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1.
J Trauma ; 51(6): 1075-82, 2001 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11740256

RESUMO

BACKGROUND: Postinjury small bowel ileus is poorly characterized and may be an important factor in intolerance to enteral nutrition (EN). We, therefore, placed jejunal manometry catheters in high-risk trauma patients. Our hypothesis was that the presence of "fasting migrating motility complex (MMC)" activity and conversion to a "fed pattern" at goal rate of EN would be present in those patients who tolerate jejunal feeding. METHODS: After obtaining baseline fasting manometry pressure tracings, jejunal feeding was advanced stepwise to a set goal while tolerance was monitored and intolerance was treated by a standard approach. RESULTS: Of the 10 study patients, 7 were able to be maintained on EN. Five (50%) had "fasting MMCs" and had good tolerance to early advancement of EN. The remaining five patients did not exhibit "fasting MMCs" and four had poor tolerance to early advancement of EN. Overall, nine patients reached goal rate of EN of which four converted to a "fed pattern." This, however, was not associated with later tolerance to EN. CONCLUSION: EN is feasible following severe traumatic shock. Surprisingly, half of the patients had fasting MMCs. This requires intact neural and motor function and was associated with good tolerance of early EN.


Assuntos
Nutrição Enteral , Obstrução Intestinal/fisiopatologia , Complexo Mioelétrico Migratório , Choque Traumático/fisiopatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Escala de Gravidade do Ferimento , Obstrução Intestinal/etiologia , Jejunostomia , Jejuno/fisiopatologia , Jejuno/cirurgia , Masculino , Manometria , Pessoa de Meia-Idade , Choque Traumático/complicações
2.
Cancer Invest ; 19(1): 23-7, 2001.
Artigo em Inglês | MEDLINE | ID: mdl-11291552

RESUMO

BACKGROUND: A thorough understanding of malignant fibrous histiocytoma (MFH), the most common subtype of soft tissue sarcoma, will lead to improved histologic-specific protocols. METHODS: 126 patients with histologically confirmed MFH were analyzed. The median follow-up was 42 months (range 1-233 months). RESULTS: Overall survival was 58% at 5 years and 38% at 10 years. Grade significantly influenced prognosis, with 10-year survival of 90%, 60%, and 20% for low, intermediate, and high grade tumors, respectively (p = 0.0007). Distant metastases at initial presentation (p = 0.0002) and size of the primary tumor (p = 0.0007) influenced outcome. Neither anatomic site nor depth of the primary tumor were significant prognostic factors. Positive microscopic margins were associated with a decreased disease-free survival (p = 0.006). CONCLUSIONS: Tumor grade, size, and distant metastases at initial presentation remain the most important prognostic factors for MFH. Resection with negative microscopic margins decreased the incidence of local recurrence.


Assuntos
Histiocitoma Fibroso Benigno/diagnóstico , Intervalo Livre de Doença , Histiocitoma Fibroso Benigno/patologia , Histiocitoma Fibroso Benigno/cirurgia , Humanos , Metástase Neoplásica , Recidiva Local de Neoplasia , Prognóstico , Propilaminas , Estudos Retrospectivos
3.
J Trauma ; 50(3): 415-24; discussion 425, 2001 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-11265020

RESUMO

BACKGROUND: Variability and logistic complexity of mechanical ventilatory support of acute respiratory distress syndrome, and need to standardize care among all clinicians and patients, led University of Utah/LDS Hospital physicians, nurses, and engineers to develop a comprehensive computerized protocol. This bedside decision support system was the basis of a multicenter clinical trial (1993-1998) that showed ability to export a computerized protocol to other sites and improved efficacy with computer- versus physician-directed ventilatory support. The Memorial Hermann Hospital Shock Trauma intensive care unit (ICU) (Houston, TX; a Level I trauma center and teaching affiliate of The University of Texas Houston Medical School) served as one of the 10 trial sites and recruited two thirds of the trauma patients. Results from the trauma patient subgroup at this site are reported to answer three questions: Can a computerized protocol be successfully exported to a trauma ICU? Was ventilator management different between study groups? Was patient outcome affected? METHODS: Sixty-seven trauma patients were randomized at the Memorial Hermann Shock Trauma ICU site. "Protocol" assigned patients had ventilatory support directed by the bedside respiratory therapist using the computerized protocol. "Nonprotocol" patients were managed by physician orders. RESULTS: Of the 67 trauma patients randomized, 33 were protocol (age 40 +/- 3; Injury Severity Score [ISS] 26 +/- 3; 73% blunt) and 34 were nonprotocol (age 38 +/- 2; ISS 25 +/- 2; 76% blunt). For the protocol group, the computerized protocol was used 96% of the time of ventilatory support and 95% of computer-generated instructions were followed by the bedside respiratory therapist. Outcome measures (i.e., survival, ICU length of stay, morbidity, and barotrauma) were not significantly different between groups. Fio2 > or = 0.6 and Pplateau > or = 35 cm H2O exposures were less for the protocol group. CONCLUSION: A computerized protocol for bedside decision support was successfully exported to a trauma center, and effectively standardized mechanical ventilatory support of trauma-induced acute respiratory distress syndrome without adverse effect on patient outcome.


Assuntos
Protocolos Clínicos/normas , Cuidados Críticos/normas , Traumatismo Múltiplo/complicações , Respiração com Pressão Positiva/métodos , Respiração com Pressão Positiva/normas , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia , Adulto , Gasometria , Técnicas de Apoio para a Decisão , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Morbidade , Traumatismo Múltiplo/classificação , Traumatismo Múltiplo/terapia , Avaliação de Resultados em Cuidados de Saúde , Sistemas Automatizados de Assistência Junto ao Leito/normas , Respiração com Pressão Positiva/efeitos adversos , Guias de Prática Clínica como Assunto/normas , Síndrome do Desconforto Respiratório/metabolismo , Síndrome do Desconforto Respiratório/mortalidade , Análise de Sobrevida , Centros de Traumatologia
5.
Am J Surg ; 182(6): 630-8, 2001 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11839329

RESUMO

BACKGROUND: Damage control and decompressive laparotomies salvage severely injured patients who would have previously died. Unfortunately, many of these patients develop open abdomens. A variety of management strategies exist. The end result in many cases, however, is a large ventral hernia that requires a complex repair 6 to 12 months after discharge. We instituted vacuum-assisted wound closure (VAWC) to achieve early fascial closure and eliminate the need for delayed procedures. METHODS: For 12 months ending June 2000, 14 of 698 trauma intensive care unit admissions developed open abdomens and were managed with VAWC dressing. This was changed every 48 hours in the operating room with serial fascial approximation until complete closure. RESULTS: Fascial closure was achieved in 13 patients (92%) in 9.9 +/- 1.9 days, and 2.8 +/- 0.6 VAWC dressing changes were performed. There were 2 wound infections, no eviscerations, and no enteric fistulas. CONCLUSIONS: Use of VAWC can safely achieve early fascial closure in more than 90% of trauma patients with open abdomens.


Assuntos
Traumatismos Abdominais/cirurgia , Músculos Abdominais/cirurgia , Adulto , Fasciotomia , Feminino , Humanos , Laparotomia , Masculino , Terapia de Salvação/métodos , Procedimentos Cirúrgicos Operatórios/métodos
6.
J Neurosurg ; 93(6): 932-9, 2000 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11117865

RESUMO

OBJECT: In this study the authors describe secular trends in the incidence of three glial tumors--glioblastoma multiforme (GBM), astrocytoma not otherwise specified (ANOS), and anaplastic astrocytoma (AA)--in New York state from 1976 through 1995. They also describe the effect of age and sex on the relative risk (RR) for these tumors, specifically GBM. METHODS: Crude, age-, and sex-specific incidence rates were calculated for each tumor type from 1976 to 1995 by using data from the New York State Cancer Registry. Age-adjusted incidence rates were calculated by the direct standardization procedure, in which the 1970 United States Census Population Standard Million is used. The RR of GBM for the female population was calculated and plotted. Statistical comparisons were made using Pearson's correlation coefficient and regression analysis with the coefficient of variation. CONCLUSIONS: The age-adjusted incidence of these three glial tumors increased during the study period. Increases in age-specific incidence of GBM were primarily limited to patients 60 years of age or older. The reasons for these increases cannot be fully explained with the data. Those in the female population had a lower risk of developing these tumors than those in the male. For GBM, the protective effect of sex was first evident at the approximate age of menarche, was greatest at the approximate age of menopause, and decreased in postmenopausal age strata. The overall protective effect of female sex and the described trend in RR for GBM in the female population suggests that sex hormones and/or genetic differences between males and females may play a role in the pathogenesis of this tumor.


Assuntos
Astrocitoma/epidemiologia , Neoplasias Encefálicas/epidemiologia , Glioblastoma/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , New York , Risco
7.
J Trauma ; 49(6): 1089-95, 2000 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11130494

RESUMO

OBJECTIVE: Patients with thoracic aortic injury (TAI) usually have sustained other major trauma, and may require aggressive shock resuscitation. In the 24 hours after aortic repair and during resuscitation, our cardiothoracic surgeons request intravenous nitroprusside to maintain mean arterial pressure (MAP) less than 90 mm Hg to minimize bleeding at the repair. We compared the resuscitation response of patients who sustained major torso trauma (MTT) and TAI with that of patients who had MTT with no TAI to determine whether nitroprusside can effectively control MAP during resuscitation and whether use of nitroprusside, because of its peripheral vasodilatory effects, is associated with a favorable resuscitation response. METHODS: During the 9-month study period, 11 patients who sustained TAI and 38 patients who sustained MTT with no TAI met multiple organ failure risk/shock criteria and were resuscitated by a standardized protocol emphasizing volume loading and hemoglobin replacement to maintain systemic oxygen delivery index (DO2I) > or = 600 mL O2/min-m2 for the first 24 intensive care unit hours. For TAI patients, postoperative management included intravenous nitroprusside infusion titrated by the bedside nurse to maintain mean arterial pressure (MAP) less than 90 mm Hg during the same 24 hours. Data were obtained prospectively during resuscitation. Retrospectively, the resuscitation response of TAI and non-TAI patients was compared. RESULTS: For the TAI group, nitroprusside effectively controlled MAP (range, 77-87 mm Hg); for the non-TAI group, mean MAP exceeded 95 mm Hg within 5 hours. During the first 8 hours, MAP, pulmonary capillary wedge pressure, and systemic vascular resistance index were less, and DO2I was greater for the TAI than for the non-TAI group. The resuscitation goal of DO2I > or = 600 mL O2/ min-m2 was attained at 4 hours for the TAI group, and was attained at 12 hours for the non-TAI group. No revisions of aortic repairs were required during or as a result of resuscitation. CONCLUSION: During aggressive shock resuscitation, control of MAP using nitroprusside is feasible and is associated with a favorable resuscitation response. Nitroprusside may be a useful adjunct during shock resuscitation of MTT as a vasoactive agent that promotes peripheral tissue perfusion.


Assuntos
Aorta Torácica/lesões , Protocolos Clínicos/normas , Nitroprussiato/uso terapêutico , Choque Hemorrágico/tratamento farmacológico , Vasodilatadores/uso terapêutico , Adulto , Aorta Torácica/cirurgia , Feminino , Hidratação , Humanos , Infusões Intravenosas , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Nitroprussiato/administração & dosagem , Período Pós-Operatório , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Texas , Traumatismos Torácicos/cirurgia , Resultado do Tratamento , Vasodilatadores/administração & dosagem
8.
Surgery ; 128(4): 556-63, 2000 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-11015088

RESUMO

BACKGROUND: Sentinel lymph node biopsy (SLNB) has rapidly evolved into the standard of care for clinically node-negative melanoma. Since adopting sentinel lymph node (SLN) technology in 1993, we have periodically reviewed our institution's results and made several modifications. METHODS: From January 1993 to December 1998, 182 patients with clinically node-negative primary cutaneous melanoma underwent SLNB. Charts were retrospectively reviewed and assessed for the technique for the identification of the SLN, the pathologic analysis, and the use of intraoperative frozen section. RESULTS: The accuracy of SLN identification improved from 91% to 100% with the combination of isosulfan blue dye and radiolabeled colloid over isosulfan blue dye alone. Routine versus selective lymphoscintigraphy identified 7 in-transit SLNs and increased detection of dual nodal basin drainage (15%-27%). Identification of micrometastases in the SLN increased from 14% to 24% after a modification of pathologic evaluation. The positive SLN was the only involved node in most patients (80%). Intraoperative frozen section had a sensitivity of 58% and was of benefit in only 13 of 124 patients (10%). CONCLUSIONS: Several modifications to the identification of the SLNs and the detection of metastatic melanoma have improved our outcome with SLNB. A careful, periodic review of results to identify areas for improvement at each institution is crucial to the success of SLNB for melanoma.


Assuntos
Melanoma/secundário , Biópsia de Linfonodo Sentinela/métodos , Neoplasias Cutâneas/patologia , Adulto , Idoso , Institutos de Câncer , Feminino , Secções Congeladas , Humanos , Período Intraoperatório , Metástase Linfática , Masculino , Melanoma/epidemiologia , Melanoma/cirurgia , Pessoa de Meia-Idade , New York , Pepsinogênio C , Fatores de Risco , Corantes de Rosanilina , Sensibilidade e Especificidade , Biópsia de Linfonodo Sentinela/normas , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/cirurgia
9.
Arch Surg ; 135(6): 688-93; discussion 694-5, 2000 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-10843365

RESUMO

HYPOTHESIS: Old and young trauma patients are capable of hyperdynamic response during standardized shock resuscitation. DESIGN: The responses of old and young trauma patients resuscitated using a standardized protocol are compared in an inception cohort study. A standardized resuscitation protocol was used to attain and maintain an oxygen delivery index of 600 mL/min x m2 or greater (DO2I > or = 600) for the first 24 hours in the intensive care unit. Interventions, responses, and outcomes for old (> or = 65 years) and young (<65 years) patients are described. Data were analyzed using analysis of variance, the chi2 test, and the t test; P<.05 was considered significant. SETTING: A 20-bed shock trauma intensive care unit in a regional level I trauma center. PATIENTS: Patients at high risk of postinjury multiple organ failure, ie, major organ or vascular injury and/or skeletal fractures, initial base deficit of 6 mEq/L or greater, need for 6 units or more of packed red blood cells in the first 12 hours, or age of 65 years or older with any 2 previous criteria. INTERVENTIONS: Pulmonary artery catheter, crystalloid fluid infusion, packed red blood cell transfusion, and moderate inotrope support, as needed in that sequence, to attain DO2I > or = 600. MAIN OUTCOME MEASURES: Intensive care unit length of stay and survival. RESULTS: During 19 months ending June 1999, 12 old patients (58% male; age, 76 +/- 2 years [mean +/- SEM] [P<.0011; Injury Severity Score, 20 +/- 2 [P=.02]) and 54 young patients (61% male; age, 37 +/- 2 years; Injury Severity Score, 32 +/- 2) were resuscitated. Initially, for old patients (cardiac index, 2.0 +/- 0.2 L/min x m2) and for young patients (cardiac index, 3.0 +/- 0.2 L/min x m2; P=.01), 24-hour volumes were as follows: 16 +/- 3 L of crystalloid and 12 +/- 3 units of packed red blood cells for the old patients and 21 +/- 2 L of crystalloid and 19 +/- 2 units of packed red blood cells for the young patients. For old patients, 9 (75%) attained DO2I > or = 600, and 11 (92%) survived 7 or more days and 5 (42%) 30 or more days. For young patients, 45 (83%) attained the DO2I goal, and 48 (89%) survived 30 or more days. Intensive care unit length of stay was 25 +/- 9 days for the old patients and 23 +/- 2 days for the young patients. CONCLUSIONS: Elderly patients have initially depressed cardiac index but generate hyperdynamic response. Although ultimate outcome is poorer than in the younger cohort, resuscitation is not futile.


Assuntos
Ressuscitação , Ferimentos não Penetrantes/terapia , Adulto , Idoso , Estudos de Casos e Controles , Estudos de Coortes , Transfusão de Eritrócitos , Feminino , Hidratação , Hemodinâmica/fisiologia , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Artéria Pulmonar , Ressuscitação/métodos , Ressuscitação/mortalidade , Ferimentos não Penetrantes/mortalidade
10.
J Trauma ; 48(4): 637-42, 2000 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-10780595

RESUMO

BACKGROUND: Near infrared (NIR) spectrometry offers a noninvasive monitor of tissue hemoglobin O2 saturation and has been developed to report a quantitative clinical variable, StO2 [= HbO2/(HbO2 + Hb)]. In this study, a prototype NIR oximeter was used to investigate the hypothesis that changes in systemic O2 delivery index (D(O2)I) would be reflected by changes in StO2 in skeletal muscle, subcutaneous tissue, or both, as reperfusion occurs during shock resuscitation. StO2 was also compared with other indices of severity of shock or adequacy of resuscitation, including arterial base deficit, lactate, gastric mucosal P(CO2) (PgCO2), and mixed venous hemoglobin O2 saturation (S(VO2)). METHODS: Skeletal muscle and subcutaneous tissue StO2 were monitored simultaneously in eight severely injured trauma patients (88% blunt mechanism; age, 42 +/- 6 years; Injury Severity Score, 27 +/- 3) during standardized shock resuscitation in the intensive care unit with the primary goal of D(O2)I > or = 600 mL O2/min/m2 for 24 hours, and for an additional 12 hours during transition from resuscitation to standard intensive care unit care. RESULTS: Skeletal muscle StO2 increased significantly from 15 +/- 2% (mean +/- SEM) at the start of resuscitation to 49 +/- 14% at 24 hours, and to approximately 55% from 25 to 36 hours. Subcutaneous tissue StO2 approximately 82% and was significantly greater than skeletal muscle StO2 throughout. D(O2)I increased significantly from 372 +/- 54 to 718 +/- 47 mL O2/min/m2 during resuscitation. Over 36 hours, mean D(O2)I and skeletal muscle StO2 were highly correlated (r = 0.95). Neither D(O2)I-PgCO2 nor D(O2)I-S(VO2) were significantly correlated; neither S(VO2) nor subcutaneous tissue StO2 changed significantly. CONCLUSION: Hemoglobin O2 saturation was monitored noninvasively and simultaneously in skeletal muscle and subcutaneous tissues as StO2 (%) by using a prototype NIR oximeter. Skeletal muscle StO2 tracked systemic O2 delivery during and after resuscitation. As a rapidly deployable, noninvasive monitor of peripheral tissue oxygenation and O2 delivery, skeletal muscle StO2 obtained using NIR spectrometry would be useful to guide resuscitation in the intensive care unit, to monitor resuscitation status in the operating room, and, potentially, in combination with indicators such as base deficit and lactate, to detect shock during initial assessment of the severe trauma patient in the emergency department.


Assuntos
Hemoglobinas/análise , Monitorização Fisiológica/métodos , Oximetria/métodos , Ressuscitação , Choque Traumático/terapia , Espectroscopia de Luz Próxima ao Infravermelho , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/diagnóstico , Músculo Esquelético/química , Índices de Gravidade do Trauma
11.
Am J Surg ; 179(1): 7-12, 2000 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-10737569

RESUMO

BACKGROUND: Nonocclusive bowel necrosis (NOBN) has been associated with early enteral nutrition (EN). The purpose of this study was to determine the incidence of this complication in our trauma intensive care unit population and to define a typical patient profile vulnerable to NOBN. METHODS: Thirteen cases of NOBN were identified among 4,311 patients (0.3%) over a 64-month period ending October 1998. Their charts were analyzed for a variety of clinical data, including prospective EN tolerance data in 4. RESULTS: Twelve (92%) patients were enterally fed prior to diagnosis for 10 +/- 8 days (range 3 to 21). Tachycardia (n = 12, 92%); fever/hypothermia, (n = 12, 92%), and an abnormal white blood cell count (n = 11, 85%) were consistently present. Abdominal distention was common but tended to be a late sign (n = 12). Seven (56%) survived. In 4 patients with tolerance data, 3 reached the goal rate of feeds prior to diagnosis. Two became distended at >12 hours from diagnosis. Gastric tonometry demonstrated a decreased NgpHi (<7.30) after starting EN in all 3 in whom it was monitored. CONCLUSIONS: NOBN developed in 0.3% of our trauma patients. Onset occurs in the second week in high-acuity patients who have had a period of EN tolerance. Clinical findings resemble bacterial sepsis with tachycardia, fever, and leukocytosis. Gastrointestinal specific signs are not consistent or occur late. Thus, we could not identify an early, useful clinical indicator. Gastric carbon dioxide tonometry may detect a vulnerable subgroup of patients.


Assuntos
Estado Terminal , Nutrição Enteral , Intestinos/patologia , Ferimentos e Lesões , Adulto , Nutrição Enteral/efeitos adversos , Feminino , Humanos , Incidência , Intestinos/irrigação sanguínea , Isquemia/diagnóstico , Isquemia/epidemiologia , Isquemia/etiologia , Masculino , Necrose , Fatores de Tempo , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia
12.
Proc AMIA Symp ; : 251-5, 1999.
Artigo em Inglês | MEDLINE | ID: mdl-10566359

RESUMO

200 adult respiratory distress syndrome patients were included in a prospective multicenter randomized trial to determine the efficacy of computerized decision support. The study was done in 10 medical centers across the United States. There was no significant difference in survival between the two treatment groups (mean 2 = 0.49 p = 0.49) or in ICU length of stay between the two treatment groups when controlling for survival (F(1df) = 0.88, p = 0.37.) There was a significant reduction in morbidity as measured by multi-organ dysfunction score in the protocol group (F(1df) = 4.1, p = 0.04) as well as significantly lower incidence and severity of overdistension lung injury (F(1df) = 45.2, p < 0.001). We rejected the null hypothesis. Efficacy was best for the protocol group. Protocols were used for 32,055 hours (15 staff person years, 3.7 patient years or 1335 patient days). Protocols were active 96% of the time. 38,546 instructions were generated. 94% were followed. This study indicates that care using a computerized decision support system for ventilator management can be effectively transferred to many different clinical settings and significantly improve patient morbidity.


Assuntos
Respiração Artificial , Síndrome do Desconforto Respiratório/terapia , Terapia Assistida por Computador , Adulto , Protocolos Clínicos , Sistemas de Apoio a Decisões Clínicas , Humanos , Estudos Prospectivos , Síndrome do Desconforto Respiratório/mortalidade , Análise de Sobrevida
13.
Crit Care Med ; 27(9): 1869-77, 1999 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-10507612

RESUMO

OBJECTIVES: To monitor PO2, PCO2, and pH in the interstitium of skeletal muscle (PmO2, PmCO2, and pHm) during hemorrhage, shock, and resuscitation using fiber-optic sensors and to compare Pco2 and pH in the interstitium of gastric mucosa (PrCO2 and pHi) obtained using gastric CO2 tonometry. DESIGN: Prospective, controlled observational study in an acute experimental preparation. SETTING: Physiology laboratory in a university medical school. SUBJECTS: Nine mongrel dogs (20 to 35 kg). INTERVENTIONS: Anesthesia was induced with pentobarbital (25 mg/kg iv) and maintained (10 mg/hr) after hemorrhagic shock. Mechanical ventilation was established to maintain baseline PaCO2 approximately 35 torr. Arterial, venous, and pulmonary artery catheters were placed. Blood flow probes were placed around the right femoral artery and vein. A probe (0.5 mm in diameter) with fiber-optic PO2, PCO2, and pH sensors was placed percutaneously in the adductor muscle of the right thigh. A gastric tonometer catheter was placed in the stomach lumen. After baseline data collection, controlled hemorrhage to mean arterial pressure (MAP) of 45 to 50 mm Hg was maintained for 1 hr. Shed blood was then reinfused. Blood gas, hemodynamic, and gastric tonometric data were collected during shock and reinfusion at 30-min intervals and hourly after reinfusion for 4 hrs. Normothermia was maintained. MEASUREMENTS AND MAIN RESULTS: PmO2 decreased rapidly from 42 +/- 13 torr (mean +/- sD) to 13 +/- 9 torr within 15 mins and to 6 +/-4 torr within 30 mins of MAP reaching 45 mm Hg, and it recovered to baseline with reinfusion. pHm decreased gradually from 7.23 +/-0.09 to 6.89 +/- 0.25 during the 1-hr shock period and increased slowly toward baseline after reinfusion. pHi decreased from 7.43 +/- 0.14 to 6.91 +/- 0.23, and on average it returned to baseline 2 hrs after reinfusion. PmCO2 increased from 50 +/- 12 to 113 +/- 49 torr, increased further to 124 +/- 73 torr during reinfusion, and returned slowly toward baseline after reinfusion. PrCO2 increased from 35 +/- 8 to 60 +/- 19 torr and returned to baseline within 15 mins after reinfusion. During shock and reinfusion, oxygen delivery, mixed venous PO2, mixed venous oxygen saturation, and PmO2 responded with similar time courses. After reinfusion, on average, PmO2 exceeded baseline PmO2 and mixed venous PO2, and oxygen availability exceeded demand, suggesting an oxygen consumption defect. On average, PmCO2 and pHm did not return to baseline values 4 hrs after reinfusion, suggesting the persistence of anaerobic metabolic effects in skeletal muscle beyond the relatively short time that is required to reestablish baseline MAP, blood flow rates, oxygen delivery, PrCO2, and pHi. CONCLUSIONS: PmO2, PmCO2, and pHm, monitored simultaneously using fiber-optic sensors in a single, small probe placed percutaneously, appear to indicate greater severity of shock and more prolonged resuscitation than conventional systemic or gastric tonometric variables.


Assuntos
Dióxido de Carbono/metabolismo , Mucosa Gástrica/metabolismo , Músculo Esquelético/metabolismo , Oxigênio/metabolismo , Choque Hemorrágico/metabolismo , Animais , Cuidados Críticos , Cães , Espaço Extracelular/metabolismo , Tecnologia de Fibra Óptica , Concentração de Íons de Hidrogênio , Manometria , Fibras Ópticas , Oximetria/métodos , Pressão Parcial , Ressuscitação
14.
15.
J Trauma ; 46(2): 271-9, 1999 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-10029033

RESUMO

OBJECTIVE: To test a standardized protocol for management of intracranial pressure (ICP) after severe head injury (i.e., traumatic brain injury), consistent with published guidelines. METHODS: We compared prospective use of a standardized protocol for ICP management in 12 patients with severe head injuries and retrospective ICP management using preprinted hospital orders in combination with ad hoc physician orders in 12 historical control patients with severe head injuries. With the standardized protocol, flow-chart decision logic diagrams were applied at patient bedside by critical care practitioners, with nursing shift review. RESULTS: ICP and its variation during the first 6 intensive care unit days was less for the standardized protocol- than for the preprinted order-managed group (p <0.001), indicating better process control with the standardized protocol. ICP exceeded 25 mm Hg for less time for the standardized protocol group (182 hours; 15+/-23 hours/patient) than for prescribed order group (429 hours; 36+/-28 hours/patient) (p = 0.03). On average, ICP exceeded 20 mm Hg for 2.3 days for the standardized protocol-managed group and for 4.7 days for the prescribed order-managed group. Cerebral perfusion pressure was significantly greater and its variation less for the standardized protocol- than for the preprinted order-managed group. Fewer interventions were made for ICP management for the standardized protocol- than for the preprinted order-managed patients (601 vs. 876), suggesting more effective nursing time using the standardized protocol. CONCLUSION: ICP management was more consistent, and intracranial hypertension was better controlled, in patients managed according to a standardized, data-driven protocol for escalation and weaning of therapies in response to immediate patient needs. We recommend computerized implementation and a randomized clinical trial to compare the protocol with prescribed orders.


Assuntos
Algoritmos , Protocolos Clínicos/normas , Traumatismos Craniocerebrais/complicações , Cuidados Críticos/métodos , Árvores de Decisões , Hipertensão Intracraniana/diagnóstico , Hipertensão Intracraniana/terapia , Pressão Intracraniana , Humanos , Hipertensão Intracraniana/etiologia , Hipertensão Intracraniana/fisiopatologia , Monitorização Fisiológica , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Análise de Sobrevida , Terapia Assistida por Computador , Fatores de Tempo
16.
J Crit Care ; 13(4): 190-7, 1998 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-9869546

RESUMO

PURPOSE: The purpose of this study was to test the performance of a patient attached, on demand ex vivo arterial blood gas (ABG) monitor, and to compare the frequency of ABG analysis using the monitor, where the monitor was operated by intensive care unit (ICU) staff on shock trauma and neurosurgical intensive care patients for < or = 6 days, with standard clinical laboratory analysis. MATERIALS AND METHODS: The ABG monitor (SensiCath; Optical Sensors Inc., Minneapolis, MN) incorporates fiber optic pH, PCO2, PO2, and thermistor temperature sensors in a 0.3-mL sensor chamber that attaches in line with the patient's arterial pressure tubing and connects via a fiberoptic cable to a bedside instrument. The monitor and standard clinical laboratory performance were compared following an institutionally approved protocol. Adult ICU patients (n = 30) were studied for whom an arterial cannula was required, the expected ICU stay was > 72 hours, > or = 2 ABG analyses/day were anticipated, and informed consent had been obtained. Paired comparison ABG analyses and quality assurance checks were performed daily. The frequency of ABG analyses in this study, for which monitor values were used for clinical decision making, was compared with the frequency previously reported for the same ICUs, for which the monitor and laboratory results were compared but only the latter were used for clinical decision making. RESULTS: Five hundred ABG analyses, 436 over the first 72 hours, were obtained using the monitor for patient management over 3,248 patient hours (85 +/- 47 hours/patient). Monitor-laboratory comparison ABG analyses (n = 258) indicated stable performance over 6 days: For pH, the range of laboratory measurements was 7.200 to 7.540, accuracy (mean difference between monitor and laboratory measurement) was +0.013, and precision (standard deviation of difference between monitor and laboratory measurements) was +/-0.031. For PCO2, range: 18 to 78.5, accuracy: -0.8, precision: +/-3.4 mm Hg. For PO2, range: 41.0 to 344.0, accuracy: +2.3, precision: +/-12.8 mm Hg. The frequency of ABG analyses obtained using the monitor (ie, 15.0 +/- 11.6 ABGs/patient/72 hours) was significantly greater than that using the clinical laboratory (ie, 8.8 +/- 4.2 ABGs/patient/72 hours) (P = .01). CONCLUSION: The ABG monitor provides performance comparable to standard clinical laboratory analysis for < or = 6 days (< or = 144 hours), consistent with ICU arterial cannula changeout schedules. More frequent ABG analyses are obtained by critical care practitioners using the monitor compared with the clinical laboratory system, suggesting that clinical decision making based on ABG data may be limited by the frequency of ABG analysis.


Assuntos
Gasometria/instrumentação , Adulto , Análise de Variância , Técnicas de Laboratório Clínico , Estado Terminal , Desenho de Equipamento , Tecnologia de Fibra Óptica , Humanos , Monitorização Fisiológica/instrumentação , Fibras Ópticas , Reprodutibilidade dos Testes
17.
Acta Neurochir Suppl ; 71: 177-82, 1998.
Artigo em Inglês | MEDLINE | ID: mdl-9779178

RESUMO

Simultaneous monitoring of brain parenchyma pO2, pCO2, and pH (PbO2, PbCO2 and pHb) has been tested in ICU environments using fiber optic sensors incorporated in probes 0.5 mm in diameter. An Institutionally approved protocol was used to test the concept and technology for monitoring PbO2, PbCO2 and pHb, and to observe the effects of injury and therapy interventions on each of the variables monitored, including ICP, the clinical standard. ICP and fiber optic pO2, pCO2 and pH probes were placed in 10 SCHI patients at bedside in the ICU using sterile technique. The probes remained in place for the duration of ICP monitoring, and were functional in the ICU environment for up to 10 days. Trend patterns recurred in this series of SCHI patients: Extreme PbCO2 (high) and pHb (low) are associated with poor perfusion; increasing pbCO2 and decreasing pHb may be early indicators of ICP crisis, i.e. ICP > 20 mm Hg that tends to be unresponsive to therapy, and; pentobarbital "loading" and maintenance is associated with increased pbO2. These preliminary results from monitoring pbO2, pbCO2 and pHb in SCHI patients indicate that fiber optic sensor technology functions and is able to be used in this application. Trend patterns from this data may further indicate practical utility as a more direct monitor of the delicate balance between tissue perfusion and cell metabolism than ICP alone.


Assuntos
Equilíbrio Ácido-Base/fisiologia , Lesões Encefálicas/fisiopatologia , Dióxido de Carbono/sangue , Pressão Intracraniana/fisiologia , Monitorização Fisiológica/instrumentação , Oxigênio/sangue , Adolescente , Adulto , Encéfalo/irrigação sanguínea , Lesões Encefálicas/terapia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/terapia , Cavidades Cranianas/fisiopatologia , Feminino , Humanos , Concentração de Íons de Hidrogênio , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/fisiopatologia , Traumatismo Múltiplo/terapia , Pentobarbital/administração & dosagem , Prognóstico , Proibitinas , Sensibilidade e Especificidade
19.
Ann Surg Oncol ; 5(1): 54-63, 1998.
Artigo em Inglês | MEDLINE | ID: mdl-9524709

RESUMO

BACKGROUND: The impact on survival by components of a surveillance program (physical examination, blood tests, and chest radiograph) used to detect recurrences in patients with cutaneous melanoma was assessed. METHODS: Data were collected from medical records and tumor registry information on a historical cohort of 1004 patients who presented with AJCC Stage I or II cutaneous melanoma at Roswell Park Cancer Institute from 1971 through 1995. RESULTS: Information on method of detection was available on 154 out of 174 identified first recurrences (89%). Physical examination detected 72% of recurrences, constitutional symptoms indicated 17% of recurrences, and chest radiograph revealed 11% of recurrences. Blood tests did not predict any recurrence. Only 9 of 17 patients with recurrences detected by chest radiograph alone underwent curative surgical resection. These patients had a statistically significant prolonged survival after diagnosis of recurrence compared to those surgical candidates who did not undergo resection. There was no statistically significant difference in overall survival between patients with asymptomatic pulmonary recurrences and those whose pulmonary recurrences were detected after symptoms of metastatic disease had developed. CONCLUSIONS: Most recurrences are detected on physical examination. Blood tests have no role in surveillance programs. Chest radiographs can detect pulmonary recurrences in a small number of asymptomatic patients at a stage when surgery may prolong survival.


Assuntos
Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/secundário , Melanoma/patologia , Recidiva Local de Neoplasia/diagnóstico , Neoplasias Cutâneas/patologia , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Análise de Sobrevida
20.
J Trauma ; 44(1): 119-27, 1998 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-9464759

RESUMO

OBJECTIVE: To test fiber-optic PO2, PCO2, and pH sensors placed in skeletal muscle as monitors of hemorrhage, shock, and resuscitation, compared with mean arterial blood pressure, cardiac output, and blood gas variables. DESIGN: Observational study in physiology laboratory, using a canine controlled hemorrhagic shock model. MATERIALS AND METHODS: Mongrel dogs (20-35 kg; n = 10) were monitored with arterial, venous, and pulmonary artery catheters. A probe (0.5 mm in diameter) with fiber-optic PO2, PCO2, and pH sensors was placed percutaneously in the adductor muscle of the right medial thigh. Mean arterial blood pressure of 45 to 50 mm Hg was maintained for 1 hour with controlled hemorrhage, after which shed blood was reinfused. The animals were monitored for 4 hours after reinfusion. MEASUREMENTS AND MAIN RESULTS: Skeletal muscle PO2 (PmO2) decreased from 31+/-9 to 5+/-4 mm Hg during shock and recovered with reinfusion. Skeletal muscle pH (pHm) decreased from 7.24+/-0.10 to 6.94+/-0.12 during shock, to 6.90+/-0.13 with reinfusion, and recovered to near baseline 2 hours after reinfusion. PmCO2 increased from 48+/-14 to 134+/-86 mm Hg during shock, to 138+/-92 mm Hg with a time course inverse to pHm, and recovered to near baseline 30 minutes after reinfusion. On average, skeletal muscle PCO2 (PmCO2) and pHm did not recover to baseline, possibly indicating persistent anaerobic metabolic effects. O2 delivery, mixed venous PO2, mixed venous O2, saturation and PmO2 responded with similar time courses. CONCLUSION: PmO2, PmCO2, and pHm can be monitored simultaneously for several hours with fiber-optic sensors in a single, small probe. PmO2 may provide information comparable to O2 delivery. PmCO2 may reflect adequacy of perfusion. pHm may indicate success of resuscitation. This technology may offer new insight into the extent of injury and refinement of shock resuscitation and monitoring.


Assuntos
Dióxido de Carbono/metabolismo , Músculo Esquelético/metabolismo , Oxigênio/metabolismo , Ressuscitação , Choque Hemorrágico/metabolismo , Animais , Modelos Animais de Doenças , Cães , Hemodinâmica , Concentração de Íons de Hidrogênio , Monitorização Fisiológica , Choque Hemorrágico/sangue , Choque Hemorrágico/fisiopatologia , Choque Hemorrágico/terapia
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