Biomedical subjects

Miriam M Treggiari

Publications and source records attributed to Miriam M Treggiari.

11 recordsLinked to original sources

PubMed2006

Risk factors for reperfusion injury after lung transplantation.

OBJECTIVE: To assess the influence of recipient's and donor's factors as well as surgical events on the occurrence of reperfusion injury after lung transplantation. DESIGN AND SETTING: Retrospective study in the surgical intensive care unit (ICU) of a university hospital. METHODS: We collected data on 60 lung transplantation donor/recipient pairs from June 1993 to May 2001, and compared the demographic, peri- and postoperative variables of patients who experienced reperfusion injury (35%) and those who did not. RESULTS: The occurrence of high systolic pulmonary pressure immediately after transplantation and/or its persistence during the first 48 h after surgery was associated with reperfusion injury, independently of preoperative values. Reperfusion injury was associated with difficult hemostasis during transplantation (p=0.03). Patients with reperfusion injury were more likely to require the administration of catecholamine during the first 48 h after surgery (p=0.014). The extubation was delayed (p=0.03) and the relative odds of ICU mortality were significantly greater (OR 4.8, 95% CI: 1.06, 21.8) in patients with reperfusion injury. Our analysis confirmed that preexisting pulmonary hypertension increased the incidence of reperfusion injury (p<0.01). CONCLUSIONS: Difficulties in perioperative hemostasis were associated with reperfusion injury. Occurrence of reperfusion injury was associated with postoperative systolic pulmonary hypertension, longer mechanical ventilation and higher mortality. Whether early recognition and treatment of pulmonary hypertension during transplantation can prevent the occurrence of reperfusion injury needs to be investigated.

Adult↗

PubMed2005

A nationwide survey of intensive care unit discharge practices.

OBJECTIVE: To describe intensive care unit (ICU) discharge practices, examine factors associated with physicians' discharge decisions, and explore ICU and hospital characteristics and clinical determinants associated with the discharge process. DESIGN: Survey in adult ICUs affiliated with the Swiss Society of Intensive Care Medicine. INTERVENTIONS: Questionnaire inquiring about ICU structure and organization mailed to 73 medical directors. Level of monitoring, intravenous medications, and physiological variables were proposed as elements of discharge decision. Five clinical situations were presented with request to assign a discharge disposition. MEASUREMENTS AND RESULTS: Fifty-five ICUs participated, representing 75% of adult Swiss ICUs. Responsibility for patient management was assigned in 91% to the ICU team directing patient care. Only 22% of responding centers used written discharge guidelines. One-half of the respondents considered at least 10 of 15 proposed criteria to decide patient discharge. ICUs in central referral hospitals used fewer criteria than community and private hospitals. The availability of intermediate care units was significantly greater in university hospitals. The ICU director's level of experience was not associated with the number of criteria used. In the five clinical scenarios there was wide variation in discharge decision. CONCLUSIONS: Our data indicate that there is marked heterogeneity in ICUs discharge practices, and that discharge decisions may be influenced by institutional factors. University teaching hospitals had more intermediate care facilities available. Written discharge guidelines were not widely used.

Adult↗

PubMed2004

Transpulmonary lactate gradient after hypothermic cardiopulmonary bypass.

OBJECTIVE: Several studies demonstrated that the lungs could produce lactate in patients with acute lung injury (ALI). Because after cardiopulmonary bypass (CPB) some patients develop ALI, the effect of CPB on pulmonary lactate release was investigated. DESIGN: Prospective observational clinical study. SETTING: Twenty-beds, surgical ICU at a university hospital. PATIENTS: Sixteen deeply sedated, ventilated and post-cardiac surgery patients, all equipped with a pulmonary artery catheter. MEASUREMENTS AND RESULTS: Lactate concentration was measured using a lactate analyser in simultaneously drawn arterial (A) and mixed venous (V) blood samples. Three measurements per patients were taken at 30-min interval, after body temperature reached 37 degrees C. Concomitantly, measurements of cardiac output were also obtained. Pulmonary lactate release was calculated as the product of transpulmonary A-V lactate and cardiac index. The mean cardiopulmonary bypass duration was 100+/-44 min (SD), and the aortic cross-clamping time was 71+/-33 min. After CPB, lactate release was 0.136+/-0.210 mmol/min m(-2). These values were not correlated with cardiopulmonary bypass duration. CONCLUSION: The present study shows that in patients receiving mechanical ventilation after CPB, the lung is a source of lactate production. This pulmonary release was not dependent on cardiopulmonary bypass duration.

Aged↗

PubMed2004

Randomized trial of the effect of antipyresis by metamizol, propacetamol or external cooling on metabolism, hemodynamics and inflammatory response.

OBJECTIVE: We investigated the metabolic, hemodynamic, and inflammatory responses of pharmacological and physical therapies aimed at reducing body temperature in febrile critically ill patients. DESIGN AND SETTING: Open-label, randomized trial in a surgical ICU in a tertiary university hospital. PATIENTS: Thirty analgosedated, mechanically ventilated patients with a temperature of 38.5 degrees C or higher were randomized to receive either intravenous metamizol, intravenous propacetamol, or external cooling. MEASUREMENTS AND RESULTS: Body temperature and metabolic and hemodynamic variables were recorded at baseline and during the following 4 h. Cytokine concentrations were assessed before and 4 and 12 h after the initiation of antipyresis. Body temperature decreased significantly in all treatment groups. For a 1 degrees C temperature decrease, the energy expenditure index increased by 5% with external cooling and decreased by 7% and 8% in the metamizol and propacetamol groups, respectively. Metamizol induced a significant decrease in mean arterial pressure and urine output compared to baseline and to the other two groups. C-reactive protein increased over time, but compared to the other groups it was significantly lower in patients receiving metamizol after 4 h. Cytokine concentrations were not different among the three groups or over time, although interleukin 6 tended to decrease over time in the metamizol group. CONCLUSIONS: Metamizol, propacetamol, and external cooling equally reduced temperature. Considering the undesirable hemodynamic effects, metamizol should not be considered the first antipyretic choice in unstable patients. Propacetamol or external cooling should be preferred, although the latter should be avoided in patients unlikely to tolerate the increased metabolic demand induced by external cooling.

Acetaminophen↗

PubMed2004

Occupational asbestos exposure and the incidence of non-Hodgkin lymphoma of the gastrointestinal tract: an ecologic study.

PURPOSE: A previous case-control study observed a strong association between occupational exposure to asbestos and the incidence of non-Hodgkin lymphoma of the gastrointestinal tract (GINHL). To test this hypothesis, we sought to determine whether the geographic pattern of the incidence of GINHL in the US has paralleled that of mesothelioma. METHODS: Using data obtained from the nine US regions participating in the National Cancer Institute's Surveillance, Epidemiology and End Results program, we examined the incidence of malignancies among men ages 50 to 84 years between 1973 and 1984. RESULTS: The rates of mesothelioma, but not of GINHL, were about two times higher in the areas of Seattle and San Francisco, than in the other regions. Overall, there was no correlation between the rates of mesothelioma and of GIHNL (Pearson correlation coefficient-0.12, p = 0.77). CONCLUSIONS: This ecologic study finds no support for the hypothesis that occupational asbestos exposure is related to the subsequent incidence of GINHL.

Aged↗

PubMed2004

Effect of acute lung injury and acute respiratory distress syndrome on outcome in critically ill trauma patients.

OBJECTIVE: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are known to be associated with increased mortality and costs in trauma patients. We estimated the independent impact of these conditions on mortality and cost, beyond the severity of injury with which they are correlated. DESIGN: One-year prospective cohort. PATIENTS AND SETTING: All trauma patients admitted to the intensive care unit in a level I center were evaluated daily for ALI/ARDS using the American-European Consensus Conference definition. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were hospital mortality and costs. Logistic regression was used to model hospital mortality in relation to the presence of ALI and ARDS, adjusting for trauma severity (Injury Severity Score), Acute Physiology Score, and age. Hospital costs were modeled using multivariable linear regression. Of the 1,296 trauma patients surviving beyond the first day, 4% experienced ALI (defined as Pao2/Fio2 of 201-300 mm Hg) and 12% had ARDS (Pao2/Fio2 < or = 200 mm Hg). The crude relative risk of mortality was 2.24 (95% confidence interval, 0.92-5.45) in patients with ALI and 3.84 (95% confidence interval, 2.41-6.13) in patients with ARDS compared with those without ALI/ARDS. However, there was no association of mortality with ALI (relative risk, 0.99; 95% confidence interval, 0.29-3.36) or with ARDS (relative risk, 1.23; 95% confidence interval, 0.63-2.43) after adjustment for age, Injury Severity Score, and Acute Physiology Score. Among patients of comparable age, severity score, and length of stay, median cost was 20% to 30% higher for those with ALI/ARDS. CONCLUSIONS: There is no additional mortality associated with ALI/ARDS above and beyond the factors that can be measured at intensive care unit admission. Therefore, mortality in trauma patients is explained by injury severity at admission and is not affected by the subsequent occurrence of ALI/ARDS. Nonetheless, ALI/ARDS was associated with increased intensive care unit stay and hospital cost, independent of trauma severity.

Adult↗

PubMed2003

Cervical sympathetic block to reverse delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The purpose of the present study was to evaluate the feasibility and safety of a locoregional cervical sympathetic block to improve cerebral perfusion in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage. METHODS: Nine consecutive patients with symptoms of delayed ischemic deficits, induced by angiographically confirmed cerebral vasospasm, were treated with the injection of locoregional anesthesia to block the ascending cervical sympathetic chain at the level of the superior cervical ganglion. Neurological status was recorded before and after the procedure, and cerebral angiography was performed before and after the procedure. RESULTS: No complications occurred in this short series. The procedure appeared to be simple and safe. Horner's signs appeared within 12+/-0.1 minutes and lasted for an average of 6.3+/-4 hours. In all patients, improved cerebral perfusion was detected at the confirmatory angiography but without change in vessel caliber. One patient died of the complications of the initial hemorrhage, and 2 died of the consequences of the severe vasospasm despite maximal medical treatment. In all the other cases, the neurological status promptly returned to normal within 48 hours after the locoregional treatment. CONCLUSIONS: Patients with mild to moderate symptoms seem to benefit greatly from transient ipsilateral cervical sympathetic block. This simple technique may be helpful when used as an adjunct to the standard therapy to improve cerebral perfusion.

Adult↗

PubMed2003

Systematic review of the prevention of delayed ischemic neurological deficits with hypertension, hypervolemia, and hemodilution therapy following subarachnoid hemorrhage.

OBJECT: There is uncertainty about the efficacy of hypertension, hypervolemia, and hemodilution (triple-H) therapy in reducing the occurrence of delayed ischemic neurological deficits (DINDs) and death after subarachnoid hemorrhage. The authors therefore conducted a systematic review to evaluate the efficacy of triple-H prevention in decreasing the rate of clinical vasospasm, DINDs, and death. METHODS: The authors systematically reviewed studies identified based on a MEDLINE, EMBASE, and COCHRANE Register search of articles published between 1966 and 2001, and reference lists of identified articles. An independent assessment of each study's methodological quality, population, intervention, and outcomes (rates of symptomatic vasospasm, DINDs, and death) was performed. Summary relative risk estimates were calculated for the main outcomes using fixed- or random-effect models, as appropriate. Only four prospective, comparative studies with a total of 488 patients were identified. The median internal validity score was 0.5 (range 0-2); the median external validity score was 3 (range 2-6). Compared with no prevention, triple-H therapy was associated with a reduced risk of symptomatic vasospasm (relative risk [RR] 0.45, 95% confidence interval [CI] 0.32-0.65), but not DIND (RR 0.54, 95% CI 0.2-1.49). The risk of death was higher (RR 0.68, 95% CI 0.53-0.87). Sensitivity analyses including only randomized, controlled trials showed no evidence of statistically significant results for these major end points. CONCLUSIONS: The paucity of information and important limitations in the design of the studies analyzed preclude evaluation of the efficacy of triple-H prevention and formulation of any recommendations regarding its use for the prevention of cerebral vasospasm.

Blood Pressure↗

PubMed2002

Postmenopausal hormone use and skeletal fracture: does the size of the benefit decrease with increasing age?

Results of a recent meta-analysis of randomized trials suggest that, among postmenopausal women, the relative impact of hormone use in reducing the incidence of skeletal fracture declines with increasing age. We contend that: 1) the duration of the randomized trials in which older postmenopausal women were included was too short to adequately evaluate the impact of long-term hormone use on fracture risk; 2) randomized trials of hormone use in relation to a surrogate end point, bone mineral density, as well as nonrandomized studies of hormones and fracture risk, have documented a skeletal benefit associated with long-term hormone use among postmenopausal women irrespective of age; and 3) even if with increasing age there were a true decline in the relative benefit associated with the use of hormones, the size of the absolute reduction in fracture risk produced by hormone use among older postmenopausal women could be similar to or greater than that among younger postmenopausal women. For these reasons, we believe that when weighing the risks and benefits of the initiation or continuation of hormone therapy, a postmenopausal woman and her provider of health care need not consider her age when estimating the skeletal benefit such therapy can offer.

Age Factors↗

PubMed2002

Effect of increasing norepinephrine dosage on regional blood flow in a porcine model of endotoxin shock.

OBJECTIVE: To evaluate the effect of a norepinephrine-induced differential increase in mean arterial pressure on splanchnic and renal perfusion in a porcine model of volume-resuscitated endotoxic shock. DESIGN: Prospective, controlled, acute interventional study. SETTING: Animal research laboratory. SUBJECTS: Fourteen landrace pigs, seven treated with norepinephrine and seven used as endotoxemic controls. INTERVENTIONS: In an acute endotoxic shock model, norepinephrine was used to reverse hypotension in seven fluid-resuscitated pigs, anesthetized with alpha-chloralose and equipped with flow probes around the portal vein and renal artery, renal and jejunal mucosal laser Doppler flowmetry, and jejunal tonometry. Mean arterial pressure was increased by 10 and then 20 mm Hg above the shock level with norepinephrine. Seven shocked, fluid-resuscitated only animals served as the comparison group. MEASUREMENTS AND MAIN RESULTS: Measurements were performed before 2-hr endotoxin infusion and at the end of each increased level of mean arterial pressure. Raising mean arterial pressure with norepinephrine by 10 mm Hg significantly increased cardiac output, systemic oxygen extraction, and portal vein blood flow; stabilized metabolic acidosis; and tended to restore renal and jejunal mucosal flows to preshock levels. Increasing mean arterial pressure by 20 mm Hg further increased cardiac output and oxygen delivery but without improving portal vein, renal artery, and jejunal mucosal blood flows. CONCLUSIONS: Norepinephrine, administered to increase mean arterial pressure by 10 mm Hg in an acute model of volume-resuscitated endotoxic shock, improved systemic and regional perfusion. The administration of norepinephrine to increase mean arterial pressure 20 mm Hg above shock did not increase renal and splanchnic blood flows, despite an enhanced cardiac output.

Animals↗

PubMed2002

Air cysts and bronchiectasis prevail in nondependent areas in severe acute respiratory distress syndrome: a computed tomographic study of ventilator-associated changes.

OBJECTIVE: To investigate prevalence and spatial distribution of air cysts and bronchiectasis associated with mechanical ventilation in patients with severe acute respiratory distress syndrome. DESIGN: Retrospective observational study. SETTING: University hospital intensive care division. SUBJECTS: A total of 21 patients with severe acute respiratory distress syndrome requiring prolonged mechanical ventilation and undergoing thoracic computed tomographic scanning. MEASUREMENTS AND MAIN RESULTS: Lung fields were anatomically divided according to functional bronchial divisions in ten segments on each side. Air cysts, bronchiectasis, and the percentage of normal and abnormal tissue were quantified for each segment and correlated to the duration and variables of mechanical ventilation. Air cysts prevailed in nondependent compared with dependent areas (38% +/- 5% vs. 9% +/- 3%, respectively; p <.01). With mechanical ventilation longer than 10 days, the odds ratio was 13.1 (95% confidence interval, 1.4-118.7) for air cysts and for bronchiectasis 17.6 (95% confidence interval, 2.8-109.6). The amount of abnormal parenchyma correlated with duration of mechanical ventilation on high end-inspiratory pressure but not with tidal volume or minute ventilation. The presence of pneumothorax was not correlated with ventilation settings but with the amount of consolidated tissue revealed by the computed tomographic scan. CONCLUSIONS: These findings suggest predominant ventilator-induced lung damage in better ventilated areas (i.e., nondependent regions). Severity of changes revealed by computed tomographic imaging seems to be associated mainly with the high inspiratory pressures required and the length of mechanical ventilation.

APACHE↗