason. Sixteen (59%) courses of assisted ventilation were for ARF. The PICU mortality rate was 81% for the ARF group. Eleven (41%) courses of assisted ventilation were for reasons not involving ARF. The PICU mortality rate for the group without ARF was 9%, significantly lower (p< .01) than for the ARF group.Pneumocystis cariniipneumonia (PCP) was documented during 48% of admissions. Occurrence of PCP did not affect mortality, nor was it more likely in those with than without ARF. Two patients with ARF survived to discharge from the hospital. Both died within 1 yr of ARF. Thus, the short-term prognosis for pediatric AIDS patients requiring assisted ventilation for ARF is extremely poor.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

We used continuous positive airway pressure (CPAP) by face mask to treat 18 AIDS patients withPneumocystis cariniipneumonia (PCP) who were in hypoxic respiratory failure. Candidates for mask CPAP were conscious, not hypercarbic, and able to protect their airway on ICU admission. Treatment was effective and well tolerated. Mean Po2rose from 62 to 158 torr, respiratory rate decreased from 51 to 32 breath/min, and Pco2was unchanged. Mean duration of treatment was 4.5 days. Only one patient developed a pneumothorax; there were no other major complications. Hospital mortality was 55%. CPAP by face mask allows speech and permits discussion of therapeutic limits. We present our protocol for using CPAP by face mask and conclude that CPAP is effective supportive therapy in hypoxic respiratory failure complicating PCP and AIDS.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Although electrolyte levels are commonly determined during inhospital CPR, the clinical usefulness of these measurements is questionable. Electrolyte and digoxin levels were obtained from 99 patients during resuscitative efforts. Measurements were examined for association with pre and postarrest values, outcome from arrest, and presence or absence of refractory ventricular arrhythmias. While BUN and creatinine (Cr) values correlated closely with pre and postarrest levels (r2> 50%), Na, K, and Ca measurements were less reflective (r2<50%). When electrolyte levels obtained during CPR were correlated with outcome, linear regression showed a consistent trend for higher levels in patients who subsequently died (Kp< .001; Mgp< .02; Nap< .025; Cap< .02; BUNp< .02; Crp< .025). Finally, among the 12 patients with documented refractory ventricular arrhythmias, there appeared to be little association with K, Mg, and digoxin abnormalities observed during resuscitative efforts. These results suggest that electrolyte levels during CPR are strongly affected by metabolic disturbances and therapeutic interventions, and consequently, the clinical usefulness of these measurements may be limited.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Peritoneal dialysis is a relatively safe and effective form of therapy for acute renal failure (ARF). As dextrose in the dialysate provides the osmotic gradient to achieve fluid removal, frequent exchanges with dialysate containing high dextrose is occasionally used to achieve negative balance in fluid overloaded patients. It has previously been shown that dextrose absorption from the peritoneal cavity is significant. Using indirect calorimetry and analyzing the dialysate effluent for its dextrose concentration, we studied the effects of high dextrose-containing dialysate in five patients with ARF. Despite minimal intake of calories, all patients had an RQ >1.0 consistent with net lipogenesis resulting from dextrose absorbed from the peritoneal cavity. Four of five patients absorbed >500 g of dextrose over 24 h. As overfeeding could lead to hepatic steatosis, increased CO2production with worsening of respiratory failure, and hyperglycemia, the risks of using high dextrose-containing dialysate fluids should be weighed carefully against potential benefits. When nutritional support is indicated in such patients, contribution of dextrose calories from dialysate fluid should be taken into account.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Plasma cholesterol levels, plasma lactate, and total body RQ were measured in septic patients undergoing total parenteral nutrition (TPN) with glucose, fat, and two different branch-chain amino acid admixtures (49% BCAA and 16% BCAA). Mean plasma cholesterol for all measurements (2.61 ± 0.94 [SD] mmol/L) was lower than normal; however, it was higher with 49% BCAA than with 16% BCAA (2.94 ± 0.95 vs. 2.27 ± 0.81 mmol/L,p< .001) for comparable loads of glucose, fat, and total amino acids. Plasma lactate and RQ were lower with 49% BCAA than with 16% BCAA (p< .001 for both). Cholesterol was directly related to the absolute dose of BCAA (p< .001), was unrelated to the dose of non-BCAA, and was inversely related to lactate (p< .001). These results suggest that BCAA ketoacids contribute to cholesterol synthesis in sepsis, as well as being an oxidative source. The data also suggest that the reduction in alanine in BCAA-enriched amino-acid TPN assists in the lowering of plasma lactate secondary to abnormal septic glucose metabolism.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

Hypoxemia following long bone or pelvic fracture (LBPF) is often attributed to fat embolism syndrome (FES), but the true incidence and etiology of postfracture pulmonary shunt (Qsp) are not well defined. Over 12 months, 92 patients with LBPF admitted to a Level I trauma center were prospectively evaluated. Arterial blood gases, Hct, platelet count, serum fibrinogen, serum lipase, and urinary fat bodies (UFB) were determined serially from admission through the fifth hospital day. Patients were evaluated daily by chest x-ray, vital signs, mental status, and presence of petechiae. Four patient groups were established: No Qsp, Qsp with pulmonary injury (Qsp+PI). Qsp without pulmonary injury or petechaie (FES – P), and Qsp without pulmonary injury and with petechiae (FES + P). Qsp indicated by an alveolar/arterial Po2gradient >100 torr developed in 49 (53%) of the patients. Pulmonary injury was present in 39 (81%) of those 49 and was at least partially responsible for the shunt. The remaining ten patients were diagnosed as having FES; four had petechiae (FES + P) and six were without petechiae (FES – P). The minimum incidence of FES in LBPF is therefore 11%.

ISSN:0090-3493    

出版商:OVID    

年代:1990

数据来源: OVID