Intensive Care Med 2002 Feb;28(2):214-7
Service de Reanimation Polyvalente, Hopital Roger Salengro, CHRU Universite Lille 2, 59037 Lille, France.
OBJECTIVES: To describe five new cases of life-threatening cefepime-induced neurotoxicity observed in a 2-year period. SETTING: A university intensive care unit. PATIENTS: Five patients recently treated with cefepime, admitted for seizures and coma. All suffered from acute renal failure, induced by sepsis and combined aminoside therapy, or by cefepime itself in one case. INTERVENTIONS: All patients underwent hemodialysis, which led to complete neurological improvement in four of them. One patient remained comatose and subsequently died. MEASUREMENTS: Blood and CSF cefepime levels were measured by high performance liquid chromatography before and after hemodialysis. CONCLUSION: The frequency of cefepime-induced neurotoxicity is probably underestimated. Monitoring of renal function and close neurological survey in treated patients should allow an early diagnosis of this complication. Urgent hemodialysis seems the best therapeutic method to obtain a rapid neurological improvement.
PMID: 11907668, UI: 21904278
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Intensive Care Med 2002 Mar;28(3):304-9
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
OBJECTIVES: Trunk position at 45 degrees from the horizontal is associated with a decreased risk of gastroesophageal aspiration. The objectives of this study were to determine the accuracy of trunk flexion estimates compared to a reference standard measurement, and to determine agreement about trunk flexion among ICU clinicians. DESIGN: Prospective observational study. SETTING: Two university-affiliated medical-surgical ICUs. PATIENTS AND PARTICIPANTS: Thirty-three mechanically ventilated ICU patients, seven residents, two fellows, three intensivists, and twenty-eight bedside nurses. INTERVENTIONS: Prospectively, concurrently, and independently during rounds, one bedside nurse, one resident, one fellow, and one intensivist clinically estimated the trunk flexion of mechanically ventilated patients. To record the reference standard, a trained investigator measured trunk position in the vertical plane using a goniometer. MEASUREMENTS AND RESULTS: We made 438 clinical assessments on 33 patients aged 57.2+/-19.4 (SD) years with an APACHE II score of 27.3+/-9.4. Mean trunk flexion estimates were: nurses 24.3+/-12.3 degrees from the horizontal, residents 20.2+/-13.7, fellows 20.3+/-10.8, and intensivists 21.1+/-13.1 compared to the reference standard measurement 16.2+/-9.0 degrees. The accuracy of trunk flexion estimates was fair to moderate [intraclass correlation for reference standard versus nurses (ICC 0.42), residents (ICC 0.52), fellows (ICC 0.36), and intensivists (ICC 0.55)]. The agreement among different groups of clinicians was moderate. CONCLUSIONS: In mechanically ventilated patients, we found that clinical estimates of trunk position were moderately good, agreement amongst caregivers was moderately good, but that all clinicians tended to overestimate the angle of semirecumbency.
PMID: 11904660, UI: 21901381
Intensive Care Med 2002 Mar;28(3):272-7
Service de Reanimation Medicale, Centre Hospitalier Universitaire de Bicetre, Assistance Publique, Hopitaux de Paris, Faculte de Medecine Paris-Sud, Universite Paris XI, 78 rue du General Leclerc, 94275 le Kremlin-Bicetre Cedex, France.
OBJECTIVE: Under conditions of tissue hypoxia total CO2 production (VCO2) should be less reduced than O2 consumption (VO2) since an anaerobic CO2 production should occur. Thus the VCO(2)/VO(2) ratio, and hence the venoarterial CO2 tension difference/arteriovenous O2 content difference ratio (DeltaPCO2/C(a-v)O2), should increase. We tested the value of the DeltaPCO2/C(a-v)O2 ratio in detecting the presence of global anaerobic metabolism as defined by an increase in arterial lactate level above 2 mmol/l (Lac+). DESIGN AND SETTING: Retrospective study over a 17-month period in medical intensive care unit of a university hospital. PATIENTS: We obtained 148 sets of measurements in 89 critically ill patients monitored by a pulmonary artery catheter. RESULTS: The DeltaPCO2/C(a-v)O2 ratio was higher in those with increased ( n=73) than in the normolactatemic group (2.0+/-0.9 vs. 1.1+/-0.6, p<0.0001). Among all the O2- and CO2-derived parameters the DeltaPCO2/C(a-v)O2 ratio had the highest correlation with the arterial lactate level ( r=0.57). Moreover, for a threshold value of 1.4 the DeltaPCO2/C(a-v)O2 ratio predicted significantly better than the other parameters (receiver operating characteristic curves) the presence of hyperlactatemia (positive and negative predictive values of 86% and 80%, respectively). The overall survival estimate at 1 month was greater when the DeltaPCO2/C(a-v)O2 ratio was less than 1.4 on the first set of measurements (38+/-10% vs. 20+/-8%, p<0.01). CONCLUSION: The DeltaPCO2/C(a-v)O2 ratio seems a reliable marker of global anaerobic metabolism. Its calculation would be helpful for a better interpretation of pulmonary artery catheter data.
PMID: 11904655, UI: 21901376
Intensive Care Med 2002 Mar;28(3):256-64
Department of Intensive Care, St George's Hospital, London SW17 0QT, UK. arhodes@sghms.ac.uk
OBJECTIVE: To compare the survival and clinical outcomes of critically ill patients treated with the use of a pulmonary artery catheter (PAC) to those treated without the use of a PAC. DESIGN: Prospective, randomised, controlled, clinical trial from October 1997 to February 1999. SETTING: Adult intensive care unit at a large teaching hospital. PATIENTS: Two hundred one critically ill patients were randomised either to a PAC group ( n=95) or the control group ( n=106). One patient in the control group was withdrawn from the study and five patients in the PAC group did not receive a PAC. All participants were available for follow-up. INTERVENTIONS: Participants were assigned to be managed either with the use of a PAC (PAC group) or without the use of a PAC (control group). MAIN OUTCOME MEASURES: Survival to 28 days, intensive care and hospital length of stay and organ dysfunction were compared on an intention-to-treat basis and also on a subgroup basis for those participants who successfully received a PAC. RESULTS There was no significant difference in mortality between the PAC group [46/95 (47.9%)] and the control group [50/106 (47.6)] (95% confidence intervals for the difference -13 to 14%, p>0.99). The mortality for participants who had management decisions based on information derived from a PAC was 41/91 (45%, 95% confidence intervals -11 to 16%, p=0.77). The PAC group had significantly more fluids in the first 24 h (4953 (3140, 7000) versus 4292 (2535, 6049) ml) and an increased incidence of renal failure (35 versus 20% of patients at day 3 post randomisation p<0.05) and thrombocytopenia ( p<0.03). CONCLUSIONS: These results suggest that the PAC is not associated with an increased mortality.
Publication Types:
PMID: 11904653, UI: 21901374
Intensive Care Med 2002 Mar;28(3):235-43
Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Avenida Prof. Torrado da Silva, Pragal, 2800-525 Almada, Portugal. povoap@netcabo.pt
PMID: 11904651, UI: 21901372
Intensive Care Med 2002 Mar;28(3):230-4
PMID: 11904650, UI: 21901371
Intensive Care Med 2002 Mar;28(3):225-6
PMID: 11904648, UI: 21901369
J Paediatr Child Health 2002 Jun;38(3):246-251
Division of Newborn Services, Royal Women's Hospital, Carlton and Departments of Obstetrics and Gynaecology, and Paediatrics, University of Melbourne, Parkville, Australia.
[Record supplied by publisher]
AIM: To determine the incidence and clinical characteristics of sepsis in ventilated infants from an Australian neonatal intensive care unit (NICU) in the late 1990s. METHODS: Demographic data was collected from babies requiring assisted ventilation (AV) over the 6-month period from 1 July to 31 December 1998. Sepsis was divided into early onset sepsis (EOS; " 72 h of age) and late onset sepsis (LOS; >72 h of age), including both definite (culture-proven + abnormal markers) and probable (culture negative + abnormal markers) episodes. RESULTS: Two hundred and eleven babies required AV over this period. Of these, 64 (30.3%) had at least one infection, with 85 episodes of sepsis (40.3 episodes per 100 admissions requiring AV). There were 22 babies with 22 episodes of EOS, and 45 with 63 episodes of LOS. Three babies had both EOS and LOS. The rate of EOS was 10.4 infected infants (10.4 infections per 100 admissions requiring AV). The rate of LOS was 21.3 infected infants (29.9 infections per 100 admissions requiring AV). The rates of both EOS and LOS were higher than previously reported by Australian studies in the early 1990s. In both EOS and LOS, risk factors for infection were common. Group B streptococcus was the commonest cause of definite EOS. The mortality rate from sepsis in the EOS group was 14% (3/22). Coagulase-negative staphylococci were the commonest cause of LOS. The mortality rate from sepsis in the LOS group was 11% (5/45). CONCLUSIONS: EOS and LOS are significant problems in ventilated NICU infants in the late 1990s.
PMID: 12047691
Pediatrics 2002 Jun;109(6):e94
Section of Critical Care and Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas 77030, USA. mlmcpher@texaschildrenshospital.org
[Medline record in process]
OBJECTIVES: To describe the medical follow-up ordered, the health care utilization, the appointment compliance, and the risk factors associated with noncompliance in patients who are discharged after a pediatric intensive care unit (PICU) stay. METHODS: A prospective, analytic, cohort study of 111 critically ill children, age 1 day to 16 years, who were admitted to a 30-bed PICU in an urban, tertiary-care, pediatric teaching hospital compared children who were compliant with medical follow-up with those who were not. The main outcomes measured were emergent and unscheduled physician visits during the first 6 weeks after hospital discharge; compliance with ordered medical follow-up after hospital discharge; and comparisons of socioeconomic, demographic, and medical need factors between compliant and noncompliant children. Discharge orders for follow-up appointments with general pediatricians and subspecialists were collected from the chart at hospital discharge. Patients were contacted after hospital discharge to determine whether and when they received medical follow-up; 28% were found to be noncompliant. Risk factors associated with noncompliance were evaluated. Emergent and unscheduled physician visits were tracked during the first 6 weeks after hospital discharge. RESULTS:Lack of follow-up orders at hospital discharge did not affect the frequency of emergent visits. Children fell into 2 groups: those who were 100% compliant and those with < or =67% compliance. No socioeconomic or demographic risk factors could be identified between the 2 groups. Compared with the 100% compliant patients, patients who were compliant with < or =67% of appointments were more severely ill, as defined by higher peak pediatric risk of mortality scores during their PICU stay (11.5 vs 8.4), longer PICU length of stays (10.1 days vs 4.6 days), and longer hospital length of stays (25.5 days vs 14 days). Most predictive of noncompliance was the number of medical appointments ordered by physicians. Patients with 3 or more appointments were less likely to be compliant with follow-up. After hospital discharge, children were more likely to visit a primary care physician compared with a subspecialist (95% vs 82%). When patients were ordered to see a specialist, scheduled appointments were much better attended than the recommended appointments (92% vs 67%). CONCLUSIONS: Lack of ordered medical follow-up did not affect emergent visits. In this group of critically ill children, a significant percentage (28%) did not receive timely medical follow-up. No socioeconomic or demographic risk factors were identified in noncompliant children. However, severity of illness (higher peak pediatric risk of mortality score, longer PICU stay, and longer hospital stay) and the number of follow-up appointments ordered were predictors of noncompliance. Potential exists for implementing strategies to improve compliance in identified populations.
PMID: 12042588, UI: 22038518
Pediatrics 2002 Jun;109(6):1187-8
Section of Pediatric Clinical Pharmacology and Medical Toxicology, Children's Hospital, Columbus, OH 43205. Division of Pharmacology and Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH 44106.
PMID: 12042570, UI: 22038501
Pediatrics 2002 Jun;109(6):1036-43
Department of Pediatrics. Center for the Evaluative Clinical Sciences and Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire.
BACKGROUND: Despite high per capita health care expenditure, the United States has crude infant survival rates that are lower than similarly developed nations. Although differences in vital recording and socioeconomic risk have been studied, a systematic, cross-national comparison of perinatal health care systems is lacking. OBJECTIVE: To characterize systems of reproductive care for the United States, Australia, Canada, and the United Kingdom, including a detailed analysis of neonatal intensive care and mortality. Design/Methods. Comparison of selected indicators of reproductive care and mortality from 1993-2000 through a systematic review of journal and government publications and structured interviews of leaders in perinatal and neonatal care. RESULTS: Compared with the other 3 countries, the United States has more neonatal intensive care resources yet provides proportionately less support for preconception and prenatal care. Unlike the United States, the other countries provided free family planning services and prenatal and perinatal physician care, and the United Kingdom and Australia paid for all contraception. The United States has high neonatal intensive care capacity, with 6.1 neonatologists per 10 000 live births; Australia, 3.7; Canada, 3.3; and the United Kingdom, 2.7. For intensive care beds, the United States has 3.3 per 10 000 live births; Australia and Canada, 2.6; and the United Kingdom, 0.67. Greater neonatal intensive care resources were not consistently associated with lower birth weight-specific mortality. The relative risk (United States as reference) of neonatal mortality for infants <1000 g was 0.84 for Australia, 1.12 for Canada, and 0.99 for the United Kingdom; for 1000 to 2499 g infants, the relative risk was 0.97 for Australia, 1.26 for Canada, and 0.95 for the United Kingdom. As reported elsewhere, low birth weight rates were notably higher in the United States, partially explaining the high crude mortality rates. CONCLUSIONS: The United States has significantly greater neonatal intensive care resources per capita, compared with 3 other developed countries, without having consistently better birth weight-specific mortality. Despite low birth weight rates that exceed other countries, the United States has proportionately more providers per low birth weight infant, but offers less extensive preconception and prenatal services. This study questions the effectiveness of the current distribution of US reproductive care resources and its emphasis on neonatal intensive care.
PMID: 12042540, UI: 22038471
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