American journal of respiratory and critical care medicine
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Am. J. Respir. Crit. Care Med. · Sep 1996
Multicenter Study Comparative StudyBacteremia and severe sepsis in adults: a multicenter prospective survey in ICUs and wards of 24 hospitals. French Bacteremia-Sepsis Study Group.
To examine the relationships between bacteremia and severe sepsis and assess the influence of characteristics of infection on the risk of severe sepsis and outcome of bacteremia, we analyzed all clinically significant episodes of bacteremia occurring during a 2-mo prospective survey of 85,750 admissions to adult wards and intensive care units (ICUs) of 24 hospitals in France. Incidence rates of bacteremia and of bacteremic severe sepsis were 9.8 (95% CI: 9.2 to 10.5) and 2.6 (95% CI: 2.2 to 2.9), respectively, per 1,000 adult admissions; these rates were eight and 32 times higher in ICUs than in wards, respectively. Independent risk factors for severe sepsis during bacteremia included age (p < 0.001) and an intraabdominal (p < 0.001), pulmonary (p < 0.001), neuromeningeal (p = 0.004), or multiple (p < 0.001) source of bacteremia, but not categories of organisms involved. ⋯ The risk of death after bacteremia increased with age (p < 0.001), a rapidly or ultimately fatal underlying disease (p < 0.001), and the presence of severe sepsis (p < 0.001), shock (p = 0.03), and infection caused by gram-positive organisms other than coagulase-negative staphylococci, relative to other organisms (p < 0.001). A primary urinary tract source of infection was associated with a better prognosis (p = 0.03). We conclude that whereas sources of infection influence both the risk of severe sepsis and the outcome of bacteremia, the microbiologic characteristics of infection influence only the outcome, with gram-negative organisms and coagulase-negative staphylococci posing a lesser risk than other organisms.
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Am. J. Respir. Crit. Care Med. · Sep 1996
ReviewEthical considerations of ensuring an informed and autonomous consent in research involving critically ill patients.
Despite several codes of research ethics, the issuance of comprehensive rules regarding informed consent by governmental agencies, and numerous writings on the subject of informed consent, many commentators still question the quality of the informed consent process in clinical research. A major concern is that investigators emphasize only the information-giving aspect of "informed" consent, whereas moral philosophy stresses a more robust concept of informed consent that incorporates the additional requirements of subject competence and voluntariness of the consent, thus ensuring that a consent is not only informed, but autonomous as well. This article aims to examine the issues involved with disclosure, competence, and voluntariness, especially those related to research involving critically ill patients. Suggestions concerning methods that can promote an informed consent process that is more respectful of autonomous decision making will also be discussed.
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Am. J. Respir. Crit. Care Med. · Sep 1996
Comparative StudyEfficacy of tracheal gas insufflation in acute respiratory distress syndrome with permissive hypercapnia.
This study was conducted to assess the CO2-elimination efficiency of tracheal gas insufflation (TGI) in 20 patients with acute respiratory distress syndrome and to compare its efficacy during volume-controlled (VCV) and pressure-controlled ventilation (PCV). TGI was initially applied as an adjunct to VCV, with continuous flows (Vcath) of 4 and 6 L/min delivered through a catheter positioned 2 cm above the carina. Total effective tidal volume (VTeff) was held constant. ⋯ Twelve patients were subsequently switched to PCV combined with Vcath 6 L/min, which provided a % delta PaCO2 of 16.1 +/- 3.0% (p = NS versus 17.1 +/- 2.6% during VCV). These data suggest that in patients with ARDS the change in PETCO2 may be helpful in predicting the decrement in PaCO2 during TGI, and the existence of a high VDalv tends to limit its effectiveness. Further, the efficacy of TGI with VCV is equivalent to that with PCV.