Showing papers in "Critical Care Medicine in 1991"
TL;DR: Measurements of gastric intramucosal pH on ICU admission, and again 12 hrs later, have a high specificity for predicting patient survival in this ICU patient population (77.8% to 80.6%) and may be a useful addition to patient monitoring in the ICU.
Abstract: Objective To determine if measurements of gastric intramucosal pH have prognostic implications regarding ICU mortality. Design Prospective comparison of outcome. Setting General adult ICUs in two teaching hospitals. Patients Eighty consecutive patients age 18 to 84 yrs (mean 63.4), 50 men and 30 women, 55% in the medical and 45% in the surgical services. Methods Gastric intramucosal pH was measured on ICU admission and again 12 hrs later. A value of greater than or equal to 7.35 was used to differentiate between normal and low gastric intramucosal pH. Measurements and main results Fifty-four patients had a normal gastric intramucosal pH and 26 patients had a low gastric intramucosal pH on ICU admission. The mortality rate was greater in the low gastric intramucosal pH group (65.4% vs. 43.6%; p less than .04). The frequency of sepsis and the presence of multisystem organ failure also were greater in the low gastric intramucosal pH group (p less than .01). Further stratification of patients according to gastric intramucosal pH measured 12 hrs after admission showed a greater mortality rate in patients with persistently low gastric intramucosal pH when compared with patients with normal gastric intramucosal pH during the first 12 hrs (86.7% vs. 26.8%; p less than .001). Conclusions Measurements of gastric intramucosal pH on ICU admission, and again 12 hrs later, have a high specificity for predicting patient survival in this ICU patient population (77.8% to 80.6%). Furthermore, given its relative noninvasive nature, tonometrically measured gastric intramucosal pH may be a useful addition to patient monitoring in the ICU.
434 citations
430 citations
TL;DR: In this paper, a method and means for maintaining respiratory gas exchange by introducing into the pulmonary air passages (18) of a mammalian host a volume of perfluorocarbon liquid substantially equivalent to the pulmonary functional residual capacity of the host, by continuous positive pressure breathing or otherwise with a conventional gas respirator, for up to an hour or more.
Abstract: Method and means for maintaining respiratory gas exchange by introducing into the pulmonary air passages (18) of a mammalian host a volume of perfluorocarbon liquid substantially equivalent to the pulmonary functional residual capacity of the host, maintaining respiratory gas exchange in the perfluorocarbon liquid-laden pulmonary air passages (18) by continuous positive pressure breathing or otherwise with a conventional gas respirator (12), for up to an hour or more, and thereafter evaporating the perfluorocarbon liquid from the pulmonary air passages. Useful for treating pulmonary surfactant deficiency or dysfunction.
401 citations
TL;DR: The approach used overcomes previously identified difficulties with cerebral oximetry, and demonstrates excellent in vitro correlation, and can be performed clinically without difficulty.
Abstract: ObjectiveTo present an algorithm for noninvasive measurement of cerebral oxygen saturation (cerebral oximetry) and cerebral hemodynamics with near infrared spectroscopy.DesignIn vitro correlation of oximetry measurements with reference measurements; illustrative cases of hemodynamic and oximetric re
338 citations
TL;DR: Mild cerebral hypothermia started during or immediately after external CPR improves neurologic recovery and brain histopathologic damage scores were also lower (better) in groups 2 and 3 than in group 1.
Abstract: Background and methods This study was designed to explore the effect of mild cerebral and systemic hypothermia (34 degrees C) on outcome after prolonged cardiac arrest in dogs. After ventricular fibrillation with no flow of 10 min, and standard external CPR with epinephrine (low flow) from ventricular fibrillation time of 10 to 15 min, defibrillation and restoration of spontaneous normotension were between ventricular fibrillation time of 16 and 20 min. This procedure was followed by controlled ventilation to 20 hr postarrest and intensive care to 72 hr postarrest. In control group 1 (n = 10), core temperature was 37.5 degrees C; in control group 2 (n = 10), cooling was started immediately after restoration of spontaneous normotension; and in group 3 (n = 10), cooling was initiated with start of CPR. Cooling was by clinically feasible methods. Results Best overall performance categories achieved (1 = normal; 5 = brain death) were better in group 2 (p = .012) and group 3 (p = .005) than in group 1. Best neurologic deficit scores were 36 +/- 14% in group 1, 22 +/- 15% in group 2 (p = .02), and 19 +/- 18% in group 3 (p = .01). Brain histopathologic damage scores were also lower (better) in groups 2 (p = .05) and 3 (p = .03). Myocardial damage was the same in all three groups. Conclusion Mild cerebral hypothermia started during or immediately after external CPR improves neurologic recovery.
336 citations
TL;DR: Care of the most seriously ill children in tertiary pediatric ICUs could improve their chances of survival, and the number of deaths were significantly different than predicted.
Abstract: ObjectiveTo compare outcomes from pediatric intensive care in hospitals with different levels of resources.DesignProspective, blinded comparison of outcome and careSettingTertiary (n = 3) and nontertiary (n = 71) hospitals in Oregon and southwestern Washington.PatientsAll critically ill children adm
311 citations
TL;DR: These findings suggest that anatomical variation may partly account for the inability to cannulate the internal jugular vein in certain patients and suggest that ultrasound examination quickly establishes the position of the internaljugular vein and may allow for easy and rapid access.
Abstract: ObjectiveTo evaluate whether underlying anatomical variations in the position of the internal jugular vein may account for difficulty in obtaining central venous access in individual patients.DesignConsecutive series.SettingCardiac catheterization laboratory, coronary care unit, and ICU.PatientsTwo
307 citations
TL;DR: Percutaneous tracheostomy appeared to be superior to the conventional operation in patients with respiratory failure, and their complications tended to be more serious.
Abstract: ObjectiveTo compare percutaneous tracheostomy with conventional operative tracheostomy.DesignRandomized clinical trial.SettingThe medical and surgical critical care units of a large, tertiary-care, private hospital.PatientsTwenty-five male and 21 female translaryngeally intubated patients with respi
293 citations
TL;DR: Current evidence suggests that mucosal damage in shock, trauma, and sepsis is likely due to various combinations of intracellular hypoxia due to ischemia, tissue injury caused by reactive oxygen metabolites, the deleterious effects of various lipid mediators, and deficient utilization or supply of key nutritional substrates.
Abstract: Background and MethodsThe mucosa of the GI tract serves as an important barrier limiting the systemic absorption of luminal microbes and microbial products. Two methods commonly used to assess the integrity of the GI mucosal barrier are assessment of the extent of microbial translocation and measure
279 citations
TL;DR: An experimental canine model of hemorrhagic, hypovolemic shock is described that uses oxygen debt and its metabolic consequences of lactic acidemia and metabolic base deficit as independent variables for the prediction of probability of death and BE shows the highest explained variability.
Abstract: Background and MethodsAn experimental canine model of hemorrhagic, hypovolemic shock is described that uses oxygen debt and its metabolic consequences of lactic acidemia and metabolic base deficit as independent variables for the prediction of probability of death.ResultsLactic acidemia and metaboli
269 citations
TL;DR: Administration of sodium bicarbonate did not improve hemodynamic variables in patients with lactic acidosis, but did not worsen tissue oxygenation.
Abstract: ObjectiveTo determine whether correction of acidemia using bicarbonate improves hemodynamic variables and tissue oxygenation in patients with lactic acidosis.DesignProspective, randomized, blinded, cross over study. Each patient sequentially received sodium bicarbonate and sodium chloride. The order
TL;DR: NO appears to provide significant myocardial protection after ischemia and reperfusion, and may afford cardioprotection by incorporation into circulating blood cells (i.e., neutrophils, platelets), thereby inhibiting their accumulation and adherence in the ischemic region, or by a direct cardiac cytoprotective effect.
Abstract: BACKGROUND AND METHODS The purpose of this study was to determine the effects of nitric oxide (NO), believed to be endothelium-derived relaxing factor on reperfusion injury after myocardial ischemia (MI). The effects of NO were investigated in a 6-hr model of MI with reperfusion in open-chest, anesthetized cats. A solution containing NO was infused iv starting 30 min after occlusion of the left anterior descending coronary artery, continuing through reperfusion 1 hr later, and lasting for 5.5 hr. Estimated NO concentration in the circulation was 1 to 2 x 10(-9) M. RESULTS The areas-at-risk expressed as a percentage of the total left ventricular weights were not significantly different among either of the MI groups. However, the necrotic area (expressed as a percentage of the myocardial area-at-risk) was significantly (p less than .01) lower in the NO-treated MI cats compared with the MI + vehicle group. Cardiac myeloperoxidase activities indicated that significantly (p less than .05) fewer neutrophils were attracted to the necrotic zone of the NO-treated MI cats when compared with MI cats receiving only the vehicle. Sodium nitrate (NaNO2) (pH 7.4), a major breakdown product of NO, failed to exert any protective effect in this same model of MI and reperfusion. CONCLUSIONS NO appears to provide significant myocardial protection after ischemia and reperfusion. NO may afford cardioprotection by incorporation into circulating blood cells (i.e., neutrophils, platelets), thereby inhibiting their accumulation and adherence in the ischemic region, or by a direct cardiac cytoprotective effect. Further studies using NO donors rather than NO would be an appropriate clinically relevant mode of treatment in MI.
TL;DR: These data suggest that intraluminal production of CO2 from the titration of gastric HCO−3 by secreted H+ can result in the underestimation of Gastric pHi by tonometry, and this phenomenon can be eliminated by H2-receptor blockade.
Abstract: ObjectiveTo determine if intraluminal production of CO2 leads to underestimation of gastric intramural pH (pHi) by tonometry.DesignNonrandomized controlled study.PatientsHealthy volunteers.InterventionsNG tonometers were placed in healthy volunteers. Some of the volunteers (n = 11) were pretreated w
TL;DR: Ibuprofen was well tolerated when administered iv and rectally to patients with severe sepsis, although drug absorption was poor with the rectal route, and significant antipyretic effects of ib uprofen were demonstrated.
Abstract: Objective To evaluate the safety and physiologic actions of ibuprofen in patients with severe sepsis. Design Randomized, double-blind, placebo-controlled trial. Setting Three university hospital medical ICUs. Patients Twenty-nine patients with clinical evidence of sepsis and the need for hemodynamic monitoring with a pulmonary artery flotation catheter. Interventions Thirteen patients received placebo and 16 received ibuprofen that consisted of 600 mg (n = 11) or 800 mg (n = 5) iv over 20 mins, followed by three 800-mg doses administered as a rectal solution every 6 hrs. The initial iv dose was given within 4 hrs of the presumptive diagnosis of sepsis. Measurements and main results The peak circulating total ibuprofen concentration after the iv dose (49.4 +/- 4.5 micrograms/mL, mean +/- SEM) was higher than peak concentrations after the three rectal doses (17.0 +/- 2.7, 16.4 +/- 3.0, 16.0 +/- 3.1 micrograms/mL). Both routes of ibuprofen administration were well tolerated. Frequent monitoring for gastrointestinal bleeding and assessment of renal and hepatic function failed to demonstrate significant differences between ibuprofen and placebo. Because a trend for reduced creatinine clearance was observed at 8 hrs in the ibuprofen group, nephrotoxicity of this drug in sepsis cannot be excluded. Temperature decreased significantly within 4 hrs of the initial dose of investigational therapy in patients who received ibuprofen (38.5 +/- 0.3 degrees to 37.0 +/- 0.2 degrees C, p less than .001). However, despite this significant change in temperature, we were unable to detect significant differences in hemodynamic and respiratory values or survival when ibuprofen-treated patients were compared with controls. Conclusions Ibuprofen was well tolerated when administered iv and rectally to patients with severe sepsis, although drug absorption was poor with the rectal route. Significant antipyretic effects of ibuprofen were demonstrated. Although an excellent safety profile characterized ibuprofen in this study, the absence of ibuprofen-associated toxicity may have been secondary to poor rectal absorption of the drug. Our results support the continued clinical investigation of ibuprofen in sepsis, using an all-intravenous route of administration.
TL;DR: Although alternative explanations cannot be excluded with certainty, the use of neuromuscular junction blocking agents may lead to neurogenic atrophy and care must be taken when using them.
Abstract: OBJECTIVES Previous reports have described prolonged paralysis after treatment with neuromuscular junction blocking agents in critically ill patients. The purpose of this study was to further describe a group of patients who developed prolonged weakness after treatment with these agents. DESIGN Clinical information, electrodiagnostic and muscle pathology results are described in this group of patients. Clinical information includes diagnoses, dosage of neuromuscular junction blocker, other medications affecting the neuromuscular system, and neuromuscular examination and clinical course. SETTING All patients were seen in the ICUs of three local hospitals. PATIENTS Included were critically ill patients with a variety of diagnoses, all of whom developed severe weakness after discontinuation of neuromuscular junction blocking agents. INTERVENTIONS Electrodiagnostic studies and muscle biopsies were performed on several of the patients. MEASUREMENTS AND MAIN RESULTS All patients had pronounced weakness without sensory loss. Electrodiagnostic and muscle pathology findings were consistent with failed neuromuscular transmission. Although many patients had disorders or were taking medications that can injure the neuromuscular system, no disorder or medication was common to all. Recovery of strength often took several months and most patients were slow to wean from mechanical ventilator support. CONCLUSIONS Although alternative explanations cannot be excluded with certainty, the use of neuromuscular junction blocking agents may lead to neurogenic atrophy and care must be taken when using them.
TL;DR: The results suggest that endotoxin-induced bacterial translocation, mucosal injury, and ileal permeability are mediated via activation of xanthine oxidase, and not through complement activation or the liberation of macrophage products.
Abstract: Background and methods Previously, we documented that nonlethal doses of endotoxin injure the intestinal mucosal barrier and promote bacterial translocation from the gut to systemic organs. The current study was performed to determine the role of cytokines and complement activation in the pathogenesis of endotoxin-induced mucosal injury and bacterial translocation, as well as to quantify the magnitude of endotoxin-induced intestinal mucosal permeability. Results The frequency of endotoxin-induced bacterial translocation was similar between normal outbred (88%), complement deficient (67%), and macrophage-hyporesponsive (55%) mice, indicating that neither complement nor macrophage activation is necessary for endotoxin-induced bacterial translocation to occur. As early as 2 hrs after endotoxin challenge, there was evidence of a greater than two-fold increase in ileal (p = .008) but not jejunal (p = .11) permeability as measured by the clearance of 51Cr EDTA. Both the increase in endotoxin-induced ileal permeability and the occurrence of bacterial translocation were largely prevented by pretreatment with allopurinol, a competitive inhibitor of xanthine oxidase. Conclusions These results suggest that endotoxin-induced bacterial translocation, mucosal injury, and ileal permeability are mediated via activation of xanthine oxidase, and not through complement activation or the liberation of macrophage products.
TL;DR: Gastric intramucosal pH may provide a minimally invasive way to monitor the adequacy of splanchnic &U1E0A;o2 in patients undergoing cardiopulmonary bypass.
Abstract: ObjectiveTo determine the relationship between gastric intramucosal pH and several other indices of splanchnic perfusion in patients undergoing cardiopulmonary bypassDesignProspective, single-arm studySettingUniversity HospitalMethodsElective cardiac surgery patients (n = 8), free of hepatic dise
TL;DR: Sucralfate is an effective drug for the prevention of stress bleeding that minimizes the risk of nosocomial pneumonia in long-term ventilated ICU patients.
Abstract: Objectives and MethodsHistamine2 (H2)-receptor antagonists and antacids have been the basic drugs for the prevention of stress bleeding in ICU patients during the past decade. Recently, drugs without major influence on gastric pH have been investigated in stress bleeding prophylaxis. Therefore, a me
TL;DR: Esophageal Doppler measurement of aortic blood flow can be used for rapid, noninvasive optimization of left ventricular (LV) filling in mechanically ventilated patients.
Abstract: OBJECTIVE To confirm whether the descending aortic blood flow velocity waveform variable of flow time corrected for heart rate, measured using an esophageal Doppler transducer, can be used for noninvasive optimization of left ventricular (LV) filling. SETTING ICU and operating theater. SUBJECTS Forty-three mechanistically ventilated patients in the ICU or undergoing cardiothoracic surgery in whom a pulmonary arterial catheter was in situ. INTERVENTIONS LV preload was a) increased from hypovolemic states (pulmonary arterial occlusion pressure [PAOP] less than 8 mm Hg) by fluid challenge, b) decreased from normovolemic states (PAOP 10 to 15 mm Hg) by either iv nitrates or intravascular fluid loss, and c) decreased from heart failure or fluid overload states (PAOP greater than 20 mm Hg) by iv nitrates. No other maneuver was performed concurrently. MEASUREMENTS AND MAIN RESULTS Descending aortic blood flow was measured by an esophageal Doppler transducer. Corrected flow time was calculated by dividing systolic flow time by the square root of the cycle time. PAOP and corrected flow time increased after fluid challenges in hypovolemic states, and decreased when LV preload was decreased from normovolemic states. However, when preload was decreased from overload states, PAOP always decreased, but the corrected flow time usually increased before any subsequent decrease. The greatest value of corrected flow time corresponded with the maximal stroke volume seen. CONCLUSIONS Esophageal Doppler measurement of aortic blood flow can be used for rapid, noninvasive optimization of LV filling in mechanically ventilated patients.
TL;DR: Treatment of hyponatremic seizures with routine anticonvulsants may be ineffective and is associated with a considerable incidence of apnea, so a rapid increase in the serum sodium concentration by 3 to 5 mmol/L with the use of hypertonic saline is safe and efficacious in managing acute symptomatic hypon atremia.
Abstract: OBJECTIVE To study efficacy and safety of hypertonic saline administration in the management of hyponatremic seizures. DESIGN Retrospective, observational, cross-sectional study with factorial design. SETTING In-patient population in a university hospital. PATIENTS All children admitted with serum sodium concentrations less than 125 mmol/L. Sixty-nine episodes of severe hyponatremia in 60 children were reviewed. Forty-one of these children presented with seizures. INTERVENTIONS Twenty-five of 41 seizure patients received an iv bolus of 4 to 6 mL/kg body weight of 3% saline. Twenty-eight patients were treated with a benzodiazepine and/or phenobarbital with or without the subsequent administration of hypertonic saline. MEASUREMENTS AND MAIN RESULTS Thirteen treatment failures and ten instances of apnea occurred among the 28 patients treated with benzodiazepine/phenobarbital. Administration of hypertonic saline resulted in resolution of seizures and apnea in all cases. Those patients receiving 3% saline had a higher serum sodium increase rate from 0 to 4 hrs than the remaining patients (3.1 +/- 1.3 vs. 1.7 +/- 1.2 mmol/L.hr, p less than .01). None developed subsequent neurologic deterioration or clinical manifestations of osmotic demyelination syndrome. CONCLUSION Treatment of hyponatremic seizures with routine anticonvulsants may be ineffective and is associated with a considerable incidence of apnea. A rapid increase in the serum sodium concentration by 3 to 5 mmol/L with the use of hypertonic saline is safe and efficacious in managing acute symptomatic hyponatremia.
TL;DR: Resting energy expenditure is variable in patients with pancreatitis (77% to 139% of predicted energy expenditure) and the Harris-Benedict equations are an unreliable estimate of caloric expenditure.
Abstract: Objective To assess the resting energy expenditure of hospitalized patients with pancreatitis. Design Prospective, case-referent study. Setting Nutrition support service in a university tertiary care hospital. Patients Patients referred to the Nutrition Support Service with the diagnosis of pancreatitis. Excluded from study entry included those with cancer, obesity (greater than 150% ideal body weight), those measured within 3 postoperative days, or patients requiring ventilator support with an FIO2 of greater than 0.5. Forty-eight patients with either acute pancreatitis (n = 13), chronic pancreatitis (n = 24), acute pancreatitis with sepsis (n = 7), or chronic pancreatitis with sepsis (n = 7) were studied. The two septic groups were combined into a single pancreatitis-with-sepsis group, since no significant differences among measured variables were observed between individual septic groups. Interventions None. Measurements and main results Resting energy expenditure was measured by indirect calorimetry and compared with the predicted energy expenditure, as determined by the Harris-Benedict equations. Resting energy expenditure (percent of predicted energy expenditure) was significantly (p less than .02) greater for patients with pancreatitis complicated by sepsis (120 +/- 11%) compared with the nonseptic chronic pancreatitis group (105 +/- 14%). Resting energy expenditure for the nonseptic acute pancreatitis patients (112 +/- 17%) was not significantly different from the other groups. The septic pancreatitis group had the largest percentage (82%) of hypermetabolic (resting energy expenditure greater than 110% of predicted energy expenditure) patients, whereas 61% and 33% of the acute and chronic pancreatitis groups were hypermetabolic, respectively (p less than .02). Conclusions Resting energy expenditure is variable in patients with pancreatitis (77% to 139% of predicted energy expenditure). The Harris-Benedict equations are an unreliable estimate of caloric expenditure. Septic complications are associated with hypermetabolism and may be the most important factor influencing resting energy expenditure in pancreatitis patients.
TL;DR: Subcutaneous Po2 and Ptco2, and small intestine and sigmoid colon pHi were correlated to total body oxygen transport, and peripheral tissue perfusion followed intestinal perfusion to some extent.
Abstract: Background and MethodsTissue oxygenation, measured in peripheral tissue as transcutaneous Po2 (Ptco2) and subcutaneous Po2, was compared with the oxygenation in GI mucosa, which was measured as intramucosal wall pH (pHi), during experimental hemorrhagic shock and resuscitation in pigs. The pigs were
TL;DR: Aortic blood flow velocity waveform variables measured by Doppler ultrasound can be used to noninvasively follow changes in left ventricular preload, afterload, and inotropy.
Abstract: ObjectiveTo confirm the consistent effects on Doppler-measured aortic blood flow velocity waveform variables of alterations in left ventricular preload, afterload, and inotropy using pharmacologic and physiologic maneuvers.SettingMedical school laboratory.SubjectsHealthy volunteers.InterventionsIncr
TL;DR: Treatment with dantrolene sodium at the dose used, did not prove beneficial to patients with heatstroke and the difference in the mean cooling times was not statistically significant.
Abstract: Study ObjectiveTo determine the efficacy of dantrolene sodium in the treatment of heatstroke.DesignRandomized, double-blind, placebo-controlled trial.SettingHeatstroke center in Makkah, Saudi Arabia.PatientsFifty-two adult patients with heatstroke.InterventionsPatients were assigned to receive eithe
TL;DR: To compare vital sign and urine output monitoring of seriously burned patients with invasive monitoring during early resuscitation in a university hospital burn unit.
Abstract: Objective.To compare vital sign and urine output monitoring of seriously burned patients with invasive monitoring during early resuscitation.Design.Retrospective review.Setting.A university hospital burn unit.Patients.Fourteen seriously burned patients who had pulmonary arterial monitoring. Monitori
TL;DR: The GMSPS is a rapid clinical score that performs well in identifying children with poor prognosis who might benefit from early intensive care and should be studied prospectively and compared with other scoring systems.
Abstract: Objective To derive performance characteristics for the Glasgow Meningococcal Septicemia Prognostic Score (GMSPS). Design Retrospective case-note study. Setting Two children's hospitals with Regional Intensive Care Unit. Patients One hundred twenty-three children with proven meningococcal septicemia (some with concurrent meningitis) from January 1, 1977 to December 31, 1986. Measurements and main results All 14 children who died after arrival scored greater than or equal to 8 either on admission (n = 8) or afterward (n = 6). Of 109 survivors, five scored greater than or equal to 8 (two were postictal at the time of scoring). A GMSPS of greater than or equal to 10 at or after admission predicted death with sensitivity 100%, specificity 98%, and positive predictive value of 88%; for GMSPS of both greater than or equal to 8 or 9, the values were 100%, 95%, and 74%, respectively. Conclusions The GMSPS is a rapid clinical score that performs well in identifying children with poor prognosis who might benefit from early intensive care. It should be studied prospectively and compared with other scoring systems.
TL;DR: It is concluded that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of “weaning” patients from mechanical Ventilatory support in the ICU.
Abstract: ObjectiveTo test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency.DesignRetrospective review with cost-effectiveness analysis.SettingA 20-bed medical-surgical ICU in a 450-bed community referral teaching ho