Showing papers in "Critical Care Medicine in 1992"
TL;DR: The series of enzymatic reactions of the coagulation cascade are strongly inhibited by hypothermia, as demonstrated by the dramatic prolongation of prothrombin time and partial thromboplastin time tests at hypothermic deviations from normal temperature in a situation where factor levels were all known to be normal.
Abstract: Background and MethodsThe development of a multifactorial coagulopathy after massive transfusion is a well-recognized clinical problem that is almost always accompanied by hypothermia. The purpose of this study was to investigate the isolated effect of alterations of temperature on the integrity of
613 citations
TL;DR: The severity of lactic acidosis in critically ill patients correlates with overall oxygen debt and survival, and lactate determinations may be useful as an ongoing monitor of perfusion as resuscitation proceeds.
Abstract: Purpose This article reviews the current body of knowledge regarding lactic acidosis in critically ill patients. The classification of disordered lactate metabolism and its pathogenesis are examined. The utility of lactate as a metabolic monitor of shock is examined and current therapeutic strategies in the treatment of patients suffering from lactic acidosis are extensively reviewed. The paper is designed to integrate basic concepts with a current approach to lactate in critical illness that the clinician can use at the bedside. Data sources Comprehensive review of the available, basic science, medical, surgical, and critical care literature. Conclusions The severity of lactic acidosis in critically ill patients correlates with overall oxygen debt and survival. Lactate determinations may be useful as an ongoing monitor of perfusion as resuscitation proceeds. Therapy of critically ill patients with lactic acidosis is designed to maximize oxygen delivery in order to reduce tissue hypoxia by increasing cardiac index, while maintaining hemoglobin concentration. Buffering agents have not been shown to materially affect outcome from lactic acidosis caused by shock. The benefits of other specific therapies designed to reduce the severity of lactic acidosis remain unproven.
578 citations
383 citations
TL;DR: Although medical ICU patients tended to have more dental plaque than preventive dentistry clinic patients, there was no statistically significant association noted between the presence of dental plaque and respiratory pathogen colonization.
Abstract: Objective:To assess the prevalence of oral colonization by respiratory pathogens in a group of ICU patients, with specific attention to dental plaque and the oral mucosa.Design:Prospective, nonrandomized study with age-matched controls.Settings:Medical ICU in a tertiary-care Veterans Affairs Medical
364 citations
TL;DR: Patients fed by jejunal tube received a significantly higher proportion of their daily goal caloric intake, had a significantly greater increase in serum prealbumin concentrations, and had a lower rate of pneumonia than patients fed by continuous gastric tube feeding.
Abstract: OBJECTIVE To compare nutritional status, gastric colonization, and rates of nosocomial pneumonia in ICU patients randomized to gastric tube feeding vs. patients fed by an endoscopically placed jejunal tube. DESIGN Randomized, prospective study. SETTING Medical and surgical ICUs at Boston City Hospital; surgical ICU at University Hospital. PATIENTS Of the 38 study patients, 19 were randomized to gastric tube feeding and 19 were randomized to an endoscopically placed jejunal tube. The two groups were similar in age, sex, race, underlying disease, and type of surgery. RESULTS The two patient groups were similar in number of days fed, duration of ICU stay, duration of mechanical ventilation, days of antibiotic therapy, and days with fever. Compared with the gastric group, the jejunal group had more patients with circulatory shock on admission (79% vs. 68.4%), higher admission Acute Physiology Score (24.0 vs. 21.7), and fewer patients with pneumonia at randomization (26.3% vs. 31.6%). The jejunal group received a significantly higher percentage of their daily goal caloric intake (p = .05), and had greater increases in serum prealbumin concentrations (p < .05) than the patients with gastric tube feeding. Although the jejunal tube group had more days of diarrhea (3.3 +/- 6.6 vs. 1.8 +/- 2.9), this difference was not statistically significant. Nosocomial pneumonia was diagnosed clinically in two (10.5%) patients in the gastric tube group and in no patients in the jejunal tube group. CONCLUSIONS Patients fed by jejunal tube received a significantly higher proportion of their daily goal caloric intake, had a significantly greater increase in serum prealbumin concentrations, and had a lower rate of pneumonia than patients fed by continuous gastric tube feeding.
356 citations
TL;DR: It is documented that N-acetylcysteine acts as an anticoagulant and perhaps decreases pulmonary fibrin uptake during ARDS and might be of benefit in ARDS.
Abstract: Objective To examine whether the antioxidant N-acetylcysteine could ameliorate the course of the adult respiratory distress syndrome (ARDS) in man. Design Randomized, double-blind, placebo-controlled study. Setting Medical and surgical ICU in a regional hospital. Patients Sixty-six ICU patients with ARDS. Interventions Patients with ARDS (PaO2/FiO2 ratio less than 250 torr) were treated with either the antioxidant N-acetylcysteine 150 mg/kg as a loading dose and then 20 mg/kg/hr, or with placebo for 6 days. Measurements and main results No improvement could be demonstrated in the PaO2/FiO2 ratio in the study group as compared with the control group on any day. Pulmonary compliance was higher in the N-acetylcysteine group than in the placebo group on all days, but this difference did not reach the chosen 5% level of significance. No difference between the two groups could be demonstrated on chest radiograph or on survival rate. We documented that N-acetylcysteine acts as an anticoagulant and perhaps decreases pulmonary fibrin uptake during ARDS. Conclusions N-acetylcysteine might be of benefit in ARDS. Before further clinical studies are started, problems with N-acetylcysteine and coagulation have to be elucidated in order to find out whether N-acetylcysteine could have a beneficial effect in the treatment of ARDS.
239 citations
TL;DR: It is confirmed that hypothermia associated with sepsis syndrome has a significant relationship to outcome manifest by increased frequency of shock and death from shock, in sharp contrast to the protective effects of induced Hypothermia in septic animals and perhaps man.
Abstract: ObjectiveTo evaluate the consequences of clinical hypothermia associated with sepsis syndrome and septic shock.DesignAnalysis of data from a multi-institutional, randomized, placebo-controlled, prospective study with predetermined end-point analysis of development of shock, recovery from shock, hosp
230 citations
TL;DR: Venous air embolism is an infrequent complication of invasive diagnostic and therapeutic maneuvers that may all be affected, with severity ranging from no symptoms to immediate cardiovascular collapse.
Abstract: ObjectiveTo examine the existing literature concerning venous air embolism Causes, patho-physiology, and management are emphasizedData SourcesThe literature that was reviewed was retrieved from the MEDLINE System under the headings “venous air embolism,” “air embolism,” “therapy of air embolism,”
228 citations
TL;DR: Recommendations regarding daily supplementation with these vitamins in clinical practice cannot be made on the basis of these results, as the functional importance of these observations is not, at present, clear.
Abstract: ObjectivesTo investigate the effect, if any, of the acute-phase response on blood vitamin concentrations and to test the hypothesis that these concentrations may change during stress.DesignOpen study, utilizing a volunteer sample of patients.SettingTertiary care center.PatientsTwenty-six healthy adu
215 citations
TL;DR: Complications in serial patients with croup or epiglottitis were related to the duration of intubation and mechanical ventilation, and the frequency of accidental extubation was related to that duration.
Abstract: ObjectiveTo assess the frequency of complications of endotracheal intubation and mechanical ventilation.DesignProspective cohort study.SettingPediatric tertiary multidisciplinary ICU.PatientsEight hundred sixty-nine serial patients, of whom 500 were endotracheally intubated and 431 were mechanically
205 citations
TL;DR: Moderate hypoglycemia may evoke a significant stress response, behavioral changes, and alterations in cerebral blood flow and metabolism, which must be addressed when caring for patients with cerebral ischemia or intracranial compliance problems.
Abstract: Purpose This review focuses on the neurologic issues concerning the treatment of hypo- or hyperglycemia in the critically ill patient. Data sources Articles written in English and identified through the Bibliographic Retrieved Service Colleague database. Study selection Articles chosen on the basis of their relevance to the issue of blood glucose management and its neurologic effects in critically ill patients. Data extraction Data from articles were analyzed to obtain a scientific foundation and rationale for treating abnormal blood glucose levels. Data synthesis Moderate hypoglycemia may evoke a significant stress response, behavioral changes, and alterations in cerebral blood flow and metabolism. It is unclear what effect prolonged or repeated episodes of moderate hypoglycemia may have on patient outcome. However, alterations in cerebral vascular physiology must be addressed when caring for patients with cerebral ischemia or intracranial compliance problems. Depending on its severity, hypoglycemia has varying influences on neurologic damage after ischemia. Hyperglycemia may impair neuronal recovery following cerebral ischemia. However, the detrimental effects of hyperglycemia vary depending on the types of brain ischemia sustained (focal or global). Evidence suggests that hyperglycemia during global and incomplete global ischemia events is detrimental to neurologic outcome. However, the relationship between hyperglycemia and outcome after focal ischemia is controversial. Conclusion Because both hypo- and hyperglycemia may produce neurologic changes, aggressive management of abnormal glucose values is warranted.
TL;DR: This study confirms previous findings that TNF is a major mediator involved in the pathogenesis of septic shock, although further studies are needed to determine whether IL-6 is directly involved in mediating the lethal complications of sepsis or whether it should be considered an “alarm hormone” that reflects endothelial cell injury.
Abstract: Objective: To study the patterns of plasma concentrations of endotoxin, tumor necrosis factor-alpha (TNF), interleukin-6 (IL-6), plasminogen activator inhibitor-1, C-reactive protein, and serum amyloid A during the treatment of human sepsis. Design: A prospective case series study. Setting: ICU of the Department of Internal Medicine, University Hospital Groningen, The Netherlands. Patients: Twenty consecutive patients (11 female, 9 male, mean age 67 yrs) with clinically defined sepsis. Eighteen patients were admitted from the outpatient emergency ward; two patients were already inpatients. The control group (n = 7) comprised patients with nonseptic shock. Measurements and Main Results: Ten (50%) septic patients had detectable endotoxemia (> 5 ng/L). TNF concentrations on admission were increased in 94% of the septic patients, whereas IL-6 and plasminogen activator inhibitor plasma concentrations were increased in all septic patients. The septic group showed significantly (p <.05) higher concentrations of TNF, IL-6, plasminogen activator inhibitor-1, C-reactive protein, and serum amyloid A compared with the nonseptic patients. In the septic group, we found a correlation of both IL-6 and plasminogen activator inhibitor concentrations with severity of illness (r2 = .33, p <.05; r2 = .22, p <.05, respectively). After the start of antibiotic treatment, high concentrations of TNF and plasminogen activator inhibitor persisted in the nonsurvivors in contrast to decreasing concentrations in most of the survivors. After an initial increase in seven patients, IL-6 concentrations decreased in all septic patients and also in nonsurvivors. Conclusions: This study confirms previous findings that: a) TNF is a major mediator involved in the pathogenesis of septic shock; b) plasminogen activator inhibitor activity is significantly increased in septic patients and might be involved in the pathogenesis of disseminated intravascular coagulation associated with sepsis; and c) IL-6 is involved in the pathophysiology of septic shock, although further studies are needed to determine whether IL-6 is directly involved in mediating the lethal complications of septic shock or whether it should be considered an "alarm hormone" that reflects endothelial cell injury. Our findings also suggest that the concentrations and trends of these mediators during treatment are valuable for monitoring septic patients.
TL;DR: Notably, available technology within hospitals and individual units was increased as hospital size increased; surgical units tended to have more available technology than other unit types.
Abstract: Objective To gather data about available technology, staffing, administrative policies, and bed capacities of ICUs in the United States. Design and setting On January 15, 1991, survey instruments were mailed to the administrators of 4,233 hospitals to gather information from the medical director of the institutions' respective ICUs for the purpose of developing a database on ICUs in the United States. The sampling frame for this study was based on all American Hospital Association (AHA) hospitals that stated they have ICUs. Measurements Census questionnaires solicited information on types of hospitals, types of ICUs, number of ICU beds open and closed, technology available to the unit, organizational structure and management of the ICU, as well as the staffing and certification of unit personnel. Main results Data were obtained on 32,850 ICU beds with 25,871 patients from 2,876 separate ICUs in 1,706 hospitals in the United States. Census responses came from units in all sizes of hospitals within all ten census regions in the country, all states, and all types of hospital sponsorship (federal, state, and local government, private nonprofit and private for profit). The census response rate was 40% of the AHA hospitals that stated that they have ICUs, with specific ICU data on 38.7% of the nation's ICUs. The number of ICUs per hospital increases with overall hospital size. The smallest hospitals (less than 100 beds) usually had only one ICU. As hospital size increased, the single, all inclusive medical/surgical/coronary care units diminished, and in hospitals with greater than 300 beds, specialization of units became prevalent. In absolute terms, hospitals had the following number of ICUs: 1.04 +/- 0.20 (less than or equal to 100 beds); 1.30 +/- 0.65 (101 to 300 beds); 2.37 +/- 1.58 (301 to 500 beds); and 3.34 +/- 2.21 (greater than 500 beds). ICU beds averaged, nationally, 8.09% of hospital-licensed beds with a median of 6.98%. Generally, medical units, pediatric units, coronary care units (CCUs), and medical/surgical/CCUs reported an average of 10 beds per unit. Neonatal units averaged 21 beds, and surgical units averaged 12 beds. The average ICU size, nationally, was 11.7 +/- 7.8 beds per unit. Available technology within hospitals and individual units was increased as hospital size increased; surgical units tended to have more available technology than other unit types. A wide range of organizational arrangements within hospitals determines where the ICU appears in an organizational chart and to whom unit management is accountable. Thirty-six percent of the units were located organizationally within the hospital's department of medicine, while 23% were considered "free standing," having no departmental affiliation. Although units must have a medical director, the perception as to whether this director supervises the day-to-day operation was different in larger vs. smaller hospitals. In hospitals with less than or equal to 100 beds, 72% of the units were perceived to be supervised by the medical director, whereas in larger hospitals (greater than 500 beds), 81% of units were supervised. Study results indicated that medical directors in pediatric, neonatal, and burn units most often were perceived to supervise the unit. Presently, 63% of all ICUs responding are directed by an internist. The next largest group to direct ICUs were surgeons, followed by pediatricians. Pediatrician involvement tended to be exclusive in pediatric and neonatal units. Surgeons directed most surgical and neurologic units and were involved in 21% of mixed medical/surgical units. Internists predominated in medical units and in CCUs, as well as in combined medical/surgical/CCUs. Direction by anesthesiologists, although relatively infrequent, predominated in the surgical unit. Critical care medicine certification of the medical director and attending staff of the ICU increased as hospital size increased, although only 44% of all units stated that thei
TL;DR: Death was associated with increased tissue needs for oxygen that were not adequately satisfied by the available levels of oxygen supply, and tonometrically measured gastric intramucosal pH is a useful noninvasive adjunct to current methods of monitoring systemic oxygenation.
Abstract: ObjectiveTo determine the relationship of tonometrically measured gastric intramucosal pH to clinically accepted indices of systemic oxygenation.DesignProspective, nonintervention study.SettingMedical and surgical ICUs of a university hospital.PatientsCritically ill patients (n = 22) with pulmonary
TL;DR: Nitric oxide synthesis provides a protective function against lipopolysaccharide-induced liver injury that increases in importance as the degree of endotoxemia increases and is an important part of the liver's response to a systemic inflammatory stimulus.
Abstract: Background and MethodsNitric oxide synthesis occurs both in vitro and in vivo in response to inflammatory stimuli and can have profound effects on the local cellular environment. Hepatocytes, Kupfler cells, and endothelial cells produce nitric oxide in vitro, but the in vivo role of this reactive me
TL;DR: Although the clinical importance of bacterial biofilms on catheter surfaces is speculative, their presence and potential to serve as a nidus for infection and bacteremia in critically ill immunocompromised hosts are cause for concern.
Abstract: Background and MethodsSome bacteria have a natural tendency to adhere to available surfaces and to form biofilms. Biofilms have been demonstrated on right heart flow-directed catheters, endocardial pacemaker leads, urinary catheters, and other medical devices. In this study, we examined arterial and
TL;DR: To determine the usefulness of midazolam as a therapeutic agent for status epilepticus refractory to conventional treatment, retrospective study ofICUs of two university hospitals is conducted.
Abstract: ObjectiveTo determine the usefulness of midazolam as a therapeutic agent for status epilepticus refractory to conventional treatment.DesignRetrospective study.SettingICUs of two university hospitals.PatientsSeven patients with refractory status epilepticus who failed treatment with diazepam, lorazep
TL;DR: DIC enhances posttrauma coagulation and fibrinolytic activity and plasminogen activator inhibitor activity can be inferred in DIC patients, andfibrinopeptide A as an assessment criterion for the effectiveness of anticoagulant treatment.
Abstract: ObjectiveTo determine the effects of disseminated intravascular coagulation (DIC) and headinjury on posttrauma coagulation and fibrinolysis.DesignCase-control study.SettingGeneral ICU (tertiary care center) in a city hospital serving a population of 150 million people.PatientsForty trauma victims: 1
TL;DR: Mean airway pressure closely reflects mean alveolar pressure, except when flow-resistive pressure losses differ greatly for the inspiratory and expiratory phases of the ventilatory cycle.
Abstract: PurposesTo discuss the theoretical relationship of mean alveolar pressure to its most easily measured analog, mean airway pressure, and to describe the key determinants, measurement considerations, and clinical implications of this index.Data SourcesRelevant articles from the medical and physiologic
TL;DR: It is suggested that age alone may be an inappropriate criterion for allocation of ICU resources and the quality of life and mortality rate after discharge of critically ill "oldest-old" patients.
Abstract: OBJECTIVE To determine the short-term and long-term outcome of critically ill "oldest-old" (greater than or equal to 85 yrs) patients. DESIGN Retrospective chart review and follow-up telephone interview. SETTING ICUs at a tertiary care hospital. METHODS The medical records of all patients greater than or equal to 85 yrs of age admitted to the ICUs during 1988 were reviewed. Demographic information, severity of illness, major interventions, mortality rate, and hospital charges were examined. A follow-up telephone interview was conducted to determine the quality of life and mortality rate after discharge. RESULTS Of 34 patients greater than or equal to 85 yrs of age admitted to the ICU, 21 (62%) survived to discharge from the hospital, and 13 (62%) of these 21 patients were discharged to home. Mean +/- SD hospital charges were $34,738 +/- 34,366. Seventeen of the 21 patients were contacted for long-term follow-up, and ten of these patients were alive at a mean follow-up time of 18 +/- 10 months (range 1 to 32). Eight of the ten patients described their quality of life as fair or good. CONCLUSION These findings suggest that age alone may be an inappropriate criterion for allocation of ICU resources.
TL;DR: The changes in circulating levels do not appear to be injury specific, but tend to reflect the severity of the traumatic insult, and there are some data for cortisol and thyroxine that show their concentrations may be of predictive value.
Abstract: ObjectivesTo review the hormonal changes that have been reported after trauma, to define their etiologies, and to describe their consequences.Data SourcesLiterature review using MEDLINE and original data.Data SynthesisHormonal responses to trauma are bidirectional. Functional derangements include in
TL;DR: Within the very elderly population, acute severity of illness is the most significant predictor of mortality after anICU admission and for most very elderly patients, surviving 1 yr after an ICU admission, there is little change in functional status.
Abstract: ObjectivesTo determine if age, previous functional status, or acute severity of illness affect the acute and long-term mortality rates and functional status of the very elderly (≥85 yrs) after an ICU admission.DesignCohort study (retrospective entry for the first year of the study and prospective en
TL;DR: The characteristics of patients who forgo treatment are described, the range and sequential process of forgoing treatment is determined, and ethical and public policy implications are suggested.
Abstract: Objectives The difficult decision to forgo (withhold or withdraw) life-sustaining treatment has received extensive commentary. Little attention has been paid to how physicians do, and should, care for dying patients once this decision is made. This study describes the characteristics of patients who forgo treatment, determines the range and sequential process of forgoing treatment, and suggests ethical and public policy implications. Design The charts of all patients who died at the University of Minnesota Hospital during a 2-month period were reviewed. The patient information that was collected included age and sex, diagnoses, mental status, location in the hospital length of hospital stay, method of payment, the timing of the first decision to forgo treatment, and the range and sequence of interventions forgone. Setting All ICUs and general wards in a 586-bed tertiary care university hospital. Patients All patients who died at the University of Minnesota Hospital during May and June 1989. Main results A total of 52 (74%) of 70 patients who died had some intervention withheld or withdrawn before death. Those patients in whom treatment was forgone were more likely to have an underlying malignancy or impaired mental status and longer hospital stays. Thirty-two (62%) of 52 patients who declined some treatment were in an ICU; 26 (50%) of 52 patients required mechanical ventilation. On average, 5.4 separate interventions were forgone per patient. Resuscitation and/or endotracheal intubation were generally the first measures withheld; once a patient required a ventilator, withdrawing the ventilator was a late decision. Precise methods of ventilatory and vasopressor withdrawal varied considerably among patients. Conclusions Forgoing life-sustaining treatment is not a single decision but it often occurs in a sequential manner over several days. A strict analysis of the benefits and burdens of various interventions may be inadequate in deciding what interventions are appropriate in the care of the dying patient.
TL;DR: The markedly decreased respiratory syncytial virus mortality risk in patients with congenital heart disease currently experienced is likely secondary to improvements in intensive care management and advances in the surgical correction in this population rather than antiviral therapy.
Abstract: ObjectiveTo determine recent morbidity and mortality rates from respiratory syncytial virus infection in a pediatric congenital heart disease population.DesignRetrospective cohort study design.SettingThe C. S. Mott Children's Hospital, University of Michigan Medical Center.PatientsA total of 740 ped
TL;DR: These results indicate that early after burn injury there is a correspondence of IL-1β and TNFα with certain host responses, but these correlations disappear with the progression of illness.
Abstract: OBJECTIVES To measure plasma interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF alpha) concentrations after burn injury and to determine if these concentrations relate to clinical status. DESIGN Prospective assessment. SETTING Hospital burn unit. PATIENTS Thirty-one patients with second- or third-degree burns, covering 10% to 95% of body surface area. MEASUREMENTS AND MAIN RESULTS Initial concentrations of IL-1 beta were increased (mean 188 +/- 31 pg/mL), and the concentrations for each patient correlated with body temperature at the time of the blood sample (rho = 0.51, p < .015) (rho is a nonparametric statistical measure; a nonparametric analysis is mandatory for data that is categorical [Acute Physiology and Chronic Health Evaluation, APACHE, scores] and data that are not normally distributed [IL-1 beta and tumor necrosis factor, TNF, data]). Mean TNF alpha concentrations were initially 264 +/- 132 pg/mL, and these concentrations were positively related to body temperature (rho = 0.41, p < .05) and inversely related to the total WBC count (rho = -0.45, p < .025). Through the course of hospitalization, plasma cytokine levels fluctuated, but transient increases (sometimes into the nanogram/mL range) did not consistently correspond to changes in clinical signs or severity of illness, as determined by APACHE II scores. The maximum plasma cytokine levels in any patient were not related to age, but maximum IL-1 beta concentrations were inversely related to burn size (rho = -0.46, p < .015). The final IL-1 beta concentrations measured in the patients who died (n = 7) were significantly less than measurements in surviving patients matched for burn size and age taken at approximately the same time after admission. CONCLUSIONS These results indicate that early after burn injury there is a correspondence of IL-1 beta and TNF alpha with certain host responses, but these correlations disappear with the progression of illness. In general, IL-1 beta and TNF alpha appear to be poor indicators of prognosis during burn injury; however, the association of mortality with low circulating IL-1 beta values supports the concept of IL-1 beta as being an essential mediator of host defenses.
TL;DR: The increased volume of distribution in critically ill patients is the major determinant for the observed slower elimination of midazolam, and it is unlikely that the hepatic metabolism of midAZolam was impaired in these patients.
Abstract: Objective To determine the pharmacokinetics of continuously infused midazolam in patients during intensive care. Design Descriptive trial. Setting General ICU in a Swiss hospital. Subjects Eight critically ill patients requiring mechanical ventilation. Interventions To achieve an appropriate level of long-term sedation, the rate of iv infusion of midazolam in ICU patients was adjusted individually to between 6 and 15 mg/hr. Blood samples were taken during and after the continuous infusion of midazolam. Measurements Measurements included plasma concentration time profiles of midazolam and pharmacokinetic parameters, such as elimination half-life, clearance, and volume of distribution. Results The elimination half-life was prolonged (mean 5.4 vs. 2.3 hrs) and the volume of distribution was larger (3.1 vs. 0.9 L/kg) in patients vs. healthy volunteers. The clearance did not differ between groups (6.3 vs. 4.9 mL/min/kg in patients vs. volunteers, respectively). Conclusions The increased volume of distribution in our critically ill patients is the major determinant for the observed slower elimination of midazolam. It is unlikely that the hepatic metabolism of midazolam was impaired in these patients. (Crit Care Med 1992; 20:1123–1126)
TL;DR: In patients with cirrhosis, septic shock was characterized by severe liver dysfunction, low blood temperature, marked increases in cardiac index and lactic acidemia, and a 100% ICU mortality rate.
Abstract: Objectives:To examine the hemodynamic and metabolic characteristics and ICU outcome of septic shock in patients with cirrhosis.Design:Prospective, comparative study. Measurements performed in the first 24 hrs of septic shock.Setting:A general hospital ICU.Patients:Twelve patients with cirrhosis and
TL;DR: Intravenous nicardipine is as effective as sodium nitroprusside in the therapy of postoperative hypertension and specific advantages have been identified.
Abstract: OBJECTIVE To compare the efficacy and safety of iv nicardipine with sodium nitroprusside in the treatment of postoperative hypertension after both cardiac and noncardiac surgery. DESIGN Multicenter, prospective, randomized, open-label study. SETTING Six tertiary referral medical centers (recovery rooms and surgical ICUs). PATIENTS A total of 139 patients with postoperative hypertension: i.v. nicardipine (n = 71), sodium nitroprusside (n = 68). INTERVENTION Administration of i.v. nicardipine or sodium nitroprusside. MEASUREMENTS Vital signs (BP, heart rate), hemodynamic variables, medication dosage, total number of dose changes, and time to achieve BP control were recorded. MAIN RESULTS Both medications were equally effective in reducing BP in both the cardiac and noncardiac surgical groups. Under the conditions of the study, i.v. nicardipine controlled hypertension more rapidly than sodium nitroprusside (i.v. nicardipine 14.0 +/- 1.0 mins and sodium nitroprusside 30.4 +/- 3.5 mins, p = .0029). The total number of dose changes required to achieve therapeutic BP response was significantly less in the i.v. nicardipine-treated patients (i.v. nicardipine 1.5 +/- 0.2 vs. sodium nitroprusside 5.1 +/- 1.4, p < .05). Adverse effects were observed with both drugs (i.v. nicardipine 7% [5/71] and sodium nitroprusside 18% [12/68] [NS]). CONCLUSIONS Intravenous nicardipine is as effective as sodium nitroprusside in the therapy of postoperative hypertension. Specific advantages have been identified. The use of i.v. nicardipine should be considered in the therapy of postoperative hypertension.
TL;DR: Socially and legally created “shades of gray” have blurred the distinctions between withholding or withdrawing therapies and euthanasia and have left physicians without guidelines.
Abstract: ObjectivesMedical decisions concerning the prolongation of life, the right to die, and euthanasia are among the most extensively discussed decisions within medicine and law today. The responses of 360 physicians, housestaff, and medical students to a questionnaire were analyzed to identify attitudes