Showing papers in "Critical Care Medicine in 1982"
TL;DR: The data suggest that the commonly monitored variables, in and of themselves, do not reflect adequately the blood volume status in critically ill patients.
Abstract: Blood volumes measured by indicator dilution method in over 1500 instances of critically ill patients of various etiologies and at various times throughout their critical illness were compared with the values of concomitantly measured mean arterial pressure (MAP), CVP, pulmonary arterial wedge pressure (WP), Hct, and cardiac output. During resuscitation from hypovolemic shock, the patients' blood volumes and the monitored variables were significantly altered. However, there were poor correlations between the extent of blood volume changes and these variables during resuscitation as well as throughout the critical illness, irrespective of the etiologic type or stage of shock. With administration of a fluid load, blood volume and values of the commonly monitored variables improved appropriately, but the correlation coefficients, in general, were not good. The data suggest that the commonly monitored variables, in and of themselves, do not reflect adequately the blood volume status in critically ill patients.
303 citations
TL;DR: The critically ill are at high risk of venous thromboembolism and low-dose heparin prophylaxis is warranted in those who have no hemostatic impairment, according to a randomized, double-blind study.
Abstract: The incidence of deep venous thrombosis of the legs (DVT) was studied in 119 critically ill patients by 125I-labeled fibrinogen scanning; the efficacy of low-dose heparin prophylaxis was assessed in a randomized, double-blind study. DVT occurred in 29% of control patients and in 13% of patients receiving heparin 5000 U subcutaneously twice daily. DVT was found mainly in men and was associated with circulatory impairment, respiratory failure and recent vascular or cancer surgery. In a comparison study of medical patients, DVT occurred in 10% untreated and 2% treated. In conclusion, the critically ill are at high risk of venous thromboembolism and low-dose prophylaxis is warranted in those who have no hemostatic impairment.
284 citations
TL;DR: Patients admitted to the ICU have a higher risk of nosocomial infection than other hospitalized patients, and patients who had prolonged ICU stays and those on the obstetrics and gynecology, orthopedics, and general surgery services were more likely to become infected.
Abstract: Patients admitted to the ICU have a higher risk of nosocomial infection than other hospitalized patients. Whereas general medical/surgical ward patients have a 6% overall risk of acquiring an infection during their hospital stay, critically ill patients in the ICU have an 18% risk (P greater than 0.001). During this 2-year study, 440 of 2441 patients admitted to an ICU developed nosocomial infections. Patients who had prolonged ICU stays and those on the obstetrics and gynecology, orthopedics, and general surgery services were more likely to become infected. The most common bloodstream pathogens were Staphylococcus epidemidis, Staphylococcus aureus, and Serratia and Pseudomonas species.
250 citations
TL;DR: Alterations in calcium regulation and calcium concentrations are common during critical illness and optimal management of altered calcium concentrations requires an understanding of the pathophysiology behind these alterations.
Abstract: Hypocalcemia is an important metabolic problem in critical care medicine. To determine the frequency of this problem and the patient subsets at risk, a retrospective study of a large series of ICU patients was performed. During the study period, 259 patients were admitted to the ICU, of whom 210 (81
244 citations
TL;DR: The data suggest that the cardiorespiratory pattern of survivors are the appropriate goals of therapy for critically ill patients, rather than the norms of unstressed healthy volunteers.
Abstract: The hypothesis was tested that the median values of survivors of life-threatening postoperative conditions, rather than the norms of unstressed healthy volunteers, are the appropriate therapeutic goals for critically ill postoperative patients. The authors studied prospectively a series of 100 consecutive critically ill postoperative patients; normal values were used as the therapeutic goals of the control patients, while the median values of survivors were used as the goals of therapy for the protocol group. The age, sex, primary illness, surgical operation, lowest mean arterial pressure (MAP), time in hypotension incidence of severe hypotension (MAP greater than 50 mm Hg), and presence of associated severe medical illnesses (defined by predetermined criteria) were comparable in the control and protocol groups; i.e., clinical conditions of the protocol group were at least as severe as those of the control group. The mortality was significantly less in the protocol group (13%) than in the control group (48%); the number of life-threatening complications were also greater in the control group. These data suggest that the cardiorespiratory pattern of survivors are the appropriate goals of therapy for critically ill patients.
214 citations
TL;DR: Lack of augmented TSH concentrations, absence of low plasma reverse T3, and presence of hypermetabolism suggest that the reduced plasma free T3 does not indicate functional hypothyroidism, but may represent an adaptation to the assumption of metabolic control by the sympathetic nervous system.
Abstract: : The free tetraiodothyronine index (FT4I) and free triiodothyronine index (FT3I) in burn patients represented the serum levels of free (dialyzable) T4 and free T3, respectively. FT4I and FT3I were lower with greater burn size and were lower in nonsurvivors than expected for the burn size. There was no compensatory elevation of basal or releasing hormone-stimulated thyrotrophin (TSH) concentrations. Reverse T3 was higher with greater burn size. T3 treatment restored FT3I but did not affect mortality or resting metabolic rate (MR) measured in survivors, compared with placebo therapy. Whereas the hypermetabolic response to burn injury appeared to be independent of thyroid hormones, MR was correlated positively with burn size and with elevated plasma norepinephrine and epinephrine concentrations for several weeks after injury. Lack of augmented TSH concentrations, absence of low plasma reverse T3, and presence of hypermetabolism suggest that the reduced plasma free T3 does not indicate functional hypothyroidism, but may represent an adaptation to the assumption of metabolic control by the sympathetic nervous system.
188 citations
187 citations
186 citations
TL;DR: Parenteral nutrition should be guided by whether the goal is to preserve lean body mass in patients who are in satisfactory nutritional condition but whose return to oral intake is not imminent, or restore lean body weight in Patients who have lost greater than 10% of normal body weight.
Abstract: SUMMARYMalnutrition and weight loss are among the signs of a poor prognosis in the natural history of patients with COLD123, 124 Patients whose only source of daily nutrition is 2–31 of 5% dextrose suffer malnutrition and weight loss This has been documented to be detrimentalCurrently, there are
146 citations
TL;DR: The effect of PEEP on cardiac performance was evaluated in 21 patients with left ventricular (LV) dysfunction and when PAWP exceeded 18 mm Hg, PEEP was safe and in many instances augmented CO.
Abstract: The effect of PEEP on cardiac performance was evaluated in 21 patients with left ventricular (LV) dysfunction. Twenty-three data sets were divided into three groups according to pulmonary arterial wedge pressure (PAWP). In three of four group A data sets (PAWP = 12 mm Hg), cardiac output (CO) decreased when PEEP was added. In four of six group B data sets (PAWP = 14-18 mm Hg) and in 12 of 13 group C data sets (PAWP less than or equal to 19 mm Hg), CO increased with addition of PEEP. In group C, the mean increase in CO was 500 ml/min, and the mean level of best PEEP was 3.9 cm H2O. When PAWP exceeded 18 mm Hg, PEEP was safe and in many instances augmented CO.
146 citations
TL;DR: Use of the conventional "normal values" as cut-offs failed to discriminate between survivors and nonsurvivors better than chance alone.
Abstract: Seventeen critically ill patients were studied prospectively to determine the relationship of serum albumin, creatinine-height index (CHI) and weight-height index (WHI) to clinical outcome. Use of the conventional "normal values" as cut-offs failed to discriminate between survivors and nonsurvivors better than chance alone. A serum albumin less than 2.5 g/dl correctly separated 93% of the patients in terms of survival prognosis.
TL;DR: In a study of 28 ventilated patients in the ICU, cimetidine was ineffective in maintaining gastric pH above 4 and bacteriological examination of daily gastric aspirates showed that when the pH was above 4, there was rapid colonization with high counts of organisms, predominantly coliforms.
Abstract: In a study of 28 ventilated patients in the ICU, cimetidine was ineffective in maintaining gastric pH above 4. Quantitative and qualitative bacteriological examination of daily gastric aspirates showed that when the pH was above 4, there was rapid colonization with high counts of organisms, predominantly coliforms. Progressive colonization by yeasts, independent of pH, was noted in nearly one-half of the patients. Gastric colonization has possible implications in terms of crossinfection of development of aspiration pneumonia. As these are seriously ill patients with compromised gastrointestinal (GI) barriers and decreased immunity, the large numbers of bacteria or their endotoxins may contribute to the high incidence of septicemia.
TL;DR: Routine daily chest radiographs were judged to be valuable in identifying abnormalities in critically ill patients, however, the system for providing this service was only 63% efficient, and improvement must be sought in this regard.
Abstract: Two hundred routine chest x-rays were evaluated to determine their value in the management of critically ill patients in a Medical ICU (MICU). Seventy-four x-rays (37%) were of suboptimal value or were delivered to the MICU too late for inclusion on morning rounds. Of the remaining 126 films, 54 (43%) showed worsening of a known, or development of a new, cardiopulmonary abnormality, or an unexpected misplacement of an invasive device. On the basis of these findings, routine daily chest radiographs were judged to be valuable in identifying abnormalities in critically ill patients. However, the system for providing this service was only 63% efficient, and improvement must be sought in this regard.
TL;DR: Flood resuscitation of circulatory shock with colloid solutions increases COP and requires less volume of resuscitative fluid and saline resuscitation required significantly larger amounts of fluid.
Abstract: The effects of fluid resuscitation with 6% hetastarch, 5% albumin, or 0.9% saline solutions on plasma colloid osmotic pressure (COP) were examined in 26 patients with hypovolemic circulatory shock. One liter of hetastarch produced a 36% increase in COP compared to an 11% increase after 1 L of albumi
TL;DR: It is concluded that changing from CMV to IMV has salutory effects on the patient's hemodynamic values with normal left ventricular function, but in patients with failing left ventricle, volume overload of right ventricularle which occurs with the institution of spontaneous respiration during IMV can be effectively negated by the application of IMV5 PEEP.
Abstract: Hemodynamic effects of controlled mechanical ventilation (CMV), intermittent mandatory ventilation (IMV), and intermittent mandatory ventilation with 5 cm H20 PEEP (IMV 5 peep) were studied in 20 patients after aortocoronary bypass surgery. Significant increases in cardiac index (CI) and stroke volume index (SI) (p less than 0.01) resulted in patients with normal left ventricular end-diastolic pressure (LVEDP) and ejection fraction (EF) changing from CMV to IMV. With a change from IMV to IMV 5 peep, the CI and SI returned to CMV values. However, in patients with increased LVEDP with an EF of less than 0.6, suggesting poor ventricular function and reserve, when the mode of ventilation was changed from CMV to IMV, right atrial pressure (RAP) and pulmonary artery occlusion pressure (PAOP) significantly increased (p less than 0.01) with an associated significant decrease in mean arterial pressure (MAP), CI, SI (p less than 0.01). When these patients were placed on IMV 5 peep, the hemodynamic variables returned to the values obtained during CMV. We conclude that changing from CMV to IMV has salutory effects on the patient's hemodynamic values with normal left ventricular function. But in patients with failing left ventricle, volume overload of right ventricle which occurs with the institution of spontaneous respiration during IMV has deleterious effects on the hemodynamic variables. These deleterious effects can be effectively negated by the application of IMV 5 peep.
TL;DR: Phasic variation in cardiac output (CO) of 10–50% during mechanical ventilation was documented in dogs, and in 1 patient by injection of thermal indicator at 1-sec intervals throughout the ventilation cycle.
Abstract: Phasic variation in cardiac output (CO) of 10-50% during mechanical ventilation was documented in dogs, and in 1 patient by injection of thermal indicator at 1-sec intervals throughout the ventilation cycle. Measured flow variation increased with inflation pressure when other variables were unchanged, and was not influenced to a significant degree by the injection of iced vs room temperature injectate. Such variation can occur in adult patients requiring only minimally increased airway pressure for ventilation. The technique of injecting indicator at a particular moment of the ventilation cycle is not appropriate to monitor absolute or even relative changes in CO because of occasional changes in the phase relation between the ventilation cycle and the flow variation. The mean CO by thermodilution technique is approximately best by the mean of values taken at regularly spaced intervals through the ventilation cycle.
TL;DR: It is suggested that the use of a general severity of illness index and multivariate statistical techniques could, after further refinement and validation, improve interhospital comparisons of the outcome of acutely ill patients.
Abstract: To contrast mortality for groups of ICU patients treated in different hospitals, we surveyed 795 consecutive ICU admissions in 5 ICUs using a general severity of illness classification system. After obtaining information from the medical record on age, sex, indication for ICU admission, and severity of illness, we used a logistic multiple regression equation to project death rates for each ICU based on data from a sixth reference hospital. There were substantial differences in severity of acute illness among the hospitals which accounted for most of the variation in death rates. In all ICUs, however, projected death rates were quite similar to observed deaths. These findings suggest that the use of a general severity of illness index and multivariate statistical techniques could, after further refinement and validation, improve interhospital comparisons of the outcome of acutely ill patients.
TL;DR: Interactive television was used to provide consultation with university-based critical care physicians for patients in the ICU of a 100-bed hospital and had greater clinical and educational impact than consultation using the telephone.
Abstract: We introduced telemedicine, i.e., telecommunications for delivery of health services, to alleviate scarcity and maldistribution of critical care services. For 18 months, we used interactive television to provide consultation with university-based critical care physicians for patients in the ICU of a 100-bed hospital. Telemedicine "visits" (1548) were made to 395 patients. Television consultation had greater clinical and educational impact than consultation using the telephone. Equipment was expensive but proved to be reliable and easy to use. Interactive television extended the availability of specialist expertise, but full exploitation of this technology for delivery of critical care services was not achieved. Extensive background research, currently underway at the University of Pittsburgh, is necessary before the next telemedicine demonstration.
TL;DR: Results suggest that the decrease in CO is the most likely mechanism of the fall in HPF during CPPV, which was related to the level of PEEP.
Abstract: To quantify the influence of continuous positive pressure ventilation (CPPV) on hepatic plasma flow (HPF) in 8 critically ill patients submitted to controlled ventilation, we measured simultaneously HPF by the indocyanine green dye (IGD) clearance and cardiac output (CO) by the thermodilution techni
TL;DR: In 15 adult cardiac surgical patients who manifested combined oliguria and left ventricular dysfunction postoperatively, low-dose dopamine infusion produced significant improvement in renal function, with resolution of oliguria in every case, and with no deleterious hemodynamic effect.
Abstract: Hemodynamic and renal function response to low-dose (100 and 200 μg/min) dopamine infusion was studied in 15 adult cardiac surgical patients who manifested combined oliguria and left ventricular dysfunction postoperatively. Patients were studied an average of 6.6 h after ICU admission, at normotherm
TL;DR: It is concluded that evaluation of ICU outcome should provide information on 6-month survival and HS and include important variables as age, previous HS, and severity of acute illness.
Abstract: Age, previous health status (HS), and severity of acute illness were assessed prospectively on 228 unselected patients admitted over 1 yr to the multidisciplinary ICU, to determine their influence on outcome. One hundred and fifty patients (66%) were discharged from the ICU, but the survival rate fe
TL;DR: Ventilator-dependent patients who respond to nutritional support with an increase in protein synthesis are more likely to wean from mechanical ventilation than those who do not.
Abstract: Over a 2-year period, 14 viable ventilator-dependent patients were transferred from the Medical Intensive Care Unit (MICU) to a general ward floor for nutritional support after failing to wean from mechanical ventilation (MV) while in the MICU These patients were retrospectively grouped based on their ultimate ability to wean from MV: group 1 (N = 6) did not wean from MV and ultimately died in the hospital; group 2 (N = 8) weaned from MV and were eventually discharged Before transfer from the MICU, the two groups did not differ with regard to serum albumin or transferrin levels, or in total lymphocyte count After the period of aggressive nutritional support, group 2 patients showed an increase in serum albumin and transferrin whereas patients in group 1 showed a decrease The differences between these groups were significant (p less than 005) The lymphocyte count did not change significantly Ventilator-dependent patients who respond to nutritional support with an increase in protein synthesis are more likely to wean from mechanical ventilation than those who do not
TL;DR: Three cases of PP are presented and the literature reviewed in order to demonstrate the source of the intra-abdominal gas, the factors predisposing to PP, the causes and mechanisms of PP, and its diagnosis and treatment.
Abstract: Pneumoperitoneum (PP) in artificially ventilated patients is usually caused by barotrauma to the lungs or by perforation of an intra-abdominal viscus. The differential diagnosis is sometimes difficult but important, as unnecessary laparotomy could result if the PP is due to pulmonary barotrauma. Three cases of PP are presented and the literature reviewed in order to demonstrate the source of the intra-abdominal gas, the factors predisposing to PP, the causes and mechanisms of PP, and its diagnosis and treatment. A classification based on the mechanism involved in the production of PP is presented.
TL;DR: It is concluded that a central venous catheter can replace the PA catheter to collect blood representative of mixed venous blood samples for the above purposes, however, the exact numerical value of mixed blood samples can only be measured from blood collected from the PA itself.
Abstract: To estimate the value of central venous blood as representative of real changes in pulmonary shunt (Qsp/Qt), mixed venous oxygen saturation and arteriovenous oxygen content difference [C(a-v)O2] during active phases of adult intensive care therapy, 86 blood samples were withdrawn from 42 patients as quadruple simultaneous collections from systemic artery, pulmonary artery (PA), superior caval vein (CV) and right atrium (RA). We found a significant positive correlation of the measured variables and especially of the subsequent changes of these variables in individual patients between PA blood samples and both CV and RA blood samples (p less than 0.001). We, therefore, conclude that a central venous catheter can replace the PA catheter to collect blood representative of mixed venous blood samples for the above purposes. However, the exact numerical value of mixed venous blood samples can only be measured from blood collected from the PA itself.
TL;DR: A method using an external air/oxygen blender was found that provided a stable Fio2 for metabolic measurements for each of the ventilators tested and was successful in measuring Vo2 on mechanically ventilated patients.
Abstract: The determination of minute oxygen consumption (Vo2) for metabolic studies on patients using either the Beckman Metabolic Cart (MMC) or the Respiratory Monitoring System (RMS) requires a stable fractional inspired oxygen concentration (Fio2). Measurement of Vo2 on mechanically ventilated patients us
TL;DR: The authors administered halothane anesthesia to treat a child with status asthmaticus that was refractory to conventional pharmacological therapy and mechanical ventilation and suggested role for its use in childhood asthma is proposed.
Abstract: The authors administered halothane anesthesia to treat a child with status asthmaticus that was refractory to conventional pharmacological therapy and mechanical ventilation. Halothane is an inhalation anesthetic with potent bronchodilator properties. Marked improvement in gas exchange occurred in t
TL;DR: Preoperative respiratory function tests were correlated with postoperative respiratory complications and the percentage of predicted vital capacity provided the best indicator of outcome and values of <30% were associated with major rtspiratory complications.
Abstract: Scoliosis associated with muscular dystrophy frequently necessitates surgical stabilization of the spine. The timing of surgery usually is based on the degree of spinal angulation. Pulmonary function, which deteriorates with age in children with muscular dystrophy, should also be an important consideration in this timing. In a retrospective study of 48 patients who underwent spinal stabilization, preoperative respiratory function tests were correlated with postoperative respiratory complications. The percentage of predicted vital capacity provided the best indicator of outcome and values of less than 30% were associated with major respiratory complications. Spinal fixation failed to arrest the decline in respiratory function in these patients, but it seemed to slow the rate of deterioration compared with preoperative changes. Evaluation of pulmonary function should play a major role in the timing of surgical intervention in muscular dystrophy.
TL;DR: It is concluded that prophylactic therapy (cimetidine or antacids) given without titration is associated with a lower frequency of upper gastrointestinal hemorrhage than when no medication is given.
Abstract: Because approximately 20% of patients receiving mechanical ventilation have upper gastrointestinal bleeding, these patients were prophylatically treated with either antacids, cimetidine, or a placebo in a double-blind randomized fashion. The authors did not titrate gastric acidity because it is a time-consuming process that requires a nasogastric tube. When gastrointestinal bleeding developed in 9 of the 36 patients entered in the study, the treatment code was broken to assess the efficacy of prophylaxis and the frequency of complications. In the antacid group, 5 of the 11 patients were unable to ingest and tolerate their antacids (p less than 0.05 when compared to the control and cimetidine groups). Gastrointestinal bleeding did not occur in any of the six subjects receiving antacids but did occur in one of the 11 subjects receiving cimetidine, in 5 of the 14 control patients, and in 3 of the 5 patients who were unable to tolerate antacids. These differences were not significant. When groups were rearranged, though, there was a significant difference between them. Only 1 of 17 patients receiving medication (antacids or cimetidine) bled, whereas 8 of 19 patients receiving no medications bled (p less than 0.01). The average number of risk factors was not significantly different in the treatment groups. The authors conclude that prophylactic therapy (cimetidine or antacids) given without titration is associated with a lower frequency of upper gastrointestinal hemorrhage than when no medication is given. The authors also conclude that more subjects are able to tolerate cimetidine than antacids.