Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation with an incidence ranging from 9-70% and averaging around 25%. The pathogenesis of VAP requires abnormal oropharyngeal and gastric colonisation and then aspiration of these contents into the lower airways. Another co-existing mechanism could be direct oropharyngeal or lower airways inoculation of microorganisms through contaminated respiratory therapy equipment. Read More
Purpose: To review critically the literature on pulmonary barotrauma in mechanically ventilated patients.
Methods: Data sources included MEDLINE and citation lists of relevant articles. Articles investigating the aetiology or prevention of pulmonary barotrauma were critically evaluated according to published guidelines. Read More
A presumption based on the literature obtained from general hospitals is widespread among physicians, namely that patients with active malignant disease, particularly if metastatic, should not be resuscitated if they have a cardiorespiratory arrest. This attitude is not supported by studies performed on cardiopulmonary resuscitation (CPR) in cancer centres which report results similar to those obtained in non-cancer patients. In fact, cancer, even if metastatic, is not a contraindication in itself to CPR. Read More
Despite more than 25 years of extensive research the mortality of ARDS patients remains high. Besides the often deleterious course of the underlying disease, another reason for this high mortality lies in the aggressive ventilatory regimen which is required to maintain arterial blood gases in a more or less normal range. Therapeutic methods which are used to reduce iatrogenic damage to the lungs are pressure controlled ventilation with permissive hypercapnia, differential lung ventilation, positioning therapy, dehydration, and extracorporeal gas exchange with membrane lungs. Read More
Objective: To determine the safety and pharmacokinetics of an anti-tumour necrosis factor (TNF alpha) monoclonal antibody in the treatment of septic shock, and to evaluate the biological evolution of cytokine response.
Design: Open-label, prospective, pilot trial with escalating doses of a murine monoclonal antibody (B-C7) directed against TNF alpha.
Setting: University medical centre intensive care unit. Read More
The diagnosis of ventilator-associated pneumonia (VAP) is difficult for several reasons. Firstly, clinical markers show a large percentage of false-positive and false-negative results. Secondly, microbiological diagnosis based on quantitative cultures of protected specimen brush (PSB), bronchoalveolar lavage (BAL), and endotracheal aspirates also present false-positive and false-negative results. Read More
Objectives: This study examined the efficacy of predicting power for hospital mortality of three different scoring systems in a neurosurgical intensive care unit (NICU).
Setting: An eight-bed NICU in a 1,270-bed medical centre (Taichung Veterans General Hospital).
Subjects: Two hundred patients with head injury, brain tumour, hypertensive intracerebral haemorrhage, rupture of aneurysm or arteriovenous malformation, or other categories were included in our study in a consecutive period of 14 months. Read More
Over the past two decades, clinical studies have provided convincing evidence that early nutritional support benefits metabolically stressed surgical patients by preventing acute protein malnutrition. However, the optimal route of substrate delivery (ie, enteral versus parenteral) continues to be debated. Recent basic and clinical investigation offers the exciting possibility that the beneficial effects of traditional nutritional support can be amplified by supplementing specific nutrients that exert pharmacological immune-enhancing effects. Read More
We report our experience of using the Pall BB50T heat and moisture exchanging filter (HMEF) in critically ill patients undergoing long-term ventilation. Three hundred and sixty-four ventilated patients humidified with the Pall HMEF were studied prospectively. Thirty-five patients (mean APACHE II score 24. Read More
Objective: The aim of this study was to assess whether non-invasive positive pressure ventilation delivered intermittently (Ni-IPPV) by means of a facial or nasal mask is beneficial in haematological patients suffering from acute respiratory failure.
Design: Prospective, open, non-randomised study.
Setting: University Hospital, medical intensive care unit. Read More
Objective: Measurement of quality of life three months following critical illness, to assess impact on health expectations.
Design: Continuous quantitative study of patients admitted to a combined intensive and coronary care unit during a nine-month period. Questionnaires giving baseline information were completed soon after admission, and postal questionnaires incorporating the Nottingham Health Profile were sent to surviving patients three months following discharge from the unit. Read More
The transition from mechanical ventilation to spontaneous breathing in the intensive care unit is a two-stage process: weaning and extubation. Certain parameters require consideration before the commencement of weaning, namely respiratory function (both pulmonary gas exchange and respiratory muscle strength), cardiovascular status, stability of clinical condition, low metabolic demands, psychological factors and, possibly, patient collaboration. Appropriate sedation is crucial for successful weaning to keep the patient rested and to maintain the oxygen consumption and carbon dioxide production low. Read More
Sedation in the intensive care unit (ICU) aims to improve patient comfort and facilitate treatment procedures. Most units still rely on a combination of opioid and benzodiazepines with the addition of other drugs for specific requirements. However, the effect of sedative agents in critically ill patients is often unpredictable, so frequent assessment of the depth of sedation is essential to match the depth to patient requirements. Read More
Sedative drugs are widely used in intensive care, primarily in ventilated patients. The common actions and side-effects of these agents are widely recognised. However, recent evidence suggests that opiates and other sedative agents that are used in this situation also have important, but not widely appreciated, effects on metabolism, physiological signalling and disease mechanisms. Read More
A randomised crossover study was undertaken to compare the quality and cost of controlled versus empirical sedation with midazolam in critically ill patients. Patients (n = 40) entering the ICU were enrolled provided they satisfied the strict entry criteria. During 90 hours of midazolam sedation, patients received randomly allocated 10-hour periods of controlled or empirical sedation. Read More
An open, prospective study was carried out on 45 patients with multiple injuries to compare the mortality and incidence of sepsis between those given early total enteral nutrition (TEN) when sedated with propofol and historical controls who had been given total parenteral nutrition (TPN) and sedated with midazolam. TEN was instituted immediately after surgery via gastrostomy and/or jejunostomy tube inserted during laparotomy or via an endoscope and was continued for the whole stay in the intensive care unit (ICU). Dramatic reductions in both mortality (24. Read More
Objective: The normal reference range for the anion gap (AG) has recently been questioned by several authors. Lowering the upper limit of normal of the AG has been found to be more sensitive in predicting elevated lactate in critically ill adults. The objectives of this study are i) to define a new upper limit of normal of the AG in a study population of healthy adult volunteers, ii) to determine the sensitivity, specificity, the positive predictive value and the negative predictive value of the new upper limit for AG in detecting elevated lactate in critically ill children and to compare these results to the old upper limit of normal of AG (16 mmol/l), iii) to construct a receiver-operating-characteristic (ROC) curve for anion gap as a predictor of elevated lactate, iv) to determine the relationship between anion gap and serum lactate levels in critically ill patients. Read More
With a view to minimising staff exposure to exhaled isoflurane which had been used for sedation, we assessed the efficacy of either activated charcoal adsorption or active or passive mechanical scavenging systems in intensive care units (ICUs). Personal monitoring revealed minimal exposure of staff to the sedating agent. Infra-red analyses of ambient air rarely showed isoflurane levels greater than 26 ppm, with mean concentrations of around 1 ppm. Read More
The systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) are significant causes of morbidity and mortality in the intensive care unit. The pathogenesis of MODS is poorly understood; however, endotoxin (LPS) and cytokines (for example interleukins, tumor necrosis factor and platelet activating factor) are thought to play a major role by inducing microvascular injury. A crucial step in the normal functioning of the immune system is the adhesion of cells to each other and, via extravasation, penetration of the extracellular matrix. Read More
The majority of patients have little or no memory of their stay in ICU or remember only pain, suctioning or lack of sleep. Dreams and nightmares while in the intensive care unit (ICU) and after discharge home have also been reported. The few studies investigating the longer-term psychological problems of critical illness point to a picture of social isolation with patients avoiding company and showing less affection to their partners. Read More
Chest tubes are placed to empty the pleural space of air or fluid which prohibits full lung expansion. The function of these tubes is dependent on adequate placement, effective drainage and frequent re-evaluation of the patient and the chest drainage system. Knowledge of the principles of chest tube drainage is important to evaluate adequately the function of a tube thoracostomy. Read More
A one-year prospective study was carried out to assess the value of routine serum C-reactive protein (CRP) measurement in the early diagnosis of infection in ICU patients of a District General Hospital. Ninety-one patients were included in the study. Sixty-eight patients yielded 28 proved and 77 suspected episodes of infection. Read More
We evaluated the Baxter/Edwards Critical-Care Swan Ganz IntelliCath continuous cardiac output catheter and Vigilance continuous cardiac output monitor in critically ill adult intensive care patients, and compared cardiac output measurements obtained from this new system with those from a standard bolus thermodilution technique using cold normal saline. Nine Swan Ganz IntelliCath catheters were inserted into patients selected at random, following the decision that pulmonary artery catheter monitoring was required. A total of 100 comparisons were made in nine patients. Read More
The precise role of the pulmonary artery catheter (PAC) in reducing the morbidity and mortality of intensive care patients remains uncertain. Future studies of the different patient groups who possibly benefit from their use may well require multicentre trials in order to include sufficient numbers and produce significant conclusions. This would suggest a need for a consensus opinion on how PACs are actually used to obtain the different physiological variables which can influence patient management. Read More
We collected all complete sets of measurements of cardiac index and oxygen-derived variables available in the recent literature (1975-1991; computerised Medline search) on critically ill patients with sepsis (n=21 studies), septic shock (n=20 studies) or severe heart failure (n=13 studies). For each study, the mean value for cardiac index, oxygen delivery (DO 2), oxygen uptake (VO 2), oxygen extraction ratio (O 2ER) and lactate concentration (when available) were analysed together with mortality rates. There was a significant relationship between VO 2 and DO 2 for the studies on patients with severe heart failure (r=0. Read More
This paper reviews the present state and future perspectives of the peri-operative application of Transoesophageal Echocardiography (TEE) for early detection of myocardial ischaemia during general surgery. The increasing clinical relevance of this problem parallels the progressively higher frequency of surgery performed in patients at relatively high cardiovascular risk, due to a longer life-span and improved anaesthetic techniques. TEE potentially provides a powerful method for detailed cardiac monitoring in patients undergoing general surgery. Read More
Pacing of the heart is one of the most effective emergency measures in the management of critical bradycardic arrhythmias. Positioning of the pacing catheter is safest under fluoroscopic control; however, this facility is not always readily available in emergency situations. A procedure was therefore developed by which pacing catheters could be easily positioned under echocardiographic control after echogenic marking. Read More
The short-term reproducibility in cardiac output (CO) and stroke volume (SV) measurements by transthoracic electrical bioimpedance (TEB) and thermodilution (TH) and their agreement were studied in 31 consecutive patients in the Intensive Care Unit (ICU). For comparison of changes in CO and SV, six patients were studied separately. TEB data were not obtainable in four patients due to interference with impedance signals or heart rate detection. Read More
Myocardial infarction occurs with an incidence of approximately 1.5 million cases annually in the United States. Mortality remains at about 12% despite recent advances in medical and interventional therapies. Read More
Percutaneous dilational tracheostomy (PDT) originated in the USA and now an increasing number of UK centres are adopting the technique. It compares favourably with traditional surgical tracheostomy; PDT can be performed more satisfactorily at the bedside, avoiding the transport of critically ill patients to the operating theatre. It is a more rapid and convenient technique and evidence increasingly suggests that it is associated with significantly fewer and less severe complications. Read More
The liver has a wide range of functions that may be disturbed in different ways by the many diseases which affect it and, in consequence, there are a large number of tests which look at different aspects of its function. Specific diagnoses are made using a range of clinical, biochemical, histological and radiological methods. Measurement of the plasma concentration of alanine aminotransferase (ALT, SGPT), gamma-glutamyl transpeptidase (gammaGT) and albumin are particularly valuable as these substances are specifically affected by liver disease. Read More
If the effect of intensive care on the patient is to be fully assessed then the health status of patients before and after admission to ICU must be measured. The validity of a simplified system which can also use relatives, where necessary, as informants on the patients' pre-morbid health status has been evaluated. In a District General Hospital Intensive Care Unit a questionnaire based survey of 85 patients admitted over a period of eight months used a new specially-designed instrument and compared this with the Functional Limitations Profile (FLP) and the Perceived Quality of Life instrument (PQL). Read More