If asked, hospitalized patients will choose whether to receive life-sustaining therapies.

Background: No national policy requires health care providers to discuss with hospitalized patients whether the latter would want cardiopulmonary resuscitation (CPR) or mechanical ventilation (MV) in the event of cardiopulmonary failure.

Objective: To determine whether hospitalized patients are willing to discuss end-of-life issues and choose whether to receive CPR and MV.

Design: Prospective randomized trial.

Critical care physicians' practices and attitudes and applicable statutes regarding withdrawal of life-sustaining therapies.

Objective: To describe intensivist-educators' practices and opinions regarding the withdrawal of life-sustaining therapies, and to juxtapose these with applicable end-of-life statutes.

Methods: A questionnaire was sent to critical care program directors in Connecticut, New York, Illinois, California, Florida and Texas (to examine regional variability). Statutes regarding end-of-life care were ascertained for these states.

Fluid balance and weaning outcomes.

Objective: To examine the relationship of fluid balance and weaning outcomes.

Methods: We prospectively collected demographic, physiological, daily fluid balance (measured inputs minus outputs), and weaning data from 87 mechanically ventilated patients.

Patients: We examined 87 patients, a median age of 66 years, APACHE II of 22, and performed 205 breathing trials (BT); 38 patients (44%) were successfully extubated after their first BT with minimal or no pressure support.

Patients' understanding of advance directives and cardiopulmonary resuscitation.

Objective: To describe understanding of end-of-life issues and compare characteristics of patients with and without advance directives.

Setting: A 325-bed community teaching hospital.

Measurements: Questionnaires were administered to all patients admitted to the medical-surgical wards.

Permanent pacemakers and implantable defibrillators: considerations for intensivists.

Pacemakers and cardioverter-defibrillators are implanted in patients with cardiovascular disease for an ever-increasing array of indications. Intensivists provide care frequently for patients who have these devices, and thus, they must be familiar with common problems and nuances that may contribute to critical illness. Close collaboration of the critical care physician and cardiologist/electrophysiologist assures that pacemakers and defibrillators are tuned to optimize the hemodynamic milieu of critically ill patients.

Neurologic status, cough, secretions and extubation outcomes.

Objective: To determine the degree to which neurologic function, cough peak flows and quantity of endotracheal secretions affected the extubation outcomes of patients who had passed a trial of spontaneous breathing (SBT).

Design: Prospective observational study.

Setting: The medical intensive care unit of a 325-bed teaching hospital.

Informed consent for medical procedures: local and national practices.

Background: No studies have assessed whether clinicians obtain informed consent for invasive medical procedures, and there are no explicit national standards to guide the process.

Hypothesis: Informed consent practices are inconsistent for commonly performed invasive medical procedures.

Methods: A simple questionnaire was electronically mailed and/or faxed to training program directors of critical care medicine and internal medicine departments, and to ICU directors in the state of Connecticut.

Cough peak flows and extubation outcomes.

Background: Semiobjective methods of quantifying cough strength and endotracheal secretions have been demonstrated to predict extubation outcomes of patients who have passed a spontaneous breathing trial (SBT).

Hypothesis: Cough strength, measured by voluntary cough peak expiratory flow (PEF), and endotracheal secretions, measured volumetrically, predict extubation outcomes of patients who have passed an SBT.

Patient Population: Critically ill patients admitted to the medical ICU of a 300-bed community teaching hospital.

Lactic acidosis in status asthmaticus : three cases and review of the literature.

Lactic acidosis is a frequent laboratory finding in patients with severe exacerbations of asthma. The pathogenesis of lactic acidosis in asthma is not well understood, but it has been presumed, by some, to be generated by fatiguing respiratory muscles. We herein report the cases of three patients with status asthmaticus and lactic acidosis despite pharmacologic muscle relaxation.

Risks for developing critical illness with GI hemorrhage.

Study Objectives: To define risk factors, identifiable on initial presentation, that predict subsequent physiologic derangements that are consistent with critical illness in patients presenting to hospital with GI hemorrhage (GIH).

Design: Observational, cohort study.

Setting: Fourteen-bed medical ICU in a 300-bed community teaching hospital.

Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study.

Objective: We hypothesized that patients with septic shock who achieve negative fluid balance (< or =-500 mL) on any day in the first 3 days of management are more likely to survive than those who do not.

Design: Retrospective chart review.

Patients: Thirty-six patients admitted with the diagnosis of septic shock.

Effect of erythromycin on myocardial repolarization in patients with community-acquired pneumonia.

Background: Erythromycin has been associated with prolongation of myocardial repolarization and torsades de pointes (TdP).

Methods: To determine the frequency, dose-response, and risk factors for erythromycin-associated prolongation of myocardial repolarization, we observed data of patients admitted to our hospital with pneumonia who were treated with erythromycin.

Results: In 35 women and 28 men enrolled in this study, the QTc increased from 434 +/- 4 milliseconds at baseline to 464 +/- 5 milliseconds after receiving a cumulative dose of 3.

Erythema nodosum after smoke inhalation-induced bronchiolitis obliterans organizing pneumonia.

Bronchiolitis obliterans organizing pneumonia and erythema nodosum are immunologic diseases that have not been reported to occur together. We report the case of a lady who developed bronchiolitis obliterans organizing pneumonia and erythema nodosum simultaneously, several weeks after smoke inhalation in a house fire.

Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage: retrospective analysis of risks and outcomes.

Objectives: To determine the frequency of and risk factors for myocardial infarction (MI) in patients admitted to an ICU with GI hemorrhage, and the effects of MI on mortality and length of stay.

Methods: A retrospective review of the medical records of patients admitted to our ICU with GI hemorrhage was conducted. Charts were reviewed for various demographic, laboratory, and outcome parameters.

Liberation from mechanical ventilation: a decade of progress.

Multiple complications associated with mechanical ventilation mandate that clinicians expeditiously define and reverse the pathophysiologic processes that precipitate respiratory failure and then, detect the earliest point that a patient can breathe without the ventilator. Over the past decade, numerous laboratory and clinical studies have been reported that may inform transformation of the "art of weaning" to the science of liberation. We review these studies and use them to formulate a systematic approach to assure early, safe, and successful liberation of patients from mechanical ventilation.

Tension hydrothorax.

Tension hydrothorax is a rare complication associated with a variety of diseases. In this case report, we describe the acute hemodynamic and respiratory effects of tube thoracostomy drainage in a patient with tension hydrothorax.

The effect of volume infusion on dead space in mechanically ventilated patients with severe asthma.

Mechanical ventilation of patients with severe asthma is associated with elevated airway pressures that may contribute to increased physiologic dead space. To our knowledge, no previous reports have considered the effect of intravascular volume status on dead space fraction. We herein describe three patients whose dead space decreased by a mean of 4.

The effect of sepsis on breathing pattern and weaning outcomes in patients recovering from respiratory failure.

Objective: To determine the effects of sepsis on breathing pattern and weaning outcome in medical patients recovering from respiratory failure.

Design: Prospective, observational study.

Setting: Medical ICU of a 300-bed community teaching hospital.

The unassisted respiratory rate/tidal volume ratio accurately predicts weaning outcome in postoperative patients.

Objective: To evaluate the accuracies of the respiratory rate/tidal volume ratio (rate/volume ratio), minute volume, and negative inspired force in predicting weaning outcome in postoperative mechanically ventilated patients.

Design: A prospective, observational study.

Setting: Surgical intensive care unit of a 270-bed community teaching hospital.