Relationship of mortality to increasing oxygen delivery in patients > or = 50 years of age: a prospective, randomized trial

Noninvasive hemodynamic monitoring for early warning of adult respiratory distress syndrome in trauma patients

PURPOSE

Traditionally hemodynamic patterns after adult respiratory distress syndrome (ARDS) are described after appropriate diagnostic criteria have been met, but studies begun after the diagnosis of ARDS miss the antecedent circulatory influences that may contribute to its development. This study tests the hypothesis that noninvasive monitoring before the appearance of ARDS may reveal early circulatory deficiencies that lead to this disorder. The aims of this study are as follows: (1) to describe the time course of hemodynamic and tissue perfusion patterns in severely traumatized postoperative patients from the period immediately after admission and during surgical repair to the time that ARDS developed or to hospital discharge in patients who did not develop ARDS, (2) to compare the time course of these patterns in survivors and nonsurvivors of ARDS, and (3) to suggest that reduced flow and perfusion may be early warning signs of ARDS. Prospective descriptive study of severely injured trauma patients noninvasively monitored in the emergency department, operating room, and intensive care unit (ICU). Early hemodynamic pattems were described in the surviving and nonsurviving patients who subsequently developed ARDS. The study was performed in a University-affiliated Level I trauma center and ICU.

PATIENTS AND METHODS

A consecutively monitored series of 60 severely injured patients were prospectively monitored by cardiac output, pulse oximetry (Sapo2), and transcutaneous O2 and co2 (Ptco2 and Ptc(co2)) sensors immediately after emergency admission. Twenty-nine patients developed ARDS in their ICU course, whereas 31 were discharged from the ICU and the hospital without developing ARDS.

RESULTS

Patients who developed ARDS had significantly lower cardiac index and Ptco2 and higher Ptc(co2) values beginning with the early stage compared with those who did not develop ARDS. Nonsurvivors of ARDS had lower Ptco2 values than did the survivors.

CONCLUSION

Early noninvasive monitoring in the emergency department, operating room, and ICU showed reduced cardiac and tissue perfusion functions in patients who subsequently developed ARDS. These patterns were more pronounced in the ARDS patients who died; these patterns may serve as early warning of ARDS.

Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients

OBJECTIVE

To evaluate the effects of maximizing the oxygen delivery on morbidity and mortality in patients >60 yrs of age and/or with chronic diseases of vital organs who underwent major elective surgery.

DESIGN

Prospective, randomized, controlled trial.

SETTING

A 24-bed general intensive care unit of a teaching hospital.

PATIENTS

Thirty-seven high-risk patients who underwent major surgery.

INTERVENTIONS

The hemodynamic and oxygen transport variables and outcomes in 18 patients (control group) treated to maintain normal values of oxygen delivery were compared with 19 patients (protocol group) treated to maintain "supranormal" values. Therapy in both groups consisted of volume expansion and, when necessary, dobutamine to reach target values, during the surgery and 24 hrs postoperatively.

MEASUREMENTS AND MAIN RESULTS

We interrupted the study because of a significant difference in the 60-day mortality rate. The mortality rate in the control group was significantly higher when compared with the protocol group (9/18 [50%] vs. 3/19 [15.7%], p < .05). The prevalence of clinical and infectious complications was higher in the control group than in the protocol group (67% and 31% respectively; relative risk, 0.47; 95% confidence interval, 0.226-0.991; p < .05) and there was a trend toward more severe organ dysfunction in nonachievers patients (17/24 [71%] vs. 6/13 [46%], relative risk, 0.65; 95% confidence interval, 0.343-1.237; NS).

CONCLUSION

Older patients with existing cardiorespiratory illness undergoing major surgery have a reduced morbidity and mortality when dobutamine is used to maximize oxygen transport.

Oxygen consumption in the early postinjury period: use of continuous, on-line indirect calorimetry

OBJECTIVE

To determine the patterns of oxygen consumption (Vo2) using indirect calorimetry (IC) for the first 24 hrs after serious blunt traumatic injury.

DESIGN

Prospective, observational study.

SETTING

Surgical intensive care unit of a Level 1 trauma center.

PATIENTS

Sixty-six mechanically ventilated patients with blunt traumatic injury and Injury Severity Score >15.

INTERVENTIONS

IC for 24 hrs postinjury. Patients were resuscitated to standard parameters of perfusion.

MEASUREMENTS AND MAIN RESULTS

Mean patient age was 50.1+/-18.7 yrs with a mean Injury Severity Score 30.7+/-11.3). Mean Vo2 for all patients for the 24-hr study period was 168.5+/-29.5 mL/min/m2. The level of Vo2 was not related to Injury Severity Score, the number or combination of organ systems injured, or to the use of vasoactive agents. Patients >65 yrs of age had significantly lower Vo2 (P = .0038) compared with patients < or =50 yrs. Vo2 did not change over time after resuscitation to normal parameters of perfusion. Mean Vo2 was 156.5+/-63.2 mL/min/m2 in patients who developed multiple organ dysfunction, and 172.4+/-33.3 mL/min/m2 in those who did not develop multiple organ dysfunction (p = .16).

CONCLUSIONS

Seriously injured patients are hypermetabolic in the early postinjury period. The level of Vo2 is unrelated to injury severity or number of organ systems involved. Elderly patients can be expected to have lower levels of Vo2. Vo2 does not change significantly in response to resuscitation to normal parameters of perfusion. Vo2 measured by IC did not predict the development of multiple organ dysfunction.

Blood transfusion for treating malarial anaemia

BACKGROUND

Blood transfusion is used in patients with severe malarial anaemia, but risks adverse reactions, transmission of disease, and is complicated to organise in developing countries.

OBJECTIVES

This review evaluates the effects of routine blood transfusion for severe anaemia on death and adverse outcomes in malarious areas.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, African Index Medicus, LILACS, EMBASE and reference lists of relevant articles, and contact with researchers and organizations working in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials of blood transfusion compared with conservative management in malaria-associated severe anaemia.

DATA COLLECTION AND ANALYSIS

Trials were identified and extracted by a single reviewer (MM) and checked by a second (HS). Inclusion criteria were applied and data were extracted independendtly by both reviewers.

MAIN RESULTS

Two randomised trials of 230 children were included. In the transfusion group, there was a non-significant tendency towards fewer deaths (RR 0.41, 95% CI 0.06 to 2.70), but significantly more severe adverse events (RR 8.60, 95% CI 1.11 to 66. 43). In one trial by Bojang (1997a) respiratory distress was less common and hospital stay was shorter in the transfusion group (WMD 1.9 days, 95% CI 2.4 to 1.3). Subsequent need for urgent blood transfusion was less common in the transfusion group (RR 0.11, 95% CI 0.02 to 0.62). Day 28 packed cell volume was less in the transfusion group (WMD -1.34, 95% CI -2.57 to -0.11). There was no information on HIV or Hepatitis B virus transmission.

REVIEWER'S CONCLUSIONS

There is insufficient data to be sure whether routinely giving blood to clinically stable children with severe anaemia in endemic malarious areas reduces death, or results in higher haematocrit measured at one month.

Adjunctive Therapies for Sepsis and Septic Shock

The inflammatory cascade that ensues after an infectious insult is protean in its manifestations, resulting in mild self-limited illness in some patients, while progressing to fulminant sepsis and multisystem organ failure in others. Research into the pathophysiology of this cascade has been intense, but advances in the treatment of sepsis have been few and far between. Although mortality rates have been impacted slightly in patients with sepsis--with improved survival in certain patient subgroups--overall survival still reaches only 55% to 60%. In this paper we will review some of the most recent advances in the therapy of the sepsis syndrome, specifically the roles of cytokine modifiers, supranormal delivery of oxygen, granulocyte colony-stimulating factor administration in leukopenic patients, and parenteral nutrition. Hopefully, these modalities represent additional steps in the path towards a meaningful improvement in survival from this catastrophic condition.