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Am J Crit Care 2003 Mar;12(2):147-53
Wayne State University School of Medicine, Detroit Receiving Hospital, Detroit, Mich., USA.
[Medline record in process]
BACKGROUND: Although low concentrations of inhaled nitric oxide may by therapeutic, both nitric oxide and its oxidation product nitrogen dioxide are potentially toxic. The threshold limits for time-weighted average concentrations of nitric oxide and nitrogen dioxide issued by the American Conference of Governmental Industrial Hygienists are 25 and 3 ppm, respectively. The concentrations of these gases in the breathing space of hospital personnel during administration of nitric oxide to adult patients have not been reported. METHODS: Air was sampled from the breathing zone of intensive care unit nurses via collar-mounted tubes during the nurses' routine duties attending patients who were receiving inhaled nitric oxide at 5 or 20 ppm. The exhaust ports of the mechanical ventilators were left open to the room. Nitric oxide and nitrogen dioxide were chemically assayed as nitrite from sorbent tubes by using spectrophotometry. Ambient nitric oxide levels were measured at sequential distances from the ventilator by using chemiluminescence. RESULTS: The time-weighted average concentrations of inspired gas for nurses during inhaled nitric oxide treatment were 0.45 ppm or less for nitric oxide and less than 0.29 ppm for nitrogen dioxide. Nitric oxide levels at the ventilator during delivery at 20 ppm were 9.2 ppm, but dropped off markedly beyond 0.6 m (2 ft), to a mean of about 30 ppb. CONCLUSION: Inhaled nitric oxide therapy at doses up to 20 ppm does not appear to pose a risk of excessive occupational exposure to nitric oxide or nitrogen dioxide to nurses during routine delivery of critical care.
PMID: 12625173, UI: 22512874
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Anaesth Intensive Care 2003 Feb;31(1):21-7
Intensive Care Unit, Nepean Hospital, University of Sydney, PO Box 63, Penrith, N.S.W. 2750.
Patients admitted to an Intensive Care Unit (ICU) frequently have underlying cardiac dysfunction. Early interventions are sometimes difficult to initiate because of diagnostic uncertainty as to whether cardiac failure is present As B-type natriuretic peptide (BNP) has been shown to be increased in cardiac dysfunction, we sought to demonstrate whether BNP can be used as a screening tool for cardiac dysfunction in patients admitted to ICU. All patients admitted to a combined medical and surgical ICU over a four-week period were included in the study. BNP was measured on the point of admission using a hand-held meter. Clinicians were blinded from the measurement when diagnoses were made as to whether or not the patients had clinically significant cardiac dysfunction. Patients with cardiac dysfunction had a significantly higher level of BNP when compared to the non-cardiac dysfunction group: 516 +/- 385 pg/ml (n = 26) v 67 +/- 89 pg/ml (n = 58) (P < 0.0001) A BNP cut-off value at 144 pg/ml exhibited a 92% sensitivity, 86% specificity and 96% negative predictive value. The sensitivity improved to 96% when the analysis was confined to patients > or = 55 years. At this cut-off value, BNP is a strong predictor of cardiac dysfunction. BNP measurement offers a rapid and affordable way to screen for cardiac dysfunction in patients admitted to ICU. An increased BNP level warrants further cardiac investigations so as to implement early interventions for cardiac decompensation in ICU patients.
PMID: 12635390, UI: 22523267
Anaesthesia 2003 Mar;58(3):271-4
Intensive Care Unit, Chelsea and Westminster Hospital, London, UK.
PMID: 12638567, UI: 22525038
Crit Care Med 2003 Mar;31(3):998-9
Publication Types:
PMID: 12627033, UI: 22513553
Crit Care Med 2003 Mar;31(3):968-9
PMID: 12627013, UI: 22513533
Crit Care Med 2003 Mar;31(3):858-63
OBJECTIVE Although admission of patients to a medical ward after 5:00 pm has been associated with increased mortality rate and possibly shorter hospital stay, the association between timing of admission to the intensive care unit and outcome has not been studied. The objective of this study was to determine whether there are any associations between the timing of patient admission to a medical intensive care unit and hospital outcome.DESIGN A retrospective cohort study that used an Acute Physiology and Chronic Health Evaluation III database containing prospectively collected demographic, clinical, and outcome information for patients. Patients were divided according to the time of admission into daytime (from 7:00 am to 5:00 pm) and nighttime admissions. We further subdivided nighttime admissions into two groups (regular and heavy workload) according to the number of patients who were admitted during the same shift.SETTING Medical intensive care unit (a 15-bed unit in an academic referral hospital).PATIENTS 6,034 patients consecutively admitted to our medical intensive care unit over a 5-yr period starting April 10, 1995.INTERVENTIONS None.MEASUREMENTS AND MAIN RESULTS The patients admitted at night had a lower mortality rate (13.9 vs. 17.2%, <.0001), adjusted for admission source and severity of illness. Their hospital stay was shorter, 11.0 days +/- 13.5 (median 7) vs. 12.7 +/- 14.8 (median 8; <.0001), as was their intensive care unit stay, 3.5 +/- 4.4 days (median 2) vs. 3.9 +/- 4.7 (median 2; <.0001), compared with the daytime admission group. The nighttime shifts that admitted three or more patients (heavy workload) had the same mortality rate (13.2%) as those with fewer admissions (14.5%; =.5961). Hospital and intensive care unit stays were also similar in both workload groups.CONCLUSIONS Nighttime admission to our intensive care unit is not associated with a higher mortality rate or a longer hospital or intensive care unit stay compared with daytime admission.
PMID: 12626997, UI: 22513517
Crit Care Med 2003 Mar;31(3):847-52
OBJECTIVE To compare the survival of patients in a teaching hospital pediatric intensive care unit in which residents provided after-hours in-house coverage with survival in the same unit with hospitalists providing this coverage.DESIGN Retrospective cohort study.SETTING Pediatric intensive care units in two teaching hospitals that are managed by the same group of academic pediatric intensivists, one of which transitioned from the traditional resident-staffed model to a hospitalist-staffed model for after-hours in-house coverage.PATIENTS All pediatric patients admitted to the study pediatric intensive care unit and to the control pediatric intensive care unit from April 1997 through March 1998, the resident era, and from October 1998 through September 1999, the hospitalist era.INTERVENTIONS Multivariate analysis, with survival as the dependent variable and era (hospitalist vs. resident) as an independent variable, was used to compare odds of survival during the hospitalist era with that of the resident era, adjusted for severity of illness. Multivariate linear regression was used to compare length of stay during the hospitalist era with that of the resident era, adjusted for severity of illness. Pediatric Risk of Mortality scores and those diagnostic categories typically associated with higher mortality rates also were included as independent variables in both analyses to adjust for severity of illness.MEASUREMENTS AND MAIN RESULTS Multivariate analysis yielded an estimated odds ratio of survival of 2.8 for the hospitalist era compared with the resident era ( =.013), and our analysis supported an independent association between survival and hospitalist era. Multivariate linear regression showed that length of stay, also adjusted for severity of illness, during the hospitalist era was 21.1 hrs shorter than during the resident era ( =.013). Neither survival nor length of stay was significantly associated with era at the control hospital.CONCLUSION Improved survival with hospitalists, rather than residents, providing after-hours care when an intensivist is not in house suggests that the quality of care of critically ill patients is improved when more experienced physicians are providing bedside care. Shorter length of stay with the hospitalist model also may reflect improved quality of care.
PMID: 12626995, UI: 22513515
Crit Care Med 2003 Mar;31(3):841-6
OBJECTIVE We evaluated the variable Kt/V, which has become established in the therapy of end-stage renal disease in acute renal failure, to assess the influence of the filtration volume of continuous venovenous hemofiltration on Kt/V. We measured the variables of acid-base balance and uremia control.DESIGN Prospective interventional pilot study.SETTING Medical intensive care unit of a university hospital.PATIENTS Fifty-six patients with acute renal failure and continuous venovenous hemofiltration treatment.INTERVENTIONS The patients were consecutively treated with a filtration volume of either 1 L/hr (group 1) or 1.5 L/hr (group 2).MEASUREMENTS AND MAIN RESULTS Patients with a filtration volume of 1.5 L/hr achieved a Kt/V of 0.8 per day, which was significantly higher than in the patient group treated with 1 L/hr (0.53, <.05). The filtration volume of 1.5 L/hr led to a markedly better control of blood urea nitrogen concentrations, 69.3 +/- 6.6 mg/dL vs. 52.1 +/- 5.2 ( <.05), and to a much quicker and longer lasting compensation of acidosis. Both groups had acidotic pH at the beginning of therapy (group 1, 7.29 +/- 0.02; group 2, 7.29 +/- 0.02, nonsignificant). In group 2, a significantly higher pH value than in group 1 was measured after 24 hrs of continuous venovenous hemofiltration ( <.001; 7.39 +/- 0.02 vs. 7.31 +/- 0.02). The pH values in group 1 did not normalize until after 4 days. The filtration volume of 1.5 L/hr led to a quicker increase in bicarbonate concentrations after 24 hrs of therapy (group 1, 2.8 +/- 3.2 mmol/L; group 2, 6.5 +/- 3.1 mmol/L, <.001).CONCLUSIONS The standardized urea clearance Kt/V is a valuable tool in the treatment of acute renal failure. Higher Kt/V levels were associated with a better control of uremia and acid-base balance. However, there were no differences in the clinical course, patient survival, percentage of patients with or without renal failure who were transferred from the intensive care unit, or Acute Physiology and Chronic Health Evaluation III scores.
PMID: 12626994, UI: 22513514
Crit Care Med 2003 Mar;31(3):787-92
OBJECTIVES Some propofol emulsion formulations contain EDTA or sodium metabisulfite to inhibit microbe growth on extrinsic contamination. EDTA is not known to react with propofol formulation components; however, sulfite has been shown to support some oxidation processes and may react with propofol. This study compared the oxidation of propofol and the formation of free radicals by electron paramagnetic resonance analysis in EDTA and sulfite propofol emulsions during a simulated intensive care unit 12-hr intravenous infusion.DESIGN Controlled laboratory study.SETTING University laboratory.MEASUREMENTS AND MAIN RESULTS Propofol emulsions (3.5 mL) were dripped from spiked 50-mL vials at each hour for 12 hrs. Two propofol oxidation products, identified as propofol dimer and propofol dimer quinone, were detected in sulfite and EDTA propofol emulsions; however, sulfite propofol emulsion contained higher quantities of both compounds. After initiation of the simulated infusion, the quantities of propofol dimer and propofol dimer quinone increased in the sulfite propofol emulsion, but the lower levels in the EDTA propofol emulsion remained constant. Sulfite propofol emulsion began to visibly yellow at about 6-7 hrs. The EDTA propofol emulsion remained white at all times. The absorbance spectra of the propofol dimer and propofol dimer quinone extracted from sulfite propofol emulsion showed that propofol dimer did not absorb in the visible spectrum, but the propofol dimer quinone had an absorbance peak at 421 nm, causing it to appear yellow. Electron paramagnetic resonance analysis of the propofol emulsion containing metabisulfite revealed that the sulfite propofol emulsion yielded a strong free radical signal consistent with the formation of the sulfite anion radical (SO ). The EDTA propofol emulsion yielded no free radical signal above background.(3)CONCLUSION Sulfite from the metabisulfite additive in propofol emulsion creates an oxidative environment when these emulsions are exposed to air during a simulated intravenous infusion. This oxidation results in propofol dimerization and emulsion yellowing, the latter of which is caused by the formation of propofol dimer quinone. These processes can be attributed to the rapid formation of the reactive sulfite free radical.
PMID: 12626985, UI: 22513505
Crit Care Med 2003 Mar;31(3):781-6
OBJECTIVE To investigate salivary flow and frequency of oral mucositis in intensive care unit patients compared with patients admitted because of elective coronary artery bypass graft (CABG) surgery. In addition, the pattern of oropharyngeal colonization was investigated in these patients.DESIGN Prospective study.SETTING Mixed intensive care unit and cardiosurgical ward.PATIENTS In this study, 24 ventilated intensive care unit patients and 20 CABG patients were included.MEASUREMENTS AND MAIN RESULTS Two dental hygienists examined intensive care unit patients for the presence of periodontal disease and mucositis at admission and subsequently every week during their stay in the intensive care unit. At the same time, stimulated salivary flow and salivary total immunoglobulin A output were measured. Oropharyngeal cultures were obtained as well. CABG patients were examined the day before the operation, 1 day, 1 wk, and 2 wks after the operation. The following results were obtained: a) temporarily reduced postoperative stimulated salivary flow and total salivary immunoglobulin A output in CABG patients and nearly absent stimulated salivary flow in intensive care unit patients; b) oropharyngeal colonization with potentially pathogenic microorganisms in intensive care unit and not in CABG patients; and c) the increase in mucositis index in intensive care unit patients paralleled the increase in potentially pathogenic microorganism oropharyngeal colonization, especially and.CONCLUSIONS Absence of adequate salivary flow in intubated intensive care unit patients causes severe xerostomia, which may contribute to the development of mucositis and oropharyngeal colonization with Gram-negative bacteria.
PMID: 12626984, UI: 22513504
Crit Care Med 2003 Mar;31(3):752-7
OBJECTIVE To generate and validate a predictive score of yeast isolation based on independent risk factors of yeast isolation in intensive care unit patients with peritonitis.DESIGN Retrospective cohort study to determine independent risk factors of yeast isolation, generation of the score, and validation in a prospective cohort of patients with peritonitis.SETTING Tertiary-care, university-affiliated hospital.PATIENTS Two hundred twenty-one patients with peritonitis hospitalized in a surgical intensive care unit between 1994 and 1999 for the retrospective cohort and 57 patients in the prospective cohort (2000).MEASUREMENTS AND MAIN RESULTS Four independent risk factors of yeast isolation in peritoneal fluid (similar odds ratio) were found in the retrospective cohort: female gender, upper gastrointestinal tract origin of peritonitis, intraoperative cardiovascular failure, and previous antimicrobial therapy at least 48 hrs before the onset of peritonitis. A score based on the number of risk factors was constructed (grade A = zero or one risk factor, grade B = at least two risk factors, grade C = at least three risk factors, and grade D = four risk factors), and validated in the prospective cohort. For a grade C score, sensitivity was 84%, specificity was 50%, positive and negative predictive values were 67% and 72%, respectively, and overall accuracy was 71%.CONCLUSIONS Four independent risk factors of yeast isolation in the peritoneal fluid were identified in critically ill surgical patients with peritonitis. The presence of at least three of these factors (grade C score) was associated with a high rate of yeast detection. This approach could be helpful to initiate early antifungal therapy in this patient population.
PMID: 12626979, UI: 22513499
Crit Care Med 2003 Mar;31(3):699-704
OBJECTIVE To determine whether use of a hygroscopic and hydrophobic heat and moisture exchanger (HME) for 7 days without change affects its efficiency in long-term, mechanically ventilated, chronic obstructive pulmonary disease (COPD) patients.DESIGN Prospective, randomized, controlled clinical study comparing two combined HMEs.SETTING Medical intensive care unit at a university teaching hospital.PATIENTS Long-term, mechanically ventilated, COPD patients compared with non-COPD patients.INTERVENTIONS In the first part of the study, COPD patients were studied with the Hygroster HME changed once a week. For the second part, the Hygroster was assessed in non-COPD patients and compared with the Hygrobac HME used in COPD and non-COPD patients for 1 wk without change. Devices could be changed if hygrometric measurements indicated insufficient humidity delivery.MEASUREMENTS AND MAIN RESULTS Daily measurements were recorded for inspired gas temperature and relative and absolute humidity. Ventilatory variables, clinical indicators of efficient humidification, were also recorded. No tracheal tube occlusion occurred. However, contrary to the manufacturer advertisement, the Hygroster experienced surprisingly low values for absolute humidity in both COPD and non-COPD patients. Such events did not occur with the Hygrobac. Absolute humidity with the Hygroster was constantly and significantly lower during the 7-day study period than with the Hygrobac. Absolute humidity measured in COPD patients was identical to that measured in the rest of the study population with both HMEs.CONCLUSIONS Manufacturer specifications and bedside measurements of absolute humidity differed considerably for the Hygroster, which in certain instances did not achieve efficient humidification in both COPD and non-COPD patients. This did not occur with the Hygrobac, which performed well throughout the 7-day period in both COPD and non-COPD patients. Our results speak for independent and evaluation of HMEs.
PMID: 12626972, UI: 22513492
Crit Care Med 2003 Mar;31(3):694-8
OBJECTIVE To determine the frequency of adverse drug reactions in surgical intensive care units and evaluate their effect on the length of stay.DESIGN Prospective cohort study. Between May 1997 and December 1999, while the patients were staying in the surgical intensive care unit, data were gathered regarding suspected adverse drug reactions and on different variables related to the length of stay.SETTING Surgical intensive care units of our hospital.PATIENTS A total of 401 patients hospitalized in the surgical intensive care unit.MAIN RESULTS In 37 of the 401 patients seen (9.2%; 95% confidence interval, 6.6-12.5), 39 different adverse drug reactions were detected. The adverse drug reactions were most frequently caused by the following drugs: morphine hydrochloride (n = 13), meperidine hydrochloride (n = 9), and metamizole (n = 7). Five adverse drug reactions were severe, the suspected medication had to be discontinued in 14 cases, and new drugs were necessary to manage the adverse drug reaction in 28 cases. The crude estimation of the effect of adverse drug reactions performed on the length of stay with a bivariant regression model indicated that each adverse drug reaction was related to an increase of 3.39 days (95% confidence interval, 1.47-5.31) in the length of stay. This estimation was reduced to 2.31 days (95% confidence interval, 0.64-3.99) when considering other variables that might cause confusion for analysis, although it is still important.CONCLUSIONS Adverse drug reactions are a significant clinical and economic problem in surgical intensive care units.
PMID: 12626971, UI: 22513491
Crit Care Med 2003 Mar;31(3):S119-20
PMID: 12626955, UI: 22513475
Crit Care Nurse 2002 Dec;Suppl:1-12; discussion 12-4; quiz 15-6
Department of Anesthesia, Stanford University School of Medicine, Stanford, Calif., USA.
Although anemia is apparently tolerated in most patients, particularly those who are relatively healthy, the ICU population must be thought of differently. Anemia in the ICU may be due to acute blood loss, phlebotomy, or to the presence of inflammatory disease. The anemia in critically ill patients resembles anemia of chronic disease, which is believed to result from a poor endogenous erythropoietin response or erythropoietin deficiency. The risks of blood transfusions are many and ICU patients may not tolerate infusions of older, stored blood. Nonetheless, hemoglobin levels at or above 100 g/L may be important for oxygen delivery to vital organs, especially in critically ill patients with increased oxygen demands. The appropriate transfusion trigger for critically ill patients in this setting remains unknown. Blood transfusions in the ICU may not improve outcomes, and numerous studies have been published to suggest the contrary, that transfusions may actually worsen patients' outcomes in certain ICU settings. Recombinant human erythropoietin (rHuEPO, epoetin alfa) has been shown to reduce transfusion needs and increase hemoglobin levels in multiple settings and now, it appears to also do so in the ICU.
PMID: 12518573, UI: 22407013
Crit Care Nurse 2002 Dec;22(6):66-8
Pediatric Intensive Care Unit, Children's Medical Center, Dayton, Ohio, USA.
PMID: 12518570, UI: 22407010
Crit Care Nurse 2002 Dec;22(6):35-43
Department of Nursing, University of Southern California, Los Angeles, Calif., USA.
PMID: 12518566, UI: 22407006
Crit Care Nurse 2002 Dec;22(6):29-34
Texas Children's Hospital, Houston, Tex., USA.
PMID: 12518565, UI: 22407005
Crit Care Nurse 2002 Dec;22(6):20-6; quiz 27-8
University of Oklahoma, USA.
PMID: 12518564, UI: 22407004
Crit Care Nurse 2002 Dec;22(6):12-9
PMID: 12518563, UI: 22407003
JAMA 2003 Feb 26;289(8):985-6; author reply 986-7
PMID: 12597749, UI: 22486945
JAMA 2003 Feb 26;289(8):986; author reply 986-7
PMID: 12597748, UI: 22486944
JAMA 2003 Feb 26;289(8):981; author reply 981
PMID: 12597737, UI: 22486933
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Thorax 2003 Feb;58(2):157-62
Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge, UK. Keith_McNeil@health.qld.gov.au
The management of severe pulmonary hypertension associated with right ventricular failure is reviewed and its relevance to adults with acute respiratory distress syndrome (ARDS) is discussed.
PMID: 12554902, UI: 22442953
Wien Klin Wochenschr 2002 Dec 30;114(23-24):1017-22
Division of Neonatology, Department of Pediatrics, University of Vienna, Vienna, Austria. angelika.berger@akh-wien.ac.at
BACKGROUND: It is known that infections with Serratia marcescens can take a progressive course in preterm infants and that meningoencephalitis with this pathogen exhibits an extremely bad neurologic prognosis. METHODS AND RESULTS: We report on five cases of septicemia with Serratia marcescens in preterm infants during a nosocomial outbreak. Three patients developed meningoencephalitis with brain abscesses. Mild clinical and laboratory findings of infection contrasted with destructive findings on MRI scan. All five patients survived, those with isolated bacteremia without neurologic sequelae. CONCLUSION: When Serratia marcescens is isolated from any source in a neonatal intensive care unit, preventive measures including strict hygiene and cohorting of infants must be implemented immediately since this pathogen seems to exhibit specific affinity for the central nervous system and Serratia marcescens meningoencephalitis takes a progressive and destructive course despite antibiotic therapy.
PMID: 12635472, UI: 22523351