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Items 1 - 7 of 7 |
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Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of Sequential Organ Failure Assessment scores in decision making.
Cabre L, Mancebo J, Solsona JF, Saura P, Gich I, Blanch L, Carrasco G, Martin MC; and the Bioethics Working Group of the SEMICYUC.
Hospital de Barcelona, SCIAS, Diagonal 660, 08034, Barcelona, Spain, 10654lcp@comb.es.
OBJECTIVE: This study examined the incidence and mortality of multiple organ dysfunction syndrome (MODS) in intensive care units, evaluated the limitation of life support in these patients, and determined whether daily measurement of the Sequential Organ Failure Assessment (SOFA) is useful for decision making.DESIGN AND SETTING: Prospective, observational study in 79 intensive care units.PATIENTS AND PARTICIPANTS: Of the 7,615 patients admitted during a 2-month period we found 1,340 patients to have MODS.MEASUREMENTS AND RESULTS: We recorded mortality and length of stay in the intensive care unit and the hospital and the maximum and minimum total SOFA scores during MODS. Limitation of life support in MODS patients was also evaluated. Stepwise logistic regression was used to determine the factors predicting mortality. The in-hospital mortality rate in patients with MODS was 44.6%, and some type of limitation of life support was applied in 70.6% of the patients who died. The predictive model maximizing specificity included the following variables: maximum SOFA score, minimum SOFA score, trend of the SOFA for 5 consecutive days, and age over 60 years. The model diagnostic yield was: specificity 100%, sensitivity 7.2%, positive predictive value 100%, and negative predictive value 57.3%; the area under the receiver operating characteristic curve was 0.807.CONCLUSIONS: This model showed that in our population with MODS those older than 60 years and with SOFA score higher than 9 for at least 5 days were unlikely to survive.
PMID: 15856171 [PubMed - as supplied by publisher]
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Comment on "Mode of death after admission to an intensive care unit following cardiac arrest" by Laver et al.
O'leary MJ.
Intensive Care Unit, St George Hospital, Gray Street, Kogarah, Australia, m.oleary@unsw.edu.au.
PMID: 15856169 [PubMed - in process]
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End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom.
Wunsch H, Harrison DA, Harvey S, Rowan K.
Department of Anesthesiology, Columbia University, New York-Presbyterian Hospital, 630 W 168th St, New York, NY, 10025, USA.
OBJECTIVE: To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.DESIGN AND SETTING: Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.PATIENTS: 118,199 adult admissions to ICUs.MEASUREMENTS AND RESULTS: The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7-96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.CONCLUSIONS: Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.
PMID: 15856168 [PubMed - as supplied by publisher]
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Relationship between injury severity and lactate levels in severely injured patients.
Cerovic O, Golubovic V, Spec-Marn A, Kremzar B, Vidmar G.
Preglov trg 10, 1000, Ljubljana, Slovenia, ognjen.cerovic@kclj.si
OBJECTIVE: To determine the correlation of blood concentration of lactate and severity of injury and survival in severely injured patients. DESIGN AND SETTING: A prospective study of severely injured patients admitted directly from an emergency surgical unit to a surgical intensive care unit with an Injury Severity Score (ISS) of 16 points or more. The study was conducted over 30 months. PATIENTS: 98 severely injured subjects aged between 16 and 82 years with ISS range from 16 to 75 points, overall 25.5% mortality. INTERVENTIONS: Blood lactate concentrations were measured once on admission, twice daily during the first 2 days and once daily during the next 3 days. ISS, Revised Trauma Score, Shock Index, and Trauma and Injury Severity Score were calculated for each subject. MEASUREMENTS AND RESULTS: Of 98 severely injured patients 91 had elevated blood lactate concentration (over 2.0 mmol/l). Regression analyses demonstrated that injury severity, as measured by ISS, can be predicted from lactate concentration on admission, while survival, either actual or predicted by Trauma and Injury Severity Score higher than 0.5, can be predicted from lactate concentration after 12 h. We also found that patients with Shock Index higher than 0.9 had significantly higher lactate levels during the first 36 h than those with values less than 0.9. CONCLUSIONS: This study confirmed the relationship between blood lactate levels and injury severity as well as the prognostic value of blood lactate level for survival of severely injured patients.
PMID: 12904861 [PubMed - indexed for MEDLINE]
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Usefulness of procalcitonin for diagnosing complicating sepsis in patients with cardiogenic shock.
Geppert A, Steiner A, Delle-Karth G, Heinz G, Huber K.
Department of Cardiology, University of Vienna, AKH, Wahringer Gurtel 18-20, 1090, Vienna, Austria. Alexander.Geppert@univie.ac.at
OBJECTIVE: Patients in cardiogenic shock (CS) often present with signs of systemic inflammation that mimic infection, especially in the setting of multiple organ failure (MOF). To clarify the usefulness of procalcitonin (PCT) for diagnosing complicating sepsis in patients with CS, especially in the presence of MOF we compared PCT concentrations in patients with CS with and without MOF to those in patients with septic shock (SS). DESIGN AND SETTING: Retrospective analysis in the cardiovascular ICU at a university hospital. PATIENTS: 40 patients with CS, 15 patients with SS, and 11 noncritically ill patients without infection. MEASUREMENTS AND RESULTS: Infection was excluded by clinical and microbiological examination in all CS patients at the time of blood sampling. Nevertheless 35% exhibited CRP concentrations higher than 10 mg/dl and 25% PCT concentrations higher than 2 ng/ml. Median PCT concentrations were higher in CS patients than in controls but lower than in patients with SS. CS patients with MOF at the time of blood sampling exhibited higher PCT concentrations than patients without organ failure. In the pooled population of patients with CS and SS PCT had a higher area under the receiver operating characteristic curve (0.86 vs. 0.83) than CRP and a PCT concentration of 10 ng/ml or higher had greater specificity for sepsis than a PCT concentration of 2 ng/ml or higher but lower negative predictive value. CONCLUSIONS: PCT concentrations above 2 ng/ml are frequently found in CS patients with MOF and do not necessarily indicate infection. PCT was slightly better than CRP for diagnosing sepsis in our study, but a PCT concentration of 10 ng/ml or higher seems to be more appropriate for diagnosing this complication in CS patients than 2 ng/ml.
Publication Types:
PMID: 12827235 [PubMed - indexed for MEDLINE]
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Plasma oxidative parameters and mortality in patients with severe burn injury.
Ritter C, Andrades M, Guerreiro M, Zavaschi L, Gelain DP, Souza LF, Ribeiro CA, Clausell N, Menna-Barreto S, Moreira JC, Dal-Pizzol F.
Departamento de Bioquimica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600 anexo, 90035-003, Porto Alegre, RS, Brazil.
OBJECTIVE: To determine xanthine oxidase and superoxide dismutase activities, lipid peroxidation, protein carbonylation, and total radical-trapping antioxidant parameter in survivors and nonsurvivors patients with severe burn injury. DESIGN AND SETTING: Prospective, comparative observational study in an intensive care unit, burn division, in a trauma hospital. PATIENTS: Twenty-five consecutive patients who met the established criteria for severe burn injury (total burn surface area of more than 30%). MEASUREMENTS AND RESULTS: Plasma thiobarbituric acid reactive species and protein carbonyls levels were significantly higher in nonsurvivors than in survivors at 0 and 6 h. Elevated xanthine oxidase activity at 0 h was associated with adverse outcome after burn injury. In contrast, plasma superoxide dismutase activity and total radical-trapping antioxidant parameter did not differ significantly between nonsurvivors and survivors at any time point. CONCLUSIONS: For the first time we demonstrate the value of oxidative parameters, namely thiobarbituric acid reactive species, protein carbonyls, and xanthine oxidase activity, in identifying burn patients with a poor prognosis. Whether these parameters are merely markers of clinical course, or whether they signal specific deleterious effects of oxidative stress during the burn injury remains to be elucidated.
PMID: 12774162 [PubMed - indexed for MEDLINE]
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Ibutilide for rapid conversion of atrial fibrillation or flutter in a mixed critically ill patient population.
Delle Karth G, Schillinger M, Geppert A, Haumer M, Gwechenberger M, Meyer B, Heinz G, Siostrzonek P.
Department of Cardiology, Medical University of Vienna, Vienna, Austria. georg.delle-karth@meduniwien.ac.at
INTRODUCTION: Ibutilide is an intravenous class III antiarrhythmic agent that has been shown to be effective in converting acute onset atrial fibrillation/flutter in stable medical and cardio-surgical patients. Data on its use in critically ill patients are rare. The aim of this open, non-randomized, prospective trial was to assess the potential role of ibutilide for conversion of recent onset atrial fibrillation/flutter in a mixed critically ill ICU-population. METHODS: Twenty cardiac-surgical and 17 medical patients with acute tachycardic atrial fibrillation or flutter received up to two 10-min intravenous infusions of 1.0 mg ibutilide. RESULTS: The cumulative conversion efficacy of ibutilide was 56.8% (21 of 37 patients). The mean time to termination of the arrhythmia was 17.7 +/- 12.5 min (range 4 to 45 min) after the start of the first infusion. Conversion success was significantly higher in medical compared to cardiac-surgical patients (82.4 versus 35.0%, p=.0063). In a multivariate binary stepwise logistic regression analysis adjusted for age, heart rate and reduced left ventricular function, cardiac surgery remained significantly associated with a lower conversion probability (RR, .14; 95%CI, 0.02 to 0.76; p=.0190). Serious, ibutilide-induced ventricular arrhythmias developed in 3/37 patients (8.1%). Two of these 3 patients had a left ventricular ejection fraction < 20%. CONCLUSION: Ibutilide is an effective treatment for conversion of acute tachycardic atrial fibrillation/flutter in critically ill patients. Higher efficacy can be expected in medical than cardiac-surgical patients. Ventricular proarrhythmia, especially in patients with severely depressed left ventricular function represents the most important limitation of ibutilide treatment.
Publication Types:
- Clinical Trial
- Controlled Clinical Trial
PMID: 15773423 [PubMed - indexed for MEDLINE]
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