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Biomedical subjects

C A Manthous

Publications and source records attributed to C A Manthous.

At least 37 records · Page 2Linked to original sources
PubMed1999

Myocardial infarction complicating gastrointestinal hemorrhage.

OBJECTIVE: To determine the frequency of and risk factors for myocardial infarction (MI) in patients admitted to an intensive-care unit (ICU) with gastrointestinal (GI) hemorrhage and to ascertain the effects on mortality and lengths of stay. MATERIAL AND METHODS: Demographic, laboratory, and outcome data were determined for all patients admitted to a medical ICU with GI hemorrhage between April 1996 and January 1997. Serial creatine kinase with isoenzyme levels and electrocardiograms were interpreted blindly by a senior cardiologist. RESULTS: For 83 consecutive admissions to the ICU because of GI hemorrhage, the patients' mean (+/- standard error) age was 65.0 +/- 1.7 years and APACHE II (acute physiology and chronic health evaluation) score was 15.7 +/- 0.8. In-hospital death occurred in 16 patients (19%). Patients who did not survive had a lower admission systolic blood pressure (99.2 +/- 4.5 versus 115.0 +/- 4.0 mm Hg; P = 0.01) than did those who survived. Eleven of 83 patients (13%) fulfilled both enzymatic and electrocardiographic criteria for MI. Ten patients (12%) had electrocardiographic evidence of myocardial ischemia but did not meet criteria for MI. Patients with MI were older (74.4 +/- 4.0 versus 61.7 +/- 2.0 years; P < 0.05), had a higher acuity of illness (APACHE II score, 21.6 +/- 3.0 versus 14.6 +/- 0.7; P < 0.05), and had more coronary risk factors (2.3 +/- 0.3 versus 1.4 +/- 0.1; P < 0.05) in comparison with those without MI or ischemia. Patients with MI also had longer ICU (8.6 +/- 2.4 versus 3.3 +/- 0.4 days; P < 0.05) and hospital (16.3 +/- 3.4 versus 9.1 +/- 0.8 days; P < 0.05) lengths of stay. Patients older than 65 years had a threefold increased risk (risk ratio, 4.0; 95% confidence interval, 0.9 to 17.4) and those with two or more risk factors for coronary artery disease had a ninefold increased risk of MI (risk ratio, 10.2; 95% confidence interval, 1.4 to 76.1) in comparison with those who were younger or who had fewer coronary risk factors, respectively. MI complicating GI hemorrhage did not significantly affect the risk of in-hospital mortality (risk ratio, 1.5; 95% confidence interval, 0.5 to 4.4). CONCLUSION: MI occurs frequently in patients with GI hemorrhage admitted to an ICU. Age more than 65 years and two or more risk factors for coronary artery disease identify patients who are at greatest risk for occurrence of MI, which is associated with longer ICU and hospital stays.

APACHE↗
PubMed1998

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.

Algorithms↗
PubMed1998

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. Patients were categorized as having MI, not having MI, or inadequate data to allow classification. RESULTS: Two hundred thirty admissions to the ICU for GI hemorrhage were reviewed. One hundred thirteen cases had serial creatine phosphokinase (CK) measurements with isoenzymes allowing diagnosis of MI. In these 113 cases, patients' mean age was 67.4+/-1.3 years and the mean APACHE II (acute physiology and chronic health evaluation) score was 10.9+/-0.6. The in-hospital mortality rate was 13/113 (11.5%). Patients who did not survive had a higher admission APACHE II score (15.8+/-2.0 vs 10.2+/-0.5; p = 0.02), lower initial systolic BP (104.5+/-4.4 vs 121.2+/-3.2 mm Hg; p = 0.005), and a longer length of ICU stay (8.3+/-1.8 vs 4.0+/-0.4 days; p = 0.04) than those who survived. Sixteen of 113 patients met enzymatic and ECG criteria for MI. One patient complained of chest pain and nine of 16 had shortness of breath and/or dizziness. Patients with MI had significantly more cardiac risk factors (2.4+/-0.2 vs 1.6+/-0.1; p = 0.006), lower presenting hematocrit (26.0+/-1.3 vs 30.5+/-0.8; p = 0.007), and lower lowest hematocrit in the first 48 h (22.3+/-0.9 vs 25.1+/-0.6; p = 0.01), and tended to have a longer ICU stays (7.9+/-2.2 vs 4.0+/-0.4 days; p = 0.09) than those without MI. Patients who had MI were not more likely to die during hospitalization (risk ratio = 1.8; 95% confidence interval, 0.6 to 5.8). CONCLUSIONS: Myocardial infarction occurs frequently in patients admitted to intensive care with GI hemorrhage. A clinical history of and multiple risk factors for coronary artery disease may help identify patients who are at increased risk of MI, which tends to be associated with a higher acuity of illness and in-hospital mortality. Prospective studies are required to further substantiate these associations.

APACHE↗
PubMed1997

Inhaled helium-oxygen revisited: effect of inhaled helium-oxygen during the treatment of status asthmaticus in children.

OBJECTIVES: To assess the effects of breathing a low-density gas mixture on dyspnea and the pulsus paradoxus in children with status asthmaticus. DESIGN: In an urban academic tertiary referral center, 18 patients, aged 16 months to 16 years, who were being treated for status asthmaticus with continuously inhaled beta-agonist and intravenously administered methylprednisolone and had a pulsus paradoxus of greater than 15 mm Hg received either an 80%:20% helium-oxygen gas mixture (HELIOX patients) or room air (control patients) at 10 L/min by nonrebreathing face mask in a double-blind, randomized, controlled trial. In all patients, baseline data, including pulsus paradoxus (determined by sphygmomanometer or arterial catheter blood pressure readings), respiratory rate, heart rate, investigator-scored dyspnea index, and oxygen saturation, were compared with values obtained 15 minutes during and after intervention. In a subset of patients, peak flows before and after breathing HELIOX or room air were measured. When clinically indicated, arterial blood gases were obtained. RESULTS: The pulsus paradoxus (in millimeters of mercury) fell significantly from an initial mean value of 23.3 +/- 6.8 to 10.6 +/- 2.8 with HELIOX breathing (p < 0.001) and increased again to 18.5 +/- 7.3 after cessation of HELIOX. Peak flow increased 69.4% +/- 12.8% during HELIOX breathing (p < 0.05). The dyspnea index decreased from an initial mean value of 5.7 +/- 1.3 to 1.9 +/- 1.7 with HELIOX breathing (p < 0.0002) and increased again to 4.0 +/- 0.5 after cessation of HELIOX breathing. In control patients, there was no significant difference in pulsus paradoxus or dyspnea index at any time during the study period. Mechanical ventilation was averted in three patients in whom dyspnea lessened dramatically during breathing of HELIOX. CONCLUSION: During acute status asthmaticus, inhaled HELIOX significantly lowered the pulsus paradoxus, increased peak flow, and lessened the dyspnea index. Moreover, HELIOX spared three patients a planned intubation and caused no apparent side effects. Thus HELIOX reduces the work of breathing and may forestall respiratory failure in children with status asthmaticus, thus preventing the need for mechanical ventilation.

Administration, Inhalation↗
PubMed1997

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. PATIENTS: One hundred eighty-three postoperative, mechanically ventilated patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The spontaneous minute volume, unassisted respiratory rate/tidal volume ratio, and negative inspired force were measured just before weaning. The rate/volume ratio was remeasured after 30 to 60 mins of weaning. Weaning was conducted by the patients' primary physicians. Weaning success was defined as unassisted breathing for >24 hrs. Predictive characteristics were computed using threshold values of 100 breaths/min/L, 10 L/min, and -20 cm H2O for the rate/volume ratios, minute volume, and negative inspired force, respectively. Receiver operating characteristic curves were also constructed to assess each parameter. Sensitivities for the initial rate/volume ratio, rate/volume ratio after 30 mins, minute volume, and negative inspired force were 0.97, 0.96, 0.76, and 0.96, respectively. Specificities were 0.33, 0.31, 0.40, and 0.07, respectively. Areas (+/- SD) for receiver operating characteristic curves were 0.76 +/- 0.08, 0.75 +/- 0.06, 0.54 +/- 0.08, and 0.62 +/- 0.07, respectively. The rate/volume ratio after 30 mins correlated with the initial rate/volume ratio; the rate/volume ratio after 30 mins did not add significant, additional predictive information. CONCLUSIONS: The rate/volume ratio measured at the beginning and after 30 mins of weaning is more highly predictive of weaning outcome than the negative inspired force and minute volume. The principal weakness of the rate/volume ratio is false-positive results.

APACHE↗
PubMed1997

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.

Aged↗
PubMed1997

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. MEASUREMENTS: Patients were classified as having sepsis or not having sepsis on the first day of weaning. The respiratory rate:tidal volume ratio (RVR), maximal inspiratory pressure (MIP), respiratory system mechanics, minute volume, WBC count, and maximal temperature (Tmax) were recorded for the first day of weaning. Weaning was then conducted by the patients' primary physicians; weaning outcomes and days spent receiving mechanical ventilation were recorded. RESULTS: Sixty patients were studied over 64 separate ICU admissions. Twenty-five patients met criteria for sepsis and had a higher mean APACHE II (acute physiology and chronic health evaluation) score than patients without sepsis (mean+/-SE: 23.4+/-1.3 vs 18.7+/-1.0; p<0.05). Respiratory mechanics, age, and minute volumes were not different between patients with and without sepsis. Patients with sepsis had a higher RVR than patients without sepsis (94.3+/-10.1 vs 66.6+/-6.4 breaths/min/L; p<0.05) and tended to have a lower MIP (25.0+/-2.0 vs 31.0+/-2.3 cm H2O; p=0.055). The MIP and RVR were moderately correlated (r=0.50, p<0.001). WBC count and Tmax did not correlate with RVR in the total population or in sepsis/nonsepsis subpopulations. First-day weaning success was higher in patients without sepsis (17/39=44%) than patients with sepsis (6/25=24%; odds ratio=2.4; 95% confidence interval=0.8 to 7.3). Patients with sepsis tended to require a longer duration of weaning (3.8+/-0.6 vs 2.5+/-0.5 days; p=0.1) and mechanical ventilation (7.4+/-1.0 vs 5.6+/-1.0 days; p=0.2) than patients without sepsis. Differences were not significant when patients were stratified by ICU admission APACHE II scores. CONCLUSIONS: Patients recovering from sepsis breathe with a higher RVR, tend to have a lower MIP, and tend to be more likely to encounter first-day weaning failure compared to patients without sepsis. Our data also suggest that the severity of illness on ICU admission could explain some of these differences.

APACHE↗
PubMed1997

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 4.2% in response to intravascular volume expansion with 250 or 500 mL of normal saline solution administered as part of their routine treatment. No significant changes in CO2 production, minute volume, or airway pressures occurred over the time interval. We conclude with a brief discussion of potential mechanisms to explain these findings and their potential clinical application.

Adolescent↗
PubMed1997

Effects of a medical intensivist on patient care in a community teaching hospital.

OBJECTIVE: To determine the effect of adding a trained intensivist on patient care and educational outcomes in a community teaching hospital. MATERIAL AND METHODS: We retrospectively reviewed outcomes for patients admitted to the medical intensive-care unit (MICU) of a 270-bed community teaching hospital between July 1992 and June 1994. Mortality rates and durations of stay were determined for the year before (BD, 1992 through 1993) and the first year after (AD, 1993 through 1994) introduction of a full-time director of critical care. Performance of resident trainees on a standardized critical-care examination was measured for the same periods. RESULTS: Overall, 459 patients in the BD period were compared with 471 patients in the AD period. The mix of cases and severity of illness (acute physiology and chronic health evaluation or APACHE II scores) on admission were similar for the BD and AD periods. MICU mortality decreased from 20.9% during the BD to 14.9% during the AD period (P = 0.02), and in-hospital mortality decreased from 34.0% to 24.6% (P = 0.002). Disease-specific mortalities were lower during the AD period for most categories of illness. Detailed analysis of a subgroup of patients (those with pneumonia) demonstrated no differences in distribution of patients by gender, race, or acuity of illness (APACHE II scores). The mortality rate due to pneumonia decreased from 46% during the BD period to 31% during the AD period. This decrease was consistent across categories of APACHE II scores. From BD to AD periods, mean durations of total hospital stay decreased from 22.6 +/- 1.4 days to 17.7 +/- 1.0 days, and mean MICU stay decreased from 5.0 +/- 0.3 days to 3.9 +/- 0.3 days (P < 0.05). Critical-care in-service examination scores for 22 residents increased from 53.8 +/- 1.7% to 67.5 +/- 2.2% (P < 0.01), and AD scores were significantly higher than BD scores for residents at similar levels of training. CONCLUSION: Addition of a medical intensivist was temporally associated with improved clinical and educational outcomes in our community teaching hospital.

APACHE↗
PubMed1997

Preoperative pulmonary function tests do not predict outcome after coronary artery bypass.

PURPOSE: To evaluate the utility of preoperative pulmonary function tests in predicting postoperative complications and lengths of stay after coronary artery bypass grafting. METHODS: Medical records of 193 consecutive patients who underwent coronary artery bypass grafting from October 1993 to September 1994 were reviewed. Preoperative pulmonary function tests, comorbid conditions, smoking history, postoperative complications, and total days in the intensive care unit, hospital, and on mechanical ventilation were abstracted. Data were analyzed using linear regressions, analyses of variance, and nonpaired Student's t tests. RESULTS: Pulmonary function tests were normal in 56 subjects (29%, group 1), mildly impaired in 72 (37%, group 2), and moderately impaired in 35 (18%, group 3). Thirty patients (16%) had no pulmonary function tests. Group 3 subjects were older (71) compared to groups 1 and 2 (63 and 65, P < 0.05). There was no major difference in comorbid conditions or smoking status among the groups. All patients had atelectasis postoperatively. The most frequent postoperative complications were pleural effusions (43%), pulmonary edema or congestive heart failure (28%), and atrial fibrillation (35%). The repeat surgery rate was 3.6%. The mean length of hospital stay was 10.1 +/- 0.6 days, with 1.5 +/- 0.1 days of mechanical ventilation and 2.8 +/- 0.2 days of intensive care unit stay. Overall, pulmonary function tests had no predictive value for postoperative pulmonary and nonpulmonary complications, nor for durations of mechanical ventilation and intensive care unit stay. There was a trend toward increased length of hospital stay in patients with impaired pulmonary function tests (group 18.6 +/- 0.6, group 2 9.6 +/- 0.8, group 312.7 +/- 2.3 days, P = 0.09) but this was consistent with random variation. CONCLUSIONS: Preoperative pulmonary function tests were not useful in predicting postoperative outcomes in patients undergoing coronary artery bypass grafting.

Aged↗
PubMed1996

The unassisted respiratory rate-tidal volume ratio accurately predicts weaning outcome.

PURPOSE: To assess the accuracies of four commonly used parameters in predicting weaning outcome and whether breathing pattern changes during weaning. PATIENTS AND METHODS: We prospectively examined the predictive accuracies of four weaning parameters in mechanically ventilated patients in the medical and cardiac intensive care units of a 270-bed community teaching hospital. The spontaneous respiratory rate:tidal volume ratio (RVRi), negative inspiratory force (NIF), and spontaneous minute volume (VE) at the onset of weaning, and the RVR at 30 to 60 minutes of weaning (RVR30) were measured. Weaning decisions were made by patients' primary physicians independent of this study. Threshold values for computations of predictive values were as follows: RVR 100 < or = breaths per minute/L, NIF < or = -20 cm H2O, VE < or = 10 Lpm. Receiver operator curves were generated for each parameter. RESULTS: One hundred medical/cardiac intensive care unit patients were studied. Their mean age was 64.6 +/- 15.8 years, mean APACHE II score of 15.8 +/- 6.7 and mean duration of mechanical ventilation before the study of 4.9 +/- 8.1 days. RVRi sensitivity was 89%, specificity was 41%, positive predictive value was 72%, negative predictive value was 68%, and accuracy was 71%. The RVR30 sensitivity was 98%, specificity was 59%, positive predictive value was 83%, negative predictive value was 94%, and accuracy was 85%. Accuracies for the NIF and VE were 66% and 62%, respectively. The area under the receiver operator curve of the RVR30 (0.92 +/- 0.03) was higher than the RVRi (0.74 +/- 0.05), NIF (0.68 +/- 0.06) and VE (0.54 +/- 0.06) (p < 0.05). CONCLUSIONS: The RVR is more accurate than other commonly utilized clinical tools in predicting the outcome of weaning from mechanical ventilation. The RVR measured at 30 minutes is superior to the RVR in the first minute of weaning. The predictive accuracy and unique simplicity of the RVR justify its use in the care of mechanically ventilated patients.

Aged↗
PubMed1996

Cardiac ischemia during weaning from mechanical ventilation.

In this prospective study, we measured the ST segments, heart rate-systolic BP product (RPP), respiratory rate to tidal volume ratio (RVR), and pulse oximetry saturations of patients in our medical/cardiac ICUs before and during weaning from mechanical ventilation. Ninety-three patients were enrolled with a mean age of 66.5 +/- 15.0 years (mean +/- SD), mean acute physiology and chronic health evaluation (APACHE) II score of 16.0 +/- 6.9, and mean duration of mechanical ventilation of 5.2 +/- 8.6 days. Forty-nine patients had coronary artery disease (CAD). Six of 93 patients (6.4%) experienced ECG evidence of ischemia during weaning. Five of these six had a precedent history of CAD and four failed initial weaning attempts (22% of patients with CAD who failed weaning). The RPP, for the group as a whole, increased significantly during weaning from 12.0 +/- 3.1 to 13.4 +/- 4.0 mm Hg.bpm.10(3) (p<0.01). The rate to volume ratio did not change significantly during weaning, except in the subgroup of patients who failed to wean, in whom it increased from 98.4 +/- 45.2 to 124.9 +/- 54.9 bpm/L (p<0.05). Oxygenation also decreased significantly from 0.98 +/- 0.02 to 0.96 +/- 0.03 and was significantly associated with weaning failure (risk ratio [RR]=3.9; 95% confidence interval [CI]=1.7 to 9.0). Thirty-seven patients failed the initial weaning attempt. Cardiac ischemia (RR= 1.8; 95% CI=1.0 to 3.4) and an increased RVR (RR=1.7; 95% CI=0.9 to 3.4) tended to increase the risk of weaning failure. Cardiac ischemia, although infrequent (6%) in the general population of weaning medical/cardiac ICU patients, should be considered in patients with CAD who fail to wean.

Adult↗
PubMed1996

Torulopsis pneumonia. A case report and review of the literature.

Torulopsis glabrata is a rare cause of pneumonia in immunocompromised patients. We herein describe the case of an elderly man who presented with fulminant Torulopsis pneumonia and septic shock leading to death. We then review the literature, describe the clinical syndrome, and delineate an approach to diagnosis and treatment of Torulopsis pneumonia.

Aged↗
PubMed1995

Management of severe exacerbations of asthma.

Asthma is a common disease that afflicts as many as 5% of Americans. Severe exacerbations of asthma can be life-threatening if not treated aggressively. Despite publication of therapeutic guidelines developed by experts in this field, the clinical management of severe exacerbations of asthma varies widely among institutions and practitioners. This article briefly reviews the pathophysiology of asthma and outlines a systematic, mechanistic approach to treating patients with severe asthma that integrates many clinical advancements made during the past 5 to 10 years.

Acute Disease↗