Showing papers in "Critical Care Medicine in 1998"
TL;DR: In this paper, the authors evaluated the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients in ICU.
Abstract: ObjectiveTo evaluate the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients.DesignProspective, multicenter study.SettingForty intensive care units (ICUs) in 16 countries.PatientsPatients admitted to the
2,958 citations
TL;DR: Administration of modest doses of hydrocortisone in the setting of pressor-dependent septic shock for a mean of >96 hrs resulted in a significant improvement in hemodynamics and a beneficial effect on survival.
Abstract: ObjectivesPreliminary studies have suggested that low doses of corticosteroids might rapidly improve hemodynamics in late septic shock treated with catecholamines. We examined the effect of hydrocortisone on shock reversal, hemodynamics, and survival in this particular setting.DesignProspective, ran
820 citations
TL;DR: In this article, the authors evaluated the safety and physiologic response of inhaled nitric oxide (NO) in patients with acute respiratory distress syndrome (ARDS) and evaluated the effect of various doses of NO on clinical outcome parameters.
Abstract: Objectives To evaluate the safety and physiologic response of inhaled nitric oxide (NO) in patients with acute respiratory distress syndrome (ARDS). In addition, the effect of various doses of inhaled NO on clinical outcome parameters was assessed. Design Prospective, multicenter, randomized, double-blind, placebo-controlled study. Setting Intensive care units of 30 academic, teaching, and community hospitals in the United States. Patients Patients with ARDS, as defined by the American-European Consensus Conference, were enrolled into the study if the onset of disease was within 72 hrs of randomization. Interventions Patients were randomized to receive placebo (nitrogen gas) or inhaled NO at concentrations of 1.25, 5, 20, 40, or 80 ppm. Measurements and main results Acute increases in PaO2, decreases in mean pulmonary arterial pressure, intensity of mechanical ventilation, and oxygenation index were examined. Clinical outcomes examined were the dose effects of inhaled NO on mortality, the number of days alive and off mechanical ventilation, and the number of days alive after meeting oxygenation criteria for extubation. A total of 177 patients were enrolled over a 14-month period. An acute response to treatment gas, defined as a PaO2 increase > or =20%, was seen in 60% of the patients receiving inhaled NO with no significant differences between dose groups. Twenty-four percent of placebo patients also had an acute response to treatment gas during the first 4 hrs. The initial increase in oxygenation translated into a reduction in the FIO2 over the first day and in the intensity of mechanical ventilation over the first 4 days of treatment, as measured by the oxygenation index. There were no differences among the pooled inhaled NO groups and placebo with respect to mortality rate, the number of days alive and off mechanical ventilation, or the number of days alive after meeting oxygenation criteria for extubation. However, patients receiving 5 ppm inhaled NO showed an improvement in these parameters. In this dose group, the percentage of patients alive and off mechanical ventilation at day 28 (a post hoc analysis) was higher (62% vs. 44%) than the placebo group. There was no apparent difference in the number or type of adverse events reported among those patients receiving inhaled NO compared with placebo. Four patients had methemoglobin concentrations >5%. The mean inspired nitrogen dioxide concentration in inhaled NO patients was 1.5 ppm. Conclusions From this placebo-controlled study, inhaled NO appears to be well tolerated in the population of ARDS patients studied. With mechanical ventilation held constant, inhaled NO is associated with a significant improvement in oxygenation compared with placebo over the first 4 hrs of treatment. An improvement in oxygenation index was observed over the first 4 days. Larger phase III studies are needed to ascertain if these acute physiologic improvements can lead to altered clinical outcome.
730 citations
TL;DR: There was an increasing prevalence of Gram-positive causative organisms, and a change of the predominant origin of sepsis from the abdomen to the chest, in patients with bacteremia as an entry criterion.
Abstract: ObjectivesTo determine whether a systematic review of the literature could identify changes in the mortality of septic shock over time.Data SourcesA review of all relevant papers from 1958 to August 1997, identified through a MEDLINE search and from the bibliographies of articles identified.Data Syn
568 citations
TL;DR: Survivors of ARDS showed statistically significant impairments in all eight health dimensions of the SF-36 when compared with normal controls, and patients reporting multiple adverse experiences described the lowest health-related quality of life.
Abstract: ObjectivesDespite considerable progress in intensive care management of the acute respiratory distress syndrome (ARDS), little is known about health-related quality of life in long-term survivors. In addition, intensive care treatment can be extremely stressful, and many survivors of ARDS report adv
568 citations
TL;DR: Analysis of the PbtO2 monitoring data suggested that the likelihood of death increased with increasing duration of time at or below a PBTO2 of 15 torr (2.0 kPa) or with the occurrence of any Pbt O2 values of < or =6 torr (< or =0.8 kPa).
Abstract: ObjectiveTo determine thresholds of brain tissue PO2 (PbtO2) that are critical for survival after severe head injury.DesignProspective data collection.SettingNeurosurgical intensive care unit of Ben Taub General Hospital, a comprehensive academic neurosurgical facility and Level I trauma center.Pati
414 citations
TL;DR: In severely ill ICU patients with SIRS, an early 40% decrease in plasma selenium concentrations is observed, reaching values observed in deleterious nutritional seenium deficiency, which could explain the three-fold increase in morbidity and mortality rates.
Abstract: ObjectivesTo confirm early, marked decrease in plasma selenium concentrations in patients admitted to a surgical and medical intensive care unit (ICU), and to study this decrease according to the presence or absence of systemic inflammatory response syndrome (SIRS), sepsis, or direct ischemia-reperf
368 citations
TL;DR: Treatment of severe head injury with hypertonic saline is superior to that treatment with lactated Ringer's solution, and to keep ICP at <15 mm Hg, group 2 patients required significantly fewer interventions (p < .02).
Abstract: OBJECTIVES Resuscitation in severe head injury may be detrimental when given with hypotonic fluids. We evaluated the effects of lactated Ringer's solution (sodium 131 mmol/L, 277 mOsm/L) compared with hypertonic saline (sodium 268 mmol/L, 598 mOsm/L) in severely head-injured children over the first 3 days after injury. DESIGN An open, randomized, and prospective study. SETTING A 16-bed pediatric intensive care unit (ICU) (level III) at a university children's hospital. PATIENTS A total of 35 consecutive children with head injury. INTERVENTIONS Thirty-two children with Glasgow Coma Scores of 92%, and hematocrit of >0.30). MEASUREMENTS AND MAIN RESULTS Mean arterial pressure and intracranial pressure (ICP) were monitored continuously and documented hourly and at every intervention. The means of every 4-hr period were calculated and serum sodium concentrations were measured at the same time. An ICP of 15 mm Hg was treated with a predefined sequence of interventions, and complications were documented. There was no difference with respect to age, male/female ratio, or initial Glasgow Coma Score. In both groups, there was an inverse correlation between serum sodium concentration and ICP (group 1: r = -.13, r2 = .02, p < .03; group 2: r = -.29, r2 = .08, p < .001) that disappeared in group 1 and increased in group 2 (group 1: r = -.08, r2 = .01, NS; group 2: r = -.35, r2 =.12, p < .001). Correlation between serum sodium concentration and cerebral perfusion pressure (CPP) became significant in group 2 after 8 hrs of treatment (r = .2, r2 = .04, p = .002). Over time, ICP and CPP did not significantly differ between the groups. However, to keep ICP at <15 mm Hg, group 2 patients required significantly fewer interventions (p < .02). Group 1 patients received less sodium (8.0 +/- 4.5 vs. 11.5 +/- 5.0 mmol/kg/day, p = .05) and more fluid on day 1 (2850 +/- 1480 vs. 2180 +/- 770 mL/m2, p = .05). They also had a higher frequency of acute respiratory distress syndrome (four vs. 0 patients, p = .1) and more than two complications (six vs. 1 patient, p = .09). Group 2 patients had significantly shorter ICU stay times (11.6 +/- 6.1 vs. 8.0 +/- 2.4 days; p = .04) and shorter mechanical ventilation times (9.5 +/- 6.0 vs. 6.9 +/- 2.2 days; p = .1). The survival rate and duration of hospital stay were similar in both groups. CONCLUSIONS Treatment of severe head injury with hypertonic saline is superior to that treatment with lactated Ringer's solution. An increase in serum sodium concentrations significantly correlates with lower ICP and higher CPP. Children treated with hypertonic saline require fewer interventions, have fewer complications, and stay a shorter time in the ICU.
359 citations
TL;DR: It is shown how hypoalbuminemia lowers the anion gap, which can mask a significant gap acidosis; and to derive a correction factor for it, which is adjusted for the effect of abnormal serum albumin concentrations.
Abstract: ObjectivesTo show how hypoalbuminemia lowers the anion gap, which can mask a significant gap acidosis; and to derive a correction factor for it.DesignObservational study.SettingIntensive care unit in a university-affiliated hospital.SubjectsNine normal subjects and 152 critically ill patients (265 m
344 citations
TL;DR: Whether the administration of recombinant human erythropoietin to critically ill patients in the intensive care unit (ICU) would reduce the number of red blood cell (RBC) transfusions required is investigated.
Abstract: Objective:To determine whether the administration of recombinant human erythropoietin (rHuEPO) to critically ill patients in the intensive care unit (ICU) would reduce the number of red blood cell (RBC) transfusions required.Design:A prospective, randomized, double-blind, placebo-controlled, multice
329 citations
TL;DR: ProCT, in addition to being an important marker of severity of systemic inflammation and mortality, is an integral part of the inflammatory process and directly affects the outcome.
Abstract: ObjectivesProcalcitonin (ProCT), the precursor to the calcitonin hormone, is abnormally increased in experimental and clinical systemic inflammation, including sepsis. Initially, we investigated the effects of supraphysiologic amounts of ProCT administered to animals with septic peritonitis. Subsequ
TL;DR: Intervention before ICU admission and support of patients after discharge from the ICU should be part of the effort to decrease mortality for ICU patients, according to early identification of patients at risk.
Abstract: ObjectiveTo identify priorities for intensive care unit (ICU) intervention and research.DesignAnalysis of a large intensive care database.SettingTwenty-four ICUs in the North Thames region of the United Kingdom.PatientsAll patients admitted to an ICU between January 1, 1992, and April 31, 1996, on w
TL;DR: Dental plaque colonization by aerobic pathogens might be a specific source of nosocomial infection in ICU patients, and a high bacterial concordance was found between dental plaque and tracheal aspirate cultures, and in the additional study, between salivary and dental plaque cultures.
Abstract: Objective: To study the dental status and colonization of dental plaque by aerobic pathogens and their relation with nosocomial infections in intensive care unit (ICU) patients.Design: A prospective study in a medical ICU of a university-affiliated hospital.Patients: Consecutive patients adm
TL;DR: The results suggest that mechanically ventilated adult patients with extended ICU care who receive large doses of analgesic and sedative medications are at risk for acute withdrawal syndromes during drug weaning.
Abstract: ObjectivesTo estimate the frequency of acute withdrawal syndrome related to the administration of analgesic and sedative medications in mechanically ventilated adult intensive care unit (ICU) patients; to identify associated clinical factors.DesignRetrospective review of medical records.SettingAn ad
TL;DR: While the administration of enteral IMN to a general, critically ill population did not affect mortality, those patients in whom it was possible to achieve early enteral nutrition with Impact had a significant reduction in the morbidity of their critical illness.
Abstract: ObjectiveTo assess the effects of enteral immunonutrition (IMN) on hospital mortality and length of stay in a heterogeneous group of critically ill patients.DesignProspective, randomized, double-blind, controlled clinical trial with an a priori subgroup analysis according to the volume of feed deliv
TL;DR: APACHE III accurately predicted aggregate hospital mortality in an independent sample of U.S. ICU admissions and further improvements in calibration can be achieved by more precise disease labeling, improved acquisition and weighting of neurologic abnormalities, adjustments that reflect changes in treatment outcomes over time, and a larger national database.
Abstract: Objective: To assess the accuracy and validity of Acute Physiology and Chronic Health Evaluation (APACHE) III hospital mortality predictions in an independent sample of U.S. intensive care unit (ICU) admissions. Design: Nonrandomized, observational, cohort study. Setting: Two hundred eighty-five ICUs in 161 U.S. hospitals, including 65 members of the Council of Teaching Hospitals and 64 nonteaching hospitals. Patients: A consecutive sample of 37,668 ICU admissions during 1993 to 1996; including 25,448 admissions at hospitals with >400 beds and 1,074 admissions at hospitals with <200 beds. Interventions: None. Measurements and Main Results: We used demographic, clinical, and physiologic information recorded during ICU day 1 and the APACHE III equation to predict the probability of hospital mortality for each patient. We compared observed and predicted mortality for all admissions and across patient subgroups and assessed predictive accuracy using tests of discrimination and calibration. Aggregate hospital death rate was 12.35% and predicted hospital death rate was 12.27% (p=.541). The model discriminated between survivors and nonsurvivors well (area under receiver operating curve = 0.89). A calibration curve showed that the observed number of hospital deaths was close to the number of deaths predicted by the model, but when tested across deciles of risk, goodness-of-fit (Hosmer-Lemeshow statistic, chi-square = 48.71, 8 degrees of freedom, p<.0001) was not perfect. Observed and predicted hospital mortality rates were not significantly (p <.01) different for 55 (84.6%) of APACHE III's 65 specific ICU admission diagnoses and for 11 (84.6%) of the 13 residual organ system-related categories. The most frequent diagnoses with significant (p<.01) differences between observed and predicted hospital mortality rates included acute myocardial infarction, drug overdose, nonoperative head trauma, and nonoperative multiple trauma. Conclusions: APACHE III accurately predicted aggregate hospital mortality in an independent sample of U.S. ICU admissions. Further improvements in calibration can be achieved by more precise disease labeling, improved acquisition and weighting of neurologic abnormalities, adjustments that reflect changes in treatment outcomes over time, and a larger national database.
TL;DR: Hypertonic saline administration as a 3% infusion appears to be a promising therapy for cerebral edema in patients with head trauma or postoperative edema, and further studies are required to determine the optimal duration of benefit and the specific patient population that is most likely to benefit from this treatment.
Abstract: Objective To determine the effect of continuous hypertonic (3%) saline/acetate infusion on intracranial pressure (ICP) and lateral displacement of the brain in patients with cerebral edema. Design Retrospective chart review. Settings Neurocritical care unit of a university hospital. Patients Twenty-seven consecutive patients with cerebral edema (30 episodes), including patients with head trauma (n = 8), postoperative edema (n = 5), nontraumatic intracranial hemorrhage (n = 8), and cerebral infarction (n = 6). Intervention Intravenous infusion of 3% saline/acetate to increase serum sodium concentrations to 145 to 155 mmol/L. Measurements and main results A reduction in mean ICP within the first 12 hrs correlating with an increase in the serum sodium concentration was observed in patients with head trauma (r2 = .91, p = .03), and postoperative edema (r2 = .82, p = .06), but not in patients with nontraumatic intracranial hemorrhage or cerebral infarction. In patients with head trauma, the beneficial effect of hypertonic saline on ICP was short-lasting, and after 72 hrs of infusion, four patients required intravenous pentobarbital due to poor ICP control. Among the 21 patients who had a repeat computed tomographic scan within 72 hrs of initiating hypertonic saline, lateral displacement of the brain was reduced in patients with head trauma (2.8 +/- 1.4 to 1.1 +/- 0.9 [SEM]) and in patients with postoperative edema (3.1 +/- 1.6 to 1.1 +/- 0.7). This effect was not observed in patients with nontraumatic intracranial bleeding or cerebral infarction. The treatment was terminated in three patients due to the development of pulmonary edema, and was terminated in another three patients due to development of diabetes insipidus. Conclusions Hypertonic saline administration as a 3% infusion appears to be a promising therapy for cerebral edema in patients with head trauma or postoperative edema. Further studies are required to determine the optimal duration of benefit and the specific patient population that is most likely to benefit from this treatment.
TL;DR: The low mortality compared with previous outcome studies strongly indicates that this therapy improves outcome for severe head injuries, however, a randomized, controlled study is needed to reach general acceptance of this new therapy.
Abstract: ObjectiveTo assess the new "Lund therapy" of posttraumatic brain edema, based on principles for brain-volume regulation and improved microcirculation.DesignA prospective, nonrandomized outcome study over a 5-yr period on severely head-injured patients with increased intracranial pressure, comparing
TL;DR: To evaluate the effect of intravenous bolus administration of 23.4% saline (8008 mOsm/L) on refractory intracranial hypertension (RIH) in patients with diverse intrusion diseases, a neurosciences intensive care unit in a university hospital is chosen.
Abstract: ObjectiveTo evaluate the effect of intravenous bolus administration of 23.4% saline (8008 mOsm/L) on refractory intracranial hypertension (RIH) in patients with diverse intracranial diseases.DesignRetrospective chart review.SettingA neurosciences intensive care unit in a university hospital.Patients
TL;DR: The family needs instrument was reliable and demonstrated a high degree of concordance with a second respondent in the same family surveyed, suggesting that this instrument may be a useful adjunct in assessing quality of critical care services provided.
Abstract: Objective: To measure the ability to meet family needs in an intensive care unit (ICU).Design: Descriptive survey.Setting: University hospital ICU.Subjects: Ninety-nine next of kin respondents and 16 secondary family respondents were recruited.Interventions: A modified Society of Critical Ca
TL;DR: The data suggest that for patients with septic shock on wards, there were clinically important delays in transfer of patients to the ICU, receipt of intravenous fluid boluses, and receipt of inotropic agents, and the most powerful predictors of mortality were APACHE II scores and bloodstream infection with Candida species.
Abstract: Objective: To determine if early interventions for septic shock were associated with reduced mortality. Design: Retrospective cohort study. Setting: University hospital intensive care unit (ICU) and general wards. Patients: Forty-one consecutive patients prospectively identified with positive blood cultures and septic shock. Although all patients were eventually treated in an ICU, ten (24%) patients were on a general ward at the onset of septic shock, and 31 (76%) were in an ICU setting. Interventions: None. Measurements and Main Results: Over a period of 9 mos, a cohort of 41 patients who had positive blood cultures and septic shock was prospectively identified. The 28-day crude mortality was 46% (19 deaths). We compared the management of septic shock and outcome for patients on a general ward vs. those patients in an ICU setting. Of the ten patients on the ward at time of shock onset (median age 55.5 yrs; median Acute Physiology and Chronic Health Evaluation [APACHE] II score of 18.5), seven (70%) died. In contrast, the 31 patients receiving intensive care when shock developed were older and more ill (median age 66 yrs; median APACHE II 24), yet had a mortality of 39% (12 deaths). The odds ratio (OR) for death for ward patients compared with ICU patients was 3.57 (p = .17). In a multivariate logistic regression analysis, two risk factors for mortality were important: APACHE II score (p =.015) and ward status (p = .08). Candida species in the bloodstream is known to have a high attributable mortality. When type of bloodstream pathogen (Candida species vs. bacteria) was added to the model, APACHE II (OR 2.64 for 10-unit increase) remained significant (p =.014), but ward status (OR 3.97) became statistically nonsignificant (p = .222). The patients who were on a general ward when their shock developed had a median delay of 67 mins before transfer to an ICU setting. Ward patients received an intravenous fluid bolus after a median delay of 27 mins, whereas those in the ICU who received a fluid bolus did so after a median of 15 mins (p =.48). Ward patients also had a median delay of 310 mins to receive inotropic support compared with a median 22.5 mins (p =.037) for the patients in an ICU setting when shock started. Conclusions: The data suggest that for patients with septic shock on wards, there were clinically important delays in transfer of patients to the ICU, receipt of intravenous fluid boluses, and receipt of inotropic agents. However, the most powerful predictors of mortality were APACHE II scores and bloodstream infection with Candida species.
TL;DR: Patients at risk for unplanned extubation are characterized by oral intubation and insufficient sedation, and a PaO2/FiO2 ratio <200 torr (<26.7 kPa) are factors associated with a risk of reintubation.
Abstract: ObjectivesTo define patients at risk for unplanned extubation; to assess the influence of nursing workload on the incidence of unplanned extubation; and to determine predictive criteria for patients requiring reintubation.DesignA prospective, case-control study, with 10 and 15 mos of data collection
TL;DR: Current recommended protein requirements in critically ill sepsis or trauma patients during the first 2 wks after admission to the intensive care unit are excessive if they are indexed to the body weight measured soon after the onset of critical illness.
Abstract: ObjectiveTo obtain optimal protein requirements in critically ill sepsis or trauma patients during the first 2 wks after admission to the intensive care unit.DesignRetrospective study.SettingDepartment of critical care medicine at a teaching hospital.PatientsImmediate posttrauma patients or severely
TL;DR: Severe underlying cardiac disease, intraoperative blood loss, surgical reexploration, long ischemic times, immediate postoperative cardiovascular dysfunction, global ischemia and metabolic dysfunction, and anemia beyond the second postoperative day predicted poor outcome in the elderly after cardiac surgery.
Abstract: Objective: To determine perioperative predictors of morbidity and mortality in patients >or=to75 yrs of age after cardiac surgery. Design: Inception cohort study. Setting: A tertiary care, 54-bed cardiothoracic intensive care unit (ICU). Patients: All patients aged >or=to75 yrs admitted over a 30-month period for cardiac surgery. Intervention: Collection of data on preoperative factors, operative factors, postoperative hemodynamics, and laboratory data obtained on admission and during the ICU stay. Measurements and Main Results: Postoperative death, frequency rate of organ dysfunction, nosocomial infections, length of mechanical ventilation, and ICU stay were recorded. During the study period, 1,157 (14%) of 8,501 patients >or=to75 yrs of age had a morbidity rate of 54% (625 of 1,157 patients) and a mortality rate of 8% (90 of 1,157 patients) after cardiac surgery.Predictors of postoperative morbidity included preoperative intraaortic balloon counterpulsation, preoperative serum bilirubin of >1.0 mg/dL, blood transfusion requirement of >10 units of red blood cells, cardiopulmonary bypass time of >120 mins (aortic cross-clamp time of >80 mins), return to operating room for surgical exploration, heart rate of >120 beats/min, requirement for inotropes and vasopressors after surgery and on admission to the ICU, and anemia beyond the second postoperative day. Predictors of postoperative mortality included preoperative cardiac shock, serum albumin of 10 units of red blood cells, cardiopulmonary bypass time of >140 mins (aortic cross-clamp time of >120 mins), subsequent return to the operating room for surgical exploration, mean arterial pressure of 120 beats/min, central venous pressure of >15 mm Hg, stroke volume index of 300 mg/dL after surgery, and anemia beyond the second postoperative day. During the study period, the study cohort used 6,859 (21.5%) ICU patient-days out of a total 31,867 ICU patient-days. Nonsurvivors used 2,023 (30%) ICU patient-days and patients with morbidity used 5,903 (86%) ICU patient-days. Conclusions: Severe underlying cardiac disease (including shock, requirement for mechanical circulatory support, hypoalbuminemia, and hepatic dysfunction), intraoperative blood loss, surgical reexploration, long ischemic times, immediate postoperative cardiovascular dysfunction, global ischemia and metabolic dysfunction, and anemia beyond the second postoperative day predicted poor outcome in the elderly after cardiac surgery. Postoperative morbidity and mortality disproportionately increased the utilization of intensive care resources in elderly patients. Future efforts should focus on preoperative selection criteria, improvement in surgical techniques, perioperative therapy to ameliorate splanchnic and global ischemia, and avoidance of anemia to improve the outcome in the elderly after cardiac surgery. (Crit Care Med 1998; 26:225-235) In the last few decades, the fastest growing segment of the U.S. population has been the age group >65 yrs. In 1990, the percentage of people >65 yrs of age in the U.S. population was 12.6% (31.4 million), a figure that is projected to increase to 19.6% (58.9 million) by the year 2025 [1]. Although this age group constitutes only 13% of the current population, they account for the use of [approximately]33% of all healthcare resources [2]. The recent increase in healthcare costs has led to evaluation of recent advances in medical and surgical technology offered to elderly patients. Cardiovascular disease is the most common cause of death in the elderly population. With a rapid increase in the size of the elderly population, the demands on resources for cardiac surgery will continue to increase [3]. The appropriateness of cardiac surgery in the group >or=to75 yrs of age has often been debated [4]. It has been suggested that since morbidity and mortality rates are so high in this particular age group, the age of 75 yrs should be used as a cutoff for denial of surgical treatment. With continued advances in operative and anesthetic techniques, this opinion is no longer tenable. A study by Parry et al. [5] addressed the risks and benefits of cardiac surgery in the elderly population and found that the morbidity and mortality rates were not significantly different from those of younger patients. Elective cardiac surgery was found to improve the longevity and functional outcome in selected elderly patients without a prohibitive rate of morbidity or mortality. Several scoring systems were developed to predict postoperative morbidity and mortality of patients undergoing coronary artery bypass surgery (CABG) [6-8]. The scoring systems utilized preoperative risk factors identified from patient cohorts with a wide range of age for a specific surgical procedure. There are several reasons for concern about the validity of such scoring systems being utilized for elderly patients. The disparity of the case-mix of the cohorts used for the development and validation of scoring systems can affect the calibration and discrimination characteristics when applied to elderly patients [9]. These scoring systems lacked definition of operative events which may precipitate subsequent morbidity and mortality in the elderly. Early hemodynamic and biochemical correlates of underlying physiologic derangement immediately after surgery and on admission to the intensive care unit (ICU) were also deficient in these scoring systems [6-8]. There is a demand for accurate definition of risk factors for morbidity and mortality in the elderly patient undergoing cardiac surgery, especially with increasing pressures to limit the critical care resources [10]. Rational allocation of critical care resources to elderly patients is a subject of continuous debate because of the ethical and financial concerns resulting from the futile prolongation of life of elderly patients [11]. The current study was designed to examine potential risk factors for morbidity and mortality in a cohort of elderly patients who underwent cardiac surgery at a single institution. The objectives were a) to determine the frequency rate of postoperative morbidity and mortality; and b) to identify perioperative factors: preoperative, operative, and early postoperative factors (on ICU admission) which predict morbidity and mortality in this cohort of patients. Finally, the study was to delineate the impact of postoperative morbidity and mortality on the utilization of ICU resources by the elderly.
TL;DR: In patients with severe acute brain trauma and intracranial hypertension associated with compromised cerebrospinal fluid spaces, monitoring and managing cerebral extraction of oxygen in conjunction with cerebral perfusion pressure result in better outcome than when cerebral perfusions pressure is managed alone.
Abstract: Objective: To comparatively assess outcome of patients undergoing monitoring and management of cerebral extraction of oxygen along with cerebral perfusion pressure vs outcome of patients undergoing monitoring and management of cerebral perfusion pressure alone in severe acute brain traumaD
TL;DR: Proactive ethics consultation for high-risk patient populations offers a promising approach to improving decision-making and communication and reducing length of ICU stay for dying patients.
Abstract: Objective: To assess the effect of proactive ethics consultation on documented patient care communications and on declsions regarding high-risk intensive care unit (ICU) patients.Design: Prospective, controlled study.Patients: Ninety-nine ICU patients treated with >96 hrs of continuous mecha
TL;DR: CVVH resulted in a decrease in plasma TNF-alpha concentrations as compared with CVVHD, while the type of transport mechanism used did not influence plasma concentrations of IL-6, IL-10, soluble L-selectin, or endotoxin.
Abstract: ObjectiveTo compare two forms of continuous renal replacement therapy, continuous venovenous hemofiltration (CVVH) vs. continuous venovenous hemodialysis (CVVHD), in terms of the removal of inflammatory mediators from the blood of patients with systemic inflammatory response syndrome and acute renal
TL;DR: After recent introduction of an antibiotic treatment for suspected ventilator-associated pneumonia, protected specimen brush and bronchoalveolar lavage culture thresholds must be decreased to maintain good accuracy.
Abstract: Objective: To determine whether the diagnostic accuracy of bronchoscopy samples in patients with suspected ventilator-associated pneumonia is affected by prior antibiotic treatment given for a previous infection, and/or by antibiotic treatment recently started to treat suspected ventilator-a
TL;DR: Continuous infusion midazolam provides effective sedation in the ICU with few complications overall, especially when the dose is titrated.
Abstract: ObjectiveTo describe the various complications that have been reported with use of midazolam for sedation in the intensive care unit (ICU).Data SourcesPublications in scientific literature.Data ExtractionComputer search of the literature.SynthesisSedation is required in the ICU in order for patients
TL;DR: It is hypothesized that human neutrophil activation and adhesion vary, depending on the type and amount of resuscitation fluid used, as demonstrated by the dose-related increase in neutrophIL activation andAdhesion.
Abstract: Objective: To determine whether activated neutrophils play a major role in secondary tissue injury after resuscitation in trauma. We hypothesized that human neutrophil activation and adhesion vary, depending on the type and amount of resuscitation fluid used. Setting: University-based research facility. Subjects: Ten healthy adult volunteers. Design: Whole blood from volunteers was serially diluted in polypropylene tubes with various resuscitation fluids. Fluids tested were phosphate-buffered saline, normal saline, lactated Ringer's solution, dextran, hespan, 5% human albumin, 25% human albumin, 3.5% hypertonic saline, and 7.5% hypertonic saline. Neutrophil activation (intracellular oxidative burst activity with dichlorofluorescin diacetate staining) and adhesion (integrin cell surface expression of CD18) were measured with flow cytometry (fluorescence-activated cell sorting). Blood was diluted with hypertonic saline by controlling for sodium content equal to normal saline. Measurements and Main Results: There was a significant dose-related increase in neutrophil oxidative burst activity as the result of dilution followed with crystalloid fluids and artificial colloids (dextran and hespan). The increase was 12-18 × baseline at the 75% dilution. The increase with 5% human albumin was only 2.2 × baseline, and 25% albumin did not demonstrate any increased intracellular activity. A similar significant increase in the neutrophil adhesion expression (CD18) occurred with artificial colloids (p <.05) and, to a lesser extent, with crystalloids, but not with albumin. Hypertonic saline caused a decrease in CD18 cell surface expression. Conclusions: This study suggests that the neutrophil activation and adhesion may vary, depending on the type of resuscitative fluid used. All artificial resuscitative fluids may not be similar or innocuous, as demonstrated by the dose-related increase in neutrophil activation and adhesion.