New horizons (Baltimore, Md.)最新文献

{"title":"Recent advances in pediatric cardiopulmonary resuscitation and advanced life support.","authors":"A L Zaritsky","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The end point of uncorrected shock is cardiac arrest. Once cardiac arrest occurs, the outcome in children is typically poor, reflecting the fact that cardiac arrest does not occur until the child's physiologic reserves are exhausted. Despite more than 35 years of research in cardiac arrest, the optimal management and treatment remain uncertain. The optimal method of basic and advanced life support to restore cardiac function and preserve brain function is unclear, as is the appropriate application of pharmacologic agents to restart the heart and subsequently to manage postarrest shock. New techniques in basic life support merit evaluation in children, particularly interposed abdominal compression and active compression-decompression cardiopulmonary resuscitation. Epinephrine remains the pharmacologic agent of choice. The role of bicarbonate in the management of acidosis and the role of calcium in restarting the heart remain controversial. If and when the heart is restarted following cardiac arrest, the work is just beginning for the intensivist to manage the postarrest shock state. Dobutamine is useful in the normotensive child while epinephrine infusions are used to stabilize hypotensive, postarrest shock in the child.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20572505","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nutrition and shock in pediatric patients.","authors":"M A Curley,&nbsp;L Castillo","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Critically ill patients, including those in shock, often present with significant metabolic derangement in protein and energy metabolism characterized by: increased protein breakdown which is not suppressed by protein or energy intake; reprioritization of protein synthesis with increased synthesis of acute-phase proteins; decreased synthesis of structural proteins; and high protein turnover. In addition, there is also glucose and lipid intolerance. Adequate nutritional and metabolic support of the critically ill child under these conditions is a challenging endeavor. Traditionally, critically ill children have received nutritional requirements based on those of healthy children despite the fact that the critically ill population is physiologically and metabolically different. Furthermore, nutritional requirements in healthy children are largely based on limited data. With emerging knowledge of non-nutritional functions of nutrients, adequacy of nutritional support and requirements will eventually depend on the goals to be achieved: nutritional, physiologic, and/or pharmacologic.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20572506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Antibiotic prophylaxis in clean surgery: does it work? Should it be used if it does?","authors":"R Platt","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Perioperative antibiotic prophylaxis has been demonstrated to prevent postoperative wound infection after clean surgery in a majority of clinical trials with sufficient power to identify a 50% reduction in risk. The low risk of infection after many clean procedures requires studies of more than 1,000 procedures (sometimes many more) to detect such reductions reliably. This is a serious obstacle to performing conclusive tests of efficacy, and it all but precludes use of conventional clinical trials to identify optimal regimens. Regimens that have been shown to be effective have usually been those with efficacy against Staphylococcus aureus and other pathogens that may be carried in the nares or on the skin. In addition, relatively long half-life in the serum and low cost are important considerations. Cefazolin is a good prophylaxis agent for many clean surgical procedures, although special characteristics of the procedure, increased likelihood of antimicrobial resistance, or antibiotic utilization concerns may make other agents more suitable in specific situations The decision to use perioperative antibiotic prophylaxis for clean surgical procedures depends not only on its efficacy, but also on the cost of preventing infection. Few cost-benefit analyses have been performed, especially for procedures in which prophylaxis has been least used. To perform such analyses, it will be necessary to acquire information that is currently lacking for many procedures. This includes the risk and cost of postoperative infection, adverse reactions to the prophylaxis agent, and increased antimicrobial resistance; in addition, detailed information is needed on infection-associated costs of medical care, lost productivity, and the value that the infected person places on avoiding infection. For many procedures, timely use of an appropriate antibiotic is the single most effective infection prevention method that can be implemented and monitored on a broad scale. These features make it amenable to adoption as a subject of continuous quality improvement activities. To accomplish this, it is necessary to articulate standards of care clearly so that systems to support the intended goal can be developed. Both the standards and the support systems can be tailored to specific surgical situations and to the values of providers and patients.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20573096","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ventilator-associated bacterial pneumonia: challenges in diagnosis, treatment, and prevention.","authors":"Donald E. Craven, K. Steger","doi":"10.1097/00043860-199901000-00005","DOIUrl":"https://doi.org/10.1097/00043860-199901000-00005","url":null,"abstract":"Ventilator-associated pneumonia (VAP) is a common infection in intensive care unit patients that results in high mortality and morbidity and increased duration of hospital stay. Clinical diagnostic methods are sensitive, but lack specificity. Quantitative analysis of specimens from the lower respiratory tract increases specificity. Bacteria causing VAP may originate from the patient's endogenous flora, other patients or hospital personnel, or from environmental sources. Aspiration or direct inoculation are the major routes of bacterial entry into the lower respiratory tract. The bacterial inoculum and host response in the lung are important factors for pathogenesis. Late-onset nosocomial pneumonia is often caused by Pseudomonas aeruginosa, Acinetobacter species, and Staphylococcus aureus. Streptococcus pneumoniae and Haemophilus influenzae, however, are the more common pathogens in early-onset disease. Oropharyngeal and gastric colonization with bacteria, cross-infection, as well as the indiscriminate use of antibiotics or invasive devices substantially increase the risk of VAP. An understanding of the epidemiology and pathogenesis of VAP, along with implementation of appropriate preventive measures, are needed to decrease the incidence, morbidity, and mortality associated with VAP.","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75803558","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Potential protective role of the heat shock response in sepsis.","authors":"H R Wong","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The heat shock response, a primitive and highly conserved cellular defense mechanism, has broad protective effects against sepsis-induced injury. In various models of sepsis, induction of the heat shock response protects against sepsis-induced mortality, organ injury, cardiovascular dysfunction, and apoptosis. The mechanisms by which the heat shock response protects against sepsis-induced injury are currently under investigation. One potential mechanism involves the ability of the heat shock response to inhibit proinflammatory responses. The heat shock response has been demonstrated to inhibit expression of the cytokines tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta. The heat shock response has also been demonstrated to inhibit cytokine-mediated expression of inducible nitric oxide synthase. Recent studies demonstrated that the heat shock response inhibits nuclear translocation of nuclear factor-kappaB (NF-kappaB), a transcription factor involved in the regulation of many proinflammatory responses. Heat shock response-mediated inhibition of NF-kappaB nuclear translocation involves stabilization of an NF-kappaB inhibitory protein called I-kappaBalpha. The heat shock response also increases expression of I-kappaBalpha, thus providing another potential mechanism by which the heat shock response can modulate proinflammatory responses. Future studies designed to further understand the protective role of the heat shock response against sepsis-induced injury may allow for the development of rational pharmacologic agents or gene therapy methods to safely induce the heat shock response as a strategy to treat patients with sepsis.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20572504","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Surgical invasion and infection conference: introductory remarks.","authors":"E P Dellinger,&nbsp;P O Nyström","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20573090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Linear and nonlinear dynamics and the pathophysiology of shock.","authors":"D L Toweill,&nbsp;B Goldstein","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Rapid progress has been made in the use of linear and nonlinear time series analysis of heart rate and blood pressure variability as an indicator of disease severity and prognosis for patients in shock. Clinical and experimental studies have demonstrated the potential for linear and nonlinear measurements as a method for quantifying changes in neuroautonomic cardiovascular regulatory mechanisms. These measures have been demonstrated to correlate with severity of illness and outcome for critically ill and injured patients, including those with shock. These powerful mathematical techniques may allow for new insights into the pathophysiology of shock. In addition, these measures may also enable detection of early changes in neuroautonomic cardiovascular regulatory mechanisms during the development of shock before the onset of overt hypotension and inadequate tissue perfusion or may be used to assess the response to therapy. Further studies are needed to establish the role of these tools in clinical use.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20572501","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of laparoscopic surgery on stress responses, immunofunction, and risk of infectious complications.","authors":"H Kehlet,&nbsp;H J Nielsen","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Open laparotomy is followed by profound changes in endocrine metabolic function and various host defense mechanisms, impaired pulmonary function, and hypoxemia, all of which may be important for the development of postoperative infectious complications. Laparoscopic surgery, however, leads to a reduced inflammatory response (C-reactive protein and interleukin-6), a reduced immunomodulatory response, improvement in pulmonary function, and less hypoxemia, whereas classic endocrine metabolic responses are less influenced or not influenced compared with similar open operation. The clinical implications of laparoscopic surgery on postoperative infectious complications have not been assessed in large-scale prospective, randomized studies, except in appendectomy, in which a reduced incidence of wound infection has been demonstrated. Data from cholecystectomy and colorectal surgery suggest a reduction in wound complications, whereas the sparse data on intraperitoneal infections and sepsis are not conclusive. Thus, laparoscopic surgery modifies the injury response and reduces the risk of infectious complications. If integrated into an accelerated rehabilitation program, further improvement may result. The impact of these findings on prophylactic antibiotic regimens cannot be assessed from available data and requires evaluation in prospective clinical studies.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20573241","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predicting the need for reoperation for abdominal infection.","authors":"J M Bohnen,&nbsp;B D Schouten","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Abdominal infection complicating abdominal operation is a serious clinical problem that is subject to diagnostic delay, which is a risk factor for adverse outcomes. Clinical examination and laboratory and imaging modalities become more accurate at achieving a diagnosis once the patient becomes sicker from infection but cannot reliably predict the need for reoperation early in the postoperative course. The Abdominal Reoperation Predictive Index scoring system synthesizes common sense and objective measurements in an attempt to predict the need for reintervention before it is too late. We encourage other centers to test this predictor in their own patient populations.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20573242","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cardiogenic shock.","authors":"A R Bengur,&nbsp;J N Meliones","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The pathophysiology of cardiogenic shock in infants and children is multifactorial and include noncardiac as well as cardiac etiologies, both congenital and acquired heart disease. The management of patients in cardiogenic shock requires a rational approach that is based upon the underlying pathophysiology. The diagnosis and management of cardiogenic shock, therefore, requires a thorough understanding of not only the underlying pathophysiology, but also the diagnostic modalities used in making the diagnosis. In the pediatric population, echocardiography plays a pivotal role in the diagnosis and management of infants and children presenting with cardiogenic shock. In this article, the pathophysiology of cardiogenic shock and the use of echocardiography in reaching a differential diagnosis are discussed. In addition, the management of cardiogenic shock is reviewed.</p>","PeriodicalId":79357,"journal":{"name":"New horizons (Baltimore, Md.)","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"1998-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20573246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}