Internists, Critical Care Specialist
31 years of experience
Video profile
Accepting new patients
Bassett Healthcare M I Bassett Hospital
1 Atwell Rd
Cooperstown, NY 13326
607-547-3909
Locations and availability (1)

Education ?

Medical School Score Rankings
The Ohio State University (1979)
  • Currently 3 of 4 apples
Top 50%

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Acidosis (Lactic Acidosis)
Appointments
Wayne State Univ School Of Med (1984 - 2004)
Associations
American Board of Internal Medicine

Affiliations ?

Dr. Kruse is affiliated with 8 hospitals.

Hospital Affilations

Score

Rankings

  • Little Falls Hospital
    140 Burwell St, Little Falls, NY 13365
    • Currently 4 of 4 crosses
    Top 25%
  • Cobleskill Regional Hospital
    178 Grandview Dr, Cobleskill, NY 12043
    • Currently 4 of 4 crosses
    Top 25%
  • Bassett Healthcare M I Bassett Hospital
    1 Atwell Rd, Cooperstown, NY 13326
    • Currently 2 of 4 crosses
  • O'Connor Hospital
    460 Andes Rd, Delhi, NY 13753
  • Mary Imogene Bassett Acute Care
  • Mary Imogene Bassett Oss Psych Unit
  • Mary Imogene Bassett Hospital
  • Mary Imogene Bassett Dialysis
  • Publications & Research

    Dr. Kruse has contributed to 68 publications.
    Title The Influence of Early Hemodynamic Optimization on Biomarker Patterns of Severe Sepsis and Septic Shock.
    Date September 2007
    Journal Critical Care Medicine
    Excerpt

    BACKGROUND: Despite abundant experimental studies of biomarker patterns in early severe sepsis and septic shock, human data are few. Further, the impact of the severity of global tissue hypoxia resulting from resuscitative strategies on these early biomarker patterns remains unknown. METHODS: The temporal patterns of interleukin-1 receptor antagonist, intercellular adhesion molecule-1, tumor necrosis factor-alpha, caspase-3, and interleukin-8 were serially examined over the first 72 hrs of hospitalization after early hemodynamic optimization strategies of early goal-directed vs. standard therapy for severe sepsis and septic shock patients. The relationship of these biomarker patterns to each hemodynamic optimization strategy, severity of global tissue hypoxia (reflected by lactate and central venous oxygen saturation), organ dysfunction, and mortality were examined. RESULTS: Abnormal biomarker levels were present upon hospital presentation and modulated to distinct patterns within 3 hrs based on the hemodynamic optimization strategy. The temporal expression of these patterns over 72 hrs was significantly associated with the severity of global tissue hypoxia, organ dysfunction, and mortality. CONCLUSION: In early severe sepsis and septic shock, within the first 3 hrs of hospital presentation, distinct biomarker patterns emerge in response to hemodynamic optimization strategies. A significant association exists between temporal biomarker patterns in the first 72 hrs, severity of global tissue hypoxia, organ dysfunction, and mortality. These findings identify global tissue hypoxia as an important contributor to the early inflammatory response and support the role of hemodynamic optimization in supplementing other established therapies during this diagnostic and therapeutic "window of opportunity."

    Title Hemolysis and Methemoglobinemia Secondary to Rasburicase Administration.
    Date February 2006
    Journal The Annals of Pharmacotherapy
    Excerpt

    OBJECTIVE: To report a case of hemolytic anemia and methemoglobinemia developing after rasburicase administration to a patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency. CASE SUMMARY: A 50-year-old African American man was hospitalized with new onset seizure, diabetic ketoacidosis, respiratory failure, and acute renal failure. Serum uric acid concentrations were elevated, and the patient was treated with one dose of intravenous rasburicase 22.5 mg for acute renal failure secondary to hyperuricemia. Routine arterial blood gas analyses performed after rasburicase was administered revealed elevated methemoglobin concentrations, which peaked at 14.7%. Hemolytic anemia developed as evidenced by a fall in blood hemoglobin from 14.8 to 5.3 g/dL. The patient made a full recovery following aggressive fluid therapy, blood transfusions, and respiratory support. G6PD deficiency was subsequently confirmed. The Naranjo probability scale indicated that rasburicase was a probable cause of hemolytic anemia and methemoglobinemia. DISCUSSION: Rasburicase is contraindicated in patients with G6PD deficiency as it may cause hemolytic anemia and methemoglobinemia. As of September 26, 2005, simultaneous occurrence of hemolytic anemia and methemoglobinemia has not been reported in patients receiving rasburicase. CONCLUSIONS: As of September 26, 2005, screening for G6PD deficiency should be performed whenever possible prior to chemotherapy administration in patients at risk of developing tumor lysis syndrome.

    Title Failure to Respond to Endogenous or Exogenous Melatonin May Cause Nonphotoresponsiveness in Harlan Sprague Dawley Rats.
    Date October 2005
    Journal Journal of Circadian Rhythms
    Excerpt

    BACKGROUND: Responsiveness to changing photoperiods from summer to winter seasons is an important but variable physiological trait in most temperate-zone mammals. Variation may be due to disorders of melatonin secretion or excretion, or to differences in physiological responses to similar patterns of melatonin secretion and excretion. One potential cause of nonphotoresponsiveness is a failure to secrete or metabolize melatonin in a pattern that reflects photoperiod length. METHODS: This study was performed to test whether a strongly photoresponsive rat strain (F344) and strongly nonphotoresponsive rat strain (HSD) have similar circadian urinary excretion profiles of the major metabolite of melatonin, 6-sulfatoxymelatonin (aMT6s), in long-day (L:D 16:8) and short-day (L:D 8:16) photoperiods. The question of whether young male HSD rats would have reproductive responses to constant dark or to supplemental melatonin injections was also tested. Urinary 24-hour aMT6s profiles were measured under L:D 8:16 and L:D 16:8 in young male laboratory rats of a strain known to be reproductively responsive to the short-day photoperiod (F344) and another known to be nonresponsive (HSD). RESULTS: Both strains exhibited nocturnal rises and diurnal falls in aMT6s excretion during both photoperiods, and the duration of the both strains' nocturnal rise was longer in short photoperiod treatments. In other experiments, young HSD rats failed to suppress reproduction or reduce body weight in response to either constant dark or twice-daily supplemental melatonin injections. CONCLUSION: The results suggest that HSD rats may be nonphotoresponsive because their reproductive system and regulatory system for body mass are unresponsive to melatonin.

    Title The Following is the Abstract of the Article Discussed in the Subsequent Letter:.
    Date June 2005
    Journal Journal of Applied Physiology (bethesda, Md. : 1985)
    Excerpt

    Sublingual and intestinal mucosal blood flow and Pco(2) were studied in a canine model of endotoxin-induced circulatory shock and resuscitation. Sublingual Pco(2) (Ps(CO(2))) was measured by using a novel fluorescent optrode-based technique and compared with lingual measurements obtained by using a Stowe-Severinghaus electrode [lingual Pco(2) (Pl(CO(2)))]. Endotoxin caused parallel changes in cardiac output, and in portal, intestinal mucosal, and sublingual blood flow (Q(s)). Different blood flow patterns were observed during resuscitation: intestinal mucosal blood flow returned to near baseline levels postfluid resuscitation and decreased by 21% after vasopressor resuscitation, whereas Q(s) rose to twice that of the preshock level and was maintained throughout the resuscitation period. Electrochemical and fluorescent Pco(2) measurements showed similar changes throughout the experiments. The shock-induced increases in Ps(CO(2)) and Pl(CO(2)) were nearly reversed after fluid resuscitation, despite persistent systemic arterial hypotension. Vasopressor administration induced a rebound of Ps(CO(2)) and Pl(CO(2)) to shock levels, despite higher cardiac output and Q(s), possibly due to blood flow redistribution and shunting. Changes in Pl(CO(2)) and Ps(CO(2)) paralleled gastric and intestinal Pco(2) changes during shock but not during resuscitation. We found that the lingual, splanchnic, and systemic circulations follow a similar pattern of blood flow variations in response to endotoxin shock, although discrepancies were observed during resuscitation. Restoration of systemic, splanchnic, and lingual perfusion can be accompanied by persistent tissue hypercarbia, mainly lingual and intestinal, more so when a vasopressor agent is used to normalize systemic hemodynamic variables.

    Title Lingual, Splanchnic, and Systemic Hemodynamic and Carbon Dioxide Tension Changes During Endotoxic Shock and Resuscitation.
    Date May 2005
    Journal Journal of Applied Physiology (bethesda, Md. : 1985)
    Excerpt

    Sublingual and intestinal mucosal blood flow and Pco(2) were studied in a canine model of endotoxin-induced circulatory shock and resuscitation. Sublingual Pco(2) (Ps(CO(2))) was measured by using a novel fluorescent optrode-based technique and compared with lingual measurements obtained by using a Stowe-Severinghaus electrode [lingual Pco(2) (Pl(CO(2)))]. Endotoxin caused parallel changes in cardiac output, and in portal, intestinal mucosal, and sublingual blood flow (Q(s)). Different blood flow patterns were observed during resuscitation: intestinal mucosal blood flow returned to near baseline levels postfluid resuscitation and decreased by 21% after vasopressor resuscitation, whereas Q(s) rose to twice that of the preshock level and was maintained throughout the resuscitation period. Electrochemical and fluorescent Pco(2) measurements showed similar changes throughout the experiments. The shock-induced increases in Ps(CO(2)) and Pl(CO(2)) were nearly reversed after fluid resuscitation, despite persistent systemic arterial hypotension. Vasopressor administration induced a rebound of Ps(CO(2)) and Pl(CO(2)) to shock levels, despite higher cardiac output and Q(s), possibly due to blood flow redistribution and shunting. Changes in Pl(CO(2)) and Ps(CO(2)) paralleled gastric and intestinal Pco(2) changes during shock but not during resuscitation. We found that the lingual, splanchnic, and systemic circulations follow a similar pattern of blood flow variations in response to endotoxin shock, although discrepancies were observed during resuscitation. Restoration of systemic, splanchnic, and lingual perfusion can be accompanied by persistent tissue hypercarbia, mainly lingual and intestinal, more so when a vasopressor agent is used to normalize systemic hemodynamic variables.

    Title Review: Metformin Does Not Increase Risk for Lactic Acidosis or Increase Lactate Levels in Type 2 Diabetes.
    Date August 2004
    Journal Acp Journal Club
    Title Vasopressin Vs Norepinephrine in Endotoxic Shock: Systemic, Renal, and Splanchnic Hemodynamic and Oxygen Transport Effects.
    Date March 2004
    Journal Journal of Applied Physiology (bethesda, Md. : 1985)
    Excerpt

    The effects of intravenous norepinephrine (NE, group 1) and vasopressin (AVP, group 2) infusions on systemic, splanchnic, and renal circulations were studied in anesthetized dogs under basal conditions and during endotoxic shock. Under basal conditions, AVP infusion induced a 12 +/- 7% drop in left ventricular stroke work, a 45 +/- 5% fall in portal venous blood flow, and a 31 +/- 13% decrease in intestinal mucosal blood flow (P < 0.05). AVP also decreased splanchnic oxygen delivery (Do2) and increased splanchnic and renal oxygen extraction significantly during basal conditions. Except for more pronounced brady-cardia among animals in group 2, the systemic and splanchnic changes were comparable between study groups during endotoxic shock. AVP infusion restored renal blood flow and Do2 in endotoxic shock compared with animals resuscitated with NE, which had persistently low renal blood flow and Do2. Our data demonstrate that, in contrast to NE, administration of AVP effectively restores renal blood flow and Do2 with comparable systemic and splanchnic hemodynamic and metabolic effects in endotoxin-induced circulatory shock.

    Title Bioavailability of Gatifloxacin by Gastric Tube Administration with and Without Concomitant Enteral Feeding in Critically Ill Patients.
    Date June 2003
    Journal Critical Care Medicine
    Excerpt

    OBJECTIVE: Sequential intravenous-to-oral antimicrobial therapy with highly bioavailable antiinfective agents such as the fluoroquinolones may improve patient safety and decrease cost of infection management. However, physiologic changes associated with critical illness may alter drug absorption, distribution, and clearance, and concomitant enteral feeding may decrease fluoroquinolone bioavailability. We evaluated the effect of critical illness and concomitant gastric tube feeding on gatifloxacin bioavailability. DESIGN: Prospective, randomized, single-dose, two-way crossover, pharmacokinetic study.SETTINGA tertiary, level-one, trauma center. PATIENTS: Sixteen critically ill patients (baseline Acute Physiology and Chronic Health Evaluation II score >or=16) tolerating enteral nutrition administered by gastric tube (NG) for >or=12 hrs were randomized to receive gatifloxacin concurrently with continuous tube feeding or with interrupted tube feeds. Patients with renal insufficiency or those receiving concomitant fluoroquinolone therapy or postpyloric feeding were excluded. Patients received gatifloxacin 400 mg either by the intravenous or NG route followed by the alternative dosage form after a 72-hr washout period. MEASUREMENTS AND MAIN RESULTS: Serial serum gatifloxacin concentrations (from 5 mins to 24 hrs) were analyzed using a validated high-performance liquid chromatography method. Bioavailability was determined as the ratio of NG/intravenous area under the concentration-time curve (AUC infinity ) measured by the trapezoidal method. Although there was no difference in the bioavailability between NG (AUC infinity : 38.0 [range 20.1 to 48.5] microg x h/mL) and intravenous (AUC infinity : 39.5 [range 24.1 to 63.1] microg x h/mL, p =.60) gatifloxacin (bioavailability: 98.5% [range 61.1% to 119.7%]), a wide variability was observed in three of eight patients (>30% reduction in bioavailability). Concomitant gastric tube feeding did not affect gatifloxacin bioavailability (interrupted tube feeds: 98.5% [range 61.1% to 119.7%]; continuous tube feeding: 109.0% [range 86.2% to 142.1%]; p =.42). Neither a period nor differential carryover effect was observed. CONCLUSIONS: Although concomitant tube feeding did not affect gatifloxacin bioavailability, critical illness resulted in significant variability that may complicate the role of gatifloxacin in sequential intravenous-to-oral therapy. More research is needed to identify those patients in whom gatifloxacin bioavailability is reduced and for whom an empirical increase in gatifloxacin dose should be considered.

    Title Exposure of Intensive Care Unit Nurses to Nitric Oxide and Nitrogen Dioxide During Therapeutic Use of Inhaled Nitric Oxide in Adults with Acute Respiratory Distress Syndrome.
    Date June 2003
    Journal American Journal of Critical Care : an Official Publication, American Association of Critical-care Nurses
    Excerpt

    BACKGROUND: Although low concentrations of inhaled nitric oxide may by therapeutic, both nitric oxide and its oxidation product nitrogen dioxide are potentially toxic. The threshold limits for time-weighted average concentrations of nitric oxide and nitrogen dioxide issued by the American Conference of Governmental Industrial Hygienists are 25 and 3 ppm, respectively. The concentrations of these gases in the breathing space of hospital personnel during administration of nitric oxide to adult patients have not been reported. METHODS: Air was sampled from the breathing zone of intensive care unit nurses via collar-mounted tubes during the nurses' routine duties attending patients who were receiving inhaled nitric oxide at 5 or 20 ppm. The exhaust ports of the mechanical ventilators were left open to the room. Nitric oxide and nitrogen dioxide were chemically assayed as nitrite from sorbent tubes by using spectrophotometry. Ambient nitric oxide levels were measured at sequential distances from the ventilator by using chemiluminescence. RESULTS: The time-weighted average concentrations of inspired gas for nurses during inhaled nitric oxide treatment were 0.45 ppm or less for nitric oxide and less than 0.29 ppm for nitrogen dioxide. Nitric oxide levels at the ventilator during delivery at 20 ppm were 9.2 ppm, but dropped off markedly beyond 0.6 m (2 ft), to a mean of about 30 ppb. CONCLUSION: Inhaled nitric oxide therapy at doses up to 20 ppm does not appear to pose a risk of excessive occupational exposure to nitric oxide or nitrogen dioxide to nurses during routine delivery of critical care.

    Title Dopamine-1 Receptor Stimulation Impairs Intestinal Oxygen Utilization During Critical Hypoperfusion.
    Date February 2003
    Journal American Journal of Physiology. Heart and Circulatory Physiology
    Excerpt

    Effects of a dopamine-1 (DA-1) receptor agonist on systemic and intestinal oxygen delivery (Do(2))-uptake relationships were studied in anesthetized dogs during sequential hemorrhage. Control (group 1) and experimental animals (group 2) were treated similarly except for the addition of fenoldopam (1.0 microg x kg(-1) x min(-1)) in group 2. Both groups had comparable systemic critical Do(2) (Do(2crit)), but animals in group 2 had a higher gut Do(2crit) (1.12 +/- 1.13 vs. 0.80 +/- 0.09 ml. kg(-1) x min(-1), P < 0.05). At the mucosal level, a clear biphasic delivery-uptake relationship was not observed in group 1; thus oxygen consumption by the mucosa may be supply dependent under physiological conditions. Group 2 demonstrated higher peak mucosal blood flow and lack of supply dependency at higher mucosal Do(2) levels. Fenoldopam resulted in a more conspicuous biphasic relationship at the mucosa and a rightward shift of overall splanchnic Do(2crit) despite increased splanchnic blood flow. These findings suggest that DA-1 receptor stimulation results in increased gut perfusion heterogeneity and maldistribution of perfusion, resulting in increased susceptibility to ischemia.

    Title Tachyphylaxis Associated with Continuous Cisatracurium Versus Pancuronium Therapy.
    Date January 2003
    Journal Pharmacotherapy
    Excerpt

    STUDY OBJECTIVES: To compare dosing requirements over time among patients receiving continuous cisatracurium versus pancuronium therapy, and to identify factors that may account for changes in pancuronium versus cisatracurium infusion requirements over time. DESIGN: Retrospective, comparative cohort analysis. SETTING: A tertiary level 1 trauma center. PATIENTS: Forty-five consecutive adult patients who were admitted to intensive care units at our institution from January 1998-August 2000 and received continuous cisatracurium or pancuronium therapy for at least 48 hours. MEASUREMENTS AND MAIN RESULTS: Dosing requirements of patients treated with pancuronium or cisatracurium were recorded over time throughout the treatment period. Factors that could affect dosing requirements of a neuromuscular blocking agent (NMBA) were stratified as time invariant (admitting service, acute physiology and chronic health evaluation II score, duration of mechanical ventilation, pressure control ventilation, baseline hepatic or renal insufficiency, thermal injury, train-of-four assessment, and concurrent drug administration or disorders affecting neuromuscular transmission) or time variant (concurrent sedation and narcotic analgesia therapy; serum magnesium, potassium, and creatinine concentrations; arterial pH level; temperature; peak airway pressure; and partial pressure of oxygen:fraction of inspired oxygen ratio). Hierarchical linear modeling was used to compare the dosing requirements and to identify confounders affecting the relationship. The infusion rate escalation for the cisatracurium group was greater (0.39 microg/kg/min; 95% confidence interval [CI] 0.22-0.56; 23 patients) than for the pancuronium group (-0.06 microg/kg/min; 95% CI -0.24-0.12; 22 patients; p<0.001) and was associated with an average daily cost/patient significantly higher (p<0.001) with cisatracurium ($258+/-$114) than pancuronium ($11+/-$5). Confounder analysis revealed that only the admitting service and the number of times the NMBA infusion was suspended because no twitch was detected differed between groups. Neither of these confounders significantly affected the temporal relationship between cisatracurium and pancuronium infusion rates. CONCLUSION: Dosing requirements increase over time at a significantly greater rate for cisatracurium than pancuronium infusions. Tachyphylaxis with cisatracurium is associated with substantial drug-related costs and is not accounted for by various disease-, patient-, and therapy-related factors. Further investigation is required to elucidate the mechanisms and risk factors underlying this phenomenon.

    Title Dopamine-1 Receptor Stimulation Attenuates the Vasoconstrictive Response to Gut Ischemia.
    Date September 2001
    Journal Journal of Applied Physiology (bethesda, Md. : 1985)
    Excerpt

    The effects of fenoldopam, a dopamine-1 (DA-1) receptor agonist, were studied in two groups of anesthetized dogs before and after induction of splanchnic ischemia by way of hemorrhage. During the first portion of the experiment, both groups received fenoldopam (1.5 microg x kg(-1) x min(-1)) for 45 min followed by a 45-min washout. During the second portion, hemorrhage (10 ml/kg) was induced, followed by no intervention in group I (controls) and restarting of the fenoldopam infusion in group II. Prehemorrhage, fenoldopam increased composite portal blood flow by 33% (P < 0.01). After hemorrhage-induced splanchnic ischemia, fenoldopam restored portal vein blood flow to near baseline, maintained the splanchnic fraction of cardiac output, and attenuated the rise in gut mucosal PCO(2). DA-1 receptor stimulation increased portal blood flow and redistributed blood flow away from the serosal layer in favor of the mucosa during basal conditions and after hemorrhage, suggesting a more concentrated distribution of splanchnic DA-1 receptors within the mucosal layer vasculature. Fenoldopam maintained splanchnic blood flow during hypoperfusion and attenuated the splanchnic vasoconstrictive response to hemorrhage.

    Title Metformin-associated Lactic Acidosis.
    Date May 2001
    Journal The Journal of Emergency Medicine
    Excerpt

    In 1995, the oral antihyperglycemic agent, metformin, was introduced in the United States for treating diabetes mellitus. Rare cases of metformin-associated lactic acidosis caused by the accumulation of the drug in patients with renal dysfunction have been described, although a detailed time course of the resulting metabolic derangements has not been reported. A case of metformin-associated lactic acidosis is presented along with key serial laboratory abnormalities observed during the treatment phase. The patient made a complete recovery following therapy with hemodialysis and supportive care.

    Title E5 Murine Monoclonal Antiendotoxin Antibody in Gram-negative Sepsis: a Randomized Controlled Trial. E5 Study Investigators.
    Date April 2000
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    CONTEXT: Knowledge and understanding of gram-negative sepsis have grown over the past 20 years, but the ability to treat severe sepsis successfully has not. OBJECTIVE: To assess the efficacy and safety of E5 in the treatment of patients with severe gram-negative sepsis. DESIGN: A multicenter, double-blind, randomized, placebo-controlled trial conducted at 136 US medical centers from April 1993 to April 1997, designed with 90% power to detect a 25% relative risk reduction, incorporating 2 planned interim analyses. SETTING: Intensive care units at university medical centers, Veterans Affairs medical centers, and community hospitals. PATIENTS: Adults aged 18 years or older, with signs and symptoms consistent with severe sepsis and documented or probable gram-negative infection. INTERVENTION: Patients were assigned to receive 2 doses of either E5, a murine monoclonal antibody directed against endotoxin (n = 550; 2 mg/kg per day by intravenous infusion 24 hours apart) or placebo (n = 552). MAIN OUTCOME MEASURES: The primary end point was mortality at day 14; secondary end points were mortality at day 28, adverse event rates, and 14-day and 28-day mortality in the subgroup without shock at presentation. RESULTS: The trial was stopped after the second interim analysis. A total of 1090 patients received study medication and 915 had gram-negative infection confirmed by culture. There were no statistically significant differences in mortality between the E5 and placebo groups at either day 14 (29.7% vs 31.1%; P = .67) or day 28 (38.5% vs 40.3%; P = .56). Patients presenting without shock had a slightly lower mortality when treated with E5 but the difference was not significant (28.9% vs 33.0% for the E5 and placebo groups, respectively, at day 28; P = .32). There was a similar profile of adverse event rates between E5 and placebo. CONCLUSIONS: Despite adequate sample size and high enrollment of patients with confirmed gram-negative sepsis, E5 did not improve short-term survival. Current study rationale and designs should be carefully reviewed before further large-scale studies of patients with sepsis are conducted.

    Title Gut Mucosal-arterial Pco2 Gradient As an Indicator of Splanchnic Perfusion During Systemic Hypo- and Hypercapnia.
    Date January 2000
    Journal Critical Care Medicine
    Excerpt

    OBJECTIVES: By accounting for influences of systemic acid-base disturbances, gut mucosal-arterial Pco2 gradient (Pico2 - Paco2) has been increasingly advocated as a more specific marker of splanchnic perfusion than Pico2 alone. We examined the stability of the Pico2 - Paco2 gradient compared with raw Pico2 measurements during induced systemic hypo- and hypercapnia. DESIGN: A prospective animal study. SETTINGS: A university research laboratory. SUBJECTS: Twenty anesthetized, paralyzed, and mechanically ventilated mongrel dogs. INTERVENTIONS: After a baseline period during which Paco2 was maintained near 40 torr, the animals were divided into four groups. Minute ventilation was then altered by adjusting tidal volume, frequency, or both to achieve group Paco2 values of 15, 20, 60, and 80 torr for groups 1 through 4, respectively. Portal blood flow was monitored and maintained near baseline levels by infusion of intravenous fluids. Intestinal Pico2 was measured continuously by using capnometric recirculating gas tonometry. MEASUREMENTS AND MAIN RESULTS: Mean (+/- SE) aggregate baseline Pico2 - Paco2 was 16.9+/-3.3 torr. After 60 mins of hypoventilation, Pico2 - Paco2 decreased to 14.2+/-1.1 and to 13.7+/-2.7 torr in groups 3 and 4, respectively (p = NS, compared with baseline for both). On the other hand, after 60 mins of hyperventilation, Pico2 - Paco2 increased to 37.9+/-3.6 and 28.0+/-6.3 torr in groups 1 and 2, respectively (p < .0001, compared with baseline for both). CONCLUSIONS: In this model of maintained portal blood flow, Pico2 - Paco2 remained essentially stable after hypoventilation but increased significantly after inducing hyperventilation. Our findings warrant cautious interpretation of Pico2 - Paco2 as an indicator of splanchnic perfusion during systemic hypocapnia.

    Title Methemoglobinemia Induced by Topical Anesthesia: a Case Report and Review.
    Date January 2000
    Journal The American Journal of the Medical Sciences
    Excerpt

    Topical anesthetic drugs are widely used by clinicians during hospital and outpatient procedures and are also available to the public in a variety of over-the-counter preparations. Although generally safe, they may cause potentially life-threatening methemoglobinemia. We describe a patient who developed repeated episodes of severe methemoglobinemia after administration of topical Cetacaine spray (a proprietary mixture of benzocaine, tetracaine, and butamben) employed for pharyngeal anesthesia before endotracheal intubation, and briefly review the etiology and pathophysiology of this disorder. Cautious interpretation of oxyhemoglobin saturation values obtained by pulse oximetry or estimated from arterial blood gas analysis is crucial lest the diagnosis of severe methemoglobinemia and the resulting hypoxemia are overlooked. If necessary, the condition is usually readily corrected by intravenous administration of methylene blue.

    Title Splanchnic Hemodynamics and Gut Mucosal-arterial Pco(2) Gradient During Systemic Hypocapnia.
    Date October 1999
    Journal Journal of Applied Physiology (bethesda, Md. : 1985)
    Excerpt

    The effects of hypocapnia [arterial PCO(2) (Pa(CO(2))) 15 Torr] on splanchnic hemodynamics and gut mucosal-arterial P(CO(2)) were studied in seven anesthetized ventilated dogs. Ileal mucosal and serosal blood flow were estimated by using laser Doppler flowmetry, mucosal PCO(2) was measured continuously by using capnometric recirculating gas tonometry, and serosal surface PO(2) was assessed by using a polarographic electrode. Hypocapnia was induced by removal of dead space and was maintained for 45 min, followed by 45 min of eucapnia. Mean Pa(CO(2)) at baseline was 38.1 +/- 1.1 (SE) Torr and decreased to 13.8 +/- 1.3 Torr after removal of dead space. Cardiac output and portal blood flow decreased significantly with hypocapnia. Similarly, mucosal and serosal blood flow decreased by 15 +/- 4 and by 34 +/- 7%, respectively. Also, an increase in the mucosal-arterial PCO(2) gradient of 10.7 Torr and a reduction in serosal PO(2) of 30 Torr were observed with hypocapnia (P < 0.01 for both). Hypocapnia caused ileal mucosal and serosal hypoperfusion, with redistribution of flow favoring the mucosa, accompanied by increased PCO(2) gradient and diminished serosal PO(2).

    Title Searching for the Perfect Indicator of Dysoxia.
    Date April 1999
    Journal Critical Care Medicine
    Title Gastric Intramucosal Pco2 As a Quantitative Indicator of the Degree of Acute Hemorrhage.
    Date August 1998
    Journal Journal of Critical Care
    Excerpt

    PURPOSE: Gastric intramucosal PCO2 (PiCO2) is a marker of splanchnic dysoxia and hypoperfusion that is increasingly used in intensive care medicine. We assessed two methods, saline-balloon tonometry versus continuous capnometric recirculating gas tonometry (CRGT), for detecting changes in PiCO2 in animals subjected to various degrees of hemorrhage and examined whether changes in PiCO2 would correlate with the degree of hemorrhage as assessed by blood loss volume. MATERIALS AND METHODS: Following a baseline equilibration period, 20 anesthetized dogs were subjected to bleeding of 0, 23, 35, 41, or 47 mL/kg. After 30 minutes, the shed blood was reinfused and the experiments continued for an additional 120 minutes. RESULTS: Aggregate baseline PiCO2 was 43 mm Hg by both methods. PiCO2 did not change significantly over time in the control animals by either method. PiCO2 by CRGT rose significantly in each of the other groups at the end of the hemorrhage period and after resuscitation. Similar trends were observed in PiCO2 measured by saline tonometry but were significant only with the most severe hemorrhage. Strong correlation was observed between the degree of hemorrhage and change in PiCO2 by both methods. CONCLUSION: PiCO2 serves as a quantitative indicator of the severity of hypovolemic perfusion failure associated with hemorrhage. Compared with standard saline tonometry, CRGT may be a more sensitive method of monitoring the severity of hemorrhage.

    Title Therapeutic Use of Antithrombin Concentrate in Sepsis.
    Date July 1998
    Journal Seminars in Thrombosis and Hemostasis
    Excerpt

    Sepsis and its associated complications of disseminated intravascular coagulation (DIC) and multiple organ dysfunction syndrome (MODS) continue to be a major cause of morbidity and mortality. Improved detection of all forms of DIC is essential to assure earlier diagnosis. Studies already indicate that the therapeutic use of antithrombin (AT) concentrate may produce a more positive outcome for sepsis-associated DIC. If DIC could be identified earlier and AT concentrate could then be given earlier in the sepsis continuum, study results for the use of AT concentrate in humans might reveal a statistically significant difference versus placebo, and the efficacy of AT concentrate for this syndrome is more likely to be proved. Fixed-bolus doses of AT concentrate based on body weight are currently preferred, but improved, user-friendly assays for plasma AT levels would permit more rapid turnaround time for AT results and could help fine-tune the use of AT concentrate to the specific needs of each patient. Clinical trials involving the therapeutic use of AT concentrate in sepsis should continue, and it can be hoped that their design will reflect the concepts and conclusions offered by this panel of investigators.

    Title Gastric and Esophageal Intramucosal Pco2 (pico2) During Endotoxemia: Assessment of Raw Pico2 and Pco2 Gradients As Indicators of Hypoperfusion in a Canine Model of Septic Shock.
    Date May 1998
    Journal Chest
    Excerpt

    STUDY OBJECTIVES: To validate capnometric recirculating gas tonometry (CRGT) for continuously monitoring gut intramucosal PCO2 (PiCO2) in a septic shock model, and to compare gastric vs esophageal PCO2 vs intramucosal-arterial PCO2 gradients. INTERVENTIONS: CRTG catheters were placed in the stomach and esophagus of six anesthetized dogs. A saline solution filled balloon tonometry (ST) catheter was also placed in the stomach. After equilibration, 3 mg/kg Escherichia coli lipopolysaccharide (LPS) was administered IV. PiCO2 measurements were made at 0, 45, and 90 min post-LPS by ST and continuously by CRGT. RESULTS: Baseline PiCO2 was 41.5+/-1.9 (+/-SE) in the stomach by CRGT, 38.0+/-1.0 by ST, and 43.0+/-4.4 mm Hg in the esophagus (p=not significant). Gastric PiCO2 by CRGT increased to 47.0+/-2.4 mm Hg by 25 min post-LPS (p<0.05), whereas gastric (ST) and esophageal PiCO2 increased significantly by 45 min post-LPS. Good agreement was observed between gastric CRGT and ST measurements (mean bias, 1.3 mm Hg). The PiCO2-PaCO2 gradient increased post-LPS, but was significant only for gastric CRGT measurements 90 min post-LPS infusion. CONCLUSION: CRGT provided continuous gastric PiCO2 measurements that were in close agreement with ST but detected changes earlier than the conventional technique. Continuous esophageal PiCO2 represents a valid alternative for assessing gastric PiCO2.

    Title Relationship Between Systemic Oxygen Supply Dependency and Gastric Intramucosal Pco2 During Progressive Hemorrhage.
    Date April 1998
    Journal The Journal of Trauma
    Excerpt

    BACKGROUND: As systemic oxygen delivery (DO2) is reduced, oxygen consumption (VO2) is maintained until a critical level is reached (DO2crit) below which VO2 becomes supply-dependent and anaerobic metabolism ensues. We examined the relationship between gastric intramucosal PCO2 (PiCO2) and the onset of systemic supply dependency. We also compared PiCO2 to mixed venous and portal venous blood PCO2 (PmvCO2 and PpvCO2) to assess their utility as premonitory indicators of supply dependency. METHODS: Six dogs were subjected to stepwise hemorrhage to effect a progressive decrease in DO2. Inflection points for changes in VO2, PiCO2, PmvCO2, and PpvCO2 versus DO2 were determined. RESULTS: Mean DO2crit was 6.0 +/- 0.7 mL x kg(-1) x min(-1), whereas the DO2 at which inflection points occurred for PiCO2 and PpvCO2 were 13.2 +/- 1.4 and 11.2 +/- 1.5 mL x kg(-1) x min(-1), respectively (p < 0.05 for both). CONCLUSION: Continuous monitoring of PiCO2 using capnometric recirculating gas tonometry can serve as an early indicator of systemic hypoperfusion before the onset of systemic supply dependency.

    Title End-tidal Partial Pressure of Carbon Dioxide As a Noninvasive Indicator of Systemic Oxygen Supply Dependency During Hemorrhagic Shock and Resuscitation.
    Date February 1998
    Journal Shock (augusta, Ga.)
    Excerpt

    When oxygen delivery (DO2) critically decreases, oxygen consumption (VO2) becomes supply dependent. We examined whether end-tidal PCO2 (PetCO2) would identify supply dependency during shock. Five dogs (Group I) underwent progressive hemorrhage to decrease DO2 until they could no longer maintain a stable blood pressure. Five additional animals (Group II) were bled until VO2 decreased to 70% of baseline, followed by resuscitation. The PetCO2 versus time inflection point was compared with the DO2 at onset of supply dependency (DO2crit). DO2crit for Groups I and II were 6.9 +/- .4 and 8.1 +/- 1.3, respectively (p = NS), and not statistically different from the DO2 values at which PetCO2 decreased (6.6 +/- .7 and 6.3 +/- .7 mL/kg per min, respectively). AT constant minute volume, PetCO2 effectively indicated the onset of supply dependency and rapidly increased during resuscitation, paralleling the changes in VO2 in this model of hemorrhagic shock.

    Title Failure of Three Decision Rules to Predict the Outcome of In-hospital Cardiopulmonary Resuscitation.
    Date July 1997
    Journal Medical Decision Making : an International Journal of the Society for Medical Decision Making
    Excerpt

    The objective of this study was to evaluate three decision-support tools (the Pre-Arrest Morbidity or PAM score, the Prognosis After Resuscitation or PAR score, and the Acute Physiology and Chronic Health Evaluation or APACHE III score) for their abilities to predict the outcomes of in-hospital cardiopulmonary resuscitation (CPR). The medical records of all 656 adult inpatients undergoing CPR during a two-to-three-year period in three large hospitals were retrospectively reviewed, and demographic and clinical variables were abstracted. Of 656 patients undergoing resuscitation, 248 (37.8%) survived the resuscitation attempt long enough to be stabilized (immediate survival), but only 35 (5.3%) survived to discharge. Only 11 patients had PAM scores higher than 8, none of whom survived to discharge; 131 patients had PAR scores above 8, of whom six survived to discharge. The PAR score and the APACHE III score had the greatest areas under the receiver operating characteristic curves (when predicting the outcome of survival to discharge), although no individual area for either outcome was greater than 0.6. None of the decision-support tools studied was able to effectively discriminate between survivors and non-survivors for the outcomes of immediate survival and survival to discharge following in-hospital CPR. This is consistent with previous work utilizing the APACHE II score, which did not identify a threshold above which patients did not benefit from CPR. The findings for the PAR score and the PAM score stand in contrast to previous studies that found them to be potentially useful decision rules. Further work is needed to develop a decision-support tool that better discriminates between survivors and non-survivors of in-hospital CPR.

    Title Continuous Assessment of Gastric Intramucosal Pco2 and Ph in Hemorrhagic Shock Using Capnometric Recirculating Gas Tonometry.
    Date April 1997
    Journal Critical Care Medicine
    Excerpt

    OBJECTIVES: To test a novel device for continuous monitoring of gut intramucosal PCO2 and pH and to compare its use with conventional intermittent saline balloon-tonometry in a model of hemorrhagic shock. DESIGN: A prospective animal study. SETTINGS: A university research laboratory. SUBJECTS: Eight anesthetized, mechanically ventilated mongrel dogs. INTERVENTIONS: Two balloon-tip tonometry catheters, one conventional and one modified for continuous recirculating gas tonometry, were inserted into each animal's stomach by the oral route. Gastric intramucosal PCO2 was recorded continuously by capnometric recirculating gas tonometry throughout the experiment. After a baseline period of 90 mins, vital signs, arterial and mixed venous blood gases, and intramucosal PCO2 values were obtained by recirculating gas tonometry and by the conventional method. Using a modified Wiggers' model, the animals were then subjected to hemorrhage of up to 45 mL/kg, or the volume required to effect a decrease in mean arterial pressure to < 30 mm Hg. After 30 mins, the shed blood was reinfused and the experiment continued for an additional 30 mins. Vital signs, arterial and mixed venous blood samples, saline tonometry samples, and recirculating gas tonometry readings were obtained immediately before and 30 mins after reinfusion of blood. MEASUREMENTS AND MAIN RESULTS: Mean +/- SD baseline intramucosal PCO2 was 47.6 +/- 9.5 torr (6.3 +/- 1.3 kPa) by capnometric recirculating gas tonometry and 45.8 +/- 3.4 torr (6.1 +/- 0.5 kPa) by conventional saline tonometry (p = NS). By 5 mins after inducing hemorrhage, intramucosal PCO2 by recirculating gas tonometry had increased significantly (49.3 +/- 9.7 torr [6.6 +/- 1.3 kPa]; p < .05), and by 30 mins, it had increased to 59.7 +/- 11.3 torr (8.0 +/- 1.5 kPa; p < .001 compared with baseline). After 30 mins of hemorrhage, the conventional method showed an increase in intramucosal PCO2 to 63.0 +/- 20.9 torr (8.4 kPa +/- 2.8 kPa; p = NS vs. baseline by conventional method; p = NS vs. corresponding recirculating gas tonometry values). Gastric intramucosal pH, as determined by recirculating gas tonometry, decreased significantly at 5 mins after starting hemorrhage (7.13 +/- 0.10 to 7.10 +/- 0.10, p < .02). After 30 mins of hemorrhage, intramucosal pH decreased to 6.88 +/- 0.14 (from 7.10 +/- 0.10) by the conventional saline tonometry technique (p < .01) and to 6.89 +/- 0.10 by recirculating gas tonometry (p < .001 vs. baseline). Intramucosal PCO2 by both techniques remained significantly increased above baseline values 30 mins after reinfusion of the shed blood. CONCLUSIONS: Capnometric recirculating gas tonometry allows continuous and automated assessment of gastrointestinal tract perfusion by providing on-line measurements of intramucosal PCO2, which can also be used to derive intramucosal pH. The technique is able to detect changes in intramucosal PCO2 in response to an induced insult over intervals as short as 5 mins.

    Title Poor in Vivo Reproducibility of Gastric Intramucosal Ph Determined by Saline-filled Balloon Tonometry.
    Date January 1997
    Journal Journal of Critical Care
    Excerpt

    PURPOSE: The reproducibility of gastric intramucosal pH (pHi) determinations by saline-filled balloon tonometry has not been assessed adequately. We examined the agreement of pHi obtained using pairs of tonometry catheters under various conditions in a canine model of global hypoxia. METHODS: Two gastric balloon tonometry catheters were inserted into each of 16 anesthetized dogs. Cimetidine was administered to six of the animals (group 1). Hypoxia was induced for 30 minutes by reducing the F1O2 to 0.08. pHi was determined under basal conditions, at completion of hypoxia, and during the posthypoxic period. RESULTS: The mean bias of the paired pHi determinations was 0.03 for group 1 and 0.00 for group 2 (P = NS). The corresponding 95% limits of agreement spanned 0.24 and 0.28 pH units, respectively. Agreement of pHi determinations between tonometry catheters was not significantly affected by varying of the equilibration period, by administration of cimetidine, or by the presence of posthypoxic conditions. CONCLUSIONS: Clinically important disagreement was observed in simultaneous pHi determinations obtained using separate gastric balloon tonometry catheters exposed to identical in vivo conditions. Poor reproducibility of individual pHi determinations may limit the accuracy of pHi obtained by gastric balloon tonometry in the clinical setting.

    Title Continuous Infusion Versus Intermittent Administration of Ceftazidime in Critically Ill Patients with Suspected Gram-negative Infections.
    Date January 1997
    Journal Antimicrobial Agents and Chemotherapy
    Excerpt

    The pharmacodynamics and pharmacokinetics of ceftazidime administered by continuous infusion and intermittent bolus over a 4-day period were compared. We conducted a prospective, randomized, crossover study of 12 critically ill patients with suspected gram-negative infections. The patients were randomized to receive ceftazidime either as a 2-g intravenous (i.v.) loading dose followed by a 3-g continuous infusion (CI) over 24 h or as 2 g i.v. every 8 h (q8h), each for 2 days. After 2 days, the patients were crossed over and received the opposite regimen. Each regimen also included tobramycin (4 to 7 mg/kg of body weight, given i.v. q24h). Eighteen blood samples were drawn on study days 2 and 4 to evaluate the pharmacokinetics of ceftazidime and its pharmacodynamics against a clinical isolate of Pseudomonas aeruginosa (R288). The patient demographics (means +/- standard deviations) were as follows: age, 57 +/- 12 years; sex, nine males and three females; APACHE II score, 15 +/- 3; diagnosis, 9 of 12 patients with pneumonia. The mean pharmacokinetic parameters for ceftazidime given as an intermittent bolus (IB) (means +/- standard deviations) were as follows: maximum concentration of drug in serum, 124.4 +/- 52.6 micrograms/ml; minimum concentration in serum, 25.0 +/- 17.5 micrograms/ml; elimination constant, 0.268 +/- 0.205 h-1; half-life, 3.48 +/- 1.61 h; and volume of distribution, 18.9 +/- 9.0 liters. The steady-state ceftazidime concentration for CI was 29.7 +/- 17.4 micrograms/ml, which was not significantly different from the targeted concentrations. The range of mean steady-state ceftazidime concentrations for the 12 patients was 10.6 to 62.4 micrograms/ml. Tobramycin peak concentrations ranged between 7 and 20 micrograms/ml. As expected, the area under the curve for the 2-g q8h regimen was larger than that for CI (P = 0.003). For IB and CI, the times that the serum drug concentration was greater than the MIC were 92 and 100%, respectively, for each regimen against the P. aeruginosa clinical isolate. The 24-h bactericidal titers in serum, at which the tobramycin concentrations were < 1.0 microgram/ml in all patients, were the same for CI and IB (1:4). In the presence of tobramycin, the area under the bactericidal titer-time curve (AUBC) was significantly greater for IB than CI (P = 0.001). After tobramycin was removed from the serum, no significant difference existed between the AUBCs for CI and IB. We conclude that CI of ceftazidime utilizing one-half the IB daily dose was equivalent to the IB treatment as judged by pharmacodynamic analysis of critically ill patients with suspected gram-negative infections. No evaluation comparing the clinical efficacies of these two dosage regimens was performed.

    Title Progressive Gastric Intramucosal Acidosis Follows Resuscitation from Hemorrhagic Shock.
    Date December 1996
    Journal Shock (augusta, Ga.)
    Excerpt

    The time course of gastric intramucosal pH (pHi) during the early phase of resuscitation of hemorrhagic shock has not been adequately characterized. We examined pHi using gastric tonometry catheters in an anesthetized dog model of hemorrhagic shock. Shock was induced in 10 animals to maintain mean arterial blood pressure (MAP) at 40-45 mmHg for 30 min, followed by transfusion of shed blood plus additional saline as needed to maintain MAP at pre-shock values. Five animals served as controls. Baseline pHi values were nearly identical in both groups. Resuscitation promptly restored MAP. Following a precipitous drop of pHi during shock, there was only partial recovery 60 min post-shock, followed by progressive worsening of intramucosal acidosis (7.02 +/- .10 vs. 6.82 +/- .24 at 60 and 210 min post-shock, respectively; p < .002). MAP, heart rate, and pHi did not change significantly during the experiment in the control group. These results indicate that prompt and adequate MAP response to resuscitation failed to prevent significant decreases of pHi in the first few hours post-resuscitation. This finding may be related to persistent splanchnic hypoperfusion or reperfusion injury.

    Title Use of Pulse Oximetry for Assessing Ulnar Collateral Flow.
    Date September 1996
    Journal Annals of Internal Medicine
    Title Accuracy of Estimated Creatinine Clearance in Obese Patients with Stable Renal Function in the Intensive Care Unit.
    Date May 1996
    Journal Pharmacotherapy
    Excerpt

    We compared agreement between creatinine clearance values in obese, critically ill patients calculated using three common empirically derived formulas and modifications thereof, with creatinine clearance obtained by conventional 24-hour urine collection. We selected the charts of 22 patients in intensive care units (86% medical, 14% surgical) according to the following criteria: actual body weight greater than 150% of ideal body weight; serum creatinine variation of less than 15% from the day of starting 24-hour urine collection to the day before or after the collection; presence of a urinary bladder catheter; no history of renal dialysis; and clinical indication for renal function assessment. Mean measured 24-hour urinary creatinine clearance for all patients was 72 +/- 64 ml/minute (range 8-248 ml/min). The method of estimating creatinine clearance that showed the least mean bias was the equation of Salazar and Corcoran using a corrected serum creatinine concentration (mean bias -2 ml/min); however, the corresponding 95% confidence intervals were wide (-133-129 ml/min). The narrowest range of 95% confidence intervals were seen with Jelliffe's equation (mean bias 25 ml/min, 95% confidence intervals -41-90 ml/min). In this sample, estimated creatinine clearances did not agree acceptably with measured values. Despite low mean bias values, none of the empirically derived equations that we studied had clinically acceptable 95% confidence intervals. We recommend using the 24-hour urine collection method when assessing creatinine clearance in obese, critically ill patients.

    Title Development and Validation of a Technique for Continuous Monitoring of Gastric Intramucosal Ph.
    Date March 1996
    Journal American Journal of Respiratory and Critical Care Medicine
    Excerpt

    A novel method for continuously monitoring gastric intramucosal PCO2 and pH was developed and tested. Gas was continuously circulated through a modified balloon-tipped catheter connected to an external closed system fitted with an infrared CO2 sensor to monitor PCO2. Performance of the capnometric recirculating gas tonometry (CRGT) system was tested in vitro using an equilibration chamber and in vivo in six anesthetized dogs. Serial PCO2 measurements were made using CRGT and compared with intermittent PCO2 values obtained by conventional tonometry catheters. In the animal experiments, gastric intramucosal PCO2 and pH were determined before and after inducing hypoxia by decreasing the Flo2 to 0.08. After initial placement, PCO2 determined by the CRGT reached a near plateau within 45 min, and at that time point values were comparable to those obtained by conventional intermittent tonometry. Significant increases in gastric intramucosal PCO2 were detectable by CRGT within 5 min of inducing systemic hypoxia, and there was a concomitant significant decrease in intramucosal pH. Continuous monitoring of gastric intramucosal PCO2 and pH is feasible, has potential advantages over conventional methods, and can provide significant trending information over intervals as short as 5 min.

    Title Catheter Breakage: an Unusual Complication of Nasoenteric Feeding Tubes.
    Date August 1995
    Journal The American Journal of Gastroenterology
    Title Effect of Race on Survival Following In-hospital Cardiopulmonary Resuscitation.
    Date July 1995
    Journal The Journal of Family Practice
    Excerpt

    BACKGROUND. Race has been shown to be a significant predictive factor in a number of treatment decisions and outcomes, including survival following out-of-hospital cardiopulmonary resuscitation (CPR). The goal of this study was to determine whether race is associated with the rate of survival to discharge following in-hospital CPR. METHODS. Consecutive adult patients undergoing attempted CPR at three teaching hospitals were identified. Demographic, clinical, and laboratory data from the time of admission, information about the resuscitation attempt, and the outcome of CPR were recorded for each patient. The characteristics of black and non-black patients were compared. Logistic regression was used to determine whether race was a significant independent predictor of CPR outcome. RESULTS. A total of 656 patients were identified. Black patients had a higher mean severity of illness as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) III score, were more likely to have an initial rhythm of electromechanical dissociation or asystole, were less likely to have an admitting diagnosis of myocardial infarction or a history of coronary artery disease, and had a higher serum creatinine level, lower serum albumin value, and lower 24-hour urine output for the first 24 hours. There was no difference between black and nonblack patients regarding the rate of survival of the resuscitative effort itself. However, black patients were significantly less likely than nonblack patients to survive to discharge following resuscitation (Mantel-Haenszel odds ratio, 0.31; 95% confidence interval, 0.15 to 0.68). This relationship persisted after adjusting for potential confounders such as age, sex, initial cardiac rhythm, diagnosis of pneumonia, serum creatinine level, hospital, and APACHE III score. CONCLUSIONS. Black race is significantly associated with a lower rate of survival to discharge following in-hospital CPR. Further work is needed to explore this association in other settings; to examine the effect of other possible confounding variables, such as tobacco use, socioeconomic status, and marital status; and to further study the determinants of physician decision-making about resuscitation.

    Title Concentrated Potassium Chloride Infusions in Critically Ill Patients with Hypokalemia.
    Date April 1995
    Journal Journal of Clinical Pharmacology
    Excerpt

    Although concentrated infusions of potassium chloride commonly are used to treat hypokalemia in intensive care unit patients, few studies have examined their effects on plasma potassium levels. Forty patients with hypokalemia were given infusions of 20 mmol of potassium chloride in 100 mL of normal saline over 1 hour; 26 patients received the infusions through the central vein and 14 patients through the peripheral vein. Plasma potassium ([K]p) was measured at 15-minute intervals during and after the infusion in 31 patients. delta K was defined as the difference between each potassium determination and baseline plasma potassium concentration. Continuous electrocardiographic recording was carried out during the infusion and during the 1-hour period immediately preceding the infusion. Mean baseline [K]p was 2.9 mmol/L and all subsequent plasma concentrations significantly increased from baseline. Mean peak [K]p was 3.5 mmol/L, [K]p (1 hour postinfusion) was 3.2 mmol/L, and mean postinfusion delta K was 0.48 mmol/L (range -0.1-1.7 mmol/L). Arrhythmias, changes in cardiac conduction intervals, and other complications did not occur. The frequency of premature ventricular beats decreased significantly during the infusion compared with that of the control period. The high concentration (200 mmol/L) and rate of delivery (20 mmol/hr) of the potassium chloride infusions were well tolerated, decreased the frequency of ventricular arrhythmias, and did not cause transient hyperkalemia.

    Title The Serum Osmole Gap.
    Date January 1995
    Journal Journal of Critical Care
    Excerpt

    Estimation and measurement of serum osmolality can be of value in the clinical management of certain forms of critical illness. Osmolality is a measure of the concentration of osmotically active particles, or solutes, in a solution. Only low-formula weight ions and uncharged molecules that are present in relatively high concentrations contribute significantly to serum osmolality. Serum osmolality can be easily estimated from the three major osmotic constituents of normal serum (sodium, urea, and glucose) by a simple formula. An understanding of serum osmolality, its laboratory measurement, its bedside estimation, and the concept of the osmole gap, is crucial in making a preliminary diagnosis of methanol and ethylene glycol intoxication, as well as a few other related compounds. There are important caveats to this use of the osmole gap, because under certain circumstances both false-positive and false-negative interpretations may occur. The osmole gap may also be helpful for confirming pseudohyponatremia, as a gauge for dosing mannitol and glycerol when used to treat intracranial hypertension, and as a prognostic indicator in circulatory shock.

    Title Hemodynamics and Oxygen Transport: Using Your Computer to Manage Data. A User-friendly Tool for Data Calculation, Storage, and Retrieval.
    Date July 1994
    Journal The Journal of Critical Illness
    Excerpt

    Efficient calculation, storage, and retrieval of hemodynamic and oxygen transport data can be a problem in the clinical setting. A free computer program is now available to calculate commonly used hemodynamic and oxygen transport variables and to provide results in a chart-ready format or in a side-by-side comparison when serial measurements are performed. The program was developed to be easy to use, menu-driven, and usable at various institutions. The program automatically conducts error checking during the simple data entry process as well as during data calculation and retrieval.

    Title A Proposed Model for the Cost of Cardiopulmonary Resuscitation.
    Date June 1994
    Journal Medical Care
    Excerpt

    In-hospital cardiopulmonary resuscitation (CPR) is associated with substantial costs beyond those of the resuscitation itself. These costs are important to understand because health care resources are limited. To that end, a model of CPR is proposed, including an examination of the effect of several variables on the cost per patient surviving to discharge. The cost of CPR was estimated using a model that describes the CPR process as a series of decision points, each with an associated survival rate and cost. Sensitivity analyses were performed for critical variables to examine their effect on cost. The cost per patient surviving to discharge increases exponentially as the rate of survival to discharge decreases. This cost was $117,000 for a rate of survival to discharge of 10%, $248,271 for a rate of 1%, and $544,521 for a rate of 0.2%. Analysis of the model shows that health care costs related to CPR could be reduced most by decreasing the hospital length of stay and charges for patients who survive the initial resuscitation event, by increases in the overall survival rate, and by the prospective stratification of hospitalized patients according to their anticipated response to resuscitation efforts. The model allows the marginal cost-effectiveness of CPR to be quantitatively evaluated relative to survival rate.

    Title Intraosseous Infusions: a Flexible Option for the Adult or Child with Delayed, Difficult, or Impossible Conventional Vascular Access.
    Date June 1994
    Journal Critical Care Medicine
    Title Detection and Prevention of Central Venous Catheter-related Infections.
    Date February 1994
    Journal Nutrition in Clinical Practice : Official Publication of the American Society for Parenteral and Enteral Nutrition
    Excerpt

    Infectious complications of central venous catheterization are an important clinical problem. Although systemic infection complicates only a small fraction of cases, the prevalence of catheter-related sepsis remains high because of the widespread use of these catheters in acutely ill hospitalized patients. The major route of infection is probably by migration of microorganisms from the skin along the outer surface of the catheter and through the subcutaneous catheter tract to the bloodstream. Semi-quantitative catheter tip cultures have become a standard clinical tool for the evaluation for catheter-related infection. Despite the use of this technique and a variety of other proposed methods for evaluating catheter colonization and infection, discriminating catheter-related sepsis from sepsis originating at another site is often difficult. Prevention of these infections is important. There have been many investigations of the factors that contribute to catheter infections. These studies have shown that meticulous attention to sterile technique during catheter insertion and during routine maintenance is critical.

    Title Lactic Acidosis and Acute Ethanol Intoxication.
    Date February 1994
    Journal The American Journal of Emergency Medicine
    Excerpt

    Ethanol intoxication has been widely reported as a cause of lactic acidosis. To determine the frequency and severity of ethanol-induced lactic acidosis, patients who presented to an emergency department with a clinical diagnosis of acute ethanol intoxication and a serum ethanol concentration of at least 100 mg/dL were studied. Arterial blood was sampled for lactate and blood gas determinations. A total of 60 patients (mean age, 41 years) were studied. Twenty-two patients sustained minor trauma. Ethanol concentrations ranged from 100 to 667 mg/dL (mean, 287 mg/dL). Lactate concentrations were abnormal (> 2.4 mmol/L) in seven patients (11.7%). In all cases, blood lactate was less than 5 mmol/L. Of the patients with elevated lactate, other potential causes for lactic acidosis, including hypoxia, seizures, and hypoperfusion, were also present. Only one case with elevated blood lactate concentration had associated acidemia. Significant elevations of blood lactate are uncommon in acute ethanol intoxication. In patients with ethanol intoxication who are found to have lactic acidosis, other etiologies for the elevated lactate level should be considered.

    Title Therapy with Cefoperazone Plus Sulbactam Against Disseminated Infection Due to Cefoperazone-resistant Pseudomonas Aeruginosa and Escherichia Coli in Granulocytopenic Mice.
    Date December 1993
    Journal Antimicrobial Agents and Chemotherapy
    Excerpt

    Using a granulocytopenic murine model, we evaluated the efficacy of cefoperazone plus sulbactam against disseminated infection due to isolates of beta-lactamase-producing, cefoperazone-resistant (MIC, > or = 50 micrograms/ml) Escherichia coli and Pseudomonas aeruginosa. Both isolates were susceptible in vitro to cefoperazone plus sulbactam (MIC, < or = 6.3 micrograms/ml). Mice rendered granulocytopenic with cyclophosphamide were divided into three groups: group A--infected, untreated mice (controls); group B--infected, cefoperazone-treated mice (700 mg/kg of body weight); and group C--infected, cefoperazone-plus-sulbactam-treated mice (700 mg plus 350 mg). In the E. coli experiment, survival rates in groups A, B, and C were 25, 46, and 73%, respectively. In the experiment with P. aeruginosa, survival rates in groups A, B, and C were 0, 10, and 50%, respectively (P < 0.001). Highly significant differences also were noted for colony counts in the blood, liver, and spleen of group C mice versus group A or B mice in both experiments. Thus, cefoperazone plus sulbactam appears to be a promising combination for the treatment of infections due to certain cefoperazone-resistant gram-negative bacilli, including P. aeruginosa.

    Title Techniques for Vascular Access when Venous Entry is Impossible. Route Depends on Urgency and the Agent to Be Administered.
    Date August 1993
    Journal The Journal of Critical Illness
    Excerpt

    When a patient requires parenteral fluid or drug administration and venous cannulation cannot be performed, consider less typical routes. Intraosseus infusions are usually more effective in children than adults, but intraosseus cannulation failure may occur in as many as 20% of patients. Intra-arterial infusions are possible if pump pressures are kept high. Hypodermoclysis (infusion into the subcutaneous tissues) can correct moderate dehydration. Administering resuscitative drugs endobronchially is usually safe and effective, although pulmonary function may be somewhat compromised. A number of drugs may be given sublingually, either by injection or topical application. Finally, the corpora cavernosa of the penis may be used for short-term, large-volume fluid administration.

    Title Lactic Acidosis and Aids.
    Date August 1993
    Journal Annals of Internal Medicine
    Title Alternative Techniques for Gaining Venous Access. What to Do when Peripheral Intravenous Catheterization is Not Possible.
    Date June 1993
    Journal The Journal of Critical Illness
    Excerpt

    There are a number of therapeutic options for fluid administration in patients who lack usual venous access. Ways to establish this access include limb elevation and wrapping, the application of nitroglycerin ointment to dilate veins, and blood pressure cuff inflation. Ultrasonography can also be used to delineate vascular structures. Cutdown procedures are the oldest, most direct method to reach uncommon venous sites, such as the inferior epigastric, intercostal, iliac, and lateral thoracic veins. Today, cutdown procedures are regarded as the method of last resort, and they should be performed in operating suites or similar settings. Possible complications include inadvertent arterial puncture and hemorrhage.

    Title Severity of Illness Scoring: East Meets West.
    Date June 1993
    Journal Critical Care Medicine
    Title Methanol Poisoning.
    Date January 1993
    Journal Intensive Care Medicine
    Excerpt

    Methanol ingestion is an uncommon form of poisoning that can cause severe metabolic disturbances, blindness, permanent neurologic dysfunction and death. While methanol itself may be harmless, it is converted in vivo to the highly toxic formic acid. The diagnosis is sometimes elusive and requires a high index of suspicion. Because antidotal treatment is available it is important to recognize methanol poisoning promptly. The presence of metabolic acidosis associated with an increased anion gap and increased osmol gap are important laboratory findings. Specific therapeutic measures include correction of the metabolic acidosis with sodium bicarbonate and administration of enteral or parenteral ethanol to competitively inhibit the metabolic breakdown of methanol to formic acid. Hemodialysis accelerates the elimination of both methanol and formic acid and also assists in correction of the metabolic acidosis. Experimental data suggests that administration of folic acid may be of benefit by hastening the metabolism of formic acid to carbon dioxide. Prompt institution of specific therapy can probably decrease the morbidity and mortality associated with this form of poisoning.

    Title Arterial Catheterization.
    Date November 1992
    Journal Critical Care Clinics
    Excerpt

    Arterial catheterization is used frequently in the management of critically ill patients, both for continuous blood pressure monitoring and access to the arterial circulation to obtain frequent blood gas measurements. The procedure is usually easily accomplished at the bedside using percutaneous methods such as the Seldinger technique to cannulate the radial, brachial, axillary, femoral, or dorsalis pedis artery. Meticulous attention to aseptic technique is necessary during insertion and catheter maintenance to minimize the risk of catheter-related infection. Other potential complications include hemorrhage, ischemia, arteriovenous fistula, and pseudoaneurysm formation.

    Title Temporary Transvenous Cardiac Pacing.
    Date November 1992
    Journal Critical Care Clinics
    Excerpt

    Temporary cardiac pacing in the critical care setting can be a lifesaving intervention in a number of clinical situations. A variety of catheter types and pulse generators are available. Insertion techniques include the use of fluoroscopic imaging, intracavitary ECG monitoring, and blind advancement with surface ECG monitoring. This article focuses on the indications, equipment, techniques, complications, and troubleshooting of temporary transvenous cardiac pacemakers.

    Title Nasogastric and Nasoenteric Intubation.
    Date November 1992
    Journal Critical Care Clinics
    Excerpt

    Among the most commonly performed nonvascular procedures in hospitalized patients are the placement of nasogastric tubes and nasoenteric feeding tubes. Large-bore nasogastric tubes are commonly used for both diagnostic and therapeutic purposes; small-bore nasoenteric tubes are used primarily for intestinal feeding. The techniques of insertion, methods of ensuring proper positioning, and the potential complications of these devices are similar, and thus they are reviewed together in this article.

    Title Fatal Rodenticide Poisoning with Brodifacoum.
    Date March 1992
    Journal Annals of Emergency Medicine
    Excerpt

    The increased prevalence of rodents resistant to warfarin led to the development of the hydroxycoumarin anticoagulant brodifacoum. A 25-year-old man attempted suicide by consuming four boxes of d-CON Mouse-Prufe II; each box contains 42 g of bait that is 0.005% brodifacoum. He presented to a hospital nine days later with syncope, hematochezia, gross hematuria, epistaxis, anemia, and a severe coagulopathy. Radiographic studies were consistent with pleural, pericardial, and mediastinal hemorrhages. Vitamin K and fresh frozen plasma were given, and he was later discharged on oral phytonadione (vitamin K1). The patient's coagulopathy recurred, necessitating multiple plasma transfusions and prolonged treatment with oral phytonadione. Fifteen weeks after hospital discharge, he presented again with a history of additional brodifacoum ingestion. Neurologic status was initially normal, but in the emergency department he suddenly became comatose soon after emesis was induced with syrup of ipecac. Computed tomography of the brain revealed a subarachnoid hemorrhage that led to brain death less than 24 hours later. This case demonstrates the severe and prolonged coagulopathy that can result from ingestion of brodifacoum, a compound that has a toxic potency about 200-fold that of warfarin and a half-life as much as 60 times longer.

    Title Hemodynamic Responses to Gram-positive Versus Gram-negative Sepsis in Critically Ill Patients with and Without Circulatory Shock.
    Date January 1992
    Journal Critical Care Medicine
    Excerpt

    OBJECTIVE: To examine the hemodynamic patterns of critically ill patients with septicemia to evaluate their relationship to blood bacteriology. DESIGN: Retrospective study. SETTING: Medical ICUs of a tertiary care medical center. PATIENTS: Total of 59 critically ill patients with bacteremia: 33 with Gram-positive and 26 with Gram-negative bacteremia. MEASUREMENTS: Hemodynamic variables and mixed venous oxygen saturation (SvO2) measurements associated with the highest cardiac index measured within 72 hrs of positive blood cultures. MAIN RESULTS: No significant differences in cardiac index, mean arterial pressure, systemic vascular resistance, oxygen extraction ratio, or SvO2 were observed comparing the two groups. CONCLUSION: We were unable to demonstrate clinically important differences between the hemodynamic responses to Gram-positive vs. Gram-negative sepsis.

    Title Use of Vasoactive Drugs to Support Oxygen Transport in Sepsis.
    Date March 1991
    Journal Critical Care Medicine
    Title Lactate Levels As Predictors of the Relationship Between Oxygen Delivery and Consumption in Ards.
    Date November 1990
    Journal Chest
    Excerpt

    We reviewed the changes in Do2 and Vo2 in 58 patients with ARDS after interventions which included fluid loading, blood transfusion, and PEEP. After a significant change in Do2, patients with lactic acidosis (lactate level greater than 2.4 mmol/L) exhibited significant corresponding changes in Vo2 (p less than 0.001); however, no change in Vo2 was observed in patients without lactic acidosis (1-beta greater than 0.8). We conclude that a biphasic pattern of oxygen utilization in patients with ARDS emerges when subsets of patients with and without lactic acidosis are compared. Lactic acidosis, a marker of anaerobic metabolism, may be a characteristic of patients with ARDS who exhibit changes in Vo2 that are dependent on changes in Do2.

    Title Risk Factors for Human Immunodeficiency Virus Infection Among Parenteral Drug Abusers in a Low-prevalence Area.
    Date October 1990
    Journal Southern Medical Journal
    Excerpt

    Information is scant regarding epidemiologic risk factors for human immunodeficiency virus (HIV) infection among parenteral drug abusers (PDAs) residing in areas of low seroprevalence. A detailed interview and HIV serologic testing were conducted among PDAs hospitalized at Detroit Receiving Hospital for reasons unrelated to HIV infection. The study involved 22 seropositive (17 men, 5 women) and 52 seronegative (34 men, 18 women) drug abusers in Detroit, Michigan, an area of relatively low HIV prevalence. The interviews included inquiries regarding risk factors such as duration of drug abuse, visits to "shooting galleries," use of "hit men," needle sharing, sterile injection techniques, use of "street" antibiotics, promiscuity, visits to prostitutes, homosexuality, history of sexually transmitted diseases, and history of travel to areas of high HIV prevalence. A strong association was noted between the number of risk factors present and HIV seropositivity. The presence of any three or more risk factors was significantly associated (P less than .05) with seropositivity. Awareness of epidemiologic risk factors for HIV infection among PDAs in a low-prevalence area is useful in identification of seropositive drug abusers and is crucial in designing educational interventional strategies to interrupt viral transmission.

    Title Double-blind Study of Endotracheal Tobramycin in the Treatment of Gram-negative Bacterial Pneumonia. The Endotracheal Tobramycin Study Group.
    Date May 1990
    Journal Antimicrobial Agents and Chemotherapy
    Excerpt

    A prospective, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of endotracheal tobramycin (ETT) for treatment of gram-negative bacterial pneumonia. Patients were randomized to either 40 mg of tobramycin or a placebo instilled endotracheally every 8 h. Patients also received intravenous tobramycin plus either cefazolin or piperacillin. Of 85 patients enrolled, 41 were assessable. Most microbiologic diagnoses were made by endotracheal aspiration with strict grading criteria. The clinical-radiographic responses of patients and standard demographic data were recorded. Pseudomonas aeruginosa, "multiple pathogens," and Klebsiella-Enterobacter-Serratia-Citrobacter species were isolated in 41, 32, and 15% of the instances, respectively. Causative pathogens were eradicated from sputum significantly more frequently by patients who received ETT (P less than 0.05). However, no significant differences were noted in the clinical outcomes of the two study groups. No local adverse reactions attributable to the administration of this agent were observed, but four patients had supraventricular tachycardia, compared with none who received the placebo (P = 0.053). ETT may be considered as adjunctive therapy for seriously ill individuals.

    Title Lactate Measurement: Plasma or Blood?
    Date April 1990
    Journal Intensive Care Medicine
    Title Rapid Correction of Hypokalemia Using Concentrated Intravenous Potassium Chloride Infusions.
    Date April 1990
    Journal Archives of Internal Medicine
    Excerpt

    There are conflicting recommendations regarding the use of intravenous potassium chloride infusions for acute correction of hypokalemia. We examined the effects of 495 sets of potassium chloride infusions administered to a medical intensive care unit population. The infusion sets consisted of one to eight consecutive individual infusions, each containing 20 mEq of potassium chloride in 100 mL of saline administered. The mean preinfusion potassium level was 3.2 mmol/L, and the mean postinfusion potassium level was 3.9 mmol/L. The mean increment in serum potassium level per 20-mEq infusion was 0.25 mmol/L. No temporally related life-threatening arrhythmias were noted; however, there were 10 instances of mild hyperkalemia. Our data endorse the relative safety of using concentrated (200-mEq/L) potassium chloride infusions at a rate of 20 mEq/h via central or peripheral vein to correct hypokalemia in patients in the intensive care unit.

    Title Relationship Between the Apparent Dissociation Constant of Blood Carbonic Acid and Severity of Illness.
    Date December 1989
    Journal The Journal of Laboratory and Clinical Medicine
    Excerpt

    The Henderson-Hasselbalch equation is commonly used to calculate plasma bicarbonate and CO2 content (tCO2) from blood gas measurements and an assumed constant value of the apparent dissociation constant of blood carbonic acid (pK'). Several studies have reported pK' to be variable in critically ill patients. We prospectively compared the pK' of patients in an intensive care unit to their severity of illness. Blood specimens were analyzed for pH, Pco2, and tCO2, and the results were used to calculate pK'. The tCO2 was also calculated from this equation by means of the measured pH and Pco2 and from an assumed constant pK'. Severity of illness was evaluated with the acute physiology score and the Therapeutic Intervention Scoring System. A total of 2004 specimens were analyzed; they had a mean pK' of 6.126. A strong correlation was shown between calculated and measured tCO2; however, there was essentially no correlation between disease severity and pK'. We conclude that bicarbonate and tCO2 can be accurately calculated in critically ill patients.

    Title Triple- Vs Single-lumen Central Venous Catheters. A Prospective Study in a Critically Ill Population.
    Date June 1989
    Journal Archives of Internal Medicine
    Excerpt

    To evaluate a new multilumen central venous catheter we prospectively compared the infection rates of 63 single-lumen and 157 triple-lumen catheters in 145 critically ill patients. Using acute physiology scores, severity of illness was shown to be similar in the two patient groups. There were no significant differences in the rate of catheter colonization or catheter-related sepsis comparing single-lumen with triple-lumen catheters. However, the use of total parenteral nutrition or insertion at the femoral vein site significantly increased the rate of colonization. The only factor that was clearly associated with catheter sepsis was the duration of catheterization. Catheter sepsis increased from 1.5% to 10% when the period of catheterization exceeded 6 days. We conclude that the use of triple- and single-lumen central venous catheters in critically ill patients entails similar risks of infection.

    Title Comparison of Critical Care by Family Physicians and General Internists.
    Date January 1989
    Journal Jama : the Journal of the American Medical Association
    Title Lactate Metabolism.
    Date November 1988
    Journal Critical Care Clinics
    Excerpt

    Lactate is the end product of the anaerobic metabolism of glucose, and its accumulation in the blood signals an increase in production or a decrease in utilization, or both. The most common etiology of lactic acidosis is hypoperfusion, which represents an imbalance between systemic oxygen demand and oxygen availability with resultant tissue hypoxia. A wide variety of other etiologies of hyperlactatemia have been identified or implicated. However, most of these are uncommon causes, and many actually represent an associated perfusion failure. Clinical recognition of hyperlactatemia is facilitated by an awareness of the clinical settings in which it is likely to occur. Serum electrolyte and arterial blood gas studies are helpful to recognize lactic acidosis, but direct assay of blood lactate is necessary to identify milder degrees of lactate elevation, to confirm and quantitate the severity of more severe degrees, and to monitor the progress of therapy. Therapy should be directed toward measures to ensure adequate systemic oxygen delivery and specific treatment of the underlying causes.

    Title Comparison of Clinical Assessment with Apache Ii for Predicting Mortality Risk in Patients Admitted to a Medical Intensive Care Unit.
    Date October 1988
    Journal Jama : the Journal of the American Medical Association
    Excerpt

    The APACHE II (Acute Physiology and Chronic Health Evaluation) system has been widely used as an objective means of predicting outcome in critically ill patients. We prospectively evaluated patients consecutively admitted to the medical intensive care unit to compare the predictive accuracy of APACHE II with clinical assessment by critical care personnel. At the time of admission to the intensive care unit, the house staff and nurse responsible for each patient were asked to estimate the patient's hospital mortality risk. The patient's APACHE II score was calculated and a prediction of the patient's hospital mortality risk was then computed on the basis of this score. A total of 366 patients were studied. Mortality predictions were obtained from 57 physicians and 33 critical care nurses. We were unable to demonstrate a significant difference in the accuracy of APACHE II predictions compared with either physicians' or nurses' predictions. Clinical assessment and APACHE II were both highly predictive of outcome.

    Title Constancy of Blood Carbonic Acid Pk' in Patients During Cardiopulmonary Resuscitation.
    Date July 1988
    Journal Chest
    Excerpt

    Previous studies have suggested that the apparent dissociation constant of blood carbonic acid (pK') may actually vary in acutely ill patients. We prospectively compared the pK' of healthy control subjects to that of patients undergoing cardiopulmonary resuscitation (CPR). Arterial blood obtained from 20 patients undergoing CPR and from 30 healthy volunteers was analyzed for Na+, pH, PCO2, and total CO2 content (tCO2). pK' was calculated from this data, using the Henderson-Hasselbalch equation. Total CO2 was then calculated in the CPR patients, using this equation and the control pK'. Mean pK' was 6.109 +/- 0.004 (SEM) for the control group and 6.123 +/- 0.007 for the CPR group (p = NS). In the CPR group, calculated tCO2 was not significantly different from measured from tCO2, and the correlation between calculated and measured tCO2 was 0.99. In patients undergoing CPR, pK' does not differ significantly from normal, and tCO2 can be accurately estimated with the Henderson-Hasselbalch equation.

    Title Training and Practice Patterns of Society of Critical Care Medicine Internists.
    Date December 1987
    Journal Critical Care Medicine
    Title Significance of Blood Lactate Levels in Critically Ill Patients with Liver Disease.
    Date August 1987
    Journal The American Journal of Medicine
    Excerpt

    Lactic acidosis unrelated to tissue hypoxia has been described in patients with liver disease. This raises questions regarding the utility of the arterial lactate level as an indicator of tissue hypoperfusion in critically ill patients with hepatic dysfunction. The incidence of hyperlactatemia in a group of critically ill patients with liver disease and its association with clinical indicators of circulatory shock as well as hospital mortality were examined. The medical records of all patients admitted to the medical intensive care unit of Detroit Receiving Hospital between July 1, 1984, and June 30, 1985, with parenchymal liver disease and a total bilirubin level of more than 2 mg/dl were reviewed. Patients were excluded if lactate was not assayed. The severity of liver disease was assessed by Child's classification. Shock was defined as a systolic blood pressure of less than 90 mm Hg and at least two of the following: urine output of less than 20 ml/hour, evidence of decreased skin perfusion, or acutely altered mentation. These criteria were met in 35 patients; three patients had two medical intensive care unit admissions separated by more than one week. There were two patients in Child's class A, three in class B, and 30 in class C. Shock was identified in 27 of the 38 medical intensive care unit admissions. In the group with shock, the maximal lactate level ranged from 1.2 to 30 mM (mean, 9.6). The lactate level was significantly lower (p less than 0.0005) in the group without shock, ranging from 0.6 to 2.0 mM (mean, 1.3). The mean bilirubin level was significantly higher in the group without shock (16.7 mg/dl) than in the group with shock (8.5 mg/dl). A maximal arterial lactate concentration of more than 2.2 mM was significantly associated with hospital mortality. Thus, lactic acidosis in critically ill patients with liver disease is associated with clinical evidence of shock and with increased hospital mortality.

    Title Nosocomial Infection Among Patients in Different Types of Intensive Care Units at a City Hospital.
    Date June 1986
    Journal Critical Care Medicine
    Excerpt

    Available data on the characteristics of infections in different types of ICUs are limited. Between May and July 1984, overall infection rates of patients in the ICUs and in the general wards at the Detroit Receiving Hospital were 19.2% and 9.8%, respectively (p less than .001). Specific infection rates (number of infections/100 admissions in each unit) were 35.2% for surgical unit, 29.8% for burn unit, 13.9% for medical unit, and 6.6% for coronary unit. Of the total number of patients admitted, only 1.9% patients in the coronary unit became infected while 10.9% to 13.6% in the other three units acquired infection. There were more infections per patient in the surgical unit than in the others. Device-related infections involving the urinary and respiratory tracts were the most common. Predominant pathogens isolated in order of frequency were Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Staphylococcus aureus. Death rates among the infected patients were high; of those infected, nine patients (75%) of 12 in the surgical unit and ten (91%) of 11 in the medical unit died. For those who died, the duration from ICU admission to infection was 2 to 22 days (mean 6.5) and length of survival after becoming infected was 2 to 50 days (mean 22). The mortality rates between the infected and uninfected patients in the medical, surgical, and burn units were significantly different (p less than .0005). Awareness of patterns for nosocomial infection in different ICUs is of value in the adoption of appropriate infection control policies within each unit.

    Title Intra-arterial Monitoring During Cardiopulmonary Resuscitation.
    Date January 1986
    Journal Catheterization and Cardiovascular Diagnosis
    Excerpt

    Because arterial cannulation assists in management of critically ill patients (pts), we assessed the utility of extending intra-arterial monitoring to hospitalized patients suffering in-hospital cardiopulmonary arrest outside of intensive care wards. A totally self-contained, readily portable system for rapid insertion of emergency intra-arterial lines was evaluated in 16 pts from 53 to 89 years old (mean = 66.5 years) undergoing cardiopulmonary resuscitation. Cannulation was successful in 14 pts (88% success rate). In 8 of 14 pts, cannulation was achieved rapidly and efficiently, whereas in six it was slightly delayed, once due to technical problems and five times due to difficulty cannulating the vessel. In addition to providing continuous pressure monitoring and ready access to arterial blood samples, direct feedback from the intra-arterial pressure waveform frequently led to improved compression technique by the resuscitator performing external cardiac massage. We conclude that under selected circumstances emergency intra-arterial monitoring has a potentially important adjuvant role during cardiopulmonary resuscitation.

    Title Time Series Methodology in the Study of Sexual Hormonal and Behavioral Cycles.
    Date February 1983
    Journal Archives of Sexual Behavior
    Excerpt

    This paper addresses problems in the study of sexual behavior that require the detection of cyclicity in one set of data over time and synchronicity in two sets of data over time. Time-series analysis is discussed, in particular, the use of the spectral density function and coherence. The proposed methods are then applied to the study of hormonal levels in young couples as a function of the wives' menstrual cycles.


    Similar doctors nearby

    Dr. Danielle Grandrimo

    Hospitalist
    8 years experience
    Cooperstown, NY

    Dr. Donald Lewis

    Internal Medicine
    39 years experience
    Cooperstown, NY

    Dr. Jonathan Croft

    Hospitalist
    8 years experience
    Cooperstown, NY

    Dr. Ann Eldred

    Internal Medicine
    17 years experience
    Cooperstown, NY

    Dr. Nancy Merrell

    Internal Medicine
    34 years experience
    Cooperstown, NY

    Dr. Sandy Nath

    Internal Medicine
    4 years experience
    Cooperstown, NY
    Search All Similar Doctors