Showing papers in "Critical Care Medicine in 1984"
TL;DR: The simplified acute physiology score (SAPS), evaluated in 679 consecutive patients admitted to eight multidisciplinary referral ICUs in Francece, was a simpler and less time-consuming method for comparative studies and management evaluation between different ICUs.
Abstract: We used 14 easily measured biologic and clinical variables to develop a simple scoring system reflecting the risk of death in ICU patients. The simplified acute physiology score (SAPS) was evaluated in 679 consecutive patients admitted to eight multidisciplinary referral ICUs in France. Surgery accounted for 40% of admissions. Data were collected during the first 24 h after ICU admission. SAPS correctly classified patients in groups of increasing probability of death, irrespective of diagnosis, and compared favorably with the acute physiology score (APS), a more complex scoring system which has also been applied to ICU patients. SAPS was a simpler and less time-consuming method for comparative studies and management evaluation between different ICUs.
1,230 citations
TL;DR: It is suggested that PA catheterization is both indicated and useful in the management of critically ill patients because of the difficulty of predicting accurately hemodynamics based solely on clinical evaluation.
Abstract: Although pulmonary artery (PA) catheterization is frequently employed in the management of critically ill patients, there is little documentation that the information obtained alters patient management. This study evaluated prospectively this question in 103 PA catheterizations. Before catheterization, physicians were asked to predict the range of several hemodynamic variables, the presumed diagnosis, and their plan for therapy. After catheterization, each chart was reviewed. The hemodynamics at the time of catheterization and therapy within 8 h of catheterization were noted. Pulmonary artery occlusive (wedge) pressure (WP) was correctly predicted 30% of the time. Cardiac output, systemic vascular resistance (SVR), and right atrial pressure (RAP) were correctly predicted approximately 50% of the time. There was no significant difference in the ability to predict hemodynamics of subgroups with either hypotension or impaired oxygenation. After catheterization, planned therapy was altered in 58% of the cases. Unanticipated therapy was added in 30% of the cases. This study documents the difficulty of predicting accurately hemodynamics based solely on clinical evaluation. Thus, the information obtained by catheterization often leads to alterations in the therapeutic plan. We suggest that PA catheterization is both indicated and useful in the management of critically ill patients.
361 citations
TL;DR: In all nonsurvivors, it was impossible to maintain diastolic pressure above 30 mm Hg even with large doses of epinephrine and saline, which appears important for survival.
Abstract: A study was done to determine if 12 dogs could be resuscitated from 30 min of ventricular fibrillation if aortic diastolic blood pressure was maintained above 30 mm Hg by administration of epinephrine and, in 6 cases, saline solution during cardiopulmonary resuscitation (CPR). Of the 12 dogs seven were resuscitated successfully. The survivors received 3.4 +/- 1.7 mg of epinephrine, whereas the nonsurvivors received 11.1 +/- 2.1 mg of epinephrine. The aortic diastolic blood pressure was significantly higher (p less than .05) in the survivors at 12, 18, 24, and 30 min of ventricular fibrillation. In all nonsurvivors, it was impossible to maintain diastolic pressure above 30 mm Hg even with large doses of epinephrine and saline. Maintenance of an adequate diastolic blood pressure during CPR appears important for survival.
207 citations
TL;DR: Preliminary trials of long-term therapy with oral verapamil for control of atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia suggest that this agent is effective for therapy of these arrhythmias.
Abstract: Calcium ions play an important role in the cardiovascular system. They are involved in electrophysiologic processes, link excitation to muscular contraction, control energy storage and utilization, and constrict vascular smooth muscle in coronary and systemic arteries. A new group of pharmacologic agents that block the passage of calcium ions across cell membranes has been developed. These agents act during the slow inward current of cellular depolarization. The most extensive clinical experience has been obtained with four of these agents: verapamil, nifedipine, perhexiline, and diltiazem. Verapamil, which has profound electrophysiologic effects on the slow inward current, is emerging as a valuable antiarrhythmic agent. Re-entrant supraventricular arrhythmias, such as paroxysmal supraventricular tachycardia, are particularly amenable to treatment with intravenous verapamil. Preliminary trials of long-term therapy with oral verapamil for control of atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia suggest that this agent is effective for therapy of these arrhythmias.
177 citations
TL;DR: It is documented that a calcium entry blocker, given after cardiac arrest, can ameliorate late postischemic neurologic deficit (ND) and ND scores improved consistently through the 96-h observation period in the lidoflazine-treated dogs.
Abstract: Calcium entry blockers can ameliorate postischemic cerebral hypoperfusion, protect the myocardium against ischemia, and may protect against early postischemic neurologic deficit. This study documents that a calcium entry blocker, given after cardiac arrest, can ameliorate late postischemic neurologi
161 citations
TL;DR: Three pediatric patients with generalized status epilepticus unresponsive to therapy with conventional anticonvulsants were successfully treated with moderate hypothermia and barbiturate coma with thiopental, indicating that the patient can be managed in an ICU without the need for general anesthesia with volatile anesthetic agents.
Abstract: Three pediatric patients with generalized status epilepticus unresponsive to therapy with conventional anticonvulsants were successfully treated with moderate hypothermia (30 degrees to 31 degrees C) and barbiturate coma with thiopental. All 3 patients were treated with thiopental at doses producing burst suppression or an isoelectric tracing on the EEG and thiopental and barbiturate levels were followed sequentially in the plasma. Continuous thiopental infusion rates of 5 to 55 mg/kg X h maintained burst suppression and correlated with plasma thiopental levels of 25 to 40 mg/dl. Total doses of thiopental used to obtain and maintain burst suppression ranged from 15 to 50 g over 48 to 120 h. In all 3 patients, control of the status epilepticus was obtained. Moderate hypothermia and thiopental barbiturate coma are indicated in patients with generalized tonic-clonic status epilepticus which cannot be controlled with standard anticonvulsant drug therapy. This regimen has the advantage that the patient can be managed in an ICU without the need for general anesthesia with volatile anesthetic agents.
152 citations
TL;DR: Physiologic changes associated with endotracheal intubation were examined in 10 preterm infants and laryngoscopy was associated with apnea and minor abnormalities in cardiac rhythm in 2 infants.
Abstract: Physiologic changes associated with endotracheal intubation were examined in 10 preterm infants. Laryngoscopy was associated with apnea and minor abnormalities in cardiac rhythm in 2 infants. Three infants had nasal airflow recordings which demonstrated obstructed breaths during laryngoscopy. Systolic blood pressure (BP) increased 47% when the trachea was intubated, whereas heart rate and transcutaneous oxygen tension (PtcO2) decreased. Because endotracheal intubation is a physiologically stressful procedure, personnel who intubate preterm infants must be skilled and experienced to minimize the duration of laryngoscopy and the number of intubation attempts.
151 citations
TL;DR: Results indicate that lipid peroxidation may contribute to the development of DIC in critically ill patients.
Abstract: Plasma lipid peroxide measured as thiobarbituric acid reactive substances (TBARS) and alpha-tocopherol levels in 24 critically ill patients were compared with those of control subjects The mean plasma alpha-tocopherol level was significantly lower and the mean TBARS level was significantly higher in critically ill patients Eight ICU patients developed disseminated intravascular coagulation (DIC); the mean TBARS level during DIC was significantly above the mean pre-DIC level These results indicate that lipid peroxidation may contribute to the development of DIC in critically ill patients
125 citations
TL;DR: After cardiac surgery, 44 children received a continuous iv infusion of morphine sulfate at 10 to 30 Mg/kg-h and during spontaneous ventilation serum morphine levels less than 30 ng/ml were not associated with elevated Paco2.
Abstract: After cardiac surgery, 44 children received a continuous iv infusion of morphine sulfate at 10 to 30 Mg/kg-h. During weaning from assisted ventilation and during spontaneous ventilation serum morphine levels less than 30 ng/ml were not associated with elevated Paco2. Five extubated patients breathed
122 citations
116 citations
TL;DR: Clinical criteria of pneumonia include fever, leukocytosis, purulent tracheobronchial secretions, and a new infiltrate on chest x-ray—all of which are also frequently observed in patients free of pneumonia.
Abstract: Nosocomial pneumonia occurs in 0.5% to 5.0% of all hospital admissions and is responsible for 15% of hospital deaths. Up to 60% of ICU patients may develop pneumonia, depending on the severity of their underlying disease. Despite the availability of potent antibiotics, ICU patients who develop Gram-negative pneumonia have a disturbingly high mortality rate. Specific etiologic diagnosis is frequently lacking because microbiological samples are commonly contaminated by oropharyngeal secretions which are colonized by Gram-negative bacilli (GNB) in up to 100% of ICU patients. Great controversy surrounds the value of various methods used to diagnose nosocomial pneumonia. Clinical criteria of pneumonia include fever, leukocytosis, purulent tracheobronchial secretions, and a new infiltrate on chest x-ray--all of which are also frequently observed in patients free of pneumonia. Tracheobronchial secretions are often contaminated by microorganisms colonizing the upper airways and their examination may provide misleading information and result in patient mismanagement. Blood cultures are valuable but positive in only a small proportion of patients with nosocomial pneumonia. Transtracheal and transthoracic aspiration are unsatisfactory in the intubated patient requiring mechanical ventilation. Immunologic techniques like countercurrent immunoelectrophoresis are promising but presently inadequate to screen for a wide variety of organisms. Transbronchial or open-lung biopsy may be considered if the pneumonia is thought to be due to opportunistic organisms rather than bacteria.(ABSTRACT TRUNCATED AT 250 WORDS)
TL;DR: The experience in the use of intensive therapy for a group of 30 patients suffering from leukemia, bone-marrow aplasia, or lymphoma, who were hypoxemic and responded poorly to the administration of high oxygen concentrations via face mask is presented.
Abstract: The development of acute respiratory failure (ARF) in patients with hematologic disorders (HDs) is a life-threatening condition which does not respond well to intensive therapy. We present our experience in the use of intensive therapy for a group of 30 patients suffering from leukemia (21 cases), b
TL;DR: Continuous positive airway pressure delivered by mask proved to be a nearly effortless form of postoperative respiratory therapy that was less painful than incentive spirometry or coughing and deep breathing, and therefore may be preferable.
Abstract: Of 38 patients undergoing median sternotomy for cardiac operations all developed profound restrictive defects in pulmonary function during the first 72 h after tracheal extubation. Although decreased lung volumes were refractory to correction by vigorous, aggressive pulmonary therapy during this period, frequent and supervised treatment may prevent further deterioration in pulmonary function. The overall incidence of pneumonia was only 3% (1/38). Continuous positive airway pressure delivered by mask proved to be a nearly effortless form of postoperative respiratory therapy that was less painful than incentive spirometry or coughing and deep breathing, and therefore may be preferable.
TL;DR: Salbutamol was found to be a safe and effective bronchodilator capable of reversing severe bronchospasm in most children who would otherwise require mechanical ventilation, and its greater specificity for beta2-receptors may make it preferable to isoproterenol.
Abstract: The management of status asthmaticus using a continuous iv infusion of salbutamol was studied in 14 children with a total of 16 episodes of respiratory failure, unresponsive to conventional bronchodilator therapy. The mean PaCO2 at the start of the infusion was 60 +/- 6 torr. A loading dose of 1 microgram/kg X min body weight was given over 10 min, followed by an infusion of 0.2 microgram/kg X min which was increased in 0.1-microgram/kg steps according to response. The maximum dose was 4 microgram/kg X min. On 11 (69%) occasions a sustained reduction in PaCO2 was achieved within 4 h of starting the infusion. In 5 (11%) instances no reduction in PaCO2 was seen and mechanical ventilation was instituted because of increasing respiratory distress and CO2 retention. Mean heart rate during the infusion increased from 161 to 183 beat/min. Comparison with previous data from 30 pediatric patients (40 infusions) receiving iv isoproterenol showed less effect on heart rate and a more sustained fall in PaCO2 without the recurrence of bronchospasm. We found salbutamol to be a safe and effective bronchodilator capable of reversing severe bronchospasm in most children who would otherwise require mechanical ventilation. Its greater specificity for beta 2-receptors may make it preferable to isoproterenol.
TL;DR: A total of 2711 pulmonary artery wedge pressure measurement attempts were made prospectively from WP recordings in 44 critically ill patients, using 77 flow-directed catheters, and 322 failed to yield a WP measurement, and 521 were associated with technical problems.
Abstract: A total of 2711 pulmonary artery wedge pressure (WP) measurement attempts were made prospectively from WP recordings in 44 (30 men) critically ill patients, using 77 flow-directed catheters. Of these, 322 (12%) failed to yield a WP measurement, and 521 (18%) were associated with technical problems.
TL;DR: A former ICU nurse who required prolonged mechanical ventilation and paralysis and received morphine as a sedative recently cared for, and stressed the need for very frequent reorientation to time and her desire for constant explanation and re-explanation of all procedures being done by the nursing and physician staff.
Abstract: Prolonged therapeutic paralysis with pancuronium is commonly used in ICUs to facilitate mechanical ventilation of patients with respiratory failure. Sedation is usually given concomitantly to reduce patient discomfort, but assessment of its adequacy is made difficult by the paralysis. We recently ca
TL;DR: Five patients with nonoliguric adult respiratory distress syndrome (ARDS) secondary to severe sepsis showed improved blood oxygenation after up to 36 h of conventional therapy and mechanical ventilation with optimal positive end-expiratory pressure but metabolic acidosis was unchanged, and blood urea had increased.
Abstract: Five patients with nonoliguric adult respiratory distress syndrome (ARDS) secondary to severe sepsis showed improved blood oxygenation after up to 36 h of conventional therapy and mechanical ventilation with optimal positive end-expiratory pressure. However, metabolic acidosis was unchanged, and blood urea had increased. Some patients showed hemodynamic signs of incipient heart failure. After sequential hemofiltration, the altered physiologic shunt and blood pH returned to normal. Chest x-rays showed clearing of interstitial pulmonary edema. Patients recovered from ARDS in spite of fluid accumulation. Mechanical ventilation was stopped up to 8.5 h after the last hemofiltration. We postulate that convective ultrafiltration clears the blood of circulating low- and middle-weight vasoactive molecules implicated in the development of high microvascular permeability acute pulmonary edema secondary to sepsis.
TL;DR: Sequential cardiopulmonary variables were analyzed in 32 infants and children with septic shock and revealed significantly more dysfunction in nonsurvivors than survivors during the postresuscitation (PR) and middle (M) shock stages.
Abstract: Sequential cardiopulmonary variables were analyzed in 32 infants and children with septic shock. Variables were staged by a system based on therapeutic efforts to control blood pressure. There were 14 survivors and 18 nonsurvivors. Systemic circulation variables (MAP, cardiac index [CI], systemic vascular resistance index [SVRI], wedge pressure [WP], left cardiac work index [LCWI]) and pulmonary circulation variables (mean pulmonary artery pressure [MPAP], pulmonary vascular resistance index [PVRI], CVP, right cardiac work index [RCWI]) were similar in survivors and nonsurvivors. Pulmonary variables (intrapulmonary shunt [Qsp/Qt], fraction of inspired oxygen [FIO2], Pao2, PaCO2) revealed significantly more dysfunction in nonsurvivors than survivors during the postresuscitation (PR) and middle (M) shock stages. Even though oxygen delivery was equivalent in survivors and nonsurvivors, nonsurvivors demonstrated decreased oxygen utilization variables (oxygen consumption [Vo2], arteriovenous oxygen content difference [C(a-v)O2], O2 extraction index, core temperature) during the resuscitation (RS) and PR stages.
TL;DR: A compact instrument designed for monitoring VO2 and VCO2 in the critically ill adult, measured under controlled laboratory conditions using oxygen-enriched air, PEEP, and intermittent mandatory ventilation (IMV).
Abstract: In the critically ill patient the monitoring of oxygen consumption (VO2) and carbon dioxide production (VCO2) can identify abnormalities in tissue perfusion and metabolism. A patient's metabolic utilization can be calculated by indirect calorimetry, once VO2 and VCO2 are measured. This paper evaluates a compact instrument designed for monitoring VO2 and VCO2 in the critically ill adult. Accuracy was measured under controlled laboratory conditions using oxygen-enriched air, PEEP, and intermittent mandatory ventilation (IMV). Accuracy averaged 1.3% for VO2 and 0.9% for VCO2 when room air was used. Accuracy was 11.7% for VO2 and 6.8% for VCO2 when 80% oxygen was used. PEEP of 30 cm H2O had little effect on accuracy. IMV at 2 breath/min (room air) resulted in an accuracy of 4.0% and 4.1% for VO2 and VCO2, respectively.
TL;DR: Objective and quantitative methods were used to measure severity of illness and outcome of intensive care in critically ill patients, in terms of success or failure of therapy within the ICU, survival or death at 1 yr, quality of life in survivors, and utilization of resources.
Abstract: Objective and quantitative methods were used to measure severity of illness and outcome of intensive care in critically ill patients, in terms of success or failure of therapy within the ICU, survival or death at 1 yr, quality of life in survivors, and utilization of resources. One hundred ninety-ni
TL;DR: It is concluded that use of TLC catheters in critically ill patients does not appear to increase the risk of infectious disease and thrombocytopenia.
Abstract: The incidence of thrombocytopenia and catheter-induced infection and colonization after the use of triple lumen (TLC), pulmonary artery (PA), and single lumen central venous (CVP) catheters was studied in 29 critically ill patients. Catheter-induced sepsis was documented in 7% of patients with TLC and 10% of patients with CVP and PA catheters. Thirty-three percent of TLC, 20% of PA and 10% of CVP catheters became contaminated during the study. Staphylococcus epidermidis most commonly caused catheter sepsis and contamination. Only patients with PA catheters showed significant decrease in their platelet count. We conclude that use of TLC catheters in critically ill patients does not appear to increase the risk of infectious disease and thrombocytopenia.
TL;DR: The relationship between maximum inspiratory pressure and the patient's inorganic phosphate level is presented and the importance of obtaining and maintaining normal values of the serum phosphorus level to achieve successful weaning is illustrated.
Abstract: Hypophosphatemia has been only occasionally implicated as the cause of respiratory failure. This report illustrates its pathogenetic importance in the maintenance of such condition, as well as the importance of obtaining and maintaining normal values of the serum phosphorus level to achieve successful weaning. The relationship between maximum inspiratory pressure and the patient's inorganic phosphate level is presented (r = .97; p less than .01).
TL;DR: The dissimilar histologic injury patterns seen with 2 different forms of mechanical ventilation suggest different mechanisms of injury.
Abstract: We compared the tracheobronchial histopathology seen after conventional mechanical ventilation (CMV) and high-frequency jet ventilation (HFJV) in 44 adult cats. Two different HFJV humidity systems were examined: one used entrained mist alone, and the other infused 3 ml/kgh of 0.45% NaCl directly int
TL;DR: It is suggested that QR during CPR can be improved by augmenting perfusion-pressure gradients across the cerebral and coronary circulations by using radiolabeled microspheres.
Abstract: We studied regional blood flow (QR) using radiolabeled microspheres in 12 anesthetized dogs during cardiopulmonary resuscitation (CPR). A circumferential vest and abdominal binder were used with a mechanical ventilator to deliver 30 simultaneous chest compressions and ventilations per minute. When this device was modified to increase aortic pressure (Pao) during compression and the aortic-to-right atrial pressure gradient (Pao-Pra) during relaxation, cerebral and myocardial QR increased significantly. These findings suggest that QR during CPR can be improved by augmenting perfusion-pressure gradients across the cerebral and coronary circulations.
TL;DR: A no-code order is suggested which provides greater specificity for individual patients after it was found that review of patients' charts indicated that 24 contained no documentation of treatment limitation plans beyond the no- code order.
Abstract: To identify treatment-withholding intentions for 56 VA medicine inpatients who received a no-code order, 31 resident physicians who wrote the orders completed a checklist on which they indicated the interventions they intended to withhold from each patient. Review of patients' charts indicated that 24 (43%) contained no documentation of treatment limitation plans beyond the no-code order. To identify the general interpretations of no-code orders, "cross-covering" physicians indicated on a questionnaire the likelihood that they would withhold specific interventions from patients they were covering who had received a no-code order. Both the intention and interpretation of no-code orders were characterized by variability, and interpretation of the orders was characterized by uncertainty as well. Because of these discrepancies, we suggest a no-code order which provides greater specificity for individual patients.
TL;DR: It is found that results from a transcutaneous arterial hemoglobin oxygen-saturation monitor correlated well with those from a co-oximeter and was not disturbed by differing hematocrit levels, the presence of fetal hemoglobin, or hypotension.
Abstract: We found that results from a transcutaneous arterial hemoglobin oxygen-saturation monitor correlated well with those from a co-oximeter. The monitor was not disturbed by differing hematocrit levels, the presence of fetal hemoglobin, or hypotension. We also found that the results of simultaneous transcutaneous arterial hemoglobin oxygen saturation (StcaO2) and transcutaneous oxygen tension (PtcO2) monitoring were predictably correlated over a wide range of hemoglobin saturations in preterm infants. When StcaO2 was between 80% and 95%, PtcO2 was at a safe level of 40 to 80 torr in 94% of the patients studied. StcaO2 monitoring as an index of arterial oxygenation has several advantages for the preterm infant.
TL;DR: Circulating levels of lactoferrin and ECP were serially measured in patients at risk for adult respiratory distress syndrome to support other clinical and experimental observations suggesting a central pathophysiologic role for granulocytes in ARDS.
Abstract: Circulating levels of lactoferrin, a specific granule protein of neutrophilic leukocytes, and eosinophil cationic protein (ECP), a specific granule protein of eosinophilic leukocytes, were serially measured in 19 patients at risk for adult respiratory distress syndrome (ARDS). Those patients who developed ARDS had significantly higher concentrations of both proteins than the patients without signs of ARDS. High ECP levels were observed in spite of peripheral eosinopenia. The lactoferrin levels were also increased in relation to circulating numbers of neutrophils. These findings are consistent with an enhanced turnover and/or activity of eosinophils and neutrophils in ARDS and thereby support other clinical and experimental observations suggesting a central pathophysiologic role for granulocytes in ARDS. No relation was found between ARDS or serum concentrations of lactoferrin or ECP and degree of complement consumption, suggesting that other mechanisms besides complement activation may underlie granulocyte activation in ARDS.
TL;DR: Echocardiographic, ECG, and serum enzyme studies closely correlated with impaired myocardial contractility and development of cardiogenic shock in patients with meningococcal bacteremia suggest that the onset of cardiac dysfunction precedes clinical manifestations of shock.
Abstract: Comparative hemodynamic measurements recorded in 19 cases of septic shock associated with Neisseria meningitidis bacteremia and in 20 shock cases associated with bacteremia due to other Gram-negative bacilli showed a significantly higher incidence of early myocardial depression in the cases with meningococcal infection. Echocardiographic, ECG, and serum enzyme (CK-MB isoenzyme) studies closely correlated with impaired myocardial contractility and development of cardiogenic shock in patients with meningococcal bacteremia. Autopsy of the heart from three patients who succumbed to shock confirmed the presence of myocarditis with intracellular Gram-negative diplococci. Our observations suggest that the onset of cardiac dysfunction precedes clinical manifestations of shock.
TL;DR: It is believed that indocyanine green clearance in the critically ill surgical patient is a simple, useful measure of hepatic function which is directly associated with outcome.
Abstract: The plasma clearance rate of indocyanine green (ICG) by the liver was measured in 39 critically ill surgical patients, 5 of whom died. The clearance rate in survivors and nonsurvivors was 11.1 +/- 7.1% and 4.8 +/- 4.3%, respectively (p less than .001). We believe that indocyanine green clearance in the critically ill surgical patient is a simple, useful measure of hepatic function which is directly associated with outcome.