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Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation.
Grap MJ, Strickland D, Tormey L, Keane K, Lubin S, Emerson J, Winfield S, Dalby P, Townes R, Sessler CN.
Virginia Commonwealth University, Richmond, Va., USA.
BACKGROUND: Use of protocols to reduce weaning time for patients receiving mechanical ventilation helps reduce cost and length of stay. However, implementation of this type of protocol is not easy and requires a consistent collaborative effort. OBJECTIVE: To provide a systematic approach to the weaning process by developing, implementing, and evaluating a protocol for weaning patients from mechanical ventilation in a medical respiratory intensive care unit. METHODS: The weaning protocol used was a modification of a protocol developed by Ely et al. Modifications included a more aggressive approach in proceeding to the spontaneous breathing trial, inclusion of the Richmond Agitation-Sedation Scale, and documentation of the production of secretions. RESULTS: Implementation of the protocol significantly reduced the duration of mechanical ventilation as measured by 8-hour shifts and ventilator days. Although length of stay in the intensive care unit was not significantly reduced (P = .29), a continuing downward trend occurred, from a mean of 8.6 days before the protocol was implemented to 7.9 days during the last 6 months of data collection (P = .07). CONCLUSIONS: The need to provide efficient care requires the collaboration of all disciplines involved in providing patients' care. The weaning protocol introduced in this study demonstrates the benefits of using a collaborative team to identify best practices and implement them in a practice setting.
Publication Types:
PMID: 14503429 [PubMed - indexed for MEDLINE]
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Bold voices: fearless and essential.
Barden C.
Mercy Hospital, Miami, Fla., USA.
PMID: 14503425 [PubMed - indexed for MEDLINE]
Critical care medicine in AJRCCM 2003.
Tobin MJ.
Division of Pulmonary and Critical Care Medicine, Loyola University of Chicago Stritch School of Medicine and Hines Veterans Affairs Hospital, Hines, IL 60141, USA. mtobin2@lumc.edu
Publication Types:
PMID: 14718238 [PubMed - indexed for MEDLINE]
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Advances in critical care hepatology.
Marrero J, Martinez FJ, Hyzy R.
Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
Publication Types:
PMID: 14668256 [PubMed - indexed for MEDLINE]
Comment on:
Cardiovascular management of septic shock.
Pravinkumar E.
Publication Types:
PMID: 14707616 [PubMed - indexed for MEDLINE]
Comment on:
Early goal-directed therapy.
Rivers EP, Nguyen HB, Huang DT, Donnino M.
Publication Types:
PMID: 14707615 [PubMed - indexed for MEDLINE]
Comment on:
Induced hypothermia in traumatic brain injury: effective if properly employed.
Polderman KH, van Zanten AR, Nipshagen MD, Girbes AR.
Publication Types:
PMID: 14707614 [PubMed - indexed for MEDLINE]
Comment on:
Normality.
Verdant CL, Dubois MJ.
Publication Types:
PMID: 14707613 [PubMed - indexed for MEDLINE]
Comment on:
Optimal discard volumes for arterial blood analysis.
Morris C.
Publication Types:
PMID: 14707610 [PubMed - indexed for MEDLINE]
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Acute management of severe traumatic brain injury.
Dark P.
Publication Types:
PMID: 14707609 [PubMed - indexed for MEDLINE]
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Monitoring right-to-left intracardiac shunt in acute respiratory distress syndrome.
Michard F, Alaya S, Medkour F.
Publication Types:
PMID: 14707608 [PubMed - indexed for MEDLINE]
Comment on:
Bacterial infection.
Benoit DD, Depuydt P, Vandewoude KH.
Publication Types:
PMID: 14707607 [PubMed - indexed for MEDLINE]
Comment on:
Transit care medicine--a critical link.
Nagappan R.
Publication Types:
PMID: 14707606 [PubMed - indexed for MEDLINE]
Comment on:
Caveats of evaluating costs in critical care.
Holt AE 4th, Slonim AD.
Publication Types:
PMID: 14707602 [PubMed - indexed for MEDLINE]
Comment on:
Can endotracheal tube occlusion be predicted?
Durbin CG Jr.
Publication Types:
PMID: 14707601 [PubMed - indexed for MEDLINE]
Comment on:
How relaxed should we be with acute respiratory distress syndrome?
Freebairn R.
Publication Types:
PMID: 14707600 [PubMed - indexed for MEDLINE]
Comment on:
Cardiogenic shock: art and science.
Bromet DS, Klein LW.
Publication Types:
PMID: 14707598 [PubMed - indexed for MEDLINE]
Comment on:
Anemia and blood transfusion in the critically ill: a decade without change.
Shah JS, Hickey R.
Publication Types:
PMID: 14707596 [PubMed - indexed for MEDLINE]
Comment on:
Con: Is the tele-intensive care unit ready for prime time?
Peters SG, Farmer JC.
Publication Types:
PMID: 14707595 [PubMed - indexed for MEDLINE]
Comment in:
Comment on:
Pro: Multiplier.
Bekes C.
Publication Types:
PMID: 14707594 [PubMed - indexed for MEDLINE]
Comment on:
Mediator modulation therapy of severe sepsis and septic shock: does it work?
Phillip Dellinger R, Parrillo JE.
Publication Types:
PMID: 14707593 [PubMed - indexed for MEDLINE]
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Role of adenosine in immunomodulation: review of the literature.
McCallion K, Harkin DW, Gardiner KR.
Department of Surgery, Queen's University of Belfast.
OBJECTIVE: Advances in the understanding of sepsis have failed to deliver satisfactory new treatments aimed at attenuating inflammatory-mediated organ dysfunction. Phagocytic cells play a pivotal role in driving the inflammatory response and causing direct tissue injury. Adenoreceptor stimulation may attenuate such inflammatory-mediated damage by down-regulating phagocytic activity and preventing excessive respiratory burst activation. DATA: A Medline database was used to perform a literature search for all articles relating to the use of adenosine as an immunomodulatory agent. CONCLUSION: There is convincing evidence to suggest that adenoreceptor modulation can prevent tissue injury through a variety of pathways. The use of adenosine modulation in ischemia/reperfusion injury has been the subject of considerable investigation, although experience with its use in sepsis is limited.
Publication Types:
PMID: 14707591 [PubMed - indexed for MEDLINE]
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Guidelines for critical care medicine training and continuing medical education.
Dorman T, Angood PB, Angus DC, Clemmer TP, Cohen NH, Durbin CG Jr, Falk JL, Helfaer MA, Haupt MT, Horst HM, Ivy ME, Ognibene FP, Sladen RN, Grenvik AN, Napolitano LM; American College of Critical Care Medicine.
Johns Hopkins Hospital, Department of Anesthesia and Critical Care Medicine, Baltimore, MD, USA.
OBJECTIVE: Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care. PARTICIPANTS: A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine. SCOPE: Physician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization. DATA SOURCES AND SYNTHESIS: Relevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline. CONCLUSIONS: Guidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.
Publication Types:
- Guideline
- Practice Guideline
PMID: 14707590 [PubMed - indexed for MEDLINE]
Comment in:
Guidelines for the inter- and intrahospital transport of critically ill patients.
Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM; American College of Critical Care Medicine.
Northwest Community Hospital, Arlington Heights, IL, USA.
OBJECTIVE: The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient. DATA SOURCE: Expert opinion and a search of Index Medicus from January 1986 through October 2001 provided the basis for these guidelines. A task force of experts in the field of patient transport provided personal experience and expert opinion. STUDY SELECTION AND DATA EXTRACTION: Several prospective and clinical outcome studies were found. However, much of the published data comes from retrospective reviews and anecdotal reports. Experience and consensus opinion form the basis of much of these guidelines. RESULTS OF DATA SYNTHESIS: Each hospital should have a formalized plan for intra- and interhospital transport that addresses a) pretransport coordination and communication; b) transport personnel; c) transport equipment; d) monitoring during transport; and e) documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process. CONCLUSION: The transport of critically ill patients carries inherent risks. These guidelines promote measures to ensure safe patient transport. Although both intra- and interhospital transport must comply with regulations, we believe that patient safety is enhanced during transport by establishing an organized, efficient process supported by appropriate equipment and personnel.
Publication Types:
- Guideline
- Practice Guideline
PMID: 14707589 [PubMed - indexed for MEDLINE]
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Effects of feeding on gastric tonometric measurements in critically ill children.
Thorburn K, Durward A, Tibby SM, Murdoch IA.
Department of Paediatric Intensive Care, Royal Liverpool Children's Hospital-Alder Hey, UK.
OBJECTIVE: To determine the effect of gastric feeding on the measurement of gastric intramucosal PCO2 (PiCO2) and its derived gastric intramucosal PCO2-arterial PCO2 difference (PiCO2-PaCO2 difference) and gastric intramucosal pH (pHi) in a group of critically ill children using recirculating gas tonometry. DESIGN: Prospective clinical pilot study. SETTING: Sixteen bed pediatric intensive care unit. PATIENTS: Ten mechanically ventilated and hemodynamically stable children (median age, 20.1 months [interquartile range (IQR), 9.7-47.6 months] and median weight, 10.2 kg [IQR, 10-16.5 kg]). INTERVENTIONS: A 7-French recirculating gas tonometer was placed in the stomach via the orogastric route. MEASUREMENTS: In each patient, baseline fasted/unfed PiCO2, PiCO2-PaCO2 difference, and pHi were determined hourly over a 5-hr period. Gastric feeding was then reestablished (3 mL/kg/hr) within a median time of 3 hrs and a further 5 hourly measurements were determined. Concurrent arterial blood gas and lactate measurements were taken. Blood pressure and heart rate was monitored throughout. MAIN RESULTS: Hemodynamic parameters remained stable throughout the study period. When compared with the unfed/fasting state, PiCO2 measurements and PiCO2-PaCO2 difference were consistently lower and pHi values higher than when the patients were fed (two-way analysis of variance for repeated measures: all p <.001 between groups). Measurements did not vary over time. CONCLUSIONS: In our patient group, gastric feeding decreased the PiCO2 and PiCO2-PaCO2 difference and increased pHi compared with the unfed state. These findings are in contrast to those found in adult studies.
PMID: 14707587 [PubMed - indexed for MEDLINE]
Comment in:
Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome.
Gainnier M, Roch A, Forel JM, Thirion X, Arnal JM, Donati S, Papazian L.
Service de Reanimation Medicale, Hopitaux Sud, Marseille, France.
OBJECTIVE: To evaluate the effects of a 48-hr neuromuscular blocking agents (NMBA) infusion on gas exchange over a 120-hr time period in patients with acute respiratory distress syndrome. DESIGN: Multiple center, prospective, controlled, and randomized trial. SETTING: Four adult medical or mixed medical-surgical intensive care units. PATIENTS: A total of 56 patients with acute respiratory distress syndrome with a PaO2/FiO2 ratio of <150 at a positive end-expiratory pressure of > or =5 cm H2O. INTERVENTIONS: After randomization, patients received either conventional therapy without NMBA (control group) or conventional therapy plus NMBA for the next 48 hrs. The initial ventilator mode was volume-assist/control. The ventilator remained on assist-control mode throughout the initial 48-hr period in both groups. Tidal volume was 6-8 mL/kg ideal body weight. MEASUREMENTS AND MAIN RESULTS: When analyzed for the entire 120 hrs, there was a significant effect of the NMBA on the course of PaO2/FiO2 ratio (p =.021). Separate comparisons at each time point indicated that patients randomized to the NMBA group had a higher PaO2/FiO2 at 48, 96, and 120 hrs after randomization. Moreover, a decrease of positive end-expiratory pressure (p =.036) was only found in the NMBA group. Two-way repeated-measures analysis of variance exhibited a decrease in positive end-expiratory pressure over time (p =.036). Concerning short-term effects, there was no modification of PaO2/FiO2 ratio 1 hr after randomization in either group. Only one patient (from the control group) developed pneumothorax. CONCLUSIONS: Use of NMBA during a 48-hr period in patients with acute respiratory distress syndrome is associated with a sustained improvement in oxygenation.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 14707568 [PubMed - indexed for MEDLINE]
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Early enteral nutrition in mechanically ventilated patients in the prone position.
Reignier J, Thenoz-Jost N, Fiancette M, Legendre E, Lebert C, Bontemps F, Clementi E, Martin-Lefevre L.
Polyvalent Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. jean.reignier@chd-vendee.fr
OBJECTIVE: To assess the tolerance of early enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position. DESIGN: Prospective, comparative study. SETTING: General intensive care unit in a university-affiliated hospital. PATIENTS: A total of 71 consecutive patients receiving invasive mechanical ventilation with early nasogastric enteral nutrition were studied for 5 days while being treated continuously in the supine position (supine position group, n = 37) or with intermittent prone positioning for severe hypoxemia (prone position group, n = 34). INTERVENTIONS: Inclusion occurred within 24 hrs of mechanical ventilation initiation. Daily 18-hr enteral nutrition via a 14F gastric tube was initiated. Prone position patients were turned every 6 hrs as long as PaO2/FiO2 remained at <150, with a FiO2 of 0.6 and positive end-expiratory pressure of 10; the head was slightly elevated. When supine, patients in both groups were semirecumbent. Residual gastric volume was measured every 6 hrs, and enteral nutrition was discontinued if it exceeded 250 mL or vomiting occurred. MEASUREMENTS AND MAIN RESULTS: The groups were similar for age, sex, Simplified Acute Physiology Score II, mortality, and risk factors for enteral nutrition intolerance. At baseline, PaO2/FiO2 was lower in prone position patients than in supine position patients (127 +/- 55 vs. 228 +/- 102; p <.001). As compared with supine position patients, prone position patients had significantly greater residual gastric volumes on days 1, 2, and 4 and experienced more vomiting episodes (median, 1 [interquartile range, 0-2] vs. 0 [interquartile range, 0-1]; p <.05). Enteral nutrition was stopped in 82% of prone position patients and 49% of supine position patients (p <.01) so that daily enteral nutrition volumes were lower with prone position patients. In the prone position group, vomiting occurred more frequently in the prone than in the supine position (relative risk, 2.5; 95% confidence interval, 1.5-4.0; p <.001). CONCLUSION: In critically ill patients receiving invasive mechanical ventilation in the prone position, early enteral nutrition is poorly tolerated. Prokinetic agents or transpyloric feeding and semirecumbency should be considered to enhance gastric emptying and to prevent vomiting in patients receiving mechanical ventilation in the prone position.
PMID: 14707565 [PubMed - indexed for MEDLINE]
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Evaluation of density area in dorsal lung region during prone position using transesophageal echocardiography.
Tsubo T, Yatsu Y, Tanabe T, Okawa H, Ishihara H, Matsuki A.
Intensive Care Unit, University of Hirosaki School of Medicine, Aomori-ken, Japan.
OBJECTIVE: To evaluate the changes of density area in the dorsal lung regions of acute respiratory distress syndrome patients during prone position using transesophageal echocardiography. DESIGN: Retrospective clinical study. SETTING: General intensive care unit in a university hospital. PATIENTS: Ten patients with acute respiratory distress syndrome who underwent prone position therapy. INTERVENTIONS: Density areas in the left dorsal lung region were observed using transesophageal echocardiography before and after patients were in the prone position for 2 hrs. In five patients, a pediatric transesophageal echocardiography probe was left in the esophagus and used for observation during the prone procedure. MEASUREMENTS AND MAIN RESULTS: Changes of density area and PaO2/FiO2 were observed. The density areas decreased after prone position compared with those of preprone position (preprone 11.4 +/- 5.1 cm2, after prone 5.6 +/- 3.5 cm2, mean +/- sd, p <.01, respectively). There was also a significant correlation between the percentage change of density area and PaO2/FiO2 (r =.47, p <.05) after prone position. During prone position, the density area decreased; however, there was no correlation between the percent changes of density area and PaO2/FiO2. CONCLUSION: It was possible to observe the change in density area during prone position using transesophageal echocardiography. The change of density area estimated with transesophageal echocardiography during prone position was useful to estimate the effectiveness of the procedure.
PMID: 14707563 [PubMed - indexed for MEDLINE]
Comment in:
Long-term mortality and quality of life after prolonged mechanical ventilation.
Chelluri L, Im KA, Belle SH, Schulz R, Rotondi AJ, Donahoe MP, Sirio CA, Mendelsohn AB, Pinsky MR.
Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA. Chelluril@ccm.upmc.edu
OBJECTIVE: To describe and identify factors associated with mortality rate and quality of life 1 yr after prolonged mechanical ventilation. DESIGN: Prospective, observational cohort study with patient recruitment over 26 months and follow-up for 1 yr. SETTING: Intensive care units at a tertiary care university hospital. PATIENTS: Adult patients receiving prolonged mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured mortality rate and functional status, defined as the inability to perform instrumental activities of daily living (IADLs) 1 yr following prolonged mechanical ventilation. The study enrolled 817 patients. Their median age was 65 yrs, 46% were women, and 44% were alive at 1 yr. Median ages at baseline of 1-yr survivors and nonsurvivors were 53 and 71 yrs, respectively. At the time of admission to the hospital, survivors had fewer comorbidities, lower severity of illness score, and less dependence compared with nonsurvivors. Severity of illness on admission to the intensive care unit and prehospitalization functional status had a significant association with short-term mortality rate, whereas age and comorbidities were related to long-term mortality. Fifty-seven percent of the surviving patients needed caregiver assistance at 1 yr of follow-up. The odds of having IADL dependence at 1-yr among survivors was greater in older patients (odds ratio 1.04 for 1-yr increase in age) and those with IADL dependence before hospitalization (odds ratio 2.27). CONCLUSIONS: Mortality rate after prolonged mechanical ventilation is high. Long-term mortality rate is associated with older age and poor prehospitalization functional status. Many survivors needed assistance after discharge from the hospital, and more than half still required caregiver assistance at 1 yr. Interventions providing support for caregivers and patients may improve the functional status and quality of life of both groups and thus need to be evaluated.
PMID: 14707560 [PubMed - indexed for MEDLINE]
Comment in:
The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States.
Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E, MacIntyre NR, Shabot MM, Duh MS, Shapiro MJ.
Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA. howard.l.corwin@hitchcock.org
OBJECTIVE: To quantify the incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to examine the relationship of anemia and RBC transfusion to clinical outcomes. DESIGN: Prospective, multiple center, observational cohort study of intensive care unit (ICU) patients in the United States. Enrollment period was from August 2000 to April 2001. Patients were enrolled within 48 hrs of ICU admission. Patient follow-up was for 30 days, hospital discharge, or death, whichever occurred first. SETTING: A total of 284 ICUs (medical, surgical, or medical-surgical) in 213 hospitals participated in the study. PATIENTS: A total of 4,892 patients were enrolled in the study. MEASUREMENTS AND MAIN RESULTS: The mean hemoglobin level at baseline was 11.0 +/- 2.4 g/dL. Hemoglobin level decreased throughout the duration of the study. Overall, 44% of patients received one or more RBC units while in the ICU (mean, 4.6 +/- 4.9 units). The mean pretransfusion hemoglobin was 8.6 +/- 1.7 g/dL. The mean time to first ICU transfusion was 2.3 +/- 3.7 days. More RBC transfusions were given in study week 1; however, in subsequent weeks, subjects received one to two RBC units per week while in the ICU. The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital lengths of stay and an increase in mortality. Patients who received transfusions also had more total complications and were more likely to experience a complication. Baseline hemoglobin was related to the number of RBC transfusions, but it was not an independent predictor of length of stay or mortality. However, a nadir hemoglobin level of <9 g/dL was a predictor of increased mortality and length of stay. CONCLUSIONS: Anemia is common in the critically ill and results in a large number of RBC transfusions. Transfusion practice has changed little during the past decade. The number of RBC units transfused is an independent predictor of worse clinical outcome.
Publication Types:
PMID: 14707558 [PubMed - indexed for MEDLINE]
Comment in:
Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock.
Lopez A, Lorente JA, Steingrub J, Bakker J, McLuckie A, Willatts S, Brockway M, Anzueto A, Holzapfel L, Breen D, Silverman MS, Takala J, Donaldson J, Arneson C, Grove G, Grossman S, Grover R.
Hospital Infanta Cristinam, Badajoz, Spain.
OBJECTIVE: To assess the safety and efficacy of the nitric oxide synthase inhibitor 546C88 in patients with septic shock. The predefined primary efficacy objective was survival at day 28. DESIGN: Multiple-center, randomized, two-stage, double-blind, placebo-controlled, safety and efficacy study. SETTING: A total of 124 intensive care units in Europe, North America, South America, South Africa, and Australasia. PATIENTS: A total of 797 patients with septic shock diagnosed for <24 hrs. INTERVENTIONS: Patients with septic shock were allocated to receive 546C88 or placebo (5% dextrose) for up to 7 days (stage 1) or 14 days (stage 2) in addition to conventional therapy. Study drug was initiated at 0.05 mL.kg(-1).hr(-1) (2.5 mg.kg(-1).hr(-1) 546C88) and titrated up to a maximum rate of 0.4 mL.kg(-1).hr(-1) to maintain mean arterial pressure between 70 and 90 mm Hg while attempting to withdraw concurrent vasopressors. MEASUREMENTS AND MAIN RESULTS: Hemodynamic variables, organ function data, microbiological data, concomitant therapy, and adverse event data were recorded at baseline, throughout treatment, and at follow-up. The primary end point was day-28 survival. The trial was stopped early after review by the independent data safety monitoring board. Day-28 mortality was 59% (259/439) in the 546C88 group and 49% (174/358) in the placebo group (p <.001). The overall incidence of adverse events was similar in both groups, although a higher proportion of the events was considered possibly attributable to study drug in the 546C88 group. Most of the events accounting for the disparity between the groups were associated with the cardiovascular system (e.g., decreased cardiac output, pulmonary hypertension, systemic arterial hypertension, heart failure). The causes of death in the study were consistent with those expected in patients with septic shock, although there was a higher proportion of cardiovascular deaths and a lower incidence of deaths caused by multiple organ failure in the 546C88 group. CONCLUSIONS: In this study, the nonselective nitric oxide synthase inhibitor 546C88 increased mortality in patients with septic shock.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 14707556 [PubMed - indexed for MEDLINE]
Comment in:
Cardiovascular effects of the nitric oxide synthase inhibitor NG-methyl-L-arginine hydrochloride (546C88) in patients with septic shock: results of a randomized, double-blind, placebo-controlled multicenter study (study no. 144-002).
Watson D, Grover R, Anzueto A, Lorente J, Smithies M, Bellomo R, Guntupalli K, Grossman S, Donaldson J, Le Gall JR; Glaxo Wellcome International Septic Shock Study Group.
Department of Intensive Care, Homerton Hospital, London, UK.
OBJECTIVE: To assess the hemodynamic effects of the nitric oxide synthase inhibitor 546C88 in patients with septic shock, although this was not a stated aim of the protocol. The predefined primary efficacy objective of the protocol was resolution of shock determined at the end of a 72-hr treatment period. DESIGN: Multicentered, randomized, placebo-controlled, safety and efficacy study. SETTING: Forty-eight intensive care units in Europe, North America, and Australia. PATIENTS: A total of 312 patients with septic shock diagnosed within 24 hr before randomization. INTERVENTIONS: Patients were randomly allocated to receive either 546C88 or placebo (5% dextrose) by intravenous infusion for up to 72 hrs. Conventional vasoactive therapy was restricted to norepinephrine, dopamine, and dobutamine. Study drug was initiated at 0.1 mL/kg/hr (5 mg/kg/hr 546C88) and titrated according to response up to a maximum rate of 0.4 mL/kg/hr with the objective to maintain mean arterial pressure at 70 mm Hg while attempting to withdraw any concurrent vasopressor(s). MEASUREMENTS AND MAIN RESULTS: Requirement for vasopressors, systemic and pulmonary hemodynamics, indices of oxygen transport, and plasma concentrations of arginine and nitrate were assessed over time. The median mean arterial pressure for both groups was maintained > or =70 mm Hg. There was an early increase in systemic and pulmonary vascular tone and oxygen extraction, whereas both cardiac index and oxygen delivery decreased for patients in the 546C88 cohort. Although these parameters subsequently returned toward baseline values, the observed differences between the treatment groups, except for pulmonary vascular resistance and oxygen extraction, persisted throughout the treatment period, despite a reduced requirement for vasopressors in the 546C88 cohort. These changes were associated with a reduction in plasma nitrate concentrations, which were elevated in both groups before the start of therapy. CONCLUSIONS: The nitric oxide synthase inhibitor 546C88 can reduce the elevated plasma nitrate concentrations observed in patients with septic shock. In this study, treatment with 546C88 for up to 72 hrs was associated with an increase in vascular tone and a reduction in both cardiac index and oxygen delivery. The successful maintenance of a target mean arterial blood pressure > or =70 mm Hg was achieved with a reduction in the requirement for, or withdrawal of, conventional inotropic vasoconstrictor agents (i.e., dopamine and norepinephrine). There were no substantive untoward consequences accompanying these hemodynamic effects. An international, randomized, double-blind, placebo-controlled phase III study has since been conducted in patients with septic shock. Recruitment into the study was discontinued due to the emergence of increased mortality in the 546C88-treated group.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 14707555 [PubMed - indexed for MEDLINE]
Comment in:
Administration of the nitric oxide synthase inhibitor NG-methyl-L-arginine hydrochloride (546C88) by intravenous infusion for up to 72 hours can promote the resolution of shock in patients with severe sepsis: results of a randomized, double-blind, placebo-controlled multicenter study (study no. 144-002).
Bakker J, Grover R, McLuckie A, Holzapfel L, Andersson J, Lodato R, Watson D, Grossman S, Donaldson J, Takala J; Glaxo Wellcome International Septic Shock Study Group.
Department of Intensive Care, Gelre Lukas Hospital, Apeldoorn, The Netherlands.
OBJECTIVE: To assess the safety and efficacy of the nitric oxide synthase inhibitor 546C88 in patients with septic shock. The predefined primary efficacy objective was resolution of shock, defined as a mean arterial pressure > or =70 mm Hg in the absence of both conventional vasopressors and study drug, determined at the end of the 72-hr treatment period. DESIGN: Multicentered, randomized, placebo-controlled, safety and efficacy study. SETTING: Forty-eight intensive care units in Europe, North America, and Australia. PATIENTS: A total of 312 patients with septic shock diagnosed within 24 hr before randomization. INTERVENTIONS: Patients were randomly allocated to receive either 546C88 or placebo (5% dextrose) by intravenous infusion for up to 72 hrs. Conventional vasoactive therapy was restricted to norepinephrine, dopamine, and dobutamine. Study drug was initiated at 0.1 mL/kg/hr (5 mg/kg/hr 546C88) and titrated according to response up to a maximum rate of 0.4 mL/kg/hr with the objective to maintain mean arterial pressure at 70 mm Hg while attempting to withdraw any concurrent vasopressor(s). MEASUREMENTS AND MAIN RESULTS: Requirement for vasopressors, systemic hemodynamics, indices of organ function and safety (including survival up to day 28) were assessed. The median mean arterial pressure for both groups was maintained >70 mm Hg. Administration of 546C88 was associated with a decrease in cardiac index while stroke index was maintained. Resolution of shock at 72 hr was achieved by 40% and 24% of the patients in the 546C88 and placebo cohorts, respectively (p =.004). There was no evidence that treatment with 546C88 had any major adverse effect on pulmonary, hepatic, or renal function. Day 28 survival was similar for both groups. CONCLUSIONS: In this study, treatment with the nitric oxide synthase inhibitor 546C88 promoted the resolution of shock in patients with severe sepsis. This was associated with an acceptable overall safety profile.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 14707554 [PubMed - indexed for MEDLINE]
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Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units.
Finfer S, Bellomo R, Lipman J, French C, Dobb G, Myburgh J.
Anzics Clinical Trials Group, 10 Iavers Terrace, Carlton, VIC 3053, Australia.
OBJECTIVE. To determine the population incidence and outcome of severe sepsis occurring in adult patients treated in Australian and New Zealand intensive care units (ICUs), and compare with recent retrospective estimates from the USA and UK. DESIGN. Inception cohort study. SETTING. Twenty-three closed multi-disciplinary ICUs of 21 hospitals (16 tertiary and 5 university affiliated) in Australia and New Zealand. PATIENTS. A total of 5878 consecutive ICU admission episodes. MEASUREMENTS AND RESULTS. Main outcome measures were population-based incidence of severe sepsis, mortality at ICU discharge, mortality at 28 days after onset of severe sepsis, and mortality at hospital discharge. A total of 691 patients, 11.8 (95% confidence intervals 10.9-12.6) per 100 ICU admissions, were diagnosed with 752 episodes of severe sepsis. Site of infection was pulmonary in 50.3% of episodes and abdominal in 19.3% of episodes. The calculated incidence of severe sepsis in adults treated in Australian and New Zealand ICUs is 0.77 (0.76-0.79) per 1000 of population. 26.5% of patients with severe sepsis died in ICU, 32.4% died within 28 days of the diagnosis of severe sepsis and 37.5% died in hospital. CONCLUSION. In this prospective study, 11.8 patients per 100 ICU admissions were diagnosed with severe sepsis and the calculated annual incidence of severe sepsis in adult patients treated in Australian and New Zealand ICUs is 0.77 per 1000 of population. This figure for the population incidence falls in the lower range of recent estimates from retrospective studies in the U.S. and the U.K.
PMID: 14963646 [PubMed - as supplied by publisher]
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Application of therapeutic hypothermia in the intensive care unitOpportunities and pitfalls of a promising treatment modality-Part 2: Practical aspects and side effects.
Polderman KH.
Department of Intensive Care, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
Induced hypothermia can be used to protect the brain from post-ischemic and traumatic neurological injury. Potential clinical applications and the available evidence are discussed in a separate paper. This review focuses on the practical aspects of cooling and physiological changes induced by hypothermia, as well as the potential side effects that may develop. These side effects can be serious and, if not properly dealt with, may negate some or all of hypothermia's potential benefits. However, many of these side effects can be prevented or modified by high-quality intensive care treatment, which should include careful monitoring of fluid balance, tight control of metabolic aspects such as glucose and electrolyte levels, prevention of infectious complications and various other interventions. The speed and duration of cooling and rate of re-warming are key factors in determining whether hypothermia will be effective; however, the risk of side effects also increases with longer duration. Realizing hypothermia's full therapeutic potential will therefore require meticulous attention to the prevention and/or early treatment of side effects, as well as a basic knowledge and understanding of the underlying physiological and pathophysiological mechanisms. These and other, related issues are dealt with in this review.
PMID: 14767590 [PubMed - as supplied by publisher]
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Post-traumatic stress disorder-related symptoms in relatives of patients following intensive care.
Jones C, Skirrow P, Griffiths RD, Humphris G, Ingleby S, Eddleston J, Waldmann C, Gager M.
Department of Medicine, Intensive Care Research Group, University of Liverpool, L69 3GA, Liverpool, Merseyside, UK.
OBJECTIVE. To evaluate the effectiveness of the provision of information in the form of a rehabilitation program following critical illness in reducing psychological distress in the patients' close family. DESIGN. Randomised controlled trial, blind at follow-up with final assessment at 6 months. SETTING. Two district general hospitals and one teaching hospital. PATIENTS AND PARTICIPANTS. The closest family member of 104 recovering intensive care unit (ICU) patients. INTERVENTIONS. Ward visits, ICU clinic appointments at 2 and 6 months. Relatives and patients received the rehabilitation program at 1 week after ICU discharge. The program comprised a 6-week self-help manual containing information about recovery from ICU, psychological information and practical advice. MEASUREMENTS AND RESULTS. Psychological recovery of relatives was assessed by examining the rate of depression, anxiety, and post-traumatic stress disorder (PTSD)-related symptoms by 6 months after ICU. The proportion of relatives scoring in the range >19 on the Impact of Events Scale (cause for concern) was high in both groups at 49% at 6 months. No difference was shown in the rate of depression, anxiety, or PTSD-related symptoms between the study groups. CONCLUSION. A high incidence of psychological distress was evident in relatives. Written information concerning recovery from ICU provided to the patient and their close family did not reduce this. High levels of psychological distress in patients were found to be correlated with high levels in relatives.
PMID: 14767589 [PubMed - as supplied by publisher]
Comment in:
Variability in interventions with pulmonary artery catheter data.
Jain M, Canham M, Upadhyay D, Corbridge T.
Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA. m-jain@northwestern.edu
OBJECTIVES: To determine if intensivists given PAC data from critically ill patients make uniform management choices. DESIGN: Cross-sectional survey of board-certified intensivists. SETTING: Medical intensive care unit. PARTICIPANTS: Board-certified intensivists who are members of the American College of Chest Physicians and Society of Critical Care Medicine. INTERVENTIONS: A survey questionnaire containing three medical intensive care clinical vignettes was mailed to critical care physicians. Each vignette contained PAC data and one-half of the surveys contained echocardiographic (Echo) information. Every respondent was asked to select one of six interventions for each vignette. MEASUREMENTS: There were 126 evaluable surveys returned. In vignette 1 an intervention (none of the above) was selected by more than 50% of respondents. In vignettes 2 and 3, the most frequent selection was chosen only 44 and 37% of the times, respectively. There was a significant difference in the distribution of management choices between te Echo and the non-Echo subgroups. CONCLUSIONS: There is a significant heterogeneity in selecting an intervention based on PAC data among intensivists. The presence of Echo information may change the intervention selected but does not reduce heterogeneity. Any randomized trial evaluating efficacy of PAC's will have to have strict treatment protocols.
PMID: 14669763 [PubMed - indexed for MEDLINE]
Comment on:
Acute bacterial meningitis: time for a better outcome.
Zimmerli W.
Publication Types:
- Comment
- Editorial
- Review
- Review, Tutorial
PMID: 14669755 [PubMed - indexed for MEDLINE]
Comment on:
Hemodynamic assessment: the technique or the physician at fault?
De Backer D.
Publication Types:
PMID: 14669754 [PubMed - indexed for MEDLINE]
Comment on:
Is parenteral nutrition guilty?
Varga P, Griffiths R, Chiolero R, Nitenberg G, Leverve X, Pertkiewicz M, Roth E, Wernerman J, Pichard C, Preiser JC.
Publication Types:
- Comment
- Editorial
- Review
- Review, Tutorial
PMID: 14669752 [PubMed - indexed for MEDLINE]
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Tetracyclines for treating multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia.
Wood GC, Hanes SD, Boucher BA, Croce MA, Fabian TC.
Department of Clinical Pharmacy, The University of Tennessee College of Pharmacy, 26 South Dunlap, Memphis, Tennessee 38163, USA. cwood@utmem.edu
OBJECTIVE: To report the use of tetracyclines for the treatment of multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia (VAP). DESIGN: Observational case series. SETTING:. The Presley Regional Trauma Center located within the Regional Medical Center, Memphis, Tennessee, USA. PATIENTS AND PARTICIPANTS: Seven critically ill trauma patients with VAP caused by A. baumannii isolates that were resistant to all antibiotics tested except for doxycycline or minocycline. INTERVENTIONS: Patients were treated with IV doxycycline or minocycline for an average of 13.5 (range 9-20) days. MEASUREMENTS AND RESULTS: Doxycycline or minocycline was successful in six of seven patients. CONCLUSIONS: Doxycycline or minocycline may be effective for treating multidrug-resistant A. baumannii VAP.
PMID: 14556048 [PubMed - indexed for MEDLINE]
Comment on:
Comment on "Death by parenteral nutrition" by Marik and Pinsky.
Furst P.
Publication Types:
PMID: 14551683 [PubMed - indexed for MEDLINE]
Comment on:
Parenteral nutrition in the critically ill.
Anderson AD, Jain PK, MacFie J.
Publication Types:
PMID: 14534779 [PubMed - indexed for MEDLINE]
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Intra-abdominal pressure may be decreased non-invasively by continuous negative extra-abdominal pressure (NEXAP).
Valenza F, Bottino N, Canavesi K, Lissoni A, Alongi S, Losappio S, Carlesso E, Gattinoni L.
Istituto di Anestesia e Rianimazione, Ospedale Maggiore di Milano-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Universita degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy.
OBJECTIVE: To investigate the possibility of artificially decreasing intra-abdominal pressure (IAP) by applying continuous negative pressure around the abdomen. MATERIAL AND METHODS: We investigated the effects of negative extra-abdominal pressure (NEXAP) on IAP and central venous pressure (CVP) in 30 patients admitted to our intensive care unit (age 57+/-17 years, BMI 26.1+/-4.0 kg/m2, SAPS II 41.8+/-17.0). Patients with severe hemodynamic instability and/or those admitted following a laparotomy were not studied. Measurements included bladder pressure as an estimate of IAP, CVP, invasive mean arterial pressure (MAP) and heart rate (HR). In five patients extensive hemodynamic measurements were also taken using a Swan-Ganz catheter. Following measurements at baseline (Basal), NEXAP (Life Care - Nev 100, Respironics) was applied on the abdomen, in random order, at a pressure equal to IAP (NEXAP0), 5 cmH(2)O (NEXAP-5) or 10 cmH(2)O (NEXAP-10) more negative than NEXAP0. RESULTS: Basal IAP ranged from 4 to 22 mmHg. NEXAP decreased IAP from 8.7+/-4.3 mmHg to 6+/-4.2 (Basal vs NEXAP0 p<0.001). There was a further decrease of IAP when more negative pressure was applied: 4.3+/-3.2 mmHg, 3.8+/-3.7 mmHg (NEXAP-5 and NEXAP-10 vs NEXAP0, respectively, p<0.001). Similarly, CVP decreased from 9.3+/-3.4 mmHg to 7.5+/-3.8 (Basal vs NEXAP-10, p<0.001). The lower the IAP when NEXAP was applied, the lower the CVP (r2=0.778, p<0.001, multiple linear regression). When measured, cardiac output did not significantly change with NEXAP. CONCLUSIONS: Negative extra-abdominal pressure may be applied in critically ill patients to decrease intra-abdominal pressure non-invasively.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14530858 [PubMed - indexed for MEDLINE]
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Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death.
Azoulay E, Pochard F, Garrouste-Orgeas M, Moreau D, Montesino L, Adrie C, de Lassence A, Cohen Y, Timsit JF; Outcomerea Study Group.
Saint-Louis Teaching Hospital, Medical ICU Department, 1 Avenue Claude Vellefaux, 75010, Paris, France. elie.azoulay@outcomerea.org
OBJECTIVE: More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality. DESIGN AND SETTING: Prospective multicenter 2-year study in six ICUs in France. PATIENTS: The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs. MEASUREMENTS AND RESULTS: The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887). CONCLUSIONS: DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.
PMID: 14530857 [PubMed - indexed for MEDLINE]
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Coingestion of cyclooxygenase inhibitors can worsen severe paracetamol poisoning by middle-sized and small arteries vasoconstriction.
Schneider F, Neuville A, Meziani F, Meyer C, Assemi P, Lavigne T, Castelain V.
Service de Reanimation Medicale, Hopitaux Universitaires de Strasbourg, Hopital de Hautepierre, Avenue Moliere, 67098, Strasbourg, France. Francis.Schneider@chru-strasbourg.fr
OBJECTIVE: We report fatal cases of multifocal ischemic injuries occurring in patients awaiting liver transplantation after severe concomitant paracetamol and cyclooygenase inhibitors self-poisoning. DESIGN AND SETTING: Case report in an intensive care unit. PATIENTS: In addition to signs of acute liver failure with a systemic inflammatory response syndrome, these three previously healthy young women demonstrated cutaneous vasoconstriction. One patient displayed a sudden ST-segment elevation with ventricular fibrillation. INTERVENTIONS: Angiography, plasma endothelin concentrations measurements, and autopsy. RESULTS: Radiography showed diffuse vasospasm on mesenteric and renal arteries, transiently reversed by vasodilators. We measured tenfold higher plasma endothelin concentrations than in healthy controls. Autopsy revealed no atherosis (including coronary arteries); organs showed multifocal ischemic injuries without thrombosis. CONCLUSIONS: Such injuries subsequent to dramatic vasoconstriction suggest that cyclooygenase inhibition has specific deleterious vascular side effects once systemic inflammatory response syndrome is in progress during paracetamol poisoning.
Publication Types:
PMID: 14513213 [PubMed - indexed for MEDLINE]
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Accuracy and repeatability of pediatric cardiac output measurement using Doppler: 20-year review of the literature.
Chew MS, Poelaert J.
Department of Anesthesia and Intensive Care, Lund University Hospital, 22185, Lund, Sweden. mchew@iekf.au.dk
OBJECTIVE: Review of the accuracy and repeatability of Doppler cardiac output (CO) measurements in children. DESIGN: Publications in the scientific literature retrieved using a computerized Medline search from 1982-2002 and a manual review of article bibliographies. Studies comparing Doppler flow measurements with thermodilution, Fick, or dye dilution methods in the pediatric critical care setting were identified to assess the bias, precision, and intra- and interobserver repeatability of Doppler CO measurement. Where results were not suitable for comparison and the original measurements available, data were re-analyzed using appropriate statistical methods and presented in comparative tables. RESULTS: The precision of pediatric Doppler CO measurements compared to thermodilution, dye dilution, or Fick methods is around 30% and repeatability varies from less than 1% to 22%. Bias is generally less than 10% but varies considerably. CONCLUSIONS: The bias, precision, and repeatability from study to study indicate that Doppler CO measurements are acceptably reproducible in children, with best results when used to track changes rather than absolute values, and using the transesophageal approach.
Publication Types:
PMID: 12955181 [PubMed - indexed for MEDLINE]
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Ventilator-associated pneumonia: caveats for benchmarking.
Eggimann P, Hugonnet S, Sax H, Touveneau S, Chevrolet JC, Pittet D.
Infection Control Program, Department of Internal Medicine, University Hospitals of Geneva, 1211, Geneva 14, Switzerland.
OBJECTIVE: To determine the influence of using different denominators on risk estimates of ventilator-associated pneumonia (VAP). DESIGN AND SETTING: Prospective cohort study in the medical ICU of a large teaching hospital. PATIENTS: All consecutive patients admitted for more than 48 h between October 1995 and November 1997. MEASUREMENTS AND RESULTS: We recorded all ICU-acquired infections using modified CDC criteria. VAP rates were reported per 1,000 patient-days, patient-days at risk, ventilator-days, and ventilator-days at risk. Of the 1,068 patients admitted, VAP developed in 106 (23.5%) of those mechanically ventilated. The incidence of the first episode of VAP was 22.8 per 1,000 patient-days (95% CI 18.7-27.6), 29.6 per 1,000 patient-days at risk (24.2-35.8), 35.7 per 1,000 ventilator-days (29.2-43.2), and 44.0 per 1,000 ventilator-days at risk (36.0-53.2). When considering all episodes of VAP (n=127), infection rates were 27.3 episodes per 1,000 ICU patient-days (95% CI 22.6-32.1) and 42.8 episodes per 1,000 ventilator-days (35.3-50.2). CONCLUSIONS: The method of reporting VAP rates has a significant impact on risk estimates. Accordingly, clinicians and hospital management in charge of patient-care policies should be aware of how to read and compare nosocomial infection rates.
PMID: 12955177 [PubMed - indexed for MEDLINE]
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Accidental methadone overdose in an opiate-naive elderly patient.
Hantson P, Vanbinst R, Wallemacq P.
Publication Types:
PMID: 12942172 [PubMed - indexed for MEDLINE]
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Differences in the deflation limb of the pressure-volume curves in acute respiratory distress syndrome from pulmonary and extrapulmonary origin.
Albaiceta GM, Taboada F, Parra D, Blanco A, Escudero D, Otero J.
Intensive Care Unit, Hospital Central de Asturias, Celestino Villamil s/n, 33006, Oviedo, Spain. gmuniz@hcas.insalud.es
OBJECTIVE: To assess the differences in the deflation pressure-volume (PV) curves between acute respiratory distress syndrome from pulmonary (ARDSp) and extrapulmonary (ARDSe) origin. DESIGN:. Prospective study. SETTING: Twenty-bed intensive care unit in an university hospital. PATIENTS: Ten patients within the first 24 h from meeting ARDS criteria, classified as ARDSp or ARDSe in a clinical basis. INTERVENTIONS: A deflation PV curve was recorded by means of decreasing steps of continuous positive airway pressure (CPAP) from 35 to 0 cmH(2)O. RESULTS: The simultaneous recording of pressure at the airway opening (Pao), esophageal pressure (Pes) and volumes (V) allows us to trace the Pao-V, Pes-V and transpulmonary pressure (Ptp)-V curves. These data were fitted to a sigmoid model and ARDSp and ARDSe groups were compared. ARDSp has lower lung compliance and higher chest wall compliance than ARDSe (35.9+/-11.3 vs. 77.2+/-50.6 and 199.6+/-44.4 vs. 125.5+/-16.5 ml/cmH(2)O, respectively, P<0.05). The Pao-V curve in ARDSp is shifted down and right with respect to ARDSe. The Ptp-V curve shows a similar displacement. The Pes-V curve in the ARDSp group is, however, shifted to the left. When relative values (percentage to the maximum volume achieved at 35 cmH(2)O) are considered, these differences persist, but, in the Ptp-V curves, are only significant in the low-pressure range. CONCLUSIONS: Differences between ARDSp and ARDSe PV curves are present all along the pressure axis and are related to differences not only in the Pes-V curve, but also in the Ptp-V curve.
PMID: 12942171 [PubMed - indexed for MEDLINE]
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Early patterns of static pressure-volume loops in ARDS and their relations with PEEP-induced recruitment.
Vieillard-Baron A, Prin S, Chergui K, Page B, Beauchet A, Jardin F.
Medical Intensive Care Unit, University Hospital Ambroise Pare, Assistance Publique Hopitaux de Paris, 9 avenue Charles de Gaulle, 92104, Boulogne Cedex, France.
OBJECTIVE: Evaluation of low-flow pressure-volume loop at the bedside in ARDS, as an aid to assess recruitment produced by PEEP. MATERIALS AND METHODS: Low-flow pressure-volume loop at the bedside were obtained on the first day of respiratory support in 54 successive pulmonary ARDS patients (49 of whom had pneumonia) treated between April 1999 and June 2002. From the loop obtained at ZEEP, we determined manually the lower inflexion point (LIP). By superimposing the pressure-volume loop at ZEEP and at PEEP, we evaluated recruitment obtained at a constant elastic pressure of 20 cm H2O. RESULTS: We observed two different types of loops, according to the pattern of the inflation limb. In type 1 (38 cases) the inflation limb was characterized by an inflexion zone, resulting from a progressive or a sudden improvement in compliance. In type 2 (16 patients) the inflation limb was virtually linear, without significant improvement in compliance during inflation, which remained particularly low (26+/-9 cm H2O). Use of a low PEEP (6+/-2 cm H2O) produced a substantial recruitment in type-1 patients (74+/-53 ml), which was marginally improved by a higher PEEP (89+/-54 ml). In type 2, recruitment produced by PEEP was significantly lower (48+/-26 ml, p=0.006). CONCLUSION: Pressure-volume loop at bedside confirmed that a low PEEP was sufficient to obtain recruitment in ARDS. This study also individualized a group of pulmonary ARDS patients exhibiting a markedly reduced compliance, in whom recruitment obtained by PEEP was limited.
PMID: 12923622 [PubMed - indexed for MEDLINE]
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Pharmacokinetics of long-term sufentanil infusion for sedation in ICU patients.
Ethuin F, Boudaoud S, Leblanc I, Troje C, Marie O, Levron JC, Le Moing JP, Assoune P, Eurin B, Jacob L.
Reanimation chirurgicale, Departement d'Anesthesie, Hopital Saint-Louis, 1 avenue Claude Vellefaux, 75475, Paris cedex 10, France. frederic.ethuin@sls.ap-hop-paris.fr
OBJECTIVE: To determine the pharmacokinetics of long-term infusion of sufentanil in ICU patients. DESIGN AND SETTING: Open-label study in a surgical intensive care unit. PATIENTS: Ten consecutive patients without renal or hepatic failure requiring mechanical ventilation for at least 6 days. INTERVENTIONS: Patients received sufentanil (initial bolus 0.5 micro g/kg and continuous infusion rate of 0.5 micro g/kg per hour) and midazolam (initial bolus 0.08 mg/kg and continuous infusion 0.05 mg/kg per hour). Sedation was adjusted according to the Ramsay scale (score >3). Blood samples were taken during and up to 72 h after the infusion, and plasma concentrations were measured using a sensitive radioimmunoassay method. MEASUREMENTS AND RESULTS: Plasma concentration-time profiles of sufentanil and pharmacokinetic parameters such as initial postinfusion half-life (t(1/2alpha)), elimination half-life (t(1/2beta)), total clearance (Cl), volume of distribution (Vdbeta), and time required to obtain a 50% decrease in plasma concentration (tcp(0/2)). The mean duration of sedation was 12+/-7 days. The initial half-life t(1/2alpha) was 1.33+/-1.15 h. The observed prolonged elimination half-life (t(1/2beta)=25.5+/-9.4 h) was related to the large volume of distribution (Vdbeta=22.6+/-9.4 l/kg). The mean total clearance was 13.4+/-7.0 ml/kg per minute. The mean time required to obtain a 50% decrease in plasma concentration was short (tcp(0/2=)4.7+/-3.7 h). CONCLUSIONS: The pharmacokinetic analysis of sufentanil for ICU sedation revealed increased volume of distribution and elimination half-life. Nevertheless the rapid distribution and elimination processes suggest that the rapid reversibility of sedation with sufentanil is maintained after long duration of infusion. Further studies should be carried out to evaluate the clinical relevance of these results.
Publication Types:
- Clinical Trial
- Controlled Clinical Trial
PMID: 12923616 [PubMed - indexed for MEDLINE]
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Immunoparalysis as a cause for invasive aspergillosis?
Hartemink KJ, Paul MA, Spijkstra JJ, Girbes AR, Polderman KH.
Department of Intensive Care, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
Aspergillus infections are among the most feared opportunistic infections in humans. These organisms are ubiquitous in nature; protection against infection is usually provided by anatomical barriers and by the immune system. Tissue invasion by Aspergillus is uncommon, occurring primarily in the setting of immunosuppression. The prognosis of invasive aspergillosis is very poor. Although it is widely recognised that critically ill patients in the Intensive Care Unit (ICU) are at risk for nosocomial infections, it is not generally appreciated that such patients may also be at risk for opportunistic infections usually seen only in immunocompromised patients. This might be explained by a biphasic immunological pattern during sepsis: an early hyperinflammatory phase followed by an anti-inflammatory response, leading to a hypo-inflammatory state, the so-called compensatory anti-inflammatory response syndrome (CARS or immunoparalysis). We describe four patients admitted to our ICU for various reasons, without a history of abnormal immune function, who developed invasive pulmonary aspergillosis. We hypothesise that the occurrence of these opportunistic infections in our patients may have been due to immunoparalysis, and that perhaps all ICU patients with sepsis and multiple organ dysfunction syndrome (MODS) may be at risk for opportunistic infections such as aspergillosis as a result of this syndrome. Physicians treating critically ill patients in the ICU should be aware of the CARS/immunoparalysis syndrome and its potential to cause opportunistic infections, even in patients with normal immune function prior to ICU admission.
Publication Types:
PMID: 12768234 [PubMed - indexed for MEDLINE]
Parenteral nutrition solution retrieved by lumbar puncture following left saphenous vein catheterization.
Clarke P, Wadhawan R, Smyth J, Emmerson AJ.
Neonatal Intensive Care Unit, St Mary's Hospital, Manchester, UK. paul.clarke@srht.nhs.uk
Two extremely preterm infants had silastic lines inserted via the left great saphenous vein for intravenous feeding. Clinical deterioration approximately 10 days later led to lumbar puncture as part of a sepsis screen. Parenteral nutrition solution was recovered in the cerebrospinal fluid and heralded potentially life-threatening catheter malposition. The cases illustrate another percutaneous central line-associated morbidity, which is avoidable by careful verification of line position. All previously reported cases of this unusual complication are reviewed and we describe its likely mechanism. We postulate that the phenomenon is a complication peculiar to percutaneous catheterization of the left lower limb.
Publication Types:
- Case Reports
- Review
- Review of Reported Cases
PMID: 12887673 [PubMed - indexed for MEDLINE]
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A time-dependent analysis of intensive care unit pneumonia in trauma patients.
Bochicchio GV, Joshi M, Bochicchio K, Tracy K, Scalea TM.
R Adams Cowley Shock Trauma Center and University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. gbochicchio@umm.edu
BACKGROUND: Appropriate and timely antibiotic therapy to treat pneumonia in trauma patients is extremely important. We evaluated the incidence and microbiology of pneumonia stratified by days postadmission and risk factors. METHODS: Prospective data were collected on 714 trauma patients admitted to the intensive care unit over a 1-year period. Pneumonia was classified as community acquired (CAP) (< or = 3 days), early nosocomial (ENP) (4-6 days), or late nosocomial (LNP) (> or = 7 days). In addition, pneumonia was classified as CAP only, nosocomial only (NI), or combination (CAP and NI, or ENP and LNP) pneumonia. Strict institutional guidelines were followed for diagnosis. RESULTS: One hundred eighty-two patients (25%) were diagnosed with 204 pneumonias over the study period. One hundred twenty-five (61%) of these pneumonias were ventilator associated. Staphylococcus aureus and Haemophilus influenzae were the most common pathogens isolated. Twenty-one percent of patients with CAP acquired an LNP (p < 0.025), in which Pseudomonas was the most common organism. Haemophilus caused LNP in 12% of patients. Cancer (p < 0.01), liver failure (p < 0.05), and age (p < 0.01) were predictive of nontypical pathogens in patients with CAP and ENP (p < 0.05). Obesity was most predictive of increased ventilator days (p < 0.001) and intensive care unit length of stay (p < 0.001). Increased age, alcohol abuse, and field airway were most predictive of mortality. CONCLUSION: Unanticipated pathogens were isolated in each class of pneumonia. The clinician must be aware of significant risk factors that may predispose patients to pathogens that are not ordinarily covered with standard antibiotic therapy.
PMID: 14960971 [PubMed - in process]
Veracity in medicine.
Hill J.
Joal.Hill@advocatehealth.org
PMID: 14667776 [PubMed - indexed for MEDLINE]
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Urinary catheter care in the intensive care unit.
Marklew A.
Department of Critical Care, Queen Alexandra Hospital, Portsmouth. annamarklew@ntlworld.com
Urinary catheters are associated with a number of complications, and nurses are ideally suited to minimize the associated risks by utilizing the available research in their practice. Urine tract infections caused by urine catheters are associated with increased mortality; however, urine catheter care is a nursing procedure, the importance of which is sometimes overlooked. This study reviews recommended guidelines on urine catheter care and current published literature on the subject. The aim of the study was to identify recommended practice and compare it with the current research and literature to conclude best practice. Conclusions made from this study are that existing guidelines correspond to the recommendations and findings in recent research and literature. However, more detailed guidelines and further research on how to prevent catheter-associated urine tract infections and other complications may be of benefit.
PMID: 14871006 [PubMed - in process]
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