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Am J Crit Care 2002 Jul;11(4):326-30; quiz 331-2
Cardiothoracic Surgery Service, Veterans Administration Medical Center, Denver, Colo, USA.
[Medline record in process]
Although nearly 10% of patients experience profound vasodilatory shock after cardiopulmonary bypass, some patients remain refractory to traditional resuscitation. Among this subset are patients who have inappropriately low levels of endogenous vasopressin. Thus, vasopressin replacement is an intuitively attractive intervention. The purposes of this review are to outline the pathophysiology of vasodilatory shock after cardiopulmonary bypass, to discuss the physiological role of endogenous vasopressin, to explore the clinical basis for vasopressin replacement, and to review the pharmacology and dosing guidelines.
PMID: 12102433, UI: 22096746
Other Formats:
Br J Anaesth 2002 May;88(5):700-7
Department of Anaesthesia, Leeds Teaching Hospital Trust, UK.
Publication Types:
PMID: 12067009, UI: 22061758
Br J Anaesth 2002 May;88(5):669-75
Department of Anaesthesia and Intensive Care, Worthing Hospital, West Sussex, UK.
BACKGROUND: The pharmacokinetics of the alpha-2 adrenoceptor agonist dexmedetomidine were studied in 10 patients requiring postoperative sedation and mechanical ventilation in the intensive care unit (ICU), and compared with previous volunteer data. METHODS: On arrival in the ICU, sedation with dexmedetomidine was commenced with a loading dose of 2.5 microg kg(-1) h(-1) over 10 min followed by a maintenance infusion of 0.7 microg kg(-1) h(-1) into a central vein. Blood samples for measurement of plasma dexmedetomidine concentrations were taken during and after sedative infusions at predetermined intervals. Pharmacokinetic variables were estimated using non-compartmental methods. In addition, non-linear mixed effects modelling was used to obtain variable estimates not readily attainable from non-compartmental methods. Respiratory and haemodynamic data were recorded to enable correlation of any adverse events with the calculated pharmacokinetic profile. RESULTS: The harmonic mean distribution half-life of dexmedetomidine was 8.6 min and the harmonic mean terminal half-life was 3.14 h. Steady-state volume of distribution averaged 173 litres, clearance averaged 48.3 litres h(-1), and the mean residence time averaged 3.86 h. CONCLUSIONS: Mean dexmedetomidine pharmacokinetic variables seen in postoperative, intensive care patients were similar to those previously found in volunteers, with the exception of the steady-state volume of distribution. A small loading dose provided effective sedation with no adverse events.
PMID: 12067004, UI: 22061753
Crit Care Med 2002 Jun;30(6):1400-1
PMID: 12072711, UI: 22067378
Crit Care Med 2002 Jun;30(6):1392-3
PMID: 12072705, UI: 22067372
Crit Care Med 2002 Jun;30(6):1389-90
PMID: 12072703, UI: 22067370
Crit Care Med 2002 Jun;30(6):1382-3
PMID: 12072698, UI: 22067365
Crit Care Med 2002 Jun;30(6):1365-78
Children's Hospital of Pittsburgh, Division of Critical Care Medicine, 15213, USA. carcilloj@anes.upmc.edu
BACKGROUND: The Institute of Medicine has called for the development of clinical guidelines and practice parameters to develop "best practice" and potentially improve patient outcome. OBJECTIVE: To provide American College of Critical Care Medicine clinical guidelines for hemodynamic support of neonates and children with septic shock. SETTING: Individual members of the Society of Critical Care Medicine with special interest in neonatal and pediatric septic shock were identified from literature review and general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (1998-2001). METHODS: The MEDLINE literature database was searched with the following age-specific keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and extracorporeal membrane oxygenation. More than 30 experts graded literature and drafted specific recommendations by using a modified Delphi method. More than 30 more experts then reviewed the compiled recommendations. The task-force chairman modified the document until <10% of experts disagreed with the recommendations. RESULTS: Only four randomized controlled trials in children with septic shock could be identified. None of these randomized trials led to a change in practice. Clinical practice has been based, for the most part, on physiologic experiments, case series, and cohort studies. Despite relatively low American College of Critical Care Medicine-graded evidence in the pediatric literature, outcomes in children have improved from 97% mortality in the 1960s to 60% in the 1980s and 9% mortality in 1999. U.S. hospital survival was three-fold better in children compared with adults (9% vs. 27% mortality) in 1999. Shock pathophysiology and response to therapies is age specific. For example, cardiac failure is a predominant cause of death in neonates and children, but vascular failure is a predominant cause of death in adults. Inotropes, vasodilators (children), inhaled nitric oxide (neonates), and extracorporeal membrane oxygenation can be more important contributors to survival in the pediatric populations, whereas vasopressors can be more important contributors to adult survival. CONCLUSION: American College of Critical Care Medicine adult guidelines for hemodynamic support of septic shock have little application to the management of pediatric or neonatal septic shock. Studies are required to determine whether American College of Critical Care Medicine guidelines for hemodynamic support of pediatric and neonatal septic shock will be implemented and associated with improved outcome.
PMID: 12072696, UI: 22067363
Crit Care Med 2002 Jun;30(6):1348-55
Division of Neurosciences Critical Care, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
OBJECTIVE: To evaluate the reliability of transcranial Doppler ultrasound in detecting symptomatic vasospasm in patients after aneurysmal subarachnoid hemorrhage and monitoring response after hypertensive and endovascular treatments. DESIGN: Retrospective chart review. SETTING: Neurosciences critical care unit in a tertiary-care university hospital. PATIENTS: All patients admitted to a neurosciences critical care unit with the diagnosis of subarachnoid hemorrhage between January 1990 and June 1997. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: We reviewed transcranial Doppler ultrasound data of 199 patients; 55 had symptomatic vasospasm. Clinical symptoms and corresponding vascular distributions were identified, as was angiographic vasospasm (n = 35). The sensitivity and specificity of transcranial Doppler ultrasound for anterior circulation vessels were calculated by using a mean cerebral blood flow velocity criterion of >120 cm/sec. Clinical diagnosis of symptomatic vasospasm was used as the standard to determine sensitivity and specificity of transcranial Doppler ultrasound and cerebral angiography. The sensitivity of transcranial Doppler ultrasound for anterior circulation in patients with symptomatic vasospasm was 73% with a specificity of 80%. The sensitivity of cerebral angiography was 80%. For individual vessels, the sensitivity and specificity of transcranial Doppler ultrasound were middle cerebral artery, 64% and 78%; anterior cerebral artery, 45% and 84%; and internal carotid artery, 80% and 77%, respectively. The mean times for symptomatic and transcranial Doppler ultrasound signs of vasospasm presentation were 6.4 +/- 2 and 6.1 +/- 3 days, respectively. In patients without symptomatic vasospasm, the mean time for mean cerebral blood flow velocities >120 cm/sec was 7.0 +/- 3 days (p <.05). Symptomatic vasospasm also was associated with thickness of clot on head computed tomography scan and rapidly increasing mean cerebral blood flow velocities. Transcranial Doppler ultrasound signs of vasospasm improved after endovascular treatment in 30 patients. CONCLUSIONS: The reliability of transcranial Doppler ultrasound was better at detecting high mean cerebral blood flow velocities in patients with symptomatic vasospasm related to middle cerebral and internal carotid artery distributions than for anterior cerebral artery distribution. Transcranial Doppler ultrasound was as sensitive as cerebral angiography at detecting symptomatic vasospasm. High mean cerebral blood flow velocities can be apparent before the presence of symptomatic vasospasm. Daily transcranial Doppler ultrasound monitoring could provide early identification of patients with aneurysmal subarachnoid hemorrhage who are at high risk for symptomatic vasospasm and may be helpful at following success of endovascular treatment.
PMID: 12072693, UI: 22067360
Crit Care Med 2002 Jun;30(6):1280-90
Intensive Care Unit, Critical Care and Emergencies Department, Hospital de Poniente, El Ejido, Almeria, Spain.
OBJECTIVE: To review reversible myocardial dysfunction affecting critically ill patients without cardiac pathology. DATA SOURCES: The bibliography for the study was compiled through a search of different databases for the period 1966-2001. References cited in the selected articles also were reviewed. STUDY SELECTION: The selection criteria included all articles published on reversible myocardial dysfunction in critically ill patients. CONCLUSIONS: Reversible myocardial dysfunction may develop in a situation of critical pathology, but the etiology of reversible myocardial dysfunction is not fully understood. This dysfunction may be accompanied by increases in enzyme concentrations and electrocardiographic changes. Reversible myocardial dysfunction probably is underdiagnosed, although its presence is associated with a worsening of the prognosis and with more specific therapeutic options. Further studies are necessary to define its true incidence and clinical implications.
PMID: 12072682, UI: 22067349
Crit Care Med 2002 Jun;30(6):1267-73
Mercy Hospital of Pittsburgh, PA, USA.
OBJECTIVE: The adrenal gland is the endocrine organ most commonly involved in patients infected with human immunodeficiency virus (HIV). It is important to recognize patients with adrenal insufficiency, because this disorder may be fatal if untreated. The incidence of adrenal insufficiency in critically ill HIV-infected patients is unclear, partly because different criteria are used to diagnose adrenal insufficiency. To help clarify the incidence of adrenal insufficiency in HIV-infected critically ill patients, we compared the incidence based on the stress cortisol concentration, low-dose corticotropin stimulation test, and high-dose corticotropin stimulation test. SETTING: Medical intensive care unit. PATIENTS: Twenty-eight critically ill patients with HIV, mean age 43 +/- 9 years; 20 were male; 54% died. INTERVENTIONS: We performed a 1-microg (low-dose adrenocorticotropic hormone; LD-ACTH) and 249 microg (high-dose; HD-ACTH) corticotropin stimulation test in HIV-infected critically ill patients not receiving corticosteroids. According to results of the stress serum cortisol concentration and LD-ACTH and HD-ACTH tests, patients were classified as having adrenal insufficiency or as normal. The results of newly revised diagnostic criteria for adrenal insufficiency (i.e., stress cortisol concentration and cortisol response to LD-ACTH <25 microg/dL) were compared with the traditional criteria (i.e., stress cortisol level and response to HD-ACTH <18 microg/dL). In addition, the associations between adrenal insufficiency and the CD4 count, human cytomegalovirus antigenemia, and other risk factors for adrenal insufficiency were determined. MEASUREMENTS AND MAIN RESULTS: When we used a stress cortisol concentration <18 microg/dL as the sole diagnostic threshold for diagnosis of adrenal insufficiency, 50% (14 of 28) of patients had adrenal insufficiency. The incidence was 75% (21 of 28) when we used a diagnostic threshold of <25 microg/dL for the stress cortisol concentration. When we used both the stress cortisol concentration and LD-ACTH test with a diagnostic cortisol threshold concentration <18 microg/dL, 21% (six of 28) had adrenal insufficiency. The incidence was 46% (13 of 28) when we used a cortisol diagnostic threshold concentration of <25 microg/dL. When we used both the stress cortisol concentration and the HD-ACTH stimulation test with a diagnostic cortisol threshold of <18 microg/dL, 7% (two of 28) had adrenal insufficiency. The incidence of adrenal insufficiency was 21% (six of 28) with a cortisol diagnostic threshold value of <25 microg/dL. Human cytomegalovirus antigenemia was the only variable assessed that was associated with adrenal insufficiency. CONCLUSION: There is a high incidence of adrenal insufficiency in critically ill HIV-infected patients that varies with the criteria used to diagnose adrenal insufficiency. The LD-ACTH stimulation test is more sensitive than the high-dose test for diagnosing adrenal insufficiency in this population. Because of the high incidence of inadequate adrenal function, all critically ill HIV-infected patients should undergo an evaluation for adrenal insufficiency with the stress cortisol concentration and LD-ACTH stimulation tests.
PMID: 12072680, UI: 22067347
Crit Care Med 2002 Jun;30(6):1237-41
Service de Reanimation Polyvalente, Centre Hospitalier Departemental, La Roche-sur-Yon, France.
OBJECTIVE: To determine whether erythromycin facilitates early enteral nutrition in mechanically ventilated, critically ill patients. DESIGN: Prospective, randomized, placebo-controlled, single-blind trial. SETTING: General intensive care unit in a university-affiliated general hospital. PATIENTS: Forty consecutive critically ill patients receiving invasive mechanical ventilation and early nasogastric feeding. INTERVENTIONS: Patients were assigned randomly to intravenous erythromycin (250 mg/6 hrs; n = 20) or a placebo (intravenous 5% dextrose, 50 mL/6 hrs; n = 20) for 5 days. The first erythromycin or 5% dextrose injection was given at 8 am on the day after intubation. One hour later, a daily 18-hr enteral nutrition regimen via a 14-Fr gastric tube was started. Residual gastric volume was aspirated and measured every day at 9 am, 3 pm, 9 pm, and 3 am. Enteral nutrition was discontinued if residual gastric volume exceeded 250 mL or the patient vomited. MEASUREMENTS AND MAIN RESULTS: On the first day, residual gastric volume was smaller in the erythromycin than in the placebo group (3 pm, 15 +/- 7 mL vs. 52 +/- 14 mL, p <.05; 9 pm, 29 +/- 15 mL vs. 100 +/- 20 mL, p <.001; 3 am, 11 +/- 4 mL vs. 54 +/- 13 mL, p <.05). With erythromycin, residual gastric volume at 9 pm was smaller on the second day (33 +/- 11 mL vs. 83 +/- 19 mL, p <.01) and residual gastric volume at 3 pm was smaller on the third day (39 +/- 15 mL vs. 88 +/- 19 mL, p <.05) than with placebo. On the fourth and fifth days, the differences in residual gastric volume were not significant. Enteral nutrition was discontinued before the end of the 5-day period in seven of the 20 erythromycin patients and 14 of the 20 placebo patients (p <.001). CONCLUSION: In critically ill patients receiving invasive mechanical ventilation, erythromycin promotes gastric emptying and improves the chances of successful early enteral nutrition.
PMID: 12072674, UI: 22067341
Crit Care Med 2002 Jun;30(6):1231-6
Department of Pediatric Intensive Care, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.
OBJECTIVES: To compare propofol with ketamine sedation delivered by pediatric intensivists during painful procedures in the pediatric critical care department (PCCD). DESIGN: Prospective 15-month study. SETTING: An 18-bed multidisciplinary, university-affiliated PCCD. INTERVENTIONS: All children were randomized to the propofol or ketamine protocol according to prescheduled procedure dates. Propofol was delivered by continuous infusion after a loading bolus dose and a minidose of lidocaine (PL). Ketamine was given as a bolus injection together with midazolam and fentanyl (KMF). Repeated bolus doses of both drugs were given to achieve the desired level of anesthesia. The studied variables included procedures performed, anesthetic drug doses, procedure and recovery durations, and side effect occurrence. The patient's parents, PCCD nurse and resident physician, pediatric intensivist, and the physician performing the procedure graded the adequacy of anesthesia. MEASUREMENTS AND MAIN RESULTS: Of the 105 procedures in 98 children, PL sedation was used in 58 procedures, and KMF was used in 47. Recovery time was 23 mins for PL and 50 mins for KMF, and total PCCD monitoring was 43 mins for PL and 70 mins for KMF. Five children (10.6%) in the KMF group and in none in the PL group experienced discomfort during emergence from sedation. Transient decreases in blood pressure, partial airway obstruction, and apnea were more frequent in the PL than in the KMF sedation. All procedures were successfully completed, and no child recalled undergoing the procedure. The overall sedation adequacy score was 97% for PL and 92% for KMF (p <.05). CONCLUSIONS: Both PL and KMF anesthesia are effective in optimizing comfort in children undergoing painful procedures. PL scored better by all evaluators, recovery from PL anesthesia after procedural sedation was more rapid, total PCCD stay was shorter with PL, and emergence from PL was smoother than with KMF. Because transient respiratory depression and hypotension are associated with PL, it is considered safe only in a monitored environment (e.g., a PCCD).
PMID: 12072673, UI: 22067340
Crit Care Med 2002 Jun;30(6):1210-3
Department of Intensive Care Gelre Hospital, Apeldoorn, The Netherlands.
OBJECTIVE: Peripheral perfusion in critically ill patients frequently is assessed by use of clinical signs. Recently, the pulse oximetry signal has been suggested to reflect changes in peripheral perfusion. A peripheral perfusion index based on analysis of the pulse oximetry signal has been implemented in monitoring systems as an index of peripheral perfusion. No data on the variation of this index in the normal population are available, and clinical application of this variable in critically ill patients has not been reported. We therefore studied the variation of the peripheral perfusion index in healthy adults and related it to the central-to-toe temperature difference and capillary refill time in critically ill patients after changes in clinical signs of peripheral perfusion. DESIGN: Prospective study. SETTING: University-affiliated teaching hospital. PATIENTS: One hundred eight healthy adult volunteers and 37 adult critically ill patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Capillary refill time, peripheral perfusion index, and arterial oxygen saturation were measured in healthy adults (group 1). Capillary refill time, peripheral perfusion index, arterial oxygen saturation, central-to-toe temperature difference, and hemodynamic variables were measured in critically ill patients (group 2) during different peripheral perfusion profiles. Poor peripheral perfusion was defined as a capillary refill time >2 secs and central-to-toe temperature difference > or = 7 degrees C. Peripheral perfusion index and arterial oxygen saturation were measured by using the Philips Medical Systems Viridia/56S monitor. In group 1, measurements were made before and after a meal. In group 2, two measurements were made, with the second measurement taken when the peripheral perfusion profile had changed. A total of 216 measurements were carried out in group 1. The distribution of the peripheral perfusion index was skewed and values ranged from 0.3 to 10.0, median 1.4 (inner quartile range, 0.7-3.0). Seventy-four measurements were carried out in group 2. A significant correlation between the peripheral perfusion index and the core-to-toe temperature difference was found (R2=.52; p <.001). A cutoff peripheral perfusion index value of 1.4 (calculated by constructing a receiver operating characteristic curve) best reflected the presence of poor peripheral perfusion in critically ill patients. Changes in peripheral perfusion index and changes in core-to-toe temperature difference correlated significantly (R =.52, p <.001). CONCLUSIONS: The peripheral perfusion index distribution in the normal population is highly skewed. Changes in the peripheral perfusion index reflect changes in the core-to-toe temperature difference. Therefore, peripheral perfusion index measurements can be used to monitor peripheral perfusion in critically ill patients.
PMID: 12072670, UI: 22067337
Crit Care Med 2002 Jun;30(6):1191-6
Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
OBJECTIVE: To estimate the cost effectiveness of aggressive care for patients with nontraumatic coma. DESIGN: Cost-effectiveness analysis. SETTING: Five academic medical centers. PATIENTS: Patients with nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Patients with reversible metabolic causes of coma such as diabetic ketoacidosis or uremia were excluded. MEASUREMENTS: We calculated the incremental cost effectiveness of continuing aggressive care vs. withholding cardiopulmonary resuscitation and ventilatory support after day 3 of coma. We estimated life expectancy based on up to 4.6 yrs of follow-up. Utilities (quality-of-life weights) were estimated using time-tradeoff questions. Costs were based on hospital fiscal data and Medicare data. Separate analyses were conducted for two prognostic groups based on five risk factors assessed on day 3 of coma: age > or = 70 yrs, abnormal brainstem response, absent verbal response, absent withdrawal to pain, and serum creatinine > or = 132.6 micromol/L (1.5 mg/dL). RESULTS: For the 596 patients studied, the median (25th, 75th percentile) age was 67 yrs (range, 55-77), and 52% were female. By 2 months after enrollment, 69% had died, 19% were severely disabled, 7% had survived without severe disability, and 4% had survived with unknown functional status. The incremental cost effectiveness of the more aggressive care strategy was $140,000 (1998 dollars) per quality-adjusted life year (QALY) for high-risk patients (3-5 risk factors, 93% 2-month mortality) and $87,000/QALY for low-risk patients (0-2 risk factors, 49% mortality). In sensitivity analyses, the incremental cost per QALY did not fall below $50,000/QALY, even with wide variation in our baseline estimates. CONCLUSIONS: Continuing aggressive care after day 3 of nontraumatic coma is associated with a high cost per QALY gained, especially for patients at high risk for poor outcomes. Earlier decisions to withhold life-sustaining treatments for patients with very poor prognoses may yield considerable cost savings.
PMID: 12072667, UI: 22067334
Crit Care Nurse 2002 Feb;22(1):11-2
PMID: 11852483, UI: 21842254
J Trauma 2002 Jun;52(6):1087-90; discussion 1090
Department of Surgery, University of Florida Health Sciences Center, Jacksonville, Florida 32209, USA. miren.schinco@jax.usl.edu
BACKGROUND: The core of general surgery supports multiple disciplines, each of which entails similar operative care for different diseases. The purpose of this study was to compare variations of practice patterns of four general surgeons to define the general surgical core that each shared in common, and to determine the effect of subspecialization in surgical critical care on the scope of practice and efficiency of revenue production. METHODS: The charges and collections of four members of the same surgical faculty were analyzed for the 6 months beginning July 1, 2000. Three members practiced general surgery with additional specialization in surgical oncology, surgical endoscopy, and trauma/critical care. The fourth covered all aspects of general surgery, including in-house trauma call, but not surgical critical care. Data were stratified by Current Procedural Terminology code and categorized as operative, bedside care (which included minor procedures), and evaluation/consultation care. Scope of practice was defined as the proportion of operative cases represented by the 10 most frequently performed procedures. General surgical core was defined as those cases that were preformed by all four surgeons at the same frequency. Efficiency of revenue generation was defined as collection rate for these procedures divided by the established, budgeted collection rate for each practitioner. All results were compared using chi(2) with significance accepted at p < 0.05. RESULTS: Fifteen operative procedures were performed with equal frequency by each surgeon and represented a broad spectrum of surgical disease. These procedures constituted a similar proportion of operative practice for all specialists (mean, 45.2%; 90% confidence limit, 3.5%), yet occupied 70% of the trauma surgeon's 10 most frequent surgical procedures versus 36% for the surgical oncology and surgical endoscopy. Charges generated by the provision of surgical critical care, especially in bedside procedures commonly performed in the intensive care unit, exceeded all of the other three surgeons and equaled the revenue generated by operative care. Although overall revenue-generating efficiency was less for the trauma surgeons (57% of eventual collections vs. 67%, chi(2) p = 0.1), immediate reimbursement for critical care was higher than for any other clinical services. CONCLUSION: These data demonstrate that subspecialization in surgical critical care provides valid additional earning capacity to surgical practitioners. Reimbursement is at least as good as for traditional operative care, and fees generated can actually exceed revenue from operative care. With impending decreases in global reimbursement, and attempts to unbundle operative fees, this additional capability becomes an important consideration in potential career choice, as well as a major component in the fiscal stability of trauma programs.
PMID: 12045634, UI: 22040668
J Trauma 2002 Jun;52(6):1037-47; discussion 1047
Legacy Emanuel Hospital Shock/Trauma Program, Legacy Emanuel Hospital, Portland, Oregon 97227, USA. amichael@lhs.org
INTRODUCTION: We present a series of adult patients treated under a protocol for severe lung failure (acute respiratory distress syndrome [ARDS]) that uses positive end-expiratory pressure (PEEP) optimization and intermittent prone positioning (IPP) to reduce shunt, improve oxygen (O(2)) delivery, and reduce FiO(2). METHODS: Trauma, emergency vascular, and general surgical patients with PaO(2)/FiO)(2) (PF) ratio < 200 were entered into a protocol designed to maintain mixed venous saturation (SVO(2)) > 70% with FiO(2) < 0.50. Therapy involved a sequential algorithmic approach that included pulmonary artery oximetry, "best-PEEP" determination, optimization of cardiac function, limitation of VO(2), transfusion to hematocrit of 35%, frequent bronchoscopy, rational diuresis and, if the FiO(2) was > 0.50, a trial of IPP with every-6-hour rotations. Unstable spine fractures and pelvic external fixators were the only contraindications to IPP. We collected data prospectively and from the charts and trauma registry. RESULTS: Forty adults were treated by protocol, 29 were injured and 11 had vascular or general surgical primary problems. The patients were 46.3 +/- 3.1 years old (the trauma patients were 42.9 +/- 3.2, and the vascular/general patients were 62 +/- 7.5 years old). Average Injury Severity Score was 25.9 +/- 3.7 and the Murray lung injury score was 2.65 +/- 0.9. IPP was used in all patients including those with recent tracheostomy, open abdomens, laparotomy, thoracotomy, leg external fixators, central nervous system injury, continuous venovenous hemofiltration and extracorporeal membrane oxygenation cannulae, vasopressor therapy, recent chest wall open reduction and internal fixation, and facial fractures. With the initiation of IPP therapy, the PF ratio increased from 132.1 +/- 8.5 to 231.6 +/- 14.2 (p < 0.001), the FiO(2) was decreased from 65.9 +/- 4.0% to 47.0 +/- 1.1% (p < 0.001), and the SVO(2) increased from 75.3 +/- 1.8% to 78.6 +/- 1.6% (p = 0.023). PEEP and static compliance were unchanged. The duration of IPP was 85.6 +/- 14.9 hours (median, 55 hours; range, 12 to 490 hours). Within 48 hours, all patients were on FiO(2) < or = 50. Mortality was 20% (14% for trauma) and none died of ARDS. The only complications of IPP were one case of partial-thickness skin loss from a malpositioned nasogastric tube and a case of transient lingual edema. CONCLUSION: IPP was independently responsible for an increase in PF ratio and SVO(2). We effectively and safely used IPP in our patients with ARDS, including many with issues generally considered to be contraindications. IPP and best-PEEP therapy enabled us to wean all of our patients' Fio2 to < or = 0.50 within 48 hours of ARDS onset.
PMID: 12045628, UI: 22040662
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