Showing papers in "Critical Care Medicine in 1973"
TL;DR: The addition of PEEP to IPPV during therapy for acute respiratory failure does not in-crease the incidence of pulmonary barotrauma, and the presence of pneumonitis and pulmonary edema in the majority of patients is revealed.
Abstract: In the treatment of acute respiratory failure, pulmonary barotrauma (subcutaneous emphysema, pneumothorax, and pneumomediastinum) developed in ten patients (10%) receiving IPPV without PEEP and in seven patients (11%) receiving IPPV with PEEP. Pre-existing chronic obstructive pulmonary disease seemed to predispose to the development of pulmonary barotrauma. Necropsy findings revealed the presence of pneumonitis and pulmonary edema in the majority of patients, in addition to pulmonary emphysema in some. Available information fails to demonstrate a correlation between the incidence of pulmonary barotrauma and the magnitude of air-way pressure required for adequate mechanical ventilation. The addition of PEEP to IPPV during therapy for acute respiratory failure does not in-crease the incidence of pulmonary barotrauma.
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TL;DR: Data from critical care units of six community hospitals could serve as a measure of the severity of illness at the time of admission and provide a quantitative guide for objective comparison of the effectiveness with which critical care services are delivered in acute care units.
Abstract: A total of 410 critically ill patients in critical care units of six community hospitals were surveyed for a period of 31 days. A prognostic index of survival was derived by discriminant function analysis utilizing measurement of blood lactate, blood pressure, heart rate, arrhythmias, spontaneous respiration, urine volume, body temperature, age, and a five-point rating of clinical condition by the nursing staff. The case fatality rate in patients in whom blood lactate exceeded 2.7 mM was 50% fatality rate was 5% when lactate was less than 2.7 mM. The best prediction of survival was obtained by combining the plasma lactate and the five-point rating of the patient's condition. These data therefore could serve as a measure of the severity of illness at the time of admission and provide a quantitative guide for objective comparison of the effectiveness with which critical care services are delivered in acute care units. They can also provide an objective basis for priority assignment to cardiac care, intensive care, and other specialized units of the hospital
139 citations
TL;DR: Furosemide, 0.5 to 1.0 mg per kilogram intravenously, was given to 20 patients with left ventricular failure after acute myocardial infarction as mentioned in this paper.
Abstract: Furosemide, 0.5 to 1.0 mg per kilogram intravenously, was given to 20 patients with left ventricular failure after acute myocardial infarction. Within five to 15 minutes, average left ventricular filling pressure fell from 20.4 to 14.8 mm Hg, accompanied by a 52 per cent increase in mean calf venous capacitance. During the same period there was no physiologically important change in either urine output or heart rate, blood pressure and cardiac output. Peak increase in urine flow (from mean of 0.82 to 4.0 ml per minute) occurred at 30 minutes, and peak natriuretic effect at 60 minutes. Thus, the action of furosemide in the treatment of pulmonary congestion is immediate and is not related to its diuretic properties. Rather, the prompt fall in left ventricular filling pressure probably is primarily vascular in origin, since marked changes in venous capacitance accompany this phenomenon, which is only later supplemented by the increase in urine output and electrolyte excretion. (N Engl J Med 288:1087...
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TL;DR: Monitoring during discontinuance of mechanical ventilation revealed that some post-cardiomy patients who were ready for weaning responded with a sudden unexpected reduction in cardiac output, associated with reduced oxygen availability and consumption as well as increased pulmonary vascular resistance.
Abstract: Homodynamic monitoring during discontinuance of mechanical ventilation revealed that some post-cardiomy patients who were ready for weaning, by the usual criteria, responded with a sudden unexpected reduction in cardiac output. This paradoxical decrease in cardiac output was not correlated with a decreased arterial oxygen tension or other blood gas changes, but was associated with reduced oxygen availability and consumption as well as increased pulmonary vascular resistance. Subsequent weaning attempts were successful in 16 of these 18 patients and repeated cardiac output determinations in a few showed “recovery” of the heart with in-creased cardiac output upon discontinuance of the ventilator.
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TL;DR: In this paper, the authors defined three types of consumptive processes involving the hemostatic apparatus: combined platelet and fibrinogen consumption, which represents an exaggeration of the physiologic response, and selective platelet destruction, which reflects platelet thrombus formation on abnormal surfaces in the arterial system.
Abstract: Survival and turnover measurements of platelets and fibrinogen in 35 normal subjects and 104 selected patients defined three types of consumptive processes involving the hemostatic apparatus. The first, characterized by combined platelet and fibrinogen consumption, represents an exaggeration of the physiologic hemostatic response. It occurs in patients with venous thrombosis, tissue trauma, widespread cancer, obstetric complications, and bacteremia. The result of activation of the coagulation system, this process can be modified by heparin. The second, characterized by selective platelet destruction, appears to reflect platelet thrombus formation on abnormal surfaces in the arterial system, including prosthetic devices and arterial thrombosis, thrombotic thrombocytopenic purpura, hemolytic-uremic syndrome, and vasculitis syndromes. This process is reversed by certain inhibitors of platelet function or adrenocortical steroid suppression of vascular inflammation. The third involves selective destru...
TL;DR: In this article, a total of 32,877 patients had general anesthesia at the Mayo Clinic; 422 had previous myocardial infarction, of these 6.6% experienced another one during the first postoperative week.
Abstract: During 1967 and 1968, a total of 32,877 patients had general anesthesia at the Mayo Clinic; 422 had previous myocardial infarction. Of these 6.6% experienced another infarction during the first postoperative week. There was no relationship between incidence of postoperative reinfarction and type or duration of anesthesia. However, operations on the thorax and upper abdomen were followed by three times as many reinfarctions as operations at other sites. Patients who were operated on within three months of infarction had a 37% reinfarction rate. This rate decreased to 16% in patients at three to six months after infarction, and remained at 4% to 5% when infarction had occurred more than six months previously. A significantly higher number of myocardial infarctions occurred during the third postoperative day.
TL;DR: Serial plasma determinations of the isoenzymes of CPK by this method provides both a sensitive and specific indication of acute myocardial infarction.
Abstract: Serial plasma determinations of the isoenzymes of CPK were performed in all patients (376) admitted to a coronary care unit during a 12-month period with diagnosis of possible acute myocardial infarction. Results were compared with data from other enzyme studies and from the electrocardiogram. An attempt was made to determine the incidence of falsely positive CPK-MB (myocardial-specific form). "No acute infarction" was diagnosed in all patients in whom neither total CPK nor the isoenzymes of LDH indicated myocardial necrosis, and in whom there were no QRS changes on ECG. Incidence of falsely negative CPK isoenzyme data was also determined. All patients, in whom total CPK was transiently elevated, and LDH1 exceeded LDH2, and new QRS changes occurred, were termed "definite" acute infarction. CPK-MB form was present in all 55 of these (0% false negative). Therefore, determination of the isoenzymes of CPK by this method provides both a sensitive and specific indication of acute myocardial infarction.
TL;DR: This paper presents a clinical methodology for the analysis of oxyhemoglobin dissociation so that oxygen avail-ability can be mathematically modified by subtracting the calculated mixed venous content at a tension of 20 torr (consumable oxygen).
Abstract: Oxygen delivery to the tissues, studied as oxygen availability, does not take account of the changes in oxyhemoglobin dissociation. Oxygen at a tension of less than 20 torr is considered relatively unavailable. This paper presents a clinical methodology for the analysis of oxyhemoglobin dissociation so that oxygen avail-ability can be mathematically modified by subtracting the calculated mixed venous content at a tension of 20 torr (consumable oxygen). Similar modification of the arterial oxygen content and oxygen utilization coefficient give more realistic indices of oxygen delivery. Examples are given to show how the use of these indices give a better understanding and quantification of the effects of changes in oxyhemoglobin dissociation characteristics on oxygen transport. The conventional estimations of oxygen avail-ability, arterial oxygen content and utilization coefficient do not change with shifts of the dissociation curve. A rightward shift of the curve gives a higher consumable oxygen, consumable arterial oxygen content, and a lower consumable oxygen coefficient, reflecting that more oxygen is available to the tissues before significant anaerobic metabolism is initiated.
TL;DR: A forceful blow to the precordium has been recommended as the first resuscitative measure following diagnosis of cardiac arrest because of sporadic reports that precordial thumping was followed by recovery of patients thought to have cardiac arrest.
Abstract: A forceful blow to the precordium has been recommended as the first resuscitative measure following diagnosis of cardiac arrest. This is the result of sporadic reports that precordial thumping was followed by recovery of patients thought to have cardiac arrest. In 1920, Schott first reported that a blow to the chest restored a palpable pulse in a patient with an Adams- Stokes attack (1). Since that time, supporting testimonials have failed to establish adequately the conditions existing at the time of treatment. Scherf and Bornemann in 1960 suggested that precordial thumping revived ventricular automatism during cardiac standstill (2). They demonstrated electrocardiographic tracings showing single and multiple ectopic depolarizations following blows to the precordium in 11 patients thought to have cardiac standstill. Three of the 11 patients were resuscitated. In one of the three survivors, circulatory arrest at the time of thumping was questionable.
TL;DR: In this paper, increased physical activity and intramuscular injections were considered as potential etiologic factors of abnormal creatine phosphokinase (CPK) levels in patients with chest pain, particularly when the electrocardiogram and other serum enzymes are not confirmatory.
Abstract: Although elevated serum creatine phosphokinase (CPK) activity is a sensitive indicator of myocardial necrosis, abnormal values may occur in a variety of extracardiac disorders. Fifty-two of 100 consecutive patients admitted to a short-term medical ward had elevated CPK activity; 26 of them had more than twice normal. Increased physical activity and intramuscular injections should be considered as potential etiologic factors of abnormal CPK levels in patients with chest pain, particularly when the electrocardiogram and other serum enzymes are not confirmatory. It is hazardous to diagnose myocardial necrosis on the basis of an isolated CPK elevation in the absence of other suggestive evidence. With the development of tissue-specific CPK isoenzymes, however, the clinical usefulness of this test may be enhanced.
TL;DR: It is concluded that this noninvasive, simple, and safe technic should prove to be a useful bedside method for routine clinical measurement of systemic vascular resistance.
Abstract: Measurement of systemic vascular resistance in man currently requires arterial and venous cannulation, so that cardiac output and mean arterial blood pressure may be simultaneously determined. This report describes a noninvasive technic for determining systemic vascular resistance (SVRn), utilizing an ultrasonic method for cardiac output measurement, and a combination of sphygmomanometry and external carotid pulse tracing analysis for determination of mean arterial blood pressure. SVRn was measured by this technic in 18 patients and compared with systemic vascular resistance determined by conventional methods at cardiac catheterization (SVRc). There was excellent correlation, with SVRc = 0.865 SVRn+216 and r = 0.85. The sensitivity of the method was verified in studies on 12 normal subjects in whom SVRn while supine (1235 ± 61 dyne-sec-cm–5, mean ± se) was less than SVRn while standing (1416 ± 81, P < 0.01) and greater than SVRn supine after amyl nitrite inhalation (652 ± 41,P < 0.0001). It is concluded t...
TL;DR: Three distinct patterns of responses to furosemide elucidation of some of the physiologic mechanisms which are illustrated in Figures 1 and 2 are elucidated.
Abstract: as well as in the evaluation of the recovery of renal Responses to Furosemide function. Further, the responses to furosemide and vasopressin administration used as an appmach to Three distinct patterns of responses to furosemide elucidation of some of the physiologic mechanisms which are illustrated in Figures and 2* The first p u p may be opemtive in the development of acute tubular sisted of the 15 patients who were studied prior to the
TL;DR: Lateral tracheal wall, intracuff, and airway pressures were measured in 50 endotracheal and tracheostomy tube cuffs using an acrylic mock trachea to increase safety of cuff systems.
TL;DR: Eleven patients with malignant or accelerated hypertension refractory to conventional drugs were treated with minoxidil as the primary antihypertensive agent, with reversal of myocardial ischemia and hypertrophy in some.
Abstract: Eleven patients with malignant or accelerated hypertension refractory to conventional drugs were treated with minoxidil as the primary antihypertensive agent. Seven had advanced renal disease and all were candidates, by conventional criteria for nephrectomy to control blood pressure. The blood pressure was reduced to or near normal levels in all patients, with remarkably few side effects and was well controlled in supine and standing positions. Initiation and maintenance of therapy with minoxidil required meticulous adjustment of diuretic agents to control fluid retention and of propranolol to control reflex cardiac stimulation. The cardiac status improved in all patients treated for more than two months, with reversal of myocardial ischemia and hypertrophy in some. Because of few drug-related symptoms patient acceptance was excellent. Seven patients remain on minoxidil therapy at present. The use of minoxidil in managing hypertensive patients should be carefully weighed against the more heroic a...
TL;DR: In this article, the clinical records of 47 patients with documented aspiration were reviewed and the overall mortality was 62%, if only one lobe was involved roentgenographically, mortality was 41%, if two or more lobes on one or both sides were involved, and mortality was in the range of 90%.
Abstract: The clinical records of 47 patients with documented aspiration were reviewed. The overall mortality was 62%. If only one lobe was involved roentgenographically, mortality was 41%. If two or more lobes on one or both sides were involved, mortality was in the range of 90%. Acutely ill, comatose patients with gastrointestinal or neurologic disease and an indwelling nasogastric tube were at particular risk. All hospital patients, however, appear to be vulnerable. Antibiotics, steroids, and ventilatory assistance were utilized in various combinations, but none seemed to effectively change the outcome following aspiration.
TL;DR: Use of this technique improved oxygenation and allowed the Fio2 to be reduced in the majority of these patients, and is attributed to a change in FRC toward the normal.
Abstract: Nine consecutive patients with flail chest injuries were treated with mechanical ventilation and positive end-expiratory pressure (PEEP). Twenty-eight studies were performed, beginning on the day of admission. Blood and gas samples were evaluated during ZEEP and again after 30 min of PEEP of 10 or 1
TL;DR: In this paper, hyperchloremic metabolic acidosis was observed in 11 infants receiving total parenteral nutrition containing mixtures of synthetic L-amino acids, which was not due to excessive gastrointestinal or renal losses of base as judged by the stool undetermined anion content and the urinary net acid excretion.
Abstract: Hyperchloremic metabolic acidosis was observed in 11 infants receiving total parenteral nutrition containing mixtures of synthetic L-amino acids. The observed acidosis was not due to excessive gastrointestinal or renal losses of base as judged by the stool undetermined anion content and the urinary net acid excretion, nor was it due to infusion of preformed hydrogen ion as judged by the titratable acidity of the synthetic amino acid mixtures. Instead, the synthetic amino acid mixtures contain an excess of cationic amino acids in relation to anionic amino acids or other organic anions. Metabolism of these cationic amino acids results in a net excess of hydrogen ion, explaining the observed acidosis.