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Biomedical subjects

C E Wiles

Publications and source records attributed to C E Wiles.

At least 19 recordsLinked to original sources
PubMed1999

Critical care apheresis: hepatic failure.

Hepatic failure is a common feature of critical care. Most hepatic dysfunction in the ICU responds to medical management and metabolic support. The role of extracorporeal organ support in hepatic failure is not as well defined as it is in renal failure and pulmonary failure. Nevertheless, artificial organ support has been successful in the treatment of advanced liver failure. Hybrid bioartificial liver substitutes show great promise, especially as a bridge to liver transplant.

Blood Component Removal↗
PubMed1998

Overfeeding macronutrients to critically ill adults: metabolic complications.

Metabolic complications from overfeeding critically ill patients are serious and sometimes fatal. Nutrition care is best provided through repeated evaluation of patients' responses to feeding. Nutrition support may need to be modified over time to maintain metabolic stability and promote recovery. This article describes the etiology of 10 metabolic complications of overfeeding. Guidelines for recommending macronutrients are discussed, as are factors that could increase the risk of overfeeding. Patients who are very small, very large, or very old are particularly vulnerable to overfeeding. Overfeeding protein has led to azotemia, hypertonic dehydration, and metabolic acidosis. Excessive carbohydrate infusion has resulted in hyperglycemia, hypertriglyceridemia, and hepatic steatosis. High-fat infusions have caused hypertriglyceridemia and fat-overload syndrome. Hypercapnia and refeeding syndrome have also been caused by aggressive overfeeding. Dietitians can prevent or curtail the metabolic complications of overfeeding by identifying patients at risk, providing adequate assessment, coordinating interdisciplinary care plans, and delivering timely and appropriate monitoring and intervention. Dietitians need to document complications, interventions, and the outcomes of their clinical care to evaluate the appropriateness of existing nutrition guidelines.

Acidosis↗
PubMed1998

Flush resuscitation for group A streptococcus toxic shock: a possible role for continuous renal replacement therapy and plasmapheresis.

Group A streptococcus has emerged as a major cause of aggressive life-threatening deep-seated infections. In addition, toxic shock syndrome caused by Group A streptococcus was recognized in 1983. Group A streptococcus produces several potent exotoxins which explain the pathophysiology of these invasive infections. Other virulence factors such as M protein, which can impede phagocytosis, are associated with some Group A streptococcus. M protein and streptococcal pyrogenic exotoxins may act as super antigens. Host factors may influence the severity of infection. Blood purification techniques such as continuous renal replacement therapy and plasmapheresis can remove streptococcal exotoxins as well as inflammatory mediators. Replacement with fresh-frozen plasma corrects coagulopathy and may provide some antibody protection. Four patients with Group A streptococcus-toxic shock syndrome treated with continuous renal replacement therapy, plasmapheresis, or both showed dramatic, rapid improvement in cardiovascular dynamics and respiratory parameters. Two patients died. The mainstay of treatment for Group A streptococcus-toxic shock syndrome remains early diagnosis, aggressive surgical control of the infection, and appropriate antibiotics (i.e., penicillin and clindamycin). Flush resuscitation may rescue some patients from profound toxic shock. The mechanisms of action need to be delineated.

Anti-Bacterial Agents↗
PubMed1997

Physicians prefer goal-oriented note format more than three to one over other outcome-focused documentation.

To assess preference for outcome-focused nutrition notes, two note formats were selected from the literature and tested against a modified, goal-oriented format. Focus charting and intervention, evaluation, and revision (IER) formats were compared with a charting-by-exception style that was modified to include goals and reassessment of risk. Notes were handwritten in each format and contained the same information. Physicians were asked to choose their preference and explain why that format was selected. Initially, focus charting was tested against the goal-oriented format. The more popular of the two was then tested against the IER format. Nineteen physicians were surveyed by a registered dietitian for each comparison. Physicians preferred the goal-oriented format over focus charting and IER formats 9:1 and 3:1, respectively. In the first survey, physicians preferred the goal-oriented format because the plan was clearly stated, thereby rendering the note easier to understand. The goal-oriented format was preferred in the second survey because the note was considered to be concise and easy to read and contained expected outcomes. Physicians want short communication that includes easily identifiable goals and plans. We recommend that experienced dietitians use the goal-oriented format developed for this study, and preferred by physicians, for follow-up nutrition notes.

Attitude of Health Personnel↗
PubMed1995

Glucose dynamics during continuous hemodiafiltration and total parenteral nutrition.

OBJECTIVE: To determine glucose balance during dextrose-free continuous hemodiafiltration with or without dextrose-containing ultrafiltrate replacement fluid and full nutritional support. DESIGN: Prospective, nonrandomized, observational study. SETTING: A 24-bed multiple trauma critical care unit in a level-I trauma center. PATIENTS: Seventeen multiple trauma patients with multiple organ dysfunction syndrome requiring hemodialysis for acute renal failure. INTERVENTIONS: Continuous hemodiafiltration effluent volume and glucose concentration were measured. Study days were classified according to whether dextrose was used in the ultrafiltrate replacement therapy. Use of dextrose in replacement therapy was determined clinically. Parenteral nutrition was not altered for potential glucose absorption from continuous hemodiafiltration. Ultrafiltrate replacement consisted of 5% dextrose in saline on 21 study days (D5YES) and dextrose-free solutions on 54 study days (D5NO). RESULTS: The D5YES group received 316 +/- 145 g glucose/day from the ultrafiltrate replacement fluid, in addition to glucose in total parenteral nutrition (total glucose intake = 942 +/- 229 g/day in D5YES, 682 +/- 154 g/day in D5NO) (p < 0.05). Glucose loss in continuous hemodiafiltration effluent was 82 +/- 61 g/day in D5YES and 57 +/- 22 g/day in D5NO (P < 0.05), for a net glucose uptake of 8.1 +/- 2.1 mg/kg per min in D5YES and 5.4 +/- 1.5 mg/kg per min in D5NO (p < 0.05). Glucose loss was predictable when dialysate and ultrafiltrate replacement fluids were dextrose-free (R2 = 0.77), but less so when dextrose was used as ultrafiltrate replacement (R2 = 0.47). CONCLUSION: Dextrose-free dialysate promotes glucose loss during continuous hemodiafiltration, but the loss is small and predictable. Use of a dextrose-containing ultrafiltrate replacement fluid results in a significant increase in glucose intake without a commensurate increase in glucose loss, and makes glucose loss in effluent less predictable.

Acute Kidney Injury↗
PubMed1995

Post-traumatic multiple organ dysfunction syndrome--infection is an uncommon antecedent risk factor.

A pattern of multiple organ dysfunction syndrome (MODS) and risk factors following blunt trauma was identified, based on analyses of clinical data from 3611 patients who were admitted directly to a level I trauma centre and had hospital stays > or = 3 days. Five system dysfunctions were simultaneously associated (P < 0.05) with death (adjusted odds ratio): adult respiratory distress syndrome (ARDS) (4.9), renal failure (6.7), hyperglycaemia (3.6), recurrent acidosis (4.8) and hypoalbuminaemia (1.8). Mortality increased with the number of system dysfunctions. For the 336 patients with MODS (> or = 2 dysfunctions), mortality was 32.4 per cent compared with 1.3 per cent in the non-MODS group (P = 0.0001). Of the 254 with MODS occurring within 72 hours, mortality was 27 per cent compared with 49 per cent in those manifesting MODS later (P < 0.001). The 175 (52.1 per cent) with organ failure (renal failure and/or ARDS) also had metabolic dysfunction. Seven admission risk factors were independently associated (P < 0.003) with MODS [adjusted odds ratio]: pre-existing condition (3.4), age > 50 (3.1), Injury Severity Score > or = 25 (6.4), hypotension (2.8), acidaemia (2.2), 24 h blood loss > 1 l (3.7), and major base deficit (1.6). Only 13 per cent with MODS had an infection in the 5 days before or at initiation of MODS. Haemodynamic instability, acidosis, blood loss, pre-existing condition, age and serious injury were risk factors independently related to life-threatening MODS, but infection was an uncommon precursor except in late MODS.(ABSTRACT TRUNCATED AT 250 WORDS)

Acidosis↗
PubMed1995

Delayed embolization of a shotgun pellet from the chest to the middle cerebral artery.

Embolization of metallic missiles into the cerebral circulation is a rare occurrence. Most of the cases reported were due to gunshot wounds and shotgun wounds to the neck and face. Embolization from injuries sustained to the chest are extremely rare. We report a case of delayed pellet embolization to the middle cerebral artery resulting from a shotgun injury to the left chest.

Adult↗
PubMed1994

Urea removal during continuous hemodiafiltration.

OBJECTIVE: To compare urea nitrogen removal by continuous hemodiafiltration vs. functional native kidneys in critically ill, septic patients receiving > 2 g of amino acids/kg body weight per day. DESIGN: Prospective, comparative, unblinded study. SETTING: Trauma critical care units of a Level I adult trauma hospital. PATIENTS: Fifteen septic patients with multiple organ failure including renal failure who were receiving continuous hemodiafiltration; 11 septic patients with multiple organ failure without renal failure (control group). Ages of patients ranged from 18 to 60 yrs. INTERVENTIONS: Collection of effluent (dialysate + ultrafiltrate) from hemodiafilters. Collection of urine from control patients. MEASUREMENTS: Urea nitrogen and creatinine concentrations in blood, urine, and the hemodiafiltration effluent, measured every 24 hrs for 6 days. Effluent and urine volumes were measured. MAIN RESULTS: Hemodiafilters were operational for 21.8 +/- 3.0 hrs/day. Mean urea nitrogen removal in the renal failure group was 28 +/- 10 g/day. Blood urea nitrogen was stable over the 6-day study period. In control subjects, urea nitrogen removal was 27 +/- 9 g/day, which was not significantly different from the continuous hemodiafiltration group. Blood urea nitrogen concentrations in control patients increased over the 6-day study period (p < .05). Urea nitrogen removal correlated moderately well with amino acid intake in the control group (r2 = .30), but not in the continuous hemodiafiltration group (r2 = .0004). In patients receiving continuous hemodiafiltration, effluent volume was most significantly correlated with urea nitrogen removal (r2 = .69). CONCLUSIONS: The technique of continuous hemodiafiltration can remove substantial amounts of urea nitrogen, similar to that of normal native kidneys. In addition, at amino acid intake rates of > 2 g/kg body weight/day, urea nitrogen removal during continuous hemodiafiltration remains a function of effluent volume, so there is no need to restrict amino acid intake in acute renal failure patients supported with continuous hemodiafiltration.

Acute Kidney Injury↗
PubMed1994

Relationships between resting and total energy expenditure in injured and septic patients.

OBJECTIVE: To quantify resting and total energy expenditure in patients who have suffered severe trauma and sepsis. DESIGN: Prospective, unblinded, observational, nonrandomized study. SETTING: Critical care unit of a Level I adult trauma center. PATIENTS: Immediate posttrauma patients or trauma patients exhibiting signs of sepsis with multiple organ dysfunction. INTERVENTIONS: An indirect calorimeter was used to measure energy expenditure at rest (resting energy expenditure) at 0700 and 1900 hrs. The energy expenditure measurement was then continued for up to 12 hrs (total energy expenditure). Clinical data were collected for computation of an illness severity score. RESULTS: Thirteen trauma and 20 septic patients were studied 240 times. All patients were mechanically ventilated. Morphine or fentanyl was infused during 99% of studies. Neuromuscular blocking agents were used in 42% of septic studies. Both the trauma and septic groups were hypermetabolic (mean trauma resting energy expenditure, 36 +/- 6 kcal/kg; mean septic resting energy expenditure, 44 +/- 8 kcal/kg; p < .05). Total energy expenditure was similar to resting energy expenditure (trauma total energy expenditure = resting energy expenditure x 1.035 +/- 0.078, septic total energy expenditure = resting energy expenditure x 1.039 +/- 0.071). Total energy expenditure and resting energy expenditure were linearly related (r2 = .89, p < .0001). CONCLUSIONS: Trauma and septic patients are hypermetabolic, even when heavily sedated or medically paralyzed. A measurement of resting energy expenditure is a close approximation of total energy expenditure in most patients.

Adult↗
PubMed1994

Inflammatory markers: superior predictors of adverse outcome in blunt trauma patients?

OBJECTIVE: To assess whether variables reflective of early metabolic responses to injury are predictors of outcome in critically ill trauma patients. DESIGN: Clinical inception cohort study comparing conventional measures of injury severity with early host response markers for the correlation of each with outcome. These data are prospectively collected in a group of patients being evaluated in a nutritional support investigation. SETTING: Intensive care unit (ICU) of a major Level I trauma center. PATIENTS: Seventeen blunt trauma patients, aged 18 to 60 yrs with an Injury Severity Score of > or = 15, requiring early mechanical ventilation. INTERVENTIONS: Blood and urine samples were routinely obtained from patients undergoing nutritional support by one of three routes. MEASUREMENTS AND MAIN RESULTS: Conventional assessment was consistent with moderate severity and variation: Injury Severity Score, 41 +/- 15; Glasgow Coma Score, 11 +/- 4; admission circulating lactate concentration, 4.8 +/- 2.2 mmol/L; and first 24-hr transfusion requirement, 3.1 +/- 2.9 L. The mean concentrations of inflammatory marker during the first week were: cholesterol, 2.67 +/- 0.80 mmol/L (103.2 +/- 31 mg/dL); C-reactive protein, 23 +/- 11 mg/dL; transferrin, 1.44 +/- 0.47 g/L; glucose, 9.21 +/- 2.27 mmol/L (166 +/- 41 mg/dL); albumin, 26 +/- 5 g/L; and nitrogen loss, 24 +/- 9 g/d. Hospital outcome variables were: ventilator days, 17 +/- 7; ICU days, 26 +/- 10; hospital days, 38 +/- 15; occurrence rate of adult respiratory distress syndrome (ARDS), 35%; infections, 82%; multiple organ failure, 71%; and total of hospital plus professional charges, $125,000 +/- $56,000. A significant (p < .05), but weak, correlation existed between all seven outcome variables and the inflammatory markers: ventilator days with cholesterol and C-reactive protein; ICU days with transferrin; total stay with cholesterol; ARDS with C-reactive protein; infections with glucose, cholesterol, and nitrogen loss; multiple organ failure with albumin and C-reactive protein; and financial charges with glucose. However, a significant correlation existed between only two of seven outcome variables and conventional measures of severity: multiple organ failure with lactate and financial charges with transfusion requirement. CONCLUSION: Readily obtainable inflammatory marker measurements may better reflect the summation effects of the early perfusion deficit and tissue injury in the blunt trauma patient compared with conventional measures of injury severity.

Adult↗
PubMed1993

Pharmacology, monitoring, and nutritional support.

Three areas of particular importance in dealing with critical complications of trauma are pharmacology, monitoring, and nutritional support. This article deals with each of these from the perspective of the doctor or nurse at the bedside. This survey stands as a sampler and guidebook to these subjects as they pertain to the critically ill multiple trauma patient.

Chronic Disease↗
PubMed1991

Continuous arteriovenous hemofiltration with dialysis (CAVH-D): an alternative to hemodialysis in the mass casualty situation.

Renal failure is a common sequela of mass casualty, particularly when crush injury is involved. Traditional management of renal failure with hemodialysis equipment may be difficult or inaccessible due to lack of electricity and water supply or damage to existing equipment. Furthermore, a sudden new population of renal failure patients may overwhelm an existing dialysis program. The rapid mobilization of traditional hemodialysis equipment may be delayed due to limited supply, manufacturing delays, or inventory shortages. For these reasons, we propose the use of continuous arteriovenous hemofiltration with dialysis (CAVH-D) as an alternative renal support modality for the mass casualty situation.

Acute Kidney Injury↗
PubMed1991

Efficacy of continuous arteriovenous hemofiltration with dialysis in patients with renal failure.

OBJECTIVE: To document the efficacy of continuous arteriovenous hemofiltration with dialysis following renal failure, without protein restriction, and to explore the magnitude and clinical applications of total daily urea clearance. DESIGN: A noncomparative, descriptive account of a case series. Data were collected prospectively and analyzed retrospectively. SETTING: A tertiary care facility in a statewide emergency medical services system. PATIENTS: Twenty-eight patients with renal failure were supported by continuous arteriovenous hemofiltration with dialysis in a critical care unit during a 14-month period (21 patients with multitrauma; three patients with soft tissue infections; and four patients with multisystem organ failure who had been transferred from other hospitals). Renal failure was most commonly due to multisystem organ failure or associated with adult respiratory distress syndrome. RESULTS: Continuous arteriovenous hemofiltration with dialysis days totaled 308 (mean 10.9). All patients received full protein alimentation (mean protein load 131 g/day). The blood urea nitrogen concentration was controlled, generally to 40 to 75 mg/dL (14.3 to 26.7 mmol/L) within 3 to 5 days. Total daily urea clearance ranged from 15 to 21 g/day. Five (18%) of the 28 patients survived. CONCLUSION: Continuous arteriovenous hemofiltration with dialysis appears to be effective for the control of blood urea nitrogen and clearance of urea. This modality also permits full protein alimentation. Total daily urea clearance can be calculated easily and may have important clinical uses and implications.

Adult↗