Br J Anaesth 2002 Mar;88(3):434-8
Department of Anaesthesia and Intensive Care, North Hampshire Hospital, Basingstoke, UK.
[Medline record in process]
We report the successful use of i.v. magnesium sulphate to control life-threatening autonomic hyper-reflexia associated with chronic spinal cord injury in the intensive care environment. A 37-yr-old, male was admitted to the intensive care unit with a diagnosis of septic shock and acute renal failure secondary to pyelonephritis. He had been found unresponsive at home following a 2-day history of pyrexia and purulent discharge from his suprapubic catheter. He had sustained a T5 spinal cord transection 20 yr previously. Initial management included assisted ventilation, fluid resuscitation, vasopressor support, and continuous veno-venous haemofiltration. The sepsis was treated with antibiotic therapy and percutaneous nephrostomy drainage of the pyonephrosis. On the fifth day, the patient developed profuse diarrhoea. This was associated with paroxysms of systemic hypertension and diaphoresis, his arterial pressure rising on occasion to 240/140 mm Hg. A diagnosis of autonomic hyper-reflexia was made and a bolus dose of magnesium sulphate 5 g was administered over 15 min followed by an infusion of 1-2 g h(-1). There was an almost immediate decrease in the severity and frequency of the hypertensive episodes. There were no adverse cardiac effects associated with the administration of magnesium, only a slight decrease in minute ventilation as the plasma level approached the upper end of the therapeutic range (2-4 mmol litre(-1)). In view of the beneficial effects observed in this case we advocate further research into the use of magnesium sulphate in the treatment or prevention of autonomic hyper-reflexia secondary to chronic spinal cord injury in the intensive care unit.
PMID: 11990279, UI: 21985658
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Chest 2002 Apr;121(4):1382
Publication Types:
PMID: 11948091, UI: 21942372
Chest 2002 Apr;121(4):1376-7; discussion 1377
PMID: 11948085, UI: 21942366
Chest 2002 Apr;121(4):1345-9
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224-6801, USA.
PMID: 11948073, UI: 21942354
Chest 2002 Apr;121(4):1290-300
Critical Care Program, University of Ottawa, Ottawa, Canada.
There are a number of difficulties in the conduct of randomized trials in the critically ill. These include difficulties in the definition of diseases and syndromes, a heterogenous population of patients undergoing a variety of therapeutic interventions, and outcomes that may not be able to discriminate between beneficial and risky therapies. Following a brief description of different randomized clinical trials (RCTs) and design philosophies, we outline the effects of different design choices in the complex critical care environment. Once the study topic has been determined to be relevant and important, then the potential investigator must establish whether efficacy or effectiveness will be the focus of the RCT. If an effectiveness design philosophy is chosen, then broad representation of study sites, liberal eligibility criteria, easily implemented intervention study protocols, and patient-centered outcomes should be chosen. The potential investigator wishing to establish efficacy will conduct the study in the centers of excellence and adopt stringent eligibility criteria, rigorous study protocols, and opt for outcomes that will be sensitive to change. In conclusion, we describe some of the major challenges and possible solutions to help a potential investigator through the myriad of difficulties in initiating an RCT in a complex environment.
PMID: 11948065, UI: 21942346
Chest 2002 Apr;121(4):1262-8
Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC, USA. AFSHORR@DNAMAIL.COM
STUDY OBJECTIVES: To determine the relationship between d-dimer (DD) and both proinflammatory and anti-inflammatory cytokine levels, and to confirm the association between DD status and outcomes in critically ill patients. DESIGN: Prospective observational study. SETTING: Medical ICU (MICU) of a tertiary care, academic medical center. PATIENTS: Individuals admitted to the MICU. INTERVENTIONS: Within 24 h of MICU admission, patients had DD status determined and interleukin (IL) levels (IL-6, IL-8, and IL-10) and tumor necrosis factor (TNF)-alpha measured. The strength of the DD level was also noted. Subjects were then monitored prospectively to determine mortality rate and the incidence of organ failure. MEASUREMENT AND RESULTS: The study cohort included 79 patients (mean age, 65.2 years; 54.5% male patients). DD was present in 53.2% of subjects. The DD reaction was weak (1+) in 15 patients and strong (2+) in 27 patients. The TNF-alpha, IL-6, and IL-8 levels all increased in parallel with the increasing strength of the DD level. IL-10 levels did not differ based on DD status. Similarly, the severity of illness as measured by the APACHE (acute physiology and chronic health evaluation) II score was highest among those with higher DD levels: 24.7 +/- 6.2 for those with 2+ DD vs 17.2 +/- 3.1 and 11.5 +/- 2.7 for those with 1+ DD and no circulating DD, respectively (p < 0.001). For patients lacking DD, the mortality rate was 8.1%, compared to 13.3% and 55.6% for those with 1+ and 2+ DD levels, respectively (p < 0.001). No patient without DD had multisystem organ failure (MSOF) develop, while the incidence of MSOF also increased with increasing DD levels. As a screening test for mortality, the DD performed as well as the APACHE II system. CONCLUSIONS: The coagulation system is active in critically ill patients, and DD levels correlate with activation of the proinflammatory cytokine cascade. The absence of a relationship between DD and anti-inflammatory cytokines (IL-10) suggests that the presence of DD may reflect the imbalance between proinflammatory and anti-inflammatory cytokines. DD identifies patients at increased risk for both MSOF and death.
PMID: 11948062, UI: 21942343
Chest 2002 Apr;121(4):1245-52
Service de Reanimation Medicale, Hopital de Bicetre, Faculte de Medecine Paris-Sud, Paris, France. boulain@hotmail.com
OBJECTIVE: To test the hypothesis that passive leg raising (PLR) induces changes in arterial pulse pressure that can help to predict the response to rapid fluid loading (RFL) in patients with acute circulatory failure who are receiving mechanical ventilation. DESIGN: Prospective clinical study. SETTING: Two medical ICUs in university hospitals. PATIENTS: Thirty-nine patients with acute circulatory failure who were receiving mechanical ventilation and had a pulmonary artery catheter in place. INTERVENTIONS: PLR for > 4 min and a subsequent 300-mL RFL for > 20 min. MEASUREMENTS AND MAIN RESULTS: Radial artery pulse pressure (PPrad), heart rate, right atrial pressure, pulmonary artery occlusion pressure (PAOP), and cardiac output were measured invasively in a population of 15 patients at each phase of the study procedure (i.e., before and during PLR, and then before and after RFL). PPrad, PAOP, and stroke volume (SV) significantly increased in patients performing PLR. These changes were rapidly reversible when the patients' legs were lowered. Changes in PPrad during PLR were significantly correlated with changes in SV during PLR (r = 0.77; p < 0.001). Changes in SV induced by PLR and by RFL were significantly correlated (r = 0.89; p < 0.001). Finally, PLR-induced changes in PPrad were significantly correlated to RFL-induced changes in SV (r = 0.84; p < 0.001). In a second population of 24 patients, we found the same relationship between PLR-induced changes in PPrad and RFL-induced changes in SV (r = 0.73; p < 0.001). CONCLUSION: The response to RFL could be predicted noninvasively by a simple observation of changes in pulse pressure during PLR in patients with acute circulatory failure who were receiving mechanical ventilation.
PMID: 11948060, UI: 21942341
Crit Care Med 2002 Mar;30(3):709-10
PMID: 11990943, UI: 21986338
Crit Care Med 2002 Mar;30(3):703-5
PMID: 11990940, UI: 21986335
Crit Care Med 2002 Mar;30(3):581-5
Department of Pediatrics, University of Washington School of Medicine, Children's Hospital, Seattle, USA.
OBJECTIVE: To determine differences in therapies and outcomes among pediatric intensive care units for patients with acute severe asthma. DESIGN: Retrospective cohort study. SETTING: Eleven pediatric intensive care units participating in the Pediatric Intensive Care Evaluations. PATIENTS: Patients were 1528 children with a primary diagnosis of asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied severity of illness, length of stay, and use of invasive interventions. The patients at the centers had similar median physiologic measures of illness and Pediatric Risk of Mortality III scores. The patients received a wide range of invasive interventions depending on institution, including mechanical ventilation (3% to 47%), arterial catheter placement (4% to 46%), central venous catheter (2% to 51%), and determination of a blood gas (24% to 70%). At institutions where mechanical ventilation was used more commonly (>20%, high use), intensive care and hospital stays were longer for asthmatic patients regardless of mechanical ventilation requirement compared with centers with lower use of mechanical ventilation. The status of "high-use center" was an independent predictor for intensive care stay (p = .005) and hospital length of stay (p = .017) as well as duration of mechanical ventilation (p = .014) after adjustment for age, degree of hypercarbia, maximal respiratory rate, use of an arterial catheter, and Pediatric Risk of Mortality III scores among ventilated children. CONCLUSIONS: We found that use of invasive interventions including mechanical ventilation and vascular monitoring varied greatly by institution. Centers with higher use of mechanical ventilation had longer median intensive care stay and hospital stays. Pediatric asthma management for acute severe asthma may be improved by clear elucidation of the institutional practices where fewer invasive interventions were used to achieve better outcomes.
PMID: 11990919, UI: 21986313
Crit Care Med 2002 Mar;30(3):574-6
Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA.
OBJECTIVE: Patients admitted to the trauma intensive care unit (TICU) often require bedside imaging procedures such as radiographs, fluoroscopic placement of enteral feeding tubes, and insertion of vena cava filters. The potential for scattered radiation exposure is a concern to healthcare workers. Our study's purpose was to measure the level of scattered ionizing radiation present in a TICU. DESIGN AND SETTING: This prospective study was conducted over 3 months in an open-design, ten-bed TICU of a Level I trauma center. INTERVENTIONS AND MEASUREMENTS: Fifteen dosimeters were placed in selected areas of the TICU to measure the amount of scattered radiation present. Standard radiation protection precautions were used throughout the study period. At the end of each month, data from the dosimeters were sent to the manufacturer for analysis. MAIN RESULTS: One thousand seventy-four radiologic studies were performed at the bedside during the study period (803 portable chest radiographs, 103 abdominal radiographs, 303 extremity radiographs, 223 spine radiographs, and 15 fluoroscopic procedures). Dosimetry analysis showed <5 mrem (1/1000 roentgen equivalent in man) scattered radiation per month (<60 mrem/year) in each of the monitored areas. All monitored areas measured <2 mrem per week of scattered radiation when adjusted for occupancy. CONCLUSIONS: The level of scattered radiation in our TICU is less than the recommended allowable exposure of <100 mrem/year, indicating that radiation exposure is not a significant occupational hazard in our TICU, even in the setting of frequent use of bedside imaging studies.
PMID: 11990917, UI: 21986311
Crit Care Med 2002 Mar;30(3):529-35
Service de Reanimation Medicale, Hjpital Broussais, Paris, France.
OBJECTIVE: To evaluate diagnostic and prognostic values of C-reactive protein (CRP) dosage in critically ill patients. DESIGN: Prospective, observational study. SETTING: Medical intensive care unit (ICU) in a university hospital. PATIENTS: A consecutive series of 74 patients admitted to the ICU. INTERVENTION: CRP measurements at admission and every 4 days thereafter. MEASUREMENTS AND MAIN RESULTS: At admission, 28 patients (38%) had microbiologically proven infections. Compared with uninfected patients, their mean +/- SD CRP level was 191 +/- 123 vs. 83 +/- 91 mg/L (p < .0001), respectively, white blood cell count was 15.3 +/- 7.5 vs. 11.4 +/- 5.3 G/L (p = .01), and the systemic inflammatory response syndrome (SIRS) was present for 96% vs. 67% (p = .008). No threshold value could be identified to discriminate between these two populations. Multivariate analysis retained CRP and SIRS as the only variables independently associated with the presence of an infection. The combination of CRP > or = 50 mg/L with SIRS was identified as the best model to diagnose infection at admission. This multivariate model performed better than temperature, CRP alone, and white blood cell count. Among the 28 infected patients, 10 recovered; CRP values decreased significantly in this population as compared with patients with persistent infection (-130 +/- 110 vs. 12 +/- 97 mg/L, respectively; p = .004). A CRP decrease > or = 50 mg/L between admission and day 4 was the best cutoff value to diagnose recovery (sensitivity 89%, specificity 79%). CONCLUSION: CRP in combination with SIRS was useful to diagnose infection in ICU patients; a CRP decrease > or = 50 mg/L between admission and day 4 was the best predictor of recovery.
PMID: 11990910, UI: 21986304
Crit Care Med 2002 Mar;30(3):501-7
Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, Canada.
OBJECTIVE: To measure the association between intensive care unit (ICU) admission and both hospital and long-term mortality, separate from the effect of hospital admission alone. DESIGN: Retrospective cohort study. SETTING: All hospitals in British Columbia, Canada, during 3 fiscal years, 1994 to 1996. PATIENTS: A total of 27,103 patients admitted to ICU and 41,308 (5% random sample) patients admitted to hospital but not to ICU. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Although ICU admission was an important factor associated with hospital mortality (odds ratio: 9.12; 95% confidence interval: 8.34-9.96), the association between ICU admission and mortality after discharge was relatively minimal (hazard ratio: 1.21; 95% confidence interval: 1.17-1.27) and was completely overshadowed by the effect of age, gender, and diagnosis. CONCLUSIONS: After controlling for the effect of hospital admission, admission to ICU has minimal independent effect on mortality after discharge.
PMID: 11990906, UI: 21986300
Crit Care Nurse 2001 Oct;21(5):66-8
Pediatric intensive care unit, The Children's Hospital at Sinai, Baltimore, MD, USA.
PMID: 11855604, UI: 21844378
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