Arieh Oppenheim

Evaluation of triage decisions for intensive care admission

OBJECTIVE To assess physician decision-making in triage for intensive care and how judgments impact on patient survival. DESIGN Prospective, descriptive study. SETTING General intensive care unit, university medical center. INTERVENTIONS All patients triaged for admission to a general intensive care unit were studied. Information was collected for the patients age, diagnoses, surgical status, admission purpose, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mortality. The number of available beds at the time of triage and reasons for refused admission were obtained. MEASUREMENTS AND MAIN RESULTS Of 382 patients, 290 were admitted, 92 (24%) were refused admission, and 31 were admitted at a later time. Differences between admission diagnoses were found between patients admitted or not admitted (p < .001). Patients refused admission had higher APACHE II scores (15.6+/-1.5 admitted later and 15.8+/-1.4 never admitted) than did admitted patients (12.1+/-.4; p < .001). The frequency of admitting patients decreased when the intensive care unit was full (p < .001). Multivariate analysis revealed that triage to intensive care correlated with age, a full unit, surgical status, and diagnoses. Hospital mortality was lower in admitted (14%) than in refused patients (36% admitted later and 46% never admitted; p < .01) and in admitted patients with APACHE II scores of 11 to 20 (p = .02). The 28-day survival of patients was greater for admitted patients compared with patients never admitted (p = .01). CONCLUSIONS Physicians triage patients to intensive care based on the number of beds available, the admission diagnosis, severity of disease, age, and operative status. Admitting patients to intensive care is associated with a lower mortality rate, especially in patients with APACHE scores of 11 to 20.

Tension Pneumoperitoneum after Blast Injury: Dramatic Improvement in Ventilatory and Hemodynamic Parameters after Surgical Decompression

Tension pneumoperitoneum is a known although rare complication of barotrauma, which can accompany blast injury. We report two patients who suffered from severe pulmonary blast injury, accompanied by tension pneumoperitoneum, and who were severely hypoxemic, hypercarbic, and in shock. After surgical decompression of their pneumoperitoneum, respiratory and hemodynamic functions improved dramatically. Several mechanisms to explain this improvement are suggested. In such cases the release of the tension pneumoperitoneum is mandatory, and laparotomy with delayed closure can be contemplated.

Positive end-expiratory pressure increases pulmonary venous vascular resistance in patients after coronary artery surgery

OBJECTIVE To investigate the effect of positive and-expiratory pressure (PEEP) on the longitudinal distribution of pulmonary vascular resistance in patients immediately after coronary artery bypass grafting. DESIGN Prospective, intervention study. SETTING Postcardiac surgery intensive care unit in a teaching institution. PATIENTS Twenty patients after elective coronary artery bypass grafting. INTERVENTION The effect of PEEP on pulmonary circulation, at four different levels (0, 5, 10, and 15 cm H2O), was analyzed in 20 patients. MEASUREMENTS AND MAIN RESULTS Mean pulmonary arterial pressure, left atrial pressure, pulmonary artery occlusion pressure, and pulmonary capillary pressure were measured at each PEEP level. A model consisting of two resistances in series was used to analyze the effect of PEEP on the pulmonary circulation. The pulmonary vascular resistance for each area (arterial and venous) of the circulation was calculated. Pulmonary vascular resistance increased from 216 +/- 70 dyne.sec/cm5 at a PEEP of 0 cm H2O to 308 +/- 125 dyne.sec/cm5 at a PEEP of 15 cm H2O (p < .001). This increase, however, resulted solely from an increase in the resistance of the venous part of the pulmonary circulation from 66 +/- 29 to 134 +/- 69 dyne.sec/cm5 (p < .001), without any change in pulmonary arterial resistance. CONCLUSIONS PEEP increases pulmonary vascular resistance solely by increasing pulmonary venous resistance. When applying PEEP, changes in pulmonary vascular resistance may impede the resorption of pulmonary edema fluid.

Effect of haemofiltration on pathological fibrinolysis due to severe sepsis: a case report

Bleeding due to coagulopathy is a frequent complication of severe sepsis, especially in burn patients. The primary treatment is aimed at the underlying cause but additional supportive measures, consisting mainly of coagulation factor replacement, are frequently necessary. We describe the salutary effect of continuous veno-venous haemofiltration (CVVH) with predilution on diffuse haemorrhage in a patient with severe septic shock and renal failure. The diffuse haemorrhage was initially treated with replacement of coagulation factors. Prothrombin time and partial thromboplastin time became normal while diffuse bleeding continued and the thrombelastogram showed evidence of fibrinolysis. A short period of CVVH lead to the cessation of bleeding which was reflected by a normal thrombelastogram.

INTRAVENOUS DOPAMINE ASSOCIATED WITH NEPHROGENIC DIABETES INSIPIDUS-LIKE SYNDROME

Dopamine is often used for maintenance of haemodynamic stability in critically ill patients in the setting of intensive care units. ‘Renal’ doses (1 to 2 μg/kg/min) or ‘pressor’ doses (above 5 to 10 μg/kg/min) are used distinctly for various clinical disorders. Dopamine may be associated with diabetes insipidus, manifested by serum hypertonicity, urine hypotonicity and polyuria.[1] The mechanism of the potentiation of free water excretion remains obscure, although inhibition of pituitary vasopressin or increased solute excretion have been proposed.[1] In this case report, we describe a patient who developed acute diabetes insipidus associated with dopamine administration, where neither of these mechanisms appears likely.