Br J Anaesth 2003 Mar;90(3):410-423
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PMID: 12594168
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Br J Anaesth 2003 Mar;90(3):273-80
Universitatsklinik fur Anaesthesiologie am St Josef-Hospital, Ruhr-Universitat Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany.
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BACKGROUND: We hypothesized that emergence from sedation in postoperative patients in the intensive care unit would be faster and more predictable after sedation with desflurane than with propofol. METHODS: Sixty patients after major operations were allocated randomly to receive either desflurane or propofol. The target level of sedation was defined by a bispectral index(TM) (BIS(TM)) of 60. All patients were receiving mechanical ventilation of the lungs for 10.6 (SD 5.5) h depending on their clinical state. The study drugs were stopped abruptly in a calm atmosphere with the fresh gas flow set to 6 litres min(-1), and the time until the BIS increased above 75 was measured (t(BIS75), the main objective measure). After extubation of the trachea, when the patients could state their birth date, they were asked to memorize five words. RESULTS: Emergence times were shorter (P<0.001) after desflurane than after propofol (25th, 50th and 75th percentiles): t(BIS75), 3.0, 4.5 and 5.8 vs 5.2, 7.7 and 10.3 min; time to first response, 3.7, 5.0 and 5.7 vs 6.9, 8.6 and 10.7 min; time to eyes open, 4.7, 5.7 and 8.0 vs 7.3, 10.5 and 20.8 min; time to squeeze hand, 5.1, 6.5 and 10.2 vs 9.2, 11.1 and 21.1 min; time to tracheal extubation, 5.8, 7.7 and 10.0 vs 9.7, 13.5 and 18.9 min; time to saying their birth date, 7.7, 10.5 and 15.5 vs 13.0, 19.4 and 31.8 min. Patients who received desflurane recalled significantly more of the five words. We did not observe major side-effects and there were no haemodynamic or laboratory changes except for a more marked increase in systolic blood pressure after stopping desflurane. Using a low fresh gas flow (air/oxygen 1 litre min(-1)), pure drug costs were lower for desflurane than for propofol (95 vs 171 Euros day(-1)). CONCLUSIONS: We found shorter and more predictable emergence times and quicker mental recovery after short-term postoperative sedation with desflurane compared with propofol. Desflurane allows precise timing of extubation, shortening the time during which the patient needs very close attention. Br J Anaesth 2003; 90: 273-80
PMID: 12594136, UI: 22482050
Br J Anaesth 2003 Mar;90(3):267-9
Department of Anaesthesia, City Hospital, Dudley Road, Birmingham, B18 7QH, UK University Department of Anaesthesia and Intensive Care Medicine, N5 Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
PMID: 12594134, UI: 22482048
Intensive Care Med 2003 Feb 21;
Intensive Care Unit, Royal Children's Hospital, Flemington Road, VIC 3052, Parkville, Australia.
OBJECTIVE. To evaluate the long-term outcome of children following admission to a paediatric intensive care unit. DESIGN. Prospective, long-term follow-up study. SETTING. Sixteen-bed multi-disciplinary paediatric intensive care unit in a free-standing, university, tertiary, teaching hospital. PATIENTS. All children consecutively admitted to the paediatric intensive care unit from 1(st) January, 1995, to 31(st) December, 1995. INTERVENTIONS. Outcome was evaluated, by telephone interview, at a median of 3.5 years (range 2.3-6 years) after admission to the intensive care unit using a modification of the Glasgow Outcome Score (GOS) to assess functional outcome and the Health State Utility Index (Mark 1) to assess quality of life. MEASUREMENTS AND MAIN RESULTS. Of the children admitted to the intensive care unit, 83.8% were alive at the time of follow-up. While 10.3% of the survivors had an unfavourable outcome and were likely to live dependent on care, 89.7% had a favourable outcome and were likely to lead an independent existence. Although 16.4% had an unfavourable quality of life, 83.6% of the children survived with a favourable quality of life. At the time of follow-up, 16.2% of the children were dead: 49% died in the intensive care unit, 5% died in hospital and 46% died after discharge from hospital. CONCLUSIONS. The majority of children admitted to a paediatric intensive care unit survive with an excellent functional outcome and quality of life. Long-term outcome assessment provides a basis for observing trends in outcome over time within the same institution.
PMID: 12595983
Department of Critical Care Medicine, Hopital Saint-Louis and University of Paris VII, 1 Rue Claude Vellefaux, 75010, Paris, France.
OBJECTIVE. Thrombotic microangiopathy (TMA) has been associated with a large number of underlying diseases. We conducted a descriptive, retrospective study including all TMA adult patients admitted to our ICU, with a particular interest in infectious episodes as a trigger of TMA. PATIENTS. All adult patients (30) with a diagnosis of TMA admitted to the medical ICU at Saint-Louis Hospital (Paris, France) between 1992 and 1998 were retrospectively included. METHODS. All patients with clinical and microbiological evidence of bacterial infection were treated with intravenous antibiotics. The specific treatment of TMA consisted in solvent/detergent-treated plasma administration by plasma exchange or high volume plasma infusion (30 ml/kg per day) in fractionated doses. RESULTS. Among the 30 adult patients studied, TMA in 16 (53%) was associated with microbiologically documented infection. An acute infection was found in 8/9 patients with an HIV-related TMA, in 2/6 patients with a systemic lupus erythematosus (SLE)-related TMA and in 3/6 patients with TMA associated with other disorders. In three patients, an acute infectious disease was the only cause associated with the TMA. Four other patients had clinical manifestations suggesting an infection process but without bacteriological documentation. Escherichia coli was isolated in 7/16 cases and verotoxin was found in the stools of two other patients. All patients were treated with plasma administration and those with evidence of infection were systematically and intensively treated with antibiotics. Eventually 8 patients died (27%), 20 (67%) reached complete remission and 2 partial remission. CONCLUSION. Bacterial infections are commonly observed amongst TMA patients hospitalized in ICUs and may act as a trigger of this disease. Screening for infection is a requirement in patients with TMA, either idiopathic or associated with other conditions.
PMID: 12595979
Intensive Care Unit and Trauma Center, Nord Hospital, Marseilles University Hospital System, AP-HM, Marseilles School of Medicine, 13915, Marseilles, France.
OBJECTIVE. In a previous non-randomized study, we demonstrated that no difference occurred in the rate of acquisition of bacteriuria between a complex closed drainage system (CCDS) and a two-chamber drainage system (TCDS) in patients in an intensive care unit (ICU). To confirm this result, we performed a randomized, prospective, and powerful study assessing the effectiveness of the CCDS and the TCDS in ICU patients. DESIGN. Randomized, prospective, and controlled study. SETTING. Medico-surgical intensive care unit (16 beds) in a teaching hospital. PATIENTS AND INTERVENTIONS. Three hundred and eleven patients requiring an indwelling urinary catheter for longer than 48 h were assigned individuals to the TCDS group or CCDS group 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. Bacteriuria occurred in 8% and 8.5% of patients for TCDS and CCDS, respectively. Rates of urinary tract infection were 12.1 and 12.8 episodes per 1,000 days of catheter. CONCLUSION. This randomized study, that compares the effectiveness of a TCDS and a CCDS in ICU patients, confirms the results of our previous study. No differences were noted between the two systems (a =0.05). The higher cost of CCDS is not justified for ICU patients.
PMID: 12595976
Intensive Care Med 2003 Feb;29(2):321-4
Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, P.O. Box 340, 00029 Helsinki, Finland, tom.silfvast@hus.fi
OBJECTIVES. To characterise discrepancies between clinical and autopsy diagnoses in patients who die in the intensive care unit. DESIGN. Retrospective chart review. SETTING. Ten-bed closed mixed adult intensive care unit in a tertiary referral teaching hospital. PARTICIPANTS. All the clinical notes and autopsy reports of 346 patients who died in the intensive care unit in 1996-2000. INTERVENTIONS. Discrepancies between clinical and autopsy diagnoses were reviewed by two intensivists, a specialist in infectious diseases, a pathologist and an anaesthesiologist. New findings which would have changed current therapy in the intensive care unit were categorised as a Class I discrepancy, and those related to death but which would not have altered therapy as a Class II discrepancy. RESULTS. Of 2370 patients admitted, 388 (16.4%) died. An autopsy was performed in 346 (89%) of the deceased patients. A Class I discrepancy was found in 8 patients (2.3%) and a Class II discrepancy in 11 patients (3.2%). Five of the eight (62%) Class I discrepancies were infections which occurred in patients already treated for another infections. CONCLUSION. Despite the availability of advanced diagnostic facilities, especially infectious complications seem to remain undiagnosed. Autopsy is a valuable tool with which to monitor diagnostic accuracy in these patients.
PMID: 12594594, UI: 22482532
Intensive Care Med 2003 Feb;29(2):317-20
Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore169608, Singapore, gm3oth@sgh.com.sg
OBJECTIVES. Massive hemoptysis can cause airway or hemodynamic compromise requiring intensive care. We reviewed the management and outcome of this group of patients in our institution. DESIGN. Retrospective analysis. SETTING. Medical intensive care unit (MICU) in a tertiary care hospital. PATIENTS. Patients (29 patients with 31 episodes) who were admitted to the MICU for massive hemoptysis (greater than 300 ml/24 h or requiring intubation) between August 1997 and April 2001. MANAGEMENT. Patients were intensively monitored and electively intubated if there was danger of airway compromise. Fiberoptic bronchoscopy was performed to assess the site of bleeding and patients had bronchial artery embolisation if deemed suitable. Patients in whom bleeding could not be controlled were referred for emergency surgery. RESULTS. In 26/31 (84%) episodes, patients required intubation. Bronchoscopy was more helpful in localising the bleeding (site of bleeding identified in 90%) than chest X-ray alone (identified site of bleeding in 64%). Bleeding was stopped with medical therapy in 8/31 (26%) patient; 16/31(51%) patients were successfully treated with embolisation. Only four (13%) patients went for emergency surgery, of whom one died. Overall in-hospital mortality was 4/31 patients (13%). Over a 2 year follow-up, 6/27 (22%) survivors had recurrent hemoptysis and another 4 (15%) died of unrelated causes. CONCLUSIONS. Intensive care and monitoring with endotracheal intubation, when necessary, are useful in massive hemoptysis. Bronchoscopy should be performed to help localise the bleeding site. Embolisation is a suitable first-line treatment for massive hemoptysis, reserving emergency surgery for cases where the above measures are insufficient to control bleeding.
PMID: 12594593, UI: 22482531
Intensive Care Med 2003 Feb;29(2):241-8
Departement Reanimation Medicale, Hopital St. Louis, Universite Paris VII, Paris, France, philipp.metnitz@univie.ac.at
OBJECTIVE. To evaluate risk factors in critically ill patients who were readmitted to an intensive care unit (ICU) during their hospital stay. DESIGN. Prospective multicenter cohort study. PATIENTS AND SETTING. A total of 15,180 patients discharged from 30 medical, surgical and mixed ICUs in Austria over a 2-year period. MEASUREMENTS AND RESULTS. The data analyzed included data on patients' clinical characteristics, Simplified Acute Physiology Score II (SAPS II), Logistic Organ Dysfunction system (LOD), Simplified Therapeutic Intervention Scoring System (TISS-28), length of ICU stay, ICU mortality and hospital mortality. Of the 15,180 patients who survived the first ICU stay, 780 patients (5.1%) were readmitted. These patients had more than a fourfold risk of dying during their hospital stay (21.7 vs 5.2%, p<0.001). For mechanically ventilated patients, the time between extubation and discharge during the first ICU stay was significantly shorter for readmitted than for non-readmitted patients (median 1 vs 2 days, p<0.001). On the day of their first ICU discharge, readmitted patients were in greater need of organ support, with more patients still requiring ventilatory, cardiovascular and renal support than non-readmitted patients. CONCLUSIONS. The results of this study provide evidence that there exists a group of patients at higher risk of readmission to the ICU. At the time of their first ICU discharge, these patients presented with residual organ dysfunctions, which were associated with an increased risk of being readmitted. Optimizing organ functions in these patients before discharge from the ICU could result in reduced readmission rates.
PMID: 12594586, UI: 22482524
Intensive Care Med 2003 Feb;29(2):201-7
Department of Anaesthesia and Intensive Care, Worthing Hospital, Lyndhurst Road, Worthing, West Sussex BN11 2DH, UK, richard@svenn.freeserve.co.uk
OBJECTIVE. To evaluate dexmedetomidine for sedation of patients in the medical ICU. DESIGN AND SETTING. Prospective observational study in an intensive care unit of a university hospital. PATIENTS. Twelve ventilated patients with median APACHE II score 23 (range 10-26). INTERVENTIONS. Patients received a loading dexmedetomidine infusion of 1 micro g kg(-1) over 10 min followed by a maintenance infusion rate of 0.2-0.7 micro g kg(-1) h(-1) for up to 7 days. After experience with the first four patients this maintenance rate of infusion was increased to a maximum of 2.5 micro g kg(-1) h(-1). If required, propofol and morphine provided rescue sedation and analgesia, respectively. RESULTS. The first four patients with dexmedetomidine infusion at 0.7 micro g kg(-1) h(-1)all required rescue sedation with a propofol infusion. A protocol amendment allowed the next eight patients to receive higher dexmedetomidine infusions (mean 1.0+/- micro g kg(-1) h(-1)). Five of the next eight patients did not required propofol, and two patients only required minimal propofol infusions (20-40 mg h(-1)). A further patient, with hepatic encephalopathy, required a propofol at 50-100 mg h(-1). Only modest falls in arterial pressure, heart rate and cardiac output were seen, and no rebound sequelae occurred on discontinuation of dexmedetomidine. Adverse cardiovascular events were nearly all confined to the initial loading dose period of dexmedetomidine. CONCLUSIONS. Sedation with dexmedetomidine is efficacious in critically ill medical patients requiring mechanical ventilation in the intensive care unit. A reduction in loading infusion is advised, but higher maintenance infusions may be required to that seen previously in the postoperative ICU patient.
PMID: 12594584, UI: 22482522
JAMA 2003 Feb 19;289(7):885-8
Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, Tex, USA.
CONTEXT: Previous surveillance studies have documented increasing rates of antimicrobial resistance in US intensive care units (ICUs) in the early 1990s. OBJECTIVES: To assess national rates of antimicrobial resistance among gram-negative aerobic isolates recovered from ICU patients and to compare these rates to antimicrobial use. DESIGN AND SETTING: Participating institutions, representing a total of 43 US states plus the District of Columbia, provided antibiotic susceptibility results for 35 790 nonduplicate gram-negative aerobic isolates recovered from ICU patients between 1994 and 2000. MAIN OUTCOME MEASURES: Each institution tested approximately 100 consecutive gram-negative aerobic isolates recovered from ICU patients. Organisms were identified to the species level. Susceptibility tests were performed, and national fluoroquinolone consumption data were obtained. RESULTS: The activity of most antimicrobial agents against gram-negative aerobic isolates showed an absolute decrease of 6% or less over the study period. The overall susceptibility to ciprofloxacin decreased steadily from 86% in 1994 to 76% in 2000 and was significantly associated with increased national use of fluoroquinolones. CONCLUSIONS: This study documents the increasing incidence of ciprofloxacin resistance among gram-negative bacilli that has occurred coincident with increased use of fluoroquinolones. More judicious use of fluoroquinolones will be necessary to limit this downward trend.
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PMID: 12588273, UI: 22477323