Cory Franklin

Present use of bedside right heart catheterization in patients with cardiac disease

On September 18, 1996, a report describing a potential increase in morbidity and mortality associated with the use of the pulmonary artery balloon catheter in critically ill patients was published in the Journal of the American Medical Association [(1)][1]. The publication of this report was

Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation

To determine the incidence of life-threatening hypotension (LTH) suffered by patients in the initial hours after emergency intubation and mechanical ventilation, prospective, consecutive case series of patients undergoing endotracheal intubation and mechanical ventilation were evaluated in the adult emergency department of a large urban hospital. Eight-four medical patients who received intubation and mechanical ventilation for ventilatory failure, respiratory failure, or airway protection (trauma patients exluded) were included. LTH, defined as a decrease in mean arterial pressure of 60 mm Hg or an absolute decrease to a systolic blood pressure < 80 mm Hg in the first 2 hours after intubation, was observed in 24 of the 84 patients who met study criteria (incidence 28.6%). Eleven patients (incidence 13.1%) required treatment for LTH with vasopressors. There was one cardiac arrest, and there were no deaths. There was a statistically significant association between LTH and hypercarbic (PCO2 > 50 mm) chronic obstructive pulmonary disease (COPD) (P = .004). There was also a weaker statistical association between LTH and hypoxemic respiratory failure (P = .019). No association could be established between LTH and the other diagnoses, arterial blood gas (ABG) derangements, or the administration of sedatives or paralytic medications. LTH represents a serious complication of emergency intubation in the initial phase of mechanical ventilation. Because it occurs in more one quarter of all cases, it should be anticipated during intubation and the initial phase of ventilator management, especially in high-risk patients such as those with hypercarbic COPD.(ABSTRACT TRUNCATED AT 250 WORDS)

Life-threatening Candida Infections in the Intensive Care Unit

In the past decade there has been a dramatic increase in the incidence of life-threatening Candida infections in patients in intensive care units (ICUs). Once considered a minor pathogen, Candida is now among the most commonly cultured pathogens in the ICU. This phenomenon is in part attributable to greater numbers of immunocompromised patients being hospitalized and the more frequent use of surgery, instrumentation, and broadspectrum antibiotics. Serious Candida infections can present as generalized sepsis, as focal involvement of virtually any organ, or as part of the syndrome of multiple system organ failure. Once established, these infections can be difficult to detect until their late stages and consequently are responsible for significant morbidity and mortality in ICU patients. For treatment to be successful it must be instituted promptly and, on occasion, empirically. As a result, new diagnostic techniques, treatments, and prophylactic strategies to minimize the occurrence of Candida infections are the subjects of ongoing research. This article is intended to provide practitioners with an understanding of why serious Candida infections are increasing, as well as information on pathogenesis, diagnosis, treatment, and some measures that can be taken to prevent such infections in critically ill patients.

Hypoxemia and Hypoxia

A. Although the terms hypoxia and hypoxemia are often used interchangeably, they are not synonymous. Hypoxemia is defined as a condition where arterial oxygen tension (Pao 2 ) is below normal (normal Pao 2 = 80–100 mmHg). Hypoxia is defined as the failure of oxygenation at the tissue level. It is not measured directly by a laboratory value (though an increased arterial lactate level usually accompanies tissue hypoxia). Hypoxia and hypoxemia may or may not occur together. Generally, the presence of hypoxemia suggests hypoxia. However, hypoxia may not be present in patients with hypoxemia if the patient compensates for a low Pao 2 by increasing oxygen delivery. This is typically achieved by increasing cardiac output or decreasing tissue oxygen consumption. Conversely, patients who are not hypoxemic may be hypoxic if oxygen delivery to tissues is impaired or if tissues are unable to use oxygen effectively. Nevertheless, hypoxemia is by far the most common cause of tissue hypoxia. The five causes of tissue hypoxia are listed below: