危重患者腹腔内高压的发生率及其危险因素评估

目的探讨危重患者腹腔内高压(IAH)的发病率及相关危险因素。 方法采用前瞻性研究方法,对2013年7～11月期间入住广州市第一人民医院重症加强护理病房(ICU)的54例危重患者,经膀胱尿管间接测定腹腔内压力,记录人口学特征、入住ICU时的主要诊断、是否辅助通气及呼气末正压值、腹部手术情况、临床检验结果、腹围、中心静脉压、液体平衡、危重评分等指标,并采用logistic回归分析探讨IAH的危险因素。 结果危重患者的IAH发生率为37.0%(20/54),其中Ⅰ级10例,Ⅱ级8例,Ⅲ级2例,Ⅳ级0例。IAH患者较非IAH患者拥有较高急性生理与慢性健康评分[(20.1±6.2)分,(14.9±5.6)分,t＝8.04,P＝0.000]、贯续器官衰竭估计评分[(10.4±6.4)分,(5.5±4.3)分,t＝7.31,P<0.05]及中心静脉压[(10.4±2.8)mmHg,(8.9±2.0)mmHg,t＝6.21,P<0.05](1mmHg＝0.133kpa),相关危险因素有机械通气、腹腔积液、感染性休克、胆道疾病(均P<0.05)。 结论ICU危重患者的IAH发生率较高,且以轻中度为主,与机械通气、腹腔积液、感染性休克及胆道系统疾病密切相关。     

Assessing illness severity and outcome in critically ill patients

Severity of illness scores have great potential to improve use of scarce resources and to help monitor quality of care. Injury severity scores can reliably separate trauma patients into high- and low-mortality groups, but have limitations when applied in triage decision making. Specific predictive models for chest pain patients have improved admitting practices in some emergency departments. Univariate predictors of survival include age, severity of illness, and presence of chronic illnesses, especially cancer. General multivariate models for intensive care patients have correctly categorized hospital outcome in approximately 85 per cent of cases when applied in a retrospective fashion. These models are insufficiently precise for application to individual patients; but they may be helpful in assessing quality of care in the intensive care unit, in assessing efficacy of new technologies, and in utilization review audits.     

Arterial carboxyhemoglobin level and outcome in critically ill patients

OBJECTIVE: Arterial carboxyhemoglobin is elevated in patients with critical illness. It is an indicator of the endogenous production of carbon monoxide by the enzyme heme oxygenase, which modulates the response to oxidant stress. The objective was to explore the hypothesis that arterial carboxyhemoglobin level is associated with inflammation and survival in patients requiring cardiothoracic intensive care. DESIGN: Prospective, observational study. SETTING: A cardiothoracic intensive care unit. PATIENTS: All patients admitted over a 15-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Arterial carboxyhemoglobin, bilirubin, and standard biochemical, hematologic, and physiologic markers of inflammation were measured in 1,267 patients. Associations were sought between levels of arterial carboxyhemoglobin, markers of the inflammatory response, and clinical outcome. Intensive care unit mortality was associated with lower minimum and greater maximal carboxyhemoglobin levels (p < .0001 and p < .001, respectively). After adjustment for age, gender, illness severity, and other relevant variables, a lower minimum arterial carboxyhemoglobin was associated with an increased risk of death from all causes (odds risk of death, 0.391; 95% confidence interval, 0.190-0.807; p = .011). Arterial carboxyhemoglobin correlated with markers of the inflammatory response. CONCLUSIONS: Both low minimum and high maximum levels of arterial carboxyhemoglobin were associated with increased intensive care mortality. Although the heme oxygenase system is protective, excessive induction may be deleterious. This suggests that there may be an optimal range for heme oxygenase-1 induction.     

Diminished reactive hyperemia in the skin of critically ill patients

Reactive hyperemia (RH) in the forearm skin after an arterial occlusion of 5 min was investigated in 29 ICU patients and 17 age-matched healthy control subjects using a transcutaneous PO2/PCO2 electrode heated to 37 degrees C. There was no difference in preocclusive baseline PtCO2 between patients (8 +/- 5 torr) and control subjects (8 +/- 4 torr). Patients exhibited a significantly decreased RH (16 +/- 9 torr) in comparison with control subjects (26 +/- 8 torr) and a diminished CO2 elimination. There was no correlation between the RH response and the oxygen extraction ratio, Hgb concentration, and hemodynamic and blood gas variables in patients. In contrast with control subjects, there was a significant correlation between CO2 elimination from the skin and the amount of RH in patients. The finding of a diminished RH in the patients was not related to a specific disease but correlated with the degree of physiologic derangement as assessed by the APACHE II score.     

Short-term prognosis of critically ill surgical patients: the impact of duration of invasive organ support therapies

Purpose

We wanted to identify the importance of the duration of invasive ventilation and of renal replacement therapy for short-term prognosis of surgical patients treated in an intensive care unit (ICU).

Methods

We analyzed adult patients (n = 1462) who had an ICU length of stay of more than 4 days and who were followed up until the end of the short-term phase after ICU admission. Duration of different invasive therapies was evaluated by constructing specific vectors that tested effects of time-dependent variables on outcome after a lag time of 7 days.

Measurements and Main Results

Eight hundred eight patients (56.6%) were still alive at the end of the short-term phase. During the short-term phase, 85.3% of the 1462 patients required invasive ventilation, and 16.1%, a continuous renal replacement therapy. Besides the underlying disease and disease severity at ICU admission, the need for invasive ventilation or renal replacement therapy was associated with poorer outcome. Duration of invasive ventilation shortened survival if treatment lasted for more than 11 days (nonlinear association). In contrast, duration of renal replacement therapy was unimportant for short-term prognosis.

Conclusion

Prolonged duration of invasive ventilation but not of renal replacement therapy is inversely related to short-term survival.     

Prognostic impact of fecal pH in critically ill patients

ABSTRACT: INTRODUCTION: We have reported that altered gut flora is associated with septic complications and eventual death in critically ill patients with systemic inflammatory response syndrome. It is unclear how fecal pH affects these patients. We sought to determine whether fecal pH can be used as an assessment tool for the clinical course of critically ill patients. METHODS: Four hundred ninety-one fecal samples were collected from 138 patients who were admitted to the Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan. These patients were treated in the intensive care unit for more than 2 days. Fecal pH, fecal organic acids, and fecal bacteria counts were measured and compared by survived group and nonsurvived group, or nonbacteremia group and bacteremia group. Logistic regression was used to estimate relations between fecal pH, age, sex, or APACHE II score and mortality, and incidence of bacteremia. Differences in fecal organic acids or fecal bacteria counts among acidic, neutral, and alkaline feces were analyzed. RESULTS: The increase of fecal pH 6.6 was significantly associated with the increased mortality (odds ratio, 2.46; 95% confidence interval, 1.25 to 4.82) or incidence of bacteremia (3.25; 1.67 to 6.30). Total organic acid was increased in acidic feces and decreased in alkaline feces. Lactic acid, succinic acid, and formic acid were the main contributors to acidity in acidic feces. In alkaline feces, acetic acid was significantly decreased. Propionic acid was markedly decreased in both acidic and alkaline feces compared with neutral feces. No differences were noted among the groups in bacterial counts. CONCLUSIONS: The data presented here demonstrate that the fecal pH range that extended beyond the normal range was associated with the clinical course and prognosis of critically ill patients.     

Causes of death and determinants of outcome in critically ill patients

Introduction  

Whereas most studies focus on laboratory and clinical research, little is known about the causes of death and risk factors for death in critically ill patients.     

Impact of neutropenia duration on short-term mortality in neutropenic critically ill cancer patients

OBJECTIVE: To identify predictors of 30-day mortality and to assess the impact of neutropenia recovery (NR) on 30-day mortality in critically ill cancer patients (CICPs). DESIGN AND SETTING: Retrospective review of the medical records of the 102 neutropenic CICPs admitted to a medical intensive care unit (ICU) over a 10-year period. INTERVENTION: None. MEASUREMENTS AND RESULTS: Malignancies consisted of acute leukemia (n=42), lymphoma (n=23), myeloma (n=28), and solid tumors (n=9). Reasons for ICU admission were acute respiratory failure (n=81), shock (n=58), acute renal failure (n=33), and coma (n=13). Seventy patients needed conventional mechanical ventilation (MV) and 21 noninvasive MV, 67 vasopressor agents, and 28 dialysis. Sixty-two patients experienced NR during their ICU stay. In a multivariate logistic regression model, 30-day mortality was higher in patients with acute respiratory or renal failure and lower in patients with NR (OR, 0.09 [0.01-0.86]). This model assumed that patients who experienced NR in the ICU were merely these who did not die early in the ICU. To take into account the effect of time to occurrence of NR on time to death we secondarily used a Cox model including neutropenia duration and NR as time-dependent variables. In this second model, the only significant predictors of 30-day mortality were age, respiratory failure, renal failure, and coma. CONCLUSION: Organ failure but not disease progression or neutropenia duration affect 30-day mortality in neutropenic CICPs. ICU-acquired events might be modeled as time-dependent variables in a Cox model, rather than standard covariates in logistic regression models.     

危重患者腹腔内高压的发生率及其影响因素

目的：观察危重患者腹腔内高压（IAH）的发生率及其影响因素。方法：采用前瞻性队列研究方法,选择我院重症监护病房（ICU）的患者341例,采用经膀胱尿管间接测定方法,每日监测患者lAP,连续监测7d,按IAH的有无分组并进行临床资料比较,计量资料用t检验,计数资料用x^2检验,危险因素以单因素及多因素Logistic回归模型进行分析。结果：341例患者中88例（25．8％）患者发生腹腔内高压（IAH）,15例（4．5％）患者发生腹腔间室综合征（ACS）。腹腔感染,大量液体复苏,肠梗阻,感染性休克,肝功能不全与IAH的发生密切相关（P=0．000,0．000,0．007,0．000,0．000）。结论：IAH的发生在危重患者中较常见,腹腔感染,大量液体复苏,感染性休克,肝功能不全可能是IAH发生的独立危险因素。     

Unrecognised myocardial infarction and its relationship to outcome in critically ill patients with cardiovascular disease

Purpose

To establish the incidence of myocardial infarction (MI) in ICU patients with co-existing cardiovascular disease (CVD), and explore its association with long-term survival.

Methods

In a multi-centre prospective cohort study in 11 UK ICUs, we enrolled 273 critically ill patients with co-existing CVD. We measured troponin I (cTnI) with a high sensitivity assay for 10 days; ECGs were carried out daily for 5 days and analysed by blinded cardiologists for dynamic changes. Data were combined to diagnose myocardial ‘infarction’, ‘injury’ or ‘no injury’ according to the third universal definition of MI. Patients were followed-up for 6 months. Regression and mediation analyses were used to explore relationships between acute physiological derangements, MI, and mortality.

Results

cTnI was detected in all patients, with a rise/fall pattern consistent with an acute hit. In 73% of patients, this peaked on days 1–3 [median 114 ng/l (first, third quartiles: 27, 393)]. Serial ECGs indicated 24.2% (n?=?66) of patients experienced MI, but?>?95% were unrecognized by clinical teams. Type 2 MI was the most likely aetiology in all cases. A further 46.1% (n?=?126) experienced injury (no ECG changes). Injury and MI were both associated with 6-month mortality (reference: no injury): OR injury 2.28 (95% CI 1.06–4.92, p?=?0.035), OR MI 2.70 (95% CI 1.11–6.55, p?=?0.028). Mediation analysis suggested MI partially mediated the relationship between acute physiological derangement and 6-month mortality (p?=?0.002), suggesting a possible causal association.

Conclusions

Undiagnosed MI occurs in around a quarter of critically ill patients with co-existing CVD and is associated with lower long-term survival.

     

重症患者急性皮肤衰竭的研究进展

重症患者易出现皮肤完整性受损,但某些皮肤完整性受损是因低灌注引起的皮肤和皮下组织死亡,即急性皮肤衰竭.该文对重症患者急性皮肤衰竭的定义及诊断标准、危险因素、与压力性损伤的鉴别及其评估、预防、管理进行综述,以期提高我国护理工作者对重症患者急性皮肤衰竭的认识,拓展皮肤护理内涵,并为推动我国急性皮肤衰竭的研究提供借鉴.     

Parenteral L-alanyl-L-glutamine improves 6-month outcome in critically ill patients

OBJECTIVE: Glutamine is recognized as a conditionally indispensable amino acid. The purpose of the current study was to investigate whether supplemental l-alanyl-l-glutamine to parenteral nutrition can alter clinical outcome in intensive care unit patients. DESIGN: Prospective, open, randomized trial. SETTING: Postoperative intensive care unit of a university hospital. PATIENTS: Male and female critically ill patients with indications for parenteral nutrition and an expected stay on intensive care unit for >or=5 days. INTERVENTIONS: Patients were randomized to receive either standard parenteral nutrition or supplemented parenteral nutrition with l-alanyl-l-glutamine (0.3 g.kg.body weight [bw] per day). Total amount of amino acids comprised 1.5 g.kg.bw per day. Caloric support was managed by metabolic variables (glucose and triglyceride plasma values). Target values for energy supply were 3 g.kg.bw carbohydrates and 1 g.kg.bw fat per day. MEASUREMENTS AND MAIN RESULTS: Medical treatment, nutritional therapy, vital variables, and biochemical data were recorded. Clinical outcome was measured by average length of stay in the intensive care unit and hospital and the mortality in the intensive care unit and within 30 days and 6 months. A total of 144 patients were randomized; 95 patients were treated for >or=5 days and 68 patients for >or=9 days under standardized conditions. In the treatment group, plasma glutamine concentrations significantly increased within 6-9 days. Six-month survival was significantly improved for patients treated for >or=9 days (66.7% [glutamine supplemented] vs. 40% [control]). CONCLUSION: Study results support the hypothesis that replacement of glutamine deficiency may correct the excess mortality in intensive care unit patients caused by inadequate parenteral nutrition.     

Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients

OBJECTIVE: Tracheostomy practice in the setting of critical illness is controversial because evidence demonstrating unequivocal benefit is lacking. We undertook this study to determine the relationship between tracheostomy timing and duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay and to evaluate the relative influence of clinical and nonclinical factors on tracheostomy practice. DESIGN: Analysis of Project Impact, a multi-institutional critical care administrative database. SETTING: Medical school. PATIENTS: Data from 43,916 patients were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheostomy was performed in 2,473 (5.6%) of 43,916 patients analyzed. Tracheostomy patients had a higher survival rate than nontracheostomy patients (78.1 vs. 71.7%, p < .001) and underwent this procedure following a median (25th-75th percentile) of 9.0 (5.0-14.0) days of ventilatory support. Tracheostomy frequency and timing varied significantly comparing patient, intensive care unit, and hospital characteristics (p < .05 for all). Tracheostomy timing correlated significantly with duration of mechanical ventilation (r = .690), intensive care unit (r = .610), and hospital length of stay (r = .341, p < .001 for all). At most, 22% of patients were supported via tracheostomy at any given time. Although a minority, tracheostomy patients accounted for 26.2%, 21.0%, and 13.5% of all ventilator, intensive care unit, and hospital days, respectively. CONCLUSIONS: Although practice varies substantially, tracheostomy timing appears significantly associated with duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay. These findings emphasize the need for an adequately supported multiple-center trial to better define patient selection for tracheostomy and to test the hypothesis that timing of this procedure influences clinically important outcomes.