Biomedical subjects

J Hudson-Civetta

Publications and source records attributed to J Hudson-Civetta.

10 recordsLinked to original sources

PubMed1998

The impact of antioxidant and splanchnic-directed therapy on persistent uncorrected gastric mucosal pH in the critically injured trauma patient.

BACKGROUND: Critically ill trauma patients with gastric intramucosal acidosis, as measured by gastric tonometry, have an increased incidence of multiple organ dysfunction syndrome despite supranormal O2 delivery. We altered our resuscitation protocol to maximize splanchnic blood flow and decrease oxygen-derived free radical damage. DESIGN: Prospective clinical trial with historical controls. METHODS: The protocol differed from control by including administration of folate, mannitol, and low-dose isoproterenol. All patients had gastric tonometers and pulmonary artery catheters. If the intramucosal pH (pHi) was less than 7.25, splanchnic-sparing inotropic and vasodilatory agents were used to optimize systemic cardiac output. Two groups of trauma patients with persistent intramucosal acidosis at 24 hours (pHi < 7.25) were compared: a control group (n = 7), and patients who received the splanchnic/antioxidant protocol (n = 13). RESULTS: The two groups were similar based on Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, age, cardiac index, oxygen delivery, and oxygen consumption. The "splanchnic therapy" group had fewer organ system failures as well as shortened length of intensive care unit and hospital stay. Three of 7 patients in the control group and 2 of 13 patients in the splanchnic therapy group had a final pHi < 7.25. CONCLUSION: Gastric tonometry-guided resuscitation and antioxidant/splanchnic therapy in critically ill trauma patients with persistent gastric mucosal acidosis may decrease multiple organ dysfunction syndrome.

APACHE↗

PubMed1998

Failure of splanchnic resuscitation in the acutely injured trauma patient correlates with multiple organ system failure and length of stay in the ICU.

INTRODUCTION: The purpose of our study was to evaluate the relationship between the state of splanchnic perfusion and morbidity and mortality in the hemodynamically unstable trauma patient acutely resuscitated in the ICU. METHODS: Gastric intramucosal pH (pHi) was monitored in a blinded fashion in 19 consecutive critically ill trauma patients with evidence of systemic hypoperfusion (arterial pH [pHa] <7.35, base excess >2.3 mmol/L, lactic acid >2.3 mEq/L) who received right heart catheters to guide resuscitation and subsequent hemodynamic monitoring. DESIGN: Prospective randomized consecutive series with retrospective analysis of data. SETTING: University hospital, surgical ICU. RESULTS: The mean values of APACHE II (acute physiology and chronic health evaluation) Injury Severity Score, pHa, arterial base excess, cardiac index, oxygen delivery index, and oxygen consumption index by 24 h were similar (Student's t test, p>0.1) between survivors and nonsurvivors and between those who developed at most a single (SOF) vs multiple organ system failure (MOSF). Supranormal oxygen delivery and utilization parameters were evenly distributed among survivors and nonsurvivors and patients with SOF and MOSF (chi2, p>0.5). Ten patients had a pHi <7.32 and nine patients had a pHi > or = 7.32 by 24 h. Fifty percent of patients with a pHi <7.32 died, compared with 11% of patients with a pH > or = 7.32 (chi2, p=0.07). Sixty percent of patients with a pHi <7.32 developed MOSF compared with 11% of patients with a pHi > or = 7.32 (chi2, p=0.03). The one patient who developed MOSF and died in the pHi > or = 7.32 cohort suffered from massive head trauma and had all futile medical interventions halted. No other patients who achieved a pH > or = 7.32 by hour 24 developed MOSF. Survivors with a pHi <7.32 at hour 24 had an increased ICU stay (pHi <7.32=46+/-15 days, pHi > or = 7.32=13+/-9 days; p<0.01). A pHi <7.32 carried a relative risk of 4.5 for death and 5.4 for the occurrence of MOSF. CONCLUSION: Attainment of a pHi > or = 7.32 at hour 24 carried a significantly reduced likelihood of MOSF. Being an inference of the state of regional perfusion, in a high-risk microvascular bed, gastric intraluminal tonometry should identify perfusion states of compensated or uncompensated shock during hemodynamic resuscitation of the critically ill injury patient. A low pHi appears to be a marker of postresuscitative morbidity and subsequent increased length of stay.

Critical Care↗

PubMed1997

Stab wounds to the back and flank in the hemodynamically stable patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacification.

PURPOSE: The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back. PATIENTS AND METHODS: One hundred forty-five consecutive patients were categorized as low-risk ( penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings. RESULTS: There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases. CONCLUSIONS: Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours.

Abdominal Injuries↗

PubMed1997

Management of paroxysmal atrioventricular nodal reentrant tachycardia in the critically ill surgical patient.

OBJECTIVES: Paroxysmal atrioventricular nodal reentrant tachycardia is an infrequently encountered supraventricular arrhythmia that continues to present difficult management problems in the critically ill surgical patient. The purpose of this study was to evaluate the efficacy of a new treatment algorithm involving the sequential administration of different classes of antiarrhythmic agents until conversion to sinus rhythm was achieved. DESIGN: Nonrandomized, consecutive, protocol-driven descriptive cohort. SETTING: University hospital surgical and trauma intensive care unit (ICU). PATIENTS: During an 11-month period, we prospectively evaluated all hemodynamically stable patients who sustained new-onset atrioventricular nodal reentrant tachycardia. INTERVENTIONS: Vagal maneuver, followed by the rapid, sequential infusion of antiarrhythmic agents (i.e., adenosine, verapamil, and esmolol, respectively) until the arrhythmia was terminated. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (4% of all admissions) were evaluated, including 16 trauma patients (injury Severity Score of 20 +/- 8) and 11 general surgical patients (Acute Physiology and Chronic Health Evaluation II score of 17 +/- 7). Time from ICU admission to onset of atrioventricular nodal reentrant tachycardia was 4.5 +/- 5 days (median 2.5). Arrhythmia termination was achieved in all patients within minutes (mean 13 +/- 10 [SD]). Incremental sequential adenosine administration alone, however, was successful in affecting conversion to sinus rhythm in only 44% of initial episodes of atrioventricular nodal reentrant tachycardia (95% confidence interval 21% to 67%). A total of 14 (52%) patients developed 38 relapses of paroxysmal supraventricular tachycardia in the ICU after initial conversion to sinus rhythm. These relapses required additional antiarrhythmic therapy. Adenosine was only effective in 34% of the relapses (95% confidence interval 17% to 53%). Seven (50%) of these 14 patients developed multiple relapses. However, only two patients were receiving suppressive calcium-channel or beta-adrenergic receptor blockade at the time of relapse. CONCLUSIONS: The use of a multiagent algorithm was effective for the initial conversion of new-onset atrioventricular nodal reentrant tachycardia to sinus rhythm in critically ill surgical and trauma patients. This preliminary report suggests that adenosine has marginal efficacy in the critically ill surgical or trauma patient. Given the high frequency of relapses, regardless of the agents used to achieve initial control, suppression therapy for the arrhythmia during the period of maximal cardiovascular stress is essential.

Adult↗

PubMed1996

Cost effectiveness in the intensive care unit.

Effective policies to reduce true costs will require integrated information systems and demand behavioral changes from providers. A congenial environment must be created among medical educators, providers, vendors, and consumers if cost reduction is to be accomplished without compromising quality or access to critical care services. Physicians should do everything they believe may be of benefit for their patients, but we have an obligation to educate the public about the limitations of our art and the fact that "doing everything" is not always best for the patient or the grieving family. A significant method of controlling ICU costs is closely monitoring which patients are admitted and when they are discharged. Laboratory tests represent a source of cost reduction, and physicians must learn to order specific tests and not simply a battery of tests which includes the actual test desired. Limits should be placed on the tests that are ordered in terms of number and frequency. Improved efficiency of the utilization of resources should improve the care of our patients. The largest budget item of any or most critical care units is nursing; it is paramount that this essential and invaluable resource be utilized in a cost-effective manner. Diminishing unnecessary activity will both decrease complications and have salutary effects. Having more time to be with patients and their families will decrease our sense of failure and fulfill the important goal of caring. Physicians and nurses can return to thinking, assessing, and decision making instead of frenetically ordering, reacting, and intervening, which, we believe, accurately describes informational overload created by undue emphasis on high technology. In this way, we can respond to Fuch's exhortation that "physicians consider the possibility of contributing more by doing less." In responding, however, we must never forget that the societal, not merely the economic impact of medical care, is our principal consideration. We must first contribute more by achieving a greater understanding of the medical care process. Only then can we know how to do less at the bedside. We can and must distinguish between costly and high-quality care--they are not necessarily synonymous.

Cost Control↗

PubMed1996

Re-engineering ventilatory support to decrease days and improve resource utilization.

OBJECTIVE: The objective of this study was to describe the development of a cost-effective ventilatory strategy using a portable microprocessor-controlled respiratory monitor (Bicore CP-100; Allied Healthcare Products, Riverside, CA.) SUMMARY BACKGROUND DATA: Until recently, clinicians have had to accept the uncertainties of clinical judgment, which unfortunately, often biased the patient to a prolonged ventilatory course to avoid extubation failures, necessitating reintubation. METHODS: Over a 4-year period, the authors attempted to re-engineer the process of ventilatory support based on measured work of breathing (WOB), including physiologic (WOBPhys), imposed (WOBImp) and total (WOBTot). RESULTS: The authors made 90 determinations of WOB in 31 patients. The coefficient of determination (i2) of WOBTot, with the breathing frequency was 0.35, with tidal volume was 0.10, and with the rapid shallow breathing index (f/V(tau)) was 0.23; therefore, the authors discarded them as reliable inferences. Of 27 patients ventilated for > 2 days with satisfactory blood gases, but with breathing frequency > 30 breaths/minute, 6 had WOBTot < 0.8 J/L and were extubated successfully. In 21 patients, WOBTot was elevated to 1.6 +/- 0.83 J/L, WOBImp was 1.1 +/- 0.64 J/L, approximately twice the WOBPhys (0.5 +/- 0.26 J/L), a normal value. Extubation was successful in 20 of those 21 patients. This approach was extended to the spontaneous breathing pre-extubation trial. In addition, the ventilator was adjusted so that the patient sustained a WOBTot of 0.6 to 1 J/L during the ventilatory support. This evolution was tracked for 18 months in a series of 838 trauma intensive care unit patients. Average duration of ventilation decreased from 8.2 to 4.2 days (49%; p < 0.01). This translated into approximately 2400 decreased ventilator days per year. CONCLUSION: Objective measurement to guide the adequacy of ventilatory support and interpret apparent clinical weaning failures decreased total ventilatory time by 50%, permitting extubation in nearly 20% of patients previously considered failures.

Adult↗

PubMed1996

Decreasing catheter-related infection and hospital costs by continuous quality improvement.

OBJECTIVES: a) To reduce the rate of catheter-related infection, using improved skin preparation and catheters impregnated with silver sulfadiazine and chlorhexidine; b) to decrease the number of unnecessary guidewire exchanges of existing catheters by substituting suspected catheter-related sepsis for fever alone as an indication to change an indwelling catheter; and c) to decrease the hospital costs associated with guidewire exchanges and new catheter insertions. DESIGN: Sequential, prospective, descriptive studies using a continuous quality management approach. SETTING: A 20-bed trauma intensive care unit at a university teaching hospital. PATIENTS: Patients (n = 147) admitted from July 1 to December 31, 1992 (phase 1); 34 patients admitted in June and September 1993 (phase 2); and 156 patients admitted between January 1 and June 30, 1994 (phase 3). INTERVENTIONS: Phase 1: Proportions of catheter-related infections and catheter-related bacteremia were compared with our prior reported results. Indications for guidewire exchange were analyzed, and the rate of catheter-related infection for each indication was derived. Phase 2: The rate of catheter-related infection was determined for a trial group of triple-lumen catheters impregnated with silver sulfadiazine and chlorhexidine. Phase 3: Four components were altered. Impregnated triple-lumen catheters were used instead of unprotected catheters. Chlorhexidine skin cleanser was substituted for povidone-iodine solution during initial aseptic preparation during catheter insertion and subsequent guidewire exchange. Suspected catheter-related sepsis was substituted for fever as an indication for guidewire exchange. The "safe" period (the time before considering changing a catheter because catheter-related sepsis was suspected) was extended from 2 to 4 days. MEASUREMENTS AND MAIN RESULTS: The overall rate of catheter-related infection in phase 1 was 15% (15% for triple-lumen catheters and 16% for introducers). Catheters changed for site inflammation had a 46% rate of catheter-related infection, significantly higher than for all other indications, including fever (p < .03). The rate of catheter-related infection was significantly (p = .0002) higher for catheters in place for > 10 days compared with lesser durations. Fever was the indication for 42% of all guidewire exchanges. In phase 2, the catheter-related infection rate was 2% (one positive of 48 catheters), significantly (p = .0231) lower than the phase 1 rate. In phase 3, the overall rate of catheter-related infection was 8.6%, significantly (p = .0067) lower than the 15% rate in phase 1. The proportion of protected triple-lumen catheter catheter-related infections decreased significantly (p = .0024) from 15% to 6%. The rate of catheter-related infection for introducers was the same in both phases (p = .33). The days of catheterization for all catheters increased from 4.5 +/- 2.6 to 5.4 +/- 3.6 (p < .0001). The days for triple-lumen catheters increased from 4.7 +/- 2.7 to 7.0 +/- 3.9 (p < .0001). For introducers, there was no difference in the days of catheterization. The proportion of catheters changed for suspected catheter-related sepsis decreased significantly (p < .0001) to 23% from the 42% changed for fever in phase 1. The proportion of catheter-related infections for catheters changed for fever was 18% in phase 1. The proportion of catheter-related infections for catheters changed for suspected catheter-related sepsis was 13% in phase 3 (p = .43). The total number of catheters used per patient in phase 3 was 1.9 +/- 1.4, significantly lower than the 2.6 +/- 2.7 catheters used in phase 1 (p = .0018). The number of triple-lumen catheters decreased from 1.8 +/- 1.2 to 1.0 +/- 1.2 in phase 3 (p = .0001). CONCLUSIONS: Catheters impregnated with silver sulfadiazine and chlorhexidine had a smaller proportion of catheter-related infection compared with unprotected catheters. Fever alone as an indication for guidewire exchange resu

Anti-Infective Agents↗

PubMed1987

Titrating positive end-expiratory pressure therapy in patients with early, moderate arterial hypoxemia.

A prospective randomized study to compare two physiologic end-points for titrating positive end-expiratory pressure (PEEP) was performed in patients with early, moderate arterial hypoxemia after surgery or trauma. All patients initially received 5 cm H2O of PEEP. In group 1 patients, PEEP was increased only if PaO2 decreased below 65 torr on an inspired oxygen fraction (FIO2) of 0.45. PEEP was then added in 2- to 3-cm H2O increments until PaO2 again was above 65 torr. Group 2 patients were treated with incremental PEEP until the PaO2/FIO2 ratio was greater than 300 or physiologic shunt (Qsp/Qt) was less than 0.20. All therapy other than PEEP was similar in the two groups. There were no statistically significant differences in entry PaO2 (mean 85 +/- 11 [SD] and 87 +/- 11 torr in groups 1 and 2, respectively), and Qsp/Qt was 0.22 in each group. Five (28%) of 18 patients in group 1 and 19 (95%) of 20 patients in group 2 received more than 5 cm H2O of PEEP. Between groups 1 and 2 there were no statistically significant differences in days intubated (3.4 +/- 3 vs. 5.3 +/- 5, respectively), ICU days (5.3 +/- 3 vs. 6.6 +/- 5), hospitalization days (26 +/- 24 vs. 28 +/- 24), incidence of pulmonary barotrauma (0/18 vs. 1/20), ICU mortality (22% vs. 20%), or overall mortality (33% vs. 25%). The number of blood gas analyses and cardiac output measurements, and the total hospital charges were also similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1983

Intravascular catheters: current guidelines for care and maintenance.

Many considerations resulting in the formulations of guidelines for the use of intravascular catheters in the care of critically ill patients are well explored and documented; other areas are highly conjectural, are virtually unchartered, or have not even been explored. The sterility of transducer and flush assembly over time, the use of a five-lumen PA catheter as an avenue for both hemodynamic measurement and nutritional support, and the meaningful interpretation of cultures obtained from all of the catheters are necessary areas of present research to replace theoretical concepts with data. We hope that the necessity for future research will provide data for the ICU practitioner to deliver the safest and most cost-effective methods of intravascular catheterization in a constantly changing environment.

Bacterial Infections↗

PubMed1980

Nursing assessment of intermittent mandatory ventilation.

IMV provides the ICU nurse responsible for total multifunctional patient care with many advantages. First of all, it allows more time to perform other needed tasks. Time is made available for counseling the patient and family; consulting with the social worker, occupational therapist, and other staff members; and participating actively on team patient care conferences. IMV permits the patient to perform at an optimal level throughout the ICU stay and to participate in the treatment program. This is perhaps the greatest advantage of IMV for both the nurse and the patient. The patient's comprehension and ability to communicate are not limited by sedation or anxiety, the patient is more responsive when at least some control is retained over the environment. This reassures the family. Allowing the patient to be as awake and alert as possible not only assists the staff in assessment but allows positive feedback to the patient. It is difficult for a nurse to argue with the advantages of this method in contrast to the difficulty of caring for a sedated patient receiving controlled ventilation. Incrementally decreased ventilatory support lessens anxiety during weaning, thereby minimizing one of the negative aspects of critical illness. Because less sedation is required, the patient's overall safety is improved. The ICU team can more easily find out about such problems as abdominal pain and difficulty in breathing. An alarm aids the nurse in discriminating anxiety from hypoxia/hypercapnia. With definitive guidelines for its use and careful delineation of team members' responsibilities, IMV provides the nurse with a simple, flexible, and innovative tool for patient care.

Hemodynamics↗