J Trauma
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Comparative Study
Diagnosing pneumonia in mechanically ventilated trauma patients: endotracheal aspirate versus bronchoalveolar lavage.
We prospectively investigated the diagnostic value of semiquantitative (semiQC) and quantitative (QC) cultures of endotracheal aspirate (ETA) compared with QC of bronchoalveolar lavage (BAL) fluids in 18 mechanically ventilated trauma patients with clinical signs of pneumonia. The general agreement between QC of ETA and BAL was 89% when conventional cutoffs for the QC were used and 94% if the cutoffs were adjusted for previous antibiotic therapy. In all six patients whose clinical diagnoses of pneumonia were considered definite, both QC of ETA and QC of BAL were positive; however, standard semiQC of ETA showed comparable results in this group. ⋯ Semiquantitative cultures of ETA were positive in all these patients. Five (28%) patients experienced a decrease in PaO2/FiO2 (> 15% of previous value) 2 hours after BAL, and in three (17%) this derangement persisted for 24 hours. These data suggest that BAL may be hazardous in mechanically ventilated trauma patients and that its use should be restricted to patients in whom the diagnosis is in doubt.
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Routine morning chest x-ray films (CXRs) are widely obtained in surgical intensive care unit (SICU) patients. During a 1-month time period we prospectively evaluated 525 routine morning CXRs in patients admitted to the SICU of a university trauma center (n = 256) or a suburban affiliate hospital (n = 269) to assess the impact of these CXRs on patient care. All CXRs were read by radiologists. ⋯ Of the 89 new CP findings, only three had any potential clinical impact (pneumothorax in two, effusion in one). These data demonstrate an extremely low yield of clinically significant and unsuspected new CP findings or device malposition on the routine morning CXR. We conclude that routine daily chest radiography should be abandoned and that the need for a morning CXR should be based on clinical necessity.
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Previous reports cite optimization of O2 delivery (DO2) to 660 mL/min/m2, O2 consumption (VO2) to 170 mL/min/m2, and cardiac index (CI) of 4.5 L/min as predicting survival. We prospectively evaluated 76 consecutive patients with multiple trauma admitted directly to the ICU from the operating room or emergency department. Patients had serum lactate levels and oxygen transport measured on ICU admission and at 8, 16, 24, 36, and 48 hours. ⋯ Fifteen of the survivors never achieved any of these criteria. Optimization alone does not predict survival. However, the time needed to normalize serum lactate levels is an important prognostic factor for survival in severely injured patients.
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Cerebral blood flow (CBF) varies unpredictably in patients after head injury and hemorrhagic shock. Proper treatment requires knowledge of ischemic versus hyperemic flow. The degree to which the size or severity of the injury may contribute to CBF abnormalities is unknown. ⋯ In the small lesion group traumatic brain injury, followed by shock and resuscitation, produced a significant and sustained elevation in bihemispheric regional CBF and cerebral oxygen delivery that was significantly greater than that observed in either the large lesion group or the controls (p < 0.05). There were no significant differences between the experimental groups in volume of hemorrhage, intracranial pressure, cerebral perfusion pressure, arterial oxygen content, or PaCO2. These data suggest that the volume of injured tissue may determine post-resuscitation CBF, and that interventions to reduce cerebral blood volume (i.e., hyperventilation) may not be universally applicable in all head injured patients.
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Laparoscopy is frequently used for diagnosis and treatment of critically ill trauma patients. Its effects on cardiopulmonary performance in the intensive care unit patient population, however, are not well-defined. This study evaluated the effects of positive end-expiratory pressure (PEEP) and carbon dioxide (CO2) pneumoperitoneum on hemodynamic function during mechanical ventilation. ⋯ Pulmonary gas exchange was not affected by CO2 pneumoperitoneum. The results indicate that, in this paradigm, CO2 pneumoperitoneum for laparoscopy increases ventricular afterload and exacerbates the adverse effects of PEEP. These findings could be clinically significant in critically ill patients.