Dennis M. Greenbaum

Cardiac performance in response to PEEP in patients with cardiac dysfunction.

The effect of PEEP on cardiac performance was evaluated in 21 patients with left ventricular (LV) dysfunction. Twenty-three data sets were divided into three groups according to pulmonary arterial wedge pressure (PAWP). In three of four group A data sets (PAWP = 12 mm Hg), cardiac output (CO) decreased when PEEP was added. In four of six group B data sets (PAWP = 14–18 mm Hg) and in 12 of 13 group C data sets (PAWP ≥ 19 mm Hg), CO increased with addition of PEEP. In group C, the mean increase in CO was 500 ml/min, and the mean level of best PEEP was 3.9 cm H2O. When PAWP exceeded 18 mm Hg, PEEP was safe and in many instances augmented CO.

The value of routine daily chest x-rays in intubated patients in the medical intensive care unit.

Two hundred routine chest x-rays were evaluated to determine their value in the management of critically ill patients in a Medical ICU (MICU). Seventy-four x-rays (37%) were of suboptimal value or were delivered to the MICU too late for inclusion on morning rounds. Of the remaining 126 films, 54 (43%) showed worsening of a known, or development of a new, cardiopulmonary abnormality, or an unexpected misplacement of an invasive device. On the basis of these findings, routine daily chest radiographs were judged to be valuable in identifying abnormalities in critically ill patients. However, the system for providing this service was only 63% efficient, and improvement must be sought in this regard.

Accidental hypothermia in an alcoholic population

Abstract Thirty-nine cases of accidental hypothermia are reviewed. Data indicate that mortality varies with the presence of underlying disease rather than with the degree of hypothermia or the methods of rewarming. In 31 patients with hypothermia alone (average temperature 85 °F) mortality was 6.25 per cent. In eight patients with hypothermia and another primary condition (average temperature 84 °F) mortality was 75 per cent. Intractable cardiac arrhythmia has been reported as the primary cause of death in hypothermia. In these patients, death during hypothermia resulted from pulmonary complications. Ventricular arrhythmias, when they occurred, were responsive to routine measures such as electrical cardioversion and myocardial suppressant drugs. Methods of treatment are discussed.

Effectiveness of intensive nutritional regimes in patients who fail to wean from mechanical ventilation.

Over a 2-year period, 14 viable ventilator-dependent patients were transferred from the Medical Intensive Care Unit (MICU) to a general ward floor for nutritional support after failing to wean from mechanical ventilation (MV) while in the MICU. These patients were retrospectively grouped based on their ultimate ability to wean from MV: group 1 (N = 6) did not wean from MV and ultimately died in the hospital; group 2 (N = 8) weaned from MV and were eventually discharged.Before transfer from the MICU, the two groups did not differ with regard to serum albumin or transferrin levels, or in total lymphocyte count. After the period of aggressive nutritional support, group 2 patients showed an increase in serum albumin and transferrin whereas patients in group 1 showed a decrease. The differences between these groups were significant (p < 0.05). The lymphocyte count did not change significantly.Ventilator-dependent patients who respond to nutritional support with an increase in protein synthesis are more likely to wean from mechanical ventilation than those who do not.

Adult respiratory distress syndrome caused by Mycoplasma pneumoniae.

Two patients with the adult respiratory distress syndrome were found to have rising complement-fixation titers to Mycoplasma pneumoniae. This unusual presentation of Mycoplasma and its management are discussed. The need to consider M pneumoniae in a patient with the adult respiratory distress syndrome is emphasized.

Availability of critical care personnel, facilities, and services in the United States

This survey of 1474 special care units in the United States found that smaller hospitals tended to have only one ICU. The number of ICUs increased wth overall hospital size; when a hospital had two ICUs, the second unit was usually for coronary care. Internists directed most of the ICUs, followed in decreasing order by surgeons, family practitioners, anesthesiologists, and pediatricians. More than 40% of ICUs were directed by cardiologists, reflecting the frequency of coronary care units. About eight times as many pulmonary medicine physicians directed ICUs as intensivists trained in critical care medicine. An increasing number of ICU directors received salaries for their services as hospital size increased, and the size of this salary also tended to increase with unit size.Average nurse/patient ratios tended to be better than 1:23 for all shifts. Few ICUs used private-duty nurses, although a substantial number required per-diem nurses. The level of nurse education increased with the size of the unit.The number of house officers varied widely according to hospital size, as did the numbers of subspecialty fellows and nonphysician professional and paraprofessional personnel. The availability of services in hospitals also varied according to hospital size, particularly for intra-aortic balloon counterpulsation, CT scanning, and intracranial pressure monitoring. Urban setting more significantly affected size and available services than did geographic region. Regardless of hospital size, geographic area, or urban setting, more than 80% of units thought that they were adequately staffed and supplied.

Transvenous pacing in ischemic disease of the bowel.

Symptoms of mesenteric arterial insufficiency often prompt surgical intervention which incurs high morbidity and significant mortality. In certain individuals in whom a relationship can be demonstrated between bradycardia and symptoms of arterial compromise, pacemaker insertion may increase cardiac output sufficiently to offer an alternative for patients who are poor operative candidates.