Introduction The ideal timing of tracheostomy in intensive care units (ICUs) for critically ill patients undergoing prolonged mechanical ventilation (MV) is still a controversial issue. Objectives To determine the proper timing of tracheostomy and its impact on various clinical outcomes of adult patients in ICUs undergoing prolonged MV. Methods The present study consisted of a sample of 67 ICU adult patients who were submitted to open surgical tracheostomy and divided into two groups: 30 patients in the early tracheostomy (ET) group (within 1–10 days post intubation), and 37 patients in the late tracheostomy (LT) group (within 11–21 days post intubation). The correlation between the timing of tracheostomy of each group and various associated ICU clinical parameters were analyzed. Results The sample consisted of 61.19% male and 38.81% female patients, with a mean age of 47.263 ± 7.581 years. The mean MV duration in days was 7.91 ± 4.937 standard deviation (SD) in the ET group, and 15.32 ± 7.472 SD in the LT group ( p = 0.001), with a mean sedation time of 6.13 ± 4.647 SD in the ET group, and of 11.98 ± 6.596 SD in the LT group ( p = 0.001). The duration of the weaning process duration had a mean of 2.75 ± 2.586 SD days in the ET group, and of 5.39 ± 5.817 SD days in the LT group ( p = 0.025), with a weaning failure rate of 28.57% in the ET group and 71.42% in the LT group ( p = 0.01). The Mean ICU stay was 26.18 ± 4.732 SD in the ET group, and 11.98 ± 6.596 SD in the LT group ( p = 0.879), and the incidence of ventilator-associated pneumonia (VAP) of 23.33% in the ET group and of 27.02% in the LT group ( p = 0.15). Conclusion Early tracheostomy had a notable benefit in shortening the duration of the MV, lessening the sedation time and minimizing the risks of weaning failure, but it had no significant impact on both the overall duration of ICU stay and VAP incidence.
We conducted a prospective cohort study to detect any relationships between specific clinical features and laboratory indices at initiation of hemodialysis and long-term survival. One hundred and thirty-nine consecutive patients with chronic renal failure hospitalized to start maintenance hemodialysis between January 1990 and December 1994 were enrolled, and follow-up was completed through December 1995. At baseline, subjects were assigned to one of five groups based on their major indication for initiation of hemodialysis. The indications were: (a) nausea and vomiting; (b) severe weakness; (c) no major symptom (dialysis started because of ‘high’ serum creatinine and blood urea nitrogen concentrations); (d) volume overload, and (e) miscellaneous (angina, pericarditis, seizure, pruritus, and hyperkalemia). Blood urea nitrogen, serum creatinine and serum albumin concentrations were measured once before the first dialysis. The main outcome measure was death. The 139 study subjects included 77 women and 62 men comprising 116 Blacks (83%), 15 Hispanics (11%), and 8 Whites (6%) of mean age 54 ± 15 years. Mean length of follow-up was 39 months. At baseline, mean blood urea nitrogen concentration was 121 ± 38 mg/dl, mean serum creatinine concentration was 12.6 ± 5.2 mg/dl, and mean serum albumin concentration was 3.5 ± 0.62 g/dl. Forty-two subjects (30%) died during follow-up. Cox regression analysis showed that there was no significant association between mortality and any of the indicators evaluated (indication for initiation of dialysis (p = 0.2), serum creatinine concentration (<10 vs. ≥10 mg/dl) (p = 0.8), blood ure nitrogen concentration (<100 vs. ≥100 mg/dl) (p = 0.68) and serum albumin concentration (<4 vs. ≥4 g/dl) (p = 0.62). All analyses included adjustment for age and diabetes.We conclude that in patients with chronic renal failure, the clinical features and laboratory indices used as guidelines for initiation of renal replacement therapy do not correlate with survival. Objective parameters that will permit initiation of dialysis at a time that will maximize survival in patients with chronic renal failure are needed.
Anemia in chronic renal failure is predominantly caused by diminished erythropoietin synthesis by diseased kidneys. While iron deficiency is often stated as a cause of anemia in chronic renal failure prior to end-stage renal disease, its relative contribution is debated. It is speculated that rather than frank ‘iron deficiency’, many patients with chronic renal failure may indeed have impaired utilization of iron. We analyzed 139 consecutive patients with chronic renal failure starting maintenance hemodialysis to determine the relationship between hematocrit, measures of renal function (blood urea nitrogen and serum creatinine concentration), and measures of iron availability (serum transferrin saturation, serum iron level and serum ferritin). The 139 study subjects (60 men, 79 women) comprised 116 blacks (83%), 15 hispanics (11%), and 8 whites (6%) of a mean age 56 ± 15 years. Only 23 (17%) of 139 subjects had positive hemoccult stool test for blood. Their mean hematocrit was 24 ± 4.5%, mean blood urea nitrogen concentration was 121 ± 38, mean serum creatinine concentration was 12.6 ± 5.2 mg/dl, mean serum transferrin saturation was 22 ± 14%, mean serum ferritin level was 235 ± 194 U/l, mean serum iron level was 55 ± 40 U/l, and mean total iron binding capacity was 254 ± 93%. Multiple regression analysis with hematocrit as the outcome variable, and blood urea nitrogen level, serum creatinine concentration, serum albumin concentration, serum transferrin saturation, and serum ferritin level as the independent variables, showed an inverse correlation between hematocrit and serum creatinine concentration (p = 0.002). We conclude that in patients with chronic renal failure starting uremia therapy, anemia does not correlate with any of the commonly measured indices of body iron stores. We infer that impaired utilization of iron may be a significant factor in the anemia of chronic renal failure.
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