Showing papers in "Critical Care Medicine in 2003"
TL;DR: This document reflects a process whereby a group of experts and opinion leaders revisited the 1992 sepsis guidelines and found that apart from expanding the list of signs and symptoms of sepsi to reflect clinical bedside experience, no evidence exists to support a change to the definitions.
Abstract: Objective: In 1991, the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) convened a "Consensus Conference", the goals of which were to provide a conceptual and a practical framework to define the systemic inflammatory response to infection, which is a progressive inju- rious process that falls under the gen- eralized term 'sepsis' and includes sepsis-associated organ dysfunction as well. The general definitions intro- duced as a result of that conference have been widely used in practice, and have served as the foundation for in- clusion criteria for numerous clinical trials of therapeutic interventions. Nevertheless, there has been an impe- tus from experts in the field to modify these definitions to reflect our current understanding of the pathophysiology of these syndromes. Design: Several North American and European inten- sive care societies agreed to revisit the definitions for sepsis and related con- ditions. This conference was spon- sored by the Society of Critical Care Medicine (SCCM), The European So-
5,298 citations
TL;DR: Normoglycemia was safely reached within 24 hrs and maintained during intensive care by using insulin titration guidelines, and metabolic control, as reflected by normoglycesmia, rather than the infused insulin dose per se, was related to the beneficial effects of intensive insulin therapy.
Abstract: ObjectivesMaintenance of normoglycemia with insulin reduces mortality and morbidity of critically ill patients. Here we report the factors determining insulin requirements and the impact of insulin dose vs. blood glucose control on the observed outcome benefits.DesignA prospective, randomized, contr
1,161 citations
TL;DR: The accumulation of activated neutrophils in the lungs is an early step in the pulmonary inflammatory process that leads to ALI, and modulation of the activation of p38, Akt, and nuclear factor-&kgr;B in neutrophil appears to be an appropriate therapeutic target in severely ill patients with ALI.
Abstract: Objective: Neutrophils are an important component of the inflammatory response that characterizes acute lung injury (ALI). This discussion aims to review the contribution of neutrophils to the development and progression of ALI and to highlight the major intracellular signaling pathways that are involved in neutrophil activation in the setting of ALI. Data Sources: MEDLINE, original research papers, and review papers. Study Selection: Relevant laboratory and clinical studies. Data Extraction: Systemic review. Data Synthesis: Activated neutrophils appear to play a central role in the development of most cases of ALI. In experimental models, the elimination of neutrophils markedly decreases the severity of ALI. Furthermore, in neutropenic patients with lung injury, deterioration of pulmonary function as neutropenia resolves has been well described. The neutrophils that accumulate in the lungs in models of ALI demonstrate increased activation of the kinases Akt and p38; increased nuclear accumulation of the transcriptional regulatory factor, nuclear factor-κB; and increased production of proinflammatory cytokines, particularly those whose transcription is dependent on nuclear factor-KB. Decreased apoptosis among neutrophils in the lungs is also characteristic. Inhibiting p38, Akt, or nuclear factor-KB activation diminishes the severity of endotoxin- or hemorrhage-induced ALI. Conclusions: The accumulation of activated neutrophils in the lungs is an early step in the pulmonary inflammatory process that leads to ALI. Although experimental models indicate that the activation of p38, Akt, and nuclear factor-KB in neutrophils contributes to ALI, the relative importance of these pathways in critically ill patients remains to be determined. Nevertheless, modulation of the activation of p38, Akt, and nuclear factor-κB in neutrophils appears to be an appropriate therapeutic target in severely ill patients with ALI.
836 citations
TL;DR: Critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills.
Abstract: ObjectiveTo measure and compare critical care physicians’ and nurses’ attitudes about teamwork.DesignCross-sectional surveys.SettingEight nonsurgical intensive care units in two teaching and four nonteaching hospitals in the Houston, TX, metropolitan area.SubjectsPhysicians and nurses who worked in
773 citations
TL;DR: In patients admitted to the ICU for sepsis, the adequacy of initial empirical antimicrobial treatment is crucial in terms of outcome, although early mortality rate was unaffected by the appropriateness of empirical antibiotic therapy.
Abstract: ObjectivesOur primary goal was to evaluate the impact on in-hospital mortality rate of adequate empirical antibiotic therapy, after controlling for confounding variables, in a cohort of patients admitted to the intensive care unit (ICU) with sepsis The impact of adequate empirical antibiotic therap
681 citations
TL;DR: Patients with ventilator-associated pneumonia had significantly longer ICU and hospital LOS, with higher crude hospital cost and mortality rate compared with uninfected patients, and hospital costs were higher than average.
Abstract: ObjectiveTo determine the attributable cost of ventilator-associated pneumonia from a hospital-based cost perspective, after adjusting for potential confounders.DesignPatients admitted between January 19, 1998, and December 31, 1999, were followed prospectively for the occurrence of ventilator-assoc
565 citations
TL;DR: The structure and function of endothelial cells are differentially regulated in space and time and may vary in its response to pathophysiologic stimuli and therefore contribute to the focal nature of vasculopathic disease states.
Abstract: Objective: To review recent advances in the field of endothelial cell heterogeneity, and to apply this knowledge to an understanding of site-specific vasculopathy, including acute lung injury. Data Sources and Study Selection: Published research and review articles in the English language related to endothelial cell biology and endothelial cell heterogeneity. Data Extraction and Synthesis: The results of published studies have been used to provide a perspective of endothelial cell phenotypes in health and disease. Conclusions: The structure and function of endothelial cells are differentially regulated in space and time. Far from being a giant monopoly of homogeneous cells, the endothelium represents a consortium of smaller enterprises of cells located within blood vessels of different tissues. Although united in certain functions, each enterprise is uniquely adapted to meet the demands of the underlying tissue. The endothelium may also vary in its response to pathophysiologic stimuli and therefore contribute to the focal nature of vasculopathic disease states. In acute lung injury, the unique properties of the endothelium may conspire with systemic imbalances to localize pathology to the pulmonary vasculature.
528 citations
TL;DR: Intensive care unit admissions meeting severe sepsis criteria have a high mortality rate and high resource use, and most were nonsurgical, and the most common organ system dysfunctions were seen in the cardiovascular and respiratory systems.
Abstract: OBJECTIVE: To investigate the numbers, clinical characteristics, resource use, and outcomes of admissions who met precise clinical and physiologic criteria for severe sepsis (as defined in the PROWESS trial) in the first 24 hrs in the intensive care unit. DESIGN: Observational cohort study, with retrospective analysis of prospectively collected data. SETTING: Ninety-one adult general intensive care units in England, Wales, and Northern Ireland between 1995 and 2000. PATIENTS: Patients were 56,673 adult admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We found that 27.1% of adult intensive care unit admissions met severe sepsis criteria in the first 24 hrs in the intensive care unit. Most were nonsurgical (67%), and the most common organ system dysfunctions were seen in the cardiovascular (88%) and respiratory (81%) systems. Modeling the data for England and Wales for 1997 suggested that 51 (95% confidence interval, 46-58) per 100,000 population per year were admitted to intensive care units and met severe sepsis criteria in the first 24 hrs.Of the intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, 35% died before intensive care unit discharge and 47% died during their hospital stay. Hospital mortality rate ranged from 17% in the 16-19 age group to 64% in those >85 yrs. In England and Wales in 1997, an estimated 24 (95% confidence interval, 21-28) per 100,000 population per year died after intensive care unit admissions with severe sepsis in the first 24 hrs. For intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, median intensive care unit length of stay was 3.56 days (interquartile range, 1.50-9.32) and median hospital length of stay was 18 days (interquartile range, 8-36 days). These admissions used 45% of the intensive care unit and 33% of the hospital bed days used by all intensive care unit admissions. CONCLUSIONS: Severe sepsis is common and presents a major challenge for clinicians, managers, and healthcare policymakers. Intensive care unit admissions meeting severe sepsis criteria have a high mortality rate and high resource use.
475 citations
TL;DR: In patients with suspected infection, this model identifies significant correlates of death and allows stratification of patients according to mortality risk and as new therapies become available for patients with sepsis syndromes, the ability to predict mortality risk may be helpful in triage and treatment decisions.
Abstract: ObjectivesOur objectives were a) to identify univariate correlates of death in emergency department patients at risk for infection; b) to perform multivariate analyses and identify independent predictors of death; and c) to develop and internally validate a prediction rule that may be used in the em
461 citations
TL;DR: Serial measurements of CPIS can define the clinical course of VAP resolution, identifying those with good outcome as early as day 3, and could possibly be of help to define strategies to shorten the duration of therapy.
Abstract: ObjectivesTo prospectively evaluate the performance of the Clinical Pulmonary Infection Score (CPIS) and its components to identify early in the hospital course of ventilator-associated pneumonia (VAP) which patients are responding to therapy.DesignProspective, multicenter, in a cohort of mechanical
438 citations
TL;DR: A self-help rehabilitation manual is effective in aiding physical recovery and reducing depression in patients recalling delusional memories from the ICU, however, further psychological care may be needed to reduce the incidence of anxiety and PTSD-related symptoms.
Abstract: Objective: To evaluate the effectiveness of a rehabilitation program following critical illness to aid physical and psychological recovery. Design: Randomized controlled trial, blind at follow-up with final assessment at 6 months. Setting: Two district general hospitals and one teaching hospital. Patients: Patients were 126 consecutively admitted intensive care patients meeting the inclusion criteria. Interventions: Control patients received ward visits, three telephone calls at home, and clinic appointments at 8 wks and 6 months. Intervention patients received the same plus a 6-wk self-help rehabilitation manual. Measurements and Main Results: We measured levels of depression and anxiety (Hospital Anxiety and Depression Scale), phobic symptoms (Fear Index), posttraumatic stress disorder (PTSD)-related symptoms (Impact of Events Scale), and scores on the Short-Form Health Survey physical dimension 8 wks and 6 months after intensive care unit (ICU) treatment. Memory for ICU was assessed at 2 wks post-ICU discharge using the ICU Memory Tool. The intervention group improved, compared with the control patients, on the Short-Form Health Survey physical function scores at 8 wks and 6 months (p .006), and there was a trend to a lower rate of depression at 8 wks (12% vs. 25%). However, there were no differences in levels of anxiety and PTSD-related symptoms between the groups. The presence of delusional memories was correlated significantly with both anxiety and Impact of Events Scale scores. Conclusions: A self-help rehabilitation manual is effective in aiding physical recovery and reducing depression. However, in those patients recalling delusional memories from the ICU, further psychological care may be needed to reduce the incidence of anxiety and PTSD-related symptoms. (Crit Care Med 2003; 31:2456‐2461)
TL;DR: PCT is a better marker of sepsis than CRP and shows a closer correlation than that of CRP with the severity of infection and organ dysfunction.
Abstract: ObjectiveTo compare the clinical informative value of procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations in the detection of infection and sepsis and in the assessment of severity of sepsis.DesignProspective study.SettingMedicosurgical intensive care unit.PatientsSeventy consecut
TL;DR: The study suggests that the Nursing Activities Score measures the consumption of nursing time in the intensive care unit.
Abstract: Objectives: The instruments used for measuring nursing workload in the intensive care unit (e.g., Therapeutic Intervention Scoring System-28) are based on therapeutic interventions related to severity of illness. Many nursing activities are not necessarily related to severity of illness, and cost-effectiveness studies require the accurate evaluation of nursing activities. The aim of the study was to determine the nursing activities that best describe workload in the intensive care unit and to attribute weights to these activities so that the score describes average time consumption instead of severity of illness. Design: To define by consensus a list of nursing activities, to determine the average time consumption of these activities by use of a 1-wk observational cross-sectional study, and to compare these results with those of the Therapeutic Intervention Scoring System-28. Setting: A total of 99 intensive care units in 15 countries. Patients: Consecutive admissions to the intensive care units. Intervention: Daily recording of nursing activities at a patient level and random multimoment recording of these activities. Results: A total of five new items and 14 subitems describing nursing activities in the intensive care unit (e.g., monitoring, care of relatives, administrative tasks) were added to the list of therapeutic interventions in Therapeutic Intervention Scoring System28. Data from 2,041 patients (6,451 nursing days and 127,951 multimoment recordings) were analyzed. The new activities accounted for 60% of the average nursing time; the new scoring system (Nursing Activities Score) explained 81% of the nursing time (vs. 43% in Therapeutic Intervention Scoring System-28). The weights in the Therapeutic Intervention Scoring System-28 are not derived from the use of nursing time. Conclusions: Our study suggests that the Nursing Activities Score measures the consumption of nursing time in the intensive care unit. These results should be validated in independent databases. (Crit Care Med 2003; 31:374 ‐382)
TL;DR: Severe weakness requiring prolonged rehabilitation and abnormal clinical neurologic findings are extremely common in survivors of protracted critical illness, and can be found up to 5 yrs after intensive care unit discharge in >90% of these long-stay patients.
Abstract: ObjectiveTo establish the prevalence, clinical characteristics, and electrophysiologic features of residual neuromuscular dysfunction after prolonged critical illness.DesignProspective follow-up study of survivors of prolonged critical illness.SettingA university hospital and two district general ho
TL;DR: This review will cover septic shock as a manifestation of severe sepsis, the collision of the body’s defenses with the invading organism, and based on current understanding of the pathophysiology, this seems to be particularly appropriate terminology.
Abstract: This review will cover septic shock as a manifestation of severe sepsis. The reader is referred to other articles, which review the myriad multisystem dysfunctions associated with severe sepsis (1– 4), and is reminded that as in all patients with sepsis early initiation of appropriate antibiotics and adequate source control are key components of septic shock treatment. Ascertaining the incidence of septic shock is limited by the variability in definitions used in epidemiologic studies, the analysis of septic shock as a subset of patients with severe sepsis, and shortcomings of methods used to calculate the incidence of severe sepsis. In five recent large clinical trials that enrolled a total of 5,461 patients with severe sepsis (criteria evidence of infection, systemic inflammatory response syndrome, and at least one organ dysfunction/hypoperfusion), the incidence of septic shock ranged from 52% to 71% of patients with severe sepsis, with a mean of 58% (5–9). A recent study used International Classification of Diseases (ICD)-9 hospital diagnostic codes for infection and acute organ dysfunction to estimate 751,000 cases of severe sepsis per annum in the United States (10). Taking the incidence of septic shock in severe sepsis from the five studies above, septic shock would, therefore, be predicted to occur annually in 435,580 patients in the United States. The mortality of septic shock can be estimated more reliably. Table 1 shows a compilation of septic shock mortalities drawn from the placebo arms of clinical trials (8, 9, 11–22). Figure 1 shows improvement in septic shock mortality over time (23). Historical Perspective The word sepsis is derived from the Greek language (24). Pepsis was good, embodying the natural processes of maturation and fermentation. Sepsis, however, was bad and synonymous with putrefaction as characterized by bad smell. It was thousands of years later before Pasteur conclusively linked putrefaction to a bacterial cause. The word shock has its derivation from the French root “choquer,” meaning “to collide with.” Based on our current understanding of the pathophysiology of septic shock, the collision of the body’s defenses with the invading organism, this seems to be particularly appropriate terminology.
TL;DR: It is believed that a random cortisol concentration of <25 &mgr;g/dL in a highly stressed patient is a useful diagnostic threshold for the diagnosis of adrenal insufficiency.
Abstract: ObjectiveTo determine whether a baseline (random) cortisol concentration <25 μg/dL in patients with septic shock was a better discriminator of adrenal insufficiency than the standard (250 μg) and the low-dose (1 μg) corticotropin stimulation tests as assessed by the hemodynamic response to steroid r
TL;DR: Prolonged neuropsychological impairment is common among survivors of the medical intensive care unit and occurs with greater than anticipated frequency when compared with relevant normative data.
Abstract: ObjectiveTo examine neuropsychological function, depression, and quality of life 6 months after discharge in patients who received mechanical ventilation in the intensive care unit.DesignProspective cohort study.SettingTertiary care, medical and coronary intensive care unit of a university-based med
TL;DR: Plasma vasopressin levels are almost always increased at the initial phase of septic shock and decrease afterward, and relative vasoppressin deficiency is seen in approximately one-third of late septicshock patients.
Abstract: ObjectiveTo assess the frequency of vasopressin deficiency in septic shock.DesignProspective cohort study.SettingIntensive care unit at Raymond Poincare University Hospital.PatientsA cohort of 44 patients who met the usual criteria for septic shock for <7 days. A second cohort of 18 septic shock pat
TL;DR: The success of anticoagulant or fibrinolytic strategies designed to reverse the abnormalities of local fibrin turnover in acute lung injury supports the inference that abnormalities of coagulation, fibinolysis, andfibrin deposition have a critical role in the pathogenesis of acute lung Injury.
Abstract: ObjectivesTo review: a) the role of extravascular fibrin deposition in the pathogenesis of acute lung injury; b) the abnormalities in the coagulation and fibrinolysis pathways that promote fibrin deposition in the acutely injured lung; and c) the pathways that contribute to the regulation of the fib
TL;DR: These EOLC domains and the associated quality indicators, developed through a consensus process, provide clinicians and researchers with a framework for understanding quality of E OLC in the intensive care unit.
Abstract: ObjectiveThe primary goal of this study was to address the documented deficiencies in end-of-life care (EOLC) in intensive care unit settings by identifying key EOLC domains and related quality indicators for use in the intensive care unit through a consensus process. A second goal was to propose sp
TL;DR: Induced hypothermia has a role in selected patients in the intensive care unit and critical care physicians should be familiar with the physiologic effects, current indications, techniques, and complications of induced hyperthermia.
Abstract: Background: Clinical trials of induced hypothermia have suggested that this treatment may be beneficial in selected patients with neurologic injury. Objectives: To review the topic of induced hypothermia as a treatment of patients with neurologic and other disorders. Design: Review article. Interventions: None. Main Results: Improved outcome was demonstrated in two prospective, randomized, controlled trials in which induced hypothermia (33°C for 12‐24 hrs) was used in patients with anoxic brain injury following resuscitation from prehospital cardiac arrest. In addition, prospective, randomized, controlled trials have been conducted in patients with severe head injury, with variable results. There also have been preliminary clinical studies of induced hypothermia in patients with severe stroke, newborn hypoxic-ischemic encephalopathy, neurologic infection, and hepatic encephalopathy, with promising results. Finally, animal models have suggested that hypothermia that is induced rapidly following traumatic cardiac arrest provides significant neurologic protection and improved survival. Conclusions: Induced hypothermia has a role in selected patients in the intensive care unit. Critical care physicians should be familiar with the physiologic effects, current indications, techniques, and complications of induced hyperthermia. (Crit Care Med 2003; 31:2041‐2051)
TL;DR: Dopamine and norepinephrine have similar hemodynamic effects, but epinephrine can impair splanchnic circulation in severe septic shock.
Abstract: ObjectiveTo assess the effects of different doses of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in patients with septic shock.DesignProspective, randomized, open-label study.SettingA 31-bed, medicosurgical intensive care unit of a university hospital.PatientsConvenience
TL;DR: Giving 2 mL/kg hypertonic saline solution (approximately 480 mOsm/70 kg body weight) is an effective and safe initial treatment for intracranial hypertension episodes in head-trauma patients when osmotherapy is indicated.
Abstract: ObjectiveTo evaluate the clinical benefit of increasing the osmotic load of the hypertonic solution administered for the treatment of refractory intracranial hypertension episodes in patients with severe head injury.DesignProspective, randomized study.SettingsA trauma center in a university hospital
TL;DR: Based on this analysis, which used prospective clinical trial screening data and conservative assumptions about where patients with ALI are cared for, the incidence of ALI in the United States appears to be higher than previously reported.
Abstract: ObjectiveRecent estimates of acute respiratory distress syndrome (ARDS) incidence have varied from 1.3 to 22 per 100,000 person years (105 person·years); the incidence of acute lung injury (ALI) has varied from 17.9 to 34 cases per 105 person·years. Potential reasons for this wide range include diff
TL;DR: Guidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.
Abstract: ObjectivesTo describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level.ParticipantsA multidisciplinary writing panel of professionals
TL;DR: In patients with severe sepsis, lipoprotein concentrations rapidly change and can be reduced to 50% of recovery concentrations, which is found primarily in the HDL and a slow recovery in both HDL and LDL fractions.
Abstract: Objective: Lipoproteins have been implicated to play a role in innate immunity. Changes in lipoprotein levels have been reported in a variety of inflammatory disorders. Not much is known about lipoprotein metabolism in patients with severe sepsis. We conducted an ancillary study in a multiple-center phase III sepsis trial to investigate the dynamics of plasma lipoproteins in patients with severe sepsis. Design: Prospective analysis in patients meeting criteria for severe sepsis as part of a multiple-center sepsis study (KyberSept) with antithrombin III (Kybernin P). Setting: University hospital intensive care unit. Patients: Seventeen patients were included in the study. Interventions: Randomized patients received a loading dose of 6000 IU of antithrombin III (Kybernin P) or placebo followed by a 96-hr continuous infusion of 250 IU/hr antithrombin III (Kybernin P) or placebo. In each patient, serial blood samples for total cholesterol, lipoprotein cholesterol, triglycerides, apolipoprotein A-1, apolipoprotein B, and C-reactive protein determination as well as clinical data were collected over 28 days. Measurements and Main Results: Plasma cholesterol levels rapidly decreased from 2.67 2.02 mmol/L on day 0 to a nadir of 1.41 0.70 mmol/L on day 3, followed by a slow increase to 4.18 1.94 mmol/L on day 28. High-density lipoprotein (HDL) cholesterol concentrations decreased rapidly from 0.84 0.92 mmol/L to a nadir of 0.42 0.35 mmol/L on day 3, to show a slow increase during the following 4 wks to 0.84 0.42 mmol/L. The low-density lipoprotein (LDL) cholesterol concentrations were already low (0.94 0.81 mmol/L) at study entry, to show a progressive increase to subnormal values (2.01 0.94 mmol/L) at 4 wks. Nadir and recovery lipoprotein concentrations were significantly different (paired Student’s t-test, p < .05). A significant correlation was found between HDL cholesterol and apolipoprotein A-1 (r .714, p < .05) and between LDL cholesterol and apolipoprotein B (r .733, p < .05). There was no statistical difference in lipoprotein concentrations either between survivors and nonsurvivors or between patients receiving antithrombin III or placebo. Serum amyloid A was a major apoprotein (45%) in HDL at the start of the sepsis and was slowly replaced by apolipoprotein A-1 during recovery. A positive correlation was found between plasma C-reactive protein concentrations and serum amyloid A concentrations in HDL (r .684, p < .05). No other relevant correlations were found between inflammatory and lipoprotein parameters. Conclusions: In patients with severe sepsis, lipoprotein concentrations rapidly change and can be reduced to 50% of recovery concentrations. The pattern of early rapid decline is found primarily in the HDL and a slow recovery in both HDL and LDL fractions. The correlation between apolipoprotein and lipoprotein cholesterol concentrations suggests a decline in lipoprotein particles. During severe sepsis, HDL is shifted to acute phase HDL, which is enriched in serum amyloid A and depleted of cholesterol and apolipoprotein A-1. Lipoprotein concentrations are unable to discriminate between survivors and nonsurvivors. (Crit Care Med 2003; 31:1359 ‐1366)
TL;DR: Prolonged mechanical ventilation is associated with impaired health-related quality of life compared with that of a matched general population and future studies should focus on physical or psychosocial rehabilitation that could lead to improved management of patients after their ICU stay.
Abstract: ObjectiveTo determine the outcome and health-related quality of life of patients requiring ≥14 days of mechanical ventilation in the intensive care unit (ICU).DesignProspective cohort study with post-ICU, cross-sectional, health-related quality-of-life survey.SettingA 17-bed ICU in a university hosp
TL;DR: Noise was shown to correlate with several measures of stress including tachycardia and annoyance ratings and further studies of interventions to reduce noise are essential.
Abstract: Objective To measure and describe hospital noise and determine whether noise can be correlated with nursing stress measured by questionnaire, salivary amylase, and heart rate. Design Cohort observational study. Setting Tertiary care center pediatric intensive care unit. Subjects Registered nurses working in the unit. Interventions None. Measurements and main results Eleven nurse volunteers were recruited. An audiogram, questionnaire data, salivary amylase, and heart rate were collected in a quiet room. Each nurse was observed for a 3-hr period during patient care. Heart rate and sound level were recorded continuously; saliva samples and stress/annoyance ratings were collected every 30 mins. Variables assessed as potential confounders were years of nursing experience, caffeine intake, patients' Pediatric Risk of Mortality Score, shift assignment, and room assignment. Data were analyzed by random effects multiple linear regression using Stata 6.0. The average daytime sound level was 61 dB(A), nighttime 59 dB(A). Higher average sound levels significantly predicted higher heart rates (p =.014). Other significant predictors of tachycardia were higher caffeine intake, less nursing experience, and daytime shift. Ninety percent of the variability in heart rate was explained by the regression equation. Amylase measurements showed a large variability and were not significantly affected by noise levels. Higher average sound levels were also predictive of greater subjective stress (p =.021) and annoyance (p =.016). Conclusions In this small study, noise was shown to correlate with several measures of stress including tachycardia and annoyance ratings. Further studies of interventions to reduce noise are essential.
TL;DR: Continuous and real-time monitoring of stroke volume variation by pulse contour analysis can predict volume responsiveness and allows real- time assessment of the hemodynamic effect of volume expansion in patients with reduced left ventricular function after cardiac surgery.
Abstract: ObjectiveStroke volume variation as measured by the analysis of the arterial pressure waveform enables prediction of volume responsiveness in ventilated patients with normal cardiac function. The aim of this study was to investigate the ability of monitoring stroke volume variation to predict volume
TL;DR: In ALI/ARDS patients receiving mechanical ventilation with low tidal volumes and high PEEP, short-term effects of RMs as conducted in this study are variable and Beneficial effects on gas exchange in responders appear to be of brief duration.
Abstract: OBJECTIVE Positive end-expiratory pressure (PEEP) and recruitment maneuvers (RMs) may partially reverse atelectasis and reduce ventilation-associated lung injury. The purposes of this study were to assess a) magnitude and duration of RM effects on arterial oxygenation and on requirements for oxygenation support (Fio2/PEEP) in patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS) receiving ventilation with low tidal volumes and high levels of PEEP; and b) frequency of adverse respiratory and circulatory events attributable to RMs. DESIGN Prospective, randomized, crossover study. SETTING Thirty-four intensive care units at 19 hospitals. PATIENTS Seventy-two patients with early ALI/ARDS. Baseline PEEP and Fio2 were 13.8 +/- 3.0 cm H2O and 0.39 +/- 0.10, respectively (mean +/- sd). INTERVENTIONS We conducted RMs by applying continuous positive airway pressure of 35-40 cm H2O for 30 secs. We conducted sham RMs on alternate days. We monitored oxyhemoglobin saturation by pulse oximetry (SpO2), Fio2/PEEP, blood pressure, and heart rate for 8 hrs after RMs and sham RMs. We examined chest radiographs for barotrauma. MEASUREMENTS AND MAIN RESULTS Responses to RMs were variable. Greatest increments from baseline SpO2 within 10 mins after RMs were larger than after sham RMs (1.7 +/- 0.2 vs. 0.6 +/- 0.3 %, mean +/- SEM, p < .01). Systolic blood pressure decreased more +/- 1.1 mm Hg, p < .01). Changes in Fio2/PEEP requirements were not significantly different at any time after RMs vs. sham RMs. Barotrauma was apparent on first radiographs after one RM and one sham RM. CONCLUSIONS In ALI/ARDS patients receiving mechanical ventilation with low tidal volumes and high PEEP, short-term effects of RMs as conducted in this study are variable. Beneficial effects on gas exchange in responders appear to be of brief duration. More information is needed to determine the role of recruitment maneuvers in the management of ALI/ARDS.