Patients In Critical Condition Research Articles

Tuberculous Abscess of the Psoas Muscle in a Patient with Acute Lumbar Burst Fracture: A Missed Diagnosis.

The authors present a rare case of tuberculous spondylitis and a large abscess in the left psoas muscle that occurred after spinal surgery for an acute traumatic burst fracture of the L2 vertebral body. We retrospectively reviewed the patient's first magnetic resonance imaging (MRI) we found that some unusual findings, indicative of psoas abscess had been overlooked. As a result, diagnosis and treatment of tuberculous psoas abscess and spondylitis were considerably delayed. Despite the critical condition of patients in a similar emergency, surgeons should always pay close attention to the radiological findings and clinical symptoms of the patient before considering a surgical intervention or biopsy.

Spontaneous Hemothorax Associated with von Recklinghausen’s Disease: Report of a Case

A 59-year-old woman with a history of von Recklinghausen's disease (VRD) suffered sudden chest pain. Enhanced chest computed tomography showed massive hemothorax, but no evidence of tumors or an obvious bleeding point in the thorax. After we had ensured a stable hemodynamic condition, we performed video-assisted thoracic surgery to remove the hematoma. The bleeding point was in a branch of the right subclavian artery. We performed direct surgical ligation of the bleeding vessel with a fibrin tissue-adhesive collagen fleece. Recovery was uneventful, and the patient is now doing well with no evidence of re-bleeding, 12 months postoperatively. Spontaneous hemothorax in patients with von Recklinghausen's disease represents a critical event, and exploratory video-assisted thoracic surgery appears useful in the removal of clotted blood and reinforcement of fragile arteries for the prevention of re-bleeding. We should recognize this rare and critical condition in patients with von Recklinghausen's disease.

Factores de riesgo de la disfunción hepática asociada a la nutrición parenteral

Background and objective The objective of this study is to describe the incidence of hepatic dysfunction (HD) in our hospital and evaluate the possible risk factors associated with HD development as an improvement of the caring process received by patients treated with parenteral nutrition (PN). Patients and method A prospective study of patients (n=994) who required PN during the period 2000–2004. HD is the identification of an increase above 1,5 of the top reference value of alkaline phosphatase (40–450 U/l) and gamma glutamyl transpeptidase (11–49 U/l) associated with an increase of transaminases (5–32 U/l) and a total bilirrubin higher than 1,2 mg/dl. Results The incidence of HD was 4,9% (n=49). Days with PN were significantly higher in the HD group: median (interquartile range): 30 (20–59) vs 15 (8–25) days (p<0.001). In the univariated HD analysis, the variables that reached significant odds ratio were: the critical patient condition, the PN duration, the total calorie contribution higher than 25 kcal/kg, to exceed 3 g of carbohydrates/kg, to administer more than 0.8 g/kg of lipids and to exceed 0.16 g of nitrogen/kg. In the multivariated analysis, the variables selected as independent risk factors were: to exceed 3 weeks of PN, to be a critical patient and a contribution over 0.16 g of nitrogen/kg. Conclusions The present profiles of the patients who will develop HD are those with prolonged PN. These patients undergo processes and critical therapy, where the specialists must monitor, not only calorie contribution, carbohydrates or lipids, but proteins as well.

Oxidative stress is increased in critically ill patients according to antioxidant vitamins intake, independent of severity: a cohort study

IntroductionCritically ill patients suffer from oxidative stress caused by reactive oxygen species (ROS) and reactive nitrogen species (RNS). Although ROS/RNS are constantly produced under normal circumstances, critical illness can drastically increase their production. These patients have reduced plasma and intracellular levels of antioxidants and free electron scavengers or cofactors, and decreased activity of the enzymatic system involved in ROS detoxification. The pro-oxidant/antioxidant balance is of functional relevance during critical illness because it is involved in the pathogenesis of multiple organ failure. In this study the objective was to evaluate the relation between oxidative stress in critically ill patients and antioxidant vitamin intake and severity of illness.MethodsSpectrophotometry was used to measure in plasma the total antioxidant capacity and levels of lipid peroxide, carbonyl group, total protein, bilirubin and uric acid at two time points: at intensive care unit (ICU) admission and on day seven. Daily diet records were kept and compliance with recommended dietary allowance (RDA) of antioxidant vitamins (A, C and E) was assessed.ResultsBetween admission and day seven in the ICU, significant increases in lipid peroxide and carbonyl group were associated with decreased antioxidant capacity and greater deterioration in Sequential Organ Failure Assessment score. There was significantly greater worsening in oxidative stress parameters in patients who received antioxidant vitamins at below 66% of RDA than in those who received antioxidant vitamins at above 66% of RDA. An antioxidant vitamin intake from 66% to 100% of RDA reduced the risk for worsening oxidative stress by 94% (ods ratio 0.06, 95% confidence interval 0.010 to 0.39), regardless of change in severity of illness (Sequential Organ Failure Assessment score).ConclusionThe critical condition of patients admitted to the ICU is associated with worsening oxidative stress. Intake of antioxidant vitamins below 66% of RDA and alteration in endogenous levels of substances with antioxidant capacity are related to redox imbalance in critical ill patients. Therefore, intake of antioxidant vitamins should be carefully monitored so that it is as close as possible to RDA.

Farmacovigilancia en una unidad de cuidados intensivos pediátricos

To analyze suspected drug-related adverse events as reported by pharmacists in a pediatric intensive care unit. Suspected drug-related adverse events were recorded as reported by pharmacists in an intensive care unit during hospital rounds (these were neither systematic nor continued) or patient visits to our clinic (April 2004-May 2005). Later on, the pharmacovigilance subcommittee prospectively analyzed such suspected events in order to confirm them and classify them according to their rules. Nineteen suspected adverse events were reported for 17 patients; 15 were confirmed (78%). In six cases the pharmacist suggested the way the adverse event was eventually treated. Three cases required admission to an ICU. Drug classes most commonly involved included antimicrobials, anti-epileptic drugs, and immunosuppressants. Severity was: fatal 20%, serious 34%, moderate 13%, mild 33%. Causality was definitely established for 13%, probable for 54%, and possible for 33% of patients; 20% of events were considered avoidable. Adverse events reported by pharmacists were few, as they could not attend hospital rounds on a regular basis. Imputability was difficult due to critical patient conditions. Most suspected events were later confirmed. Treatment involved therapy adjustments according to individual patient characteristics.

Evaluation of unpredictable critical conditions of patients treated in the observation unit of the Emergency Department

We evaluated unpredictable critical conditions of patients treated in the Emergency Department (ED) observation unit, who were transferred into the emergency resuscitation room from January 1 through June 30, 2001. A total of 175 patients were observed for the following critical conditions: dyspnea (51 patients; 29.14%), hypotension (28; 16.00%), chest pain (18; 10.29%), dysrhythmia (15; 8.57%), hematemesis (15; 8.57%), altered mental status (12; 6.85%), shock (10; 5.71%), coma (8; 4.57%), apnea (5; 2.86%), hematochezia (3; 1.72%), seizure (3; 1.72%), and others (7; 4.00%). The 27 patients who had cardiopulmonary resuscitation (CPR), endotracheal tube intubation, or cardioversion/defibrillation in the ED suffered an in-ED mortality of 25.9% (7) and an in-hospital mortality of 59.2% (16). The remaining 148 patients who received appropriate treatment, except for the above, had a lower in-hospital mortality (20.28%, 30 patients) ( p < 0.05). We should limit the number of patients in the observation unit to avoid overloading, and classify patients according to their clinical conditions. We should determine whether or not they have definite diagnoses or are waiting for hospital admission while receiving simple treatments. The observation unit must be provided with well-trained staff and suitable physical facilities with support services, and rapid specialty consultations must be available.

Natural human IgG inhibits the production of tumor necrosis factor-alpha and interleukin-1 alpha through the Fc portion.

The overproduction of cytokines such as the tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 alpha (IL-1 alpha) may cause further deterioration in the already critical condition of patients with shock, sepsis, and acute inflammation. The effectiveness of infusion therapy of natural human IgG to such patients is suggested to depend partly upon the inhibition of the productivity of these cytokines. In this study, we investigated the modulation effects of IgG and its fragments on the production of TNF-alpha and IL-1 alpha, on human peripheral blood mononuclear cells (PBMC). The production of TNF-alpha and IL-1 alpha was found to be dose-dependently inhibited by IgG when stimulated by lipopolysaccharide (LPS), phytohemagglutinin (PHA), concanavalin A (Con A), and interleukin-2 (IL-2). However, no inhibition was seen when stimulated by phorbormyristate acetate (PMA). The F(ab')2 fragment showed enhancing effects on cytokine production by LPS, while the Fc fragment showed not as much inhibitory effect as whole intact IgG. IgG showed no direct cytotoxic effect on PBMC. These data suggest that natural human IgG inhibits TNF-alpha and IL-1 alpha production by PBMC through the Fc portion. The results of this study led us to conclude that whole intact IgG may be the best form of therapeutic delivery.

Critical Care—The Overview

Important keys to successful patient management include: 1. Identify and treat the most life-threatening problems first. 2. Make the patient as stable as possible before undertaking stressful procedures. 3. The critical patient's condition is rapidly changing and requires intensive monitoring and frequent reevaluation. 4. It is important to anticipate complications and initiate monitoring procedures for early detection. 5. The trend of changes in monitored parameters is more significant than a single value. 6. Make sure that the treatment orders are clear and concise and that the technical staff and clinicians have the same interpretations of monitoring values and treatment regimens. 7. Many post-trauma complications do not become evident for 24 to 72 hours. 8. Do not take a patient's stable condition for granted. 9. There is less tolerance for error, indecisiveness, or delay in the critical patient.

RENAL TRANSPLANTATION

The surgical techniques required in homotransplantation involve more than the homografting procedure since recipient bilateral nephrectomy and splenectomy are integral parts of the plan of treatment as practiced at the University of Colorado Medical Center. Originally it was thought that multiple operations would be required because of the critical condition of patients with terminal uremia. Experience has shown that this is not the case, and for various reasons bilateral nephrectomy, splenectomy, and homotransplantation are better tolerated when performed as a single all-inclusive operation. The technical problems are the same as those encountered in any major surgical operation except that there is very little margin of safety because of the predictably poor healing capacity of these metabolically depleted patients and the necessity for immunosuppressive therapy. Special care is required to avoid breaches in aseptic technique. Preoperatively, the patient's own bacterial flora is studied by obtaining cultures of all body orifices and skin. At time of surgery, all operative sites receive double skin preparation and are heavily draped. One of the potential sources of wound contamination is the bladder, which must be opened for ureteral implantation. This hazard is minimized by performing a separate 10-minute perineal prep, placing a Foley catheter, and instilling a solution containing bacitracin and neomycin into the bladder. The fluid is retained until just before ureteral implantation is begun. A variety of surgical approaches may be employed depending upon the circumstances of the individual case. Most versatile and most com-

Renal Transplantation: Surgical Technique and Complications

The surgical techniques required in homotransplantation involve more than the homografting procedure since recipient bilateral nephrectomy and splenectomy are integral parts of the plan of treatment as practiced at the University of Colorado Medical Center. Originally it was thought that multiple operations would be required because of the critical condition of patients with terminal uremia. Experience has shown that this is not the case, and for various reasons bilateral nephrectomy, splenectomy, and homotransplantation are better tolerated when performed as a single all-inclusive operation. The technical problems are the same as those encountered in any major surgical operation except that there is very little margin of safety because of the predictably poor healing capacity of these metabolically depleted patients and the necessity for immunosuppressive therapy. Special care is required to avoid breaches in aseptic technique. Preoperatively, the patient's own bacterial flora is studied by obtaining cultures of all body orifices and skin. At time of surgery, all operative sites receive double skin preparation and are heavily draped. One of the potential sources of wound contamination is the bladder, which must be opened for ureteral implantation. This hazard is minimized by performing a separate 10-minute perineal prep, placing a Foley catheter, and instilling a solution containing bacitracin and neomycin into the bladder. The fluid is retained until just before ureteral implantation is begun. A variety of surgical approaches may be employed depending upon the circumstances of the individual case. Most versatile and most com-

ARTIFICIAL MAINTENANCE OF CIRCULATION DURING EXPERIMENTAL OCCLUSION OF PULMONARY ARTERY

Approximately one hundred and forty-two Trendelenburg operations for massive pulmonary embolism have been reported, and only nine of patients operated on have left hospital as cured. 1 This exceedingly high mortality is due to critical condition of patient and to operative procedure, which entails complete throttling of great vessels leading from heart for a brief period. Because of difficulty in diagnosis and uncertain prognosis, Nystrom 2 advised postponing operation until patient is practically moribund. Then, as Churchill 3 has stated, the procedure could perhaps be more properly termed an immediate postmortem examination than a surgical operation. Nystrom and Blalock 4 have demonstrated experimentally that occlusion of pulmonary artery alone may be safely maintained for a longer period than occlusion of both pulmonary artery and aorta. Kiser 1 found that constriction of afferent vessels of