Order this document
Am J Respir Crit Care Med 2002 Oct 15;166(8):1024-8
Department of Medicine, University of Chicago, Chicago, Illinois.
[Medline record in process]
PMID: 12379543, UI: 22266679
Other Formats: Links:
Am J Respir Crit Care Med 2002 Sep 15;166(6):791-6
Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Publication Types:
PMID: 12231486, UI: 22217056
Other Formats:
Br J Anaesth 2002 Aug;89(2):306-24
Department of Anaesthesia, Guy's and St Thomas' Hospital Trust, St Thomas' Street, London SE1 9RT, UK.
In the wake of recent atrocities there has been renewed apprehension regarding the possibility of chemical and biological weapon (CBW) deployment by terrorists. Despite various international agreements that proscribe their use, certain states continue to develop chemical and biological weapons of mass destruction. Of greater concern, recent historical examples support the prospect that state-independent organizations have the capability to produce such weapons. Indeed, the deliberate deployment of anthrax has claimed several lives in the USA since September 11, 2001. In the event of a significant CBW attack, medical services would be stretched. However, victim survival may be improved by the prompt, coordinated response of military and civil authorities, in conjunction with appropriate medical care. In comparison with most other specialties, anaesthetists have the professional academic background in physiology and pharmacology to be able to understand the nature of the injuries caused by CBWs. Anaesthetists, therefore, play a vital role both in the initial resuscitation of casualties and in their continued treatment in an intensive care setting. This article assesses the current risk of CBW deployment by terrorists, considers factors which would affect the severity of an attack, and discusses the pathophysiology of those CBWs most likely to be used. The specific roles of the anaesthetist and intensivist in treatment are highlighted.
PMID: 12378672, UI: 22266337
Crit Care Med 2002 Sep;30(9):2166-7
PMID: 12352070, UI: 22238534
Crit Care Med 2002 Sep;30(9):2164-5
PMID: 12352069, UI: 22238533
Crit Care Med 2002 Sep;30(9):2162-4
PMID: 12352068, UI: 22238532
Crit Care Med 2002 Sep;30(9):2153-4
PMID: 12352062, UI: 22238526
Crit Care Med 2002 Sep;30(9):2152-3
PMID: 12352061, UI: 22238525
Crit Care Med 2002 Sep;30(9):2151
PMID: 12352060, UI: 22238524
Crit Care Med 2002 Sep;30(9):2146-8
PMID: 12352058, UI: 22238522
Crit Care Med 2002 Sep;30(9):2129-34
Department of Neuroscience, Section of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden.
OBJECTIVE: To evaluate today's refined neurosurgical intensive care of patients with traumatic brain injury after implementation of an organized secondary insult program focused on the importance of avoiding secondary brain damage together with a standardized treatment protocol system. DESIGN: Clinical observational patient study. PATIENTS: A total of 154 patients 16-79 yrs of age with acute head trauma and pathologic computed tomographic findings treated between 1996 and 1997. SETTING: Neurointensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Good recovery was obtained in 44% of the patients, moderate disability in 35%, severe disability in 16%, and no patient remained in a vegetative state. Six percent of the patients died, but only two of these patients (1.3%) died as direct result of their head injury. When the results for patients with Glasgow Coma Scale motor scores of >or=4 were compared with the periods 1980-1981 (preneurosurgical intensive care) and 1987-1988 (basic neurosurgical intensive care), mortality had decreased from 40% in the first period to 27% in the second period and to 2.8% in the present series. Favorable outcome in the same group of patients had increased steadily from 40% in the first period, to 68% in the second period, and finally, to 84% in the present series. CONCLUSIONS: The main observation in this hospital series of traumatic brain injury patients was a low rate of death directly caused by head injury and a high rate of favorable outcome. The comparison of patients with Glasgow Coma Scale motor scores of >or=4 with the previously reported results from the same unit indicate that substantial improvement in outcome has been achieved.
PMID: 12352052, UI: 22238516
Crit Care Med 2002 Sep;30(9):2051-8
Department of Reanimation Medicale, Hopital St. Louis, University Lariboisiere-St. Louis, Paris, France. philipp.metnitz@univie.ac.at
OBJECTIVES: Acute renal failure is a complication in critically ill patients that has been associated with an excess risk of hospital mortality. Whether this reflects the severity of the disease or whether acute renal failure is an independent risk factor is unknown. The aim of this study was to analyze severity of illness and mortality in a group of critically ill patients with acute renal failure requiring renal replacement therapy in a number of Austrian intensive care units. DESIGN: Prospective, multicenter cohort study. PATIENTS AND SETTING: A total of 17,126 patients admitted consecutively to 30 medical, surgical, and mixed intensive care units in Austria over a period of 2 yrs. MEASUREMENTS AND MAIN RESULTS: Analyzed data included admission data, Simplified Acute Physiology Score, Logistic Organ Dysfunction system, Simplified Therapeutic Intervention Scoring System, length of intensive care unit stay, intensive care unit mortality, and hospital mortality. Of the admitted patients, 4.9% (n = 839) underwent renal replacement therapy because of acute renal failure (renal replacement therapy patients). These patients had a significantly higher hospital mortality (62.8% vs. 15.6%, p<.001), which remained significantly higher even when renal replacement therapy patients were matched with control subjects for age, severity of illness, and treatment center. Since univariate analysis demonstrated further intensity of treatment to be an additional predictor for outcome, a multivariate model including therapeutic interventions was developed. Five interventions were associated with nonsurvival (mechanical ventilation, single vasoactive medication, multiple vasoactive medication, cardiopulmonary resuscitation, and treatment of complicated metabolic acidosis/alkalosis). In contrast, the use of enteral nutrition predicted a favorable outcome. CONCLUSIONS: The results of our study suggest that acute renal failure in patients undergoing renal replacement therapy presents an excess risk of in-hospital death. This increased risk cannot be explained solely by a more pronounced severity of illness. Our results provide strong evidence that acute renal failure presents a specific and independent risk factor for poor prognosis.
PMID: 12352040, UI: 22238504
Crit Care Med 2002 Sep;30(9):2032-7
Department of Anaesthesiology and Intensive Care, University of Munster, Germany.
OBJECTIVE: Glutamine is recognized as a conditionally indispensable amino acid. The purpose of the current study was to investigate whether supplemental l-alanyl-l-glutamine to parenteral nutrition can alter clinical outcome in intensive care unit patients. DESIGN: Prospective, open, randomized trial. SETTING: Postoperative intensive care unit of a university hospital. PATIENTS: Male and female critically ill patients with indications for parenteral nutrition and an expected stay on intensive care unit for >or=5 days. INTERVENTIONS: Patients were randomized to receive either standard parenteral nutrition or supplemented parenteral nutrition with l-alanyl-l-glutamine (0.3 g.kg.body weight [bw] per day). Total amount of amino acids comprised 1.5 g.kg.bw per day. Caloric support was managed by metabolic variables (glucose and triglyceride plasma values). Target values for energy supply were 3 g.kg.bw carbohydrates and 1 g.kg.bw fat per day. MEASUREMENTS AND MAIN RESULTS: Medical treatment, nutritional therapy, vital variables, and biochemical data were recorded. Clinical outcome was measured by average length of stay in the intensive care unit and hospital and the mortality in the intensive care unit and within 30 days and 6 months. A total of 144 patients were randomized; 95 patients were treated for >or=5 days and 68 patients for >or=9 days under standardized conditions. In the treatment group, plasma glutamine concentrations significantly increased within 6-9 days. Six-month survival was significantly improved for patients treated for >or=9 days (66.7% [glutamine supplemented] vs. 40% [control]). CONCLUSION: Study results support the hypothesis that replacement of glutamine deficiency may correct the excess mortality in intensive care unit patients caused by inadequate parenteral nutrition.
PMID: 12352037, UI: 22238501
Crit Care Med 2002 Sep;30(9):2022-9
Department of Medicine, Queens University, Kingston General Hospital, Ontario, Canada.
OBJECTIVE: To examine the relationship between glutamine supplementation and hospital length of stay, complication rates, and mortality in patients undergoing surgery and experiencing critical illness. DATA SOURCES: Computerized search of electronic databases and search of personal files, abstract proceedings, relevant journals, and review of reference lists. STUDY SELECTION: We reviewed 550 titles, abstracts, and articles. Primary studies were included if they were randomized trials of critically ill or surgical patients that evaluated the effect of glutamine vs. standard care on clinical outcomes.DATA EXTRACTION We abstracted relevant data on the methodology and outcomes of primary studies in duplicate, independently.DATA SYNTHESIS There were 14 randomized trials comparing the use of glutamine supplementation in surgical and critically ill patients. When the results of these trials were aggregated, with respect to mortality, glutamine supplementation was associated with a risk ratio (RR) of 0.78 (95% confidence interval [CI], 0.58-1.04). Glutamine supplementation was also associated with a lower rate of infectious complications (RR, 0.81; 95% CI, 0.64-1.00) and a shorter hospital stay (-2.6 days; 95% CI, -4.5 to -0.7). We examined several -specified subgroups. Although there were no statistically significant subgroup differences detected, there were some important trends. With respect to mortality, the treatment benefit was observed in studies of parenteral glutamine (RR, 0.71; 95% CI, 0.51-0.99) and high-dose glutamine (RR, 0.73; 95% CI, 0.53-1.00) compared with studies of enteral glutamine (RR, 1.08; 95% CI, 0.57-2.01) and low-dose glutamine (RR, 1.02; 95% CI, 0.52-2.00). With respect to hospital length of stay, all of the treatment benefit was observed in surgical patients (-3.5 days; 95% CI, -5.3 to -1.7) compared with critically ill patients (0.9 days; 95% CI, -4.9 to 6.8). CONCLUSION: In surgical patients, glutamine supplementation may be associated with a reduction in infectious complication rates and shorter hospital stay without any adverse effect on mortality. In critically ill patients, glutamine supplementation may be associated with a reduction in complication and mortality rates. The greatest benefit was observed in patients receiving high-dose, parenteral glutamine.
PMID: 12352035, UI: 22238499
Crit Care Med 2002 Sep;30(9):2003-13
Service de Reanimation Polyvalente, Hopital St Joseph, Paris, France.
OBJECTIVE: The Logistic Organ Dysfunction (LOD) score has been proved effective in evaluating severity during the first day in an intensive care unit but has not been evaluated later. To evaluate attributable mortality related to nosocomial events, organ dysfunction scores that remain accurate throughout the intensive care unit stay are needed. The objective of this study was to evaluate how accurately daily LOD scoring predicts mortality comparatively with daily Sequential Organ Failure Assessment (SOFA) scoring. DESIGN: Prospective multicenter study. SETTING: Six intensive care units in France. PATIENTS: A total of 1685 patients with intensive care unit stays longer than 48 hrs were included in this study (511 hospital deaths). Median age was 66 yrs, and median Simplified Acute Physiology Score II at admission was 38. For each patient, a senior physician recorded the variables needed to compute organ dysfunction scores daily throughout the intensive care unit stay. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: SOFA and LOD scores were computed daily during the first 7 days. Calibration was evaluated based on goodness-of-fit by the Hosmer-Lemeshow chi-square statistic (lower chi-square values and higher values indicate better fit) and discrimination based on the receiver operating characteristics (ROC) area under the curve (AUC; a ROC-AUC of 1 indicates faultless discrimination and a ROC-AUC of 0.5 indicates the effects of chance alone). Because calibration of both scores was poor at all time points ( p<.001), customization was performed using the total score (model 1) or separate introduction of each dysfunction (model 2). The performance of customized LOD and SOFA scores on a given day in predicting mortality was assessed in those patients who spent at least one more calendar day in the intensive care unit. The original LOD and SOFA scores had satisfactory ROC-AUC values (0.720 to 0.766). Internal consistency of both scores was acceptable ( p< 10(-4) for each organ dysfunction). After customization, the original scores calibrated well between days 1 and 7. Discrimination by both scores was better with model 2 (AUC-ROC, 0.729-0.784). CONCLUSION: Daily LOD and SOFA scores showed good accuracy and internal consistency, and they could be used to adjust severity for events occurring in the intensive care unit.
PMID: 12352033, UI: 22238497
Crit Care Med 2002 Sep;30(9):1983-6
Saint Vincent Catholic Medical Centers, New York Medical College, New York, NY, USA.
OBJECTIVE: To evaluate the role of continuous lateral rotational therapy on the development of ventilator-associated pneumonia in patients requiring long-term mechanical ventilation. DESIGN: Prospective control study. SETTING: Chronic ventilator unit in tertiary care hospital. METHODS: Thirty-seven patients requiring long-term mechanical ventilation were assigned to receive either continuous lateral rotational therapy or conventional therapy. RESULTS: Patients receiving continuous lateral rotational therapy had a significantly lower prevalence of pneumonia (17.6%) as compared with control patients (50%, p<.05). The development of pneumonia after being entered into the study was also significantly delayed in continuous lateral rotational therapy patients, 29 +/- 8 days vs. 12 +/- 2 days in controls (p <.05). However, unit mortality, total ventilator days, and the number of patients successfully weaned were not significantly different between groups. CONCLUSION: In patients requiring long-term ventilator care, continuous lateral rotational therapy reduced the prevalence of pneumonia but did not seem to affect mortality or the period of mechanical ventilation.
PMID: 12352030, UI: 22238494
Crit Care Med 2002 Sep;30(9):1950-9
Division of Anaesthesia, University of cambridge, Addenbrooke's Hospital, Cambridge, UK. jpc44@wbic.cam.ac.uk
OBJECTIVE: To investigate the effect of hyperventilation on cerebral blood flow in traumatic brain injury. DESIGN: A prospective interventional study. SETTING: A specialist neurocritical care unit. PATIENTS: Fourteen healthy volunteers and 33 patients within 7 days of closed head injury. INTERVENTIONS: All subjects underwent positron emission tomography imaging of cerebral blood flow. In patients, PaCO2 was reduced from 36 +/- 1 to 29 +/- 1 torr (4.8 +/- 0.1 to 3.9 +/- 0.1 kPa) and measurements repeated. Jugular venous saturation (SjvO2 ) and arteriovenous oxygen content differences (AVDO2 ) were monitored in 25 patients and values related to positron emission tomography variables. MEASUREMENTS AND MAIN RESULTS: The volumes of critically hypoperfused and hyperperfused brain (HypoBV and HyperBV, in milliliters) were calculated based on thresholds of 10 and 55 mL.100g(-1).min(-1), respectively. Whereas baseline HypoBV was significantly higher in patients ( p<.05), baseline HyperBV was similar to values in healthy volunteers. Hyperventilation resulted in increases in cerebral perfusion pressure (p <.0001) and reductions in intracranial pressure (p <.001), whereas SjvO2 (>50%) and AVDO2 (<9 mL/mL) did not exceed global ischemic thresholds. However, despite these beneficial effects, hyperventilation shifted the cerebral blood flow distribution curve toward the hypoperfused range, with a decrease in global cerebral blood flow (31 +/- 1 to 23 +/- 1 mL.100g(-1).min(-1); p<.0001) and an increase in HypoBV (22 [1-141] to 51 [2-428] mL; p<.0001). Hyperventilation-induced increases in HypoBV were apparently nonlinear, with a threshold value between 34 and 38 torr (4.5-5 kPa). CONCLUSIONS: Hyperventilation increases the volume of severely hypoperfused tissue within the injured brain, despite improvements in cerebral perfusion pressure and intracranial pressure. Significant hyperperfusion is uncommon, even at a time when conventional clinical management includes a role for modest hyperventilation. These reductions in regional cerebral perfusion are not associated with ischemia, as defined by global monitors of oxygenation, but may represent regions of potentially ischemic brain tissue.
PMID: 12352026, UI: 22238490
Crit Care Med 2002 Sep;30(9):1941-9
Critical Care Department, Evangelismos General Hospital, Medical School, University of Athens, Greece. koutsoukou@yahoo.gr
OBJECTIVE: To assess the effects of different positive end-expiratory pressure (PEEP) levels (0, 5, 10, and 15 cm H2O) on tidal expiratory flow limitation (FL), regional intrinsic positive end-expiratory pressure (PEEPi) inhomogeneity, alveolar recruited volume (Vrec), respiratory mechanics, and arterial blood gases in mechanically ventilated patients with acute respiratory distress syndrome (ARDS). DESIGN: Prospective clinical study. SETTING: Multidisciplinary intensive care unit of a university hospital. PATIENTS: Thirteen sedated, mechanically ventilated patients during the first 2 days of ARDS. INTERVENTIONS: Detection of tidal FL and evaluation of total dynamic PEEP (PEEPt,dyn), total static PEEP (PEEPt,st), respiratory mechanics, and Vrec from pressure, flow, and volume traces provided by the ventilator. The average (+/-sd) tidal volume was 7.1 +/- 1.5 mL/kg, the total cycle duration was 2.9 +/- 0.45 secs, and the duty cycle was 0.35 +/- 0.05. MEASUREMENTS: Tidal FL was assessed using the negative expiratory pressure technique. Regional PEEPi inhomogeneity was assessed as the ratio of PEEPt,dyn to PEEPt,st (PEEPi inequality index), and Vrec was quantified as the difference in lung volume at the same airway pressure between quasi-static inflation volume-pressure curves on zero end-expiratory pressure (ZEEP) and PEEP. RESULTS: On ZEEP, seven patients exhibited FL amounting to 31 +/- 8% of tidal volume. They had higher PEEPt,st and PEEPi,st ( p<.001) and lower PEEPi inequality index ( p<.001) than the six nonflow-limited (NFL) patients. Two FL patients became NFL with PEEP of 5 cm H2O and five with PEEP of 10 cm H2O. In both groups, PaO2 increased progressively with PEEP. In the FL group, there was a significant correlation of PaO2 to PEEPi inequality index ( p=.002). For a given PEEP, Vrec was greater in NFL than FL patients, and a significant correlation of Pao to Vrec ( p<.001) was found only in the NFL group. CONCLUSIONS: We conclude that on ZEEP, tidal FL is common in ARDS patients and is associated with greater regional PEEPi inhomogeneity than in NFL patients. With PEEP of 10 cm H2O, flow limitation with concurrent cyclic dynamic airway compression and re-expansion and the risk of "low lung volume injury" were absent in all patients. In FL patients, PEEP induced a significant increase in PaO2, mainly because of the reduction of regional PEEPi inequality, whereas in the NFL group, arterial oxygenation was improved satisfactorily because of alveolar recruitment.
PMID: 12352025, UI: 22238489
the above reports in Macintosh PC UNIX Text HTML format documents on this page through Loansome Doc