Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 20 de 54
Filter
3.
Med Intensiva ; 32(3): 115-20, 2008 Apr.
Article in English | MEDLINE | ID: mdl-18381016

ABSTRACT

OBJECTIVE: Our objective was to compare the results of a blind lavage vs a bronchoscopic-guided bronchoalveolar lavage for the etiologic diagnosis of ventilator-associated pneumonia (VAP). DESIGN: Prospective study in consecutive patients with high probability of VAP. Every patient underwent both procedures, in a formally randomized fashion. The interpretation of quantitative cultures was done in a blind fashion. SETTING: Single center study, with a 20 bed medical and surgical Intensive Care Unit of the University Hospital in Monterrey, Mexico. PATIENTS: Twenty-five patients with high probability of VAP. INTERVENTIONS: Every patient underwent blind bronchoalveolar lavage with a modified nasogastric tube, and a bronchoscopic-guided bronchoalveolar lavage. RESULTS: Twenty-one patients underwent both procedures. Four patients were excluded due to contamination of the cultures. The quantitative cultures were compared in a paired fashion. Only two patients had discordant cultures. The correlation coefficient between the number of colonies was very high, r=0.90 (95% confidence interval [CI], 0.77-0.96; p=0.0001). CONCLUSIONS: The blind bronchoalveolar lavage with a modified nasogastric tube is a valuable tool for the identification of etiologic agent in VAP, particularly when trained bronchoscopists or the necessary resources for bronchoscopic-guided bronchoalveolar lavage are not readily available.


Subject(s)
Bronchoalveolar Lavage/methods , Bronchoscopy/methods , Intubation, Gastrointestinal/methods , Pneumonia, Ventilator-Associated/microbiology , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Pneumonia, Ventilator-Associated/therapy , Prospective Studies
4.
Med. intensiva (Madr., Ed. impr.) ; 32(3): 115-120, mar. 2008. tab
Article in Es | IBECS | ID: ibc-64774

ABSTRACT

Objective. Our objective was to compare the results of a blind lavage vs a bronchoscopic-guided bronchoalveolar lavage for the etiologic diagnosis of ventilator-associated pneumonia (VAP). Design. Prospective study in consecutive patients with high probability of VAP. Every patient underwent both procedures, in a formally randomized fashion. The interpretation of quantitative cultures was done in a blind fashion. Setting. Single center study, with a 20 bed medical and surgical Intensive Care Unit of the University Hospital in Monterrey, Mexico. Patients. Twenty-five patients with high probability of VAP. Interventions. Every patient underwent blind bronchoalveolar lavage with a modified nasogastric tube, and a bronchospic-guided bronchoalveolar lavage. Results. Twenty-one patients underwent both procedures. Four patients were excluded due to contamination of the cultures. The quantitative cultures were compared in a paired fashion. Only two patients had discordant cultures. The correlation coefficient between the number of colonies was very high, r = 0.90 (95% confidence interval [CI], 0.77-0.96; p = 0.0001). Conclusions. The blind bronchoalveolar lavage with a modified nasogastric tube is a valuable tool for the identification of etiologic agent in VAP, particularly when trained bronchoscopists or the necessary resources for bronchoscopic-guided bronchoalveolar lavage are not readily available


Objetivo. Nuestro objetivo fue el de comparar los resultados de un lavado ciego frente a un lavado broncoalveolar guiado con broncoscopio para el diagnóstico etiológico de neumonía asociada a ventilador (NAV). Diseño. Estudio prospectivo en pacientes consecutivos con alta probabilidad de NAV. En todos los pacientes se llevaron a cabo ambos procedimientos de manera aleatorizada. La interpretación de los cultivos cuantitativos fue hecha a ciegas. Ámbito. Estudio en un único centro, en una Unidad de Cuidados Intensivos Quirúrgicos con 20 camas del Hospital Universitario de Monterrey, en México. Pacientes. Veinticinco pacientes con alta probabilidad de NAV. Intervenciones. A cada paciente se le realizó un lavado broncoalveolar ciego con una sonda nasogástrica modificada y un lavado broncoalveolar guiado con broncoscopio. Resultados. Se realizaron ambos procedimientos en 21 pacientes. Cuatro fueron excluidos debido a contaminación de los cultivos. Los cultivos cuantitativos fueron comparados en pares. Solo dos pacientes tenían cultivos discordantes. El coeficiente de correlación entre el número de colonias fue muy alto, r = 0,90 (intervalo de confianza [IC] del 95% 0,77-0,96; p = 0,0001). Conclusiones. El lavado broncoalveolar ciego con sonda nasogástrica modificada es una herramienta de mucho valor para la identificación del agente etiológico en NAV, especialmente cuando un broncoscopista experto o los recursos necesarios para lavado broncoalveolar guiado con broncoscopio no están fácilmente disponibles


Subject(s)
Humans , Respiration, Artificial/adverse effects , Ventilators, Mechanical/microbiology , Pneumonia, Bacterial/microbiology , Bronchoalveolar Lavage Fluid/microbiology , Intubation, Gastrointestinal , Bronchoalveolar Lavage/methods
6.
Transplant Proc ; 35(8): 2998-3002, 2003 Dec.
Article in English | MEDLINE | ID: mdl-14697960

ABSTRACT

The organ allocation system for liver transplantation was recently changed to address criticisms that it was too subjective and relied too heavily on total waiting time. The new system, Model for End-Stage Liver Disease and Pediatric Model for End-Stage Liver Disease (MELD/PELD), stratifies patients based on the risk of 3-month pretransplant mortality, allocating livers thereby. There is concern that such a scheme gives priority to the sickest patients, who may not enjoy good posttransplant outcomes. The aim of the present study was to compare the outcomes of liver transplant recipients who had been admitted to the intensive care unit (ICU) to those who had not. Admission to the ICU is considered here to be another indicator of the severity of illness. Patients who underwent liver transplantation at the Cleveland Clinic between January 1, 1993 and October 31, 1998 and were at least 18 years of age were coded for liver transplantation as status 2, 2A, and 2B (n = 112). These patients fell into three groups: those who had been admitted to an ICU before transplantation (group A, n = 16), those who had been admitted to the hospital but not to an ICU (group B, n = 63), and those who were living at home and had undergone an elective transplant (group C, n = 33). Clinical and demographic information (age, sex, race, disease severity, disease etiology, and cold ischemia time) were associated with patient survival, patient/graft survival, and posttransplant resource utilization (hospital length of stay and hospital charges). Age, sex, race, etiology of disease, and cold ischemia time were similar among the three groups. Patient survival, patient/graft survival, and hospital charges were not statistically different between the three groups. The median length of stay was statistically different only between groups B and C (P =.006). Our data support the idea that if severely ill patients with end-stage liver disease are selected appropriately, liver transplant outcomes are similar to those observed among subjects who are less ill and are transplanted electively from home.


Subject(s)
Graft Survival/physiology , Health Care Rationing/methods , Liver Transplantation/physiology , Female , Humans , Liver Diseases/classification , Liver Diseases/surgery , Liver Transplantation/mortality , Male , Middle Aged , Models, Biological , Organ Preservation/methods , Resource Allocation/methods , Retrospective Studies , Survival Analysis , Time Factors , Treatment Outcome , Waiting Lists
7.
Chest ; 120(3): 894-9, 2001 Sep.
Article in English | MEDLINE | ID: mdl-11555526

ABSTRACT

STUDY OBJECTIVE: Unsuspected sleep-related respiratory events are common in patients with severe pulmonary disease. Sleep in patients with primary pulmonary hypertension (PPH) has not been studied (to our knowledge). The purpose of this study was to measure the prevalence of respiratory disturbances and nocturnal hypoxemia during the sleep of patients with PPH. SETTING: Tertiary-care referral hospital. DESIGN: Retrospective review. PATIENTS: Thirteen patients with PPH. MEASUREMENTS: All patients underwent a single-night comprehensive polysomnogram study. Patients who spent > 10% of the total sleep time with oxygen saturation by pulse oximetry (SpO(2)) at < 90% or who needed oxygen to maintain their SpO(2) level at > 90% were classified as nocturnal desaturators. Analysis was performed to determine which clinical variables (ie, demographics, body mass index, spirometry, diffusion capacity, right heart catheterization pressures, 6-min walk test, arterial blood gas levels, resting and walking SpO(2) levels, and polysomnogram variables) would predict nocturnal desaturation. Statistical significance was considered when p values were < 0.05. RESULTS: Of the 13 patients in the study, 10 (77%) were nocturnal desaturators. All patients had normal apnea indexes, but two had mild elevations of the hypopnea index (< 15 episodes per hour). Nocturnal desaturations occurred independently of apneas or hypopneas. Six patients who did not have O(2) titration during sleep spent > 25% of sleep time with SpO(2) < 90%. The mean (+/- SD) variables that were significantly different between desaturators (10 patients) and nondesaturators (3 patients) were FEV(1) (70.1 +/- 9.1% predicted vs 98.1 +/- 15.1% predicted, respectively; p = 0.002), resting PaO(2) (61.8 +/- 16.1 vs 90.3 +/- 2.3 mm Hg, respectively; p = 0.001), alveolar-arterial oxygen pressure difference (P[A-a]O(2)) (40.5 +/- 20.5 vs 12.2 +/- 7.2 mm Hg, respectively; p = 0.048), resting SpO(2) (91.6 +/- 5.4% vs 98.7 +/- 2.3%, respectively; p = 0.038), and walking SpO(2) (83.8 +/- 9.3% vs 95.3 +/- 1.2%, respectively; p = 0.002). The mean hemoglobin level was higher in the group of nocturnal desaturators than in the group of nondesaturators (10.43 +/- 0.31 vs 13.95 +/- 0.98 g/dL, respectively; p < 0.0001). CONCLUSION: Seventy-seven percent of patients with PPH have significant nocturnal hypoxemia that is unrelated to apneas and hypopneas. Nocturnal desaturation occurs more frequently in patients with higher P(A-a)O(2) values and lower FEV(1) values, resting arterial PaO(2) and SpO(2) values, and walking SpO(2) values.


Subject(s)
Hypertension, Pulmonary/physiopathology , Hypoxia/physiopathology , Sleep/physiology , Adult , Female , Humans , Hypertension, Pulmonary/blood , Hypertension, Pulmonary/complications , Male , Middle Aged , Oximetry , Polysomnography , Respiratory Function Tests , Retrospective Studies
8.
Cleve Clin J Med ; 68(8): 677-80, 2001 Aug.
Article in English | MEDLINE | ID: mdl-11510524

ABSTRACT

Studies have shown that noninvasive positive pressure ventilation (NPPV) is well tolerated and safe, and that it improves oxygenation in some patients with acute respiratory failure. By obviating the need for endotracheal intubation in certain conditions, it results in fewer complications, shorter hospital stays, and consequently, lower mortality rates and costs of care.


Subject(s)
Positive-Pressure Respiration/methods , Respiratory Insufficiency/therapy , Acute Disease , Humans
9.
Muscle Nerve ; 24(3): 403-9, 2001 Mar.
Article in English | MEDLINE | ID: mdl-11353427

ABSTRACT

The impact of noninvasive positive-pressure ventilation (NIPPV) on pulmonary function studies, quality of life, and survival was assessed in patients with amyotrophic lateral sclerosis. NIPPV did not change the rate of decline of the forced vital capacity (FVC) and forced expiratory volume in the first second (FEV(1)) (2.31 and 2.09 percent-predicted points per month, respectively). NIPPV resulted in a drop of FEV(1) by 5.94 percent-predicted points (P = 0.07), and of maximal inspiratory pressure by 6.33 percent-predicted points (P = 0.11). The change in FEV(1) and FVC pre- and postintervention correlated with the corresponding change in maximal inspiratory pressure. Fatigue and mastery scores were improved by NIPPV. Median survivals in patients intolerant and tolerant of NIPPV were 5 and 20 months, respectively (P = 0.002). Although NIPPV has no impact on the rate of decline of lung function and may have deleterious effects on spirometric measures, it may improve quality of life and survival.


Subject(s)
Amyotrophic Lateral Sclerosis/diagnosis , Amyotrophic Lateral Sclerosis/therapy , Positive-Pressure Respiration , Aged , Amyotrophic Lateral Sclerosis/mortality , Blood Gas Analysis , Female , Humans , Lung Volume Measurements , Male , Middle Aged , Proportional Hazards Models , Quality of Life , Spirometry , Survival Rate , Treatment Outcome , Vital Capacity
10.
Chest ; 119(5): 1489-97, 2001 May.
Article in English | MEDLINE | ID: mdl-11348958

ABSTRACT

BACKGROUND AND OBJECTIVE: Cirrhotic patients admitted to the medical ICU (MICU) are associated with high mortality rates and high resource utilization. This study identifies specific predictors of increased mortality and resource utilization and uses them to develop and validate prognostic models in cirrhotic patients admitted to the MICU. METHODS: Cirrhotic patients admitted to the MICU were identified from the Critical Care Section database (January 1993 to October 1998). Clinical data were extracted from chart review including hospital course variables, mortality, and length of stay (LOS). Total cost per case (TCPC) was obtained from the Transition System INC: Multivariate logistic and linear regression analyses identified the independent predictors of increased mortality and resource utilization used for model building (MB) and model validation (MV). RESULTS: A total of 582 cases were randomized to the MB and MV groups. Each group contained 240 cases after exclusion criteria were applied. The MICU mortality rate was 36.6%, and the in-hospital mortality rate was 49.0%. Acute physiology, age, and chronic health evaluation (APACHE) III score (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.70 to 8.16; p < 0.001), mechanical ventilation (OR, 4.57; 95% CI, 2.35 to 8.34); p < 0.001), and the use of pressors (OR, 7.57; 95% CI, 4.35 to 13.18; p < 0.001) were independent predictors of MICU mortality. APACHE III score (OR, 4.96; 95% CI, 2.97 to 8.29; p < 0.001), the use of pressors (OR, 6.55; 95% CI, 3.66 to 11.72; p < 0.001), and acute renal failure (ARF) (OR, 4.31; 95% CI, 2.41 to 7.71; p < 0.001) were independent predictors of in-hospital mortality. Increased LOS in the MICU was associated with mechanical ventilation, ARF, bronchoscopy, bacteremia, use of pressors, transjugular intrahepatic portosystemic shunt (TIPS), and never received cardiopulmonary resuscitation (CPR) (p < 0.005). Source of admission, platelet transfusion, bacteremia, pneumonia, and never received CPR were independently associated with increased total LOS (p < 0.001). Mechanical ventilation, platelet transfusion, bronchoscopy, TIPS, sepsis, and never received CPR were independent predictors of increased TCPC (p < 0.001). CONCLUSION: Simple prognostic models for mortality and resource utilization have been developed for cirrhotic patients admitted to the MICU.


Subject(s)
Hospital Mortality , Intensive Care Units/statistics & numerical data , Liver Cirrhosis/mortality , Models, Statistical , APACHE , Cause of Death , Female , Health Resources/statistics & numerical data , Hospitalization/statistics & numerical data , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Ohio/epidemiology , Prognosis
11.
Respir Med ; 95(4): 305-9, 2001 Apr.
Article in English | MEDLINE | ID: mdl-11316114

ABSTRACT

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis, which is endemic to the south-western United States. Manifestations range from flu-like illness to pneumonia and septic shock. Diagnosis may be delayed or missed in non-endemic areas because of the low index of suspicion. We describe a series of 23 patients with coccidioidomycosis at one institution in a non-endemic area. Diagnosis was often delayed. In two patients, the route of exposure could not be determined, but 20 patients had a history of residence or travel to endemic areas, and the remaining patient had an occupational history of exposure to fomites from an endemic region. Five patients were immunosuppressed. Most patients responded well to medical therapy, surgery, or both. Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled to endemic areas or who are immunosuppressed.


Subject(s)
Coccidioidomycosis/diagnosis , Lung Diseases, Fungal/diagnosis , Adult , Aged , Antifungal Agents/therapeutic use , Coccidioidomycosis/etiology , Coccidioidomycosis/therapy , Endemic Diseases , Fatal Outcome , Female , Humans , Lung Diseases, Fungal/etiology , Lung Diseases, Fungal/therapy , Male , Middle Aged , Occupational Exposure , Retrospective Studies , Risk Factors , Serologic Tests , Travel
12.
Am J Crit Care ; 10(2): 79-83, 2001 Mar.
Article in English | MEDLINE | ID: mdl-11244675

ABSTRACT

BACKGROUND: Critical care nurses must assess the effectiveness of sedatives and analgesic agents in order to titrate doses. OBJECTIVES: To measure the interrater reliability of 2 sedation scales used to assess patients in medical intensive care units. METHODS: The interrater reliabilities of the Motor Activity Assessment Scale and the Luer sedation scale were compared prospectively in 31 patients receiving mechanical ventilation in an 18-bed medical intensive care unit of a tertiary care institution. Three registered nurses, 1 clinical pharmacist, and 1 physician simultaneously and independently followed a standardized procedure to rate each patient by using the 2 scales. Scales were randomly ordered to counteract ordering effect. Analysis of variance with post hoc Duncan multiple range tests was used to detect bias; a correlation coefficient matrix was used to examine degree of association among raters; and the intraclass correlation coefficient was measured to control for multiple raters. RESULTS: No significant bias was detected with either scale. The Motor Activity Assessment Scale had less variation (Pearson r = 0.75-0.92) than did the Luer scale (Pearson r = 0.37-0.94) and had a stronger intraclass correlation coefficient (0.81 vs 0.79). CONCLUSIONS: The Motor Activity Assessment Scale showed the highest consistency among raters.


Subject(s)
Analgesics/administration & dosage , Conscious Sedation/classification , Critical Care/standards , Hypnotics and Sedatives/administration & dosage , Intensive Care Units , Humans , Motor Activity/drug effects , Nursing Assessment , Practice Guidelines as Topic , Prospective Studies , Reference Standards , Reproducibility of Results
13.
Cleve Clin J Med ; 68(1): 74-81, 2001 Jan.
Article in English | MEDLINE | ID: mdl-11204368

ABSTRACT

Low-dose spiral computed tomography (CT) shows promise as a screening test for lung cancer, as it detects many more malignant pulmonary nodules than does standard plain radiography of the chest. Yet until more data are available we need to temper our enthusiasm. No studies have yet determined if using low-dose spiral CT as a screening test will lead to lower mortality rates. This paper reviews the issue of lung cancer screening and low-dose spiral CT.


Subject(s)
Lung Neoplasms/prevention & control , Mass Screening/methods , Tomography, X-Ray Computed , Aged , Cost-Benefit Analysis , Humans , Mass Screening/economics , Middle Aged , Sensitivity and Specificity , Time Factors , Tomography, X-Ray Computed/economics
14.
Chest ; 119(2): 530-6, 2001 Feb.
Article in English | MEDLINE | ID: mdl-11171734

ABSTRACT

OBJECTIVE: To determine the degree of concordance between clinical cause of death and autopsy diagnosis in a medical ICU (MICU) setting. DESIGN: Retrospective medical chart and autopsy report review. SETTING: MICU in a tertiary referral hospital. PATIENTS: Consecutive admissions to an MICU over a 2-year period from January 1, 1994, to December 31, 1995. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One thousand eight hundred patients were admitted to the MICU during the study period. There were 401 in-ICU deaths (22.3%). The autopsy rate was 22.7% (91 of 401). The mean +/- SD age of the autopsied patients (55.1 +/- 13.5 years) was lower than those without autopsy (62.4 +/- 15.2 years; p < 0.001). The two groups were otherwise similar with regard to sex, race, APACHE (acute physiology and chronic health evaluation) III scores, and lengths of stay in the MICU and hospital. The discordance between clinical and postmortem diagnoses was 19.8% (95% confidence interval, 12 to 29%). There were no differences in age, sex, APACHE III scores, predicted mortality, and lengths of stay in MICU hospital between patients with concordant and discordant diagnoses. In 44.4% (8 of 18) of the discordant cases, management would have been modified had the autopsied diagnosis been made premortem. Seven of the autopsied patients had organ transplantation. Three of the patients who had organ transplantation had discordant diagnoses, including two patients with disseminated fungal infection that was not diagnosed clinically. Although the observed discordance in transplant patients (43%) was higher than in those without transplant (19%), the difference was not statistically significant (p = 0.15). CONCLUSION: Younger patients tended to have a higher autopsy rate than older patients. The discordance between the clinical cause of death and postmortem diagnosis was 19.8%. In 44.4% of the discordant cases, knowledge of the correct diagnosis would have altered therapy.


Subject(s)
Autopsy , Cause of Death , APACHE , Aged , Diagnostic Errors , Female , Humans , Intensive Care Units , Male , Middle Aged , Retrospective Studies
15.
Lung ; 179(4): 233-43, 2001.
Article in English | MEDLINE | ID: mdl-11891614

ABSTRACT

Lack of vasodilator substances, such as nitric oxide (NO), has been implicated in the development of pulmonary hypertension, but the pathogenesis of the disease remains speculative. We hypothesized that NO plays a role in the pathogenesis of primary pulmonary hypertension (PPH), and may serve as a sensitive and specific marker of disease progression and/or severity. To test this, exhaled NO and pulmonary artery pressure were measured in individuals with PPH and secondary pulmonary hypertension (SPH) on various therapies, including the potent vasodilator epoprostenol (prostacyclin), compared with healthy controls. NO in exhaled breath of individuals with PPH was lower than SPH or control (p<0.05). In contrast, exhaled NO of individuals with PPH or SPH receiving epoprostenol was strikingly higher than PPH or SPH individuals not receiving epoprostenol, or controls. Concomitant with higher NO levels, right ventricular systolic pressure of individuals significantly decreased with epoprostenol. Importantly, in paired measures of exhaled NO before and after epoprostenol, NO increased in all pulmonary hypertensive individuals 24 h after initiation of epoprostenol therapy (p<0.05). NO may be a useful noninvasive marker of pulmonary hypertension severity and response to prostacyclin therapy.


Subject(s)
Antihypertensive Agents/therapeutic use , Breath Tests , Epoprostenol/therapeutic use , Hypertension, Pulmonary/drug therapy , Nitric Oxide/analysis , Vasodilator Agents/therapeutic use , Adolescent , Adult , Biomarkers/analysis , Female , Humans , Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/etiology , Hypertension, Pulmonary/metabolism , Male , Middle Aged , Respiratory Mechanics , Vasodilator Agents/analysis
16.
Am J Crit Care ; 9(6): 412-8, 2000 Nov.
Article in English | MEDLINE | ID: mdl-11072557

ABSTRACT

BACKGROUND: Although popular, clinical practice guidelines are not universally accepted by healthcare professionals. OBJECTIVES: To compare nurses' and physicians' actual and perceived rates of adherence to practice guidelines used in sedation of patients receiving mechanical ventilation and to describe nurses' and physicians' perceptions of guideline use. METHODS: Pairs of fellows and nurses caring for 60 eligible patients were asked separately about their rationale for medicating patients, effectiveness of medication, and their perceived adherence to the guidelines. Actual adherence was determined independently by review of medical records. An additional 18 nurses and 11 physicians were interviewed about perceptions of guideline use. RESULTS: Use of mechanical ventilation was the most common reason given by physicians (53%) and nurses (48%) for medicating patients, although reasons for administering medication to a given patient differed in up to 30% of cases. Physicians and nurses disagreed on the effectiveness of medication in 42% (P = .01) of cases. Physicians reported following guidelines in 69% of cases, but their actual adherence rate was only 20%. Clinicians sometimes had difficulty distinguishing among anxiety, pain, and delirium. Clinicians justified variations from guidelines by citing the value of individualized patient care. Nurses and physicians sometimes had different goals in the use of sedation. CONCLUSIONS: Physicians may think they are following sedation guidelines when they are not, and they may prescribe incorrect medications if the cause of agitation is misdiagnosed. Differences between physicians and nurses in values and perceptions may hamper implementation of clinical practice guidelines.


Subject(s)
Attitude of Health Personnel , Conscious Sedation/standards , Guideline Adherence/standards , Health Knowledge, Attitudes, Practice , Medical Staff, Hospital/psychology , Neuromuscular Blockade , Nursing Staff, Hospital/psychology , Practice Guidelines as Topic/standards , Respiration, Artificial , Adult , Clinical Competence , Critical Care , Diagnostic Errors , Female , Humans , Male , Medical Staff, Hospital/education , Middle Aged , Nursing Staff, Hospital/education , Patient Selection , Prospective Studies , Psychomotor Agitation/diagnosis , Psychomotor Agitation/drug therapy , Psychomotor Agitation/etiology , Respiration, Artificial/adverse effects , Surveys and Questionnaires , Treatment Outcome
17.
Chest ; 118(4): 1106-8, 2000 Oct.
Article in English | MEDLINE | ID: mdl-11035685

ABSTRACT

BACKGROUND: Penicillin skin testing is an accurate method to determine whether a person with a history of penicillin allergy is at risk of having an immediate reaction to penicillin. A patient with a negative reaction to a skin test may be able to use a penicillin compound safely, which could reduce the use of broad-spectrum antibiotics in this patient population. METHODS: We prospectively studied all patients with histories of penicillin allergy who were admitted to a medical ICU during a 3-month period and who received antibiotics. Skin testing was performed with benzylpenicilloyl polylysine and penicillin G. We determined the incidence of true allergy, the percentage of patients in whom antibiotic coverage was modified, and the safety of the test. RESULTS: Two hundred fifty-seven patients were admitted to the medical ICU of The Cleveland Clinic Foundation during the study period. Twenty-four patients (9%), labeled as penicillin allergic and receiving antibiotics, were enrolled. Three patients (13%, 3 of 21) gave histories of type I reaction to penicillin and were not skin tested. Twenty patients (95%, 20 of 21) had negative skin test reactions to penicillin and positive skin test reactions to histamine control. One patient (4%, 1 of 21) with negative skin test reactions to both penicillin and histamine control had a test dose challenge with piperacillin that was well tolerated. There were no adverse events. Antibiotic coverage was changed in 10 patients (48%) as a result of skin testing. CONCLUSION: Most patients with histories of allergy to penicillin have negative reactions to skin tests and may receive penicillin safely. Penicillin skin testing can be utilized as a safe and effective strategy to reduce the use of broad-spectrum antibiotics.


Subject(s)
Drug Hypersensitivity/diagnosis , Intensive Care Units , Patient Admission , Penicillin G/analogs & derivatives , Penicillin G/adverse effects , Penicillins/adverse effects , Skin Tests , Adult , Aged , Aged, 80 and over , Benzeneacetamides , Drug Hypersensitivity/epidemiology , Drug Hypersensitivity/etiology , Female , Humans , Incidence , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Ohio/epidemiology , Patient Admission/statistics & numerical data , Pilot Projects , Prospective Studies
19.
Pediatr Pulmonol ; 30(3): 203-6, 2000 Sep.
Article in English | MEDLINE | ID: mdl-10973038

ABSTRACT

Central nervous system (CNS) complications occur more frequently in cystic fibrosis (CF) patients than other lung transplant recipients. The purpose of this study was to compare CF patients with and without CNS complications following lung transplantation, to identify risk factors for CNS events. Records of 21 patients with CF who underwent lung transplant between 1991-1996 were reviewed. Data were collected on multiple variables, including: age at transplant; gender; cytomegalovirus (CMV) status; cholesterol and triglyceride levels; sinusitis; percent ideal body weight (IBW); body mass index (BMI); augmented immunosuppression, acute lung rejection episodes (ALR); cyclosporine doses; electrolytes; magnesium, blood urea nitrogen (BUN), and creatinine levels; and 6-month survival. CNS complications identified were seizures, severe headaches (HA), strokes, or confusional episodes. Eleven of 21 patients (52%) with CF had CNS events: eight had seizures, five HA, three strokes, and one confusional episode. There was no difference in age at transplant, pretransplant percent IBW or BMI, cholesterol and triglyceride levels, or number of ALR. CMV mismatch and clinical sinusitis had no effect. Cyclosporine doses did not differ between groups at 30 days, or 3 or 6 months posttransplant. Both BUN and creatinine concentrations showed a rise over time that did not differ between groups. Potassium levels were within normal limits for both groups. While sodium levels did not differ between groups pretransplant, or at 30 days or 6 months posttransplant, a decrease in sodium values was seen at the time of CNS events. There was no difference in 6-month survival. We could not identify any pre- or posttransplant risk factors that predicted CNS events. It is likely that cyclosporine toxicity is the major cause of CNS complications. Despite the high rate of CNS events, the overall prognosis was good, and 6-month survival was not affected.


Subject(s)
Central Nervous System Diseases/etiology , Cystic Fibrosis/complications , Cystic Fibrosis/therapy , Lung Transplantation/adverse effects , Adolescent , Adult , Cyclosporine/adverse effects , Cyclosporine/therapeutic use , Female , Humans , Immunosuppressive Agents/adverse effects , Immunosuppressive Agents/therapeutic use , Male , Prognosis , Retrospective Studies , Risk Factors
20.
Cleve Clin J Med ; 67(6): 392, 395, 399-400, 2000 Jun.
Article in English | MEDLINE | ID: mdl-10860220

ABSTRACT

Too often, physicians, patients, and families make end-of-life care decisions despite poor physician-patient communication and misunderstanding by the patient and family about the effectiveness of cardiopulmonary resuscitation. We describe an approach to resolving conflict and reaching consensus on end-of-life care. This approach supports physician judgment to withhold futile treatment within the constraints of law and patient autonomy.


Subject(s)
Resuscitation Orders , Communication , Ethics, Medical , Humans , Medical Futility , Physician-Patient Relations
SELECTION OF CITATIONS
SEARCH DETAIL
...