Showing papers by "Detroit Receiving Hospital published in 1994"
TL;DR: The RVEDVI more accurately predicted preload recruitable increases in CI than did the PAWP, and correlated better with cardiac index than with PAWP or CVP.
Abstract: Objective: To evaluate the relative accuracy of right ventricular end-diastolic volume index (RVEDVI) and pulmonary artery wedge pressure (PAWP) for determining cardiac preload. Methods: A modified pulmonary artery catheter was used to determine RVEDVI, PAWP, and CI 238 times in 32 trauma patients. Results: The initial mean values included cardiac index (CI)=3.4±1.3 L/min/m 2 , PAWP=14.8±6.6 mm Hg, and RVEDVI=99±40 mL/m 2 . Cardiac index correlated better with RVEDVI (r=0.6440; p<0.001) than with PAWP (r=0.1068) or CVP (r=0.1604). In 84 studies in 19 patients, the PAWP was high (19+mm Hg) in spite of an RVEDVI that was low (<90 mL/mS in 22 (26%) or mid-range (90-140 mL/mS in 49 (58%) of these
126 citations
TL;DR: Overall, levofloxacin demonstrated potent bactericidal activity against S. aureus, without the emergence of resistance in an in vitro infection model, and ciprofloxacins alone and in combination with rifampin prevented the emerged of resistance.
Abstract: The pharmacodynamic properties of levofloxacin (an optically active isomer of ofloxacin), ofloxacin, and ciprofloxacin, alone and in combination with rifampin, were evaluated over 24 to 48 h against clinical isolates of methicillin-susceptible and -resistant Staphylococcus aureus (MSSA 1199 and MRSA 494, respectively) in an in vitro infection model. The incidence of the emergence of resistance among the test strains was also determined. The fluoroquinolones were administered to simulate dosage regimens of 200 mg, 400 mg given intravenously (i.v.) every 12 h (q12h), and 400 and 800 mg given i.v. q24h. Rifampin was dosed at 600 mg i.v. q24h. Although the MICs and MBCs of the quinolones were similar (< or = 0.49 microgram/ml), levofloxacin was the most potent agent in time-kill studies on the basis of the time required to achieve a 99.9% reduction in the number of log10 CFU per milliliter (e.g., with the regimen of levofloxacin [400 mg q24h, 6.5 h] versus ofloxacin [12.5 h], P < 0.024, and levofloxacin versus ciprofloxacin [6.5 versus 9.0 h], P < 0.0017) against MSSA 1199. The killing activity of levofloxacin was similar to that of ofloxacin against MRSA 494 (time to achieve a 99.9% reduction in the number of log10 CFU per milliliter, 11.1 versus 13.8 h, respectively). Levofloxacin and ofloxacin dosed once daily demonstrated greater bactericidal activity than when they were dosed twice daily against MSSA 1199. Resistance to levofloxacin or ofloxacin was not observed with any dosage regimen. Furthermore, resistance to ofloxacin was not detected when the half-life was reduced from 6 to 3 h. Regrowth and stable resistance (65-fold increase in the MIC for MSSA 1199; 16-fold increase in the MIC for MRSA 494) were noted within 24 h of exposure to ciprofloxacin at 200 mg q12h. Combination therapy with rifampin prevented the emergence of resistance to ciprofloxacin. Neither DNA gyrase alteration nor an energy-dependent efflux process mediated by the norA gene appeared to be responsible for the resistance observed. Our data suggest that with levofloxacin there is a more rapid onset of bactericidal activity than with ofloxacin or ciprofloxacin against MSSA 1199 and that the activity of levofloxacin is similar to that of ofloxacin but better than that of ciprofloxacin against MRSA 494. Resistance was noted only after exposure to the low dose of ciprofloxacin. Resistance to ofloxacin did not develop even when the pharmacokinetics of the drug were set to equal those of ciprofloxacin, suggesting that ofloxacin differs from ciprofloxacin irrespective of time of exposure. The resistance to ciprofloxacin that developed in our vitro model may be mediated by the cfx-ofx locus, which has been shown to be associated with low-level fluoroquinolone resistance. Overall, levofloxacin demonstrated potent bactericidal activity against S. aureus, without the emergence of resistance in our infection model. Quinolones dosed once daily were more effective than equivalent dosages administered twice daily. The addition of rifampin was not synergistic but prevented the emergence of ciprofloxacin resistance.
72 citations
TL;DR: Although no uniformly effective treatment regimen exists, orthostatic hypotension can often be adequately managed with a combination of nondrug and drug therapies.
Abstract: The pathogenesis, clinical manifestations, and management of orthostatic hypotension (OH) are reviewed. OH is a decline in blood pressure that occurs when one moves from a lying to a standing position that results in symptoms of cerebral hypoperfusion, most commonly lightheadedness and syncope. The disorder may result from primary autonomic disorders, such as Shy-Drager syndrome; reversible nonautonomic causes, such as reduced blood volume; underlying diseases, such as diabetes mellitus; and drugs. Elderly people are predisposed to OH. The diagnosis of OH is based on the documentation of postural hypotension accompanied by symptoms of cerebral ischemia. The goal of therapy is to relieve symptoms. Nonpharmacologic approaches are preferred and include increasing sodium intake, avoiding rapid postural changes, and wearing elastic garments. OH is difficult to treat pharmacologically because of varying responses and adverse effects. The drug of choice for all types of OH is fludrocortisone acetate, although caution must be used in patients with congestive heart failure. Prostaglandin synthetase inhibitors can also be used for all types of OH but have had more limited success. Sympathomimetics with or without monoamine oxidase inhibitors, beta-adrenergic antagonists, and ergot alkaloids should be administered only to patients with certain types of OH, and patients must be monitored closely. Clonidine, midodrine, yohimbine, octreotide, dopamine antagonists, desmopressin, and epoetin alfa have not been well studied and should be limited to patients with severe, refractory disease. Although no uniformly effective treatment regimen exists, OH can often be adequately managed with a combination of nondrug and drug therapies.
60 citations
TL;DR: Visceral packing of posttraumatic abdominal wounds circumvents expected complications of intraperitoneal hypertension and enhances the chance for survival and its ease and low morbidity also lends itself to a wide variety of other uses.
Abstract: Since 1986, we have cared for 17 patients whose abdomen could not be closed because of bowel edema and loss of abdominal wall compliance. These patients were managed by a technique of visceral packing with the intestines kept in place by a combination of rayon cloth, gauze packs, and retention sutur
59 citations
46 citations
TL;DR: To determine the frequency and severity of ethanol-induced lactic acidosis, patients who presented to an emergency department with a clinical diagnosis of acute ethanol intoxication and a serum ethanol concentration of at least 100 mg/dL were studied.
Abstract: Ethanol intoxication has been widely reported as a cause of lactic acidosis. To determine the frequency and severity of ethanol-induced lactic acidosis, patients who presented to an emergency department with a clinical diagnosis of acute ethanol intoxication and a serum ethanol concentration of at least 100 mg/dL were studied. Arterial blood was sampled for lactate and blood gas determinations. A total of 60 patients (mean age, 41 years) were studied. Twenty-two patients sustained minor trauma. Ethanol concentrations ranged from 100 to 667 mg/dL (mean, 287 mg/dL). Lactate concentrations were abnormal (> 2.4 mmol/L) in seven patients (11.7%). In all cases, blood lactate was less than 5 mmol/L. Of the patients with elevated lactate, other potential causes for lactic acidosis, including hypoxia, seizures, and hypoperfusion, were also present. Only one case with elevated blood lactate concentration had associated acidemia. Significant elevations of blood lactate are uncommon in acute ethanol intoxication. In patients with ethanol intoxication who are found to have lactic acidosis, other etiologies for the elevated lactate level should be considered.
39 citations
TL;DR: The high concentration (200 mmol/L) and rate of delivery (20 mmol/hr) of the potassium chloride infusions were well tolerated, decreased the frequency of ventricular arrhythmias, and did not cause transient hyperkalemia.
Abstract: Although concentrated infusions of potassium chloride commonly are used to treat hypokalemia in intensive care unit patients, few studies have examined their effects on plasma potassium levels. Forty patients with hypokalemia were given infusions of 20 mmol of potassium chloride in 100 mL of normal saline over 1 hour; 26 patients received the infusions through the central vein and 14 patients through the peripheral vein. Plasma potassium ([K]p) was measured at 15-minute intervals during and after the infusion in 31 patients. delta K was defined as the difference between each potassium determination and baseline plasma potassium concentration. Continuous electrocardiographic recording was carried out during the infusion and during the 1-hour period immediately preceding the infusion. Mean baseline [K]p was 2.9 mmol/L and all subsequent plasma concentrations significantly increased from baseline. Mean peak [K]p was 3.5 mmol/L, [K]p (1 hour postinfusion) was 3.2 mmol/L, and mean postinfusion delta K was 0.48 mmol/L (range -0.1-1.7 mmol/L). Arrhythmias, changes in cardiac conduction intervals, and other complications did not occur. The frequency of premature ventricular beats decreased significantly during the infusion compared with that of the control period. The high concentration (200 mmol/L) and rate of delivery (20 mmol/hr) of the potassium chloride infusions were well tolerated, decreased the frequency of ventricular arrhythmias, and did not cause transient hyperkalemia.
34 citations
TL;DR: A patient inadvertently received an overdose of etidronate by the intravenous route and subsequently developed acute renal failure as evidenced by a rapid and sustained rise in serum creatinine, strongly suggestive of etdronate-induced nephrotoxicity.
Abstract: Etidronate-induced toxicity has not been well documented in humans. This is a detailed account of a case of acute renal failure believed to be due to etidronate. The patient inadvertently received an overdose of etidronate by the intravenous route and subsequently developed acute renal failure as evidenced by a rapid and sustained rise in serum creatinine. The temporal relationship was strongly suggestive of etidronate-induced nephrotoxicity. Other possible causes, such as postrenal obstruction, acute tubular necrosis due to hypotension or sepsis, and other nephrotoxic drugs were excluded through diagnostic and laboratory tests.
27 citations
TL;DR: The patient was admitted to the high-risk obstetrics ward in her 37th week of pregnancy and a cesarean section was planned at 37 weeks gestation to prevent disruption of the mass or mechanical obstruction of the airway during a routine vaginal delivery.
26 citations
TL;DR: The differences in patient care requirements and hospital outcomes in patients with a do-not-resuscitate status are examined to determine the most appropriate care setting, eg, intensive vs nonintensive care.
Abstract: Background The intensity and nature of a patient therapeutic plan should depend upon the specific therapeutic goals. When the therapeutic plan includes a do-not-resuscitate order, the intensity of the plan may be high or low. Objective To examine the differences in patient care requirements and hospital outcomes in patients with a do-not-resuscitate status to determine the most appropriate care setting, eg, intensive vs nonintensive care. Method Data from a prospective sample of 100 patients were analyzed. Patients were grouped according to the intensity of the therapeutic plan: (1) all-but-CPR: all support except cardiopulmonary resuscitation, (2) conservative-care: medical management without the addition of life-sustaining measures, (3) comfort-only, and (4) withdrawal of life-sustaining therapy. Results Patient mortality was high for all groups except the conservative-care group. Patient care requirements remained high in the all-but-CPR group, necessitating continued intensive care. Patient care requirements decreased significantly in the comfort-only and withdrawal groups, illustrating the ability to manage these patients in a nonintensive care setting.
15 citations
TL;DR: To obtain the best results in patients with pre-existing cardiac disease, one must have a high suspicion of its presence and aggressively treat the patient to prevent hypotension and hypoxemia.
TL;DR: The effects of pooled human serum (PHS) on the killing activity of vancomycin and teicoplanin against two isolates of Staphylococcus aureus from patients treated for endocarditis are investigated.
Abstract: Study Objective. To investigate the effects of pooled human serum (PHS) on the killing activity of vancomycin and teicoplanin against two isolates of Staphylococcus aureus from patients treated for endocarditis.
Design. An in vitro assessment of antibiotic susceptibility and killing rates.
Setting. An urban university teaching hospital.
Patients. Pooled human serum from patients treated for endocarditis.
Interventions. Two clinical isolates of Staphylococcus aureus were obtained from patients treated for endocarditis. Media consisted of cation-supplemented Mueller-Hinton broth alone and in 1:1 dilutions with PHS, 2-hour heat-inactivated PHS (HI-PHS), ultrafiltrate (UF), and 2-hour heat-inactivated ultrafiltrate (HI-UF). Heat inactivation of PHS and UF was accomplished by treatment at 56°C for 2 hours.
Measurements and Main Results. Killing curves with vancomycin and teicoplanin were performed using drug concentrations of 45 μg/ml and a starting inoculum of ∼1 × 106 colony-forming units (cfu)/ml. Bactericidal rates (-log cfu/ml/hr) were calculated from the slope of the killing curves over 0–12 hours (mean 3–8 replicates).
Conclusions. The killing activity of vancomycin in PHS and HI-PHS against both isolates was significantly greater than all other media tested (p<0.0001). Ultrafiltrate tended to reverse this enhancement effect. Addition of PHS or UF did not enhance teicoplanin's killing activity against either isolate. Further investigations in our laboratory will determine if the factor is antibiotic class or organism specific.
TL;DR: A quick and simple method for fixing and applying pressure over skin graft with foam dressing and staples is described.
Abstract: Pressure applied over a skin graft prevents formation of hematoma and shearing of the graft. Most of the methods used to obtain adequate pressure are often cumbersome to apply and time-consuming. This report describes a quick and simple method for fixing and applying pressure over skin graft with foam dressing and staples.
TL;DR: In this patient, DIAN possibly was related to cefuroxime, but the patient did not experience associated allergic symptoms, and the diagnosis was supported by the temporal course of renal deterioration during exposure to cesarean section and improvement on its discontinuation; the pattern repeated with rechallenge.
Abstract: Although drug-induced allergic nephritis (DIAN) is one of the most common problems seen by nephrologists, its true frequency is probably underestimated. Diagnosis is often difficult and is typically only made in patients without another explanation for deteriorating renal function, and is often based solely on improvement after drug withdrawal. The diagnosis may be made more difficult due to lack of typical allergic symptoms, presence of other drugs, or confounding factors and equivocal noninvasive laboratory studies. The gold standard for diagnosis is renal biopsy, but it is only rarely performed during the acute phase of the reaction and is not without risk. It is important to keep a high index of suspicion with regard to DIAN since it is usually rapidly reversible. Failure to recognize it and discontinue the offending agents may result in unnecessary morbidity and occasionally, irreversible renal failure. In our patient, DIAN possibly was related to cefuroxime, but the patient did not experience associated allergic symptoms. The diagnosis was supported by the temporal course of renal deterioration during exposure to cefuroxime and improvement on its discontinuation; the pattern repeated with rechallenge. This is the first reported case of suspected DIAN due to cefuroxime.
TL;DR: In this article, a telephone survey of the infection control practices in this setting of the 100 busiest EDs in the United States (US) was performed, where the authors asked about general policy, barrier protection measures, sharps management, and educational programs directed to health care workers involved in critically injured patients.
Abstract: Prevention of transmission of bloodborne pathogens to health care workers (HCWs) involved in resuscitation of critically injured patients presents special challenges. As a step toward creation of a standard, a telephone survey of the infection control practices in this setting of the 100 busiest EDs in the United States (US) was performed. Departmental staff who were knowledgeable about ED infection prevention protocols were questioned about general policy, barrier protection measures, sharps management, and educational programs directed to HCWs. Surveys were completed for 82 EDs. Of these, 56 (68%) either function as primary trauma care facilities for the local community, or are designated level 1 trauma centers by the American College of Surgeons. Specific infection control protocols for trauma resuscitation had been printed and posted by 18 EDs (22%), with the remaining 64 (78%) using the same universal precautions for care of the severely injured as for other patients. A specific policy relating to invasive procedures had been promulgated by 66 EDs (80%). Barrier protection was used by protocol or by custom for care of all critically injured patients by 43 EDs (52%). Impermeable gowns with sleeves were available in 63 EDs (77%). Eye or face protection included face shields by 74 EDs (90%), face masks by 76 EDs (93%), and goggles by 72 EDs (88%). Only 59 EDs (72%) reported that sharp containers were always within arm's reach of HCWs with material to discard. Specially adapted equipment included self-sheathing intravenous catheters (21, 26%) and needle/syringe combinations (16, 20%). Considerable variation exists in infection control practices in busy US EDs during resuscitation of critically injured patients.(ABSTRACT TRUNCATED AT 250 WORDS)
TL;DR: Patients with PAD tend to be much older physiologically than patients of the same chronologic age who do not have vascular disease, and such patients require careful intensive care unit monitoring for at least 2 to 3 days.
TL;DR: It is indicated that cilazapril, alone or with adjunctive hydrochlorothiazide, is effective and well tolerated as treatment for mild to moderate hypertension.
Abstract: Objective: Cilazapril, a long-acting angiotensin converting enzyme (ACE) inhibitor, was evaluated against captopril for safety and efficacy in the treatment of mild to moderate essential hypertension.Methods: One hundred thirty-two patients were randomly assigned to receive cilazapril, 2.5 mg once daily; 62 patients were randomly assigned to receive captopril, 25 mg twice daily. If necessary, dosage was increased to 5.0 mg cilazapril, once daily or 50 mg captopril, twice daily. Adjunctive hydrochlorothiazide (12.5 mg once daily) was later added to this higher dosage, if required.Results: After eight weeks of monotherapy, sitting diastolic blood pressure (SDBP) had decreased 7.5 mm Hg from baseline for cilazapril-treated patients, versus 5.6 mm Hg for captopril-treated patients. These decreases were 7.6 mm Hg and 6.8 mm Hg for cilazapril and captopril, respectively, at Week 12. At Week 8, 36.5% of patients receiving cilazapril had achieved a SDBP of 90 mm Hg or less, versus 26.0% of captopril-treated patie...
TL;DR: Education and training in radiology appropriate to the responsibilities expected of the on-call emergency radiology resident are required to assure optimum patient care.
Abstract: This article summarizes the training and teaching of radiology residents before they attempt unsupervised emergency call, as reported in the radiologic literature. It is hoped that this report will prompt a serious evaluation of the responsibilities of radiology residents assigned to the emergency center and a reconsideration of the radiologic training and experience provided to radiology residents before they are required to assume these responsibilities. Clearly, education and training in radiology appropriate to the responsibilities expected of the on-call emergency radiology resident are required to assure optimum patient care.
TL;DR: A rare case is described in which a single non-fragmenting gunshot was responsible for penetrating wounds to the abdomen, chest and face.
Abstract: A rare case is described in which a single non-fragmenting gunshot was responsible for penetrating wounds to the abdomen, chest and face.