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Biomedical subjects

M H Kollef

Publications and source records attributed to M H Kollef.

At least 91 records · Page 5Linked to original sources
PubMed1995

The acute respiratory distress syndrome.

ARDS is a complex response of the lung to direct (inhalational) and indirect (hematogenous) insults. It is easy to be pessimistic about the benefit of the approaches we have described, but there is evidence that overall survival has improved in recent years. To maintain this progress, new therapies for ARDS must be rigorously evaluated, and their routine use should be recommended only after careful scrutiny of the evidence. Such a course will eliminate the unnecessary risks and costs often associated with unproved therapies.

Humans↗
PubMed1995

Triage considerations for patients with acute gastrointestinal hemorrhage admitted to a medical intensive care unit.

OBJECTIVE: To determine whether previously identified clinical criteria, available at the time of triage, can predict clinical outcomes for patients with acute gastrointestinal (GI) hemorrhage. DESIGN: An inception cohort study. SETTING: Barnes Hospital, an academic tertiary care center. PATIENTS: One hundred eight consecutive hospital admissions (103 patients) triaged to intensive care for GI hemorrhage. INTERVENTIONS: Prospective patient surveillance, data collection, and risk stratification using preselected clinical criteria and outcomes assessment. MEASUREMENTS AND MAIN RESULTS: Using clinical data available at the time of triage, 28 (25.9%) intensive care unit admissions were classified as low risk for having poor outcomes. There was no difference in the distribution of upper and lower GI tract sources of hemorrhage for the two risk groups (p = .310). Stigmata of recent hemorrhage were endoscopically identified for six (21.4%) of the low-risk patient admissions and for 16 (20.0%) of the high-risk patient admissions (p = .872). Patient admissions identified as low risk had significantly lower rates of recurrent GI hemorrhage (3.6% vs. 22.5%; p = .022), less acquired organ system derangements (1.0 +/- 0.3 vs. 1.5 +/- 1.0 organs; p < .001), shorter lengths of hospitalization (4.9 +/- 3.5 vs. 8.8 +/- 7.4 days; p < .001), required transfusion with fewer units of packed red blood cells (1.3 +/- 1.2 vs. 6.2 +/- 4.7 units; p < .001), and had a lower overall hospital mortality rate (0.0% vs. 21.3%; p = .008) compared with patient admissions identified as being high risk. CONCLUSION: These data suggest that objective clinical criteria, available at the time of triage determination, can be utilized to identify a low-risk group of patients with acute GI hemorrhage, having favorable outcomes and potentially no need for intensive care unit services.

Acute Disease↗
PubMed1995

Determinants of mortality and multiorgan dysfunction in cardiac surgery patients requiring prolonged mechanical ventilation.

OBJECTIVES: To identify characteristics associated with mortality and the development of multiorgan dysfunction in patients who had undergone cardiac surgery and required prolonged mechanical ventilation, ie, > 48 h. DESIGN: A prospective cohort study. SETTING: Barnes Hospital, St. Louis, an academic tertiary care center. PATIENTS OR OTHER PARTICIPANTS: A total of 107 consecutive patients undergoing cardiac surgery and requiring prolonged mechanical ventilation. INTERVENTIONS: Prospective patients surveillance and data collection. MAIN OUTCOME MEASURES: ICU mortality and multiorgan dysfunction. RESULTS: Among 472 consecutive patients admitted to the cardiac surgery ICU following surgery, 107 (22.7%) required prolonged mechanical ventilation. Twenty-one of these patients (19.6%) died during their hospitalization. In a logistic-regression analysis, the development of an organ system failure index (OSFI) of 3 or greater was the only characteristic independently associated with ICU mortality (p < 0.001). The occurrence of an antibiotic-resistant infection (adjusted odds ratio [AOR] = 6.1, 95% confidence interval [CI] = 2.5 to 14.6 p = 0.006), an aortic cross-clamp time equal to or greater than 1.25 h (AOR = 3.9, CI = 2.3 to 6.8, p = 0.016), the development of ventilator-associated pneumonia (AOR = 3.6, CI = 2.4 to 5.3, p < 0.001), and an APACHE III score equal to or greater than 30 (AOR = 3.1, CI = 1.8 to 5.3, p = 0.036) were independently associated with the development of an OSFI of 3 or greater. CONCLUSIONS: These data confirm that acquired multiorgan dysfunction is the best predictor of mortality in patients requiring prolonged mechanical ventilation following cardiac surgery. Additionally, they identify potential determinants of multiorgan dysfunction and suggest possible interventions for its reduction in this patient population.

Aged↗
PubMed1995

Acute respiratory failure due to extramedullary hematopoiesis.

Extramedullary hematopoiesis (EMH) associated with myelofibrosis uncommonly occurs within the thorax. We describe the first reported case of acute and rapidly fatal respiratory failure due to pulmonary interstitial EMH associated with myelofibrosis. Interstitial EMH should be considered in the differential diagnosis of patients with interstitial pulmonary infiltrates and respiratory failure accompanying a disease process known to predispose to the development of EMH.

Acute Disease↗
PubMed1995

The effect of late-onset ventilator-associated pneumonia in determining patient mortality.

STUDY OBJECTIVE: To determine whether the development of late-onset ventilator-associated pneumonia (VAP) is associated with an increased risk of hospital mortality. DESIGN: Prospective cohort study. SETTING: ICUs of two university-affiliated teaching hospitals. PATIENTS: Three hundred fourteen patients admitted to an ICU who required mechanical ventilation for greater than 5 days. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS: The primary outcome measures were the development of late-onset VAP (ie, occurring > 96 h after intubation) and hospital mortality. RESULTS: Late-onset VAP was observed in 87 patients (27.7%). Thirty-four (39.1%) patients with late-onset VAP died during hospitalization compared with 85 patients (37.4%) without late-onset VAP (relative risk, 1.04; 95% confidence interval [CI], 0.76 to 1.43). Twenty patients (6.4%) developed late-onset VAP due to a "high-risk" pathogen (ie, Pseudomonas aeruginosa, Acinetobacter sp, Xanthomonas maltophilia) with an associated mortality rate of 65%. Stepwise logistic regression analysis identified five variables as independent risk factors for hospital mortality (p < 0.05): an organ system failure index of 3 or greater (adjusted odds ratio [AOR], 3.4; 95% CI, 2.0 to 5.8; p < 0.001), having a nonsurgical diagnosis (AOR, 2.1; 95% CI, 1.3 to 3.6; p = 0.002), a premorbid lifestyle score of 2 or greater (AOR, 1.8; 95% CI, 1.1 to 2.9; p = 0.015), acquiring late-onset VAP due to a "high-risk" pathogen (AOR, 3.4; 95% CI, 1.2 to 10.0; p = 0.025), and having received antacids or histamine type-2 receptor antagonists (AOR, 1.7; 95% CI, 1.0 to 2.9; p = 0.034). Additionally, we found the occurrence of late-onset VAP due to high-risk pathogens to be the most important predictor of hospital mortality among patients developing VAP (AOR, 5.4; 95% CI, 2.8 to 10.3; p = 0.009). CONCLUSIONS: Nosocomial pneumonia due to certain high-risk microorganisms is an independent risk factor for hospital mortality among patients requiring prolonged mechanical ventilation. We suggest that future investigations of late-onset VAP stratify patient outcomes according to the distribution of high-risk pathogens when reporting their results.

APACHE↗
PubMed1995

Ventilator-associated pneumonia: an update for clinicians.

VAP is a common problem faced by clinicians caring for critically ill patients. Use of appropriate preventive, diagnostic, and therapeutic strategies should minimize morbidity resulting from this clinical problem. Future investigations need to better define the optimum diagnostic methods and the most appropriate use of antibiotics for patients with suspected VAP. Only by developing these strategies can we hope to avoid the complications associated with spiraling empiricism. These complications include numerous outbreaks of serious antibiotic-resistant nosocomial infections due to the empiric over-administration of broad-spectrum antimicrobial agents. Advances in both the clinical and basic medical sciences are likely to help further elucidate the epidemiology and pathogenesis of VAP and, thereby, improve the opportunities for future prevention of this disorder.

Cross Infection↗
PubMed1994

Comparison of venography, duplex imaging, and bilateral impedance plethysmography for diagnosis of lower extremity deep vein thrombosis.

Twenty-four consecutively hospitalized patients with clinical evidence of lower extremity deep vein thrombosis (DVT) had blinded ipsilateral ultrasonographic duplex imaging (US), contrast venography (VG), and a one-time bilateral impedance plethysmography (IPG) examination. The cases of eight (33%) of the study patients were thought to be complicated due to a prior history of DVT or the presence of ipsilateral inguinal adenopathy. Interpretable test results were obtained for 100% of the US examinations, 88% of the VG studies, and 75% of the IPGs. One additional subject, included in our study for statistical analysis, had an unblinded false-negative US examination; in this case DVT was shown by VG but could not be seen on US despite the radiologist's prior knowledge. The sensitivities, specificities, and 95% confidence intervals for the three studies were as follows: US, 92% (81% to 103%) sensitivity, 100% (99% to 101%) specificity; VG, 100% (99% to 101%) sensitivity, 75% (58% to 96%) specificity; IPG, 50% (30% to 70%) sensitivity, 83% (68% to 98%) specificity. Of the six indeterminate IPG studies, four (67%) occurred in complicated cases. These data suggest that US should be the first-line noninvasive screening study done for evaluation of suspected DVT, especially in complicated cases.

Adult↗
PubMed1994

Endotracheal tube misplacement: incidence, risk factors, and impact of a quality improvement program.

To assess the impact of a quality improvement program on the occurrence of serious complications related to endotracheal tube misplacement and to identify risk factors, we did a before and after comparison in the adult intensive care units of a military referral hospital. All adult patients requiring endotracheal intubation during two 12-month periods comprised the study population. After the identification of a sentinel case, a retrospective review identified 278 adult patients requiring endotracheal intubation over a 12-month period. Twenty-two of these patients had at least one significant endotracheal tube misplacement; five of these misplacements (23%) were associated with serious complications (anoxic encephalopathy, atelectasis and respiratory failure, gastric aspiration, pneumothorax, and hypoxemia). In four of these patients the complications directly contributed to patient morbidity and mortality. During a subsequent 12-month period, after the initiation of a quality improvement program, 246 patients requiring tracheal intubation were prospectively studied. Of these 246 patients, 113 (46%) were identified as having at least one endotracheal tube misplacement requiring immediate repositioning. The incidence of serious complications related to endotracheal tube misplacement was significantly less during the implementation of the quality improvement program (0 of 246 patients) than during the retrospective period (5 of 278 patients). Multivariate analysis showed that a longer duration of endotracheal intubation, the lack of chemical paralysis, and the occurrence of cardiac arrest were independently predictive of endotracheal tube misplacement. These results suggest that a specific ICU quality improvement program can have a favorable impact on patient outcome.

Adult↗
PubMed1994

Labetalol overdose successfully treated with amrinone and alpha-adrenergic receptor agonists.

Circulatory collapse and obtundation occurred in a 37-year-old woman following an iatrogenic overdose of labetalol. Conventional therapy with glucagon and alpha-adrenergic receptor-stimulating agents was ineffective in raising the patient's cardiac output or improving her mental status despite increasing the arterial pressure. The administration of amrinone was temporally associated with significant increases in the cardiac output accompanied by improved mental status. This case suggests that amrinone may be effective adjunctive therapy for beta-adrenergic receptor blocker overdoses by reversing their negative inotropic effects.

Adrenergic alpha-Agonists↗
PubMed1994

Pulmonary involvement in the hypereosinophilic syndrome.

Hypereosinophilic syndrome (HES) is an infiltrative disease of eosinophils affecting multiple organs, including the lung. Hypereosinophilic syndrome differs from acute and chronic eosinophilic pneumonia clinically and usually necessitates treatment with alkylating agents and/or corticosteroids. We describe two patients with HES and pulmonary involvement. One of our patients developed the adult respiratory distress syndrome thought to be a complication of the HES. Aggressive treatment of HES in both cases combined with intensive support in the patient with ARDS resulted in prolonged survival.

Adult↗
PubMed1994

The role of selective digestive tract decontamination on mortality and respiratory tract infections. A meta-analysis.

PURPOSE: To review available clinical trials of selective digestive decontamination (SDD) in patients requiring intensive care. DATA SOURCES: All relevant English-language articles from 1982 through 1992 were identified through MEDLINE search and article bibliographies. STUDY SELECTION: Twenty-one articles were identified; 16 articles were selected for analysis based on inclusion and exclusion criteria. DATA EXTRACTION: Occurrence rates for mortality, acquired pneumonia, and acquired tracheobronchitis were extracted for patients treated with SDD and for control patients. Cumulative risk differences were calculated for each of these outcomes. RESULTS: There was no significant difference between cumulative mortality rates for control patients (0.262; n = 1,165) and patients receiving SDD (0.243; n = 1,105) (p = 0.291; beta error rate = 0.16). The acquired pneumonia greater than that in patients receiving SDD (0.074; n = 1,031) (p < 0.0001). The acquired tracheobronchitis rate in control patients (0.117; n = 549) was also significantly greater than that in patients receiving SDD (0.065; n = 494) (p = 0.004). The rate of acquired pneumonia due to Gram-positive bacteria was similar between the control patients (0.033; n = 660) and the SDD-treated patients (0.033; n = 646) (p = 0.933). Colonization with pathogenic Gram-positive bacteria and pneumonia due to antibiotic-resistant Gram-positive bacteria appeared to occur more frequently in SDD-treated patients. CONCLUSIONS: These results suggest that SDD decreases the overall incidence of acquired pneumonia and tracheobronchitis in patients requiring intensive care. SDD had no apparent effect on the hospital mortality rate. The routine use of SDD cannot be supported by this meta-analysis. SDD may be useful in specific circumstances where a particular ICU or ICU population is found to have an excessive incidence of acquired infections. Any use of SDD should include careful patient surveillance for the emergence of infection due to bacteria not covered by the prophylaxis regimen and due to antibiotic-resistant bacteria.

Anti-Bacterial Agents↗
PubMed1994

Determinants of outcome for patients in the medical intensive care unit requiring abdominal surgery: a prospective, single-center study.

OBJECTIVE: To identify objective factors, available at the time of surgical evaluation, associated with outcome for patients in the medical ICU undergoing abdominal surgery. DESIGN: Single-center, prospective observational study. SETTING: An academic tertiary care center. PATIENTS: The study included 1,617 consecutive patients in the medical ICU. INTERVENTION: Prospective patient surveillance and data collection. MEASUREMENTS: Patient demographics, severity of illness, organ system derangements, abdominal processes requiring surgery, and hospital mortality. RESULTS: Sixty-seven patients in the medical ICU (4.1 percent) developed an acute abdominal process potentially amenable to surgical intervention. Eleven of these patients (16.4 percent) elected not to undergo surgery (mortality = 100 percent). Forty-two of the 56 patients who underwent surgery survived (75.0 percent). Stepwise logistic regression analysis identified two independent objective predictors of mortality for this patient cohort (p < 0.05): an organ system failure index (OSFI) > 2 (adjusted odds ratio [AOR] = 19.5; 95 percent confidence interval [CI], 7.4 to 51.5; p < 0.001); and an APACHE II score > 18 (AOR = 9.4; CI = 3.1 to 28.3; p = 0.03). The observed mortality following surgery was stratified according to the presence or absence of these two factors: neither present, 5.1 percent; APACHE II > 18 present alone, 33 percent; OSFI > 2 present alone, 60 percent; and both present, 88.9 percent (p < 0.001). Surgical nonsurvivors and patients electing not to undergo surgery were similar without significant differences for demographics, severity of illness, or organ system derangements at the time of surgical evaluation. CONCLUSIONS: The number of organ system derangements and the severity of illness, as assessed by APACHE II, appear to be useful discriminators of outcome for patients in the medical ICU undergoing abdominal surgery. These data suggest potential outcome predictors for this selected group of patients in the ICU.

APACHE↗
PubMed1994

Fallibility of persistent blood return for confirmation of intravascular catheter placement in patients with hemorrhagic thoracic effusions.

Two patients are described with hemorrhagic thoracic effusions who required central venous catheterization. Presumed subclavian and internal jugular vein cannulation, ipsilateral to the hemorrhagic thoracic effusions, was confirmed by the operators in each case by the persistent aspiration of blood. Subsequent clinical and radiologic evaluation revealed that the vascular catheters were introduced into the pleural space. In both individuals, the persistent aspiration of extravascular hemorrhagic fluid mimicked intravascular catheter positioning. Physicians treating patients with hemorrhagic thoracic effusions need to be aware of this potential complication that can result in the delayed resuscitation of hemodynamically unstable patients.

Adult↗
PubMed1994

Ventilator-associated pneumonia: clinical considerations.

Nosocomial (i.e., originating or taking place in a hospital) pneumonia is the leading cause of death from acquired nosocomial infections. The estimated prevalence of nosocomial pneumonia in intensive care units ranges from 10% to 65%, with fatality rates of 13-55%. Ventilator-associated pneumonia (VAP) specifically refers to nosocomial pneumonia in a mechanically ventilated patient that was neither present nor already developing at the time of intubation (i.e., clinical evidence of VAP occurring > 48 hr after intubation). During the past decade, some studies have suggested that VAP can be an important determinant of out-come for critically ill patients requiring mechanical ventilation. Recent investigations have provided new insights into the pathogenesis of VAP, and improved techniques have been developed for its diagnosis. Most important, emerging clinical data now suggest that new management strategies for VAP, including more specific indications for antimicrobial use, may significantly improve patients' outcomes.

Cross Infection↗
PubMed1994

Predicting intensive care unit outcome with scoring systems. Underlying concepts and principles.

The accurate prediction of outcome will continue to be an important area of future medical investigation. Physicians, health care administrators, government agencies, and insurance companies all require accurate and assessable data on which to base decision-making processes. Refinements in our ability to identify important data, collect and process the data accurately and inexpensively, and make the data readily available to those wishing access to it will be the focus of future research efforts. Future advances in computer technology and the application of outcome research methods to critical care should assist in achieving many of these goals.

Decision Making, Organizational↗