Baekhyo Shin

Evaluating outcome from intensive care: a preliminary multihospital comparison.

To contrast mortality for groups of ICU patients treated in different hospitals, we surveyed 795 consecutive ICU admissions in 5 ICUs using a general severity of illness classification system. After obtaining information from the medical record on age, sex, indication for ICU admission, and severity of illness, we used a logistic multiple regression equation to project death rates for each ICU based on data from a sixth reference hospital. There were substantial differences in severity of acute illness among the hospitals which accounted for most of the variation in death rates. In all ICUs, however, projected death rates were quite similar to observed deaths. These findings suggest that the use of a general severity of illness index and multivariate statistical techniques could, after further refinement and validation, improve interhospital comparisons of the outcome of acutely ill patients.

Intravenous phosphate repletion regimen for critically ill patients with moderate hypophosphatemia

OBJECTIVE To document the safety and efficacy of an intravenous phosphate repletion regimen that is more aggressive than recommended by previously published guidelines, in intensive care unit (ICU) patients with hypophosphatemia. DESIGN Prospective evaluation of rapid, intravenous phosphate repletion in eligible patients. SETTING Surgical ICU in a teaching hospital. PATIENTS Patients with a serum phosphorus concentration of < 2 mg/dL (< 0.65 mmol/L) while in the ICU. INTERVENTIONS Enrolled patients received 15 mmol of sodium phosphate in 100 mL of 0.9% sodium chloride, infused intravenously over a period of 2 hrs. Patients with a serum potassium concentration of < 3.5 mmol/L received potassium phosphate, if no other potassium supplementation was ordered. The same dose could be repeated to a maximum of 45 mmol in a 24-hr period if either the 6-hr or follow-up (18- to 24-hr) postinfusion serum phosphorus remained < 2 mg/dL (< 0.65 mmol). Serum electrolytes, renal function, vital signs, and reflexes were closely monitored. MEASUREMENTS AND MAIN RESULTS Eleven patients enrolled had baseline serum phosphorus values of 1.6 to 1.9 mg/dL (0.51 to 0.61 mmol/L). The serum phosphorus value immediately postinfusion was 2.3 to 5.3 mg/dL (0.74 to 1.7 mmol/L). Only one patient had a 6-hr postinfusion serum phosphorus of < 2 mg/dL (< 0.65 mmol/L), requiring two additional doses. Two other patients each required a second dose. Serum phosphorus was corrected in other patients with a single dose. No significant changes were noted in serum calcium, magnesium, or potassium concentrations, urine output, vital signs, or reflexes throughout the repletion period. CONCLUSIONS All patients were successfully repleted using the described protocol without any significant adverse effects. This repletion regimen may have widespread applicability in the ICU setting.

Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure.

Chest physiotherapy (CPT) is used frequently in the ICU, but there is little available information that quantitates its effect on cardiac or respiratory function. Nineteen mechanically ventilated patients with post-traumatic respiratory failure were studied before, immediately after, and 2 h after CPT was used to manage secretion retention. Cardiac index was unchanged, but there was an immediate decrease in intrapulmonary shunt, followed 2 h later by an increase in lung/thorax compliance. We did not find the reduced cardiac output reported by others. The reasons for this may include use of different CPT techniques, a young patient population (mean age 32.4 yr), and mechanical ventilation with positive end-expiratory pressure. CPT did not produce the deleterious cardiopulmonary changes associated with bronchoscopy, and it reduced retained lung secretions without producing hypoxemia. Intrapulmonary shunt and lung/thorax compliance were significantly improved, but the long-term clinical effect of these changes is unknown.

Creatinine Clearance for Early Detection of Posttraumatic Renal Dysfunction

Acute renal failure develops insidiously in the presence of normal urine output and vital signs. A prospective study was carried out to find whether renal impairment can be detected in the immediate postoperative period and to determine the renal function test best predicting the development of renal dysfunction. Forty patients with multiple trauma who required more than 10 units of blood and had a systolic blood pressure less than 80 mmHg on admission were studied.Creatinine clearance (Ccr), free-water clearance (CH2O), fractional excretion of Na+, blood urea nitrogen (BUN), urine flow rate, and vital signs were measured and compared in seven patients who developed renal dysfunction within a week of trauma (Group 1) and 33 patients who maintained normal renal function (Group 2). In all Group 1 patients Ccr remained less than 25 ml/min and CH2O greater than −15 ml/h for 6 h following surgery. None of the Group 2 patients had Ccr less than 25 ml/min for longer than 4 h following surgery. However, CH2O values were greater than −15 ml/h in 15 of the 33 Group 2 patients during the first 24 postoperative hours.Ccr values less than 25 ml/min were present, despite normal urine flow rate and blood pressure, in patients who subsequently developed renal dysfunction. Patients who have Ccr values less than 25 ml/min within 6 h following trauma and surgery may develop renal dysfunction, and some of them may proceed to acute renal failure. CH2O was not as good a predictor of development of renal dysfunction as Ccr.

Postoperative renal failure in trauma patients.

Since 1975 the authors had observed a sudden increase in the incidence of nonoliguric renal failure following anesthesia in trauma victims. In an attempt to find the possible causes they reviewed postoperative fluid management of 2,191 patients. During the period 1974–1975, fluid intake was increased and diuretics were administered in 960 postoperative trauma patients with oilguria (Group I). In those patients in Group I with respiratory insufficiency and oliguria, fluid therapy was restricted, and furosemide and albumin were administered. During the period of 1976–1977 postoperative creatinine and free-water clearance were monitored in 1,231 trauma victims (Group II). In patients with abnormal renal clearance values or ollguria, optimal cardiac output was maintained by maximizing preload. Diuretics were not administered unless circulatory overload was confirmed. There were 17 cases of acute renal failure in Group I and 18 in Group II. All of the 18 affected patients in Group II, but only three in Group I, were nonoliguric. Duration and severity of azotemia, complications, number of patients dialyzed, and mortality were significantly less (P < 0.05) in Group II than in Group I. It is concluded that when postoperative renal dysfunction is recognized early and therapy is directed toward attaining optimal blood volume, oliguria in acute renal failure may be avoided, thus minimizing morbidity and mortality.

Massive diuresis after acute renal failure.

Polyuria, peaking at 2000 ml/h, was seen in a patient after resuscitation of hemorrhagic shock and a brief period of oliguria. This unusual polyuria appears to be a consequence of renal tubular dysfunction that persisted after glomerular filtration rate had returned to normal.