Health-related quality of life of multiple organ dysfunction patients one year after intensive care.

OBJECTIVE: To assess the quality of life (QOL) of intensive care survivors 1 year after discharge with special emphasis on multiple organ dysfunction (MOD). DESIGN: Prospective, observational study. SETTING: A ten-bed medical-surgical intensive care unit in a tertiary care hospital. PATIENTS: Among the 591 consecutive patients admitted in the year 1995, 307 of 378 patients who survived 1 year were studied. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A generic scale assessing health-related QOL, the RAND 36-item Health Survey (RAND 36) was sent by mail 12 months after discharge. Data concerning age, severity of illness, organ dysfunctions and diagnoses were recorded. Of 307 patients, 98 (31.9 %) were able to work. The QOL measured by the RAND 36 showed clinically relevant impairment in emotional and physical role limitations compared with an age- and sex-matched general population. MOD (n = 131, 42.7 %) had a statistically significant negative effect on all QOL domains, except bodily pain and mental health, with the only clinically relevant impairment being in vitality and emotional role limitations compared with non-MOD patients. Of the 131 MOD patients, 36 (27.4 %) were able to work, 26 (19.8%) had severe limitations in their daily activities and 5 (3.8 %) were unable to live at home 1 year after discharge. CONCLUSIONS: One year after intensive care the survivors had a lower QOL than an age-matched general population with clinically relevant further impairment of MOD patients in vitality and emotional role limitations.

Replacement of major surgical blood loss by hypo-oncotic or conventional plasma substitutes.

The purpose of the study was to examine the effects of hypooncotic 4% hydroxyethyl starch 120/0.7, 3% dextran 70, 5% albumin and hyperoncotic 6% hydroxyethyl starch 120/0.7 on the perioperative colloid osmotic pressure (COP), albumin and protein concentrations and fluid balance. The plasma substitutes were used with red cell concentrates to replace blood loss with equal volume in sixty major abdominal or urological surgeries. A special effort was made to keep replacements and losses at even volumes constantly and to avoid fluctuation of blood volume. The blood specimen were obtained before induction, after each 20% blood loss, at the end of the recovery room phase and on the three following postoperative mornings. There were significant differences in the peroperative and immediate postoperative COPs. However, these differences had vanished by the first postoperative morning. COP was preserved above 16 mmHg in all groups throughout the study. The identical peroperative albumin and protein concentrations of the synthetic colloid groups suggests that their volume effect was the same, regardless of the varying COP. During the observation period there were no significant differences among the groups concerning the diuresis and the fluid balances. We conclude, that the hypooncotic 4% HES 120 and 3% dextran 70 solutions provide the same clinical effect as 6% HES 120 solution. Consequently less colloid is needed, which allows the use of greater volumes of the dilute colloid solutions in replacement therapy.

Continuous positive airway pressure by mask in patients after coronary surgery.

Thirty patients who underwent coronary artery bypass grafting were randomized to receive 30% oxygen by mask either with an ambient airway pressure or with 7.4 mmHg (1 kPa) continuous positive airway pressure (CPAP) for 8 h after extubation. Arterial blood oxygen tension (PaO2) decreased remarkably in the control group after extubation (from 19.2 +/- 5.3 kPa to 12.4 +/- 2.7 kPa) but less in the CPAP group (from 16.4 +/- 3.3 kPa to 14.0 +/- 2.1 kPa). On the second postoperative morning PaO2 was equally low in both groups (control: 8.4 +/- 1.5 kPa, CPAP: 8.9 +/- 1.9 kPa). Atelectatic areas were seen with similar frequency in both groups, 17% (whole material) on the first and 50% on the second postoperative morning. Atelectasis was more common in patients with internal thoracic artery grafting and/or pleural drainage. In conclusion, CPAP therapy was well tolerated, and minimized the decrease in PaO2 after extubation, but could not prevent the poor oxygenation or the late development of atelectatic areas on the second postoperative day.

Diaphragmatic movement studied with ultrasound during spontaneous breathing and mechanical ventilation with intermittent positive pressure ventilation (IPPV) and airway pressure release ventilation (APRV) in man.

Earlier knowledge about diaphragmatic movement during mechanical ventilation is based on radiological information. Since real-time bed-side monitoring is now possible the movement of the right hemidiaphragm was studied using ultrasound (US), both during spontaneous and mechanical ventilation. Nine healthy non-medicated volunteers lying supine were exposed to the following ventilation modes in random order: 1. breathing air at ambient pressure, or 2. at 7.6 mmHg of CPAP or 3. mechanical ventilation with airway pressure release ventilation (APRV), or 4. with IPPV, by mask. The movement of the diaphragm was recorded with a US sector transducer, imaging the ventral, dome and dorsal parts. The maximal movement was detected in the dome in four volunteers during spontaneous breathing with both ambient pressure and CPAP, but in the ventral part in seven and six volunteers, respectively, during APRV and IPPV. Diaphragmatic movement can be studied with US and the findings support the earlier study, with the diaphragm shifting towards the non-dependent regions of the lungs during mechanical ventilation. In this respect APRV is similar to IPPV.

The effect of combined high frequency ventilation with and without continuous positive airway pressure in experimental lung injury.

Combined high frequency ventilation (CHFV) with 8 mmHg (1.0 kPa) continuous positive airway pressure (CPAP) and without CPAP (CHFV0) were compared to each other, and to continuous positive pressure ventilation (CPPV) with 8 mmHg (1.0 kPa) CPAP in pigs with oleic acid induced lung injury. The respiratory rate was 15 min-1 and the high frequency (HF) rate 360 min-1. Arterial carbon dioxide tension (PaCO2) was adjusted to 5 kPa and 25% oxygen was used. After CHFV, CPAP was briefly discontinued to allow the establishment of CHFV0 in order to examine the cardiovascular and pulmonary effects of combined high frequency ventilation alone. Mean arterial oxygen tension (PaO2) was 15.8 +/- 3.9 kPa during CPPV, 15.5 + 3.2 kPa during CHFV and 13.2 +/- 5.1 kPa during CHFV0 (ns). The peak airway pressure and the pericardiac pressure were lowest during CHFV0. CHFV provoked significant cardiovascular depression (mean arterial pressure, stroke index, left and right ventricle stroke work index). When compared to CPPV, a non-significant trend towards improved cardiovascular function was found during CHFV0. With similar mean airway pressures (during CHFV0) or the same CPAP (during CHFV) as during CPPV, no further improvement in oxygenation due to HF waves was found. Airway pressure was the major factor causing alterations in cardiovascular function, not the ventilation technique.

A comparison of continuous positive pressure ventilation, combined high frequency ventilation and airway pressure release ventilation on experimental lung injury.

In pigs with oleic induced lung injury, the effectiveness of combined high frequency ventilation (CHFV, with VDR-Phasitron) and airway pressure release ventilation (APRV) were compared to continuous positive pressure ventilation (CPPV) in a randomized study. The respiratory rate was 15/min, CPAP 8 mmHg and FiO2 0.25. PaCO2 was maintained at 5 kPa. PaO2 was significantly lower with APRV (12.5 +/- 3.9 kPa, CPPV: 15.8 +/- 3.9 kPa, and CHFV: 15.5 +/- 3.2 kPa). This was in accordance with the lowest peak airway pressure during APRV (20.9 +/- 4.8 mmHg, CPPV: 26.3 +/- 4.4 mmHg and CHFV: 28.2 +/- 3.7 mmHg). There was no difference in the pericardiac pressure between the 3 ventilation modes. The pressure related depressive effects on the cardiovascular function during CHFV and APRV were similar to those during CPPV. Adequate oxygenation and ventilation could be achieved with both CHFV and APRV, but these methods were not superior to CPPV.

Diaphragmatic movement using ultrasound during spontaneous and mechanical ventilation: effect of tidal volume.

Using ultrasound (US) the effect of various tidal volumes on the movement of ventral, dome and dorsal parts of the right hemidiaphragm was studied, both during spontaneous and mechanical ventilation. Six healthy non-medicated volunteers who were in the supine position breathed spontaneously shallowly (tidal volume (VT) being 400 ml) (SB), and deeply (VT 1000 ml) (SB-deep). In addition, they were mechanically ventilated with intermittent positive pressure ventilation at three different VT's: 500 ml (IPPV-500), 1000 ml (IPPV-1000) and 1700 ml (IPPV-1700). The maximal movement was recorded in the ventral part in 2 volunteers during SB, in 3 during SB-deep, and in 3 and 5 subjects during IPPV-500 and IPPV-1700, respectively. The movement in dome was 100% during SB (all others standardized to this), 303 +/- 107% during SB-deep, 82 +/- 30% during IPPV-500, 165 +/- 70% during IPPV-1000 and 266 +/- 153% during IPPV-1700. An increased tidal volume is associated with an increase in the diaphragmatic movement studied by US. However, a larger VT is needed during mechanical ventilation to achieve the same amount of change as occurred with deep spontaneous breathing.

Albumin, HES 120 and dextran 70 as adjuvants to red blood cell concentrates: a study on colloid osmotic pressure changes in vitro.

An in vitro model of surgical bleeding was developed to simulate continuous blood loss and replacement therapy with plasma substitutes and red cell concentrates. The model was used to determine the lowest colloid concentration in vitro for each of the plasma substitutes that sustains colloid osmotic pressure above 2.4 kPa (or 18 mmHg) when used up to the recommended maximal total dose. Plasma, supernatant separated from red cell concentrates and dextran 70, hydroxyethyl starch 120 or albumin were mixed to create dilutions imitating plasma composition in the course of clinical blood loss and replacement therapy. The relative volume of each component was calculated according to the model when the bleeding was equal to multiples of 10% of blood volume up to a blood loss of 120%. Our measurements indicate that the colloid concentrations of 5.0% for albumin, 4.0% for hydroxyethyl starch 120 and 3.5% for dextran 70 preserve colloid osmotic pressure above 2.4 kPa.

Cardiorespiratory function after replacement of blood loss with hydroxyethyl starch 120, dextran-70, and Ringer's acetate in pigs.

The small intestines of 20 anesthetized pigs weighing 12 to 17 kg were exteriorized in a saline-moistened gauze in order to simulate an intra-abdominal operation. During a 2-h period, 4% of the animals' body weight was bled through an arterial cannula in six increments and replaced immediately with one of the following fluids: a) a new medium-MW hydroxyethyl starch (HES 120), b) dextran-70 (DEX), or c) Ringer's acetate (RA). The amount of fluid infused was equal to the amount of blood withdrawn in the plasma substitute groups, but was increased four-fold in the RA group. Five nonbled pigs served as controls. No statistically significant changes occurred within the control group in any of the variables measured. One animal died of hypovolemic shock 3 h after RA administration. Bleeding and fluid infusion caused a 41% and 44% reduction in Hgb in the HES and DEX groups, respectively, while RA caused only a 25% reduction. A prompt increase in cardiac output was detected in animals receiving colloids (52% with HES), and cardiac output was maintained above initial values during the entire 5-h follow-up period. In the RA group, no increase in cardiac output occurred during fluid administration; during the follow-up period, cardiac output decreased consistently. Similarly, stroke volume and arterial pressures were best maintained with HES, but decreased after RA. Oxygen consumption and delivery were highest after HES and lowest in the RA group, where arteriovenous oxygen difference increased throughout the study. We conclude that both colloid solutions were superior to RA, which did not prevent hypovolemia or maintain adequate oxygen transport.

Hydroxyethyl starch 120, dextran 70 and acetated Ringer's solution: hemodilution, albumin, colloid osmotic pressure and fluid balance following replacement of blood loss in pigs.

Twenty healthy pigs weighing 12-17 kg were anesthetized and the small intestines were exteriorized into saline-moistened gauze. During a 2-h period 4% of the animals' body weight was bled through an arterial cannula in six increments and replaced immediately by the fluid tested: hydroxyethyl starch 120 (HES, Plasmafusin, Orion Corp., Mw 120,000), dextran 70 (DEX) and Ringer's acetate (RA). The amount of fluid infused for replacement of blood loss was equal to the amount of blood withdrawn in the colloid groups but fourfold in the RA group. Five non-bled pigs served as controls. After the hemodilution the laparotomy was closed and the animals received only 5% dextrose (2 ml/kg/min) during a 5-h follow-up period. The synthetic colloids caused a more effective dilution of hemoglobin and albumin than did RA. The colloid osmotic pressure (COP) was well maintained by the plasma substitutes but decreased in the RA group to 64% of the initial values. A stable urinary output and no edema formation was found in the HES and DEX groups. The RA animals were unable to excrete the excess crystalloid, which resulted in a strikingly positive fluid balance persisting throughout the study. Thus, the synthetic colloids were superior to RA in expansion of the plasma volume, maintenance of the COP and prevention of fluid accumulation. The effect of the two colloids was similar except that COP was slightly better maintained during the follow-up period in animals which received HES 120.

Comparison of arterial and venous blood samples for the diagnosis of bacteremia in critically ill patients.

We compared the blood culture results obtained either by venipuncture or through an arterial catheter in 51 critically ill patients with 217 clinically suspected episodes of bacteremia. During each episode, three blood culture samples, two arterial and one venous, were drawn within 1 h. One or more cultures were positive in 42 (19%) of the episodes, but there were great discrepancies between the results obtained by the two methods. In only eight cases did both methods give the same microorganism. In eight other episodes, the two arterial cultures were positive while the venous sample was negative, probably indicating a continuous contamination of the catheter system. Pseudomonas aeruginosa and Staphylococcus epidermidis were the two most common microbes. The frequency of positive arterial catheter blood cultures did not increase with the length of catheter use. We conclude that an arterial catheter is not a reliable sampling site for blood cultures and does not replace the conventional venipuncture method.

Pancreatic resection versus peritoneal lavation for acute fulminant pancreatitis. A randomized prospective study.

Thirty-five patients with acute fulminant (hemorrhagic) pancreatitis, verified at laparotomy, were allocated to either pancreatic resection (18 patients) or peritoneal lavation (17 patients) therapy groups. Pancreatic resection was carried out by removing the distal pancreas well cephalad to the portal vein. For peritoneal lavation, two inlet silicone catheters were inserted at laparotomy around the pancreas and an outlet catheter was inserted in the lower abdomen, and the peritoneal cavity was thereafter lavated (1000 ml/hr) with a standard peritoneal dialysis fluid for 7 to 12 days (or until death if met earlier). In other respects, the postoperative care was similar, including intravenous fluids with total parenteral nutrition until oral intake of food was resumed, prophylactic antibiotics (tobramycin and clindamycin) and stress ulcer prophylaxis (cimetidine and antacids). In the resection group, four of the 18 patients (22.2%) died, while in the lavation group eight of the 17 patients (47.1%) died. The most common cause of death was septic complications with multiple organ failure, but one patient in each group died accidentally of airway complications. There was no difference in the incidence of septic complications (sepsis and/or intra-abdominal abscesses), but the incidence and severity of pulmonary and renal complications were greater in the lavation group. However, these complications accumulated to patients who ultimately died. Also, the need for reoperation was greater in the lavation group (20 reoperations/10 patients versus 12 reoperation/eight patients). Yet, the length of overall hospital stay was equal in the two groups. Six of the 14 survivors in the resection group developed diabetes, whereas none of the nine survivors in the lavation group got this complication. The results suggest that pancreatic resection is superior to peritoneal lavation in the management of acute fulminant (hemorrhagic) pancreatitis, decreasing mortality and affording smoother postoperative course. However, these benefits are gained at the expense of higher incidence of postoperative diabetes.

Severe bronchiolitis probably caused by varicella-zoster virus.

An unusual, severe pneumonia probably caused by varicella-zoster virus is reported in a 19-year-old previously healthy man. The diagnosis was based on high titer of varicella-zoster antibodies in serum, and demonstration of varicella-zoster antigen from lung biopsy specimen. The uncommon feature in the pathophysiological course of the disease was the selective hypercarbia that responded well to bronchodilator therapy with theophylline. Furthermore, the patient had no skin manifestations during his illness.

Ventilatory pattern in respiratory failure arising from acute myocardial infarction. II. PtcO2 and PtcCO2 compared to Pao2 and PaCO2 during IMV4 vs IPPV12 and PEEP0 vs PEEP10.

Transcutaneous oxygen and carbon dioxide tensions (PtcO2 and PtcCO2) were compared with PaO2 and PaCO2 values in 9 patients with pulmonary edema due to acute myocardial infarction (AMI) measured during four experimental interventions: (a) intermittent mandatory ventilation (IMV) 4/min + PEEP0 (cm H2O); (b) intermittent positive pressure ventilation (IPPV)12 + PEEP0; (c) IMV4 + PEEP10; and (d) IPPV12 + PEEP10. PtcO2 responded rapidly to the institution of PEEP, the rise correlating well with that in PaO2 both on IMV4 (r = 0.78) and IPPV12 (r = 0.87). On the other hand, correlations between PtcO2 vs CI and PvO2 were poor (r being 0.45 and 0.24, respectively). Transcutaneous oxygen electrode is, thus, useful in monitoring patients with post-AMI pulmonary edema, as it rapidly reflects the effects of ventilatory therapy. A nonheated PtcCO2 sensor was used in 6 patients and a heated electrode in 3 patients. With the nonheated electrode, the correlation between PaCO2 and PtcCo2 was good (r = 0.86) in 5 patients, while r in the 3 patients with the heated electrode was 0.73. One patient having a cardiac index of 1.6 L/min . M2 showed a dissociation in PCO2 values. While PaCO2 remained unchanged, PtcCO2 rose to 73 torr and within some minutes the patient had asystole. PtcCO2 tension generally shows good correlation with PaCO2 and, thus, reflects ventilation. It may also prove to be useful in the early detection of critical low cardiac output states.

Ventilatory pattern in respiratory failure arising from acute myocardial infarction. I. Respiratory and hemodynamic effects of IMV4 vs IPPV12 and PEEP0 vs PEEP10.

Positive end-expiratory pressure of 10 cm H2O (PEEP10) was compared with zero-end-expiratory pressure (PEEP0), intermittent mandatory ventilation (IMV), 4/min, with intermittent positive pressure ventilation (IPPV), 12/min, in 9 patients with pulmonary edema due to acute myocardial infarction (AMI). Systemic and pulmonary arterial pressures, pulmonary capillary wedge pressure (PCWP) and CVP, cardiac output (CO) and blood gases were measured during these four experimental interventions, and related parameters calculated. PaCO2 was 39.3 +/- 0.9 torr during IMV4 and 36.2 +/- 1.3 torr during IPPV12, and PCWP remained between 20-30 mm Hg throughout the study. The ventilatory pattern was changed at random order with the patient serving as his own control. Both PaO2 and PaO2/F102 and VO2 increased while venous admixture (Qsp/Qt) decreased with PEEP10. Cardiac and stroke indices (CI, SI) and oxygen delivery were lower with IPPV12 than they were with IMV4. Both left and right ventricular stroke work (LVSW, RVSW) were higher on IMV4. A moderate PEEP level (up to 10 cm H2O) seems beneficial in post-AMI pulmonary edema and has no significant hemodynamic side effects. The results indicate that of the four alternatives studied, IMV4 with PEEP10 is a ventilatory pattern of choice in the respiratory management of these patients, but each individual patient may require precise titration of each modality to achieve the optimal result.

Comparison of muscle relaxants in clinical use.

A prospective clinical comparison of d-tubocurarine, alcuronium, gallamine and pancuronium was performed in 400 surgical patients. Various parameters usually followed during clinical anaesthesia were recorded from the beginning of, to the recovery from anaesthesia. Endotracheal intubation was performed with or without suxamethonium. Intubation was always possible in 1-3 min when different muscle relaxants were used in the following initial doses: d-tubocurarine 0.4 mg/kg, alcuronium 0.3 mg/kg, gallamine 1.8 mg/kg, and suxamethonium 0.8 mg/kg. However, there was a statistically significant inferiority of the d-tubocurarine and gallamine groups. The use of suxamethonium seemed to shorten the duration of the initial dose of the nondepolarising agents and also to increase especially the dose of gallamine when calculated as mg/kg/h. It should be mentioned that the non-depolarising agents were given soon after suxamethonium without waiting for the return of spontaneous respiration. Pancuronium and alcuronium caused least changes in the cardiovascular parameters. Erythematous skin reactions were seen mostly after the use of d-tubocurarine and suxamethonium. This could depend on histamine liberating potency of these muscle relaxants.