Long-term survival after intensive care unit admission with sepsis.

OBJECTIVE: To evaluate the long-term survival of critically ill patients with sepsis and to assess the factors predictive of long-term survival (> 1 month after admission date). DESIGN: Prospective, cohort study. SETTING: Medical/surgical intensive care unit (ICU) in a multidisciplinary community hospital. PATIENTS: All patients admitted to the ICU from January 1, 1987 to March 31, 1991 who both demonstrated clinical evidence of the systemic inflammatory response syndrome and yielded blood cultures positive for a bacterium or fungus (n = 153). INTERVENTIONS: Random set of procedures normally performed in an ICU setting. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, including age, blood culture results, comorbid conditions, and severity of illness as estimated by the Acute Physiology Score of the Acute Physiology and Chronic Health Evaluation II prognostic system were recorded. Follow-up evaluation utilizing the National Death Index provided survival outcome for all patients 1 yr after hospital discharge. The mortality rate at hospital discharge was 51.0%, and mortality rates at 1 month, 6 months, and 1 yr after admission date were 40.5%, 64.7%, and 71.9%, respectively. A total of 33 patients survived beyond the period of observation. The analyses demonstrated the following findings: a) the survival rate was negatively correlated with the Acute Physiology Score up to 1 month after hospital admission date, but uncorrelated thereafter; b) fungal infections, such as Candida, had the shortest survival prospects of any blood-borne infection; and c) both malignancy and human immunodeficiency virus infection contributed to poorer outcomes, but differed in their patterns of long-term survival. CONCLUSIONS: The most critical period for surveillance of bacteremic patients was in months 2 through 6 after discharge, during which time, the percentage of patients surviving decreased dramatically. The degree of physiologic derangement, as measured by the Acute Physiology Score, was a useful measure of prognosis within the first month after the score was assessed at ICU admission. However, beyond this period, prognostic utility decreased significantly. Healthcare providers should use caution concerning the expected survival of hospitalized patients with human immunodeficiency virus, based on experience with distinct conditions, such as malignancies.

The effect of human immunodeficiency virus infection on the distribution and outcome of pneumonia in intensive care units.

To determine the frequency and distribution of pneumonia in an intensive care unit (ICU), we retrospectively examined the records of 1,854 consecutive ICU admissions between January 1987 and April 1990. A total of 266 patients met criteria for pneumonia (unilateral or bilateral infiltrate by chest roentgenogram, plus 2 of the following: leukocyte count > 10 x 10(9) per liter, temperature > 38.5 degrees C, or culture of blood or sputum positive for pathogens). Pneumocystis carinii pneumonia in patients infected with the human immunodeficiency virus was the most frequent cause (28%) precipitating an ICU admission in this series of patients. Streptococcus pneumoniae (13%), Staphylococcus aureus (8%), Haemophilus influenzae (4%), and viruses (4%) were also commonly observed. Overall mortality was 20%. An APACHE II score of greater than 24, the need for intubation, and the presence of P carinii were predictive of increased mortality. Age, sex, and length of stay did not predict final results. Patients with P carinii pneumonia who required intubation had an overall mortality of 54%, which was higher than patients without P carinii pneumonia who required intubation (P < .05). Our experience shows the changing spectrum of pneumonia in ICUs. In contrast to reports of a decade ago in which S pneumoniae and Pseudomonas aeruginosa are cited as most common, P carinii is now most prevalent in our ICU. Although our findings reflect the increasing incidence of human immunodeficiency virus infection in San Francisco, California, they may also be pertinent to other areas in the United States where the incidence of this infection continues to increase.

Comparison of proximal and distal colonic muscle of the rabbit.

Mechanical length-tension properties and response to neurohumoral agents were compared for proximal and distal colonic muscle. Resting tension during stretch, acetylcholine-stimulated tension, and the total tension were determined. Proximal circular muscle developed a maximum total tension of 0.96 +/- 0.18 kg/cm2 (mean +/- SE) compared to 0.86 +/- 0.06 kg/cm2 for the distal colon (P greater than 0.05). Resting tension was 0.33 +/- 0.03 kg/cm2 for the proximal colon and 0.05 +/- 0.01 kg/cm2 for the distal colon at the length of optimal acetylcholine-stimulated tension (Lo) (P less than 0.01). Longitudinal muscle showed a similar difference for the proximal and distal colon. The high resting tension in the proximal colonic muscle was reduced by nitroprusside or calcium-free Krebs with EGTA. Dose-response curves to acetylcholine, histamine, phenylephrine, and isoproterenol were similar for the muscle of either part of the colon. Gastrin or cholecystokinin had no effect on the muscle. In summary, the circular or longitudinal muscles of the proximal and distal colon have different length-tension properties but only minimal differences in response to neurohumoral agents.

Achalasia secondary to carcinoma: manometric and clinical features.

The clinical and diagnostic features of a secondary type of achalasia of the esophagus are described in seven patients with various types of malignancies. Patients with secondary achalasia presented with dysphagia of short duration and marked weight loss; mean age was 64 years. Esophageal manometry showed features identical to those of idiopathic primary achalasia: aperistalsis, poor lower esophageal sphincter relaxation, and elevated sphincter pressure. Endoscopy and barium swallow showed evidence of a tumor in only two cases. Various types of malignancies may produce a secondary form of achalasia that has diagnostic features identical to those of primary achalasia and is best identified by its clinical presentation.

Pathologic features and mechanisms of hypoxemia in adult respiratory distress syndrome.

In 45 consecutive patients referred for severe hypoxemia (Pao2 less than 100 mm Hg on positive end-expiratory pressure of 5 cm H2O and fraction of inspired O2 of 1.0), physiologic studies of gas exchange were correlated with pathologic features from 36 open lung biopsies and 15 autopsies. Three distinct groups were defined. Group 1 included 11 patients with the most severe hypoxia (Pao2, 47 +/- 12 mm Hg), minimal Pao2 response to a 10 cm H2O increase in positive end-expiratory pressure (+2.0 +/- 4.0 mm Hg), and a fixed shunt at all fractions of inspired O2. Pathologic study showed edema, exudation, and hemorrhage to the point of consolidation. In group 2 were 13 patients who had less severe hypoxia (Pao2, 60 +/- 17 mm Hg) and a moderate Pao2 response to a 10 cm H2O increase in positive end-expiratory pressure (+15 +/- 8 mm Hg), but whose maximal response was slowly achieved (30 min to several hours). Pathologic examination showed extensive fibrosis. The 21 patients in group 3 had the least hypoxia (66 +/- 15 mm Hg), and had a rapid and marked improvement in Pao2 with a 10 cm H2O increase in positive end-expiratory pressure (+68 +/- 59 mm Hg). Pathologic features were similar to but less severe than those in group 1. Venous admixture increased with decreasing inspired concentrations of O2, indicating diffusion or ventilation-perfusion abnormalities in groups 2 and 3. Prognosis was best for group 3, with 10 of 21 long-term survivors. Two of 11 group 1 patients survived, but only after prolonged periods of extracorporeal membrane oxygenation. Despite biopsy evidence of extensive fibrosis, 3 of 13 in group 2 survived with moderate to good pulmonary function, including 1 survivor who had had extracorporeal membrane oxygenation. Such combined physiologic and pathologic studies are useful (1) for optimal respiratory care, (2) for prognosis, (3) for development of indications for extracorporeal membrane oxygenation, and (4) for better understanding of the pathophysiology of adult respiratory distress syndrome.

Complications associated with membrane lung support by venoarterial perfusion.

A series of patients supported with long-term venoarterial perfusion is presented. Gas exchange was achieved with a membrane oxygenator at flows usually in excess of 50% of the patient's baseline cardiac output. Perfusions were maintained for 7 to 12 days. Two major complications were encountered: thromboembolic myocardial infarction and liquefaction necrosis of the lung. Possible etiologies and suggestions for prevention are discussed.