Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis.

To identify the potential impact of novel therapeutic approaches, we studied the early predictive factors of survival at the onset of acute respiratory distress syndrome (ARDS) in a 24-bed medical ICU of an academic tertiary care hospital. Over a 48-mo period, a total of 3,511 adult patients were admitted and 259 mechanically ventilated patients met ARDS criteria, as defined by American-European consensus conference, i.e.

Clinical evaluation of the Abbott Qvue-OptiQ continuous cardiac output system in critically ill medical patients.

Purpose: The aim of this study was to evaluate the reliability of a new continuous cardiac output (CCO) monitoring device (Qvue/OptiQ system; Abbott Critical Care Systems, Mountain View, CA) based on the pulsed warm thermodilution technique in critically ill medical patients.

Methods: Nineteen patients with cardiogenic or septic shock were included in the study. Pairs of CCO and intermittent bolus cardiac output (ICO) were noted at least every 6 hours for determination of bias, precision, and limits of agreement.

Shivering threshold during spinal anesthesia is reduced in elderly patients.

Background: Both accidental and perioperative hypothermia are common in the elderly. The elderly are at risk because their responses to hypothermia may be delayed or less efficient than in those of younger subjects. For example, the vasoconstriction threshold during isoflurane anesthesia is approximately 1 degree C less in elderly than younger patients.

CDP571, a humanized antibody to human tumor necrosis factor-alpha: safety, pharmacokinetics, immune response, and influence of the antibody on cytokine concentrations in patients with septic shock. CPD571 Sepsis Study Group.

Objectives: To determine the safety of a "humanized" antibody to human anti-tumor necrosis factor-alpha (TNF-alpha) in patients with septic shock, and to examine the pharmacokinetics, immune response, and influence of the antibody on cytokine concentrations in this patient group.

Design: Prospective, randomized, placebo-controlled, phase II multicenter clinical trial, with escalating doses of a fully humanized anti-TNF-alpha antibody (CDP571).

Setting: Seven academic intensive care units in Europe.

Should mechanical ventilation be optimized to blood gases, lung mechanics, or thoracic CT scan?

This study was aimed at providing data for optimization of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). The effects of ventilation with positive end-expiratory pressure (PEEP) titrated to blood gases were studied by thoracic computed tomographic (CT) scans and lung mechanics measurements in eight patients. CT density histograms at end-expiration were used to investigate the effects of PEEP on three differently aerated zones.

Subjective psychological status of severely ill patients discharged from mechanical ventilation.

Objective: To evaluate psychological status in consecutive survivors of ICU who needed mechanical ventilation (MV).

Design: Prospective study.

Setting: Twenty-four bed intensive care unit.

Lack of oxygen supply dependency in patients with severe sepsis. A study of oxygen delivery increased by military antishock trouser and dobutamine.

Background: During severe sepsis, the existence of a pathologic oxygen supply dependency remains controversial.

Study Objective: To evaluate the relationship between oxygen delivery (DO2) and oxygen consumption (VO2) during severe sepsis and to compare, in this respect, survivors and nonsurvivors and patients with normal or increased concentration of plasma lactate.

Study Design: Cohort analytic study.

Platelet-activating factor receptor antagonist BN 52021 in the treatment of severe sepsis: a randomized, double-blind, placebo-controlled, multicenter clinical trial. BN 52021 Sepsis Study Group.

Objective: To evaluate the safety and efficacy of a natural platelet-activating factor receptor antagonist, BN 52021 (Ginkgolide B), in the treatment of patients with sepsis syndrome.

Design: Prospective, randomized, placebo-controlled, double-blind, phase III, multicenter clinical trial.

Setting: Twenty-one academic medical center intensive care units in France.

Accuracy assessment for three fiberoptic pulmonary artery catheters for SvO2 monitoring.

Objective: To compare values of SvO2 obtained by reflectance spectrophotometry continuous monitoring with those obtained from blood samples measurements by transmission spectrophotometry (Co-Oximetry).

Design: Values of SvO2 recorded by three pulmonary artery catheters for continuous monitoring, SAT1, SAT2 and Oximetrix3 (OX3), were compared in a prospective manner to those measured on blood samples by a Co-Oximeter, using the statistical analysis of Bland and Altman.

Setting: Adult intensive care unit in an University Hospital.

Extracorporeal carbon dioxide removal technique improves oxygenation without causing overinflation.

Extracorporeal CO2 removal combined with low frequency positive pressure ventilation (ECCO2R-LFPPV) improves gas exchange and decreases peak pressures, respiratory rates, and tidal volumes in animals and in humans. Recent evidence suggests that pulmonary barotrauma results from lung overinflation rather than from high pressures. This study was to test the hypothesis whether ECCO2R-LFPPV could improve gas exchange without causing lung overinflation, despite the use of higher levels of PEEP, when compared with conventional mechanical ventilation.

Nifedipine and intraoperative core body temperature in humans.

Background: Initial anesthetic-induced hypothermia results largely from core-to-peripheral redistribution of heat. Nifedipine administration may minimize hypothermia by inducing vasodilation well before induction of anesthesia. Although vasodilation would redistribute heat to peripheral tissues, thermoregulatory responses would maintain core temperature.

Recovery from staphylococcal septicaemia in neutropenic patients without removal of the previously inserted central venous catheter.

Objectives: An open clinical study was conducted in the haematological department of an intensive care unit to investigate cure of staphylococcal septicaemia in neutropenic central venous catheter carriers without removal of the line.

Methods: Thirteen neutropenic patients with a central venous catheter were investigated. These patients were under treatment for haematological malignancies and had at least 2 blood cultures positive for Staphylococcus aureus or coagulase-negative staphylococcus.

Iatrogenic complications in adult intensive care units: a prospective two-center study.

Objectives: a) To evaluate the frequency, types, severity, and morbidity of iatrogenic complications; b) determine associated factors that favor iatrogenic complications; and c) suggest new or more efficient protective measures that may be taken to improve patient safety.

Design: Prospective, observational study.

Setting: Two ICUs in France.

Hemodialysis for acute renal failure in patients with hematologic malignancies.

Objective: To assess the prognosis of patients with hematologic malignancies in acute renal failure who require hemodialysis.

Design: Retrospective study.

Setting: ICU.

Adult overwhelming meningococcal purpura. A study of 35 cases, 1977-1989.

The study objective was to describe the clinical, biologic, and hemodynamic features of adult overwhelming meningococcal purpura and to examine the prognostic factors by multivariate analysis at the time of admission to the intensive care unit. Thirty-five patients (greater than or equal to 13 years of age) with meningococcal infection, circulatory shock, and generalized purpuric lesions of abrupt onset were recorded in eight intensive care units from 1977 to 1989. The patients were young (mean age, 26.

Right ventricular performance in adult respiratory distress syndrome.

In adult respiratory distress syndrome (ARDS), the pulmonary artery hypertension is followed by increases in right ventricular diastolic and systolic volumes and a decreased ejection fraction. The stroke volume is preserved by the Frank-Starling mechanism as preload increases, even in the presence of severe pulmonary artery hypertension. In contrast, if there coexists a depression of the right ventricle contractility, as during right ventricular contusion, septic shock or a viral myocarditis, the compensatory Frank-Starling mechanism, that maintains right ventricular pump function, seems limited.

Role of tricuspid regurgitation and left ventricular damage in the treatment of right ventricular infarction-induced low cardiac output syndrome.

To evaluate, in right ventricular (RV) myocardial infarction, the role of tricuspid regurgitation (TR) and left ventricular (LV) damage and the response to treatment of low cardiac output, 20 patients were prospectively studied. Volume infusion increased cardiac output only slightly (11%, p less than 0.001), despite a dramatic increase in ventricular filling pressures.

Mechanical effects of PEEP in patients with adult respiratory distress syndrome.

In 10 patients with adult respiratory distress syndrome, we studied the effects on respiratory system mechanics of two levels of positive end-expiratory pressure (PEEP), best PEEP (BP) and half of this value (HBP), using a respiratory inductive plethysmograph (RIP) combined with a super syringe. We found the following. 1) Inflation compliance of pressure-volume (PV) curves did not change significantly.

Heart failure in septic shock: effects of inotropic support.

Many animal studies have attempted to simulate the circulatory responses to Gram-negative septicemia (iv infusion of live bacteria, fecal inoculation into body cavities, and administration of purified endotoxins by various routes), but the contribution of the heart to the adverse hemodynamic derangements and thus to the pathogenesis of shock is difficult to determine because of peripheral vascular events that influence cardiac performance. When blood pools in the periphery, venous return decreases and cardiac output can decrease without a primary myocardial defect being present. However, early heart dysfunction has been recognized in sepsis.

Regulation of myocardial oxygen delivery.

In most organs, oxygen consumption is maintained at relatively constant levels as oxygen delivery decreases, until a critical level is reached. This biphasic action is not observed in the heart. Myocardial oxygen consumption is supply dependent at all levels of myocardial oxygen delivery, because changes in myocardial oxygen delivery modify ventricular loading conditions and hence myocardial oxygen consumption.

Right ventricular dysfunction in patients with septic shock.

Using a rapid computerized thermodilution method, we examined the evolution of right ventricular performance in 23 patients with septic shock. Nine survived the episode of septic shock. The other 14 patients died of refractory circulatory shock.

Right ventricular performance in patients with acute respiratory failure.

To examine the right ventricular response to acute respiratory failure, serial studies of biventricular performance were analysed in 34 such patients, specifically detailing the role of associated underlying disease. During the initial study, the 34 patients with acute respiratory failure had a higher right ventricular end-diastolic volume than the control group (+21%), associated with a decrease in right ventricular ejection fraction, abnormalities which tended to return to normal values in the 15 survivors. In the 9 patients who died of refractory hypoxemia with severe pulmonary hypertension, the right ventricular dilation allowed to maintain stroke volume.