An intensive communication intervention for the critically ill.

PURPOSE: We sought to determine the effects of a communication process that was designed to encourage the use of advanced supportive technology when it is of benefit, but to limit its burdens when it is ineffective. We compared usual care with a proactive, multidisciplinary method of communicating that prospectively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient. This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death. MATERIALS AND METHODS: We performed a before-and-after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care. Multidisciplinary meetings were held within 72 hours of critical care admission. Patients, families, and the critical care team discussed the care plan and the patients' goals and expectations for the outcome of critical care. Clinical "milestones" indicative of recovery were identified with time frames for their occurrence. Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient's goals. We measured length of stay, mortality, and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention. RESULTS: Intensive communication significantly reduced the median length of stay from 4 days (interquartile range, 2 to 11 days) to 3 days (2 to 6 days, P = 0.01 by survival analysis). This reduction remained significant after adjustment for acute physiology and chronic health evaluation (APACHE) 3 score [risk ratio (RR) = 0.81; 95% confidence interval (CI), 0.66 to 0.99; P = 0.04). Subgroup analysis revealed that this reduction occurred in our target group, patients with acuity scores in the highest quartile who died (RR = 0.60; 95% CI, 0.38 to 0.92; P = 0.02). The intervention, which allowed dying patients earlier access to palliative care, was not associated with increased mortality. CONCLUSIONS: Intensive communication was associated with a reduction in critical care use by patients who died. Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective.

Rewarming from hypothermia leads to elevated plasma lipopolysaccharide concentrations.

Rewarming victims of hypothermia such as divers or immersion victims, participants in winter sports and military operations, and surgical patients on cardiopulmonary bypass (CPB) may lead to vascular instability, multiorgan failure, shock, and even death. While the causes of these rewarming symptoms are unknown, they may be related to bacterial lipopolysaccharide (LPS) translocated from the intestines into the circulation due to splanchnic ischemia. We have determined LPS during the cooling (to 31.5 degrees-34.0 degrees C) and rewarming phases of hypothermic surgery in 11 patients at the Stanford University Medical Center. During rewarming, there was an LPS spike in 6/11, in one more patient there was an LPS spike during surgery but not during rewarming, and in 4/11 there was no rise in LPS, i.e., a temporary endotoxemia occurred in 7/11 (63.6%) patients, usually at the commencement of rewarming. All four patients with no LPS spike received dexamethasone for at least 7 days before surgery. We propose that hypothermia reduced splanchnic blood flow (BF), causing ischemic damage to the gut wall and translocation of LPS from the gut into the vascular space. Upon rewarming, splanchnic BF is restored, the translocated LPS transits from the splanchnic to the systemic circulations as a bolus, and the gut wall is healed. No sequelae occurred in these patients because of their adequately functioning immune systems. However, had they been immunocompromised, symptoms might have occurred. Rewarming of accident victims probably also incurs a similar risk of endotoxemia, and dexamethasone may have protected the gut wall. Further studies are indicated.

Amlodipine, a calcium channel inhibitor, and cocaine and ethanol's reinforcing effects.

The effects of amlodipine (from 0.1 to 3.0 mg/kg) on rats' pressing for rewarding brain stimulation, with and without cocaine administration, were assessed. None of the doses reliably modified the effects of cocaine. Also, amlodipine was given to two groups of rats taking alcohol: one group that was regularly taking a sweetened alcoholic beverage and the other taking an unsweetened alcoholic beverage. The only discernible effects of amlodipine on alcohol intake were associated with the highest dose and only with rats taking the sweetened beverage. The effects of this high dose could easily be attributable to behavioral toxicity elicited by the dose. In contrast, and confirming previous work, isradipine, another calcium channel inhibitor, produced reliable reductions on both cocaine's and alcohol's reinforcing effects. Despite the similarity of isradipine and amlodipine, isradipine apparently has some unique features with respect to cocaine and alcohol.

Characterization of a three-phase response in gloved cold-stressed fingers.

Seven gloves were studied worn by eight sedentary subjects (six men and two women) exposed to cold-dry, C D, (mean dry bulb temperature Tdb = -17.2 degrees C; mean dew point temperature Tdp = -25.1 degrees C), and cold-wet, C-W, (Tdh = 0 degrees C; Tdp = -8.4 degrees C) conditions. Mean endurance times were 75 min for the C-D and 162 min for the C W conditions. A three-phase response pattern of the temperature in the fingers was characterized. Phase I comprised an initial period during which finger temperature remained close to the pre-exposed level, due to delayed vasoconstriction in the finger. Phase II involved an exponential-like decrease of finger temperature indicative of the onset of vasoconstriction in the finger. Phase III manifested periodic finger temperature changes due to cold induced vasodilatation (CIVD). Mean wave patterns for phase III indicated approximately 3.5 waves x h(-1) in the C D but only about 2 waves x h(-1) in the C-W condition. Extension of endurance time, due to CIVD, was defined as the difference in time between the actual end of the experiment and the time the finger-tip would have reached the set temperature endurance limit as extrapolated by a continued exponential drop. Three overall response patterns of fingers in the cold were characterized: type A exhibiting all 3 phases; type B1 or B2 exhibiting either phases I+ II or phases II+ III; and type C showing only phase II. Considerable inter- and intra-subject variability was found. In both test conditions the final physiological thermal states of the subjects were between comfortable and slightly uncomfortable but acceptable and thus did not correlate with the responses in the fingers.

Traumatic rupture of median artery an unusual cause for acute median nerve compression.

Previous case reports of haemorrhage into the carpal tunnel causing median nerve compression were extraneural and usually associated with a blood dyscrasia although Watson Jones reported one due to direct trauma and Hayden recorded spontaneous intraneural haemorrhage not associated with trauma. We describe a case of intraneural haemorrhage, involving the median nerve in the carpal tunnel, due to indirect trauma and not associated with a blood dyscrasia. The condition required intraneural decompression to obtain relief.

The modification and generalization of voice loudness in a fifteen-year-old retarded girl.

A fifteen-year-old severely disturbed girl was treated for aphonia. Because of the extent of her withdrawal, the subject was conditioned in a laboratory setting and received tokens for speaking loudly enough to operate a voice-operated relay. Conditioning at first consisted of saying 100 monosyllabic words, with the possibility of reinforcement on each word. Later, the subject was required to say a polysyllabic word, and finally, five or six words per token. The subject was shaped to speak with normal loudness in the laboratory, and generalization to a reading situation in the laboratory was measured and observed to occur, at first for a few minutes, and later for a longer period. Generalization to a reading situation in the classroom did not occur, but the subject's voice loudness also increased in the classroom when several new reinforcement contingencies were put into effect there.

Stimulus change contemporaneous with food presentation maintains responding in the presence of free food.

The presence or absence of a change in the ambient stimulus conditions upon entry into a food source controlled the frequency with which pigeons choose one of two concurrently available grain sources. Such changes characteristically accompany the production of response-produced food and account for prior reports of responding to produce food in the presence of freely available food.