Showing papers in "Critical Care Medicine in 1997"
TL;DR: Protocol-guided weaning of mechanical ventilation, as performed by nurses and respiratory therapists, is safe and led to extubation more rapidly than physician-directed weaning.
Abstract: Objective To compare a practice of protocol-directed weaning from mechanical ventilation implemented by nurses and respiratory therapists with traditional physician-directed weaning.Design Randomized, controlled trial.Setting Medical and surgical intensive care units in two university-affiliated tea
729 citations
TL;DR: In this article, the authors evaluated the therapeutic efficacy and safety of recombinant human interleukin-1 receptor antagonist (rhlL-1ra) in the treatment of patients with severe sepsis.
Abstract: Objective: To determine the therapeutic efficacy and safety of recombinant human interleukin-1 receptor antagonist (rhlL-1ra) in the treatment of patients with severe sepsis. Design: Prospective, randomized, double-blind, placebo-controlled, multicenter trial with a planned, midstudy, interim analysis. Setting: Ninety-one academic medical center intensive care units in North America and Europe. Patients: Patients with severe sepsis or septic shock (n = 696) received standard supportive care and antimicrobial therapy for sepsis, in addition to rhIL-1ra or placebo. Interventions: Patients were randomized to receive either rhlL-1ra (100 mg) or placebo (vehicle) by intravenous bolus, followed by a 72-hr continuous intravenous infusion of either rhIL-1ra (2.0 mg/ kg/hr) or placebo. Measurements and Main Results: The study was terminated after an interim analysis found that it was unlikely that the primary efficacy end points would be met. The 28-day, all-cause mortality rate was 33.1% (116/350) in the rhlL-1ra treatment group, while the mortality rate in the placebo group was 36.4% (126/346), yielding a 9% reduction in mortality rate (p = .36). The patients were well matched at the time of study entry; 52.9% of placebo-treated patients were in shock while 50.9% of rhIL-1ra-treated patients were in shock at the time of study entry (p = .30). The mortality rate did not significantly differ between treatment groups when analyzed on the basis of site of infection, infecting microorganism, presence of bacteremia, shock, organ dysfunction, or predicted risk of mortality at the time of study entry. No excess number of adverse reactions or microbial superinfections were attributable to rhlL-1ra treatment in this study. Conclusions: A 72-hr, continuous intravenous infusion of rhlL-1ra failed to demonstrate a statistically significant reduction in mortality when compared with standard therapy in this multicenter clinical trial. If rhlL-1ra treatment has any therapeutic activity in severe sepsis, the incremental benefits are small and will be difficult to demonstrate in a patient population as defined by this clinical trial.
724 citations
653 citations
TL;DR: The rate of preventable and potential adverse drug events was twice as high in ICUs compared with non-ICUs, but there were no differences between medical ICU and surgical ICU patients.
Abstract: Objectives To compare the frequency and preventability of adverse drug events and potential adverse drug events in intensive care units (ICUs) and non-ICUs. To evaluate systems factors involving the individual caregivers, care unit teams, and patients involved in each adverse drug event by comparing
622 citations
TL;DR: The higher rate of myocardial infarctions associated with the use of bilevel positive airway pressure highlights the need for further studies to clarify its effects on hemodynamics and infarction rates, and to determine optimal pressure settings.
Abstract: Objective To evaluate whether bilevel positive airway pressure, by actively assisting inhalation, more rapidly improves ventilation, acidemia, and dyspnea than continuous positive airway pressure (CPAP) in patients with acute pulmonary edema.Design Randomized, controlled, double-blind trial.Setting
449 citations
400 citations
TL;DR: It was shown that increase of proinflammatory cytokines was a consequence of inflammation, not of shock, and measurements of NO2-/NO3- concentration and procalcitonin concentration represented the most suitable tests for defining patients with septic shock.
Abstract: Objectives To determine and compare the respective concentrations of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, soluble TNF receptors, nitrite/nitrate (NO2 sup -/NO3 sup -), and procalcitonin in the plasma of patients with septic shock, cardiogenic shock, and bacterial pneumonia without
395 citations
TL;DR: The current definitions of SIRS, sepsis, and related disorders in critically injured patients without head trauma show a significant association with physiologic deterioration and increasing organ dysfunction.
Abstract: Objectives To determine the frequency of the proposed definitions for the systemic inflammatory response syndrome (SIRS), sepsis and septic shock, and to further define severe SIRS and sterile shock as determined at 24 hrs of admission to an intensive care unit (ICU) in critically ill trauma patient
395 citations
TL;DR: The concept that the immune response of females differs from males, and that females are immunologically better positioned to meet the challenge of sepsis, is supported.
Abstract: Objectives To determine: a) whether the cell-mediated immune response during sepsis differs in females vs. males; and b) whether the survival rate in females is different than in males after a septic insult.Design A prospective, randomized animal study.Setting University research laboratory.Subjects
371 citations
367 citations
TL;DR: In septic shock patients, changes in both TNF-alpha and IL-6 were correlated with outcome, higher values being found in patients likely to die, and this finding suggests a much higher degree of activation of the immunoinflammatory cascade in septicshock than in multiple trauma patients.
Abstract: Objective To compare the patterns of evolution of two proinflammatory cytokines (tumor necrosis factor [TNF]-alpha and interleukin-6 [IL-6]) in two major clinical entities associated with systemic inflammatory response: septic shock and multiple trauma (with and without hemorrhagic shock).Design Pro
TL;DR: Increased intra-abdominal pressure appears to produce this effect by augmenting pleural and other intrathoracic pressures and causing a functional obstruction to cerebral venous outflow via the jugular venous system, and it is possible that the same phenomenon may be why persons with chronically increased intra- Abdominal Pressure suffer from a high frequency rate of idiopathic intracranial hypertension.
Abstract: ObjectivesTo determine the effect of acutely increased intra-abdominal pressure on pleural pressure, intracranial pressure, and cerebral perfusion pressure, and to clarify the relationship between these parametersDesignNonrandomized, controlled studySettingLaboratory at a university medical center
TL;DR: Findings in Rag-1 mice demonstrate that mature T and B cells and their secretory products are not necessary for apoptosis to occur during sepsis and that apoptotic cell death is not restricted to T or B cells.
Abstract: Objectives To determine if apoptosis (programmed cell death) occurs systemically in lymphoid and parenchymal cells during sepsis. To examine the potential role of T and B cells in the apoptotic process using knockout mice deficient in mature T and B lymphocytes.Design Prospective, randomized, contro
TL;DR: Efforts to develop intelligent monitoring systems have more potential to deliver significantly improved patient care by initially targeting especially weak areas in ICU monitoring, such as pulse oximetry reliability.
Abstract: Objective To identify areas requiring the most urgent improvement in the intensive care unit (ICU); and to accurately determine the positive predictive value of routine critical care patient monitoring alarms, as well as the common causes for false-positive alarms.Design Prospective, observational s
TL;DR: Guidewire exchange of central venous catheters may be associated with a greater risk of catheter-related infection but fewer mechanical complications than new-site replacement and more studies on scheduled vs. as-needed replacement strategies are warranted.
Abstract: Objective To evaluate the effect of guidewire exchange and new-site replacement strategies on the frequency of catheter colonization and infection, catheter-related bacteremia, and mechanical complications in critically ill patients.Data Sources We searched for published and unpublished research by
TL;DR: The addition of noninvasive positive pressure ventilation to standard therapy in patients with acute respiratory failure improves survival and decreases the need for endotracheal intubation.
Abstract: Objective To critically appraise and summarize the trials examining the addition of noninvasive positive pressure ventilation to standard therapy on hospital mortality and need for endotracheal intubation in patients admitted with acute respiratory failure. Data Sources We searched MEDLINE (1966 to September 1995) and key references were searched forward using the Scientific Citation Index (SCISEARCH). Bibliographies of all selected articles and review articles were examined. Authors of all selected and review articles were contacted by letter to identify unpublished work. Study Selection a) Population: patients with acute respiratory failure; b) intervention: noninvasive positive pressure ventilation; c) outcome: mortality and/or endotracheal intubation; and d) design: randomized, controlled study. Two of us independently selected the articles for inclusion; disagreements were settled by consensus. Seven (three unpublished) of 212 initially identified studies were selected. Data Extraction Two authors independently extracted data and evaluated methodologic quality of the studies. Data Synthesis Noninvasive positive pressure ventilation was associated with decreased mortality (odds ratio = 0.29; 95% confidence interval 0.15 to 0.59) and a decreased need for endotracheal intubation (odds ratio = 0.20; 95% confidence interval 0.11 to 0.36). Sensitivity analysis suggested a greater benefit of noninvasive positive pressure ventilation in patients with chronic obstructive pulmonary disease (COPD). The inclusion/exclusion of unpublished trials did not influence these results. Conclusions The addition of noninvasive positive pressure ventilation to standard therapy in patients with acute respiratory failure improves survival and decreases the need for endotracheal intubation. However, this effect is restricted to patients whose cause of acute respiratory failure is an exacerbation of COPD. Further research is warranted to determine whether noninvasive positive pressure ventilation confers benefit in patients without COPD who have acute respiratory failure. (Crit Care Med 1997; 25:1685-1692)
TL;DR: It is concluded that undesirable splanchnic effects on patients in whom that region is particularly fragile should be considered when using epinephrine for septic shock treatment.
Abstract: ObjectiveTo assess the effects of epinephrine on splanchnic perfusion and splanchnic oxygen uptake in patients with septic shock.DesignProspective, controlled trial.SettingUniversity hospital intensive care unit (ICU).PatientsEight patients with septic shock, according to the criteria of the 1992 Am
TL;DR: In the population of critically ill patients sedated with midazolam or propofol over prolonged periods, midazoliaam and propofolia were equally effective as sedative agents, however, despite remarkable differences in the cost of sedation, the economic profile is more favorable for propofols than for midazoliam due to a shorter weaning time associated with this two agents.
Abstract: Objective To compare the effectiveness of sedation, the time required for weaning, and the costs of prolonged sedation of critically ill mechanically ventilated patients with midazolam and propofol.Design Open-label, randomized, prospective, phase IV clinical trial.Setting Medical and surgical inten
TL;DR: Early enteral feeding with an arginine, dietary nucleotides, and omega-3 fatty acids supplemented diet, as well as an isonitrogenous, isocaloric control diet (placebo) were well tolerated in patients who underwent upper gastrointestinal surgery and the treatment costs were substantially reduced.
Abstract: ObjectiveTo determine if early postoperative feeding of patients with upper gastrointestinal malignancy, using an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT[registered sign], Sandoz Nutrition, Bern, Switzerland) results in an improved clinical outco
TL;DR: Korean intensive care physicians' knowledge of right-heart pulmonary artery catheterization is not uniformly good among ICU physicians, andAccreditation policies and teaching practices concerning this technique need urgent revision.
Abstract: OBJECTIVE: To evaluate French, Swiss, and Belgian intensive care physicians' knowledge about the pulmonary artery catheter. DESIGN: Survey study by questionnaire. SETTING: Eighty-six European university and nonuniversity intensive care units (ICUs). SUBJECTS: One hundred thirty-four ICUs identified from the directories of two European intensive care medicine societies were asked to participate. Five hundred thirty-five critical care physicians working in 86 ICUs participated. INTERVENTIONS: In any particular ICU, all physicians were to complete--simultaneously, anonymously and without prior notice--a multiple choice questionnaire consisting of 31 questions regarding all aspects of bedside pulmonary artery catheterization. This questionnaire was the same one already used and extensively validated in a similar study conducted several years earlier in the United States and Canada. MEASUREMENTS AND MAIN RESULTS: The percentage of correct answers per participant (score) was tabulated. Sixty-eight percent of respondents still in training (n = 232) believed that their knowledge of the pulmonary artery catheter was less than adequate; 36% of those who had completed their postgraduate training (n = 294) also believed their knowledge to be inadequate. The mean score of all respondents was 72.2 +/- 14.4%, significantly lower (p <.0001) in case of uncompleted postgraduate training (67.3 +/- 14.7%, lower quartile 56.7%, median 70.0%, upper quartile 76.7%), as compared with completed postgraduate training (76.1 +/- 13.0%, lower quartile 70.0%, median 80.0%, upper quartile 86.7%). When using multivariate analysis, the location of the ICU in a university hospital, the belief of respondent that his/her knowledge of the pulmonary artery catheter was adequate, and the responsibility for supervising catheter insertion were the only independent predictors of good performance on the questionnaire (p < .001 for all three variables). It was impossible to identify any subcategory of physicians with a uniformly good knowledge of the pulmonary artery catheter. The proportion of incorrect answers to some basic items was disturbingly high. For instance, approximately 50% of the respondents, whether trained or in training, did not correctly identify pulmonary artery occlusion pressure from a clear chart recording. CONCLUSIONS: Knowledge of right-heart pulmonary artery catheterization is not uniformly good among ICU physicians. Accreditation policies and teaching practices concerning this technique need urgent revision.
TL;DR: The clear relationship between the frequency of cerebral ischemia and hypocarbia, combined with the rarity of hyperemia, suggests that hyperventilation should be used with caution and monitored carefully in children with severe head injuries.
Abstract: Objectives To study cerebral blood flow and cerebral oxygen consumption in severe head-injured children and also to assess the effect of hyperventilation on regional cerebral blood flow.Design Prospective cohort study.Setting Pediatric intensive care unit at a tertiary-level university children's ho
TL;DR: Densitometric analysis of nitrotyrosine immunoreactivity demonstrated significantly higher values for specimens from myocarditis and sepsis patients when compared with control tissue specimens, suggesting a role for peroxynitrite in inflammation-associated myocardial dysfunction.
Abstract: Objectives Production of nitric oxide via the cytokine-mediated activation of myocardial inducible nitric oxide synthase decreases myocardial contractility. Whether myocardial dysfunction is mediated directly by nitric oxide or indirectly through the formation of secondary reaction products, such as peroxynitrite, has not been established. Peroxynitrite, but not nitric oxide, reacts with the phenolic ring of tyrosine to form the stable product 3-nitro-L-tyrosine. Demonstration of tissue nitrotyrosine residues, therefore, infers the presence of peroxynitrite or related nitrogencentered oxidants. Design Retrospective analysis of human autopsy specimens. Setting University pathology and basic science laboratories. Patients Formalin-fixed, paraffin-embedded myocardial tissue samples were obtained from 11 patients with a diagnosis of sepsis, seven patients with a diagnosis of viral myocarditis, and five control patients without clinical or pathologic cardiac disease. Interventions None. Measurements and Main Results Specific antibodies to nitrotyrosine were utilized to detect nitrotyrosine residues in human autopsy specimens. Cardiac tissue obtained from patients with myocarditis or sepsis demonstrated intense nitrotyrosine immunoreactivity in the endocardium, myocardium, and coronary vascular endothelium and smooth muscle. In contrast, connective tissue elements were without appreciable immunohistochemical staining. Nitrotyrosine antibody binding was blocked by coincubation with nitrotyrosine or nitrated bovine serum albumin, but not by aminotyrosine, phosphotyrosine, or bovine serum albumin. In situ reduction of tissue nitrotyrosine to aminotyrosine by sodium hydrosulfite also blocked antibody binding. Densitometric analysis of nitrotyrosine immunoreactivity demonstrated significantly higher values for specimens from myocarditis and sepsis patients when compared with control tissue specimens. Conclusion These results demonstrate the formation of peroxynitrite within the myocardium during inflammatory disease states, suggesting a role for peroxynitrite in inflammation-associated myocardial dysfunction. (Crit Care Med 1997; 25:812-819)
TL;DR: It is concluded that the ventilatory strategy most likely to overdistend the lungs while allowing repetitive opening and closure of alveoli (group 2) facilitated bacterial translocation from theAlveoli to the bloodstream and increased lung injury, as determined by histologic and gravimetric analysis.
Abstract: Objective To test the effect of different mechanical ventilation strategies on dissemination of intratracheally instilled Escherichia coli in dogs and to determine the extent and distribution of lung damage.Design Prospective, randomized study.Setting Experimental animal laboratory.Subjects Eighteen
TL;DR: According to the profiles of the cytokines, septic shock patients do not represent a homogeneous population and may have different profiles in the time course of their cytokine concentrations.
Abstract: ObjectiveTo look for relationships between the classification of sepsis and plasma cytokine concentrations.DesignProspective, consecutive entry study of patients meeting severe sepsis criteria and having bacteriologically documented infections.SettingUniversity hospital, surgical intensive care unit
TL;DR: WD/WHLS was the most common cause of death in academic ICUs and poor patient prognosis was considered the most important factor in deciding on WDLS, however, in contrast to other studies, future quality of life was not as frequently cited a reason for WDLS and larger amounts of morphine were used during WDLS.
Abstract: Objectives To determine the proportion of patients who died as a result of the withdrawal or withholding of life support (WD/WHLS) in the intensive care units (ICUs) of three teaching hospitals and to describe the process involved by determining: a) why the decision was made to withdraw support (WDLS); b) when WDLS took place; and c) how the WDLS process was conducted. Design Retrospective cohort study. Setting Three university-affiliated ICUs. Patients Four hundred nineteen patients who died in one of three academic, tertiary care ICUs over a 1-yr period. Interventions Retrospective chart review. Data collected included age, gender, admitting diagnoses, comorbid disease, Acute Physiology and Chronic Health Evaluation II score, and mode of death (brain death, death due to withholding of life support, death due to WDLS, or death despite ongoing therapy). For those patients dying due to WDLS, the reason for WDLS, person initiating discussion, timing of WDLS, degree of organ dysfunction, order of withdrawal of life support modalities, and the use of sedatives and analgesics were recorded. Measurements and Main Results Seventy percent of patients died by WD/WHLS and 8.4% were brain dead. Patients undergoing WD/WHLS were older and had a longer length of stay than patients dying from other causes. Poor prognosis was the most common reason given for WDLS, reflected by significant organ dysfunction at the time of WDLS. Future quality of life was a less frequently cited reason. Most patients undergoing WDLS did so early in their ICU stay, although time to WDLS appeared to reflect diagnostic group. Few meetings occurred before WDLS and death occurred soon after initiating WDLS. There was a preference of withdrawing mechanical ventilation last and large amounts of morphine (mean 21 +/- 33 [SD] mg/hr) and benzodiazepines (mean 8.6 +/- 11 mg/hr) were used. Little variability in practice was apparent among the studied ICUs. Conclusions Similar to other studies, WD/WHLS was the most common cause of death in academic ICUs and poor patient prognosis was considered the most important factor in deciding on WDLS. However, in contrast to other studies, future quality of life was not as frequently cited a reason for WDLS and larger amounts of morphine were used during WDLS. These discrepancies suggest areas for potential future research. (Crit Care Med 1997; 25:1324-1331)
TL;DR: The use of a detailed, standardized pain assessment and intervention notation algorithm that incorporates behavioral and physiological indicators may assist healthcare professionals in making relatively accurate assessments of a patient's pain intensity.
Abstract: Objectives: To examine the accuracy of inferences about critical care patients' pain based on physiological and behavioral indicators and to assess the relationship between registered nurse and patient pain scores and doses of opioids administered. Design: Descriptive, comparative analysis. Setting: Three intensive care units and two postanesthesia care units in two hospitals. Subjects: Fourteen critical care nurses who conducted 114 pain assessments on 31 surgical patients. Interventions: Nurses used a pain assessment and intervention notation algorithm that contained lists of behavioral and physiological indicators of pain to make inferences about a patient's pain intensity. Fourteen registered nurses completed up to five pain assessments on each patient over a 4-hr period. Following both the physiological and behavioral ratings, nurses rated the patients' pain intensity, using a 0 to 10 numeric rating scale, and they asked patients to provide a self-report of pain intensity, using a similar numeric rating scale. Nurses then administered an intravenous dose of an opioid from a sliding scale prescription. Measurements and Main Results: Moderate-to-strong correlations were found between the number of behavioral indicators at times 1 through 5 and between the number of physiological indicators and nurses' ratings of the patients' pain intensity at times 1 through 4 (p <.05). Although nurses' pain ratings were consistently lower than patients' pain ratings across the five time points, these differences were not significant. The amount of opioid analgesic administered by the nurse correlated more frequently with nurses' pain ratings than with patients' self-reports of pain intensity. Conclusions: The use of a detailed, standardized pain assessment and intervention notation algorithm that incorporates behavioral and physiological indicators may assist healthcare professionals in making relatively accurate assessments of a patient's pain intensity. Further research is needed to determine the specific decision-making processes and criteria that healthcare professionals use to choose doses of analgesics to administer to critically ill patients.
TL;DR: Severity of illness when pneumonia is diagnosed is the most important predictor of survival, and this determination should be used for therapeutic and prognostic stratification.
Abstract: Objective: To assess the impact of severity of illness at different times, using the Mortality Probability Models (MPM II), and the impact of etiologic agent on survival in patients with nosocomial pneumonia. Design: Retrospective, observational study. Setting: Fourteen-bed medical-surgical intensive care unit (ICU) in a teaching hospital. Patients: Sixty-two patients with nosocomial pneumonia who were receiving early appropriate antibiotic treatment. Interventions: None. Measurements and Main Results: Severity of illness at the time of admission to the ICU (M 0 , 24 hrs after admission (M 24 ), and at the time of pneumonia diagnosis (M 1 ) was determined using MPM II. Bacteriology was established by quantitative cultures from bronchoscopic samples. The outcome measure was the crude mortality rate. The crude mortality rate in the ICU was 59.7%, compared with average predicted mortality rates of 43.5% (M 0 ), 36.4% (M 2 ), and 52.2% (M 1 ). We observed significant differences in mean MPM II determinations between survivors and nonsurvivors at M 1 (39.3% vs. 60.9%, p = .001) but not at M 0 and M 24 . In the univariate analysis, the variables most predictive of mortality were the presence of coma (p = .02), inotropic medication use (p =.001), and an MPM II determination of >50% (p =.001) when pneumonia was diagnosed (M 1 ). Multivariate analysis showed that, in the absence of Pseudomonas aeruginosa, an MPM II determination of >50% at M 1 was associated with a relative risk of death of 4.8. The presence of P. aeruginosa was associated with an increase in the risk of death of 2.6 and 6.36 in both populations with MPM II determinations at M 1 of 50%, respectively. Conclusions: Severity of illness when pneumonia is diagnosed is the most important predictor of survival, and this determination should be used for therapeutic and prognostic stratification. In addition, the presence of P. aeruginosa contributed to an excess of mortality that could not be measured by MPM II alone, suggesting the importance of the pathogen in prognosis.
TL;DR: Storage of rat red blood cells for 28 days in citrate phosphate dextrose adenine-1 impaired their ability to improve tissue oxygenation when transfused into either control or septic rats placed into supply dependency of systemic VO2.
Abstract: ObjectiveTo determine whether the time that red blood cells are stored in citrate phosphate dextrose adenine-1 solution before transfusion alters the ability to improve tissue oxygenation.DesignProspective, randomized, controlled study.SettingUniversity research institute laboratory.SubjectsMale Spr