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Constantine A Manthous

Publications and source records attributed to Constantine A Manthous.

At least 19 recordsLinked to original sources
PubMed2005

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. RESULTS: Positive fluid balance (inputs>outputs) in the 24, 48, and 72 h and cumulatively (from hospital admission) prior to weaning were significantly greater in weaning failures than successes. Both univariate and multivariate analyses, adjusted for duration of mechanical ventilation and presence of chronic obstructive pulmonary disease, showed negative cumulative fluid balance 24 h prior to BTs (OR=2.9) and cumulative fluid balance (OR=3.4) to be independently associated with first-day weaning success. Similar relationships were demonstrated when all weaning attempts were analyzed. Negative fluid balance was as predictive of weaning outcomes as f/V(t) (likelihood of success was 1.7 for patients with negative fluid balance 24 h prior to weaning and 1.2 for those with f/Vt<100 min-1 l-1). Although administration of diuretics was associated with more negative fluid balance, it was not independently associated with weaning outcomes. CONCLUSIONS: These data suggest that fluid balance, a potentially modifiable factor, is associated with weaning outcomes. A randomized study is required to determine whether diuresis to treat positive fluid balance expedites liberation from mechanical ventilation.

Adult↗
PubMed2005

Outcomes of critically ill patients.

OBJECTIVE: We hypothesized that critically ill patients who remain in the ED for more than 24 hours experience worse outcomes and longer lengths of stay than those transferred to the medical intensive care unit (MICU) within 24 hours. METHODS: Medical records were examined of all patients admitted to the MICU directly from the ED of a 325-bed community teaching hospital between 2001 and 2002. RESULTS: Of 443 patients, 104 remained in the ED for 24 hours or longer (ED>or=24) before being transferred to the MICU. There were no significant differences in demographic characteristics of the 339 who were in the ED for less than 24 hours (ED <24 ) as compared with ED>or=24. APACHE II scores were 18.9+/-1.0 for a random sample of ED<24 and 20.5+/-0.9 for ED>or=24 (P=.2). Lengths of hospital stay were 10.9+/-0.8 days for ED<24 and 9.8+/-0.9 days for ED>or=24 (P=.7). Mortality rates were 26.8% for ED<24 and 26.9% for ED>or=24 (P=.5). CONCLUSIONS: These data suggest that outcomes of critically ill patients transferred from the ED to our MICU within 24 hours were not better than those who remained in the ED for longer durations. Larger studies are required to examine this hypothesis.

APACHE↗
PubMed2005

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. RESULTS: Of 755 patients admitted during the study period, 264 patients participated in the study, and 82 (31%) had living wills. Patients with living wills were more likely to be white, Protestant, and highly educated. Most (76%) created them with a lawyer or family member, whereas only 7% involved physicians. Although these patients were able to identify some components of cardiopulmonary resuscitation (CPR), few (19%) understood the prognosis after CPR. After explaining CPR, 37% of those with living wills did not want it, which was not stated in their directive or hospital record. If life-sustaining therapies were already started, 39% of these patients stated that they would not want CPR or mechanical ventilation if the likelihood of recovery was < or =10%. Patients without living wills either had not heard (18%) or did not know enough (51%) about them. After education, 5% did not want CPR, and 32% would terminate life-sustaining therapies if the likelihood of recovery was < or =10%. Seventy percent of these patients expressed interest in creating a living will. CONCLUSIONS: Patients with living wills understand poorly "life-sustaining therapies" and the implications of their advance directives. Most fail to involve physicians in creating directives. A significant number of those without living wills have end-of-life wishes that could be addressed by and appear open to the idea of creating advance directives.

Adult↗
PubMed2005

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. RESULTS: Sixty-eight of 128 queried intensivists responded to the questionnaire. They reported having withdrawn life-sustaining therapies to a median of 28 patients in the previous year. Overall, respondents answered that of patients in whom they had withdrawn life-sustaining therapies, 55% were terminal, 20.5% weren't necessarily terminal but advance directives were applied to the situation and 22% weren't necessarily terminal but families requested withdrawal. The ranges of responses were highly variable (ranging from 5%-100% patients deemed terminal). All respondents agreed that withdrawal should be allowed in non-terminal conditions in which the likelihood or quality of survival would be unacceptable to the patient. Forty-eight respondents answered that advanced Alzheimer's Disease qualifies as a terminal illness. Connecticut's end-of-life statutes were unlike those in the five other states that allowed withdrawal of life-sustaining therapies based on advance directives and/or surrogates' consent. Practices of Connecticut respondents were similar to other sampled states. CONCLUSIONS: These data suggest that Connecticut's statutes requiring that patients be deemed terminal (or permanently unconscious) before withdrawal of care are dissimilar from those in several other states. Connecticut intensivists who responded to our survey appear to practice end-of-life care that is similar to practices elsewhere.

Advance Directive Adherence↗
PubMed2004

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. MEASUREMENTS AND MAIN RESULTS: Cough peak flow (CPF), endotracheal secretions and ability to complete four simple tasks were measured just before extubation in patients who had passed a SBT. Eighty-eight patients were studied; 14 failed their first trials of extubation. The CPF of patients who failed was lower than that of those who had a successful extubation (58.1+/-4.6 l/min vs 79.7+/-4.1 l/min, p=0.03) and those with CPF 60 l/min or less were nearly five times as likely to fail extubation compared to those with CPF higher than 60 l/min (risk ratio [RR]=4.8; 95% CI=1.4-16.2). Patients with secretions of more than 2.5 ml/h were three times as likely to fail (RR=3.0; 95% CI=1.0-8.8) as those with fewer secretions. Patients who were unable to complete four simple tasks (i.e. open eyes, follow with eyes, grasp hand, stick out tongue) were more than four times as likely to fail as those who completed the four commands (RR=4.3; 95% CI=1.8-10.4). There was synergistic interaction between these risk factors. The failure rate was 100% for patients with all three risk factors compared to 3% for those with no risk factors (RR=23.2; 95% CI=3.2-167.2). The presence of any two of the above risk factors had a sensitivity of 71 and specificity of 81% in predicting extubation failure. Patients who failed a trial of extubation were 3.8 times as likely to have any two risk factors compared to those who were successful. CONCLUSIONS: These simple, reproducible methods may provide a clinically useful approach to guiding the extubation of patients who have passed a SBT.

APACHE↗
PubMed2004

Leapfrog and critical care: evidence- and reality-based intensive care for the 21st century.

In 2000, the Business Roundtable published its Leapfrog report, which contained suggestions for improving administration of critical care. The Leapfrog Group intends to influence health care policy by pressuring insurers and hospitals to implement its guidelines, and both internists and intensivists are likely to be affected if these recommendations are realized. This article outlines the Leapfrog standards for critical care and examines critically the evidence used to justify them. Aside from the guideline that all critically ill patients should be cared for by intensivists, Leapfrog's standards for critical care are based either on weak or no scientific evidence. Rather, most of the guidelines are grounded in common sense and rational extrapolation of the data; as such, they are a reasonable starting point for debate by physicians and policymakers about optimal methods of achieving intensivist-guided care of critically ill patients.

Critical Care↗
PubMed2004

Anticoagulation in hospitalized patients with renal insufficiency: a comparison of bleeding rates with unfractionated heparin vs enoxaparin.

OBJECTIVES: To compare the rates of bleeding complications in patients with renal insufficiency who receive anticoagulation therapy with the full therapeutic dose, unfractionated heparin (UFH), or with twice-daily enoxaparin. SETTING: A 325-bed community teaching hospital. STUDY TYPE: Retrospective cohort study. METHODS: The medical records of all patients with renal insufficiency who received anticoagulation therapy with UFH or enoxaparin during a 13-month period were reviewed for the occurrence of major and minor bleeding. Incidence rates were computed per 1,000-person days of anticoagulation therapy. Comparisons were made across categories of renal insufficiency and other potential confounders. RESULTS: A total of 620 patients with estimated glomerular filtration rates of < 60 mL/min were studied. Of these, 331 received anticoagulation therapy with UFH, 250 with enoxaparin, and 39 with both (not simultaneously). The major bleeding rates were 26.3 per 1,000 person-days for UFH and 20.7 per 1,000 person-days for enoxaparin. Major bleeding complications were similarly increased for both UFH and enoxaparin therapy across categories of worsening renal insufficiency. Patients with severe renal insufficiency while receiving enoxaparin had a 154% excess incidence of minor bleeding compared to those receiving UFH (incidence ratio, 2.54; 95% confidence interval, 1.01 to 6.36). Worsening renal insufficiency, female gender, and prolonged duration of anticoagulation therapy emerged as the main determinants for bleeding complications. CONCLUSION: Both the twice-daily enoxaparin and UFH regimens are associated with comparable increases in major bleeding complications in patients with renal dysfunction receiving full-dose anticoagulation therapy. Both agents should be used with caution in anticoagulation therapy for patients with renal insufficiency.

Aged↗
PubMed2004

Informed consent for invasive medical procedures from the patient's perspective.

BACKGROUND: Written informed consent is not obtained uniformly for invasive medical procedures in critically ill patients across America. The general consent-to-treat is used by some institutions in lieu of separate, procedure-by-procedure consent. OBJECTIVES: To determine whether hospitalized patients recall the general consent-to-treat and to ascertain their preferences regarding informed consent for invasive medical procedures. METHODS: A questionnaire was administered to patients admitted to a 325-bed community teaching hospital. RESULTS: Of 265 patients who participated in the study, only 8% correctly recalled all of the elements of the general consent-to-treat. One hundred twelve respondents (42.3%) trusted their doctors to perform necessary medical procedures, "as long as they were told what was going to happen and why the medical procedure was needed." These patients were older (67 vs 62 years, P = 0.02) and were less likely to hold college or advanced degrees (33% vs 44%, P = 0.04). One hundred fifty-three patients wanted to know the important benefits, risks and alternatives, and to give written permission for performance of medical procedures. On further questioning, 29 (19%) of 153 patients responded that no medical procedure should be done without getting consent first. Forty-three (28%) thought procedures with complications in < 1% of cases should not require consent, while nine (6%) thought consent should be required at a threshold of 10% complications. One hundred patients (65%) responded that procedures with small and nonserious risks (i.e., IV's, bladder catheters) should not require separate written consent. CONCLUSIONS: The general consent-to-treat is not recalled well by hospitalized patients and is unlikely to suffice as informed consent for invasive medical procedures. A majority of patients do not want to have invasive procedures without first giving their informed consent.

Adult↗
PubMed2004

Informed consent for invasive procedures in a community hospital medical intensive care unit.

OBJECTIVE: To describe the informed consent practices in the medical intensive care unit (MICU) of a university-affiliated, community teaching hospital. DESIGN: Prospective, observational study. SUBJECTS: 177 critically ill patients. MEASUREMENTS: Study personnel identified all critically ill patients who had an invasive medical procedure during the study period (120 days). It was first determined whether written informed consent was obtained for the procedure. If it was, standardized questionnaires were used to determine whether consent-givers recalled the indications, complications, and alternatives of invasive medical procedures. Documentation of consent and of the performance of invasive procedures in the medical records was also examined. An educational in-service was created to help improve the informed consent process. After a 45-day lead-in (control) period, the in-service was administered and IC was again studied for 75 days. RESULTS: A total of 181 procedures were performed on 112 patients over 120 days in the MICU. The rates of written consent for invasive procedures averaged 89%; rates of consent were not affected by the educational in-service. Following administration of the in-service, consent-givers recalled a greater number of complications (2.5 to 4.1, P=0.01) and documentation of consent improved. CONCLUSIONS: These results suggest that informed consent can be obtained procedure-by-procedure, as needed, at a high frequency, and with reasonable consenter comprehension.

Adult↗
PubMed2004

Determinants of dynamic hyperinflation in a bench model.

BACKGROUND: Previous in vivo data suggest that high airway resistance (R(aw)) promotes dynamic hyperinflation, especially when coupled to high minute ventilation (V(E)). However, no studies have systematically examined the relative effects of various mechanical parameters on dynamic hyperinflation. METHODS: Intrinsic positive end-expiratory pressure (PEEPi) was measured with a ventilator-lung model, over a range and various permutations of R(aw), V(E), respiratory system compliance (C(RS)), and duty cycles/flow regimes. RESULTS: Substantial dynamic hyperinflation (PEEPi > 5 cm H(2)O occurred at various V(E), even when R(aw) was low (4 cm H(2)O/L/s) or just above normal (18 cm H(2)O/L/s). A V(E) > or = 15 L/min was associated with increasing PEEPi in this model, across a broad range of mechanical permutations. PEEPi was significantly higher in all models during descending ramp flow than during constant flow, at equivalent peak flows (wherein duty cycle during descending ramp flow was twice that of constant flow). PEEPi was equivalent when duty cycles (and all other mechanical parameters) were equal. PEEPi was significantly greater, irrespective of duty cycle, R(aw), and C(RS), when delivered with lower tidal volume (0.6 L vs 1.0 L). The change in peak airway pressure associated with development of dynamic hyperinflation was consistently greater than the observed PEEPi. Higher V(E), resistance, compliance, and duty cycles were all independently associated with dynamic hyperinflation. CONCLUSIONS: In this bench model, dynamic hyperinflation occurred with high V(E), even at low R(aw). Since moderate R(aw) and V(E) frequently occur in vivo, even without obstructive lung disease, occult dynamic hyperinflation is likely to occur commonly. PEEPi was greater with high frequency and small tidal volume (0.6 L) than with equal V(E) of lower frequency and larger tidal volume (1.0 L).

Equipment Design↗
PubMed2003

Gender and status asthmaticus.

BACKGROUND: Adult women may be more susceptible to asthma than men. HYPOTHESIS: Women are more likely to develop status asthmaticus (SA) requiring critical care. METHODS: The medical records of patients admitted to our medical intensive care unit (ICU) for SA between 1994 and 2000 were examined. A number of demographic and physiologic variables were extracted from the medical records. RESULTS: Of 103 total admissions, 53 (of 37 patients) were age < 50 years and had clinical evidence suggesting SA. Among these 37 patients, the average (+/-SE) age was 30.8 +/- 1.0 y with average acute physiology and chronic health evaluation (APACHE) II of 9.5 +/- 0.8. Seventeen patients were Hispanic, 13 were black, and 7 were white. Twenty-four patients (accounting for 37 admissions) were female and 13 patients (16 admissions) were male. Although women accounted for a greater absolute number of endotracheal intubations (ETI; 17 vs. 12) and were more likely to be admitted to ICU more than once (7 vs. 3), men had a higher incidence of ETI (RR=1.6; 95%CI=1.04-2.6). The need for using therapeutic permissive hypercapnia and lengths of stay (ventilator, ICU, and hospital) were similar between men and women. Two patients, both women, died of causes not related to treatment of SA. CONCLUSIONS: These data suggest that although women accounted for more ICU admissions for SA, men were more likely to require ETI.

Adult↗
PubMed2003

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. METHODS: All patients who passed an SBT and were about to be extubated were studied. The best of three cough attempts, measured with an in-line spirometer, and the average hourly rate of suctioned secretions prior to extubation were recorded with other weaning parameters and demographic data. RESULTS: Ninety-five patients were studied before and after 115 extubations. There were 13 unsuccessful extubations. There were no differences in age, gender, duration of intubation, or APACHE (acute physiology and chronic health evaluation) II scores between successful and unsuccessful extubations. The magnitude of endotracheal secretions was not associated with outcomes. The PEF of patients with unsuccessful extubations was significantly lower than that of those with successful extubations (64.2 +/- 6.8 L/min vs 81.9 +/- 2.7 L/min, p = 0.03). Patients with unsuccessful extubations stayed longer in the ICU than those with successful extubations (11.7 +/- 2.1 days vs 5.3 +/- 0.4 days, p = 0.009). Those with PEF <or= 60 L/min were five times as likely to have unsuccessful extubations and were 19 times as likely to die on that hospital stay. PEF and the rapid shallow breathing index were independently associated with extubation outcomes, while only the PEF (<or= 60 L/min) was independently associated with in-hospital mortality. CONCLUSION: These data suggest that cough strength, measured objectively, is a predictor of extubation outcome, morbidity, and mortality.

APACHE↗
PubMed2003

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. The questionnaire listed common invasive medical procedures and asked the respondents to check those for which practitioners routinely obtain informed consent in their hospital. RESULTS: The three samples, national intensivists (88 respondents), Connecticut intensivists (29 respondents), and national internists (56 respondents) demonstrated heterogeneity of consenting practices. The rate of obtaining consent for common vascular access procedures ranged from 20 to 90%. The rates of obtaining consent for Foley catheterization and nasogastric intubation were uniformly < 10%, and those for endoscopic procedures were > 90%. Separate consent (beyond the general consent to treat) was not uniformly obtained for the transfusion of blood products (range, 74 to 93%) and common diagnostic medical procedures (eg, thoracentesis, paracentesis, or lumbar puncture; range, 77 to 96%). Surgical intensivists reported that the obtaining of consent for invasive procedures was less routine compared to medical intensivists. Lower rates of consent were noted by those respondents who used a "blanket" consent form, which was signed at the time of hospital admission, to cover subsequent procedures. CONCLUSIONS: In this relatively small sample, there was no uniform practice of informed consent for commonly performed invasive medical procedures. Consent was routinely obtained for GI endoscopy, bronchoscopy, and medical research, and was not obtained for Foley catheterization and nasogastric intubation. The obtaining of consent for vascular cannulation and diagnostic procedures was not routine in the ICUs of a substantial number of respondents. Explicit standards that delineate specifically which procedures require consent may be required to assure more uniform practices.

Connecticut↗