Use of bispectral electroencephalogram monitoring to assess neurologic status in unsedated, critically ill patients.

OBJECTIVE: To test whether spectral indices derived from the electroencephalogram (EEG), and especially the bispectral index (BIS), can be used as measures of neurologic status in unsedated, critically ill patients. DESIGN: Prospective, observational study. SETTING: Medical intensive care unit (ICU) of a university-affiliated teaching hospital. PATIENTS: Thirty-one awake, unsedated critically ill adults were assessed in 108 separate sessions. MEASUREMENTS AND MAIN RESULTS: In each session, severity of illness was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE III). The APACHE III Acute Physiology Score was used to quantify the degree of physiologic derangement. Neurologic function was assessed using the APACHE III Neurologic Score, the Glasgow Coma Scale, the Reaction Level Scale, and the Modified Ramsay Sedation Scale. All indices were plotted against various spectral parameters of the EEG, including BIS, an empirical index of EEG activity that is scaled from 0 to 100. BIS was significantly (p <.05) correlated with neurologic score regardless of scoring system used and was more strongly correlated than any other EEG spectral parameter. Better neurologic function was associated with higher values of BIS. In multivariate analysis, the combination of BIS and relative power in the theta band of the EEG accounted for 38% of the variability in the Glasgow Coma Scale. CONCLUSIONS: BIS provides a reliable index of neurologic status in awake, unsedated, critically ill patients. Further research is needed to determine whether the effects of neurologic status and pharmacologic sedation upon EEG are additive, whether BIS can be used to assess pharmacologic sedation in the critically ill patient population, and whether such objective measures of neurologic status have prognostic value.

Effect of clinical outcomes data on intensive care unit utilization by bone marrow transplant patients.

OBJECTIVE: To determine if a program to educate referring physicians as to the poor outcome of mechanically ventilated bone marrow transplant patients would result in a change in intensive care unit (ICU) utilization. DESIGN: Retrospective chart review. SETTING: Medical ICU at an urban university hospital. PATIENTS: Patients undergoing bone marrow transplantation in the interval before (n = 236) vs. the interval after (n = 144) a physician education program. INTERVENTIONS: Two separate educational programs were conducted for oncologists and intensivists to review the findings of an earlier study demonstrating the outcome of bone marrow transplant patients in the ICU. MEASUREMENTS AND MAIN RESULTS: The results demonstrated that this physician education intervention did not result in a change in the utilization of medical ICU resources by these patients. Comparing the time periods before and after the intervention, there were no statistically significant differences in the proportion of patients who were admitted to the medical ICU, the proportion who received mechanical ventilation, or the medical ICU lengths of stay. Similarly, the two groups did not differ regarding the 100-day survival rate of all bone marrow transplant patients studied, all bone marrow transplant patients admitted to the medical ICU, or all bone marrow transplant patients intubated. CONCLUSION: Simple educational interventions are not a powerful mechanism by which to alter the practice of physicians regarding the utilization of scarce and expensive resources, even when the physicians generally agree that the use of those resources results in dismal patient outcomes.

A trial of antioxidants N-acetylcysteine and procysteine in ARDS. The Antioxidant in ARDS Study Group.

OBJECTIVE: To determine the levels of glutathione and cysteine in patients with ARDS and examine the effect of treatment with N-acetylcysteine (NAC) and L-2-oxothiazolidine-4-carboxylate (Procysteine; Clintec Technologies Inc; Chicago [OTZ]) on these levels and on common physiologic abnormalities, and organ dysfunction associated with ARDS. DESIGN: Randomized, double-blind, placebo-controlled, prospective clinical trial. SETTING: ICUs in five clinical centers in the United States and Canada. PATIENTS: Patients meeting a predetermined definition of ARDS and requiring mechanical ventilation. INTERVENTION: Standard care for ARDS and I.V. infusion, every 8 h for 10 days, of one of the following: NAC (70 mg/kg, n=14), OTZ (63 mg/kg, n=17), or placebo (n=15). MAIN RESULTS: Both antioxidants effectively repleted RBC glutathione gradually over the 10-day treatment period (47% and 49% increases from baseline values for NAC and OTZ, respectively). There was no difference in mortality among groups (placebo, 40%; NAC, 36%; OTZ, 35%). However, the number of days of acute lung injury was decreased and there was also a significant increase in cardiac index in both treatment groups (NAC/OTZ [+]14%; placebo [-]6%). CONCLUSIONS: Our findings suggest that repletion of glutathione may safely be accomplished with NAC or OTZ in patients with acute lung injury/ARDS. Such treatment may shorten the duration of acute lung injury, but larger studies are needed to confirm this.

Measuring cardiac output in critically Ill patients: disagreement between thermodilution-, calculated-, expired gas-, and oxygen consumption-based methods.

Calculated values of oxygen consumption have been used to calculate a Fick cardiac output when thermodilution measurements are unreliable and when oxygen consumption measurements are unavailable. To determine the accuracy of these calculations, we measured cardiac output in 20 patients by four methods: (1) a reference Fick cardiac output calculated from metabolic oxygen consumption measurements and arterial-venous oxygen content difference (COmet); (2) thermodilution cardiac output (COtherm), (3) an estimated Fick cardiac output based on calculated oxygen consumption using standard equations (COcalc), and (4) an estimated Fick cardiac output using a bedside measurement of expired carbon dioxide production (COexp). The mean difference +/- 95% limits of agreement between COtherm and COmet was 1.71 +/- 5 liters/min. The mean difference between COcalc and COmet was -0.04 +/- 3.33 liters/min. The mean difference between COexp and COmet was 0.31 +/- 3.01 liters/min. On the basis of these wide confidence intervals, we conclude that (1) thermodilution and metabolic measurements of cardiac output frequently differ in critically ill patients, and (2) estimates of oxygen consumption, based on either standard equations or on expired carbon dioxide production measurements, are poor substitutes for metabolic measurements of oxygen consumption in critically ill subjects and may provide inaccurate estimates of cardiac output.

Motility agents for the placement of weighted and unweighted feeding tubes in critically ill patients.

OBJECTIVE: To determine if successful attempts at feeding tube placement into the small bowel could be increased with the use of a weighted end or by pre-treatment with a drug to increase gastric motility. DESIGN: A prospective randomized control study, double blinded for a drug study drug, in a population of critically ill patients. SETTING: A 635-bed acute care hospital in Philadelphia, Pennsylvania. PATIENTS: Eighty-three patients in the critical care setting randomized into four groups receiving either parenteral normal saline (NS) 100 cc, erythromycin (EMY) 200 mg, or metoclopramide (MET), 10 mg, 30 min prior to attempted tube placement with either a weighted (WEI) (57 patients) or unweighted tube (UNW) (26 patients). RESULTS: When analyzed for number of attempts prior to successful tube placement into the stomach there was a significant difference between the unweighted and weighted groups: 2.08 +/- 1.03 attempts vs 1.51 +/- 0.94, P < or = 0.015. Duodenal migration at 24 h was demonstrated in three patients in the NS/UNW group and in two patients in the NS/WEI group as compared to no patients in either the EMY/WEI or the MET/WEI groups (p < or = 0.025, Fisher's exact test). CONCLUSIONS: These data demonstrate that the use of weighted feeding tubes decreases the number of attempts required to achieve gastric intubation, but that motility agents given prior to tube insertion do not augment advancement of the feeding tube beyond the stomach and may in fact hinder placement into the duodenum.

Using a benchmarking system to improve patient care and assist in technology assessment.

Clinical benchmarking is a tool of CQI that can be used to improve outcomes in areas of strategic importance. While it is a simple tool, benchmarking requires a long-term commitment from the entire organization involved in its use to be successful. Benchmarking is a means of setting goals or targets. As a tool used for continuous quality management, benchmarking is an ongoing activity of comparing an organization's service, product, or process with similar ones outside the organization that are known to be the best. In attempting to emulate or surpass "best practice," an organization must set challenging but attainable goals and reach them with a plan of realistic and efficient actions.

A Fellowship in Quality Management.

The U.S. Healthcare Fellowship in Quality Management at Hahnemann University was developed by a managed health care organization and health science university in order to train physicians in the theory and practice of quality management and clinical outcomes measurement. This article describes in detail the program content and the characteristics of applicants.

The impact of HIV testing on blood utilization in the intensive care unit in patients with gastrointestinal bleeding.

OBJECTIVE: To determine whether the AIDS epidemic has influenced physician use of blood products in intensive care unit management of gastrointestinal hemorrhage. METHODS: Retrospective chart review of 148 patients with gastrointestinal hemorrhage admitted to the intensive care unit. Forty-eight patients were admitted before the onset of HIV testing of the blood supply (group 1) and 100 were admitted after HIV testing was begun (group 2). RESULTS: Of the 148 patients, 18 (eight in group 1, ten in group 2) were not transfused and had higher median hemoglobin levels on admission and higher median hemoglobin nadirs during hospitalization than patients who were transfused. Transfused patients in group 2 did not have significantly lower median hemoglobin levels on admission [7.9(4.2-12.5) g/dl] than transfused patients in group 1 [9.3 (4.1-13.5) g/dl] (p = 0.058). Patients in group 2 had significantly lower median hemoglobin concentrations prior to the first transfusion event [7.4 (4.2-10.3) g/dl] than those in group 1 [8.5 (4.2-12.1) g/dl] (p = 0.016). There were no significant differences between the two groups in terms of the total number of units of packed red blood cells, fresh frozen plasma or platelets transfused. Neither was any significant difference in mortality observed, with 11 patients (22.9%) dying in group 1 and 23 patients (23.0%) dying in group 2. The cause of death in 13 of the 34 patients was related to cardiovascular and hemodynamic complications of gastrointestinal bleeding. There was no significant difference in mean age (group 1: 60.5 years, group 2: 59.4 years) or mean hemoglobin nadir (group 1: 7.0 g/dl, group 2: 7.1 g/dl) among those who died in the two groups. CONCLUSIONS: These data indicate that physicians are transfusing patients at lower hemoglobin levels than they did before the beginning of HIV testing. However, there has been no decrease in the total median amount of blood products transfused since that time. This change in practice may be due to increased concern about HIV transmission through blood products and suggests the need for greater awareness of existing transfusion guidelines.

The automated implantable cardiac defibrillator. Prophylaxis in cardiac sarcoidosis.

A patient with cardiac sarcoidosis proved by biopsy specimen and no history of sudden death or clinical sustained ventricular tachycardia prophylactically received an implantable cardioverter defibrillator (ICD) that later reversed an episode of near syncope. The patient was supported with the ICD until heart transplantation. The physiology and treatment of arrhythmias associated with cardiac sarcoidosis is described. Consideration for use of the ICD in asymptomatic patients and as bridge therapy until heart transplantation is discussed.

Review of respiratory care of the patient with amyotrophic lateral sclerosis.

Respiratory failure is the leading cause of death in patients with amyotrophic lateral sclerosis (ALS). We review the physiology of respiratory compromise in ALS and techniques of monitoring respiratory function. Treatment options, including pharmacologic interventions, aspiration precautions, and invasive and noninvasive modes of mechanical ventilation are reviewed. Our clinical experience with respiratory failure in ALS demonstrates significantly prolonged survival in subjects who elect to receive noninvasive mechanical ventilation (19.25 vs. 80.4 days, p < 0.01). Four of 18 patients who elected to receive noninvasive ventilation decided to discontinue treatment. Four of 13 patients who were receiving mechanical ventilation elected to discontinue life support. The decision to utilize these modalities must be made with realistic considerations of the patient's quality of life.

Outcome of patients requiring medical ICU admission following bone marrow transplantation.

Despite encouraging results seen following bone marrow transplantation (BMT), it has been observed that once these patients become critically ill and require medical intensive care unit (MICU) admission, the chances of survival are poor. We hypothesized that while mechanical ventilation would be an important predictor for death in the MICU, those patients not requiring mechanical ventilation could be successfully discharged from the MICU. The records of 36 patients with 43 admissions to the MICU following BMT were analyzed. Of these admissions, 33 (76.7 percent) patients had allogeneic and 10 (23.3 percent) had autologous transplants, respectively. Overall, 14 (32.6 percent) of the admissions resulted in a satisfactory discharge from the MICU. There was no significant difference in the survival rates between those patients undergoing allogeneic or autologous transplantations, 11 (33.3 percent) vs 3 (30.0 percent), respectively. Twenty-seven (62.8 percent) of the admissions resulted in mechanical ventilation and were performed in 20 (66.7 percent) patients with allogeneic BMTs and 7 (70.0 percent) patients with autologous BMTs, which was not significantly different. The survival rate for those requiring mechanical ventilation was significantly less than for those not mechanically ventilated during their MICU stay, 1 (3.7 percent) vs 13 (81.3 percent), respectively (p < 0.001). Those patients who did not survive their MICU stay had a significantly higher mean APACHE II score of 21.2 +/- 4.7 than the survivors' score of 15.8 +/- 3.8 (p < 0.001). The average length of stay for the survivors was 4.4 + 3.0 days, which was significantly less than the 17.8 +/- 24.0 days for those patients not surviving (p < 0.001). These data indicate that admission to the MICU may result in a beneficial outcome for critically ill patients with BMTs, but for those requiring mechanical ventilation due to respiratory failure, the chances of survival are poor. This information may be useful for providing patients with BMTs and their families with realistic estimates of prognosis prior to transfer to the MICU and mechanical ventilation.

Bronchiolitis obliterans after bone marrow transplantation: the effect of preconditioning.

While half of all patients receiving bone marrow transplantation (BMT) for malignancies and related diseases may achieve prolonged disease-free survival, 2-10% of patients undergoing allogeneic transplantation develop bronchiolitis obliterans (BrOb). We have hypothesized that total body irradiation (TBI) which has been used for pretreatment may influence the subsequent development of BrOb in patients undergoing allogeneic BMT. Since 1976, we have treated 104 patients undergoing allogeneic BMT with non-TBI preconditioning. Of 60 patients that survived and were evaluable for chronic graft versus host disease (GVHD) 26 developed chronic GVHD (43%). Four of 104 patients (3.9%) developed BrOb by clinical and/or pathologic findings. Four of 4 patients (100%) with BrOb had chronic GVHD. Two of these 4 patients (50%) were alive at the end of 2 years. These data demonstrate that chronic GVHD is a risk factor for BrOb in patients receiving non-TBI preconditioning regimens. The similar incidence of BrOb in this population compared to other studies using TBI suggest that the preconditioning regimen is not a factor in the development of BrOb. Further study is needed to confirm these findings. Allogeneic bone marrow transplantation (BMT) has revolutionized the therapeutic approach toward acute and chronic leukemias, aplastic anemia and rare immunodeficiency disorders. Half of all patients that undergo BMT achieve long-term disease-free survival but a similar number develop significant complications [1].(ABSTRACT TRUNCATED AT 250 WORDS)

Primary pulmonary botryomycosis. A manifestation of chronic granulomatous disease.

A 19-year-old woman with a childhood history of cavitating left upper lobe pneumonia presented with persistent weight loss, fever, cough and roentgenographic evidence of right upper lobe pneumonia resistant to antibiotic therapy. An open lung biopsy led to the diagnosis of botryomycosis. Neutrophil function studies including flow cytometric evaluation of oxidative burst, bacterial killing and evaluation of neutrophil cytosolic proteins required for oxidase activation were consistent with chronic granulomatous disease. This is the first case report of primary pulmonary botryomycosis as a clinical manifestation of CGD. Other recent cases of immunodeficiency states associated with botryomycosis are reviewed.

Bronchiolitis obliterans after autologous bone marrow transplantation.

Two patients are reported who underwent autologous bone marrow transplantation for lymphoma and developed rapidly progressive respiratory insufficiency at posttransplant (PT) days 90 and 273. Clinical examination revealed persistent cough, exertional dyspnea, inspiratory rales, and expiratory wheezing. Results of pulmonary function studies were consistent with rapidly progressive severe respiratory disease in both patients. Despite aggressive immunosuppressive therapy, both patients had a progressive decline in respiratory function and died of respiratory insufficiency at PT days 400 and 446, respectively. Each patient had histologic evidence of bronchiolitis obliterans (BrOb). These cases demonstrate that life-threatening obliterative bronchiolitis is not limited to patients undergoing allogeneic bone marrow transplantation, but can also follow autologous transplant. Awareness that this group is also at risk for BrOb and severe respiratory compromise may lead to early diagnosis and treatment.

Cholecystopleural fistula with cholelithiasis presenting as a right pleural effusion.

At autopsy, multiple gallstones were recovered from the right pleural space of an elderly patient who presented with a massive right pleural effusion and septic shock. The mechanisms of gallstone migration and fistula formation between the gallbladder and right pleural space are described. Despite atypical presentations, gallbladder disease remains an important differential consideration of right pleural effusion in the elderly.