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Am J Respir Crit Care Med 2003 Jan 1;167(1):4-5
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PMID: 12502470, UI: 22390558
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Anaesth Intensive Care 2002 Oct;30(5):660-4
Department of Intensive Care Medicine, Royal Perth Hospital, Western Australia.
Systemic air embolism is a potentially lethal often unrecognised complication of severe chest trauma. We present a case of delayed diagnosis of cerebral air embolism in a patient with severe thoracic trauma. The initiation of positive pressure ventilation, systemic hypotension, intraparenchymal chest drains and aerial transfer to an intensive care unit were all factors contributing to the development of systemic air embolism. The common clinical features, diagnostic tests and management of systemic air emboli are discussed.
PMID: 12413269, UI: 22298893
Anesth Analg 2003 Feb;96(2):548-, table of contents
Department of Anesthesia, Austin and Repatriation Medical Centre, Melbourne, Australia. phil@austin.unimelb.edua.u
In a primary analysis of a large recently completed randomized trial in 915 high-risk patients undergoing major abdominal surgery, we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids, apart from the incidence of respiratory failure. Therefore, we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia. We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery, nor in a subgroup with failed epidural block (all P > 0.05). There was a small reduction in the duration of postoperative ventilation (geometric mean [SD]: control group, 0.3 [6.5] h, versus epidural group, 0.2 [4.8] h; P = 0.048). No differences were found in length of stay in intensive care or in the hospital. There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial. We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery.
PMID: 12538211, UI: 22425374
Anesth Analg 2003 Feb;96(2):418-25
Department of Critical Care, Mayo Clinic, Jacksonville, Florida 32224, USA.
PMID: 12538189, UI: 22425352
Anesth Analg 2003 Feb;96(2):311-4
PMID: 12538169, UI: 22425332
Crit Care Med 2003 Feb;31(2):665-6
[Medline record in process]
PMID: 12576997, UI: 22464266
Crit Care Med 2003 Feb;31(2):552-9
OBJECTIVE To evaluate the feasibility and outcome results of noninvasive mechanical ventilation (NIV) in daily clinical practice outside any prospective protocol-driven trial.DESIGN An observational retrospective cohort study.SETTING A 22-bed medical intensive care unit in a university hospital.PATIENTS A consecutive cohort of 124 patients who underwent 143 NIV trials, regardless of the indication, over two consecutive years (1997-1998).INTERVENTIONS None.RESULTS A total of 604 acute respiratory failure patients underwent mechanical ventilation, and 143 NIVs were performed in 124 patients. The overall prevalence of NIV use was 143 of 604 patients (24%) in three groups: hypoxemic acute respiratory failure (29.5%), hypercapnic acute respiratory failure (41%), and weaning/postextubation (29.5%). Intubation was avoided in 92 of 143 of the NIVs performed (64%), 19 (13%) after changing the initial NIV mode (i.e., a success rate of 62%, 51%, and 86% in the three groups, respectively). A total of 35 of 51 intubated patients (69%) required intubation during the first 24 hrs of NIV. Intensive care unit stay was 12 +/- 10 days for the overall population, and mortality, when NIV failed, was 13 of 124 patients (10.5%). Arterial pH ( =.0527) and the Pao /Fio ratio ( =.0482) after 1 hr were the only independent predictive factors for NIV failure by multivariate analysis.(2) (2)CONCLUSIONS This study confirms the results of controlled trials and demonstrates the feasibility and efficacy of NIV applied in daily clinical practice. These results suggest that NIV should be considered as a first-line ventilatory treatment in various etiologies of acute respiratory failure and as a promising weaning technique and postextubation ventilatory support. However, NIV should certainly be performed by a motivated and sufficiently trained care team.
PMID: 12576965, UI: 22464234
Crit Care Med 2003 Feb;31(2):456-61
OBJECTIVE First, to assess the pattern of the prediction of intensive care unit patients' outcome with regard to survival and quality of life by nurses and doctors and, second, to compare these predictions with the quality of life reported by the surviving patients.DESIGN Prospective opinion survey of critical care providers; comparison with follow-up for survival, functional status, and quality of life.SETTING Six-bed medical intensive care unit subunit of a 1,000-bed tertiary care, university hospital.PATIENTS All patients older than 18 yrs, admitted to the medical intensive care unit for >24 hrs over a 1-yr period (December 1997 to November 1998).INTERVENTIONS Daily judgment of eventual futility of medical interventions by nurses and doctors with respect to survival and future quality of life. Telephone interviews with discharged patients for quality of life and functional status 6 months after intensive care unit admission.MEASUREMENTS AND MAIN RESULTS Data regarding 521 patients including 1,932 daily judgments by nurses and doctors were analyzed. Disagreement on at least one of the daily judgments by nurses and doctors was found in 21% of all patients and in 63% of the dying patients. The disagreements more frequently concerned quality of life than survival. The higher the Simplified Acute Physiology Score and the longer the intensive care unit stay, the more divergent judgments were observed ( <.001). In surviving and dying patients, nurses gave more pessimistic judgment and considered withdrawal more often than did doctors ( <.001). Patients only rarely indicated bad quality of life (6%) and severe physical disability (2%) 6 months after intensive care unit admission. Compared with patients' own assessment, neither nurses nor doctors correctly predicted quality of life; false pessimistic and false optimistic appreciation was given.CONCLUSIONS Disagreement between nurses and doctors was frequent with respect to their judgment of futility of medical interventions. Disagreements most often concerned the most severely ill patients. Nurses, being more pessimistic in general, were more often correct than doctors in the judgment of dying patients but proposed treatment withdrawal in some very sick patients who survived. Future quality of life cannot reliably be predicted either by doctors or by nurses.
PMID: 12576951, UI: 22464220
Crit Care Med 2003 Feb;31(2):449-55
OBJECTIVE Acute renal failure can be treated with continuous renal replacement therapy (CRRT) or intermittent hemodialysis. There is no difference in mortality, although patients treated with CRRT may have a higher rate of renal recovery. Given these considerations, an estimate of the costs by modality may help in choosing the method of dialysis. As such, the objective of this study was to estimate the cost of CRRT and intermittent hemodialysis in the intensive care unit and to explore the impact of renal recovery on subsequent clinical outcomes and costs among survivors.DESIGN Retrospective cohort study of all patients who developed acute renal failure and required dialysis between April 1, 1996, and March 31, 1999.SETTING Two tertiary care intensive care units in Calgary, Canada.PATIENTS A total of 261 critically ill patients.INTERVENTIONS None.MEASUREMENTS All patients were followed to determine in-hospital and subsequent clinical outcomes (survival and frequency of renal recovery). The immediate and potential long-term costs of CRRT and intermittent hemodialysis were measured.MAIN RESULTS The cost of performing CRRT ranged from Can $3,486 to Can $5,117 per week, depending on the modality and the anticoagulant used, and it was significantly more expensive than intermittent hemodialysis (Can $1,342 per week). Survivors with renal recovery spent significantly fewer days in hospital (11.3 vs. 22.5 days, <.001) and incurred less healthcare costs ($11,192 vs. $73,273, <.001) over the year after hospital discharge compared with survivors who remained on dialysis.CONCLUSIONS Immediate cost savings could be achieved by increasing the use of intermittent hemodialysis rather than CRRT for patients with acute renal failure in the intensive care unit. Because of the high cost of ongoing dialysis, CRRT may still be an economically efficient treatment if it improves renal recovery among survivors; further study in this area is required.
PMID: 12576950, UI: 22464219
Crit Care Med 2003 Feb;31(2):433-41
OBJECTIVE To describe a real-time, continuous physiologic data acquisition system for the study of disease dynamics in the intensive care unit.DESIGN Descriptive report.SETTING A 16-bed pediatric intensive care unit in a tertiary care children's hospital.PATIENTS A total of 170 critically ill or injured pediatric patients.INTERVENTIONS None.MAIN OUTCOME MEASURES None.RESULTS We describe a computerized data acquisition and analysis system for the study of critical illness and injury from the perspective of complex dynamic systems. Both parametric (1 Hz) and waveform (125-500 Hz) signals are recorded and analyzed. Waveform data include electrocardiogram, respiration, systemic arterial pressure (invasive and noninvasive), central venous pressure, pulmonary arterial pressure, left and right atrial pressures, intracranial pressure, body temperature, and oxygen saturation. Details of the system components are explained and examples are given from the resultant physiologic database of signal processing algorithms and signal analyses using linear and nonlinear metrics.CONCLUSIONS We have successfully developed a real-time, continuous physiologic data acquisition system that can capture, store, and archive data from pediatric intensive care unit patients for subsequent time series analysis of dynamic changes in physiologic state. The physiologic signal database generated from this system is available for analysis of dynamic changes caused by critical illness and injury.
PMID: 12576948, UI: 22464217
Crit Care Med 2003 Feb;31(2):406-10
OBJECTIVES To evaluate the time course of hemoglobin concentrations in nonbleeding intensive care unit patients.DESIGN Prospective, observational study.SETTING Multidisciplinary (medicosurgical) department of intensive care.PATIENTS Ninety-one patients with no evidence of recent or active blood loss, no history of hematologic disease or chronic renal failure, and no need for extracorporeal epuration techniques.INTERVENTIONS None.MEASUREMENTS AND MAIN RESULTS Data collection included primary diagnoses, Acute Physiology and Chronic Health Evaluation II and sepsis-related organ failure assessment scores, signs of sepsis, 24-hr fluid balance, and hemoglobin concentrations. For the entire intensive care unit stay, the fall in hemoglobin concentrations (calculated from the mean of individual slopes of hemoglobin concentrations over time) averaged 0.52 +/- 0.69 g/dL/day. For the 33 patients who stayed in the intensive care unit for >3 days, this decline was larger for the first 3 days than for subsequent days (0.66 +/- 0.84 g/dL/day vs. 0.12 +/- 0.29 g/dL/day; <.01). After the third intensive care unit day, the change in hemoglobin concentrations was inversely related to the severity of the disease, as reflected by the Acute Physiology and Chronic Health Evaluation II and the sepsis-related organ failure assessment scores. Hemoglobin concentrations decreased by 0.44 +/- 0.70 g/dL/day in the nonseptic and 0.68 +/- 0.66 g/dL/day in the septic patients ( =.13). After the third intensive care unit day, hemoglobin concentrations continued to decrease in the septic patients but not in the nonseptic patients (-0.29 +/- 0.19 vs. 0.006 +/- 0.3 g/dL/day; =.0016). The fall in hemoglobin concentrations was not significantly related to the fluid balance. The volume of blood drawn daily for laboratory studies was 40.3 +/- 15.4 mL: 49.0 +/- 11.3 mL in the septic patients and 36.7 +/- 14.9 mL in the nonseptic patients ( =.04).CONCLUSIONS Hemoglobin concentrations typically decline by >0.5 g/dL/day during the first days of intensive care unit stay in nonbleeding patients. Beyond the third day, hemoglobin concentrations can remain relatively constant in nonseptic patients but continue to decrease in septic patients, as well as patients with high sepsis-related organ failure assessment or Acute Physiology and Chronic Health Evaluation II scores. These observations may help in the interpretation of hemoglobin concentrations in critically ill patients.
PMID: 12576944, UI: 22464213
Crit Care Med 2003 Feb;31(2):401-5
OBJECTIVE To evaluate primary success rate and effectiveness of direct-current cardioversion in postoperative critically ill patients with new-onset supraventricular tachyarrhythmias.DESIGN Prospective intervention study.SETTING Twelve-bed surgical intensive care unit in a university teaching hospital.PATIENTS Thirty-seven consecutive, adult surgical intensive care unit patients with new-onset supraventricular tachyarrhythmias without previous history of tachyarrhythmias.INTERVENTIONS Direct-current cardioversion using a monophasic, damped sinus-wave defibrillator. Energy levels used were 50, 100, 200, and 300 J for regular supraventricular tachyarrhythmias (n = 6) and 100, 200, and 360 J for irregular supraventricular tachyarrhythmias (n = 31).MEASUREMENTS AND MAIN RESULTS None of the patients was hypoxic, hypokalemic, or hypomagnesemic at onset of supraventricular tachyarrhythmia. Direct-current cardioversion restored sinus rhythm in 13 of 37 patients (35% primary responders). Most patients responded to the first or second direct-current cardioversion shock. Only one of 25 patients requiring more than two direct-current cardioversion shocks converted into sinus rhythm. Primary responders were significantly younger and demonstrated significant differences in arterial Po values at onset of supraventricular tachyarrhythmias compared with nonresponders. At 24 and 48 hrs, only six (16%) and five (13.5%) patients remained in sinus rhythm, respectively.(2)CONCLUSIONS In contrast to recent literature, direct-current cardioversion proved to be an ineffective method for treatment of new-onset supraventricular tachyarrhythmias and, in particular, atrial fibrillation with a rapid ventricular response in surgical intensive care unit patients.
PMID: 12576943, UI: 22464212
Crit Care Med 2003 Feb;31(2):390-4
OBJECTIVE To determine whether changes have occurred at our center in the incidence, patterns of organ dysfunctions, prognostic factors, and case-fatality rate of bacteremic sepsis.DESIGN Retrospective comparative study (1984-1988 vs. 1994-1997).SETTING University hospital surgical intensive care unit.PATIENTS A total of 372 critically ill patients with sepsis and positive blood cultures.INTERVENTION None.MEASUREMENTS AND MAIN RESULTS In the 1984-1988 study, 176 patients developed bacteremic sepsis (3.2 per 100 admissions), with a fatality rate of 35% at 28 days, whereas in the 1994-1997 study, 196 patients had bacteremic sepsis (4.3 per 100 admissions), with a 28-day fatality rate of 37%. The frequency of primary bacteremia increased from 21% to 47% ( <.001), paralleled by an increase in the proportional frequency of Gram-positive microorganisms. In 1984-1988, 69% (n = 120) of patients had at least one organ dysfunction, compared with 80% (n = 156) in 1994-1997 ( =.02). The prevalence of pulmonary and cardiac dysfunction increased. The case- fatality rate of septic shock remained high (69% vs. 68%). For both cohorts, the two strongest predictors of mortality remained the Acute Physiology and Chronic Health Evaluation II score at the onset of sepsis and the number of evolving organ dysfunctions.CONCLUSION The fatality rate of bacteremic sepsis remained constant over the study period, despite an increased incidence of bacteremia and associated organ dysfunction. Continued efforts need to be directed toward the prevention of bacteremic sepsis, given the magnitude and poor prognosis of this syndrome.
PMID: 12576941, UI: 22464210
Crit Care Med 2003 Jan;31(1):126-32
Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany. fri.rav@btopenworld.com
BACKGROUND: Acute mediastinitis is a serious complication; it occurs after esophageal perforation and thoracic surgery and is rarely due to infections. Clinical and computed tomographic scan signs may be nonspecific, especially in postoperative patients. DESIGN: We prospectively evaluated the value of transesophageal endosonography with guided fine-needle aspiration in the diagnosis and identification of etiologic agents in critically ill patients with suspected posterior mediastinitis. SETTING: University hospital. PATIENTS AND METHODS: Transesophageal endosonography/fine-needle aspiration was performed at the bedside in the intensive care unit with a Pentax 34UX echo-endoscope and a portable Hitachi console (EUB 525). Eighteen patients with clinically suspected mediastinitis were examined with intensive care team support. RESULTS: Computed tomography was performed before transesophageal endosonography in all 18 patients and was inconclusive in 9. Transesophageal endosonography detected mediastinal lesions in 16 (89%) of 18 patients and was more accurately diagnostic than computed tomography (p =.0082). Fifteen patients had undergone surgery (11 esophagectomy, 1 other esophageal surgery, 1 head/neck cancer surgery, 1 complication after dilatational tracheostomy, and 1 with intervention after polytrauma). Three patients were suspected to have nonpostoperative mediastinitis. In 16 patients, infectious organisms were detected (bacterial, n = 14; fungal, n = 1; tuberculosis, n = 1). Culture and sensitivity of transesophageal endosonography/fine-needle aspiration specimens led to appropriate drug therapy. In two patients, methicillin-resistant Staphylococcus aureus was detected, leading to isolation care. Twelve patients improved; six died. Of the two patients in whom transesophageal endosonography did not detect a mediastinitis, one was false negative on autopsy. There were no complications. CONCLUSION: Bedside transesophageal endosonography/fine-needle aspiration of posterior mediastinal lesions in critically ill patients was an effective and relatively noninvasive way to detect mediastinitis and provide material to identify the etiologic agent. It was particularly useful in postesophagectomy patients.
PMID: 12545005, UI: 22431146
Crit Care Med 2003 Jan;31(1):93-7
Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.
OBJECTIVE: To evaluate partial occlusion in patients with pulmonary hypertension with regard to a) the degree to which it leads to overestimation of pulmonary artery occlusion pressure (Ppao) and b) identification of factors that could enhance its recognition. DESIGN: Observational descriptive study. SETTING: Medical intensive care unit. PATIENTS: Fourteen patients with pulmonary hypertension and an increased pulmonary artery diastolic pressure (Ppad) - Ppao gradient (> or = 10 mm Hg). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Ppao was recorded during partial occlusion (partial Ppao) and after catheter repositioning to obtain a lower, more accurate value (best Ppao). The error due to partial occlusion, defined as the difference between the partial Ppao and the best Ppao, was 13 +/- 5 mm Hg (range, 6-21 mm Hg). The previously widened Ppad - Ppao gradient invariably narrowed during partial occlusion and then increased by 13 +/- 5 mm Hg (range, 5-23) during the best Ppao measurement. There was a moderate correlation between the error due to partial occlusion (partial Ppao - best Ppao) and both the mean pulmonary artery pressure (r =.77, <.01) and the Ppad - Ppao gradient (r =.79, <.01). CONCLUSIONS: Partial occlusion in patients with pulmonary hypertension may lead to significant overestimation of the Ppao and should be suspected when there is a substantial increase in the Ppao without a concomitant increase in the Ppad, as reflected by a marked narrowing of a previously widened Ppad - Ppao gradient.
PMID: 12545000, UI: 22431141
Crit Care Med 2003 Jan;31(1 Suppl):S112-7
Safar Center for Resuscitation Research and Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
OBJECTIVE: To review novel therapeutic approaches in the treatment of severe traumatic brain injury. DESIGN: Eighty-three studies were reviewed specific to the treatment of traumatic brain injury, in either experimental models or in patients. CONCLUSION: Four therapeutic strategies appear to be the most promising approaches currently in clinical trials for severe traumatic brain injury: a) the novel pharmacologic agent dexanabinol; b) hypertonic saline; c) mild hypothermia; and d) decompressive craniectomy. Each of these therapies share the common feature of targeting multiple mechanisms, suggesting this may be an important factor to the development of a successful approach to severe traumatic brain injury.
PMID: 12544985, UI: 22431126
Crit Care Med 2003 Jan;31(1 Suppl):S105-11
Children's Hospital Medical Center, Division of Critical Care Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA. bzingarelli@chmcc.org
Nuclear factor-kappaB is a transcriptional factor required for the gene expression of many inflammatory mediators. Nuclear factor-kappaB activation requires removal and degradation of its inhibitor kappaB, an event that occurs after phosphorylation of inhibitor kappaB by a complex of inhibitor kappaB kinases. These events allow nuclear factor-kappaB to translocate into the nucleus, where it binds to kappaB elements and initiates transcription. Inappropriate and prolonged activation of nuclear factor-kappaB has been linked to several diseases associated with inflammatory events, including septic shock, acute respiratory distress syndrome, ischemia, and reperfusion injury. Thus, the key role of nuclear factor-kappaB in regulating inflammation makes this factor a therapeutic target for reducing tissue and organ damage. Regulation and control of nuclear factor-kappaB can be achieved by gene modification strategies or by pharmacologic inhibition of the key components of the cascade that leads to nuclear factor-kappaB activation. The purpose of our review is to describe these novel therapeutic approaches and their potential efficacy.
PMID: 12544984, UI: 22431125
Crit Care Med 2003 Jan;31(1 Suppl):S97-104
Center for Experimental Therapeutics & Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
Caring for the critical care patient involves many different areas of clinical expertise and serves a diverse patient population. Novel therapeutics for the critically ill must be approached with caution, because the underlying molecular mechanisms of the disease process for several commonly seen types of patients (i.e., sepsis, shock, ischemia/reperfusion) are not fully understood. A potentially new and advancing area of therapeutics that may hold promise for the critically ill is inhibition of the complement system. Various novel complement inhibitors are being developed and several are in clinical trials. The advancement of this novel area of therapeutics may one day aid the clinician by providing several different complement inhibitors/antagonists for controlling complement activation or its biologically active mediators.
PMID: 12544983, UI: 22431124
Crit Care Med 2003 Jan;31(1 Suppl):S51-6
Department of Critical Care Medicine, University of Pittsburgh Medical School, Pittsburgh, PA, USA.
Pyruvate plays a central role in intermediary metabolism. Pyruvate, however, is also a potent antioxidant and free radical scavenger, and numerous studies have shown that treatment with this compound can be salutary in numerous pathologic conditions that are thought to be mediated, at least in part, by redox-dependent phenomena. Unfortunately, aqueous solutions of pyruvate rapidly undergo an aldol-like condensation reaction to form 2-hydroxy-2-methyl-4-ketoglutarate (parapyruvate), a compound that is a potent inhibitor of a critical step in the mitochondrial tricarboxylic acid cycle. To circumvent this issue, our laboratory formulated a derivative of pyruvic acid, ethyl pyruvate, in a calcium- and potassium-containing balanced salt solution. We showed that treatment with this fluid could ameliorate much of the structural and functional damage to the intestinal mucosa caused by mesenteric ischemia and reperfusion in rats. In subsequent studies, we showed that treatment with ethyl pyruvate solution could improve survival in rodent models of hemorrhagic shock and resuscitation and also down-regulate a number of proinflammatory genes. Recently, ethyl pyruvate was also shown to improve survival in murine models of acute endotoxemia and bacterial peritonitis. Although the biochemical basis for the anti-inflammatory actions of pyruvate remain to be elucidated, this simple compound warrants further evaluation as a treatment for a number of conditions commonly encountered in the practice of critical care medicine.
PMID: 12544977, UI: 22431118
Crit Care Med 2003 Jan;31(1 Suppl):S29-38
Metaphore Pharmaceuticals, St Louis, MO, USA.
Oxidative stress results from an oxidant/antioxidant imbalance, an excess of oxidants, or a depletion of antioxidants. A considerable body of recent evidence suggests that oxidative stress and exaggerated production of reactive oxygen species play a major role in several aspects of septic shock and ischemia and reperfusion. Initiation of lipid peroxidation, direct inhibition of mitochondrial respiratory chain enzymes, inactivation of glyceraldehyde-3-phosphate dehydrogenase, inhibition of membrane Na /K adenosine triphosphatase activity, inactivation of membrane sodium channels, and other oxidative protein modifications contribute to the cytotoxic effect of reactive oxygen species. In addition, reactive oxygen species are potent triggers of DNA strand breakage, with subsequent activation of the nuclear enzyme poly-adenosine 5'-diphosphate ribosyl synthetase, and eventual severe energy depletion of the cells. Pharmacologic evidence suggests that the peroxynitrite-poly-adenosine 5'-diphosphate ribosyl polymerase pathway contributes to the cellular injury in shock and endothelial injury. Treatment with superoxide dismutase mimetics, which selectively mimic the catalytic activity of the human superoxide dismutase enzymes, has been shown to prevent the cellular energetic failure associated with shock and ischemia-reperfusion and to prevent tissue damage associated with these conditions. In this article, we will briefly review the role of superoxide in septic shock and ischemia-reperfusion injury. We hope to present evidence to support the potential development of superoxide dismutase mimetics as novel and effective agents in the area of critical care medicine.
PMID: 12544974, UI: 22431115
Crit Care Med 2003 Jan;31(1 Suppl):S7-16
Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
The recent Food and Drug Administration approval of drotrecogin alfa (activated) and the potential of several other new therapies may represent the beginning of a breakthrough in the management of critical illness in the intensive care unit. However, their use in clinical practice will likely be dependent on a rigorous appraisal not only of their effects, but also of their costs. Novel therapies can no longer be judged simply by their effectiveness in treating illness, but must also be evaluated on an institutional and societal level on the basis of their cost. These considerations have important implications for the practicing intensivist, who will need to better understand the conduct and design of economic evaluations, including their strengths and weaknesses. In this article, we review the rationale behind economic evaluations of new therapies and the alternative economic approaches available. We then discuss in more detail the elements contained in a cost-effectiveness analysis, the preferred approach to pharmacoeconomic evaluation today.
PMID: 12544971, UI: 22431112
Intensive Care Med 2002 Oct;28 Suppl 2:S221
Barnes-Jewish Hospital and Washington University, Box 8118, Washington University, 660 S. Euclid Avenue, St Louis, MO 63110, USA. goodnough@pathbox.wustl.edu
PMID: 12583409, UI: 22470920
Intensive Care Med 2002 Nov;28(11):1675
PMID: 12583379, UI: 22469882
Intensive Care Med 2002 Nov;28(11):1505-1511
University Hospital Maastricht, the Netherlands.
This article describes the structures and institutions in the European Union by which professional training and qualification in medical specialities will be harmonised. All main medical specialities are represented in the European Union of Medical Specialists (UEMS) by speciality sections. For intensive care medicine, as a multidisciplinary speciality, a new structure of a Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM) within the UEMS was established in 1999. In this MJCICM the European Society of Intensive Care Medicine and the European Society of Paediatric and Neonatal Intensive Care are represented by delegates without voting capacity in a Standing Advisory Board. Statements and recommendations which the MJCICM has worked out until now are presented: Definitions of intensive care medicine, structural conditions for education and training, continuing medical education, criteria for accreditation of intensive care medicine training centres, common core curriculum for optional specialist training in intensive care medicine, as well as an intensive care units accreditation visiting programme and standards for medical treatment and nursing care.
PMID: 12583367, UI: 22468477
Intensive Care Med 2002 Dec;28(12):1825; author reply 1826
PMID: 12580165, UI: 22467577
Intensive Care Med 2002 Dec;28(12):1698-1700
PMID: 12580153, UI: 22466324
Intensive Care Med 2003 Feb 8;
Federation Anesthesie-Douleur-Urgences-Reanimation, Centre Hospitalier Universitaire de Nimes, 5 rue Hoche, 30029, Nimes, France.
[Record supplied by publisher]
OBJECTIVE. Comparisons of urinary bladder, oesophageal, rectal, axillary, and inguinal temperatures versus pulmonary artery temperature. DESIGN. Prospective cohort study. SETTING. Intensive Care Unit of a University-Hospital. PATIENTS. Forty-two intensive care patients requiring a pulmonary artery catheter (PAC). INTERVENTION. Patients requiring PAC and without oesophageal, urinary bladder, and/or rectal disease or recent surgery were included in the study. Temperature was simultaneously monitored with PAC, urinary, oesophageal, and rectal electronic thermometers and with axillary and inguinal gallium-in-glass thermometers. Comparisons used a Bland and Altman method. MEASUREMENTS AND MAIN RESULTS. The pulmonary arterial temperature ranged from 33.7 degrees C to 40.2 degrees C. Urinary bladder temperature was assessed in the last 22 patients. A total of 529 temperature measurement comparisons were carried out (252 comparisons of esophageal, rectal, inguinal, axillary, and pulmonary artery temperature measurements in the first 20 patients, and 277 comparisons with overall methods in the last patients). Nine to 18 temperature measurement comparisons were carried out per patient (median = 13). The mean differences between pulmonary artery temperatures and those of the different methods studied were: oesophageal (0.11+/-0.30 degrees C), rectal (-0.07+/-0.40 degrees C), axillary (0.27+/-0.45 degrees C), inguinal (0.17+/-0.48 degrees C), urinary bladder (-0.21+/-0.20 degrees C). CONCLUSION. In critically ill patients, urinary bladder and oesophageal electronic thermometers are more reliable than the electronic rectal thermometer which is better than inguinal and axillary gallium-in-glass thermometers to measure core temperature.
PMID: 12577157
Intensive Care Unit and Trauma Center,Nord Hospital, Marseilles University Hospital System, AP-HM, Marseilles School of Medicine, 13915, Marseille cedex 20, France.
OBJECTIVE. In a previous nonrandomized study we observed no difference in the rate of acquisition of bacteriuria between a complex closed drainage system (CCDS) and a two-chamber drainage system (TCDS) in ICU patients. To confirm this result we performed a statistically powerful study assessing the effectiveness of the CCDS and the TCDS in ICU patients. DESIGN AND SETTING. Randomized, prospective, and controlled study in the medicosurgical intensive care unit (16 beds) in a teaching hospital. PATIENTS AND INTERVENTIONS. We assigned 311 patients requiring indwelling urinary catheter for longer than 48 h to TCDS or CCDS to compare the rate of acquisition of bacteriuria. MEASUREMENTS AND RESULTS. Patients did not receive prophylactic antibiotics during placement management or catheter withdrawal. Urine samples were obtained weekly for the duration of catheterization and within 24 h after catheter removal, and each time symptoms of urinary infection were suspected. There was no statistical difference in the rate of bacteriuria between the two groups: 8% with TCDS and 8.5% with CCDS. Rates of urinary tract infection were 12.1 episodes with TCDS and 12.8 episodes with CCDS per 1000 days of catheter. CONCLUSIONS. This randomized study on the effectiveness of TCDS and CCDS in ICU patients confirms the findings of our previous study. No differences were noted between the two systems. The higher cost of CCDS is not justified for ICU patients.
PMID: 12577151
J Hosp Infect 2003 Feb;53(2):144-6
We undertook a prospective study of 887 consecutive adult patients admitted over an 11 year period to a liver intensive care unit. One or more bacterial infections occurred in 335 (37.8%) patients. Gram-positive cocci predominated. In relation to the date of admission these infections occurred in a statistically significant sequence. Streptococci infections were earliest (median time to infection two days), followed by Staphylococcus aureus (three days), coagulase-negative staphylococci (six days) and enterococci (eight days). Escherichia coli infections occurred earlier than those due to klebsiella-enterobacter (two vs seven days; P=0.0001) and, overall, Enterobacteriaceae earlier than non-fermentative Gram-negatives (four vs. eight days; P=0.0081). This study contributes to the management of high-dependency patients by confirming statistically the timing and sequence of infecting bacteria in patients with acute liver failure.
PMID: 12586576, UI: 22474468
J Hosp Infect 2003 Feb;53(2):97-102
Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
Acinetobacter baumannii is ubiquitous and has recently become one of the most important healthcare-associated (HA) pathogens in hospitals. Infection caused by this organism often leads to significant morbidity and mortality. Outbreaks of pan-drug resistant Acinetobacter baumannii (PDRAB) have rarely been reported. During a two-month period, an outbreak of PDRAB colonization and infection affecting 7 patients occurred in our surgical intensive care unit (SICU). The colonized sites were respiratory tract (N=7) and central venous catheter (N=2). One of the patients had a surgical wound infection. Extensive environmental contamination was identified, including sites such as bed rails, bedside tables, surface of ventilators and infusion pump, water for nasogastric feeding and ventilator rinsing and sinks. All of the isolates were analysed by pulsed-field gel electrophoresis (PFGE) and showed an identical pattern. After use of strict cohort nursing, hand hygiene environmental cleaning, and replacement of a dysfunctional high-efficiency particulate air filter (HEPA), the outbreak was controlled.
PMID: 12586567, UI: 22474459