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Items 1 - 51 of 51 |
One page. |
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Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit.
Hoffman LA, Tasota FJ, Zullo TG, Scharfenberg C, Donahoe MP.
Schools of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
BACKGROUND: Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff. OBJECTIVE: To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows. METHODS: During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes. RESULTS: Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02). CONCLUSIONS: In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.
PMID: 15728954 [PubMed - in process]
A review of the true methodological quality of nutritional support trials conducted in the critically ill: time for improvement.
Doig GS, Simpson F, Delaney A.
Department of Intensive Care, Northern Clinical School, University of Sydney, Royal North Shore Hospital, Pacific Highway, St. Leonards, NSW 2065, Australia. gdoig@med.usyd.edu.au
In this review we sought to appraise the true methodological quality of nutritional support studies conducted in critically ill patients and to compare these findings to the methodological quality of sepsis trials. An extensive literature search revealed 111 randomized controlled trials conducted in critically ill patients evaluating the impact of nutritional support interventions on clinically meaningful outcomes. Compared with sepsis trials, nutritional support studies were significantly less likely to use blinding (32 of 40 versus 35 of 111, P < 0.001) or present an intention-to-treat analysis (37 of 40 versus 64 of 111, P < 0.001). There was a trend toward the less frequent use of randomization methods that are known to maintain allocation concealment (12 of 40 versus 19 of 111, P = 0.10). Although nutritional support studies demonstrated a significant increase in the use of blinding after the publication of the CONSORT statement in 1996 (9 of 47 versus 26 of 64 post-CONSORT, P = 0.023), there were no improvements in other key areas. Previous publications have described the overall methodological quality of sepsis trials as "poor." Nutritional support studies were significantly worse than sepsis trials in all aspects of methodological quality, and there were few improvements noted over time. To detect important differences in clinically meaningful outcomes in critical care, the methodological quality of future studies must be improved.
PMID: 15673887 [PubMed - indexed for MEDLINE]
Potential value of adenosine 5'-triphosphate (ATP) and adenosine in anaesthesia and intensive care medicine.
Skrabanja AT, Bouman EA, Dagnelie PC.
Department of Epidemiology, NUTRIM, Maastricht University, Maastricht, The Netherlands.
Extracellular adenosine and adenosine triphosphate (ATP) are involved in biological processes including neurotransmission, muscle contraction, cardiac function, platelet function, vasodilatation, signal transduction and secretion in a variety of cell types. They are released from the cytoplasm of several cell types and interact with specific purinergic receptors which are present on the surface of many cells. This review summarizes the evidence on the potential value and applicability of ATP (not restricted to ATP-MgCl2) and adenosine in the field of anaesthesia and intensive care medicine. It focuses, in particular, on evidence and roles in treatment of acute and chronic pain and in sepsis. Based on the evidence from animal and clinical studies performed during the last 20 years, ATP could provide a valuable addition to the therapeutic options in anaesthesia and intensive care medicine. It may have particular roles in pain management, modulation of haemodynamics and treatment of shock.
PMID: 15722385 [PubMed - as supplied by publisher]
Anemia, allogenic blood transfusion, and immunomodulation in the critically ill.
Raghavan M, Marik PE.
Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Anemia and allogenic RBC transfusions are exceedingly common among critically ill patients. Multiple pathologic mechanisms contribute to the genesis of anemia in these patients. Emerging risks associated with allogenic RBC transfusions including the transmission of newer infectious agents and immune modulation predisposing the patient to infections requires reevaluation of current transfusion strategies. Recent data have suggested that a restrictive transfusion practice is associated with reduced morbidity and mortality during critical illness, with the possible exception of acute coronary syndromes. In this article, we review the immune-modulatory role of allogenic RBC transfusions in critically ill patients.
Publication Types:
PMID: 15653997 [PubMed - indexed for MEDLINE]
Comment on:
A role for one or more p450 enzymes in the response to sepsis.
Morgan ET.
Publication Types:
PMID: 15644701 [PubMed - indexed for MEDLINE]
Comment on:
Endpoint: quality of life.
Leone M.
Publication Types:
PMID: 15644700 [PubMed - indexed for MEDLINE]
Comment on:
Strong ion gap.
Omron EM, Gilbert RC.
Publication Types:
PMID: 15644699 [PubMed - indexed for MEDLINE]
Comment on:
Agitation in the critically ill patient: a marker of health or a plea for treatment?
Schweickert W, Hall JB.
Publication Types:
PMID: 15644697 [PubMed - indexed for MEDLINE]
Comment on:
Quality of life: late sequela in sepsis.
Soriano FG.
Publication Types:
PMID: 15644696 [PubMed - indexed for MEDLINE]
Comment on:
Early enteral nutrition vs. early parenteral nutrition: an irrelevant question for the critically ill?
Heyland DK, Dhaliwal R.
Publication Types:
PMID: 15644695 [PubMed - indexed for MEDLINE]
Comment on:
Hypertonic saline and stroke.
Kempski O.
Publication Types:
PMID: 15644694 [PubMed - indexed for MEDLINE]
Comment on:
Brain ischemia, obscenity, and the elusive cerebral perfusion pressure.
De Georgia M.
Publication Types:
PMID: 15644692 [PubMed - indexed for MEDLINE]
Comment on:
Recruitment, it's not just about lung function anymore.
Allen GB.
Publication Types:
PMID: 15644691 [PubMed - indexed for MEDLINE]
Comment on:
Monitoring the permeability edema of ventilator-associated lung injury.
Groeneveld AB, Plotz FB, van Genderingen HR.
Publication Types:
PMID: 15644689 [PubMed - indexed for MEDLINE]
Comment on:
Diagnosing partially obstructed endotracheal tubes: the advent of intelligent ventilator monitors.
Simpson SQ.
Publication Types:
PMID: 15644688 [PubMed - indexed for MEDLINE]
Comment on:
Intravenous amiodarone: offender or bystander?
Guglin M.
Publication Types:
PMID: 15644685 [PubMed - indexed for MEDLINE]
Comment on:
More reliable determination of central venous and pulmonary artery occlusion pressures: does it matter?
Leibowitz AB.
Publication Types:
PMID: 15644684 [PubMed - indexed for MEDLINE]
Comment on:
Vital are the vital signs.
Weissman C, Landesberg G.
Publication Types:
PMID: 15644682 [PubMed - indexed for MEDLINE]
Comment on:
Low tidal volume needs to be used in patients with acute respiratory distress syndrome.
Jain M, Sznajder JI.
Publication Types:
PMID: 15644681 [PubMed - indexed for MEDLINE]
Comment on:
Is stored blood good enough for critically ill patients?
Walsh TS.
Publication Types:
PMID: 15644680 [PubMed - indexed for MEDLINE]
Comment on:
Human leukocyte antigen expression in sepsis: what have we learned?
Tschoeke SK, Moldawer LL.
Publication Types:
PMID: 15644679 [PubMed - indexed for MEDLINE]
Comment on:
The femoral site as first choice for central venous access? Not so fast.
O'Grady NP, Dezfulian C.
Publication Types:
PMID: 15644678 [PubMed - indexed for MEDLINE]
Comment on:
Transfusion practice in the critically ill: can we do better?
Corwin HL.
Publication Types:
PMID: 15644677 [PubMed - indexed for MEDLINE]
Comment on:
Cytokines and lung injury: searching for useful biomarkers.
Martin TR.
Publication Types:
PMID: 15644676 [PubMed - indexed for MEDLINE]
Comment in:
Haloperidol use is associated with lower hospital mortality in mechanically ventilated patients.
Milbrandt EB, Kersten A, Kong L, Weissfeld LA, Clermont G, Fink MP, Angus DC.
CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
OBJECTIVE: To determine whether haloperidol use is associated with lower mortality in mechanically ventilated patients. DESIGN: Retrospective cohort analysis. SETTING: A large tertiary care academic medical center. PATIENTS: A total of 989 patients mechanically ventilated for >48 hrs. MEASUREMENTS AND MAIN RESULTS: We compared differences in hospital mortality between patients who received haloperidol within 2 days of initiation of mechanical ventilation and those who never received haloperidol. Despite similar baseline characteristics, patients treated with haloperidol had significantly lower hospital mortality compared with those who never received haloperidol (20.5% vs. 36.1%; p = .004). The lower associated mortality persisted after adjusting for age, comorbidity, severity of illness, degree of organ dysfunction, admitting diagnosis, and other potential confounders. CONCLUSIONS: Haloperidol was associated with significantly lower hospital mortality. These findings could have enormous implications for critically ill patients. Because of their observational nature and the potential risks associated with haloperidol use, they require confirmation in a randomized, controlled trial before being applied to routine patient care.
PMID: 15644675 [PubMed - indexed for MEDLINE]
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Prognostic value of procalcitonin in children with meningococcal sepsis.
Carrol ED, Newland P, Thomson AP, Hart CA.
Institute of Child Health, Liverpool Children's Hospital NHS Trust, Alder Hey, Liverpool, UK.
OBJECTIVE: To compare procalcitonin, lactate, and C-reactive protein as prognostic markers in children with meningococcal septic shock. DESIGN: Prospective observational study. SETTING: Alder Hey Children's Hospital, Liverpool, UK. PATIENTS: Children admitted to our hospital during a 16-month period with a diagnosis of meningococcal sepsis. RESULTS: Plasma procalcitonin at admission was significantly higher in children with septic shock (median, 73.80 vs. 16.44 ng/mL), those requiring ventilation (median, 47.02 vs. 12.00 ng/mL), and those with a duration of hospital stay >10 days (median, 131.35 vs. 19.26 ng/mL). Both procalcitonin and lactate reliably discriminated between those children with septic shock (area under the curve [AUC] = 0.85 and 0.84, respectively) and durations of hospital stay exceeding 10 days (AUC = 0.87 and 0.79, respectively) and those without, but C-reactive protein did not. Procalcitonin alone reliably discriminated between those children requiring ventilation and those who did not (AUC = 0.72). CONCLUSION: Procalcitonin is a reliable prognostic marker of septic shock, requirement for ventilation, and prolonged hospital stay in children with meningococcal sepsis and performs better than lactate and C-reactive protein.
PMID: 15644674 [PubMed - indexed for MEDLINE]
Comment in:
A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients.
Peter JV, Moran JL, Phillips-Hughes J.
Intensive Care Unit, The Queen Elizabeth Hospital, Woodville, South Australia.
OBJECTIVE: Nutritional support as enteral or parenteral nutrition (PN) is used in hospitalized patients to reduce catabolism. This study compares outcomes of early enteral nutrition (EN) with early PN in hospitalized patients. DESIGN: The authors conducted a metaanalysis of randomized, controlled trials (RCT) comparing early EN with PN. Studies on immunonutrition were excluded. Studies were categorized as medical, surgical, or trauma. PATIENTS: RCTs of early EN/PN were identified by search of 1) MEDLINE (1966-2002), 2) published abstracts from scientific meetings, and 3) bibliographies of relevant articles. MEASUREMENTS AND MAIN RESULTS: Thirty RCTs (ten medical, 11 surgical, and nine trauma) compared early EN with PN. The effect of nutrition type on hospital mortality and complication rates was reported as risk difference (RD%) and hospital length of stay (LOS) as mean weighted difference (MWD days). Missing data, by outcomes, varied from 20% to 63%. As a result of heterogeneity of treatment effects, the DerSimonian-Laird random-effects estimator was reported. There was no differential treatment effect of nutrition type on hospital mortality for all patients (0.6%, p = .4) and subgroups. PN was associated with increases in infective complications (7.9%, p = .001), catheter-related blood stream infections (3.5%, p = .003), noninfective complications (4.9%, p = .04), and hospital LOS (1.2 days, p = .004). There was no effect of nutrition type on technical complications (4.1%, p = .2). EN was associated with a significant increase in diarrheal episodes (8.7%, p = .001). Publication bias was not demonstrated. Metaanalytic regression analysis did not demonstrate any effect of age, time to initiate treatment, and average albumin on mortality estimates. Cumulative metaanalysis showed no change in the mortality estimates with time. CONCLUSION: There was no mortality effect with the type of nutritional supplementation. Although early EN significantly reduced complication rates, this needs to be interpreted in the light of missing data and heterogeneity. The enthusiasm that early EN, as compared with early PN, would reduce mortality appears misplaced.
Publication Types:
PMID: 15644672 [PubMed - indexed for MEDLINE]
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Incidence of acute respiratory distress syndrome in German children and adolescents: a population-based study.
Bindl L, Dresbach K, Lentze MJ.
Pediatric Cardiology, University of Aachen, Aachen, Germany.
OBJECTIVE: The objective of this study was to determine the epidemiology of acute respiratory distress syndrome (ARDS) in children and adolescents aged 1 mo to 18 yrs. DESIGN: The authors conducted a population-based prospective multicenter survey from February 1 to 28,1997, June 1 to 30, 2001, and April 1 to 30, 2004. SETTING: This study was conducted at 94 intensive care units (ICUs) in 1997, 92 ICUs in 2001 and 2004 in the district of Cologne, Germany with a population of 4.15 (1997), 4.28 (2001), and 4.35 million (2004), respectively. The survey was not confined to children's hospitals, but addressed all ICUs. PATIENTS: This study consisted of children and adolescents aged 1 mo to 18 yrs. Term neonates and premature babies with a corrected age below 43 gestational weeks were excluded. ARDS was defined according to the consensus criteria (acute-onset pulmonary process of noncardiogenic origin, Pao(2)/FIo(2) ratio <200, bilateral alveolar infiltration in chest radiograph). RESULTS: All ICUs at pediatric hospitals and all but seven adult ICUs collaborated. Incidence of ARDS was assessed as the number of patients entering ARDS criteria within the three study periods divided by the total population in this age group. During the study period, 12 pediatric patients were diagnosed as having ARDS. In five cases, onset was before the study period, representing a calculated prevalence of 5.5 x 10(-5) [3.1 x 10(-5); 9.6 x 10(-5)] cases per year and an incidence of 3. 2 x 10(-5) [1.5 x 10(-5); 6.6 x 10(-5)] cases per year in the age group under investigation. CONCLUSION: This is the first population-based evaluation of the incidence of ARDS in the pediatric age group. It shows that the incidence of ARDS in this age group is low. This makes randomized studies on pediatric ARDS aiming on the end point "outcome" nearly impossible.
Publication Types:
PMID: 15644671 [PubMed - indexed for MEDLINE]
Comment in:
Randomized, controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/6% dextran solution on increased intracranial pressure after brain injury.
Battison C, Andrews PJ, Graham C, Petty T.
Intensive Care Unit, Western General Hospital, Edinburgh, UK.
OBJECTIVE: The aim of this pilot study was to compare the effects of equimolar doses of hypertonic saline and dextran solution (HSD, Rescueflow) with 20% mannitol solution for reduction of increased intracranial pressure. DESIGN: Prospective, randomized, controlled, crossover trial in the intensive care unit of a large teaching hospital. SETTING: Academic hospital and tertiary referral center for neuroscience. PATIENTS: Nine patients with an intracranial pressure of >20 mm Hg were recruited and received two treatments of each, HSD and 20% mannitol, in a randomized order. INTERVENTION: Equimolar, rapid intravenous infusions of either 200 mL of 20% mannitol or 100 mL of 7.5% saline and 6% dextran-70 solution (HSD) over 5 mins. MEASUREMENTS: Intracranial pressure, blood pressure, serum and urine sodium and osmolality, and urine output. MAIN RESULTS: Treatments reduced intracranial pressure with both mannitol (median decrease, 7.5 mm Hg, 95% confidence interval, 5.8-11.8) and HSD (median decrease, 13 mm Hg; 95% confidence interval, 11.5-17.3). HSD caused a significantly greater decrease in intracranial pressure than mannitol (p = .044). HSD had a longer duration of effect than mannitol (p = .044). CONCLUSION: When given in an equimolar, rapid, intravenous infusion, HSD reduces intracranial pressure more effectively than mannitol.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15644669 [PubMed - indexed for MEDLINE]
Comment in:
Effect of cerebral perfusion pressure augmentation on regional oxygenation and metabolism after head injury.
Johnston AJ, Steiner LA, Coles JP, Chatfield DA, Fryer TD, Smielewski P, Hutchinson PJ, O'Connell MT, Al-Rawi PG, Aigbirihio FI, Clark JC, Pickard JD, Gupta AK, Menon DK.
University Department of Anaesthetics, Addenbrooke's Hospital, Cambridge, UK.
OBJECTIVE: In this study we have used O positron emission tomography, brain tissue oxygen monitoring, and cerebral microdialysis to assess the effects of cerebral perfusion pressure augmentation on regional physiology and metabolism in the setting of traumatic brain injury. DESIGN: Prospective interventional study. SETTING: Neurosciences critical care unit of a university hospital. PATIENTS: Eleven acutely head-injured patients requiring norepinephrine to maintain cerebral perfusion pressure. INTERVENTIONS: Using positron emission tomography, we have quantified the response to an increase in cerebral perfusion pressure in a region of interest around a brain tissue oxygen sensor (Neurotrend) and microdialysis catheter. Oxygen extraction fraction and cerebral blood flow were measured with positron emission tomography at a cerebral perfusion pressure of approximately 70 mm Hg and approximately 90 mm Hg using norepinephrine to control cerebral perfusion pressure. All other aspects of physiology were kept stable. MEASUREMENTS AND MAIN RESULTS: Cerebral perfusion pressure augmentation resulted in a significant increase in brain tissue oxygen (17 +/- 8 vs. 22 +/- 8 mm Hg; 2.2 +/- 1.0 vs. 2.9 +/- 1.0 kPa, p < .001) and cerebral blood flow (27.5 +/- 5.1 vs. 29.7 +/- 6.0 mL/100 mL/min, p < .05) and a significant decrease in oxygen extraction fraction (33.4 +/- 5.9 vs. 30.3 +/- 4.6 %, p < .05). There were no significant changes in any of the microdialysis variables (glucose, lactate, pyruvate, lactate/pyruvate ratio, glycerol). There was a significant linear relationship between brain tissue oxygen and oxygen extraction fraction (r = .21, p < .05); the brain tissue oxygen value associated with an oxygen extraction fraction of 40% (the mean value for oxygen extraction fraction in normal controls) was 14 mm Hg (1.8 kPa). The cerebral perfusion pressure intervention resulted in a greater percentage increase in brain tissue oxygen than the percentage decrease in oxygen extraction fraction; this suggests that the oxygen gradients between the vascular and tissue compartments were reduced by the cerebral perfusion pressure intervention. CONCLUSIONS: Cerebral perfusion pressure augmentation significantly increased levels of brain tissue oxygen and significantly reduced regional oxygen extraction fraction. However, these changes did not translate into predictable changes in regional chemistry. Our results suggest that the ischemic level of brain tissue oxygen may lie at a level below 14 mm Hg (1.8 kPa); however, the data do not allow us to be more specific.
PMID: 15644668 [PubMed - indexed for MEDLINE]
Comment in:
Hepatotoxicity during rapid intravenous loading with amiodarone: Description of three cases and review of the literature.
Bravo AE, Drewe J, Schlienger RG, Krahenbuhl S, Pargger H, Ummenhofer W.
Division of Clinical Pharmacology & Toxicology, University Hospital of Basel, CH-4031 Basel, Switzerland.
OBJECTIVE: Atrial fibrillation is the most common arrhythmia after cardiac surgery. Amiodarone can effectively prevent and control postoperative atrial and ventricular fibrillation. Acute hepatic damage after intravenous amiodarone, which can be fatal, is not well recognized. We describe three cases of acute hepatocellular injury after intravenous amiodarone administration in critically ill patients. Another 25 published cases and six cases reported to the Swiss Pharmacovigilance Center (Swissmedic) are discussed. DESIGN: This study consisted of a series of three case reports and review of the literature. SETTING:: This study was conducted at an operative critical care unit at the University Hospital Basel, Switzerland. PATIENTS: Three hemodynamically compromised patients after open heart surgery developed significant increases of transaminases (up to more than 100-fold of the upper limit of normal) shortly after the introduction of intravenous amiodarone. INTERVENTIONS AND MEASUREMENT: Cessation of intravenous amiodarone and of other potentially hepatotoxic drugs. RESULTS: Liver parameters significantly improved or returned to normal in all three patients, even after start of oral amiodarone in two patients. CONCLUSIONS: Amiodarone is a highly effective antiarrhythmic agent for the treatment and prevention of atrial and ventricular arrhythmias. Acute liver damage after intravenous amiodarone, possibly induced by the solubilizer polysorbate 80, is rare but potentially harmful. Amiodarone loading should therefore be adapted to the necessity of an immediate effect of the drug, and liver function should be monitored closely in critically ill patients. Oral maintenance therapy with amiodarone is possible, even in patients who developed liver disease during intravenous loading.
Publication Types:
- Case Reports
- Review
- Review of Reported Cases
PMID: 15644659 [PubMed - indexed for MEDLINE]
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Ventilator-associated pneumonia using a closed versus an open tracheal suction system.
Lorente L, Lecuona M, Martin MM, Garcia C, Mora ML, Sierra A.
Department of Critical Care, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.
OBJECTIVE: The aim of this study was to analyze the prevalence of ventilator-associated pneumonia (VAP) using a closed-tracheal suction system vs. an open system. DESIGN: Prospective and randomized study, from October 1, 2002, to December 31, 2003. SETTING: A 24-bed medical-surgical intensive care unit in a 650-bed tertiary hospital. PATIENTS: Patients requiring mechanical ventilation for >24 hrs. INTERVENTIONS: Patients were randomized into two groups; one group was suctioned with the closed-tracheal suctioning system and another group with the open system. MEASUREMENTS: Throat swabs were taken at admission and twice a week until discharge to classify pneumonia in endogenous and exogenous. MAIN RESULTS: A total of 443 patients (210 with closed-tracheal suction system and 233 with the open system) were included. There were no significant differences between groups of patients in age, sex, diagnosis groups, mortality, number of aspirations per day, and Acute Physiology and Chronic Health Evaluation II score. No significant differences were found in either the percentage of patients who developed VAP (20.47% vs. 18.02%) or in the number of VAP cases per 1000 mechanical ventilation-days (17.59 vs. 15.84). There were also no differences in the VAP incidence by mechanical ventilation duration. At the same time, we did not find any differences in the incidence of exogenous VAP. Likewise, there were also no differences in the microorganisms responsible for pneumonia. Patient cost per day for the closed suction was more expensive than the open suction system (11.11 US dollars +/- 2.25 US dollars vs. 2.50 US dollars +/- 1.12 US dollars, p < .001). CONCLUSION: We conclude that in our study, the closed-tracheal suction system did not reduce VAP incidence, even for exogenous pneumonia.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15644657 [PubMed - indexed for MEDLINE]
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Pharmacokinetics and intrapulmonary diffusion of levofloxacin in critically ill patients with severe community-acquired pneumonia.
Boselli E, Breilh D, Rimmele T, Djabarouti S, Saux MC, Chassard D, Allaouchiche B.
Department of Anesthesiology and Intensive Care, Hotel-Dieu Hospital, Lyon, France.
OBJECTIVE: To determine the steady-state plasma and epithelial lining fluid concentrations of intravenous levofloxacin, 500 mg, administered once or twice daily in critically ill patients with severe community-acquired pneumonia. DESIGN: Prospective, open-label study. SETTING: An intensive care unit and a clinical pharmacokinetic laboratory in two university hospitals. PATIENTS: Twenty-four adult patients with severe community-acquired pneumonia and receiving mechanical ventilation were enrolled. INTERVENTIONS: All subjects received 1-hr intravenous infusions of 500 mg levofloxacin once or twice daily. The plasma and epithelial lining fluid levofloxacin concentrations were determined at steady-state after 2 days of therapy with high-performance liquid chromatography. MEASUREMENTS AND MAIN RESULTS: The median (interquartile range [IQR]) plasma and epithelial lining fluid peak levofloxacin concentrations were 12.6 (IQR, 12.0-14.1) and 11.9 (IQR, 8.7-13.7) mg/L, respectively, in the once-daily group and 19.7 (IQR, 19.0-22.0) and 17.8 (IQR, 16.2-23.5) mg/L in the twice-daily group, showing a pulmonary percentage penetration of >100% in both groups. The median (IQR) total body exposures were 151 (IQR, 137-174) and 416 (IQR, 406-472) mg.hr/L, respectively, in the once-daily and twice-daily groups. CONCLUSIONS: Our results suggest that in critically ill patients who are receiving mechanical ventilation and have severe community-acquired pneumonia and creatinine clearance of >40 mL/min, the administration of 500 mg of intravenous levofloxacin once and twice daily allows for the exceeding of pharmacodynamic thresholds predictive of outcome (i.e., peak concentration to minimum inhibitory concentration ratio of >10 or area under concentration-time curve to minimal inhibitory concentration ratio of >125 hrs) both in serum and epithelial lining fluid for pathogens with minimum inhibitory concentration values of < or =1 mg/L and >1 mg/L, respectively.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15644655 [PubMed - indexed for MEDLINE]
Comment in:
Effect of airway pressure display on interobserver agreement in the assessment of vascular pressures in patients with acute lung injury and acute respiratory distress syndrome.
Rizvi K, Deboisblanc BP, Truwit JD, Dhillon G, Arroliga A, Fuchs BD, Guntupalli KK, Hite D, Hayden D; NIH/NHLBI ARDS Clinical Trials Network.
Division of Biological Sciences, University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
BACKGROUND: Previous investigations have identified significant interobserver variability in the measurements of central venous pressure and pulmonary artery occlusion pressure in critically ill patients. Large interobserver variability in the measurement of vascular pressures could potentially lead to inappropriate treatment decisions. OBJECTIVE: We postulated that adding an airway pressure signal (Paw) to pressure tracings of central venous pressure and pulmonary artery occlusion pressure would improve interobserver agreement by facilitating identification of end-expiration. DESIGN: To test this hypothesis, six independent experts used a standard protocol to interpret strip-chart recordings of central venous pressure and pulmonary artery occlusion pressure with or without Paw. Two observers were said to agree if their measurements were within 2 mm Hg of each other. SETTING/SUBJECTS/INTERVENTIONS: A total of 459 strip-chart recordings (303 without Paw and 156 with Paw) were obtained from 121 patients enrolled in the ARDSnet Fluids and Catheters Treatment Trial (FACTT) in 16 different hospitals. RESULTS:Agreement within 2 mm Hg between two measurements was 79% for central venous pressure strips without Paw vs. 86% with Paw. For pulmonary artery occlusion pressure, agreement increased from 71% without Paw to 83% with Paw. The increase in agreement with the addition of Paw was greater for strips demonstrating >8 mm Hg phasic respiratory variation compared with strips demonstrating less phasic respiratory variation. CONCLUSION: Paw display is a simple, inexpensive method to facilitate the identification of end-expiration that can significantly improve interobserver agreement.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 15644654 [PubMed - indexed for MEDLINE]
Comment in:
Impact of prolonged elevated heart rate on incidence of major cardiac events in critically ill patients with a high risk of cardiac complications.
Sander O, Welters ID, Foex P, Sear JW.
Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, UK.
OBJECTIVE: To assess the incidence of major cardiac events in critically ill patients with a high risk of cardiac complications presenting with an elevated heart rate. DESIGN AND SETTING: Observational, retrospective study in a 15-bed medical/surgical Intensive Care Unit (ICU) at a university hospital for a period of 12 months. PATIENTS: We studied patients with a high risk of cardiac complications, according to the revised Goldman index, who were treated for at least 36 hrs in the ICU. Patients presenting with prolonged elevated heart rate, defined as a heart rate >95 beats/min for >12 hrs in at least one 24-hr period of their ICU stay, were investigated. Cardiac high-risk patients not developing this criterion served as controls. Major cardiac events, defined as nonfatal myocardial infarction, nonfatal cardiac arrest, and cardiac related death, were the primary outcome measures. RESULTS: From a total of 791 patients, 69 patients were assessed as cardiac high-risk patients. Of 39 patients with prolonged elevated heart rates, 19 (49%) sustained major cardiac events, whereas in the control group of 30 patients, only four patients (13%) had a major cardiac event (p = .002; odds ratio, 6.2). Patients with elevated heart rate had to be treated 4.5 days longer in the ICU (p = .01), whereas the ICU and 30-day post-ICU discharge survival rates did not differ significantly. CONCLUSIONS: In this study, we provide evidence for an increased incidence of major cardiac events in critically ill, cardiac high-risk patients with a prolonged elevated heart rate during their ICU stay. In addition, elevated heart rate was associated with a significantly longer ICU stay.
PMID: 15644652 [PubMed - indexed for MEDLINE]
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Epidemiology of sepsis in Victoria, Australia.
Sundararajan V, Macisaac CM, Presneill JJ, Cade JF, Visvanathan K.
Victorian Department of Human Services, Melbourne, Victoria, Australia.
OBJECTIVE: To determine the clinical and epidemiologic characteristics of patients with sepsis admitted to hospitals in Victoria, Australia, including the incidence of sepsis and severe sepsis, utilization of intensive care unit (ICU) resources, and hospital mortality. DESIGN: A population-based hospital morbidity database generated from hospital discharge coding. SETTING: State of Victoria, Australia (population, 4.5 million), the 4-yr period from July 1, 1999, to June 30, 2003. PATIENTS: A total of 3,122,515 overnight hospitalizations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall hospital incidence of sepsis was 1.1%, with a mortality of 18.4%. Of septic patients, 23.8% received some care in an ICU. For these patients, hospital mortality was 28.9%. Severe sepsis, defined by sepsis and at least one organ dysfunction, occurred in 39% of sepsis patients and was accompanied by a hospital mortality of 31.1%. Fifty percent of patients with severe sepsis received at least some care in an ICU. CONCLUSIONS: Australian state hospital administrative data reveal epidemiologic features of sepsis and severe sepsis that are strikingly similar to those recently reported from comparable populations in North American and Europe. This suggests that lessons learned in this area may be directly applicable internationally.
PMID: 15644651 [PubMed - indexed for MEDLINE]
Comment in:
Acute effects of tidal volume strategy on hemodynamics, fluid balance, and sedation in acute lung injury.
Cheng IW, Eisner MD, Thompson BT, Ware LB, Matthay MA; Acute Respiratory Distress Syndrome Network.
Cardiovascular Research Institute, University of California, San Francisco, USA.
OBJECTIVE: To examine the effects of mechanical ventilation with a tidal volume of 6 mL/kg compared with 12 mL/kg predicted body weight on hemodynamics, vasopressor use, fluid balance, diuretics, sedation, and neuromuscular blockade within 48 hrs in patients with acute lung injury and acute respiratory distress syndrome. DESIGN: Retrospective analysis of a previously conducted randomized, clinical trial. SETTING: Two adult intensive care units at a tertiary university medical center and a large county hospital. PATIENTS: One hundred eleven patients who were enrolled in the National Institutes of Health ARDS Network trial at the University of California, San Francisco. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Compared with 12 mL/kg predicted body weight, treatment with a tidal volume of 6 mL/kg predicted body weight had no adverse effects on hemodynamics. There were also no differences in the need for supportive therapies, including vasopressors, intravenous fluids, or diuretics. In addition, there were no differences in body weight, urine output, and fluid balance. Finally, there was no difference in the need for sedation or neuromuscular blockade between the two tidal volume protocols. CONCLUSIONS: When compared with ventilation with 12 mL/kg predicted body weight, patients treated with the lung-protective 6 mL/kg predicted body weight tidal volume protocol had no difference in their supportive care requirements. Therefore, concerns regarding potential adverse effects of this protocol should not preclude its use in patients with acute lung injury or the acute respiratory distress syndrome.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 15644650 [PubMed - indexed for MEDLINE]
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Recruitment maneuvers during prone positioning in patients with acute respiratory distress syndrome.
Oczenski W, Hormann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD.
Department of Anesthesia and Intensive Care and the Ludwig Boltzmann Institute for Economics of Medicine in Anesthesia and Intensive Care, City of Vienna Hospital-Lainz, Vienna, Austria.
OBJECTIVE: To evaluate the interaction of recruitment maneuvers and prone positioning on gas exchange and venous admixture in patients with early extrapulmonary acute respiratory distress syndrome ventilated with high levels of positive end-expiratory pressure. We hypothesized that a sustained inflation performed after 6 hrs of prone positioning would induce sustained improvement in oxygenation (Pao2/Fio2) and venous admixture. DESIGN: Prospective, interventional study. SETTING: Tertiary care, postoperative intensive care unit. PATIENTS: Fifteen patients with early extrapulmonary acute respiratory distress syndrome. INTERVENTIONS: After 6 hrs of prone positioning, a sustained inflation was performed with 50 cm H2O maintained for 30 secs. Data were recorded in supine position, after 6 hrs of prone positioning, at 3, 30, and 180 mins following the sustained inflation. MEASUREMENTS AND MAIN RESULTS: A response to prone positioning was observed in nine of 15 patients leading to an improvement of Pao2/Fio2 (147 +/- 37 torr vs. 225 +/- 77 torr, p = .005) and venous admixture (35.4 +/- 8.3% vs. 28.9 +/- 9.8%, p = .001). Six patients did not respond to prone positioning. Following the sustained inflation, the responders to prone positioning showed a further increase of Pao2/Fio2 and decrease of venous admixture at 3 mins (Pao2/Fio2, 225 +/- 77 torr vs. 368 +/- 90 torr, p = .018; venous admixture, 28.9 +/- 9.8% vs. 18.9 +/- 6.7%, p = .05). In all six nonresponders to prone positioning, an improvement of Pao2/Fio2 and venous admixture occurred at 3 mins following the sustained inflation (128 +/- 18 torr vs. 277 +/- 59 torr, p = .03; venous admixture, 34.2 +/- 6.0% vs. 23.8 +/- 6.3%, p = .05). The beneficial effects of the sustained inflation remained significantly elevated over 3 hrs in responders and nonresponders to prone positioning. CONCLUSION: In patients with early extrapulmonary acute respiratory distress syndrome, a sustained inflation performed after 6 hrs of prone positioning induced further and sustained improvement of oxygenation and venous admixture in both responders and nonresponders to prone positioning.
PMID: 15644648 [PubMed - indexed for MEDLINE]
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Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis.
Shorr AF, Sherner JH, Jackson WL, Kollef MH.
Walter Reed Army Medical Center, Washington, DC, USA.
OBJECTIVE: Ventilator-associated pneumonia remains a major challenge in the intensive care unit. The role for invasive diagnostic methods (e.g., bronchoscopy) remains unclear. We hypothesized that invasive testing would alter antibiotic management in patients with ventilator-associated pneumonia but would not necessarily alter mortality. DESIGN: Meta-analysis of randomized, controlled trials of invasive diagnostic strategies in suspected ventilator-associated pneumonia and a separate pooled analysis of prospective, observational studies of the effect of invasive cultures on antibiotic utilization in ventilator-associated pneumonia. SETTING: NA. PATIENTS: Subjects enrolled in the various clinical trials identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified four randomized, controlled trials that included 628 patients. The overall quality of these studies was moderate (median Jadad score of 5) and there was both clinical and statistical heterogeneity among these trials. Ventilator-associated pneumonia was confirmed bronchoscopically in 44-69% of participants, with Pseudomonas aeruginosa and Staphylococcus aureus being the most frequently isolated pathogens. Most subjects (90.3%) received adequate antibiotics; however, in one trial there was a significant difference between the invasive and noninvasive arms with respect to this factor. Overall, an invasive approach did not alter mortality (odds ratio 0.89, 95% confidence interval 0.56-1.41). Invasive testing, though, affected antibiotic utilization (odds ratio for change in antibiotic management after invasive sampling, 2.85, 95% confidence interval 1.45-5.59). Five prospective observational studies examined invasive testing and included 635 subjects. These reports confirm that invasive sampling leads to modifications in the antibiotic regimen in more than half of patients (pooled estimate for rate of alteration in antibiotic prescription, 50.3%, 95% confidence interval 35.9-64.6%). CONCLUSIONS: Few trials have systematically examined the impact of diagnostic techniques on outcomes for patients suspected of suffering from ventilator-associated pneumonia. Invasive strategies do not alter mortality. Invasive approaches to ventilator-associated pneumonia affect antibiotic use and prescribing.
Publication Types:
PMID: 15644647 [PubMed - indexed for MEDLINE]
Comment in:
Messenger RNA expression of major histocompatibility complex class II genes in whole blood from septic shock patients.
Pachot A, Monneret G, Brion A, Venet F, Bohe J, Bienvenu J, Mougin B, Lepape A.
Department of Human Genetics, bioMerieux, Parc Club du Moulin a Vent, 33, avenue du Docteur LEVY, 69693 Venissieux Cedex, France. alexandre.pachot@eu.biomerieux.com
OBJECTIVE: The decreased expression of human leukocyte antigen (HLA)-DR on monocytes is proposed as a major feature of sepsis-induced immunodepression. The objective of the present study was to investigate, in whole blood from septic shock patients, the messenger RNA (mRNA) expression of a gene panel, which is essential to ensure major histocompatibility complex class II protein structure, transport, and peptide loading. DESIGN: The authors conducted a cohort study. SETTING: This study was conducted in intensive care units at a university hospital. SUBJECTS: The study included septic shock patients (n = 41) and healthy volunteers (n = 15). MEASUREMENTS AND MAIN RESULTS: Using quantitative reverse transcriptase-polymerase chain reaction, we found that the highly polymorphic HLA-DRB1 and nonpolymorphic-DRA mRNA levels were significantly decreased in whole blood from patients with septic shock compared with healthy volunteer both on days 1-3 and 4-10 after the onset of shock. This profile was also observed for genes encoding the invariant chain, the transcription factor class II transactivator (CIITA), and the enzymes involved in the peptide loading cathepsin S, HLA-DMA, and -DMB. The monocyte surface expression of HLA-DR measured by flow cytometry was significantly correlated with the whole-blood mRNA levels of HLA-DRB1 and -DRA and to a lesser extent with the other CIITA-regulated genes HLA-DMA and invariant chain. The correlation between HLA-DRB mRNA and cell-surface expression levels was also observed in a small subset of purified monocyte samples. Regarding the temporal relationship, a significant increase of whole-blood HLA-DRA, -DMA, -DMB, invariant chain, and CIITA mRNA level was observed in survivors (p = .001), whereas expressions remained low in nonsurvivors. CONCLUSIONS: A global transcriptional down regulation of a gene panel required for MHC II-restricted antigen presentation may occur in the course of septic shock. Our results suggest that the transcriptional resumption of CIITA-regulated genes might contribute to the recovery of membrane HLA-DR expression observed in survivors. These results obtained at the mRNA level support previous reports describing the loss of monocyte HLA-DR at the protein level and thus confirm the potential of measuring monocyte HLA-DR in septic patient followup.
PMID: 15644645 [PubMed - indexed for MEDLINE]
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Airway pressures, tidal volumes, and mortality in patients with acute respiratory distress syndrome.
Ferguson ND, Frutos-Vivar F, Esteban A, Anzueto A, Alia I, Brower RG, Stewart TE, Apezteguia C, Gonzalez M, Soto L, Abroug F, Brochard L; Mechanical Ventilation International Study Group.
Hospital Universitario de Getafe, Madrid, Spain.
OBJECTIVE: To determine the usual practice for setting tidal volume and other ventilatory parameters in patients with acute respiratory distress syndrome (ARDS) in the late 1990s and to determine the independent effects of these practices on intensive care unit mortality. DESIGN: Subanalysis of a prospective observational study. Multivariable logistic regression was used to analyze the effects of ventilatory management on mortality. SETTING: A total of 361 intensive care units in 20 countries in March 1998. PATIENTS: A total of 467 mechanically ventilated patients with ARDS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mean tidal volume used in the first week of ARDS was 8.8 mL/kg measured body weight, and there was great variability in these tidal volumes (sd = 2.0). Tidal volumes were significantly lower in patients with (n = 265) than without (n = 202) a recorded plateau pressure (8.6 vs. 9.1 mL/kg, p = .01). The overall intensive care unit mortality rate was 60.2%. In addition to the strong influence of organ failures and higher levels of inspired oxygen, late-onset ARDS (onset after >48 hrs of mechanical ventilation; odds ratio, 2.09) was independently associated with mortality. In addition, lower levels of positive end-expiratory pressure were independently associated with higher mortality (odds ratio, 0.91; 1 cm of H2O increments). Neither inspiratory pressures nor tidal volumes were independently associated with mortality, and there was no evidence of increased mortality with the use of lower inspiratory pressures. CONCLUSIONS: This descriptive study demonstrated considerable interpatient variability in tidal volumes during the study period. In addition to traditional prognostic indicators, timing of ARDS onset and the use of low levels of positive end-expiratory pressure or no positive end-expiratory pressure during the first week may adversely influence outcome in ARDS patients.
Publication Types:
PMID: 15644644 [PubMed - indexed for MEDLINE]
Comment in:
Revisiting transfusion practices in critically ill patients.
Hebert PC, Fergusson DA, Stather D, McIntyre L, Martin C, Doucette S, Blajchman M, Graham ID; Canadian Critical Care Trials Group.
Centre for Transfusion and Clinical Epidemiology Program, University of Ottawa, 501 Smyth Road, Box 201, Ottawa, Ontario, K1H 8L6, Canada.
OBJECTIVE: The objective of this study was to characterize contemporary red cell transfusion practice in the critically ill and to examine changes in practice over time. STUDY DESIGN: The authors conducted a scenario-based national survey. STUDY POPULATION: This study consisted of Canadian critical care practitioners. OUTCOME MEASURE: The authors evaluated transfusion thresholds in four hypothetical scenarios. RESULTS: Of 343 eligible Canadian critical care physicians, 235 (68.5%) responded to the survey. Most respondents were general internists (57%) who had been in practice for an average of 11.1 (+/-7.1) yrs and worked most often in combined medical/surgical intensive care units. Transfusion thresholds differed significantly among the four scenarios (p < .0001). The proportion of respondents adopting a threshold of 70 g/L was 63% and 70% in the hypothetical scenarios of trauma and septic shock compared with 16% and 3% who adopted the same threshold for scenarios involving patients with stable gastrointestinal hemorrhage and postoperative myocardial infarction, respectively. Fifteen percent of respondents identified transfusion thresholds exceeding 100 g/L for the postoperative myocardial infarction scenario, and 7% identified this threshold for the gastrointestinal hemorrhage scenario. Only 0.4% of respondents adopted a 100-g/L threshold for the two remaining scenarios. There was a significant decrease in transfusion thresholds in all four scenarios (p < .001) since the administration of a previous survey in 1993. The reported use of single-unit transfusions was 56% in 2002 vs. 10% in 1993. Eighty-five percent of physicians stated that they had modified their approach to transfusion, primarily in response to the publication of a major Canadian clinical trial and institutional guidelines. CONCLUSIONS: Canadian physicians appear to have adopted lower transfusion triggers and an increase in the use of single-unit red cell transfusion.
PMID: 15644642 [PubMed - indexed for MEDLINE]
Comment in:
Lower tidal volume ventilation and plasma cytokine markers of inflammation in patients with acute lung injury.
Parsons PE, Eisner MD, Thompson BT, Matthay MA, Ancukiewicz M, Bernard GR, Wheeler AP; NHLBI Acute Respiratory Distress Syndrome Clinical Trials Network.
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Fletcher Allen Health Care, University of Vermont, USA.
OBJECTIVES: To evaluate the association between interleukin-6, interleukin-8, and interleukin-10 and clinical outcomes including mortality in patients with acute lung injury and to determine whether lower tidal volume ventilation was associated with a decrease in plasma cytokines in patients with acute lung injury. DESIGN: Multiple-center, randomized trial. SETTING: Intensive care units in ten university centers. PATIENTS: The study included 861 patients enrolled in the National Heart, Lung and Blood Institute Acute Respiratory Distress Syndrome Clinical Network trial of lower tidal volumes compared with traditional tidal volumes for acute lung injury. INTERVENTIONS: Patients were randomized to a 6 mL/kg or a 12 mL/kg tidal volume strategy that has been previously described. MEASUREMENTS AND MAIN RESULTS: Baseline plasma levels of interleukin-6, interleukin-8, and interleukin-10 were each associated with an increased risk of death in both logistic regression analyses controlling for ventilator group (odds ratio 1.63 per log-10 increment, 95% confidence interval 1.33-1.98; odds ratio 2.33 per log-10 increment, 95% confidence interval 1.79-3.03; odds ratio 2.02 per log-10 increment, 95% confidence interval 1.47-2.76, respectively) and multivariate analyses controlling for ventilation strategy, Acute Physiology and Chronic Health Evaluation III score, Pao2/Fio2 ratio, creatinine, platelet count, and vasopressor use (odds ratio 1.63 per log-10 increment, 95% confidence interval 0.93-1.49; odds ratio 1.73 per log-10 increment, 95% confidence interval 1.29-2.34; odds ratio 1.23 per log-10 increment, 95% confidence interval 0.86-1.76, respectively). Interleukin-6 and interleukin-8 levels were also associated with a significant decrease in ventilator free and organ failure free days. Patients with sepsis had the highest cytokine levels and the greatest risk of death per cytokine elevation. By day 3, the 6 mL/kg strategy was associated with a greater decrease in interleukin-6 and interleukin-8 levels. There was a 26% reduction in interleukin-6 (95% confidence interval, 12-37%) and a 12% reduction in interleukin-8 (95% confidence interval, 1-23%) in the 6 mL/kg group compared with the 12 mL/kg group. CONCLUSIONS: In patients with acute lung injury, plasma interleukin-6 and interleukin-8 levels are associated with morbidity and mortality. The severity of inflammation varies with clinical risk factor, suggesting that clinical risk factor should be considered when both developing and testing therapeutic interventions. Low tidal volume ventilation is associated with a more rapid attenuation of the inflammatory response.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 15644641 [PubMed - indexed for MEDLINE]
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Bioterrorism: Preparing for the impossible or the improbable.
Karwa M, Currie B, Kvetan V.
Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA. mkarva@montefiore.org
OBJECTIVE: To review the current literature surrounding the history of bioterrorism, the relative risk of a bioterrorist attack, methods of surveillance for biological agents, identification and management of various biological agent casualties, as well as the role of the intensivist in managing a bioterrorist attack. METHODS: Internet and Medline search (from 1966 to 2004) for articles relating to bioterrorism, biological agents, biological warfare, hospital preparedness, disaster management, and intensive care. CONCLUSIONS: There are few instances of a successful large-scale biological weapons attack in history. Weaponization of biological agents for aerosol dispersal is difficult and has often proved to be the rate-limiting step for a successful attack. Although a successful biological attack is currently unlikely, it is still feasible. More importantly, the threat of one is likely to cause much panic in the public, while a successful attack would overburden the current healthcare infrastructure. Intensivists will need to have specific knowledge of identifying and managing casualties from various biological agents. In addition, they will need to play an integral part in the preparedness of their institutions and communities for managing a bioterrorist event.
Publication Types:
- Historical Article
- Review
- Review, Tutorial
PMID: 15640684 [PubMed - indexed for MEDLINE]
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Critical care requirements after mass toxic agent release.
Baker DJ.
Department of Anaesthesia and Critical Care, Hopital Necker-Enfants Malades, Paris, France.
There is an increasing risk of mass exposure of civil populations after release of toxic agents. These include military chemical warfare agents or industrial compounds, some of which have been used as a chemical. The traditional military divisions among chemical agents, toxins, and biologic agents may be viewed as a continuous spectrum of hazards. Each of these has four specific qualities (toxicity, latency, persistency, and transmissibility), which determine management of casualties and the toxic release. Toxic hazards may be released accidentally or deliberately, producing potentially large numbers of casualties. Previous incidents have shown that many of these require extended hospital care. This article reviews aspects of the nature of the toxic agents, the pathophysiology they produce, and therapeutic measures. The central and peripheral nervous systems and the respiratory systems are particularly vulnerable and may lead to fatal results unless early action is taken. Specific antidotes and life support care is required at all levels of prehospital and hospital management. Critical care management is required for severe cases, and this must combine continuing antidote, ventilatory and supportive therapy.
Publication Types:
PMID: 15640682 [PubMed - indexed for MEDLINE]
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Conventional terrorism and critical care.
Singer P, Cohen JD, Stein M.
Departments of General Intensive Care, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.
Incidents of conventional weapons terror are increasingly part of the reality of the modern world, and in Israel, 19,948 incidents have been reported from September 2000 to December 2003. Most victims are injured in explosions resulting from suicide bombings. Exposure to the blast (primary mechanism of injury) may produce unique injuries affecting gas-containing organs, including perforation of the eardrums (most common injury); pulmonary blast injury, characterized by alveolar capillary disruption and bronchopleural fistulas; and bowel perforation, which is uncommon and may be delayed from 1 to 14 days after the injury. However, most injuries are the result of penetrating trauma (secondary mechanism) resulting from bomb fragments and nails, bolts, and steel pellets embedded in the bomb striking the victim, and blunt trauma (tertiary mechanism) sustained when the victim is propelled against an object by the blast wind. The severity of the injuries is increased when the blast occurs in a confined space. Victims of terror-inflicted injuries have a high Injury Severity Score (30% >16), a high requirement for intensive care unit admission (22.8% in Israel), and have a more prolonged hospital course and higher mortality than victims of any other form of trauma.
Publication Types:
PMID: 15640681 [PubMed - indexed for MEDLINE]
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Severe acute respiratory syndrome and critical care medicine: the Toronto experience.
Booth CM, Stewart TE.
Interdepartmental Division of Critical Care Medicine and the Department of Medicine, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Canada.
BACKGROUND: The 2003 global outbreak of severe acute respiratory syndrome (SARS) provided numerous challenges to the delivery of critical care. The Toronto critical care community has learned important lessons from SARS, which will help in preparation for future disease outbreaks. OBJECTIVES: The objectives of this study were to review the epidemiology and clinical characteristics of the Toronto SARS outbreak, the challenges SARS provided to the delivery of critical care, and how we would like to be better organized for a similar challenge in the future. FINDINGS: SARS manifests clinically as atypical pneumonia and ranges in severity from minor nonspecific symptoms to adult respiratory distress syndrome (ARDS). Approximately 20% of patients with SARS will become critically ill and require admission to the intensive care unit. ARDS develops in the majority of these patients. Mortality from ARDS in SARS is high, and outcome is associated with the presence of comorbid disease and the severity of illness at presentation. The influx of critically ill patients and the transmission of SARS to front line workers created a tremendous strain on Toronto's healthcare system. From a critical care perspective, the most important limitation in the response to SARS was the absence of a coordinated leadership and communication infrastructure. Other challenges encountered during SARS include the following: closure of intensive care unit beds and loss of staff through quarantine and illness, implementing novel infection control protocols, educating staff, conducting research to learn about SARS, system planning, and maintaining staff morale during this very difficult period. CONCLUSIONS: Communication and leadership strategies were key components in the critical care response to SARS. Ideally, centers should have systems in place to allow for the rapid expansion and modification of critical care services in the event of a disease outbreak. Other critical care communities should consider their crisis response strategies in advance of similar events.
PMID: 15640680 [PubMed - indexed for MEDLINE]
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The experience at St. Vincent's Hospital, Manhattan, on September 11, 2001: preparedness, response, and lessons learned.
Kirschenbaum L, Keene A, O'Neill P, Westfal R, Astiz ME.
St. Vincent's Hospital, New York, NY, USA.
St. Vincent's Hospital in New York City was the primary recipient of patients after the 1993 bombing of the World Trade Center. This experience prompted the drafting of a formal disaster plan, which was implemented during the terrorist attack on the World Trade Center on September 11, 2001. Here, we outline the Emergency Management External Disaster Plan of St. Vincent's Hospital and discuss the time course of presentation and medical characteristics of the critically injured patients on that day. We describe how the critical care service adapted to the specific challenges presented and the lessons that we learned. We hope to provide other critical care systems with a framework for response to such large-scale disasters.
PMID: 15640679 [PubMed - indexed for MEDLINE]
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The Pentagon and 9/11.
Wang D, Sava J, Sample G, Jordan M.
Department of Surgery, Uniformed Services University of the Health Sciences, Washington, DC, USA.
OBJECTIVE: The objective of this study was to review and discuss the medical response to the Pentagon attack on September 11, 2001. DESIGN: The authors conducted a retrospective review of hospital records and emergency agency report. SETTING: This study was conducted at an adult tertiary hospital with regional burn and trauma centers. INTERVENTIONS: Observational. RESULTS: One hundred eighty-nine persons lost their lives. Area health facilities received 106 patients; 49 were admitted for treatments and 57 were treated and released. Nine patients were admitted to the burn center. The average total body burn surface was 34%. The average age was 45 yrs. A total of 108 operations were performed. The average burn critical care and hospital length of stays were 31 and 61.7 days, respectively. One patient died of an inhalation injury on day 7. CONCLUSIONS: The Pentagon attack produced few severely injured patients. The regional hospitals were back to normal function the day after. The severely burned patients increased the workload of the burn service but did not affect admissions of subsequent non-Pentagon patients after the second day. In case of a much larger number of critically injured patients, regional to national cooperation and transfer of patients should be considered.
PMID: 15640678 [PubMed - indexed for MEDLINE]
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The provision of sophisticated critical care beyond the hospital: lessons from physiology and military experiences that apply to civil disaster medical response.
Grissom TE, Farmer JC.
Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD, USA.
OBJECTIVE: The provision of sophisticated medical care in an austere environment is challenging. During and after a mass casualty event, it is likely that critical care services will be needed beyond an intensive care unit (ICU) setting. The objective of this article is to explore existing ICU care systems such as military aeromedical transport that may be applicable to disaster medicine and to providing critical care outside of an ICU setting. RESULTS: The U.S. Air Force Critical Care Aeromedical Transport (CCAT) Teams were developed in 1994 in response to an unmet military need for long-range air transport of critically ill and injured patients. This system has transported several thousand ICU patients and is an applicable model for the future development of extrahospital critical care capabilities needed during a disaster. We also discuss civilian aeromedical critical care systems, the types of medical devices used, and their applicability to disaster medical response. CONCLUSION: The U.S. Air Force CCAT Team program, as well as many civilian critical care air ambulance services, provides a workable starting point for the development of disaster medical critical care response capabilities for disaster medical systems.
PMID: 15640673 [PubMed - indexed for MEDLINE]
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Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings.
Gutierrez de Ceballos JP, Turegano Fuentes F, Perez Diaz D, Sanz Sanchez M, Martin Llorente C, Guerrero Sanz JE.
Intensive Care Service, Gregorio Maranon University General Hospital, Madrid, Spain.
BACKGROUND: At 07:39 am on March 11th, 2004, ten terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing instantly 177 people and injuring >2,000. There were 14 subsequent in-hospital deaths, bringing the definite death toll to 191 victims. This article describes the organization of the clinical management and patterns of injuries in casualties who were taken to the closest hospital, with emphasis on the critical patient population. RESULTS: There were 312 patients taken to that center, and 91 were hospitalized, 89 of them (28.5%) for >24 hrs. Sixty-two patients only had superficial bruises or emotional shock, but the remaining 250 patients had more severe lesions. The data on 243 of the latter form the basis of this report. Tympanic perforation occurred in 41% of 243 victims with moderate-to-severe trauma, chest injuries in 40%, shrapnel wounds in 36%, fractures in 18%, first- or second-degree burns in 18%, eye lesions in 18%, head trauma in 12%, and abdominal injuries in 5%. Between 8:00 am and 5:00 pm, 34 surgical interventions were performed on 32 victims. Twenty-nine casualties (12% of the total or 32.5% of those hospitalized) were deemed in critical condition, and two of them died within minutes of arrival. The other 27 survived to be admitted to intensive care units, and three of them died, bringing the critical mortality rate to 17.2% (5/29). The mean Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores of critical patients were 34 and 23, respectively. Among these critical patients, soft-tissue and musculoskeletal injuries predominated in 85% of cases, ear blast injury was identified in 67%, and blast lung injury was present in 63% (17 cases). Fifty-two percent suffered head trauma. CONCLUSIONS: There was probably an overtriage to the closest hospital, and the time of the blasts proved crucial for the adequacy of the medical and surgical response. The number of blast lung injuries seen is probably the largest reported by a single institution, and the critical mortality rate was reasonably low.
PMID: 15640672 [PubMed - indexed for MEDLINE]
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