Intensive Care Med 2001 Mar;27(3):620-1
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PMID: 11355140, UI: 21254568
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Intensive Care Med 2001 Mar;27(3):616
PMID: 11355137, UI: 21254565
Intensive Care Med 2001 Mar;27(3):613
PMID: 11355134, UI: 21254562
Intensive Care Med 2001 Mar;27(3):609-12
Internal Medicine Residency Program, University of Toronto, Toronto, Canada.
PMID: 11355133, UI: 21254561
Intensive Care Med 2001 Mar;27(3):548-54
Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, 1070 Brussels, Belgium.
OBJECTIVES: To establish a list of therapeutic interventions considered by intensive care unit (ICU) physicians to have been tested by prospective, randomised, controlled clinical trials (RCTs) in critically ill patients, and to survey the perceptions of the same physicians on the therapeutic effect of these interventions as evaluated by RCT. DESIGN AND SETTING: Self-applied questionnaire in an International Symposium of Intensive Care and Emergency Medicine, Brussels, Belgium. PARTICIPANTS: All 3250 registrants at the symposium. MEASUREMENTS AND RESULTS: There were 527 questionnaires completed, and 446 were suitable for analysis. Respondents were asked to list the therapeutic interventions used in intensive care medicine which they believed have been shown by RCTs to improve survival. Using a 5-point Likert scale, respondents were then asked to rate their assessment of the effectiveness of each intervention they listed and, using a 3-point scale, to select their level of confidence in those assessments. A total of 512 interventions were identified by the respondents as having been tested by RCT. Analysing the 42 interventions quoted more than 12 times, 31 were believed by the respondents to have been shown to have a beneficial effect, and 11 to have a harmful effect. Many of the interventions noted have not in fact been subjected to RCT. CONCLUSIONS: Many interventions that have not been tested by RCT were believed to have been tested; conversely, some interventions actually tested by RCT were not mentioned. Few interventions used in the ICU have actually been shown by RCT to have a positive effect on outcome.
PMID: 11355124, UI: 21254552
Intensive Care Med 2001 Mar;27(3):513-20
Intensive Care Department, Bichat Claude-Bernard Hospital, University Paris 7, 46 rue Henri Huchard, 75018 Paris, France. JRZahar@hotmail.com
OBJECTIVES: To clarify the patterns of pulmonary tuberculosis (TB) that should result in a high index of suspicion, to increase the chances of early therapy and to identify predictors of 30-day mortality. PATIENTS AND METHODS: Retrospective, 7-year study in two medical intensive care units (ICUs). All patients admitted with pulmonary TB were enrolled. Clinical and laboratory data at admission and events within 48 h of admission were collected. Predictors of 30-day mortality were identified by univariate and multivariate analysis. RESULTS: The study included 99 patients with a median age of 41 years. Immunodeficiency was present in 60 patients, including 38 with AIDS. Fifty-nine patients had pulmonary TB alone, 22 also had extrapulmonary TB and 18 had miliary. All 99 patients were admitted for acute respiratory failure, some also with shock (20), neurologic disorders (18) or acute renal failure (10). Mechanical ventilation was needed in 50 patients; 22 patients met criteria for acute respiratory distress syndrome (ARDS). The 30-day mortality rate was 26.2%. Four factors independently predicted mortality: a time from symptom onset to treatment of more than 1 month (OR, 3.49; CI, 1.20-10.20), the number of organ failures (OR, 3.15; CI, 1.76-5.76), a serum albumin level above 20 g/l (OR, 3.96; CI, 1.04-15.10), and a larger number of lobes involved on chest radiograph (OR, 1.83; CI, 1.12-2.98). CONCLUSION: Delayed clinical suspicion and treatment of active pulmonary TB with respiratory failure may contribute to the persistently high mortality rates in ICU patients with these diseases.
PMID: 11355119, UI: 21254547
Intensive Care Med 2001 Mar;27(3):486-92
Intensive Care Department, Corporacio Sanitaria Parc Tauli s/n, 08208 Sabadell, Spain. MFernandez@CSPT.es
OBJECTIVE: To evaluate our clinical experience with the use of non-invasive mechanical ventilation (NIMV) in patients with an acute asthmatic attack. DESIGN: Seven-year period retrospective observational study. SETTING: General intensive care department (ICU) of a county hospital. PATIENTS: From 1992 to 1998, we documented clinical data, gas exchange and outcome of every asthmatic patient admitted to our ICU because of status asthmaticus (SA) refractory to initial medical therapy. INTERVENTIONS: Clinical charts were reviewed and patients were allocated to two groups according to their suitability as participants in an NIMV trial. Patients who arrived in respiratory arrest and those who ultimately improved with medical management alone were not considered candidates for NIMV. For the present analysis, the rest of the patients were considered candidates for NIMV, while the decision to start a NIMV trial or to perform endotracheal intubation (ETI) remained at the discretion of the attending physician. When patients failed to improve with NIMV, standard mechanical ventilation (MV) with ETI was initiated. MEASUREMENTS AND RESULTS: Fifty-eight patients were included in the study. Twenty-five patients (43%) were not eligible for NIMV: 11 patients (19%) because of respiratory arrest on their arrival at the Emergency Room and 14 patients (24%) because of improvement with medical management (bronchodilators, corticoids and oxygen). The remaining 33 patients were eligible for NIMV (57%): 11 patients (33%) received invasive MV and 22 patients (67%) were treated with NIMV. Three NIMV patients (14%) needed ETI. We compared data at baseline, 30 min, 2-6 h and 6-12 h after the onset of ventilatory support. Significant differences were observed in arterial blood gases on admission to the Emergency Room between MV and NIMV: PaCO2 (89 +/- 29 mmHg vs 53 +/- 13 mmHg, p < 0.05), pH (7.05 +/- 0.21 vs 7.28 +/- 0.008, p < 0.05) and HCO3- level (22 +/- 5 mmol/l vs 26 +/- 6 mmol/l, p < 0.05). No differences were found in the median length of ICU stay (4.5 vs 3 days), median hospital stay (15 vs 12 days) and mortality (0 vs 4%). CONCLUSION: Face mask NIMV appears to be a suitable method for improving alveolar ventilation and can reduce the need for intubation in a selected group of patients with SA.
PMID: 11355116, UI: 21254544
Intensive Care Med 2001 Mar;27(3):477-85
Division of Pulmonary and Critical Care Medicine, Asan Medical Centre, College of Medicine, University of Ulsan, Seoul 138-600, Korea. cmlim@www.amc.seoul.kr
OBJECTIVES: To determine whether the response to the prone position differs between acute respiratory distress syndrome (ARDS) resulting from a pulmonary cause (ARDSp) and that from an extrapulmonary cause (ARD-Sexp). DESIGN AND SETTING: Prospective observational study in a medical ICU of a university-affiliated hospital. SUBJECTS: A consecutive series of 31 patients with ARDSp and 16 with ARDSexp within 3 days of onset of ARDS. INTERVENTION: Prone position for at least 2 h. MEASUREMENTS AND RESULTS: In ARDSp, compared with the supine position (121 +/- 49 mmHg), PaO2/FIO2 was not increased after 0.5 h but was increased after 2 h in the prone position (158 +/- 60 mmHg). In ARDSexp, compared with the supine position (106 +/- 53 mmHg), PaO2/FIO2 was increased after 0.5 h (155 +/- 91 mmHg), but was not further changed after 2 h. Marked oxygenation response (increase in PaO2/FIO2 > 40% from baseline) after 0.5 h was 23% in ARDSp and 63% in ARDSexp, and that after 2 h was 29% and 63%, respectively. Static respiratory compliance decreased in the prone position in ARDSexp (30 +/- 11 ml/cmH2O at baseline, 27 +/- 11 after 0.5 h and 25 +/- 9 after 2 h) but not in ARDSp. Consolidation score as determined on the first chest radiography taken in the prone position decreased to a greater degree in ARDSexp (-2.4 +/- 4.1) than in ARDSp (0.3 +/- 4.1). CONCLUSION: Pulmonary ARDS and extrapulmonary ARDS in their early stages respond differently to the prone position with regard to the time course of oxygenation, respiratory mechanical behaviour, and radiographic change. These findings suggest that the early pathophysiology of ARDS differs according to the type of primary insult to the lung.
PMID: 11355115, UI: 21254543
Intensive Care Med 2001 Mar;27(3):467-76
Department of Medicine-Hepatology, Royal Free and University College Medical School, Royal Free Campus, Rowland Street, Hampstead, London, UK.
Acute hepatic failure is a rare clinical syndrome associated with high mortality. Hepatic failure leads to a well-recognised pattern of clinical signs and symptoms, sometimes with rapid deterioration and progression to multi-organ failure. Early recognition of this syndrome is essential for appropriate treatment; once identified, patients benefit from early interventional support and treatment in the intensive care unit. Aggressive management may allow stabilisation of patients before their transfer to specialist liver units. At present, orthotopic liver transplantation is the only treatment modality that provides significant improvement in outcome. This review examines the aetiology and clinical presentation of acute hepatic failure, providing guidelines regarding patient management. We present a critical appraisal of specific clinical areas, including the management of cardiovascular, cerebral, renal, coagulopathic and infective complications. Liver transplantation is discussed as well as emerging therapies including non-biological and hybrid liver support systems that may provide a "bridge to transplantation".
PMID: 11355114, UI: 21254542
Intensive Care Med 2001 Mar;27(3):464-6
PMID: 11355113, UI: 21254541
Intensive Care Med 2001 Mar;27(3):461-3
PMID: 11355112, UI: 21254540
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