Showing papers in "Critical Care Medicine in 1976"
380 citations
197 citations
113 citations
TL;DR: An attempt will be made to facilitate this approach by discussing fluid changes, presenting a clinically applicable classification of shock, and outlining a rational approach to the early treatment of hemorrhagic shock, the most frequent form of shock occurring early after injury.
Abstract: Initial fluid management of the injured patient involves replacement of fluid lost incident to the trauma as well as prompt recognition and treatment of shock. Prompt fluid replacement based on these concepts will result in a reduction in mortality and prevention of many complications resulting from prolonged inadequate tissue perfusion. In this discussion, an attempt will be made to facilitate this approach by: (1) discussing these fluid changes; (2) presenting a clinically applicable classification of shock; and (3) outlining a rational approach to the early treatment of hemorrhagic shock, the most frequent form of shock occurring early after injury.
100 citations
TL;DR: A low energy charge potential was found in patients with prolonged diseases, possibly being the cellular expression for the concept of the post-traumatic catabolic state.
Abstract: Preliminary studies on muscle tissue metabolism were made in a series of 18 patients treated in an intensive care unit. In acutely ill patients with circulatory or respiratory insufficiency, there was an increase in muscle lactate content, a decrease in the phosphorylcreatine stores as well as decreased in adenosine triphosphate (ATP) and total adenine (TA) contents. These findings could partly be explained by a relative hypoxia in the muscle but acute hypoxia alone would not account for the decrease in ATP or TA. These changes in the adenylate pool were still more pronounced in patients with prolonged diseases. In this series the ATP content was only 50% of the normal, despite normal lactate content. The reason for the low adenine nucleotide level in muscle tissue is thought to be due primarily to an increased formation and deamination of adenosine monophosphate during hypoxia in combination with a decreased rate of purine synthesis in the liver and/or a decreased capacity for "purine salvage" in the muscle. This itself might, in turn, be mediated by a low energy state in muscle or liver or be due to other metabolic disturbances or tissue damage. It was found that prolonged immobilization without metabolic disturbances did not change the TA content in muscle, while short-lasting severe metabolic acidosis decreased the TA content. A correction of the metabolic disturbance immediately increased the TA content in muscle. A low energy charge potential was found in patients with prolonged diseases, possibly being the cellular expression for the concept of the post-traumatic catabolic state.
73 citations
TL;DR: If one or two arterial blood measurements are performed, low as well as high Pao2 values may be predicted from tcPo2 in patients without gross circulatory impairment in healthy persons.
Abstract: The transcutaneous oxygen tension (tcPo2) in five healthy subjects and in seven patients was monitored continuously by the technique of Huch, Huch, and Lubbers. The inspired oxygen concentration was varied between 15 and 100%. Once stable tcPo2 recordings were obtained, blood samples were drawn via an indwelling arterial catheter for oxygen tension (Pao2) determination. A comparison between the Pao2 and the tcPo2 values is illustrated graphically. There was a small difference between these values in the healthy subjects, which was attributed to variations in the skin from subject to subject. In the patients, a circulatory factor may have added to differences in the absolute levels. The coefficient of correlation between Pao2 and tcPo2 was in all cases higher than 0.98. In healthy persons, Pao2 may be predicted from tcPo2. In patients, any change in Pao2, due to deterioration or improvement, is manifested in the tcPo2 curve. If one or two arterial blood measurements are performed, low as well as high Pao2 values may be predicted from tcPo2 in patients without gross circulatory impairment.
71 citations
TL;DR: The use of the double lumen endotracheal tube, Carlens tube, and the application of differential ventilation was a safe and effective modality of therapy when conventional measures failed.
Abstract: Successful therapy of unilateral acute lung disease has been infrequent. The marked compliance difference that exists between the acutely diseased and normal lung may make conventional respiratory therapy ineffective in treating the diseased lung. Vigorous attempts at reexpansion of the involved lung including bronchoscopy, continuous positive pressure ventilation, chest physiotherapy, suctioning, and position changes are usually successful in acute lung disease but were ineffective in the case presented. The use of the double lumen endotracheal tube, Carlens tube, and the application of differential ventilation was a safe and effective modality of therapy when conventional measures failed. The method of ventilation and the patient's course are described.
55 citations
TL;DR: This communication is concerned with brain metabolism in the critically ill with emphasis on conditions of hypoglycemia, hypoxia, and ischemia, with an interest in factors that may aggravate the primary disease and in measures that may prevent or minimize its final effect on the brain.
Abstract: A large number of clinical conditions are associated with a transient or permanent disturbance of brain function. Common to all of them is that, in some way, brain metabolism is changed from the normal. These changes cover a vast spectrum, ranging from the subtle alterations of metabolism encountered in mental disease to those underlying death and dissolution of cells in conditions of oxygen lack. This communication is concerned with brain metabolism in the critically ill with emphasis on conditions of hypoglycemia, hypoxia, and ischemia. We begin by briefly recalling the salient features of brain metabolism in the healthy individual. Since clinicians caring for critically ill patients take an interest in factors that may aggravate the primary disease and in measures that may prevent or minimize its final effect on the brain, we will also briefly consider how brain metabolism is influenced by potentially harmful factors (hyperthermia, anxiety and stress, and tissue acidosis due to CO2 retention) as well as by measures that are often instituted to ameliorate the effects of hypoxia and ischemia (hypothermia, administration of anesthetics and sedatives). We refer the reader to selected references with preference to recent articles reviewing previous literature.
46 citations
39 citations
TL;DR: The application of a medical mass spectrometer for the monitoring of respired gases in the respiratory intensive care unit of a community hospital is reviewed and preliminary observations suggest it may also provide a simple technique for determining optimal expiratory retard settings.
Abstract: The application of a medical mass spectrometer for the monitoring of respired gases in the respiratory intensive care unit of a community hospital is reviewed. This monitoring system is routinely used with intubated patients for periodic monitoring of end-tidal CO2 tensions (PETCO2), FIO2, and PETO2 dead space to tidal volume ratios, and the determination of AaDO2; the value of these measurements is discussed. It is especially useful for continuous monitoring at critical points in the patient's course such as weaning from the ventilator, determining optimal ventilator settings, monitoring, unstable nonintubated patients, and in better defining the pathophysiological disturbances impeding patient progress, examples of which are presented. Preliminary observations suggest it may also provide a simple technique for determining optimal expiratory retard settings. The initial cost of such a system is justified by the benefit to the patient, i.e., reduction in the frequency of nonessential arterial blood gas determinations, shortened weaning period, and early detection of potentially dangerous trends. Technical problems encountered with this system and potential future uses are also discussed.
35 citations
TL;DR: The functional residual capacity (FRC), right-to-left intrapulmonary shunt, dynamic compliance, physiological dead space, and arterial and mixed venous blood gases were measured during mechanical ventilation and spontaneous ventilation following weaning.
Abstract: Twenty-one patients who underwent cardiopulmonary bypass for myocardial revascularization received postoperatively controlled mechanical ventilation (CMV) or intermittent mandatory ventilation (IMV), with or without positive end-expiratory pressure (PEEP). Functional residual capacity (FRC), right-to-left intrapulmonary shunt, dynamic compliance, physiological dead space, and arterial and mixed venous blood gases were measured during mechanical ventilation and spontaneous ventilation following weaning. Controlled ventilation increased physiological dead space and arterial pH. FRC correlated positively with dynamic compliance, but not with right-to-left intrapulmonary shunt. Postoperatively, FRC was significantly lower than normal when patients were ventilated without PEEP, but was normal when patients received PEEP. Arterial oxygen tension (PaO2), intrapulmonary shunt, and dead space were unaffected in spite of higher FRC, suggesting that patients who received PEEP had fewer atelectatic and fewer unperfused "silent" lung units than those who had not received PEEP.
TL;DR: Reversal of these manifestations was achieved in 3 reported cases though induction of hypothermia was delayed for as long as 24 hours, however, no beneficial effects were obtained in a fourth patient who did not receive Hypothermia until 5 days after exposure.
Abstract: Manifestations of carbon monoxide poisoning are mostly attributable to acute hypoxic insult. In the absence of immediately available hyperbaric oxygen chamber, 100% oxygen should be delivered to the patient until carboxyhemoglobin levels in the blood are less than 5%. Presence of abnormal motor activity or prolonged abnormal consciousness are indications for proceeding with hypothermia and mechanical ventilation. Reversal of these manifestations was achieved in 3 reported cases though induction of hypothermia was delayed for as long as 24 hours. However, no beneficial effects were obtained in a fourth patient who did not receive hypothermia until 5 days after exposure. The duration of hypothermia varied between 60-70 hours in patients who showed near-complete recovery.
TL;DR: Intracranial pressure (ICP) monitoring with the goal of titrated control of ICP elevations could have been added to their supportive therapy at an earlier stage, possibly with the onset of coma and grade 3 EEG changes.
Abstract: Intracranial pressure (ICP) was monitored in 9 patients with coma due to Reye-Johnson syndrome. Clinically unrecognized elevations of ICP were found in all patients and treated with ventricular fluid drainage and conventional osmotherapy. This adequately controlled ICP in 2 patients. Intractable intracranial hypertension in 4 patients responded to continuous intravenous glycerol infusion, 1 g/kg every 2 hours, administered as a 10 g/100 ml solution modified to substitute for maintenance fluids. Two patients required the addition of moderate hypothermia (30–32° C) to other therapeutic measures. Three patients survived, one with severe neurological sequelae. Before monitoring, 3 patients were suspected of herniation on clinical grounds (before they were monitored) and subsequently died. ICP monitoring with the goal of titrated control of ICP elevations could have been added to their supportive therapy at an earlier stage, possibly with the onset of coma and grade 3 EEG changes.
TL;DR: Since 1971, a mass spectrometer system for automatic hourly sampling of airway gases on a 24-hour basis in the Critical Care Unit has been used, allowing monitoring of the adequacy of alveolar ventilation both in patients on and following removal from mechanical ventilation.
Abstract: Since 1971, we have used a mass spectrometer system for automatic hourly sampling of airway gases on a 24-hour basis in our 12 bed Critical Care Unit. Used in conjunction with arterial and mixed-venous blood samples, the availability of end-tidal O2 and CO2 values allows early identification of increasing AaDO2 and aADCO2 gradients. The ability to monitor end-tidal CO2 allows the monitoring of the adequacy of alveolar ventilation both in patients on and following removal from mechanical ventilation. Continuous information of the end-tidal PCO2 is of particular value in the management of patients with severe head injury.
TL;DR: A significant bronchopleural cutaneous fistula (BPCF) developed in a 36-year-old female who required mechanical ventilation for acute respiratory failure and was weaned successfully from mechanical support with spontaneous closure of the BPCFs.
Abstract: A significant bronchopleural cutaneous fistula (BPCF) developed in a 36-year-old female who required mechanical ventilation for acute respiratory failure. Progressive increase in arterial PCO2 to 75 torr occurred because of inability to effect satisfactory alveolar ventilation. Insertion of unidirectional values into the chest tube drainage apparatus, which were closed synchronously each time the ventilator cycled to the inspiratory phase, allowed effective alveolar ventilation to be achieved with subsequent reduction of arterial CO2 to previous levels. Both high inspiratory (120 torr) and expiratory (23 torr) positive pressures were employed with intermittent mandatory ventilation (IMV). Deleterious effects on cardiopulmonary function were not observed, and the patient was weaned successfully from mechanical support with spontaneous closure of the BPCFs.
TL;DR: Axillary arterial catheterization for intraoperative and postoperative monitoring was successful in 90% of 87 attempts; there were eight hematomas, one of which was extensive.
Abstract: Axillary arterial catheterization for intraoperative and postoperative monitoring was successful in 90% of 87 attempts. Complications occurred in nine patients; there were eight hematomas, one of which was extensive. In the ninth patient, radial pulsations disappeared but returned after the catheter
Abstract: There is a special form of pulmonary dysfunction which most often occurs following massive tissue damage, such as major fractures accompanied by hypovolemia. This syndrome may be appropriately called post-traumatic pulmonary microembolism to distinguish it from other causes of respiratory failure. We believe that pathophysiology is initiated at the time of trauma and consists of platelet aggregation and fibrin deposition in the pulmonary microcirculation caused by release of tissue-thromboplastin products. Whether this acute traumatic pulmonary microembolism will progress to a fully developed post-traumatic pulmonary microembolism with respiratory symptoms depends upon the magnitude and duration of tissue-thromboplastin release and the efficiency of the fibrinolytic system to clear the lungs. The early microembolic effects on the lungs consist mainly of ventilatory derangements with a low ventilation/perfusion ratio; not until a later stage does true shunting of mixed venous blood across fluid-filled alveoli and small airways occur. Frequently determinations of Pao2 and AaDO2 during air breathing ("air-test") to reveal a low ventilation/perfusion ratio is, therefore, preferable to true shunt determinations in patients who may develop this syndrome; caution must be exercised in giving room air to critically ill patients. These ventilatory variables, combined with frequent platelet counts, allow early recognition of post-traumatic pulmonary microembolism.
TL;DR: Routine measurement of pressure-volume curves of the lungs and thorax in seven patients treated with continuous mechanical ventilation provided supportive evidence for the presence or absence of cardiogenic pulmonary edema, noncardiogenic Pulmonary Edema, pneumonia, bronchospasm, mucous plugging, intubation of mainstem bronchus, atelectasis, and results of subsequent therapy.
Abstract: Routine measurement of pressure-volume curves of the lungs and thorax in seven patients treated with continuous mechanical ventilation provided supportive evidence for the presence or absence of cardiogenic pulmonary edema, noncardiogenic pulmonary edema, pneumonia, bronchospasm, mucous plugging, intubation of mainstem bronchus, atelectasis, and results of subsequent therapy. Those conditions associated with predominantly airway disease altered dynamic more than static pressure-volume measurements. Those conditions associated with parenchymal lung disease or loss of lung volume generally altered both dynamic and static pressure-volume measurements. The effectiveness of treatment of these diseases could be monitored by their effect on the pressure-volume curve. The determination of pressure-volume measurements are simple, noninvasive, and can be accomplished within minutes. The routine use of these measurements should be one of the monitoring procedures performed in patients treated with mechanical ventilation.
TL;DR: It is concluded that ARDS with sepsis constitutes a more severe pulmonary insult than ARDS without sepsi, and/or that generalized sepsIS creates a more prolonged pulmonary insult that makes it less amenable to PEEP.
Abstract: We report an evaluation of the effect of postive-end-expiratory-pressure (PEEP) on improving pulmonary oxygenating capacity in the adult respiratory distress syndrome (ARDS), when the latter is associated with generalized gram-negative sepsis. Fifty-seven cases treated in our RICU with PEEP ventilation (April 1972 to January 1975) were retrospectively reviewed. Oxygenating capacity improvement was evaluated in terms of the changes in PaO2/FIO2 and AaDO2 (FIO2 = 1.0). Both the short term (2-3 hours from the initiation of PEEP) and the overall effects of PEEP were evaluated. A mean PEEP of 5.6 cm H2O initially increased PaO2/FIO2 by a mean of 94 torr and decreased AaDO2 (FIO2 = 1.0) by 105 torr in the 28 nonseptic patients. In the 29 septic patients, 5.1 cm H2O PEEP initially increased PaO2/FIO2 by 32 torr and decreased AsDO2 (FIO2 = 1.0) by 38 torr. The differences between the septic and nonseptic patients were statistically significant (P less than 0.001). Likewise, the long-term effect of similar levels of PEEP was in increasing PaO2/FIO2 by 142 torr and by 75 torr in the nonseptic and septic patients, respectively. The final reduction in AaDO2 (FIO2 = 1.0) was 163 torr and 87 torr in the nonseptic and septic patients, respectively. These differences between patient groups were also statistically significant (P less than 0.02). Mortality during PEEP was 15/29 and 3/28 in the septic and nonseptic patients, respectively. Overall mortality in the septic and nonseptic groups was 18/29 and 5/28, respectively. We conclude that ARDS with sepsis constitutes a more severe pulmonary insult than ARDS without sepsis, and/or that generalized sepsis creates a more prolonged pulmonary insult that makes it less amenable to PEEP. Thus, high levels of PEEP may be needed to treat ARDS associated with sepsis.
TL;DR: In this paper, the authors studied 91 near-drowning victims and found that 89 percent of the patients who were alert on arrival at the emergency room survived, but those who were comatose and had fixed dilated pupils died.
Abstract: Hospital records of 91 consecutive near-drowning victims were studied retrospectively. Eighty-one (89 percent) of these patients survived. Patients who were alert on arrival at the emergency room survived, but those who were comatose and had fixed dilated pupils died. Other states of consciousness were unreliable predictors of survival. All patients with a normal chest roentgenogram on admission survived; however, values for arterial oxygen tension (PaO2) did not necessarily correlate with the chest roentgenograms. Values for arterial blood gas tensions and pH varied widely, as follows: PaO2, 25 to 465 mm Hg; arterial carbon dioxide tension (PaCO2), 17 to 100 mm Hg; pH, 6.77 to 7.50; and arterial bicarbonate level, 6.6 to 29.7 mEq/L. The ratio of PaO2 to the fractional concentration of oxygen in the inspired gas (FIo2), which was calculated to standardize PaO2 data for varying concentrations of inspired oxygen, ranged from 30 to 585 mm Hg. Only one patient with a ratio of PaO2/FIo2 greater than 150 mm Hg on admission subsequently died; this was a neurologic rather than a pulmonary death. Serum electrolytic concentrations and values for hemoglobin level and hematocrit reading neither predicted survival nor indicated that a threat to life existed. Steroid and prophylactic antibiotic therapy did not appear to increase the chance of survival. Observations on these patients are discussed in light of previous experiments in animals, and an approach to therapy is suggested.
TL;DR: A specialized technique of dealing with ventilating the lungs differentially when their mechanical properties differ is described to illustrate the versatility of the medical mass spectrometry.
Abstract: The medical mass spectrometry as a monitoring instrument in a respiratory intensive care unit (RICU) is described. Its uses, both routine and as a tool for innovative techniques in respiratory care, are many. As an adjunct to traditional and intermittent mandatory ventilation (IMV) weaning techniques, monitoring of expired respiratory gases can hasten the safe removal of patients from mechanical ventilators. A specialized technique of dealing with ventilating the lungs differentially when their mechanical properties differ is described to illustrate the versatility of the instrument. In critical care areas, monitoring of patients with respiratory problems should include continuous monitoring of end-tidal or expired CO2.
Journal Article•
TL;DR: The risk factor of pulmonary artery catheterization was assessed in 392 critically ill patients and none of the complications were directly responsible for the deaths in this series.
Abstract: The risk factor of pulmonary artery catheterization was assessed in 392 critically ill patients. Major indications for catheterization in the operating room were marginal cardiovascular reserve, anticipated large fluid and blood loss, and hypotensive anesthesia. Immediate complications included cardiac arrhythmia, carotid artery puncture, and pneumotherax. Long-term complications included positive bacterial cultures, pulmonary infarction and neuropathy. None of the complications were directly responsible for the deaths in this series. Pulmonary artery monitoring in critically ill persons is a relatively safe procedure.