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Query: UMLS:C0243026 (sepsis)
 52,417 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

We have reported that cardiac inotropism is reduced in various shock states, most recently during chronic endotoxemia (Lee et al.: American Journal of Physiology 254:H324-H330, 1988) [1]. We based this conclusion upon the alterations observed in the slope of the end-systolic pressure-diameter relationship (ESPDR). Recently, Dietrick and Raymond (Dietrick and Raymond: Surgical Infection Society, 7th Annual Meeting, May, 1987, p 83) [2] have reported that the slope of the end-systolic pressure-wall thickness relationship was augmented in the early stages of sepsis and depressed immediately prior to expiration. One major difference between our studies is the definition of end-systole; we used the time when the ratio of pressure-to-diameter (P/D) in the left ventricle is maximal (P/Dmax), whereas they used the time when the first derivative of pressure is minimal (dP/dtmin). In order to determine if the discrepancy between our conclusions could be explained by the differing definitions of end-systole, data from previous studies were reanalyzed, and the slope of the pressure-diameter relationship at P/Dmax and at dP/dtmin was calculated. Pigs were equipped with instruments to measure left ventricular pressure, short axis diameter, and ECG. Observations during the basal state were obtained 3-7 days after surgery. Chronic endotoxemia was induced by intravenous infusion of S. enteriditis endotoxin via an osmotic minipump at 10 micrograms/kg/hr. During the basal state, the value for the slope of ESPDR at dP/dtmin was lower than the value for the slope of ESPDR at P/Dmax, and there was a good correlation between the two values. During chronic endotoxemia, the slope of ESPDR at dP/dtmin did not change. However, the slope of ESPDR at P/Dmax decreased significantly suggesting that chronic endotoxemia reduced cardiac inotropism. This conclusion is supported by the findings that chronic endotoxemia reduced steady-state values of percentage diameter-shortening (an estimate of ejection fraction) and stable stroke work at significantly higher end-diastolic diameter. These data indicate that it is possible to calculate differing slopes of ESPDR from the same observations dependent upon the time during the cardiac cycle chosen as end-systole. More importantly, these data suggest that during chronic endotoxemia, ventricular relaxation dynamics may change so that postsystolic shortening becomes more prominent and therefore higher values for the slope of ESPDR using pressure and diameter values at dP/dtmin can be calculated.
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PMID:Variation in end-systolic pressure-diameter relationship using dP/dtmin or P/Dmax as a definition of end-systole in chronic endotoxemic pigs. 273 26

Hemodynamic and oxygen transport effects of dopamine and dobutamine were studied in a series of 25 critically ill postoperative general surgical patients by a prospective, randomized crossover design after maximal response to fluids had been obtained. Dopamine increased MAP, HR, CI, PvO2, DO2, and Qsp while decreasing PaO2. Dobutamine increased HR, CI, SI, stroke work, DO2, VO2, and Qsp while decreasing PAWP and SVRI and PVRI. In general, the effects of the two drugs were greater in patients in the first 72 hours after surgery. The effects of dobutamine on flow and oxygen transport were greater than those of dopamine, especially in the early postoperative period. The effects were smaller and not significant in patients more than three days after surgery, as well as in those with sepsis, respiratory failure, renal failure, age over 65 years, and hyperdynamic states, in part because of the small number of patients in each group. These data are consistent with the hypothesis that the beta 2-adrenergic action of dobutamine vasodilates the previously constricted peripheral circulation, enhances tissue perfusion by improving micro-circulatory flow distribution, and improves DO2 and VO2.
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PMID:Comparison of hemodynamic and oxygen transport effects of dopamine and dobutamine in critically ill surgical patients. 273 68

Our 6-year experience with ventricular assist devices was reviewed to determine variables associated with improved survival. Forty-three patients (mean age 62 +/- 14 years) were supported after balloon pumping and pressors proved inadequate. Twenty-eight patients could not be weaned from cardiopulmonary bypass, 12 patients deteriorated in the intensive care unit after cardiac surgery, and three had a bridged to transplantation. Overall, 47% (20/43) of patients could not be weaned from the ventricular assist devices, and 26% (11/43) were weaned but died before discharge, resulting in a hospital mortality rate of 72% (31/43). The remaining 28% (12/43) of patients were discharged and have survived 9 to 62 months. Early institution of ventricular assist devices (p less than 0.01), use of biventricular support (p less than 0.01), use of ventricular assist devices as a bridge to transplantation (p less than 0.05), and increased operator experience (p less than 0.05) were associated with improved survival. When patient and disease-related variables were analyzed, only age less than 60 years (p less than 0.01) and unexpectedly preoperative myocardial infarction associated with shock (p less than 0.05) were related to improved survival. Death was caused by insufficient ventricular recovery, stroke, multiple organ system failure, sepsis, or a combination of these complications. During long-term follow-up, two patients have died of congestive heart failure, and one is significantly impaired from a stroke. Two other patients are functional class III and seven patients are class I. Although hospital mortality was high (72%), the use of ventricular assist device support resulted in overall "long-term" survival of a significant percentage (28%) of patients, 47% (8/17), in the past 12 months, all of whom would have died without it. Therefore we currently recommend a trial of ventricular assist devices support for most patients who fail to be weaned from cardiopulmonary bypass, deteriorate in the perioperative period, and as a bridge to transplantation. Long-term survival is determined by the complications from ventricular assist devices support and functional status of the remaining myocardium.
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PMID:Mechanical support: assist or nemesis? 281 22

A previously unreported complication of low anterior resection of the rectum, seminal vesicle-rectal fistula, was encountered one month after surgery in an elderly patient with adenocarcinoma of the midrectum. Antibiotic-induced colitis in the immediate postoperative period led to anastomotic leakage with abscess formation and ensuing fistulization to the surgically denuded right seminal vesicle. Pneumaturia, bacteriuria, and right testicular pain were treated by cutaneous vasostomy and antimicrobial therapy. Despite recurrent low-grade urinary sepsis controlled by alternating courses of various antimicrobials, and radiation therapy for local tumor recurrence, the patient remained reasonably healthy until his death two years later due to stroke associated with cerebral metastases.
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PMID:Seminal vesicle-rectal fistula. Report of a case. 291 Jun 63

The purpose of this study was to determine the incidence of death as the initial manifestation of cholelithiasis. Records of patients who died or underwent cholecystectomy for gallstone-related disease at Duke University Medical Center between 1976 and 1985 were reviewed. Thirty patients died, six of whom (20%) had previous episodes of biliary pain and stone documentation. Twenty-four (80%) were asymptomatic (three with previous incidental diagnosis of cholelithiasis). Reason for admission included acute cholecystitis (nine), pancreatitis (eight), biliary pain (six), cholangitis (four), jaundice (one), and endocarditis (one). Three patients died of gallstone complications without surgical intervention; one patient had renal failure and two had septicemia. Other causes of death were: sepsis (seven patients), cardiac failure (six), pulmonary complications (four), renal failure (three), cerebrovascular accident (three), liver failure (two), pancreatitis (one), and gastrointestinal bleeding (one). During this period, 1731 cholecystectomies were performed without mortality. In this group, the patients were younger (50 +/- 8 years vs. 64 +/- 13 years, p less than 0.001), and had a lower incidence of cirrhosis (p less than 0.001) and diabetes (p less than 0.002). The sex ratio was inverted (p less than 0.001). This study demonstrates that death from gallstones is uncommon (three cases per year), as is death from their initial clinical manifestation (1.2%). The risk of death is two- and ninefold higher in patients with acute cholecystitis or acute pancreatitis. Age, cirrhosis, and diabetes are important determinants of outcome.
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PMID:Deaths from gallstones. Incidence and associated clinical factors. 291 58

We studied the inotropic response to dopamine and digoxin in 20 patients with severe sepsis and left ventricular failure. Left ventricular failure was defined as a left ventricular stroke work index less than or equal to 40 g.m/m2 at a pulmonary artery wedge pressure greater than or equal to 15 mm Hg. Hemodynamic assessment was obtained before and following administration of digoxin 10 micrograms/kg IV or dopamine, 5 to 12 micrograms/kg/min IV. Patients treated with digoxin demonstrated a significant increase in LVSWI. The LVSWI increased 13 +/- 10 percent in the dopamine-treated patients compared with 74 +/- 16 percent in the digoxin patients (p less than 0.02). We conclude that digoxin exhibited significant inotropic activity in patients with sepsis.
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PMID:Inotropic response to digoxin and dopamine in patients with severe sepsis, cardiac failure, and systemic hypoperfusion. 292 May 91

Detailed hemodynamic course during prolonged (less than 12 h) septic shock was studied in 23 patients, of whom 12 ultimately died from sepsis. Hemodynamic presentation was similar in fatalities and in survivors, except for a higher heart rate and a markedly higher blood lactate in fatalities (8.4 +/- 1.4 vs. 3.7 +/- 0.4 mEq/l, P less than 0.01). During fluid resuscitation, the pulmonary artery occlusive pressure associated with the highest left ventricular stroke work was usually around 17 mmHg, but in some patients above 20 mmHg. During the course of septic shock, left ventricular function improved in both fatalities and survivors, so that an altered cardiac function had no ultimate pejorative implication. The higher blood lactate in the absence of a different hemodynamic pattern tends to indicate that peripheral distributive defect remains the essential anomaly in septic shock. Arterial lactate appears to represent the most reliable indicator of ultimate prognosis in septic shock.
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PMID:Ultimate survival from septic shock. 302 16

As cardiac transplantation becomes more commonplace in the treatment of end-stage heart failure and as suitable donors become less available, an increasing number of patients will require mechanical circulatory assistance to bridge to transplantation. Since 1982, refractory hemodynamic instability requiring placement of pulsatile ventricular assist devices (VADs) has developed in 11 candidates for transplantation aged 24 to 54 years (mean, 39.6 years). A pneumatic Pierce-Donachy pump was used in 9 patients and an electrical Novacor pump in 2. The cause of the cardiomyopathy was ischemic in 6, postpartum in 2, idiopathic in 2, and doxorubicin hydrochloride toxicity in 1. Seven patients required left ventricular support (LVAD); 4 required biventricular mechanical support (BVAD). Duration of support ranged from 8 hours to 91 days with flows ranging from 4.1 to 8.5 L/min (mean, 5.5 L/min). Although hemodynamic stability was achieved in all 11 patients, contraindications to transplantation developed in 5 patients during VAD support (renal failure in 4, sepsis in 3, disseminated intravascular coagulopathy in 1). The remaining 6 patients (4 with an LVAD, 2 with a BVAD) remained good candidates for transplantation despite major complications in 5 (mediastinal bleeding in 3, driveline infection in 3, development of preformed antibodies in 2, small embolic stroke caused by device malfunction in 1). The 3 patients who were supported the longest (24, 75, and 91 days) were ambulatory while awaiting a donor heart. All 6 patients underwent successful transplantation after 8 hours to 91 days (mean, 24 days) of support. Other than one sternal wound infection, there were no major complications after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Bridging to cardiac transplantation with pulsatile ventricular assist devices. 304 34

In a piglet model of group B beta Streptococci (GBS)-induced pulmonary hypertension, we have determined hemodynamic responses to epinephrine (EPI) infusion in both the systemic and pulmonary circulations. Three groups of piglets (GBS + EPI, n = 6; GBS + placebo, n = 6; placebo, n = 6) were studied. GBS, infused intravenously at approximately 5 X 10(7) organisms/kg/min, reduced cardiac index and stroke volume index while elevating pulmonary artery pressure and pulmonary vascular resistance index. Systemic vascular resistance index, heart rate and aortic pressure did not change during GBS infusion. Six piglets received intravenous EPI after cardiac index had fallen by 30% during GBS infusion. At 3.5, 7.0, and 15 micrograms/kg/min, respectively, EPI raised aortic pressure by 18.5, 31.0, and 45.0 mm Hg while EPI reduced pulmonary artery pressure by 5.2, 6.3, and 8.2 mm Hg. At each dose, EPI elevated systemic vascular resistance index and lowered pulmonary vascular resistance index. At 3.5 micrograms/kg/min, the elevation of aortic pressure was associated with an increase in both cardiac index and systemic vascular resistance index. At higher EPI doses, the rise in aortic pressure was accounted for entirely by an increase in systemic vascular resistance index. Systemic acid/base status and PaO2 did not differ among piglets who received GBS + EPI, GBS alone, or placebo. Extrapolation of these data to human infants must be approached with extreme caution. However, selective elevation of systemic blood pressure may be a feasible strategy for some infants to impede right-to-left shunting of blood often associated with sepsis-induced pulmonary hypertension.
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PMID:Selective elevation of systemic blood pressure by epinephrine during sepsis-induced pulmonary hypertension in piglets. 309 77

From August 1974 to January 1985, 53 patients (26 men; seven Maoris) mean age 45 (SD 15) years, with diabetes mellitus for a mean of 12 (SD nine) years had a renal biopsy and were followed. Indications for biopsy were nephrotic syndrome, proteinuria, renal impairment (five) and hematuria (one). Mean plasma creatinine concentration was 0.22 (SD 0.18) mmol/L and protein excretion 3.4 (SD 2.5) g/24 h. Diabetic nephropathy was demonstrated in 39 patients and significantly associated with retinopathy and insulin dependent diabetes mellitus (IDDM). Of the 39 patients followed for 25.7 (SD 22.8) months, 18 had died (nine myocardial infarction, six uremia, two sepsis, one stroke) and nine had begun dialysis. The five-year cumulative renal survival was 28%. The presence of the nephrotic syndrome and the plasma creatinine concentration at presentation were the best predictors of survival. Diabetics with IDDM of 20 years duration, retinopathy and heavy proteinuria, who survive the other complications of their disease, are likely to have diabetic nephropathy requiring renal replacement therapy.
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PMID:Renal disease in diabetics--which patients have diabetic nephropathy and what is their outcome? 324 62


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