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T J Iberti

Publications and source records attributed to T J Iberti.

At least 19 recordsLinked to original sources
PubMed1997

Thermodilution cardiac output measurement during simultaneous volume infusion through the venous infusion port of the pulmonary artery catheter.

OBJECTIVE: To determine the effect on thermodilution cardiac output (TDCO) measurements of continuous volume infusion through the right atrial venous infusion port of the pulmonary artery catheter. DESIGN: Prospective, blinded, randomly allocated crossover. SETTING: Surgical intensive care unit in a university hospital. PARTICIPANTS: Forty-nine hemodynamically stable patients between the ages of 43 and 84 in the intensive care unit and with a pulmonary artery catheter in place. INTERVENTIONS: Each patient received two room-temperature infusions (250 or 500 mL/hr) of 5% dextrose. Consecutive TDCO measurements were taken during each infusion and during a control period (no infusion). The sequence of infusion rates and control period was randomly determined. At both infusion rates, most patients exhibited a decrease in TDCO measurement of between 0.1 and 3.0 L/min. Although some patients exhibited an increase in measured TDCO, this increase was primarily between 0.1 and 0.5 L/min. MEASUREMENTS AND MAIN RESULTS: The mean TDCO measurements at infusion rates of 0, 250, and 500 mL/hr were 6.77, 6.49, and 6.47 L/min, respectively. Measured TDCO decreased on volume infusion by 0.3 +/- 0.13 L/min (mean +/- SD, p < 0.02). CONCLUSION: Rapid continuous infusion of fluid through the venous infusion port of the pulmonary artery catheter significantly limits the accuracy of simultaneous TDCO measurements. Optimally, TDCO measurements should be avoided during rapid volume infusion.

Adult↗
PubMed1995

A second large controlled clinical study of E5, a monoclonal antibody to endotoxin: results of a prospective, multicenter, randomized, controlled trial. The E5 Sepsis Study Group.

OBJECTIVE: To evaluate the safety and efficacy of E5, a murine, monoclonal antibody directed against endotoxin, in the treatment of patients with Gram-negative sepsis. DESIGN: A multicenter, randomized, double-blind, placebo-controlled trial. SETTING: Fifty-three hospitals across the United States, including university medical centers, Veterans Affairs Medical Centers, and community hospitals. PATIENTS: 847 patients were randomized into this study. Enrolled patients met criteria for three conditions: a) known or suspected Gram-negative infection; b) clinical evidence of sepsis; and c) signs of end-organ dysfunction. Patients with refractory shock were excluded from the study. INTERVENTIONS: Two doses of E5 (2 mg/kg/day by intravenous infusion 24 hrs apart), or placebo that was identical in appearance were administered. In addition, all patients received standard supportive therapy and broad-spectrum antibiotics. MEASUREMENTS AND MAIN RESULTS: The primary end point was mortality over 30 days. Secondary outcome measures included the resolution and prevention of organ failure in the same two populations. Additionally, the safety of E5 was evaluated. There was no significant improvement in survival over 30 days among patients with Gram-negative sepsis who received E5 compared with those patients who received placebo (n = 530; p = .21). In addition, E5 did not improve survival for patients with Gram-negative sepsis and organ failure (n = 139; p = .3). However, a significantly greater percentage of patients with Gram-negative sepsis experienced resolution of major organ failure if they received E5, compared with those patients who received placebo (n = 139; 48% E5 vs. 25% placebo; p = .005). This result extended to all patients who entered the study with one or more major organ failures, regardless of the etiology of the infection (n = 225; 41% E5 vs. 27% placebo; p = .024). E5 also provided protection against the development of some organ failures, but significant prevention was only observed for adult respiratory distress syndrome (p = .007) and central nervous system dysfunction (p = .050). Hypersensitivity reactions attributable to E5 occurred in 2.6% of patients. An asymptomatic antibody response occurred in 44% of the E5-treated patients and in 12% of the patients who received placebo. CONCLUSIONS: In this study, E5 did not reduce mortality in nonshock patients with Gram-negative sepsis whether or not those patients also had organ failure. However, E5 did result in greater resolution of organ failure in patients with Gram-negative sepsis. This benefit extended to those patients with suspected Gram-negative etiology. This finding is important because patients with suspected Gram-negative sepsis and organ failure can be identified without waiting for culture results. In addition, E5 resulted in the prevention of adult respiratory distress syndrome and central nervous system organ failure. However, more studies are needed to determine if this result can be extended to organ failure in general. E5 is safe as a treatment for patients with Gram-negative sepsis.

Antibodies, Monoclonal↗
PubMed1994

Recombinant human interleukin 1 receptor antagonist in the treatment of patients with sepsis syndrome. Results from a randomized, double-blind, placebo-controlled trial. Phase III rhIL-1ra Sepsis Syndrome Study Group.

OBJECTIVE: To further define the safety and efficacy of recombinant human interleukin 1 receptor antagonist (rhIL-1ra) in the treatment of sepsis syndrome. STUDY DESIGN: Randomized, double-blind, placebo-controlled, multicenter, multinational clinical trial. POPULATION: A total of 893 patients with sepsis syndrome received an intravenous loading dose of rhIL-1ra, 100 mg, or placebo followed by a continuous 72-hour intravenous infusion of rhIL-1ra (1.0 or 2.0 mg/kg per hour) or placebo. OUTCOME MEASURE: Twenty-eight-day all-cause mortality. RESULTS: There was not a significant increase in survival time for rhIL-1ra treatment compared with placebo among all patients who received the study medication (n = 893; generalized Wilcoxon statistic, P = .22) or among patients with shock at study entry (n = 713; generalized Wilcoxon statistic, P = .23), the two primary efficacy analyses specified a priori for this trial. Results from secondary analyses suggest an increase in survival time with rhIL-1ra treatment among patients with dysfunction of one or more organs (n = 563; linear dose-response, P = .009). Retrospective analysis demonstrated an increase in survival time with rhIL-1ra treatment among patients with a predicted risk of mortality of 24% or greater (n = 580; linear dose-response, P = .005) as well as among patients with both dysfunction of one or more organs and a predicted risk of mortality of 24% or greater (n = 411; linear dose-response, P = .002). CONCLUSIONS: There was not a statistically significant increase in survival time for rhIL-1ra treatment compared with placebo among all patients who received the study medication or among patients with shock at study entry. Secondary and retrospective analyses of efficacy suggest that treatment with rhIL-1ra results in a dose-related increase in survival time among patients with sepsis who have organ dysfunction and/or a predicted risk of mortality of 24% or greater.

Adult↗
PubMed1994

Abnormal coagulation profile in brain tumor patients during surgery.

Neurosurgical patients are at high risk for the development of thrombosis and thromboembolism. We compared the perioperative clotting factor and coagulation parameters of 20 patients undergoing elective craniotomy for brain tumors to those of 20 patients undergoing elective abdominal surgery. We also measured the levels of plasma arginine vasopressin to determine if changes in this hormone might be associated with changes in clotting factors, activated partial thromboplastin times, or bleeding times. The results demonstrated a significant reduction in partial thromboplastin times and bleeding times in the neurosurgery group, which began at the initiation of surgery and lasted to the end of the study (12 h postoperatively). Elevations in factor assays and plasma arginine vasopressin occurred in both groups during surgery, but there were no differences between the neurosurgical and abdominal surgical patients, except with Factor IX levels, which were elevated only in the neurosurgical patients. Serum osmolality and hemoglobin levels were significantly higher in the neurosurgical cohort. These results suggest that there are hemostatic differences between neurosurgical patients with brain tumors and abdominal surgery patients that cannot be explained solely by elevations in plasma arginine vasopressin or the clotting factors measured; these differences may be the consequence of perioperative variables such as dehydration and hyperosmolality.

Adult↗
PubMed1994

Effects of acid-base correction on hemodynamics, oxygen dynamics, and resuscitability in severe canine hemorrhagic shock.

OBJECTIVE: To compare the effects of hypertonic saline, sodium bicarbonate, and Carbicarb resuscitation on acid-base balance, hemodynamics, and oxygen dynamics in a reperfused, canine hemorrhagic shock model. DESIGN: Prospective, randomized trial. SETTING: Laboratory at a university medical center. SUBJECTS: Thirty-five anesthetized, mongrel dogs. INTERVENTIONS: After the administration of anesthesia, the dogs were intubated and mechanically ventilated. Vascular catheters were inserted into each femoral artery, for continuous blood pressure monitoring, intermittent blood sampling, and for establishing controlled hemorrhage. A pulmonary artery catheter was inserted via the right jugular vein. Inhaled and exhaled gases were continuously analyzed using a metabolic gas monitor. The animals were subjected to 90 mins of controlled hemorrhagic shock. They were then randomly given a 2.5-mL/kg equimolar injection of 8.4% sodium bicarbonate, Carbicarb, or 5.84% hypertonic saline. The sodium load per kilogram of body weight was identical in all three groups. Thirty minutes later, the animals were retransfused with the shed blood over 15 mins and further observed for 120 mins. MEASUREMENTS AND MAIN RESULTS: Carbicarb and sodium bicarbonate both significantly increased bicarbonate concentrations compared with saline. Arterial and venous blood pH increased more with Carbicarb than with bicarbonate but this increase was not statistically significant. After shock but before retransfusion, all three treatments moderately increased blood pressure, cardiac index, oxygen delivery index, and oxygen consumption index to a similar extent. After retransfusion, blood pressure, cardiac index, and oxygen dynamics temporarily improved in all groups, without significant improvement in the bicarbonate and Carbicarb-treated animals, despite their excellent acid-base status. CONCLUSIONS: In severe canine hemorrhagic shock, Carbicarb, bicarbonate, and hypertonic saline appear to possess similar hemodynamic properties despite the buffering properties of bicarbonate and Carbicarb. The similar responses may be due to their identical sodium content. Arterial pH correction does not appear to further improve the responses to blood retransfusion.

Acid-Base Imbalance↗
PubMed1994

Assessment of critical care nurses' knowledge of the pulmonary artery catheter. The Pulmonary Artery Catheter Study Group.

OBJECTIVES: To assess the knowledge and understanding of the use of the pulmonary artery catheter and interpretation of data derived from it in a group of nurses attending the American Association of Critical Care Nurses' National Teaching Institute conference. DESIGN: A 37-question multiple choice examination that tested knowledge regarding the use of the pulmonary artery catheter was administered to a group of nurses, attending a national conference, who preregistered for a hemodynamics workshop. SETTING: American Association of Critical Care Nurses' National Teaching Institute Conference, New Orleans, LA, May 1992. MEASUREMENTS AND MAIN RESULTS: Two-hundred sixteen nurses completed the questionnaire. The mean test score was 16.5 +/- 5.7 (SD) (48.5%). Test scores were significantly associated with years of experience in critical care, critical care registered nurse certification, responsibility for repositioning and manipulating the catheter, frequency of use, and self-assessed adequacy of knowledge. CONCLUSIONS: A wide variation in the understanding of the use of the pulmonary artery catheter exists among nurses using this device in the care of seriously ill patients. The results indicate that current teaching practices regarding the pulmonary artery catheter need to be reevaluated and specific credentialing policies need to be considered.

Catheterization, Peripheral↗
PubMed1993

Acute mesenteric ischemia: pathophysiology, diagnosis, and treatment.

Ischemia has traditionally been viewed as arising only from abnormalities of oxygen dynamics, namely the cellular hypoxia resulting from the imbalances between oxygen supply, consumption, and demand. Recently, it has become clear that such a view is too restrictive. Hypoperfusion may be caused by both anatomic and functional impediments to either inflow or to outflow from an organ. Furthermore, the pathophysiologic consequences are likely to involve not only cellular hypoxia, but also a restricted supply of nutrients and other important molecules and an abnormal elimination of physiologic wastes such as carbon dioxide. Hence the recommendation that ischemia be defined as a dual defect of oxygen deficit and carbon dioxide excess. AMI is, therefore, a severe anatomic or functional impediment to the splanchnic circulation, resulting in a dual defect of intestinal hypoxia and cellular hypercarbia. Although the functional and structural consequences of cellular hypoxia are well known, the pathophysiology of cellular hypercarbia has only begun to be explored. AMI syndromes include three related processes: occlusive mesenteric ischemia, nonocclusive ischemia, and sepsis-induced SI. Leakage of bacteria or bacterial toxins into the circulation during mesenteric ischemia forms the basis of the systemic components of this syndrome. Striving for an earlier diagnosis, treating the systemic (septic) consequences, and taking measures to promptly restore mucosal oxygen balance through aggressive pharmacologic and appropriate surgical intervention have significantly improved the prognosis. About 80% of patients with acute arterial embolism, 60% of those with nonocclusive ischemia, and only 20% of patients with arterial thrombosis are expected to live without significant residual nutritional deficits. The cause of death is usually sepsis and multisystem organ failure, and therefore, further reductions in mortality are likely to occur with the improved prevention and treatment of sepsis.

Acute Disease↗
PubMed1993

Epidemiology, pathophysiology and clinical presentation of gram-negative sepsis.

OBJECTIVE: To review the epidemiology and pathophysiology of gram-negative sepsis and the new consensus terminology describing the clinical signs of sepsis. DATA SOURCES: Review of the medical literature and compiled data from animal and clinical trials. PARTICIPANTS: Members of the Society of Critical Care Medicine, American College of Chest Physicians and American Association of Critical-Care Nurses with expertise on the subject of sepsis and its complications. RESULTS: Preconference and general sessions were offered at the National Teaching Institutes of the American Association of Critical-Care Nurses, with the goal of clarifying the epidemiology, risk factors and pathophysiology of gram-negative sepsis. In addition, current terminology and new (1992) consensus terminology describing the clinical signs of sepsis were presented. Special emphasis was placed on the role of the healthcare provider in the prevention and recognition of sepsis and the role of the septic mediators in the septic cascade. CONCLUSIONS: If the incidence of sepsis is to be reduced, the healthcare provider must be aware of the risk factors for sepsis and methods of reducing nosocomial infections. A thorough understanding of the role of mediators and consensus terminology used to describe sepsis, severe sepsis, septic shock and multiple organ dysfunction syndrome is necessary to recognize early or progressive signs of sepsis and to initiate state-of-the-art therapy.

Adult↗
PubMed1992

Myocardial ischemia during the weaning period.

OBJECTIVES: To estimate the incidence of silent myocardial ischemia, its pattern over time and its relationship to the time and mode of weaning high-risk cardiac patients after noncardiac surgery. DESIGN: Prospective study with random assignment to one of three weaning modes. SETTING: A surgical intensive care unit in a university hospital and a Veterans Administration hospital. PATIENTS: Sixty-two patients meeting standard criteria for extubation were randomized to one of three modes of weaning: synchronized intermittent mandatory ventilation (n = 19), T-Bar (n = 21) or continuous positive airway pressure (n = 22). METHODS: Ischemia was monitored with a continuous two-lead (V5, III) ST segment analyzer. Tracings were reviewed by a cardiologist. Ischemia was defined as greater than 1 mm ST segment depression 60 milliseconds after the J point. The monitoring period included a prewean (mean 654.0 minutes), wean (mean 46.5 minutes) and postwean (mean 1223.4 minutes) period. RESULTS: Of 62 patients, 12 (19.3%) experienced ischemia at some time during the monitoring period, most often during the weaning period. Ischemia during weaning was detected in 3 of 21 (14.3%) T-Bar patients and 2 of 22 (9.1%) continuous positive airway pressure patients but in no synchronized intermittent mandatory ventilation patients. CONCLUSION: This study demonstrates that silent myocardial ischemia occurs frequently in high-risk postoperative patients, with the highest incidence during weaning.

Aged↗
PubMed1992

Chest tube thoracostomy.

Knowledge of the indications, placement, and management of chest tubes in the intensive care unit is essential for the care of the critically ill patient. Awareness of the complications and mechanical difficulties that can occur with chest tubes and their drainage systems is essential for the safe and effective use of these devices.

Chest Tubes↗
PubMed1992

Left-sided superior vena cava: a not-so-unusual vascular anomaly discovered during central venous and pulmonary artery catheterization.

OBJECTIVE: To report our ICU experience with patients noted to have a left-sided superior vena cava after central venous and pulmonary artery catheterization. DESIGN: Retrospective review. SETTING: Surgical ICUs in a University and Veterans Administration Medical Center. PATIENTS: Five patients who had insertion of central venous or pulmonary artery catheters were noted to have abnormal placement. RESULTS: Five patients were noted to have a left-sided superior vena cava that was not appreciated on preinsertion radiography after central venous (two patients) or pulmonary artery catheterization (three patients). The finding of left-sided superior vena cava was confirmed by computed tomography scan (one patient), transesophageal echocardiography (one patient), bolus contrast injection (two patients), and intraoperative inspection (one patient). CONCLUSIONS: Left-sided superior vena cava occurs infrequently, most often in association with a right-sided superior vena cava. It is often associated with cardiac septal defects. The intensivist should be aware of its occurrence in order to not mistake catheters placed in it as being present in the arterial circulation or malpositioned outside of the venous circulation.

Adult↗
PubMed1992

Intravenous fat emulsions and the pancreas: a review.

There is conflicting evidence of the effect of intravenous fat emulsions on pancreatic secretion. Intralipid is a safe component of intravenous nutritional support in patients with pancreatic fistulas, though it may minimally increase the volume, as well as the bicarbonate and amylase concentrations, of the output. Intravenous fat emulsions may rarely cause pancreatitis; this may be more likely in patients with Crohn's disease, given that three of the four reported cases occurred in patients with Crohn's disease. It is unclear whether hypertriglyceridemia secondary to the intravenous fat emulsion is a prerequisite for this complication to occur. Intravenous fat emulsions appear to be a safe component of intravenous nutritional support for the patient with pancreatitis, based on multiple studies proving their safety in a total of nearly 100 patients. It seems prudent to avoid hypertriglyceridemia secondary to intravenous fat emulsions, as this alone is a cause of pancreatitis, albeit uncommon, in patients with abnormalities of triglyceride metabolism. However, hypertriglyceridemia resulting from parenteral nutrition may be caused by glucose intolerance and not intravenous fat emulsion administration.

Acute Disease↗