Showing papers in "Critical Care Medicine in 1977"
226 citations
TL;DR: It is believed that early extubation of patients whose postoperative course is otherwise uncomplicated following cardiac surgery allows rapid mobilization and progress to the intermediate care areas without introducing undesirable sequelae.
Abstract: Data were collected on the postoperative respiratory courses of two groups of patients following cardiac surgery: one group of 31 patients under typical management for 1973, and a second group of 72 patients from 1975–1976 representing our current management regimen. The patients in the 1973 group were allowed to wake up passively before our seeking extubation criteria. Almost half of these were extubated in the period 15 to 20 hours after admission to the ICU, i.e., the morning after surgery, and 29% were discharged from the ICU within 48 hours of admission. The patients in the 1975–1976 series had pharmacological reversal of muscle relaxants and somnolence following admission to the ICU, when their condition was shown to be stable by clinical and laboratory assessment. Criteria for extubation were then sought. Within 5 hours of ICU admission, 62.5% of the patients were extubated and almost 50% of the patients were discharged from the ICU within 24 hours. No patient in either series required reintubation, and there were no complications due to the early extubation and ICU discharge of patients in the 1975–1976 series. We believe that early extubation of patients whose postoperative course is otherwise uncomplicated following cardiac surgery allows rapid mobilization and progress to the intermediate care areas without introducing undesirable sequelae.
66 citations
TL;DR: A technique for differential lung ventilation via a Carlens tube with inspiratory retardation and the application of separate levels of PEEP to each lung are described in the treatment of a patient with severe unilateral pneumonia.
Abstract: A technique for differential lung ventilation via a Carlens tube with inspiratory retardation and the application of separate levels of PEEP to each lung are described in the treatment of a patient with severe unilateral pneumonia. In addition to isolating the diseased lung, this technique permits modification of the distribution of ventilation between the two lungs to improve the ventilation-perfusion ratio and enhance arterial oxygenation. Its clinical application is influenced by the flow characteristics of available mechanical ventilators and by the limitations of the currently available double-lumen endobronchial tubes.
64 citations
TL;DR: Noise levels have been shown to have adverse physiological and psychological effects on patients and on the errorproneness of intensive care personnel and if noise generation is a consideration in selection of equipment, industry can respond appropriately.
Abstract: Expense, noise, and bright lighting have been acknowledged disadvantages of ICU's since their establishment. Data are available regarding the first, but not the latter two disadvantages. Background sound levels were measured in four units and found to be comparable to the hospital cafeteria at noon, and only somewhat less noisy than the boiler room. Sound levels generated by numerous components of the environment were measured and related to the total noise level. Noise levels generated by seven different nebulizers, each used at three different settings, were found to show noteworthy differences. High noise levels have been shown to have adverse physiological and psychological effects on patients and on the errorproneness of intensive care personnel. If noise generation is a consideration in selection of equipment, industry can respond appropriately. Further studies can lead to measures that will reduce the noise level in ICU's.
64 citations
TL;DR: The measurement of the work of breathing against an inspiratory resistance of 5 cm H2O was useful in the identification and quantification of ventilatory reserve in patients with obstructive pulmonary disease.
Abstract: The work of breathing was measured in 10 normal subjects and in 28 critically ill patients with acute complications of obstructive pulmonary disease treated with assisted ventilation. The measurement of the work of breathing was found to be a useful objective variable for determining the capability for independent ventilation. Dependence on mechanical ventilation was observed when the respiratory work was greater than or equal to 1.7 kg-m/min. Patients were ordinarily capable of spontaneous ventilation when the respiratory work was less than or equal to 1.0 kg-m/min. Discontinuation of assisted ventilation was likely to be successful in those patients whose respiratory work was less than or equal to 1.5 kg-m/min if the patient was able to increase and maintain his work capability by a factor of two when breathing against an inspiratory resistance of 5 cm H2O for 10 min. Failure to increase the respiratory work when breathing against an inspiratory resistance indicated limitations in respiratory mechanics and was associated with the need for prolonged assisted ventilation. The measurement of the work of breathing against an inspiratory resistance of 5 cm H2O was useful in the identification and quantification of ventilatory reserve in patients with obstructive pulmonary disease.
51 citations
TL;DR: In 60 patients in whom Swan-Ganz catheters apparently had been positioned correctly, the balloon was visualized by inflation with radiopaque contrast medium and 16 were located peripherally; in 15 of these 16, the Balloon inflated eccentrically and in each of these instances, an accurate wedge pressure could not be obtained.
Abstract: In 60 patients in whom Swan-Ganz catheters apparently had been positioned correctly, the balloon was visualized by inflation with radiopaque contrast medium. Sixteen were located peripherrally; in 15 of these 16, the balloon inflated eccentrically and in each of these instances, an accurate wedge pressure could not be obtained. One patient in this group had an episode of hemoptysis immediately prior to detection of the peripheral location and eccentric inflation of the balloon. The correct placement and safe use of the Swan-Ganz catheter demand that the catheter tip be located in a large pulmonary artery and that redundant loops of catheter be avoided to prevent subsequent peripheral migration. Identification of peripheral placement and eccentric inflation should be suspected if a pulmonary wedge pressure is obtained with a significantly smaller volume of air than the balloon capacity. The use of a continuous flush system will provide an additional alert by a steady rise in the pseudowedge pressure on attempted balloon inflation.
48 citations
TL;DR: A common cardiorespiratory pattern of shock that was different for the survivors and nonsurvivors was observed, although no one variable was capable of predicting outcome, suggesting that these methods may provide a measure of the severity of acute illness as well as early warning of impending death.
Abstract: Despite the wide variety of illnesses and operations, we observed a common cardiorespiratory pattern of shock that was differenf for the survivors and nonsurvivors, although no one variable was capable of predicting outcome. Differences between the patterns of survivors and nonsurvivors were defined by range criteria and by cut-points operationally obtained from the frequency distributions of cardiorespiratory variables. The values of each of the 33 variables obtained, at times remote from therapy during each successive stage in the postoperative course, were used to predict survival and death in a series of 113 patients by the range and cut-point methods. An average of 13.5% of all the available variables gave a correct prediction by the range cirteria and 35% by the cut-point method. The mean percentage of Right--Wrong classifications throughout all stages for range and cut-point methods was 80 and 85%, respectively. Using the last available stage, the outcome was correctly predicted by the range criteria in 80% and by the cut point method in 88% of the patients. The high percentage of correct predictions suggests that these methods may provide a measure of the severity of acute illness as well as early warning of impending death.
46 citations
TL;DR: Patients in a Surgical ICU with certain syndromes had more prolonged stays, more frequent requirements for mechanical ventilation, a higher incidence of cardiac arrest and a higher mortality rate than the entire SICU population.
Abstract: Pathological behavior patterns are often observed in patients in the ICU. In a Surgical ICU (SICU), 7% (22/322) of a patient population required psychiatric consultation during a 6-month period. As a group, these patients had more prolonged stays, more frequent requirements for mechanical ventilation, a higher incidence of cardiac arrest and a higher mortality rate than the entire SICU population. The psychiatrist was asked to evaluate multiple behavioral syndromes, some of which were irreversible concomitants of grave illnesses. However, with certain syndromes, psychiatric assistance greatly facilitated the resolution of problems that hampered pre- and postoperative management and the patient's eventual recovery.
33 citations
TL;DR: A system for rapidly computing hemodynamic cardiorespiratory function in critically ill medical and surgical patients on real time in the ICU, for a capital outlay of less than $250 is presented.
Abstract: The value prompt assessment of hemodynamic cardiorespiratory function in critically ill medical and surgical patients is widely appreciated. We have presented a system for rapidly computing these variables on real time in the ICU, for a capital outlay of less than $250. In so doing, we hope to extend the benefits of this type of assessment to the smaller community hospital ICU and individual clinicians.
31 citations
TL;DR: A safe, simple, reliable technique for sampling uncontaminated peripheral bronchial secretions in patients with endotracheal tubes has been developed and requires no special training or equipment.
Abstract: A safe, simple, reliable technique for sampling uncontaminated peripheral bronchial secretions in patients with endotracheal tubes has been developed. It is easily performed and requires no special training or equipment. This report summarizes the techniques's usefulness in providing diagnostic samples of peripheral airway secretions from 20 patients with pneumonic infiltrates. In eight of the patients, a single organism was recovered from the peripheral airway despite polymicrobial colonization of the upper airways. An additional patient had two anaerobes. The recovered organism's role as a pathogen was verified by an appropriate response to specific antibiotic therapy in two patients, isolation from blood or empyema fluid in five, confirmation by bronchoscopy in one, and transtracheal aspiration after extubation in one. Peripheral bronchial secretions were sterile in the remaining 11 patients, even though multiple organsims were isolated from usual tracheal suctionings.
29 citations
TL;DR: Late neonatal hypocalcemia occurs, with malabsorption of magnesium (Mg), increased exogenous phosphate loading, after alkali therapy of diarrheal acidosis, hypoparathyroidism, and vitamin D related disorders.
Abstract: Early neonatal hypocalcemia occurs in premature infants, infants with birth asphyxia, and infants of diabetic mothers. Etiological considerations include decreased calcium (Ca) supply, increased endogenous phosphate load, hypomagnesemia, alkali therapy, functional hypoparathyroidism, defects in vitamin D metabolism, and possibly calcitonin excess. Late neonatal hypocalcemia occurs, with malabsorption of magnesium (Mg), increased exogenous phosphate loading, after alkali therapy of diarrheal acidosis, hypoparathyroidism, and vitamin D related disorders. The therapy of hypocalcemia includes oral or iv Ca salts and in the near future, possibly the newly discovered vitamin D metabolites.
TL;DR: A new device, the Roto-Rest bed, has been used in critically ill patients to effect lateral to lateral position changes and continuous rotation to influence distribution of pulmonary blood flow.
Abstract: A new device, the Roto-Rest bed, has been used in critically ill patients to effect lateral to lateral position changes and continuous rotation to influence distribution of pulmonary blood flow. Selection of extreme lateral position can be made particularly in cases of respiratory failure with primarily unilateral involvement. Dependent positioning of the uninvolved lung to match ventilation and perfusion can be accomplished simply. Rapid resolution of a large pulmonary contusion serves to illustrate the clinical use of the apparatus.
TL;DR: It is concluded that lowered COP is associated with an elevated mortality rate, however, the relationship to death is not explained by the relationships to respiratory failure.
Abstract: Plasma colloid osmotic pressure was measured each day in 84 intensive care unit patients. Probit analysis demonstrated a direct relationship between colloid osmotic pressure (COP) and survival. The COP associated with a 50% survival rate was 15.0 torr. COP was higher in survivors than in nonsurvivors without respiratory failure and in patients who recovered from respiratory failure. We conclude that lowered COP is associated with an elevated mortality rate. However, the relationship to death is not explained by the relationship to respiratory failure.
TL;DR: Because intrapleural pressure is reduced with IMV, as opposed to intermittent positive pressure ventilation (IPPV), venous return and cardiac output are maintained at more nearly normal levels, with or without positive end-expiratory pressure (PEEP).
Abstract: Intermittent Mandatory Ventilation (IMV) provides an alternative method of support to assisted and controlled mechanical ventilation in neonates with acute respiratory failure. Specific advantages include the use of only the level of mechanical support which is required on an individual basis. Because intrapleural pressure ventilation (IPPV), venous return and cardiac output are maintained at more nearly normal levels, with or without positive end-expiratory pressure (PEEP). Duration of mechanical ventilatory support is reduced, weaning enhanced, and the incidence of pulmonary barotrauma decreased with IMV. Physiological homeostasis in terms of acid-base changes is more readily maintained as a result of precise regulation of alveolar ventilation. Newer concepts in mechanical support, such as "reversed" inspiratory:expiratory ratio (I:E ratio) ventilation, are possible with IMV because of the lower ventilator rates employed compared to IPPV.
TL;DR: It is suggested that those treating critically ill patients be aware of a possible increase in the shunt when dopamine is used to correct a decreased cardiac output in patients receiving PEEP.
Abstract: PEEP has become widely used in patients with acute respiratory failure to increase arterial oxygenation. Despite a beneficial effect on the arterial oxygen content, PEEP may result in a substantial decrease in the cardiac output. This study was undertaken to determine the effectiveness of dopamine in correcting a PEEP-induced decreased cardiac output and to determine if, in increasing the cardiac output, the pulmonary shunt is affected. In 12 anesthetized, mechanically ventilated dogs the cardiac output and shunt were determined simultaneously. After control values were obtained, 10 cm of water PEEP was begun and a dopamine infusion was given for 3 hours. The infusion rate was adjusted to maintain the cardiac output near control levels, the average dose being 17.6 μg/kg/min. With the addition of PEEP, there was a decrease in the cardiac output, an increase in the pulmonary vascular resistance, and no change in the shunt. With the infusion of dopamine, the cardiac output returned to control; there was an increase in the shunt and a decrease in the pulmonary vascular resistance. When the dopamine was discontinued, there was a decrease in the cardiac output and the shunt to predopamine levels, but there was no change in pulmonary vascular resistance. On stopping PEEP, there was no change in the shunt but there was an increase in the cardiac output and a decrease in the pulmonary vascular resistance. These studies show that dopamine can correct the reduced cardiac output resulting from PEEP but that in doing so it produces a substantial increase in the pulmonary shunt. The rapid onset of the shunt with dopamine and the equally rapid decrease in the shunt on discontinuing dopamine suggests a redistribution of the increased pulmonary blood flow or the opening of anatomical arteriovenous shunts. Similar hemodynamic effects have been observed in man and it is suggested that those treating critically ill patients be aware of a possible increase in the shunt when dopamine is used to correct a decreased cardiac output in patients receiving PEEP.
TL;DR: This review begins with a discussion of the development of renal function in the neonate followed by a description of the more common causes of acute renal failure (ARF) in this age group.
Abstract: Recent advances in prenatal and neonatal care have increased the number of live births and extended the life expectancy of critically ill premature infants. These infants represent a formidable therapeutic challenge in that multisystem involvement and previously uncommon conditions, such as intravascular coagulation, acute tubular necrosis, and acute cortical necrosis are now seen with increased frequency. This review begins with a discussion of the development of renal function in the neonate followed by a description of the more common causes of acute renal failure (ARF) in this age group. Finally, the pathophysiology, diagnosis, and management of this condition are discussed.
TL;DR: The ventilatory response to uncomplicated subacute metabolic acidosis was studied by measuring arterial blood CO2 tension (PaCO2) and pH in 27 episodes of diabetic ketoacidosis without coexisting lactic acidosis, and relations were very similar to those previously described by others in patients with chronic uremic acidosis.
Abstract: The ventilatory response to uncomplicated sub-acute metabolic acidosis was studied by measuring arterial blood CO2 tension (PaCO2) and pH in 27 episodes of diabetic ketoacidosis without coexisting lactic acidosis. From those data, regression equations and 95% confidence bands were calculated for the relations between PaCO2 and pH. These relations were very similar to those previously described by others in patients with chronic uremic acidosis.
TL;DR: Standard discriminate analysis predicted a group of patients who would not survive and documented that acute renal failure was a primary predictor of death.
Abstract: To define severity of illness objectively and to justify further the need for intensive care, we have analyzed measurable objective data points (indicators) in 226 consecutive critically ill Class IV patients. The indicators include: (1) Pao2 (Fio2, 1.0), (2) platelet count, (3) cardiac index, (4) BUN, 5) creatinine, (6) acute renal failure, (7) peritoneal or hemodialysis, (8) continuous infusion of antiarrhythmia therapy, (9) base deficit greater than 10mEq/liter, (10) state of consciousness, and (11) unexpected cardiac arrest. Most indicators were significantly worse in patients who ultimately died within one year than in patients who survived with a successful recovery. An indicator profile could be derived for each disease process category, since different indicators applied to different diseases. The indicators were not markedly affected by age. Standard discriminate analysis predicted a group of patients who would not survive and documented that acute renal failure was a primary predictor of death.
TL;DR: The simplicity of the thermodilution technique and other advantages over the dye method in children, such as repeatability, and ease of calibration are discussed in relation to the increased flexibility in management which accrues.
Abstract: A 4 F thermodilution catheter for measuring cardiac output was evaluated for accuracy and linearity in the laboratory and by comparison with the dye dilution method in infants and children following cardiac surgery When 2 ml of 0 degrees C injectate were used, the correlation of computer determined flows to calibrated pump flows, over a range encountered clinically, was r = 0998 The means of triplicate determinations by both the thermal and dye methods were compared in 8 of 25 patients and the comparison found to be favorable (r = 0976) The complications of thermodilution catheter placement are described and related to the need for post-surgical chest x-ray and thermodilution recordings The simplicity of the thermodilution technique and other advantages over the dye method in children, such as repeatability, and ease of calibration are discussed in relation to the increased flexibility in management which accrues
TL;DR: The major components entering into the inspiratory pattern of various respirators were tested on a model lung which had an abnormally high airway resistance on one side and demonstrated the importance of an end inspiratory pause in improving gas distribution and efficiency of washout.
Abstract: The major components entering into the inspiratory pattern of various respirators were tested on a model lung which had an abnormally high airway resistance on one side. The tests consisted of simultaneous nitrogen washout curves from each lung separately utilizing two mass spectrometers. The components tested included a constant versus accelerating wave form and the presence, duration or absence of an end-inspiratory pause. Respirators tested included the Bennett MA1. Engstrom 300 and the Elema Schonander Servo tventilator 900. The results demonstrated the importance of an end inspiratory pause in improving gas distribution and efficiency of washout. No difference was found between a constant or accelerating air flow. Preliminary results in man appear to confirm the importance of an end inspiratory pause.
TL;DR: A peer review mechanism be set up within organized professional groups to assess major research trends and develop informed opinions on key research subjects within their domain if support commensurate with the importance of the research is to be achieved.
Abstract: Trauma and shock result in activation of a wide variety of endocrine and metabolic systems. Based upon experimental work demonstrating metabolic deficits, a variety of metabolic therapies have been developed to assist in the treatment of patients with shock or trauma. Evidence to date is inconclusive as to whether this therapy will be of significant benefit to critically ill patients. Some of the senior author's previous research has been analyzed as it relates to important health policy issues. We suggest that a peer review mechanism be set up within organized professional groups to assess major research trends and develop informed opinions on key research subjects within their domain. These peer review assessments must be effectively communicated to Congress and the executive branch of the government, as well as to the general public, if support commensurate with the importance of the research is to be achieved.
TL;DR: It is concluded that community hospitals without a nutritional team can achieve acceptable complication rates for patients receiving TPN if the staff is committed to continuous critical analysis of complications.
Abstract: The complication rate for all patients receiving total parenteral nutrition (TPN) over a 4-year period of time in a small community hospital has been continuously reviewed. Audit of the complication rate of the initial 15 patients receiving TPN revealed a 12.5% sepsis rate. After instituting rigid protocols concerning catheter insertion and care, a nursing care plan, and metabolic flow sheet, we found that the catheter sepsis rate decreased to 5.1% (P less than 0.05) in the subsequent group of 31 patients. However, metabolic complications related to TPN were not significantly different in the two groups. We conclude that community hospitals without a nutritional team can achieve acceptable complication rates for patients receiving TPN if the staff is committed to continuous critical analysis of complications. Transfer of depleted patients to institutions with demonstrated expertise in this area is recommended if such an analysis shows unacceptable complication rates.
TL;DR: These findings confirm that acute pulmonary edema, when caused by left ventricular failure, represents a form of acute perfusion failure (shock) with metabolic acidemia, lactacidemia, and a reduction in forward blood flow.
Abstract: Our findings confirm that acute pulmonary edema, when caused by left ventricular failure, represents a form of acute perfusion failure (shock) with metabolic acidemia, lactacidemia, and a reduction in forward blood flow. It is associated with a marked increase in peripheral resistance and an increase in venous capacitance. Most importantly, acute pulmonary edema is associated with a reduction in the intravascular blood volume. Acute pulmonary edema is not fundamentally different from other types of shock in which the shock state is initiated by one primary defect, and during the course of its progression, other primary mechanisms are called into action. In the instance of acute cardiogenic edema, the primary defect is cardiac pump failure and the secondary defects include hypovolemia and distributive defects associated with arterial vasoconstriction and expanded venous capacitance. Furosemide reverses acute pulmonary edema by increasing rather than decreasing intravascular blood volume with consequent improvement in the distributive and hypovolemic defects. Under extreme conditions, the volume defect in acute pulmonary edema may be so great that the patient presents with primary hypovolemia. The utilization of volume repletion is warranted under these circumstances.
TL;DR: A “functional” value of hemoglobin, based upon the effects of the shift of the oxyhemoglobin dissociation curve and, therefore, reflecting the true capacity ofhemoglobin to unload oxygen at the tissue level, was calculated, suggesting that, in spite of reduced metabolic demands, oxygenation reserves are minimal.
Abstract: Oxygen availability during cardiopulmonary bypass was assessed in 22 patients under hypothermic and relatively normothermic conditions. The patients were divided into two groups, 17 of whom received ACD blood and 5, CPD blood. The mean P50 for all patients fell from a preoperative value of 25.9 +/- 2.4 (SD) to 15.6 +/- 2.1 during hypothermia confirming a leftward shift of the oxyhemoglobin dissociation curve. Oxygen uptake, calculated from a-v oxygen content differences (avDO2) and flow, was significantly lower during hypothermic bypass (65 +/- 27 ml/min) than during rewarming (121 +/- 41 ml/min). The increase in oxygen affinity during hypothermia was influenced also by changes in acid base and 2,3-DPG concentrations, the changes being similar in both the ACD and CPD groups of patients. During rewarming, however, oxygen availability was increased in the CPD group presumably from significantly increased 2,3-DPG concentrations. A "functional" value of hemoglobin, based upon the effects of the shift of the oxyhemoglobin dissociation curve and, therefore, reflecting the true capacity of hemoglobin to unload oxygen at the tissue level, was calculated. During the hypothermic phase of bypass, this functional hemoglobin was only 4.2 g/100 ml blood, suggesting that, in spite of reduced metabolic demands, oxygenation reserves are minimal.
TL;DR: The protocol consisted of endotracheal intubation, curarization, mechanical ventilation, hypothermia to 31°C, and fluid restriction, and use of mannitol for active dehydration be reserved for cases with proven rise in ICP, in which case hemodynamics should be carefully monitored.
Abstract: Five patients suffering from progressive Reye's syndrome were aggressively treated in our ICU. Our protocol consisted of endotracheal intubation, curarization, mechanical ventilation, hypothermia to 31 degrees C, and fluid restriction. Intracranial pressure (ICP) was monitored and remained below 10-20 torr in all patients except one in whom ICP rose only once (for a few minutes) to 27 torr. Pulmonary artery wedge pressure was monitored in 4 patients and was maintained at 4-5 torr. Duration of active intervention as outlined above was 3-4 days. All 5 patients started with clinical stage IV and EEG grade IV or worse. Four patients had complete recovery and one died. In this group of patients, high ICP was not a feature of the disease. We recommend that use of mannitol for active dehydration be reserved for cases with proven rise in ICP, in which case hemodynamics should be carefully monitored.
TL;DR: Three patients are described, illustrating the administration of EPAP without intubation for mild ARDS, aspiration penumonia, and postoperative atelectasis in acute respiratory failure.
Abstract: The early institution of end expiratory pressure has been demonstrated frequently to be beneficial in acute respiratory failure. EPAP without intubation allows early therapy while avoiding the complications associated with the high flow rates utilized with CPAP. Three patients are described, illustrating the administration of EPAP for mild ARDS, aspiration penumonia, and postoperative atelectasis.
TL;DR: A detailed report on the activities of a major Australasian ICU is presented, showing a linear increase in admissions and a broadening scope of references, mortality has remained constant.
Abstract: A detailed report on the activities of a major Australasian ICU is presented. An adequate team of specially trained medical and nursing staff is required to function efficiently. Despite a linear increase in admissions and a broadening scope of references, mortality has remained constant. Practice of Intensive Care Medicine must not be confined solely to special units. Involvement in other hospital areas is described.