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Approximately 2 million people die in the United States each year, 80% of them in acute- or chronic-care institutions. Physicians now have at their disposal interventions that can postpone death in almost every instance. In these circumstances the critical-care physician cannot avoid the responsibility of orchestrating death by balancing factors such as the patient's autonomy and best interests, medical uncertainty and futility, and notions of "passive" (permissible) and "active" (forbidden) euthanasia. Pressures to make decisions unilaterally and without patient input threaten to undermine important physician/patient/family dialogue. On the other hand, the fact that medical resources are becoming increasingly expensive and scarce will inevitably lead to rationing. The critical-care physician will be caught in the middle--orchestrating clinical care to balance the interests of individual patients and families against those of the larger community.

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An assessment of the dosage regimens prescribed for potentially nephrotoxic antibiotics (amikacin, gentamicin, tobramycin, and vancomycin) was undertaken on surgical intensive care unit patients. In 166 patients, 224 series of blood antibiotic level determinations were obtained. Using individualized pharmacokinetic determinations, the regimens were revised as necessary to provide optimal blood levels. Because of variable volumes of distribution and elimination rates, dosing according to standard clinical guidelines produced significantly lower peaks than did pharmacokinetically determined regimens for gentamicin (p less than 0.005), tobramycin (p less than 0.0001), and vancomycin (p less than 0.05). Importantly, fewer patients achieved therapeutic levels with the original regimens than with the revised regimens for gentamicin (9% vs. 91%, p less than 0.0005), tobramycin (27% vs. 92%, p less than 0.0001), and vancomycin (30% vs. 69%, p less than 0.0001). Individualized pharmacokinetic analysis of potentially nephrotoxic antibiotics in critically ill patients is essential if therapeutic, non-toxic levels are to be maintained.

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Blood cardioplegia resulted in better left ventricular (LV) function than crystalloid cardioplegia after elective coronary artery bypass operations. However, most methods of cardioplegic delivery may not adequately cool and protect the right ventricle, and right ventricular (RV) dysfunction may limit hemodynamic recovery. Therefore, RV and LV temperatures were measured intraoperatively and RV and LV function were evaluated postoperatively in 80 patients with double-vessel or triple-vessel coronary artery disease who were randomized to receive either blood cardioplegia or crystalloid cardioplegia. Myocardial performance, systolic function, and diastolic function were assessed with nuclear ventriculography by evaluating the response to volume loading. Preoperatively the groups were similar. Intraoperatively, blood cardioplegia resulted in significantly warmer LV and RV temperatures (left ventricle: 15.5 degrees +/- 0.2 degrees C with blood cardioplegia and 12.6 degrees +/- 0.3 degrees C with crystalloid cardioplegia [p less than .0001]; right ventricle: 18.3 degrees +/- 0.3 degrees C with blood cardioplegia and 15.1 degrees +/- 0.3 degrees C with crystalloid cardioplegia [p less than .0001]). Postoperatively, blood cardioplegia resulted in better LV performance (higher LV stroke work index at a similar LV end-diastolic volume index [EDVI]) (p = .01), better LV systolic function (similar systolic blood pressures at smaller LV end-systolic volume indexes [ESVI]), (p = .04), and improved LV diastolic function (lower left atrial pressures at similar LVEDVIs) (p = .03).(ABSTRACT TRUNCATED AT 250 WORDS)

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Fifteen consecutive patients with toxic epidermal necrolysis or the Stevens-Johnson syndrome managed without corticosteroids after transfer to the burn center (group 2) are compared to a previous consecutive group of 15 who received high doses of these drugs (group 1). Group 2 had a 66% survival, which was a significant improvement compared to the 33% survival in group 1 (p = 0.057). In group 1, mortality was associated with loss of more than 50% of the body surface area skin. In group 2, mortality was related to advanced age and associated diseases. Age, extent of skin loss, progression of skin loss after burn center admission, incidence of abnormal liver function tests, and the incidence of septic complications were not significantly different in the two groups (p greater than 0.10). The incidence of detected esophageal slough was similar in both groups. Nonsteroid (group 2) management was associated with a decreased incidence of ulceration of gastrointestinal columnar epithelium, Candida sepsis, and an increased survival after septic complications. The combined experience of these 30 patients suggests that corticosteroids are contraindicated in the burn center management of toxic epidermal necrolysis and the Stevens-Johnson syndrome.

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In a pediatric intensive care unit we conducted a 1-year prospective study of 454 patients to determine whether wearing a gown decreased the overall nosocomial infection rate, incidence of intravascular catheter colonization, breaks in handwashing technique, and traffic. The overall infection rate was 26 (13%) of 198 admissions during the gown-wearing periods v 23 (9%) of 256 admissions for the periods when gowns were not worn (P less than .25). Of 348 intravascular catheter tips cultured 16 (4.6%) were colonized during gown-wearing periods compared with 21 (6.3%) of 330 when no gowns were worn (P less than .25). Of 78 patient contacts 54 (69%) were followed by no handwashing during gown-wearing periods and 59 (70%) of 84 contacts were followed by no handwashing during periods when no gowns were worn. The mean occurrence of visits per patient per hour and total visits per hour differed between gown-wearing and no-gown-wearing periods by analysis of variance, P less than .01 and P less than .005, respectively. Although traffic was decreased during periods of gown use, overgowns are an expensive, ineffective method of decreasing nosocomial infection rates, vascular catheter colonization rates, and breaks in handwashing technique.

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We used 14 easily measured biologic and clinical variables to develop a simple scoring system reflecting the risk of death in ICU patients. The simplified acute physiology score (SAPS) was evaluated in 679 consecutive patients admitted to eight multidisciplinary referral ICUs in France. Surgery accounted for 40% of admissions. Data were collected during the first 24 h after ICU admission. SAPS correctly classified patients in groups of increasing probability of death, irrespective of diagnosis, and compared favorably with the acute physiology score (APS), a more complex scoring system which has also been applied to ICU patients. SAPS was a simpler and less time-consuming method for comparative studies and management evaluation between different ICUs.

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Prolonged therapeutic paralysis with pancuronium is commonly used in ICUs to facilitate mechanical ventilation of patients with respiratory failure. Sedation is usually given concomitantly to reduce patient discomfort, but assessment of its adequacy is made difficult by the paralysis. We recently cared for a former ICU nurse who required prolonged mechanical ventilation and paralysis and received morphine as a sedative. When she recovered, she was able to relate her experiences. She stressed the need for very frequent reorientation to time and her desire for constant explanation and re-explanation of all procedures being done by the nursing and physician staff. Her experiences provide insights that allow all ICU staff to provide better care for patients requiring therapeutic paralysis.

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The process of pulmonary artery pressure monitoring in 50 consecutive patients in the surgical intensive care unit was analyzed to determine the number and types of problems that occurred in relation to the benefit obtained. Twenty-six percent of the patients had a change in their cardiorespiratory therapy and their conditions were improved after the pressure data were obtained. Many technical and interpretative problems that tended to decrease the desirability of using pulmonary artery pressure monitoring were identified. Most problems could be avoided by carefully calibrating the monitor system, clearing the catheter system of air bubbles and blood clots, learning to property interpret pulmonary artery pressure tracings despite large respiratory variations, and obtaining a hard-copy printout of the pressure tracing with the simultaneous ECG signal. A protocol for avoiding many difficulties was developed.

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Transcutaneous measurement of the arterial PO2 is a practicable method for clinical routine work. The covering, calibration and placing of the electrodes are simple. If the circulation is normal, there is a strong correlation between the arterial and transcutaneous PO2. The stability of the electrode permits its employment for long-term monitoring. Recalibration is necessary every 12 h. Comparison with blood gas analysis is essential for control. After measuring for 5-6 h, blistering under the electrode may occur. The electrode has to be re-applied every 4 h. Continuous measurement offers new possibilities in treatment and diagnosis.

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In the belief that secondary cerebral compression, hypoxia, and ischemia materially influence the outcome from severe head injury, a standardized protocol was followed in 160 patients, with emphasis on early diagnosis and evacuation of intracranial mass lesions by craniotomy, artificial ventilation, control of increased intracranial pressure, and aggressive medical therapy. Of these patients, 36% made a good recovery, 24% were moderately disabled, 8% were severely disabled, 2% were vegetative, and 30% died. The mortality rate compares favorably with outcomes in similar patients reported from other centers and there has been no increase in the numbers of severely disabled or vegetative patients. It is proposed that vigorous surgical and medical therapy, by preventing or reversing secondary cerebral insults, enables some patients who would have died to make a good recovery without increasing the proportion of severely disabled patients.

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Mistabron is the trade-name of a new mucolytic agent, that has certain advantages over older mucolytic agents. This drug has been used to a great extent in patients with tracheobronchial secretions in the department of intensive care medicine. Its application makes expectoration easier while its preventive administration diminishes greatly the incidence of lung complications.

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