The role of polyneuropathy in motor convalescence after prolonged mechanical ventilation.

OBJECTIVE: To test the hypothesis that prolonged motor recovery after long-term ventilation may be due to polyneuropathy and can be foreseen at an early stage by electromyography (EMG). DESIGN: Cohort study with an entry period of 18 months. Polyneuropathy was identified by EMG studies in the intensive care unit (ICU). During a 1-year follow-up, amount of time was recorded to reach a rehabilitation end point. SETTING: The general ICU of a community hospital. PATIENTS: Fifty patients younger than 75 years who were receiving mechanical ventilation for more than 7 days. MAIN OUTCOME MEASURES: A rehabilitation end point was defined as return of normal muscle strength and ability to walk 50 m independently. RESULTS: In 29 of 50 patients, an EMG diagnosis of polyneuropathy was made in the ICU. Patients with polyneuropathy had a higher mortality in the ICU (14 vs 4; P = .03), probably related to multiple organ failure (22 vs 11; P = .08) or aminoglycoside treatment of suspected gram-negative sepsis (17 vs 4; P = .05). Rehabilitation was more prolonged in 12 patients with polyneuropathy than in 12 without polyneuropathy (P = .001). Of nine patients with delays beyond 4 weeks, eight had polyneuropathy, five of whom had persistent motor handicap after 1 year. In particular, axonal polyneuropathy with conduction slowing on EMG indicated a poor prognosis. CONCLUSIONS: Polyneuropathy in the critically ill is related to multiple organ failure and gram-negative sepsis, is associated with higher mortality, and causes important rehabilitation problems. EMG recordings in the ICU can identify patients at risk.

Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: a prospective randomized study.

The efficacy of a relatively cheap regimen of selective decontamination (SDD) was evaluated in a diverse population of ICU patients. Patients requiring prolonged ICU stay (greater than 5 days) were randomly allocated to a treatment group or control group. Control patients (n = 52) received perioperative antimicrobial prophylaxis and antibiotic treatment was instituted only on sound clinical and bacteriological criteria. Treated patients (n = 48) received gastro-intestinal and oro-pharyngeal decontamination with polymyxin E, norfloxacin, amphotericin B and systemic antibiotic prophylaxis with trimethoprim until decontamination was achieved. The rate of gram-positive infections was not altered by SDD. The incidence of gram-negative respiratory tract, urinary tract and line infections was significantly reduced from 44%, 27% and 15% respectively in the control group to 6%, 4% and 0% in the treatment group. Mortality from nosocomial sepsis and overall mortality were also significantly reduced from 15% and 54% to 0% and 31% respectively. The ICU stay was not reduced by SDD, nor was time on the ventilator or use of therapeutic antibiotics. The reduction in morbidity and mortality was achieved at a relatively low cost.

Comparative study between two prophylactic antibiotic regimens of cefamandole during coronary artery bypass surgery.

In two groups of patients undergoing coronary artery bypass grafting (CABG), two different regimens of antibiotic prophylaxis with cefamandole nafate were compared. In Group 1, 30 mg per kilogram of body weight was administered intravenously during induction of anesthesia. In Group 2, a second dose of 15 mg/kg was administered intravenously shortly before cannulation. Serum and tissue levels in the right atrium, the pericardium, and the sternum were determined using high-pressure liquid chromatography. The results showed that in Group 2 the serum levels were significantly higher from 48 minutes onward after induction and remained at an acceptable level during CABG. The tissue levels in the sternum and pericardium were also significantly higher in Group 2 compared with Group 1. It is concluded that a second dose of cefamandole (15 mg/kg) shortly before the beginning of cardiopulmonary bypass is recommended, particularly for high-risk patients.

Use of an arterial pH catheter immediately after coronary artery bypass grafting.

An arterial pH catheter was inserted into a femoral artery of 15 patients immediately after coronary artery bypass grafting. Catheter pH measurements correlated well with conventional blood gas measurements during the first 12 h postsurgery, and revealed rapid pH changes during weaning and bronchial suctioning. This device is a promising step in the development of a complete on-line blood gas analyzer.

Nitroprusside and ketanserin in the treatment of postoperative hypertension following coronary artery bypass grafting: a haemodynamic and ventilatory comparison.

Postoperative hypertension following coronary artery bypass grafting is usually treated with vasodilating agents like nitroprusside. In recent studies ketanserin, a 5-hydroxytryptamine type 2 antagonist, appeared to be effective in the treatment of this clinical syndrome. In 20 patients, divided into two comparable groups, nitroprusside and ketanserin were compared with respect to their haemodynamic and ventilatory profiles. The study showed that both agents were equally effective in decreasing the raised systolic blood pressure, but that ketanserin was more advantageous with respect to the absence of reflex tachycardia and the unchanged shunt fraction.