Showing papers in "Critical Care Medicine in 1999"
TL;DR: The distribution of sites of infection in medical ICUs differed from that previously reported in NNIS ICU surveillance studies, largely as a result of anticipated low rates of surgical site infections.
Abstract: ObjectiveTo describe the epidemiology of nosocomial infections in medical intensive care units (ICUs) in the United States.DesignAnalysis of ICU surveillance data collected through the National Nosocomial Infections Surveillance (NNIS) System between 1992 and 1997.SettingMedical ICUs in the United S
1,580 citations
TL;DR: It is concluded that caspase-3-mediated apoptosis causes extensive lymphocyte apoptosis in sepsis and may contribute to the impaired immune response that characterizes the disorder.
Abstract: ObjectivesThe purpose of this study was to determine whether apoptosis is a major mechanism of cell death in patients with sepsis. The activities of caspase-3 and the antiapoptotic protein, BCL-2, were investigated also.DesignA prospective study of 20 patients who died of sepsis and multiple organ d
1,236 citations
TL;DR: The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.
Abstract: Objective:To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration.Design:Randomized, controlled clinical trial.Setting:Medical intensive care unit (19 beds) in an urban teaching hospital.Pa
973 citations
TL;DR: Infusion of stress doses of hydrocortisone reduced the time to cessation of vasopressor therapy in human septic shock and was associated with a trend to earlier resolution of sepsis-induced organ dysfunctions.
Abstract: ObjectiveTo investigate the effects of stress doses of hydrocortisone on the duration of vasopressor therapy in human septic shock.DesignProspective, randomized, double-blind, single-center study.SettingTwenty-bed multidiscipllnary intensive care unit in a 1400-bed university hospital.PatientsForty
836 citations
TL;DR: SAS is both reliable (high interrater agreement) and valid (high correlation with the Harris and Ramsay scales) in assessing agitation and sedation in adult ICU patients.
Abstract: ObjectiveSubjective scales to assess agitation and sedation in adult intensive care unit (ICU) patients have rarely been tested for validity or reliability. We revised and prospectively tested the Sedation-Agitation Scale (SAS) for interrater reliability and compared it with the Ramsay scale and the
835 citations
TL;DR: The beneficial effects of the EPA+GLA diet on pulmonary neutrophil recruitment, gas exchange, requirement for mechanical ventilation, length of intensive care unit stay, and the reduction of new organ failures suggest that this enteral nutrition formula would be a useful adjuvant therapy in the clinical management of patients with or at risk of developing ARDS.
Abstract: Objectives Recent studies in animal models of sepsis-induced acute respiratory distress syndrome (ARDS) have shown that a low-carbohydrate, high-fat diet combining the anti-inflammatory and vasodilatory properties of eicosapentaenoic acid (EPA; fish oil), gamma-linolenic acid (GLA; borage oil) (EPA+GLA), and antioxidants improves lung microvascular permeability, oxygenation, and cardiopulmonary function and reduces proinflammatory eicosanoid synthesis and lung inflammation. These findings suggest that enteral nutrition with EPA+GLA and antioxidants may reduce pulmonary inflammation and may improve oxygenation and clinical outcomes in patients with ARDS. Design Prospective, multicentered, double-blind, randomized controlled trial. Setting Intensive care units of five academic and teaching hospitals in the United States. Patients We enrolled 146 patients with ARDS (as defined by the American-European Consensus Conference) caused by sepsis/pneumonia, trauma, or aspiration injury in the study. Interventions Patients meeting entry criteria were randomized and continuously tube-fed either EPA+GLA or an isonitrogenous, isocaloric standard diet at a minimum caloric delivery of 75% of basal energy expenditure x 1.3 for at least 4-7 days. Measurements and main results Arterial blood gases were measured, and ventilator settings were recorded at baseline and study days 4 and 7 to enable calculation of PaO2/FIO2, a measure of gas exchange. Pulmonary neutrophil recruitment was assessed by measuring the number of neutrophils and the total cell count in bronchoalveolar lavage fluid at the same time points. Clinical outcomes were recorded. Baseline characteristics of 98 evaluable patients revealed that key demographic, physiologic, and ventilatory variables were similar at entry between both groups. Multiple bronchoalveolar lavages revealed significant decreases (approximately 2.5-fold) in the number of total cells and neutrophils per mL of recovered lavage fluid during the study with EPA+GLA compared with patients fed the control diet. Significant improvements in oxygenation (PaO2/FIO2) from baseline to study days 4 and 7 with lower ventilation variables (FIO2, positive end-expiratory pressure, and minute ventilation) occurred in patients fed EPA+GLA compared with controls. Patients fed EPA+GLA required significantly fewer days of ventilatory support (11 vs. 16.3 days; p = .011), and had a decreased length of stay in the intensive care unit (12.8 vs. 17.5 days; p = .016) compared with controls. Only four of 51 (8%) patients fed EPA+GLA vs. 13 of 47 (28%) control patients developed a new organ failure during the study (p = .015). Conclusions The beneficial effects of the EPA+GLA diet on pulmonary neutrophil recruitment, gas exchange, requirement for mechanical ventilation, length of intensive care unit stay, and the reduction of new organ failures suggest that this enteral nutrition formula would be a useful adjuvant therapy in the clinical management of patients with or at risk of developing ARDS.
697 citations
TL;DR: In this paper, the authors compared the effects of two acute care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.
Abstract: Objective:The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.Design:Randomized clinical trial.Set
674 citations
TL;DR: There was a perfect rank order correlation between unit-level organizational collaboration and patient outcomes across the three units, and medical ICU nurses' reports of collaboration were associated positively with patient outcomes.
Abstract: Objective:To investigate the association of collaboration between intensive care unit (ICU) physicians and nurses and patient outcome.Design:Prospective, descriptive, correlational study using self-report instruments.Settings:A community teaching hospital medical ICU, a university teaching hospital
652 citations
TL;DR: Overall, there is no apparent difference in pulmonary edema, mortality, or length of stay between isotonic crystalloid and colloid resuscitation between randomized clinical trials of adult patients requiring fluid resuscitation vs. colloids.
Abstract: ObjectiveTo systematically review the effects of isotonic crystalloids compared with colloids in fluid resuscitation.Data SourcesComputerized bibliographic search of published research and citation review of relevant articles.Study SelectionAll randomized clinical trials of adult patients requiring
556 citations
TL;DR: The reduced tidal volume strategy used in this study was safe and effective and failure to observe beneficial effects of small tidal volume ventilation treatment in important clinical outcome variables may have occurred because a) the sample size was too small to discern small treatment effects; b) the differences in tidal volumes and plateau pressures were modest; or c) reduced tidalVolume ventilation is not beneficial.
Abstract: ObjectiveTo assess the safety and potential efficacy of a mechanical ventilation strategy designed to reduce stretch-induced lung injury in acute respiratory distress syndrome.DesignProspective, randomized, controlled clinical trial.SettingEight intensive care units in four teaching hospitals.Patien
538 citations
TL;DR: Evaluated optical spectroscopic techniques for assessment of the determinants of tissue oxygenation and the notion that the disturbances in oxygen pathways in sepsis can be accounted for by enhanced functional shunting of parts of the microcirculation to evaluate the severity of microcirculatory distress and the effectiveness of resuscitation strategies.
Abstract: ObjectiveTo review optical spectroscopic techniques for assessment of the determinants of tissue oxygenation and to evaluate the notion that the disturbances in oxygen pathways in sepsis can be accounted for by enhanced functional shunting of parts of the microcirculation.Data ResourcesExperimental
Journal Article•
TL;DR: The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support and barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.
Abstract: ObjectiveTo evaluate those factors that impact on the delivery of enteral tube feeding.DesignProspective study.SettingMedical intensive care units (ICU) and coronary care units at two university-based hospitals.PatientsForty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male)
TL;DR: The benefits of enteral immunonutrition were most pronounced in surgical patients, although they were present in all groups, and the reduction in hospital length of stay and infections has resource implications.
Abstract: Objective:To perform a meta-analysis addressing whether enteral nutrition with immune-enhancing feeds benefits critically ill patients after trauma, sepsis, or major surgeryData Sources:Studies were identified by MEDLINE search (1967 to January 1998) for original articles in English using the searc
TL;DR: The frequency of enteral nutrition-related GICs in critically ill patients is high and high gastric residuals is the most frequent GIC, which decreased nutrient intake and, if persistent, could expose the patients to undernutrition.
Abstract: ObjectiveTo evaluate the frequency of gastrointestinal complications (GICs) in a prospective cohort of critically ill patients receiving enteral nutrition and to assess its effect on nutrient administration and its relationship to the patient's outcome.DesignMulticenter, prospective cohort study.Set
TL;DR: ProCT is not a better marker of infection than CRP in critically ill patients, but it can represent a useful adjunctive parameter to identify infection and is a useful marker of the severity of infection.
Abstract: ObjectiveTo determine the value of procalcitonin (ProCT) as a marker of infection in critically ill patients.DesignProspective, observational study.SettingMedicosurgical department of intensive care (31 beds).PatientsOne hundred eleven infected and 79 noninfected patients.InterventionsNone.Measureme
TL;DR: The results strongly support the conclusion that during the early phase of ARDS, the lung is the site of an intense inflammatory process with sequential activation of cytokines, chemokines, and secretion of proteases, as well as concomitant collagen synthesis.
Abstract: ObjectivesTo determine the concentrations of proinflammatory mediators, collagenases, and procollagen type III peptides in undiluted pulmonary edema fluids and in plasma obtained in patients with early acute respiratory distress syndrome (ARDS) and in control patients with hydrostatic lung edema; an
TL;DR: Intensive care unit admissions are frequently limited by the availability of beds across Europe, particularly in the south and in the United Kingdom, yet 73% of intensivists still admit patients with no hope of survival, yet important differences in attitudes also exist between Europe.
Abstract: Objective: To determine current views of European intensive care physicians regarding end-of-life decisions. Design: A questionnaire was sent to all physician members of the European Society of Intensive Care Medicine. All questionnaires were anonymous. Results: A total of 504 completed questionnaires from 16 western European countries were analyzed. Eighty-seven percent of the respondents were male. Forty-six percent of respondents said that intensive care unit admissions were generally or commonly affected by bed shortages, particularly in the south. Nevertheless, 73% of units frequently admit patients with no hope of survival, although only 33% of respondents felt that such patients should be admitted. Eighty percent of respondents felt that written do-not-resuscitate orders should be applied, but only 58% did so, with a wide variation according to country (from 8% in Italy to 91% in The Netherlands). Ninety-three percent of physicians sometimes withhold treatment from patients with no hope of a meaningful life, but withdrawal of treatment is less common. Forty percent of respondents said that they would deliberately administer large doses of drugs to such patients until death ensued. Forty-nine percent of respondents involved staff, patients, and family in end-of-life decisions. Forty-five percent of respondents felt that an ethics consultation was useful in such situations. Physicians in the countries of southern Europe were less likely than those in the north to apply do-not-resuscitate orders, withhold treatment, and discuss such issues with the patients. However, they were more likely to value the opinion of an ethics consultant. Conclusions: Intensive care unit admissions are frequently limited by the availability of beds across Europe, particularly in the south and in the United Kingdom, yet 73% of intensivists still admit patients with no hope of survival. When treating patients with no hope of survival, 40% of intensivists will deliberately administer large doses of drugs until death ensues. There are interesting differences between what a physician actually does and what he or she believes should be done with regard to various ethical questions. Important differences in attitudes also exist between European countries.
TL;DR: Therapeutic strategies to reduce production or signaling of either TNF-alpha or IL-1beta may limit myocardial dysfunction in sepsis, and together, these cytokines act synergistically to depress humanMyocardial function.
Abstract: ObjectiveProinflammatory cytokines such as tumor necrosis factor (TNF)-alpha and interleukin (IL)-1 beta have been implicated in the pathogenesis of myocardial dysfunction in ischemia-reperfusion injury, sepsis, chronic heart failure, viral myocarditis, and cardiac allograft rejection. Although circ
TL;DR: Enhanced EN appears to accelerate neurologic recovery and reduces both the incidence of major complications and postinjury inflammatory responses.
Abstract: Objective:To determine the effect of early enhanced enteral nutrition (EN) on clinical outcome of head-injured patients.Design:Prospective, randomized, controlled trial.Setting:Tertiary neurosurgical and trauma center.Patients:Eighty-two patients suffering head injury and requiring mechanical ventil
TL;DR: Volume of intraventricular hemorrhage is an important determinant of outcome in supratentorial intracerebral hemorrhage and contributed significantly to outcome prediction in the presence of Glasgow Coma Scale score.
Abstract: ObjectiveTo determine the prognostic significance and pathophysiologic implication of intraventricular extension of supratentorial intracerebral hemorrhage.DesignProspective study.SettingAcute stroke and neurointensive care units of a tertiary care hospital.PatientsOne hundred twenty-nine patients w
TL;DR: Fluconazole prophylaxis prevents colonization and invasive intra-abdominal Candida infections in high-risk surgical patients and was well tolerated, and adverse events occurred at similar frequencies in both treatment groups.
Abstract: ObjectiveTo evaluate the efficacy and safety of intravenous fluconazole for the prevention of intra-abdominal Candida infections in high-risk surgical patients.DesignRandomized, prospective, double-blind, placebo-controlled study.SettingTwo university-affiliated hospitals in Switzerland.PatientsFort
TL;DR: The MAAS is a valid and reliable sedation scale for use with mechanically ventilated patients in the SICU and is supported by generalized estimating equations, which supported MAAS validity by finding a linear trend between MAAS and the visual analog scale.
Abstract: ObjectiveTo establish the validity and reliability of a new sedation scale, the Motor Activity Assessment Scale (MAAS).DesignProspective, psychometric evaluation.SettingSixteen-bed surgical intensive care unit (SICU) of a 937-bed tertiary care, university-affiliated teaching hospital.PatientsTwenty-
TL;DR: Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, peri operative deaths and cardiorespiratory arrests.
Abstract: ObjectiveTo compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996.Data SourcesPublications obtained through a MEDLINE data-base search with a Boolean combination (tracheostomy or tracheotomy) and complications, with constraints for human studies
TL;DR: Femoral artery pulse contour CO correlates well with both COpa and COa even during substantial variations in vascular tone and hemodynamics, suggesting good agreement between the methods would indicate the potential of pulse contours analysis to monitor CO continuously and at reduced invasiveness.
Abstract: Continuous cariac output by femoral arterial thermodilution calibrated pulse contour analysis: comparison with pulmonary arterial thermodilution.
TL;DR: Deeper sedation and intermittent neuromuscular blockade were used for patients with greater ventilatory requirements and more severe lung disease, and SAS and BIS work well to describe the depth of sedation for ventilated ICU patients.
Abstract: ObjectiveTo describe the level of sedation for a cohort of mechanically ventilated adult intensive care unit (ICU) patients using validated subjective and objective tools.DesignProspective convenience sample.SettingMultidisciplinary 34-bed ICU at Maine Medical Center, a 599-bed nonuniversity, academ
TL;DR: Physicians triage patients to intensive care based on the number of beds available, the admission diagnosis, severity of disease, age, and operative status andMultivariate analysis revealed that triage tointensive care correlated with age, a full unit, surgical status, and diagnoses.
Abstract: OBJECTIVE To assess physician decision-making in triage for intensive care and how judgments impact on patient survival. DESIGN Prospective, descriptive study. SETTING General intensive care unit, university medical center. INTERVENTIONS All patients triaged for admission to a general intensive care unit were studied. Information was collected for the patient's age, diagnoses, surgical status, admission purpose, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mortality. The number of available beds at the time of triage and reasons for refused admission were obtained. MEASUREMENTS AND MAIN RESULTS Of 382 patients, 290 were admitted, 92 (24%) were refused admission, and 31 were admitted at a later time. Differences between admission diagnoses were found between patients admitted or not admitted (p < .001). Patients refused admission had higher APACHE II scores (15.6+/-1.5 admitted later and 15.8+/-1.4 never admitted) than did admitted patients (12.1+/-.4; p < .001). The frequency of admitting patients decreased when the intensive care unit was full (p < .001). Multivariate analysis revealed that triage to intensive care correlated with age, a full unit, surgical status, and diagnoses. Hospital mortality was lower in admitted (14%) than in refused patients (36% admitted later and 46% never admitted; p < .01) and in admitted patients with APACHE II scores of 11 to 20 (p = .02). The 28-day survival of patients was greater for admitted patients compared with patients never admitted (p = .01). CONCLUSIONS Physicians triage patients to intensive care based on the number of beds available, the admission diagnosis, severity of disease, age, and operative status. Admitting patients to intensive care is associated with a lower mortality rate, especially in patients with APACHE scores of 11 to 20.
TL;DR: The observation that ventilation occurs on the deflation limb of the tidal cycle-specific PV curve allows placement of the ventilatory cycle, by means of a recruitment maneuver, onto the deflation limbs of the PV envelope of the optimally recruited lung.
Abstract: To test the hypotheses that during small tidal volume ventilation (5 mL/kg) deliberate volume recruitment maneuvers allow expansion of atelectatic lung units and that a high positive end-expiratory pressure (PEEP) above the lower inflection point of the pressure/volume (PV) curve is not necessarily required to maintain recruited lung volume in acute lung injury.
TL;DR: The immune-mediated pathophysiologic mechanisms that underlie gram-positive sepsis and the potential interactions between the infecting microorganism and efficacy of anticytokine therapies require further investigation.
Abstract: ObjectiveTo review the basic differences between Gram-positive and Gram-negative sepsis and to assess the effect of these differences on current and future therapeutic strategies for sepsis.DesignLiterature review of the past 30 yrs of laboratory and clinical reports that analyze the microbial aspec
TL;DR: Despite having longer lengths of stay in the ICU and hospital, patients with respiratory failure who received a trachostomy had favorable outcomes compared with patients who did not receive a tracheostomy, suggesting that physicians are capable of selecting critically ill patients who most likely will benefit from placement of a traceostomy.
Abstract: Objective:To identify clinical predictors for tracheostomy among patients requiring mechanical ventilation in the intensive care unit (ICU) setting and to describe the outcomes of patients receiving a tracheostomy.Design:Prospective cohort study.Setting:Intensive care units of Barnes-Jewish Hospital