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Biomedical subjects

H Belzberg

Publications and source records attributed to H Belzberg.

16 recordsLinked to original sources
PubMed1991

The rapid infusion system: a superior method for the resuscitation of hypovolemic trauma patients.

The rapid infusion system (RIS), which can deliver fluids/blood products rapidly at precise rates and normothermic conditions, was compared with conventional fluid administration (CFA) in a randomized study of 36 hypovolemic trauma patients. Admission stratification criteria of the groups were similar relative to age, Glasgow Coma Score (GCS), Injury Severity Score (ISS) and plasma lactate. Despite the lack of difference in blood loss between the 24-h survivors of the two groups, the CFA group required greater total fluids (23.6/20.21), red blood cells (5.5/4.61), fresh frozen plasma (FFP) (2.8/1.91), platelets (523/204 ml), and crystalloids (12.9/10.61). Lactate levels were lower in the RIS group at virtually all times from hours 1 to 24 (4.3/5.3 mM/l, t-value = 3.3, DF = 279, P = 0.001). Post-admission hypothermia was greater in the CFA group at all times during the first 24 h (35.2/36.4 degrees C, t-value = 5.6, DF = 250, P = 0.001). The mean partial thromboplastin time was significantly higher in the CFA group (47.3/35.1 s, t-value = 3.1, DF = 279, P = 0.002). The PTT and PT were related to the degree of lactic acidosis (P = 0.0001) and hypothermia (P = 0.001) but not to the amount of FFP given (P = 0.14). The hospital costs, days in the ICU, and days on the ventilator were greater for the CFA group, as was the incidence of pneumonia (0/11 vs. 6/17; P = 0.03). Hypovolemic trauma patients resuscitated with the RIS needed fewer fluid/blood products and had less coagulopathy; more rapid resolution of hypoperfusion acidosis; better temperature preservation; and fewer hospital complications than those resuscitated with conventional methods of fluid/blood product administration.

Adult↗
PubMed1991

Efficacy of continuous arteriovenous hemofiltration with dialysis in patients with renal failure.

OBJECTIVE: To document the efficacy of continuous arteriovenous hemofiltration with dialysis following renal failure, without protein restriction, and to explore the magnitude and clinical applications of total daily urea clearance. DESIGN: A noncomparative, descriptive account of a case series. Data were collected prospectively and analyzed retrospectively. SETTING: A tertiary care facility in a statewide emergency medical services system. PATIENTS: Twenty-eight patients with renal failure were supported by continuous arteriovenous hemofiltration with dialysis in a critical care unit during a 14-month period (21 patients with multitrauma; three patients with soft tissue infections; and four patients with multisystem organ failure who had been transferred from other hospitals). Renal failure was most commonly due to multisystem organ failure or associated with adult respiratory distress syndrome. RESULTS: Continuous arteriovenous hemofiltration with dialysis days totaled 308 (mean 10.9). All patients received full protein alimentation (mean protein load 131 g/day). The blood urea nitrogen concentration was controlled, generally to 40 to 75 mg/dL (14.3 to 26.7 mmol/L) within 3 to 5 days. Total daily urea clearance ranged from 15 to 21 g/day. Five (18%) of the 28 patients survived. CONCLUSION: Continuous arteriovenous hemofiltration with dialysis appears to be effective for the control of blood urea nitrogen and clearance of urea. This modality also permits full protein alimentation. Total daily urea clearance can be calculated easily and may have important clinical uses and implications.

Adult↗
PubMed1989

Prospective evaluation of combined high-frequency ventilation in post-traumatic patients with adult respiratory distress syndrome refractory to optimized conventional ventilatory management.

This study explores the value of combined high-frequency ventilation (CHFV) in a prospective clinical trial of 35 patients suffering from severe post-traumatic and/or septic adult respiratory distress syndrome (ARDS) who were refractory to conventional controlled mechanical ventilatory (CMV) support. The severity of ARDS was quantified by lung mechanics and gas exchange variables and the patients were classified on clinical grounds as well as on the basis of their respiratory index/pulmonary shunt relationship [RI/(Qsp/Qt)]. During the same time period as the CHFV study, data from these patients were compared to those from 88 ARDS patients who had quantitatively similar degrees of respiratory insufficiency, but who were treated only with controlled mechanical ventilation (CMV). The use of CHFV in the 35 CMV refractory patients resulted in an increase in expired tidal volume (VTE) by reducing the CMV inspired tidal volume (VTI) while increasing the volume component derived from high-frequency ventilation (HFV). This procedure appeared to reveal potentially salvageable ARDS patients who were refractory to CMV. In these patients, CHFV significantly reduced pulmonary mean airway pressure (Paw). The RI also decreased significantly and it was possible to reduce significantly the FIO2. In surviving ARDS patients treated with CHFV, an improvement in blood gases at reduced FIO2, without decreased cardiac output, was produced. The CHFV technique was used for less than or equal to 25 days and resulted in 23% survival of patients who were clinically and physiologically indistinguishable from the patients in the ARDS nonsurvivor group who were treated by CMV only. In surviving CHFV patients the decrease in Paw permitted a sustained, or increased, cardiac output with a rise in the oxygen delivery/oxygen consumption ratio, thus allowing for a higher PaO2 for any given level of pulmonary shunt.

Adolescent↗
PubMed1989

Respiratory index/pulmonary shunt relationship: quantification of severity and prognosis in the post-traumatic adult respiratory distress syndrome.

The relationship between the respiratory index (RI = alveolar-arterial oxygen gradient [P(A-a)O2] normalized by PaO2) and the pulmonary shunt (Qsp/Qt) has been examined in 929 studies from 240 critically ill post-traumatic patients. Of these, 88 patients (443 studies) were individuals who developed post-traumatic adult respiratory distress syndrome (ARDS) and 152 were patients (486 studies) who did not develop ARDS. This study demonstrates that the RI to Qsp/Qt [RI/(Qsp/Qt)] relationship was significantly (p less than .0001) increased in patients who developed fatal ARDS compared with those who did not develop ARDS, or with those whose ARDS resolved. Because of the increased oxygen consumption (VO2) in ARDS patients in association with their severe limitations in gas exchange (RI) and increased Qsp/Qt, surviving ARDS patients had a significant increase in the cardiac index which resulted in a higher oxygen delivery to VO2 ratio. ARDS patients showed significant (p less than .0001) evidence of increased pulmonary vascular tone, correlated with the increase in the RI/(Qsp/Qt) relationship. In addition, those patients with high RI/(Qsp/Qt) also had increased right ventricular (RVSW) to left ventricular work (LVSW) ratios which were shown to be a direct function of the rise in RI. This increase in both RVSW/LVSW and RI/(Qsp/Qt) ratios was significantly (p less than .0001) correlated with an increased mortality. Thus, the RI/(Qsp/Qt) relationship, which can be obtained from arterial and mixed venous blood gases and saturations only, can be used to predict the severity of the ARDS process as well as important pulmonary vascular and right ventricular overload consequences.

Hemodynamics↗
PubMed1989

Methodologic approach for a large functional trauma registry.

The utility of a clinical trauma registry (TR) is directly related to the constituents of the data base and to the accuracy of the data, which is contingent on a carefully constructed data collection system. A TR was developed by traumatologists at a busy Level I trauma facility that predominantly receives patients having incurred blunt injury. Four dedicated data collectors gather the AP information within 24 to 48 hours after admission, with prompt Attending Surgical review for verification. Examples of data output prove this is a functional system. Using a careful methodologic approach for design and implementation, clinicians can create a large, functional trauma registry with many potential applications.

Data Collection↗
PubMed1988

Inhibition of post-traumatic septic proteolysis and ureagenesis and stimulation of hepatic acute-phase protein production by branched-chain amino acid TPN.

Previous studies have shown that severe sepsis after major trauma results in the reprioritization of release of hepatic acute-phase proteins (APP). They suggest competition for leucine for nutritional utilization may be responsible. To test this hypothesis, a branched-chain enriched (46.6%) amino acid mixture (BCAA) was administered on a prospective randomized basis with standard TPN therapy to 16 septic post-trauma patients. After sepsis was diagnosed, a randomized therapy (control-TPN or BCAA-TPN) was given for 12 days, or until death occurred. Total calories and amino acid nitrogen (N) administered were not different in the two groups (t-test) and q 8 h (347 study periods) amino acid clearances, urinary urea nitrogen excretion, muscle proteolysis from 3-methyl-histidine (3-MH) excretion, and standard indices of sepsis severity and hepatic function were measured, as well as platelets (PLAT), leucocytes (WBC), albumin (ALB), and six acute-phase proteins: C-reactive protein (CRP), alpha-1-antitrypsin (A1TRIP), fibrinogen (FIBRIN), alpha-2-macroglobulin (AMACRO), ceruloplasmin (CERUL), and transferrin (TRANS). Using Scheffé analysis of all contrasts the data showed: BCAA resulted in a fall in 24-hour urea N excretion (24.0 to 20.0 gm/24 hr) and in proteolysis (138 to 126 gm/24 hr) (p less than 0.0001). Prestudy CRP levels were all elevated, but compared to control where APP reprioritization occurred, over the initial 10 days of therapy BCAA patients had a more rapid fall in CRP with a more rapid rise in FIBRIN, TRANS, CERUL, ALBUMIN, AMACRO, and A1TRIP (all p less than 0.0001) relative to CRP. Also, the sepsis-reduced clearances of glutamine and glutamate, alanine, and proline were increased (p less than 0.0001) during BCAA even though urea nitrogen production was reduced (p less than 0.0001). The increase in leucine clearance with BCAA-enriched TPN was positively correlated (r2 = 0.601; p less than 0.0001) with the increase in the sum of all APP and ALB and was also associated with an increase both in FIBRIN and in platelets (p less than 0.0001). The BCAA-related increase in FIBRIN (9.1 to 11.9 mg/ml) occurred at the same time as a fall in prothrombin time (p less than 0.0001). BCAA-enriched TPN reduced proteolysis and amino acid catabolism and appeared to increase the levels of the more rapidly appearing anti-inflammatory and nutritional hepatic APP and formed coagulation elements in post-traumatic sepsis.

Acute-Phase Proteins↗
PubMed1987

Pneumothorax and pulmonary embolism complicating post-traumatic hip surgery.

A case of intraoperative pneumothorax preceded by a pulmonary embolus is presented. A high index of suspicion led to further investigation, after resolution of the pneumothorax was not accompanied by clinical improvement. The literature is reviewed, and the various methods of prophylaxis and treatment discussed.

Acetabulum↗
PubMed1987

Prediction of arterial blood gases by transcutaneous O2 and CO2 in critically ill hyperdynamic trauma patients.

The management of severe adult respiratory distress syndrome in critically injured patients requires the frequent measurement of arterial blood gases for adjustment of cardiovascular and ventilatory support. Since these require blood withdrawal and laboratory determinations, a noninvasive method of assessment of arterial gas tensions would permit more frequent assessment of the patient as well as permitting rapid changes in the patient's ventilatory status to be detected earlier in the clinical course. The role of transcutaneous O2 and CO2 tension in providing these measurements was evaluated in 92 studies in 38 critically ill patients with ARDS due to trauma and/or sepsis. All patients were normodynamic or hyperdynamic at the time of study (cardiac index 2.5 to 7.6 L/min/m2) and were intubated and on increased inspired oxygen fractions (FIO2 = 30 to 100%) delivered by mechanical ventilation, had a range of body temperature from 35.0 to 39.5 degrees C and pH from 7.29 to 7.57 The data from a transcutaneous O2 and CO2 sensor applied to the skin of the anterior thorax were analyzed by multiple regression analysis of variances. Prediction of the arterial oxygen tension (PaO2) from 52 to 253 torr was possible from regression-corrected measurements of the transcutaneous O2 (TcO2): [PaO2 = 1.1 (TcO2) - 0.28 (FIO2) + 45.5]. The arterial carbon dioxide tension (PaCO2) from 26 to 57 torr was predicted from the transcutaneous CO2 (TcCO2):[PaCO2 = 0.76 (TcCO2) + 0.06 (FIO2) + 0.035 (TcO2) + 4.1]. With these corrections, a noninvasive Respiratory Index was computed for assessing ARDS severity, and dynamic changes in arterial gases could be followed in response to postural changes, ventilatory alterations, or cardiovascular perturbations. These data suggest that a reasonable estimate of the arterial blood gases can be obtained from a regression-corrected measurement of the transcutaneous O2 and CO2 tensions in critically injured normodynamic or hyperdynamic ARDS patients.

Adult↗
PubMed1987

Thoracic CT in detecting occult disease in critically ill patients.

Bedside chest radiography is important in the detection of thoracic disease in critically ill patients. Unfortunately these studies are often of poor technical quality and are frequently difficult to interpret. Eighty-seven bedside chest radiographs and concurrent thoracic CT scans obtained in 56 critically ill patients over a 20-month period were interpreted retrospectively and independently. In most cases, the studies were obtained to search for a source of sepsis, fever, or unexplained clinical deterioration. In this series, thoracic CT added significantly more diagnostic information in 61 (70%) of these studies than was available from the corresponding bedside radiographs. Despite the difficulties of transporting critically ill patients for CT and the significant cost, our results suggest that the improved rate of detection of unsuspected thoracic disease justifies the use of CT when bedside radiographic examinations fail to adequately explain the clinical findings.

Adolescent↗
PubMed1985

Reprioritization of hepatic plasma protein release in trauma and sepsis.

We studied the temporal pattern of seven hepatic synthesized plasma proteins in 26 severely injured patients beginning in the immediate posttrauma period. Clinical sepsis developed in ten patients between three and eight days after injury, and 16 patients had nonseptic courses. In the initial five days after injury, except for albumin, all acute-phase protein levels rose. However, if sepsis developed, C-reactive protein, fibrinogen, ceruloplasmin, and alpha 1-antitrypsin levels continued to be elevated after the initial five posttrauma days, while transferrin, albumin, and alpha 2-macroglobulin levels fell. This differential response became more extreme as sepsis progressed. Covariance analysis of the regression of the five true acute-phase hepatic proteins on C-reactive protein showed that, when sepsis occurred after major traumatic injury, the C-reactive protein rise was associated with a significant reprioritization of hepatic acute-phase plasma protein release. This reprioritization response seems to be both a predictor of sepsis as well as a measure of the adequacy of the host response to trauma and sepsis.

Acute-Phase Proteins↗
PubMed1985

Quantification of asymmetric lung pathophysiology as a guide to the use of simultaneous independent lung ventilation in posttraumatic and septic adult respiratory distress syndrome.

The management of impaired respiratory gas exchange in patients with nonuniform posttraumatic and septic adult respiratory distress syndrome (ARDS) contains its own therapeutic paradox, since the need for volume-controlled ventilation and PEEP in the lung with the most reduced compliance increases pulmonary barotrauma to the better lung. A computer-based system has been developed by which respiratory pressure-flow-volume relations and gas exchange characteristics can be obtained and respiratory dynamic and static compliance curves computed and displayed for each lung, as a means of evaluating the effectiveness of ventilation therapy in ARDS. Using these techniques, eight patients with asymmetrical posttraumatic or septic ARDS, or both, have been managed using simultaneous independent lung ventilation (SILV). The computer assessment technique allows quantification of the nonuniform ARDS pattern between the two lungs. This enabled SILV to be utilized using two synchronized servo-ventilators at different pressure-flow-volumes, inspiratory/expiratory ratios, and PEEP settings to optimize the ventilatory volumes and gas exchange of each lung, without inducing excess barotrauma in the better lung. In the patients with nonuniform ARDS, conventional ventilation was not effective in reducing shunt (QS/QT) or in permitting a lower FIO2 to be used for maintenance of an acceptable PaO2. SILV reduced per cent v-a shunt and permitted a higher PaO2 at lower FIO2. Also, there was x-ray evidence of ARDS improvement in the poorer lung. While the ultimate outcome was largely dependent on the patient's injury and the adequacy of the septic host defense, by utilizing the SILV technique to match the quantitative aspects of respiratory dysfunction in each lung at specific times in the clinical course, it was possible to optimize gas exchange, to reduce barotrauma, and often to reverse apparently fixed ARDS changes. In some instances, this type of physiologically directed ventilatory therapy appeared to contribute to a successful recovery.

Adolescent↗
PubMed1985

Increased dependence of leucine in posttraumatic sepsis: leucine/tyrosine clearance ratio as an indicator of hepatic impairment in septic multiple organ failure syndrome.

The body clearance of 10 plasma amino acids (AA) was determined from the rate of compared muscle-released AA and AA administered by infusion of total parenteral nutrition (TPN) compared to their estimated extracellular (ECW) pool in patients with multiple trauma with (n = 10) or without (n = 16) sepsis at 8-hour intervals. In both nonseptic and septic trauma, increasing TPN increased the mean clearance rate of all infused AA. When the individual AA clearance rates were normalized by the total AA infusion rate, regression-covariance analysis revealed that patients with sepsis had relatively impaired clearances of alanine (p less than 0.01) and methionine, proline, phenylalanine, and tyrosine p less than 0.05 for all). In contrast, the clearances of branched-chain AA (BCAA) valine and isoleucine were maintained, and the clearance of leucine was higher (p less than 0.05) in trauma patients with sepsis than in those without. At any AA infusion rate, compared with surviving patients with sepsis (p less than 0.05), patients who developed fatal multiple organ failure syndrome (MOFS) showed increased clearances of all BCAA with further impaired clearance of tyrosine. The clearance ratio of leucine/tyrosine was increased in MOFS at any AA infusion rate (p less than 0.0001), was an indicator of severity, and, if persistent, was a manifestation of a fatal outcome. Because tyrosine metabolism occurs almost entirely in the liver while leucine can be utilized by viscera and muscle, these data suggest early and progressive septic impairment of the pattern of hepatic uptake and oxidation of AA with a greater body dependence on BCAA, especially leucine, as septic MOFS develops.

Adolescent↗