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Biomedical subjects

M H Kollef

Publications and source records attributed to M H Kollef.

At least 109 records · Page 6Linked to original sources
PubMed1993

Ventilator-associated pneumonia. A multivariate analysis.

OBJECTIVES: To identify factors associated with the development of ventilator-associated pneumonia (VAP) and to examine the incidence of VAP in different intensive care unit (ICU) populations. DESIGN: An inception cohort study. SETTING: Barnes Hospital, St Louis, Mo, an academic tertiary care center. PATIENTS OR OTHER PARTICIPANTS: A total of 277 consecutive patients required mechanical ventilation for longer than 24 hours from a medical ICU (75 patients), surgical ICU (100 patients), or cardiothoracic ICU (102 patients). INTERVENTIONS: Prospective patient surveillance and data collection. MAIN OUTCOME MEASURES: Ventilator-associated pneumonia and ICU mortality. RESULTS: Ventilator-associated pneumonia occurred in 43 patients (15.5%). Stepwise logistic regression analysis identified four factors to be independently associated with VAP (P < .05): an organ system failure index of 3 or greater (adjusted odds ratio [AOR] = 10.2; 95% confidence interval [CI], 4.5 to 23; P < .001); patient age of 60 years or older (AOR = 5.1; 95% CI, 1.9 to 14.1; P = .002); prior administration of antibiotics (AOR = 3.1; 95% CI, 1.4 to 6.9; P = .004); and supine head positioning during the first 24 hours of mechanical ventilation (AOR = 2.9; 95% CI, 1.3 to 6.8; P = .013). Ventilator-associated pneumonia occurred more often in cardiothoracic patients (21.6%) compared with medical patients (9.3%) (P = .03). Patients with VAP also had a higher mortality (37.2%) than those without VAP (8.5%) (P < .001). An organ system failure index of 3 or greater (AOR = 16.1; 95% CI, 6.1 to 42; P < .001), a premorbid lifestyle score of 2 or greater (AOR = 3.1; 95% CI, 1.3 to 7.3; P = .012), and supine head positioning during the first 24 hours of mechanical ventilation (AOR = 3.1; 95% CI, 1.2 to 7.8; P = .016) were independently associated with mortality. CONCLUSIONS: These data suggest potential interventions that might affect the incidence of VAP or outcome associated with VAP. Additionally, they indicate that different ICU populations may have different incidences of VAP.

Aged↗
PubMed1993

Endocrine profiles for outcome prediction from the intensive care unit.

OBJECTIVE: To evaluate the discriminating ability of various specific endocrine studies on patient outcome from the intensive care unit (ICU). DESIGN: Prospective cohort study of patients requiring intensive care. SETTING: Adult medical and coronary care units in a military referral hospital. PATIENTS: A total of 61 consecutive patients requiring intensive care over a 5-month period and 20 control subjects. INTERVENTIONS: Patients were evaluated within 24 hrs of ICU admission (day 1) with determination of the following variables: serum triiodothyronine, thyroxine, triiodothyronine resin uptake, thyrotropin, luteinizing hormone, follicle-stimulating hormone, testosterone, basal cortisol, adrenocorticotropic hormone-stimulated cortisol, cortisol increment, and Acute Physiology and Chronic Health Evaluation (APACHE II) score. A total of 24 hrs later (day 2), the same battery of tests was repeated with the exception of the adrenocorticotropic hormone-stimulated cortisol, cortisol increment, and APACHE II score. Individual variables were compared between survivors and nonsurvivors. MEASUREMENTS AND MAIN RESULTS: The best discriminators of patient outcome in descending order were the basal serum cortisol and triiodothyronine concentrations obtained on day 2 and the APACHE II score with predictive abilities of 81%, 74%, and 70%, respectively. No combination of variables was superior to the day 2 basal cortisol concentration for discrimination of outcome. CONCLUSIONS: The basal cortisol and triiodothyronine concentrations obtained from blood samples collected within 48 hrs of ICU admission appear to be better discriminators of patient outcome than the APACHE II score.

Adult↗
PubMed1993

Symptomatic pleural effusion after coronary artery revascularization: unsuspected pleural injury from internal mammary artery resection.

A patient with a large left pleural effusion returned to her physician 4 weeks after CABG with saphenous vein grafts. After repeated investigations the cause of the effusion still could not be ascertained. Upon subsequent review it was noted that the patient had had an aborted attempt at coronary artery revascularization using the left IMA. Nonsurgeons frequently fail to recognize the association of significant pleuropulmonary complications with harvesting of the IMA conduit as a coronary bypass graft. The delay in presentation of these complications after CABG, along with a lack of physician familiarity with them, can lead to problems in diagnosis and management. Although serious pleuropulmonary complications are an uncommon problem, physicians must become familiar with these complications because of the widespread use of the IMA graft.

Female↗
PubMed1993

Pleural effusion in patients with systemic cholesterol embolization.

We evaluated two patients with systemic cholesterol embolization (SCE) associated with the development of pleural effusions. These two patients had evidence of atherosclerosis and presented with livedo reticularis, renal insufficiency, and gangrenous cutaneous changes as manifestations of their SCE. In both cases, closed pleural biopsies demonstrated acute inflammation of the parietal pleura. Our experience with these individuals and a review of the medical literature suggest that pleural injury from atheromatous embolization may occur. Physicians caring for patients with SCE should be aware of the possible association of pleural reactions with this process.

Aged↗
PubMed1993

Recalcitrant chylothorax and chylous ascites associated with hypothyroidism.

A patient with bilateral chylous effusions and chylous ascites resulting from mediastinal and periaortic radiation for Hodgkin's lymphoma is described. The chylothoraces were resistant to medical treatment as well as to surgical pleurectomy. The patient's medical condition worsened due to progression of the chylous effusions and an episode of catheter-related bacteremia complicated by respiratory failure requiring mechanical ventilation. While receiving mechanical ventilation, the patient was found to have hypothyroidism and was subsequently begun on thyroid hormone replacement therapy. Within 1 week, the chylous drainage from the pleural spaces dramatically decreased and eventually resolved. Eighteen months after beginning thyroid hormone replacement therapy, the patient continues to do well without recurrence of the chylous effusions.

Adult↗
PubMed1992

Intrinsic PEEP and unilateral lung hyperinflation. Pathophysiology and clinical significance.

Over a 14-month period, three patients developed unilateral lung hyperinflation during mechanical ventilation as a manifestation of intrinsic PEEP. These patients all had a history of CAO and an inflammatory or fibrotic disease process involving the contralateral lung. Physicians caring for patients with CAO need to be familiar with this presentation of intrinsic PEEP due to the associated barotrauma and cardiac dysfunction which can result from it.

Aged↗
PubMed1992

Predicting outcome from intensive care for patients with rheumatologic diseases.

OBJECTIVE: To evaluate 2 prognostic scoring systems in patients with an underlying rheumatologic diagnosis admitted to an intensive care unit (ICU). METHODS: A retrospective case series review, carried out at a medical ICU in a military referral hospital. All adult ICU admissions with a known rheumatologic diagnosis were evaluated during 28 consecutive months. There were 48 ICU admissions available for review in 36 patients (1.33 ICU admissions/patient) during the study period. All patients were assigned an APACHE II and TISS score based on the first 24 h of ICU admission. RESULTS: Eleven ICU admissions resulted in patient death (22.9%) and the remaining 37 admissions (77.1%) in patient survival and hospital discharge. Overall patient mortality was 30.6% for the study population. The APACHE II and TISS scores were each significantly different for survivor and nonsurvivor subgroups (APACHE II p less than 0.0001; TISS p less than 0.0001). CONCLUSIONS: In this group of patients evaluated at a single institution both the APACHE II and TISS scoring systems allowed subgroup separation between survivors and nonsurvivors of ICU admission. However, these scoring methods demonstrated limitations in terms of outcome prediction when applied to the individual patient.

Critical Care↗
PubMed1992

The effect of an increased index of suspicion on the diagnosis of pneumothorax in the critically ill.

The impact of specialized training in critical care producing a heightened index of suspicion for the diagnosis of pneumothorax in intensive care unit (ICU) patients was prospectively examined. During a 12-month period, 28 ICU patients were found to have a pneumothorax. Nine of the 28 patients with pneumothorax (32%) were initially misdiagnosed by physicians who neither received specialized training in critical care nor routinely cared for critically ill patients. Six of these nine initially misdiagnosed pneumothoraces (67%) were correctly diagnosed by a physician with specialized training and experience in critical care medicine prior to any clinical deterioration in the condition of the patients. This study suggests that specialized training and experience in the management of critically ill patients can significantly improve upon the diagnosis of pneumothorax in these patients and limit the occurrence of tension pneumothorax in the same patient population.

Critical Care↗
PubMed1992

Lung hyperinflation caused by inappropriate ventilation resulting in electromechanical dissociation: a case report.

Lung hyperinflation has been demonstrated to occur in patients with obstructive lung disease requiring mechanical ventilation. A dramatic case of pulmonary hyperinflation occurred in the early resuscitative period after initial intubation and manual ventilation leading to the development of electromechanical dissociation. Once the presence of lung hyperinflation was recognized, manipulation of the patient's ventilator settings allowed resolution of the lung hyperinflation and reversal of the detrimental hemodynamic effects it produced. This case illustrates that lung hyperinflation should be included in the differential diagnosis of electromechanical dissociation. In selected patients if pneumothorax, hypovolemia, cardiac tamponade, and myocardial infarction are excluded as causes and pulmonary hyperinflation is suspected, then a trial of adjusted ventilation to decrease the lung hyperinflation may be useful.

Aged↗
PubMed1991

Risk factors for the misdiagnosis of pneumothorax in the intensive care unit.

OBJECTIVE: To identify risk factors predisposing to the misdiagnosis of pneumothorax in the ICU. DESIGN: A prospective case series investigation. SETTING: A medical ICU service of a military referral hospital. PATIENTS: All adult medical ICU patients were evaluated during a 12-month period. Of 464 admissions, 28 (6%) were found to have acquired a pneumothorax during their medical ICU stay. INTERVENTIONS: Nineteen (67.9%) patients with pneumothorax were diagnosed correctly on initial presentation of their pneumothorax. The remaining nine (32.1%) patients' pneumothoraces were misdiagnosed at initial presentation. MEASUREMENTS AND MAIN RESULTS: Tension pneumothorax occurred more frequently in patients with an initially misdiagnosed pneumothorax (33.3%) than in patients with pneumothoraces that were correctly diagnosed during their medical ICU stay (5.3%) (p less than .06). Thirteen variables chosen prospectively were examined using a chi-square statistic. The following four variables occurred statistically more often in nine patients with an initially misdiagnosed pneumothorax: a) mechanical ventilation required at the time of the development of pneumothorax (p less than .05); b) an atypical radiographic location of the pneumothorax (p less than .05); c) altered mental status exhibited at the time of pneumothorax presentation (p less than .05); and d) development of pneumothorax after peak physician staffing hours (p less than .02). CONCLUSIONS: Certain medical ICU patients appear to be at higher risk for the initial misdiagnosis of pneumothorax. Familiarity with factors predisposing to this problem should allow for a higher index of suspicion for the diagnosis of pneumothorax in critically ill patients and possibly improve the early detection of pneumothorax.

Causality↗
PubMed1991

Noncardiogenic pulmonary edema following upper airway obstruction. 7 cases and a review of the literature.

Pulmonary edema is a relatively common problem facing most physicians. Its separation into cardiogenic and noncardiogenic or high-permeability variants is crucial to its proper early management. Our understanding of the disease processes producing noncardiogenic pulmonary edema has greatly expanded in the last 2 decades. Upper airway obstruction (UAO) is one of many recently recognized mechanisms which can produce noncardiogenic pulmonary edema. The UAO may be subtle in some patients, making its association with the subsequent pulmonary edema difficult especially for the physician unaware of this entity and the potential risk factors contributing to it. A high index of suspicion for this diagnosis is required in the right clinical settings. Our clinical results support a noncardiogenic basis for pulmonary edema occurring after UAO. Five of our 7 patients had at least 1 identifiable risk factor for the development of peri-intubation UAO and pulmonary edema. Additionally, the onset of pulmonary edema following UAO and the duration of the pulmonary edema varied considerably in our patients. Individuals with additional risk factors for the development of noncardiogenic pulmonary edema developed a more severe form of pulmonary edema associated with other organ-system disease. However, in most individuals, UAO-associated pulmonary edema appears to be a self-limited reversible process once it is recognized and properly treated.

Adolescent↗
PubMed1991

Acute pulmonary embolism triggered by the act of defecation.

Pulmonary embolism associated with the act of defecation has not been previously well described. Recently, we reported our experience with four patients who presented to us over a 12-month period with syncope, near syncope, or sudden death following the act of defecation. In all four cases, acute pulmonary embolism was shown to be the etiology of the defecation-associated events. A retrospective chart review of all patients with the diagnosis of pulmonary embolism at our institution over a three-year period yielded five additional patients with the diagnosis of defecation-associated pulmonary embolism. These nine patients accounted for 6.8 percent of all patients with a discharge diagnosis of pulmonary embolism seen at our institution during the three-year study period. Six of the nine patients died from their defecation-associated pulmonary embolism. These six deaths accounted for 25 percent of all deaths from pulmonary embolism seen at our institution during the study period. Based on our experience, we suggest that the act of defecation may trigger the development of acute pulmonary embolism in some patients with deep vein thrombosis.

Acute Disease↗
PubMed1991

Reversible cardiogenic shock due to chest tube compression of the right ventricle.

A 62-year-old woman developed shock immediately after the insertion of a right-sided chest tube. A chest roentgenogram showed the chest tube to be overlying the heart and possibly compressing the right ventricle. An animal model was developed to replicate this clinical situation. Using a domestic goat model pulmonary artery, peripheral arterial catheters were inserted along with a right sided chest tube placed to suction. A second chest tube guided by a flexible fiberoptic bronchoscope placed within its lumen was positioned between the right ventricle and the sternum of the animals. Thirteen paired measurements in three goats (average of 4.3 measurements per animal) of cardiac output, heart rate, and mean arterial blood pressure were made at baseline and after chest tube placement over the right ventricle. The data were analyzed using a paired t test statistic. Compared with baseline measurements, there was a significant decrease in cardiac output (p less than 0.001) and mean arterial pressure (p less than 0.001) as well as an increase in heart rate (p = 0.0056) after placement of the chest tube across the right ventricle. We conclude that a misplaced chest tube compressing the right ventricle can impede cardiac output and lead to a low cardiac output state. Physicians inserting chest tubes in patients should be aware of this potential complication as it is easily treated by withdrawal of the chest tube.

Animals↗