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Comment on:
Intravenous montelukast in acute asthma.
Rodrigo GJ, Rodrigo C.
Publication Types:
PMID: 14719233 [PubMed - indexed for MEDLINE]
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[Cortisone substitution in sepsis. Is less more?]
[Article in German]
Briegel J.
Klinik fur Anaesthesiologie, Klinikum der Universitat Munchen. josef.briegel@ana.med.uni-muenchen.de
Publication Types:
PMID: 14727048 [PubMed - indexed for MEDLINE]
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[Intensive insulin therapy in sepsis. Improvement of survival chances?]
[Article in German]
Jeschke MG.
Abteilung fur Plastische und Handchirurgie, Friedrich-Alexander-Universitat Erlangen, Erlangen. Mcjeschke@hotmail.com
Publication Types:
PMID: 14727047 [PubMed - indexed for MEDLINE]
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[Early goal-directed therapy in sepsis. Old wine in new skins?]
[Article in German]
Bauer M.
Klinik fur Anaesthesiologie und Intensivmedizin, Universitat des Saarlandes, Homburg/Saar. aimbau@uniklinik-saarland.de
Publication Types:
PMID: 14727046 [PubMed - indexed for MEDLINE]
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[Meta-analysis. A meaningful tool for evidence-based (intensive) medicine]
[Article in German]
Tramer MR.
Division d'Anesthesiologie, Departement Anesthesiologie, Pharmacologie et Soins Intensifs Chirurgicaux, Hopitaux Universitaires de Geneve, Switzerland. martin.tramer@hcuge.ch
Publication Types:
PMID: 14727043 [PubMed - indexed for MEDLINE]
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Nutritional support in critical care.
Baudouin SV, Evans TW.
Department of Anaesthesia and Intensive Care Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
Despite the key role of nutrition in health and the almost universal use of supplemental feeding in the ICU, there is a lack of high-quality evidence to guide clinical practice. Enteral nutrition is superior to TPN in almost all circumstances and most patients in the ICU can be fed successfully by this route. There is little evidence to support the use of special feeds and the role of immunonutrients remains unproven. Nutritional support cannot completely prevent the adverse effects of catabolic illness and overfeeding should be avoided.
Publication Types:
PMID: 14710695 [PubMed - indexed for MEDLINE]
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Critical issues in digestive diseases.
Proctor DD.
Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 1080 LMP, New Haven, CT 06520, USA. deborah.proctor@yale.edu
This article discussed the diagnosis and management of acute GI bleeding, prophylaxis against GI bleeding, acute pancreatitis, and acalculous cholecystitis. These diseases are commonly encountered in the ICU setting. Acute GI bleeding is usually obvious and with GI and with available interventional radiologic techniques, patients rarely need surgery. Conversely, acalculous cholecystitis is difficult to diagnosis; therefore, a high degree of suspicion needs to be exercised with all critically ill patients.
Publication Types:
PMID: 14710694 [PubMed - indexed for MEDLINE]
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Critical issues in hematology: anemia, thrombocytopenia, coagulopathy, and blood product transfusions in critically ill patients.
Drews RE.
Department of Medicine, Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA. rdrews@bidmc.harvard.edu
Systematic evaluations of anemia, thrombocytopenia, and coagulopathy are essential to identifying and managing their causes successfully. In all cases, clinicians should evaluate RBC measurements alongside WBC and platelet counts and WBC differentials. Multiple competing factors may coexist; certain factors affect RBCs independent of those that affect WBCs or platelets. Ideally, clinicians should examine the peripheral blood smear for morphologic features of RBCs, WBCs, and platelets that provide important clues to the cause of the patient's hematologic disorder. Thrombocytopenia arises from decreased platelet production, increased platelet destruction, or dilutional or distributional causes. Drug-induced thrombocytopenias present diagnostic challenges, because many medicines can cause thrombocytopenia and critically ill patients often receive multiple medications. If they suspect type II HIT, clinicians must promptly discontinue all heparin sources, including LMWHs, without awaiting laboratory confirmation, to avoid thrombotic sequelae. Because warfarin anticoagulation induces acquired protein C deficiency, thereby exacerbating the prothrombotic state of type II HIT, warfarin should be withheld until platelet counts increase to more than 100,000/microL and type II HIT is clearly resolving. The presence of a consumptive coagulopathy in the setting of thrombocytopenia supports a diagnosis of DIC, not TTP-HUS, and is demonstrated by decreasing serum fibrinogen levels, and increasing TTs, PTs, aPTTs, and fibrin degradation products. Increasing D-dimer, levels are the most specific DIC parameter and reflect fibrinolysis of cross-linked fibrin. Elevated PTs or a PTTs can result from the absence of factors or the presence of inhibitors. Clinicians should suspect factor inhibitors when the prolonged PT or aPTT does not correct or only partially corrects following an immediate assay of a 1:1 mix of patient and normal plasma. In addition to factor inhibitors, antiphospholipid antibodies (e.g., lupus anticoagulant) can produce a prolonged aPTT that does not correct with normal plasma but is overcome by adding excess phospholipid or platelets. Paradoxically, a tendency to thrombosis, not bleeding, accompanies lupus anticoagulants and the antiphospholipid antibody syndrome. Transfusion of red blood cells, platelets, or plasma products is sometimes warranted, but clinicians must carefully weigh potential benefits against known risks. In critically ill patients, administering RBCs can enhance oxygen delivery to tissues. Among euvolemic patients who do not have ischemic heart disease, guidelines recommend a transfusion threshold of HGB levels in the range of 6.0 to 8.0 g/dL; patients who have HGB that is at least 10.0 g/dL are unlikely to benefit from blood transfusion. The use of rHuEPO to increase erythropoiesis offers an alternative to RBC transfusion, assuming normal, responsive progenitor cells and adequate iron, folate, and cobalamin stores. Future research should examine whether clinical outcomes from rHuEPO use in critically ill patients are important and cost-effective. Because platelets play an instrumental role in primary hemostasis, platelet transfusions are often important in managing patients who are bleeding or at risk of bleeding with thrombocytopenia or impaired platelet function. Platelet transfusions carry risks, and decisions to transfuse platelets must consider clinical circumstances. Most important, platelet transfusions are generally contraindicated if the underlying disorder is TTP or type II HIT, because platelet transfusion in these settings may fuel thrombosis and worsen clinical signs and symptoms. Plasma products can correct hemostasis when bleeding arises from malfunction, consumption, or underproduction of plasma coagulation proteins. Choice of plasma product for transfusion depends on clinical circumstances. FFP is the most commonly used plasma product to correct clotting factor deficiencies, particularly coagulopathies that are attributable to multiple clotting factor deficiency states as in liver disease, DIC, or warfarin anticoagulation. PCC or rFVIIa that is administered in small volumes may provide advantages over FFP when coagulopathies require quick reversal without risk of volume overload. Factor concentrates can replace specific factor deficiencies. Recombinant FVIIa bypasses inhibitors to factors VIII and IX and vWF. Use of rFVIIa in managing hemostatic abnormalities from severe liver dysfunction; extensive surgery, trauma, or bleeding; excessive warfarin anticoagulation; and certain platelet disorders requires further study to determine optimal and cost-effective dosing regimens. Recombinant activated protein C reduces mortality from severe sepsis that is associated with organ dysfunction in adults who are at high risk for death (APACHE scores of at least 25). In severe sepsis, levels of protein C decrease, as do fibrinogen and platelet levels. Because of its anticoagulant effect, however, drotrecogin alfa may induce bleeding. Guidelines for drotrecogin alfa use must take into account bleeding risks.
Publication Types:
PMID: 14710693 [PubMed - indexed for MEDLINE]
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Critical issues in endocrinology.
Goldberg PA, Inzucchi SE.
Section of Endocrinology, Yale University School of Medicine, TMP 534, 333 Cedar Street, New Haven, CT 06520, USA.
Endocrine emergencies are commonly encountered in the ICU. This article focuses on several important endocrine emergencies, including diabetic hyperglycemic states, adrenal insufficiency, myxedema coma, thyroid storm, and pituitary apoplexy. Other endocrine issues that are related to intensive care, such as intensive insulin therapy, relative adrenal insufficiency, and thyroid function test abnormalities are also covered in detail.
Publication Types:
PMID: 14710692 [PubMed - indexed for MEDLINE]
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Critical issues in nephrology.
Peixoto AJ.
Department of Medicine, Section of Nephrology, Yale University School of Medicine, 333 Cedar Street, 2073 LMP, New Haven, CT 06520, USA. aldo.peixoto@yale.edu
Renal and electrolyte problems are common in patients in the ICU. Several advances that occurred in the recent past have been incorporated in the diagnosis and management of these disorders and were reviewed in this article. Unfortunately, many important questions remain unanswered, especially in the area of ARF, where new therapies are anxiously awaited to make the transition from bench to bedside. Better studies are sorely needed to define the best approach to dialysis in patients who have ARF.
Publication Types:
PMID: 14710691 [PubMed - indexed for MEDLINE]
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New approaches to the treatment of sepsis.
O'Brien JM Jr, Abraham E.
Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Box C272, Denver, CO 80262, USA. james.obrien@uchsc.edu
The clinical spectrum of sepsis, severe sepsis, and septic shock is responsible for a growing number of deaths and excessive health care expenditures. Until recently, despite multiple clinical trials, no intervention provided a beneficial outcome in septic patients. Within the last 2 years, studies that involved drotrecogin alfa (activated), corticosteroid therapy, and early goal-directed therapy showed efficacy in those with severe sepsis and septic shock. These results have provided optimism for reducing sepsis-related mortality.
Publication Types:
PMID: 14710689 [PubMed - indexed for MEDLINE]
Risk of bloodstream infection can be strongly decreased by a very moderate caloric intake or strongly increased by a very low caloric intake in severely ill patients in intensive care?
Auboyer C, Bouletreau P.
Publication Types:
PMID: 14758186 [PubMed - in process]
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Premedication for tracheal intubation: a prospective survey in 75 neonatal and pediatric intensive care units.
Simon L, Trifa M, Mokhtari M, Hamza J, Treluyer JM.
Reanimation Chirurgicale, Hopital Cochin-Saint Vincent de Paul, Universite Paris V, Paris, France.
OBJECTIVE: In children, like in adults, tracheal intubation is a painful procedure that may induce hypertension, tachycardia, and other undesirable hemodynamic disorders. Although premature neonates are very sensitive to pain and vulnerable to its long-term effects, the need for sedation before tracheal intubation is still discussed in neonatal units. Our objective was to investigate the practice of premedication before tracheal intubation in neonatal and pediatric units and determine the influence of premedication on intubating conditions. DESIGN: We performed a 10-day prospective survey in 75 neonatal and pediatric intensive care units among the 98 licensed in France. A questionnaire was completed for each intubation performed in each surveyed unit. SUBJECTS: A total of 204 patients were studied: 140 neonates, 52 infants, and 12 children. MAIN RESULTS: Data on 204 tracheal intubations were collected from 223 that were performed during the study period (participation rate, 91.4%). Premedication was used before intubation for 37.1%, 67.3%, and 91.7% of neonates, infants, and children, respectively (p <.0001). In the subgroup of neonates, premedication was particularly rare for the youngest and the smallest infants. Midazolam was the principle hypnotic used in neonates, whereas propofol was mainly used in children. Opioids or muscle relaxants were used in 16.2% and 4.4% of the patients, respectively. A low success rate and a high incidence of hypoxemia and bradycardia were correlated with the inexperience of the operator. Premedication did not significantly influence either the success rate or the undesirable events associated with tracheal intubation. CONCLUSION: Use of premedication before tracheal intubation is limited in neonates and increases according to the age of the patient. Midazolam does not seem to be an accurate choice to improve intubating conditions in neonates and infants. Because tracheal intubation is a technique that requires a skill only developed by regular practice, operators who have limited experience with intubating children should be supported by senior operators.
PMID: 14758180 [PubMed - in process]
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Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system.
Diringer MN; Neurocritical Care Fever Reduction Trial Group.
Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
CONTEXT: Elevated temperature worsens injury in experimental focal and global ischemia and brain trauma. Fever is common in patients with acute neurologic illness and independently predicts poor outcome. Conventional means of treating fever are not very effective in this population. OBJECTIVE: To study the effectiveness of a catheter-based heat exchange system in reducing elevated temperatures in critically ill neurologic and neurosurgical patients. DESIGN, INTERVENTION, SETTING, AND POPULATION: This was a prospective randomized, non-blinded trial that compared conventional treatment of fever (acetaminophen and cooling blankets) with conventional treatment plus an intravascular catheter-based heat exchange system (Alsius, Irvine, CA). Patients admitted to one of 13 neurologic intensive care units in academic medical centers were eligible if they a) suffered subarachnoid hemorrhage, intracerebral hemorrhage, ischemic infarction, or traumatic brain injury; b) had a temperature >38 degrees C on two occasions or for >4 continuous hrs; and c) required central venous access. MAIN OUTCOME MEASURE: The fever burden (area under the curve >38 degrees C) for 72 hrs was compared in an intention to treat analysis. Safety of the catheter system was monitored. RESULTS: A total of 296 patients were enrolled over 20 months. Forty-one percent had subarachnoid hemorrhage, 24% had traumatic brain injury, 23% had intracerebral hemorrhage, and 13% had ischemic stroke. The groups were matched in terms of age, body mass index, sex, and Glasgow Coma Scale score distribution. Fever burden was 7.92 vs. 2.87 degrees C-hrs in the conventional group and catheter groups, respectively (64% reduction, p <.01). There was no higher rate of infection or the use of sedatives, narcotics, or antibiotics in the catheter group. The catheter did not significantly increase risk to the patient beyond that of a central catheter. CONCLUSIONS: The addition of this catheter-based cooling system to conventional management significantly improves fever reduction in neurologic intensive care unit patients.
PMID: 14758179 [PubMed - in process]
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Utility of activated partial thromboplastin time waveform analysis for identification of sepsis and overt disseminated intravascular coagulation in patients admitted to a surgical intensive care unit.
Dempfle CE, Lorenz S, Smolinski M, Wurst M, West S, Houdijk WP, Quintel M, Borggrefe M.
Department of Medicine, University Hospital of Mannheim, Germany.
OBJECTIVE: An abnormality of the optical transmission waveform obtained during measurement of the activated partial thromboplastin time (aPTT) has been described in association with overt disseminated intravascular coagulation. This abnormality, a biphasic waveform, is caused by the in vitro formation of Ca2+-induced complexes between very low density lipoprotein and C-reactive protein. We have evaluated the diagnostic utility of aPTT waveform analysis for identifying patients with overt disseminated intravascular coagulation and sepsis. DESIGN: Observational study investigating the predictive value of biphasic waveform for the diagnosis of sepsis and overt disseminated intravascular coagulation. SETTING: Surgical intensive care unit of a university hospital. SUBJECTS: We studied 331 consecutive patients admitted to the intensive care unit during a period of 6 months. INTERVENTIONS: Laboratory analyses, including prothrombin time, aPTT, aPTT waveform analysis, fibrinogen, D-dimer antigen, and platelet count. MEASUREMENTS AND MAIN RESULTS: At the most sensitive threshold value of the waveform variable for detection of the biphasic waveform (slope_1 = -0.05 %T/sec), this abnormality was detected in 54 of 331 patients (16.3%) at admission and 95 of 331 patients (28.7%) during the entire course of intensive care unit treatment. At this threshold, 59.3% of patients with a biphasic waveform on admission and 45.3% with a biphasic waveform during the total intensive care unit course were diagnosed with sepsis. Depending on the threshold value of slope_1, the sensitivity of aPTT waveform analysis for detection of sepsis varied between 22% and 55% at admission and between 48% and 74% during the entire intensive care unit stay. The specificity for sepsis varied between 92% and 98% and between 81% and 94%, for admission and total intensive care unit course, respectively. Biphasic waveform showed a comparable specificity for the diagnosis of overt disseminated intravascular coagulation, albeit at a lower sensitivity. CONCLUSIONS: As an adjunct to routine coagulation testing in intensive care unit patients, aPTT waveform analysis is an elegant means for the rapid and highly specific identification of patients with sepsis.
PMID: 14758173 [PubMed - in process]
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Medication errors involving continuously infused medications in a surgical intensive care unit.
Herout PM, Erstad BL.
Department of Pharmacy, Gundersen Lutheran Medical Center, La Crosse, WI, USA.
OBJECTIVE: To document the incidence of medication errors related to medications administered by continuous infusion. DESIGN: Observational study. SETTING: Sixteen-bed surgical intensive care unit. MEASUREMENTS AND MAIN RESULTS: All continuous infusions in the surgical intensive care unit were evaluated at least once daily for correct flow-sheet charting, concentration, infusion rate, and dose administered, as well as patients' heights and weights (actual, ideal, and "dry"). Collected information was examined to determine the error rate, types of errors occurring, and weight used for dose calculation. Variations inpatient weight measures were compared. Seventy-one patients with 202 total infusions were observed. Errors involving continuously infused medications in our surgical intensive care unit occurred at a rate of 105.9 per 1,000 patient days. For nonweight-based infusions, 94% of doses were delivered correctly. Slightly >10% of the doses administered for weight-based infusions (dose based on dry body weight) were incorrect. Significant differences were found between the weight measurements recorded, but this did not translate into statistically significant differences in the apparent calculated doses delivered. CONCLUSIONS: Medications delivered by continuous infusion, particularly those that are weight based, can contribute to medication errors in the intensive care unit. A large proportion (87.6%) of doses for weight-based infusions was calculated based on estimated or unreliable admission weights. There were no severe consequences resulting from the errors observed in this 1 month investigation; however, depending on the pharmacokinetic characteristics of the drug being administered, there is a potential to deliver artificially low or high doses resulting in subtherapeutic or adverse effects.
PMID: 14758159 [PubMed - in process]
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Limitation of life support: frequency and practice in a Hong Kong intensive care unit.
Buckley TA, Joynt GM, Tan PY, Cheng CA, Yap FH.
Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
OBJECTIVE: To examine the frequency and the decision-making processes involved in limiting (withdrawing and withholding) life support therapy in critically ill Chinese patients in the intensive care unit. DESIGN: Prospective survey of patients who had life support limited between April 1997 and March 1999. SETTING: Medical and surgical intensive care unit of a teaching hospital. PATIENTS: All patients admitted to the intensive care unit of the Prince of Wales Hospital who subsequently died and/or had life support limited. Brain-dead patients were excluded from analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 490 patients who died in the intensive care unit, limitation of life support occurred in 288 (58.8%). Relatives or patients requested limitation of life support in 32 cases (11%). The family and/or patient concurred with limitation of life support in 273 occasions (95%). Therapy was withheld in 30.8% and withdrawn in 28.0% of deaths. Therapy limited included inotropes, additional oxygen, and renal replacement therapy. CONCLUSIONS: Limitation of therapy in dying Chinese patients occurs frequently in intensive care patients, and both patients and relatives concur with medical decisions to limit therapy in these patients. Withholding therapy rather than withdrawing therapy occurs more frequently than in Western populations.
PMID: 14758157 [PubMed - in process]
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Intensive care unit survivors have fewer hospital readmissions and readmission days than other hospitalized patients in British Columbia.
Keenan SP, Dodek P, Chan K, Simon M, Hogg RS, Anis AH, Spinelli JJ, Tilley J, Norena M, Wong H.
Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, B.C., Canada.
OBJECTIVE: Intensive care unit (ICU) patients who survive their hospital admission have a long-term survival that is similar to that of hospitalized patients who do not require ICU admission. The risk of future readmission to the hospital for these two patient groups is unknown. The objective of this study was to determine the association between ICU admission and number of readmissions to the hospital and number of readmission days. DESIGN: Cohort study for 3 yrs between 1994 and 1997. SETTING: All acute care hospitals in British Columbia, Canada. PATIENTS: A total of 23,859 patients admitted to the ICU and 40,052 patients admitted to the hospital but not the ICU (5% random sample of total). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We measured the number of readmissions to the hospital and the number of readmission days after discharge from the first admission to the hospital during the study period. For survivors to the end of the study period, patients who had been in the ICU had 0.66 readmissions per year and 5.29 readmission days per year compared with 0.73 readmissions per year and 5.48 readmission days per year for control subjects. After controlling for age, sex, socioeconomic status, number of previous ICU and hospital admissions, major clinical category during index admission, comorbidity score during index admission, length of hospital stay during index admission, size of index hospital, and period of follow-up, ICU admission was associated with fewer readmissions (survivors: rate ratio, 0.80; 95% confidence interval, 0.77-0.82; nonsurvivors: rate ratio, 0.85; 95%, confidence interval, 0.82-0.89) and readmission days (survivors: rate ratio, 0.91; 95% confidence interval, 0.87-0.95; nonsurvivors: rate ratio, 0.87; 95%, confidence interval, 0.81-0.92) than admission to the hospital but not the ICU. CONCLUSIONS: Survivors of a hospital stay that includes admission to an ICU have fewer hospital readmissions and readmission days after their discharge than do survivors of a hospital stay without intensive care.
PMID: 14758153 [PubMed - in process]
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Study of clinical course of organ dysfunction in intensive care.
Doig CJ, Zygun DA, Fick GH, Laupland KB, Boiteau PJ, Shahpori R, Rosenal T, Sandham JD.
Department of Critical Care Medicine, Unversity of Calgary, Alberta, Canada.
OBJECTIVE: Multiple organ dysfunction is a common cause of death in intensive care units. We describe the daily course of multiple organ dysfunction measured by the Sequential Organ Failure Assessment score in a population-based cohort of critically ill patients. DESIGN: Prospective cohort study. SETTING: Adult multisystem intensive care units in the Calgary Health Region. PATIENTS: A total of 1,436 patients admitted from May 1, 2000 to April 30, 2001. MEASUREMENTS: Temporal change in Sequential Organ Failure Assessment score. INTERVENTIONS: None; observational study. MAIN RESULTS: The mean age was 58 yrs (range, 14-100). The mean +/- sd intensive care unit admission Acute Physiology and Chronic Health Evaluation II score was 25 +/- 9. The median intensive care unit length of stay was 4 days (interquartile range, 2-8), and the median hospital length of stay was 15 days (interquartile range, 7-32). A total of 20.5% of patients were infected at admission, and 26.0% were immediately postoperative. Intensive care unit mortality was 27.0%, and hospital mortality was 35.1%. The daily Sequential Organ Failure Assessment score was significantly higher in nonsurvivors than survivors. A population-averaged model determined a mean rate of change of Sequential Organ Failure Assessment score to be -0.29 per day (95% confidence interval, -0.32 to -0.25) for survivors and -0.03 per day (95% confidence interval, -0.08 to 0.03) for nonsurvivors (overall regression, p <.0001). Patients with infection had higher admission Sequential Organ Failure Assessment scores compared with patients without infection (difference, 1.8; p <.001), but a similar rate of daily change. CONCLUSIONS: Multiple organ dysfunction, does not follow a course of progressive and sequential failure. Evidence of differential daily change should further inform the use of organ failure scores as surrogate outcomes in clinical trials.
PMID: 14758152 [PubMed - in process]
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Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit.
Rubinson L, Diette GB, Song X, Brower RG, Krishnan JA.
Johns Hopkins University, Department of Medicine, Baltimore, MD, USA. lrubinso@jhmi.edu
OBJECTIVE: To determine whether caloric intake is associated with risk of nosocomial bloodstream infection in critically ill medical patients. DESIGN: Prospective cohort study. SETTING: Urban, academic medical intensive care unit. PATIENTS: Patients were 138 adult patients who did not take food by mouth for > or =96 hrs after medical intensive care unit admission. MEASUREMENTS: Daily caloric intake was recorded for each patient. Participants subsequently were grouped into one of four categories of caloric intake: <25%, 25-49%, 50-74%, and > or =75% of average daily recommended calories based on the American College of Chest Physicians guidelines. Simplified Acute Physiology Score II and serum albumin were measured on medical intensive care unit admission. Serum glucose (average value and maximum value each day) and route of feeding (enteral, parenteral, or both) were collected daily. Nosocomial bloodstream infections were identified by infection control surveillance methods. MAIN RESULTS: The overall mean (+/-sd) daily caloric intake for all study participants was 49.4 +/- 29.3% of American College of Chest Physicians guidelines. Nosocomial bloodstream infection occurred in 31 (22.4%) participants. Bivariate Cox analysis revealed that receiving > or =25% of recommended calories compared with <25% was associated with significantly lower risk of bloodstream infection (relative hazard, 0.24; 95% confidence interval, 0.10-0.60). Simplified Acute Physiology Score II also was associated with risk of nosocomial bloodstream infection (relative hazard, 1.27; 95% confidence interval, 1.01-1.60). Average daily serum glucose, admission serum albumin, time to initiating nutritional support, and route of nutrition did not affect risk of bloodstream infection. After adjustment for Simplified Acute Physiology Score II in a multivariable analysis, receiving > or =25% of recommended calories was associated with a significantly lower risk of bloodstream infection (relative hazard, 0.27; 95% confidence interval, 0.11-0.68). CONCLUSIONS: In the context of reducing risk of nosocomial bloodstream infections, failing to provide > or =25% of the recommended calories may be harmful. Higher caloric goals may be necessary to achieve other clinically important outcomes.
PMID: 14758147 [PubMed - in process]
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Hemoglobin solutions.
Creteur J, Vincent JL.
Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium.
OBJECTIVE: To review current knowledge about cell-free hemoglobin solutions. DATA SOURCE: A computerized MEDLINE search was used to retrieve all studies concerning cell-free hemoglobin solutions from 1990 to 2003. The reference lists of all available review articles and primary studies were also reviewed to identify references not identified in the computerized search. STUDY SELECTION: All clinical and experimental studies involving cell-free hemoglobin solutions were included. DATA EXTRACTION: From the selected studies, information was obtained regarding the experimental model or the study population in which cell-free hemoglobin solutions were investigated, the type of cell-free hemoglobin solution used, their deleterious or beneficial effects, and their possible indications. DATA SYNTHESIS: In many studies, hemoglobin solutions were considered as efficient resuscitative agents and good alternatives to red blood cell transfusion, owing to their marked vasopressor effect, coupled with their capacity to improve the microcirculation and rapidly restore metabolic parameters. The main problems identified include excessive systemic vasoconstriction and oxidative damage. Initial enthusiasm in the development of hemoglobin solutions has been tempered recently by the negative results of a U.S. multicenter trial studying the early infusion of diaspirin cross-linked hemoglobin in trauma patients. Nevertheless, the properties of diaspirin cross-linked hemoglobin (and particularly the strong vasopressor effects) cannot be attributed to all hemoglobin solutions, and results of new clinical studies are eagerly awaited to evaluate the potential benefit of such solutions in the management of trauma patients. CONCLUSIONS: Today, we are aware of the effects of the first generation of blood substitutes. Further research is ongoing into newer solutions. One area of interest is the development of new molecular structures to decrease nitric oxide binding, thus minimizing any adverse events and maximizing potential benefits. Nevertheless, possible adverse effects need to be carefully evaluated before these agents can be widely administered.
Publication Types:
PMID: 14724468 [PubMed - indexed for MEDLINE]
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Effects of storage on efficacy of red cell transfusion: when is it not safe?
Ho J, Sibbald WJ, Chin-Yee IH.
Departmentof Medicine, The University of Western Ontario, London, Canada.
OBJECTIVE: To review the literature on red blood cell storage and its relationship to the efficacy of transfusion. RESULTS: Well-documented changes occur to the red blood cell product during ex vivo storage. These changes include a reduction in red blood cell deformability, altered red blood cell adhesiveness and aggregability, and a reduction in 2,3-diphosphoglycerate and ATP. Bioactive compounds with proinflammatory effects also accumulate in the storage medium. These changes reduce posttransfusion viability of red blood cells. The clinical effects beyond posttransfusion viability are uncertain, but a growing body of evidence suggests that the storage lesion may reduce tissue oxygen availability, have proinflammatory and immunomodulatory effects, and influence morbidity and mortality. There are no published randomized, control trials examining the effect of storage duration on morbidity and mortality. Leukoreduction improves the quality of stored red blood cell products and in some studies has been shown to reduce morbidity and mortality. CONCLUSION: Although storage duration influences the quality of red blood cell product, there is currently insufficient evidence to advocate shorter storage periods for red blood cell products.
Publication Types:
PMID: 14724467 [PubMed - indexed for MEDLINE]
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Risks of blood transfusion.
Goodnough LT.
Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110-1093, USA. goodnough@pathbox.wustl.edu
OBJECTIVE: To review the current status of risks of blood transfusion. DATA SOURCES, EXTRACTIONS, AND SYNTHESIS: English-speaking literature, literature search using key works, human data, and follow-up with key bibliographic citations. CONCLUSIONS: Substantial advances have been achieved in blood safety during the last 20 yrs, particularly for transfusion-transmitted viral infections. Currently, the most serious known risks from blood transfusion are administrative error (leading to ABO-incompatible blood transfusion), transfusion-related acute lung injury, and bacterial contamination in platelet products. Emerging pathogens, such as West Nile virus infection emphasize the need for implementation of proactive strategies, such as pathogen inactivation technologies, as well as reactive strategies, such as nucleic acid testing, to ensure continued advances in blood safety.
Publication Types:
PMID: 14724466 [PubMed - indexed for MEDLINE]
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Anemia and red cell transfusion in critically ill patients.
Hebert PC, Tinmouth A, Corwin H.
University of Ottawa Centre for Transfusion Research and the Clinical Epidemiological Program, Ottawa Health Research Institute, Ontario, Canada. phebert@ohri.ca
Publication Types:
PMID: 14724465 [PubMed - indexed for MEDLINE]
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Transfusion practice in the critically ill.
Corwin HL, Surgenor SD, Gettinger A.
Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA. howard.l.corwin@hitchcock.org
BACKGROUND: Anemia in the critically ill patient population is common. This anemia of critical illness is a distinct clinical entity characterized by blunted erythropoietin production and abnormalities in iron metabolism identical to what is commonly referred to as the anemia of chronic disease. FINDINGS: As a result of this anemia, critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units receive at least one red blood cell unit, and the average is close to five red blood cell units during their intensive care unit stay. There is little evidence that "routine" transfusion of stored allogeneic red blood cells is beneficial for critically ill patients. Most critically ill patients can tolerate hemoglobin levels as low as 7 mg/dL, so a more conservative approach to red blood cell transfusion is warranted. CONCLUSION: Practice strategies should be directed toward a reduction of blood loss (phlebotomy) and a decrease in the transfusion threshold in critically ill patients.
Publication Types:
PMID: 14724464 [PubMed - indexed for MEDLINE]
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Oxygen delivery.
Hameed SM, Aird WC, Cohn SM.
Department of Surgery, University of Calgary, Alberta, Canada. Morad.Hameed@CalgaryHealthRegion.ca
Publication Types:
- Case Reports
- Review
- Review, Tutorial
PMID: 14724463 [PubMed - indexed for MEDLINE]
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Red blood cell physiology in critical illness.
Scharte M, Fink MP.
Klinik und Poliklinik fur Anasthesiologie und operativ Intensivmedizin, Universitatsklinikum Munster, Muenster, Germany.
OBJECTIVE: Reduction in red blood cell mass, as well as structural and functional alterations of erythrocytes, occurs in critical illness. This review discusses these changes in red blood cell physiology, emphasizing the pathogenesis of anemia in intensive care unit patients. DATA SOURCE: Studies published in biomedical journals. DATA SYNTHESIS AND CONCLUSION: Anemia in intensive care unit patients resembles the anemia of chronic disease, being characterized by diminished erythropoietin production relative to decreased hematocrit, altered iron metabolism, and impaired proliferation and differentiation of erythroid progenitors in the bone marrow. Inflammatory mediators play a major role in the development of insufficient erythropoiesis and altered iron metabolism. Furthermore, a proinflammatory milieu promotes structural and functional alterations of erythrocytes, impairing their deformability and possibly impairing microvascular perfusion. Collectively, these changes in red blood cell physiology can impair oxygen transport to tissues and, thereby, might contribute to the development of multiple organ failure in critical illness.
Publication Types:
PMID: 14724462 [PubMed - indexed for MEDLINE]
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Overview of anemia and blood management in critical care.
Pearl RG, Sibbald WJ.
Publication Types:
PMID: 14724461 [PubMed - indexed for MEDLINE]
Herpes simplex virus in the respiratory tract of critical care patients: a prospective study.
Bruynseels P, Jorens PG, Demey HE, Goossens H, Pattyn SR, Elseviers MM, Weyler J, Bossaert LL, Mentens Y, Ieven M.
Department of Microbiology, University Hospital of Antwerp, Antwerp, Belgium. peggy.bruynseels@uza.be
BACKGROUND: Herpes simplex virus (HSV) is occasionally detected in the lower respiratory tract of patients in intensive care, but its clinical importance in such situations remains unclear. We did a prospective cohort study to define the prevalence, origin, risk factors, and clinical relevance of HSV in the respiratory tract of patients undergoing critical care. METHODS: We tested 764 patients admitted to intensive care for the presence of HSV in the respiratory tract, and assessed statistical relations between this virus and clinical variables. FINDINGS: HSV was detected by oropharyngeal swab in the upper respiratory tract of 169 (22%) of 764 patients, within 10 days of admission for 150 (89%) of these individuals. The virus was isolated in 58 (16%) of 361 patients whose lower respiratory tract was sampled. The presence of HSV in the throat was a risk factor for development of HSV infections in the lower respiratory tract (p<0.001). HSV was isolated most frequently in patients with severe disease. HSV in the throat was associated with acute respiratory distress syndrome (p<0.001) and with increased length of stay in intensive care (p<0.001). INTERPRETATION: Our data suggest that HSV reactivation or infection of the upper respiratory tract is frequent among patients in intensive care, and is a risk factor for development of lower respiratory tract infection with this virus, possibly by means of aspiration.
PMID: 14615108 [PubMed - indexed for MEDLINE]
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