Articles: critical-care.
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Critical care medicine · Dec 1988
Unreliability of oxygen tension-based indices in reflecting intrapulmonary shunting in critically ill patients.
Measurement of intrapulmonary shunting (Qsp/Qt), a widely used method for monitoring disturbances of pulmonary oxygen transfer in critically ill patients, involves calculation of arterial and mixed venous oxygen contents. In circumstances where mixed venous blood samples are not readily available, oxygen tension-based indices such as the alveolar to arterial oxygen tension differences (P[A-a]O2), arterial oxygen tension to alveolar oxygen tension ratio (PaO2/PAO2), PaO2 to FIO2 ratio (PaO2/FIO2) and respiratory index (RI) are widely utilized to reflect Qsp/Qt. Oxygen content-based indices such as the estimated shunt are not as widely utilized as the oxygen tension indices. ⋯ Correlations between Qsp/Qt and estimated shunt were good (r = .94) and poor for the P(A-a)O2 (r = .62), PaO2/PAO2 (r = .72), PaO2/FIO2 (r = .71), and RI (r = .74). We conclude that there are no real substitutes for venous oxygen contents in critically ill patients. When pulmonary artery blood is not available for analysis, oxygen tension-based indices are unreliable reflectors of Qsp/Qt while the estimated shunt, an oxygen content-based index, provides a more reliable reflection of Qsp/Qt.
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Financial information on 131 patients and drug-related information on 176 patients admitted to a surgical intensive care unit (ICU) were prospectively collected. The average stay was nearly five days and patients received 8.6 drugs per day for a total average exposure of 12.2 different drugs. Antibiotics and analgesics were used in over 90 percent of patients. ⋯ Patients receiving systemic antifungals, triple antibiotics, catecholamines, and total parenteral nutrition had high hospital and pharmacy costs. This study suggests that ICU patients are costly to hospitals and that drug use is expensive. We suggest that increased pharmacy involvement in the care of ICU patients may help curtail escalating drug costs in these patients.
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The percutaneous common femoral vein catheter for volume replacement in critically injured patients.
The acquisition of venous access with the potential for massive volume infusion can be a major determinant in the survival of a critically injured patient. A percutaneously placed 8.5 Fr common femoral vein catheter (CFVC) was inserted in 366 patients in whom upper extremity veins were unavailable or inadequate for volume resuscitation. ⋯ Although 90% of trauma patients can be managed with a peripheral vein catheter, venous access in patients with the potential need for massive volume infusion can be achieved in a rapid, safe, and efficient manner using the CFVC in conjunction with the GIT. We conclude that this system can be used effectively in trauma patients with hemodynamic instability, unavailable or inaccessible upper extremity veins, suspected cervicothoracic major vascular injury and when massive volume or blood replacement is anticipated.
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More than 2,000 medically ill patients with delirium have been treated by intravenous administration of a combination of haloperidol and lorazepam. The protocol was developed over 8 years at two major cancer centers in the United States and Canada. The addition of the potent benzodiazepine to the neuroleptic produces rapid and safe symptomatic sedation in emergency conditions and allows the use of lower doses of haloperidol. ⋯ Patients generally respond to the first one or two doses and, in most cases, less than 100 mg/day of each drug is required. The addition of the opioid hydromorphone makes the combination ideal for the treatment of intractable pain in terminally ill cancer patients. This polypharmacological approach is advocated as the method of choice for emergency sedation of the delirious patient as well as for palliative care.