Showing papers in "Critical Care Medicine in 1974"
TL;DR: If other intensivists incorporate this system into their experience, meaningful comparisons between intensive care units can occur and the cost of intensive care relative to the extent of care offered can occur.
Abstract: A Therapeutic Intervention Scoring System (TISS) is presented to allow quantitative comparison of patient care and research experiences of different intensive care units. 57 items of therapeutic intervention are scored on a one to four basis according to intensity of involvement. The points acquired per patient per 24 hours are summated by an experienced observer. TISS has been used to: 1) determine appropriate utilization of intensive care facilities at the Massachusetts General Hospital; 2) provide information on nurse staffing ratios for various patient care areas; 3) quantitatively validate a clinical classification of critically ill patients into four categories, thereby simplifying and organizing activities relating to patient care; 4) analyze cost of intensive care relative to the extent of care offered. Assumptions inherent in formulating this system are discussed. If other intensivists incorporate this system into their experience, meaningful comparisons between intensive care units can occur.
828 citations
TL;DR: The Therapeutic Intervention Scoring System (TISS) introduced in 1974 has become a widely accepted method of classifying critically ill patients and in response to requests to update the system, some items have been deleted, some have been added, and certa are added.
Abstract: The Therapeutic Intervention Scoring System (TISS) introduced in 1974 has become a widely accepted method of classifying critically ill patients. In response to requests to update the system because of recent innovations in critical care, some items have been deleted, some have been added, and certa
150 citations
TL;DR: Values obtained in normal ambulatory and supine subjects conform closely to those previously reported.
Abstract: A method for routine determination of colloid osmotic pressure (COP) in the clinical laboratory is described. A transducer membrane system is utilized in which the colloid osmotic pressure (COP) of fresh or refrigerated plasma or albumin is compared to that of isotonic saline. The measurement is completed within an average period of less than four minutes. Duplicate measurements demonstrated high reproducibility (r = >.95) and reference measurements obtained over a period of ten months were consistently within a range of 1 torr. Heparin in excess of 200 units/ml delayed equilibration. Values obtained in normal ambulatory and supine subjects conform closely to those previously reported.
84 citations
TL;DR: Flexible fiberoptic bronchoscopy was evaluated in 71 procedures in 55 patients; 43 (81%) of these procedures were successful in improving aeration as evaluated with radiography.
Abstract: Flexible fiberoptic bronchoscopy was evaluated in 71 procedures in 55 patients. Two-thirds of these procedures were carried out in patients with ongoing mechanical ventilation as their respiratory failure contraindicated rigid bronchoscopy. A wide variety of important diagnostic information was obtained. FFB caused no mortality or serious complications. Transient tachycardia occurred in several patients, cardiac arrhythmia in two and mediastinal emphysema in one patient. Retained secretions and atelectasis were the indications for 53 FFBs; 43 (81%) of these procedures were successful in improving aeration as evaluated with radiography.
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TL;DR: A prognostic classification system was developed to help define overall therapeutic goals in critically ill patients with rapidly changing clinical status, in order: a) to force the conscious decision as to use or omission of heroic measures (including cardiopulmonary resuscitation); b) to promote dialogue between the primary physician, ICU staff and the family with respect to the treatment goals and likelihood of success; c) to prevent confusion in those charged with the overall care of the ICU; d) to encourage the development of a treatment plan based on a frequent reassessment of the patient which does not ask
Abstract: A prognostic classification system was developed to help define overall therapeutic goals in critically ill patients with rapidly changing clinical status, in order: a) to force the conscious decision as to use or omission of heroic measures (including cardiopulmonary resuscitation); b) to promote dialogue between the primary physician, ICU staff and the family with respect to the treatment goals and likelihood of success; c) to prevent confusion in those charged with the overall care of the ICU; d) to encourage the development of a treatment plan based on a frequent reassessment of the patient which does not ask the ICU staff to render extraordinary care to a patient who has no reasonable hope for survival as a person; e) to minimize the medical legal risks; f) to dignify the entire ICU operation for the patient, his family, and the staff; and most importantly, g) to guarantee continual reassessment of each individual case with respect to the goals of treatment and the determination of that point in time when treatment should be stopped, when the goals are no longer attainable.
17 citations
TL;DR: A complete anatomical and physiological picture of the respiratory distress syndrome can be produced by perfusing the brain of experimental animals with blood low in oxygen, ie, simulating the stagnant hypoxia of shock at the brain level.
Abstract: The central nervous system seems to play a major role in triggering lung damage.A complete anatomical and physiological picture of the respiratory distress syndrome can be produced by perfusing the brain of experimental animals with blood low in oxygen, ie, simulating the stagnant hypoxia of shock at the brain level.In other experiments relative to oxygen toxicity, there is evidence that a site remote from the lung where high oxygen tensions trigger lung damage. Here again, a centroneurogenic factor seems to be implicated.
TL;DR: The data presented here suggest that RDS itself, even in its most severe form, does not in the large majority result in impaired development of the survivors, and that the overall outlook for this group of infants is an extremely encouraging one, and indicates that life-support efforts are warranted.
Abstract: Follow-up evaluation was carried out in 109 (86%) of 126 children who required ventilatory support in the newborn period for respiratory failure; the commonest cause of which was the respiratory distress syndrome. The children are currently between 1 and 6 years of age. Their gestational ages ranged from 27 to 42 weeks and their birth weights from 1050 to 4360 g.The number of major abnormalities in the RDS group was small, occurring primarily in infants who were less than 1500 g birth weight, or in children who have had neonatal insults such as asphyxia or hyperbilirubinemia. The survivors of other causes of neonatal respiratory failure are too small in number to make a valid comparison with RDS survivors, but all appear to be developing normally. The data presented here suggest that RDS itself, even in its most severe form, does not in the large majority result in impaired development of the survivors, and that the overall outlook for this group of infants is an extremely encouraging one, and indicates that life-support efforts are warranted.
TL;DR: Data indicate that trauma, hemorrhage and other forms of stress produce pulmonary vasoconstriction from neural influences; initially at least, this is a compensatory mechanism which tends to redistribute blood flow upward.
Abstract: Death from pulmonary failure in clinical shock is largely due to alterations in pulmonary venous admixture with ventilation-perfusion (V/Q) abnormalities which are related to very early increases in pulmonary vascular resistance; the latter is an important early predictor of survival.Sequential hemodynamic, oxygen transport and pulmonary venous admixture measurements were performed in experimental animals as well as in shock patients remote from therapy. In surviving patients, the early physiologic response consisted of hypotension, increased PVR, normal arterial pH, and normal central blood volume. There was an increased cardiac output with normovolemia and usually decreased cardiac output in the presence of hypovolemia. During the early period of shock, the nonsurvivors had lower cardiac output, higher central blood volume, higher PVR, greater acidosis, and lower oxygen consumption.Increased PVR occurred early, often before development of maximal hypotension and low cardiac output in both clinical and experimental conditions. The magnitude of the PVR increase was roughly related to the extent of the trauma and hemorrhage; the increase was significantly greater in nonsurvivors. The increased PVR was associated with acidosis during hypovolemia, increased central blood volume after volume deficits were restored, and with the subsequent appearance of pulmonary shunting.These data indicate that trauma, hemorrhage and other forms of stress produce pulmonary vasoconstriction from neural influences; initially at least, this is a compensatory mechanism which tends to redistribute blood flow upward. However, the increased PVR may be exaggerated by metabolic, hormonal, and rheologic factors. The persistence of a high PVR leads to the backup of blood behind the lesser circulation and uneven blood flow in the microcirculation. Thus, ventilation-perfusion abnormalities are produced by maldistributions of regional or zonal pulmonary blood flow as well as maldistributions of flow at the microcirculatory level. Therapy is directed toward the reduction of PVR by correction of acidosis, the use of plasma expanders and steroids, and the avoidance of vasopressors and saline.
TL;DR: In this article, the pH, carbon dioxide tension, and bicarbonate concentration were measured and compared with those in arterial blood in 47 hospitalized patients, and a consistent difference between the two cerebrospinal-fluid compartments was noted.
Abstract: Simultaneous samples of cisternal and lumbar cerebrospinal fluid were obtained in 59 observations in 47 hospitalized patients, and the pH, carbon dioxide tension, and bicarbonate concentration were measured and compared with those in arterial blood. Eighteen patients also had simultaneous measurements of jugular venous blood. A consistent difference between the two cerebrospinal-fluid compartments was noted, with the pH lower (mean difference ± S.D., -0.039 ± 0.034) and the carbon dioxide tension higher (mean difference ± S.D., + 3.8 ± 5.2 mm Hg) in the lumbar region. Mean bicarbonate concentrations were equal in the two sites. The carbon dioxide tension of the cisternal fluid was about 1 mm Hg higher than the arithmetic mean of the arterial and jugular venous values. The reasons for the cisternal-lumbar difference in carbon dioxide tension were not established, but it is likely that they reflect differences in the ratio of local metabolism to blood flow in these regions. Differences between lumb...
TL;DR: Continuous airway monitoring which can provide data on the immediate status of respiratory function can be life-saving as well as contribute to the making of sound clinical decisions.
Abstract: The status of patients on respirators can change very suddenly; therefore, continuous airway monitoring which can provide data on the immediate status of respiratory function can be life-saving as well as contribute to the making of sound clinical decisions. A system for continuous monitoring and analysis of respiratory gas, pressure, and flow is presented.
TL;DR: A report of the outcome in 85 infants who had CHMD as infants, who have been followed for at least 6 years, and on whom sequential chest x-rays, developmental evaluations, growth patterns, and medical evaluations have been made as discussed by the authors.
Abstract: A report of the outcome in 85 infants who had CHMD as infants, who have been followed for at least 6 years, and on whom sequential chest x-rays, developmental evaluations, growth patterns, and medical evaluations have been made.
TL;DR: With today's rapid development of new therapeutic methods, including on-line computerized monitoring, use of artificial organs and extracorporeal circulation, one must anticipate that the number of both new and conventional types of paramedical specialists in intensive care facilities will continue to increase.
Abstract: The treatment of the critically ill and injured patients in separate intensive care units has created a great need for a large number of paramedical specialists and technicians of various categories. These include: respiratory therapists and technicians, physical therapists, radiology technologists, laboratory technicians, biomedical equipment technicians, social workers, unit managers, bacteriologists and bacteriology technicians, physiologists, computer scientists, programmers, computer technicians and emergency medical technicians. They can uniquely and significantly contribute to the improvement of the intensive care as well as to the reduction of mortality and long term invalidity. With today's rapid development of new therapeutic methods, including on-line computerized monitoring, use of artificial organs and extracorporeal circulation, one must anticipate that the number of both new and conventional types of paramedical specialists in intensive care facilities will continue to increase.
TL;DR: Any system of decontamination requires the meticulous application of a procedure at least once every 24 hours and the degree of contamination should not exceed that of hospital air.
Abstract: Inhalation therapy equipment is a potential vector of gram-negative bacilli. Small-volume Venturi nebulizers have a potential but are infrequently implicated in the dissemination of bacteria. Large volume nebulizers of all designs are the major source for aerosolized bacteria. Ventilators and humidifiers have minimal potential.Any system of decontamination requires the meticulous application of a procedure at least once every 24 hours. The degree of contamination should not exceed that of hospital air.
TL;DR: In this paper, a scintigraphic technic was used to monitor attempts to cannulate selectively the right and left main-stem bronchi by suction catheters.
Abstract: In 24 patients with nasotracheal, orotracheal and tracheostomy tubes in place, a scintigraphic technic was used to monitor attempts to cannulate selectively the right and left main-stem bronchi by suction catheters. Regardless of catheter type and patient positioning, the left main-stem bronchus was more difficult to enter (46 per cent success rate) than the right (75 per cent success). Angle-tipped suction catheters were more successful than straight catheters In cannulating both right and left mainstem bronchi. Catheters packed in straight, rather than coiled, configurations were more successful In achieving left-main-stem bronchus cannulation. The left main-stem bronchus was particularly difficult to enter through nasotracheal tubes. Turning the head to the right improved the success of left-main-stem-bronchus catheterization. Turning the head to the left or shoulder positioning did not assist in selective bronchial cannulation. (N Engl J Med 289:1060–1063, 1973)
Journal Article•
TL;DR: Simulated transport caused a rise in blood pressure and cardiac output in five of the six dogs, with no change in heart rate or right atrial pressure, and intermittent positive pressure ventilation had no protective action.
Abstract: This study was designed to observe the effect of movement on ill, injured, or shocked animals. Lightly-anesthetized dogs were subjected to hemorrhagic shock. Ambulance transport was simulated by shaking, jolting, and rocking a table in three axes as well as lifting and dropping it. Accelerometer readings compared well with previously reported readings in ambulances. Simulated transport caused a rise in blood pressure and cardiac output in five of the six dogs, with no change in heart rate or right atrial pressure. A 15° head-up tilt caused a marked fall in blood pressure and cardiac output in two of the six dogs, leading to asystole in one. This could be related to diminished venous return from the lower body. Intermittent positive pressure ventilation had no protective action.