Over the past two decades nutritional support has rapidly become an integral part of the medical care of critically ill patients. As scientific evidence accumulates supporting the important role of underlying nutritional status in determining the eventual outcome of many illnesses, aggressive nutritional intervention has become commonplace in our medical and surgical ICUs. However, nutritional support, particularly parenteral alimentation, is expensive and associated with important morbidity and even mortality. Furthermore, definite evidence of its clinical efficacy under certain specific conditions is often lacking and in need of properly done prospective studies. This review summarizes the basic principles of nutrition as applied to the critically ill patient in the clinical setting. Special emphasis is on practical considerations regarding cost, efficacy (or lack thereof), and potential advantages, disadvantages, and risk of complications of each proposed approach.

Although thrombolytic agents have been available for over 10 years and have demonstrated safety and efficacy in an increasing number of clinical conditions involving thrombotic phenomena, their general acceptance as first-line therapeutic agents in medical management has been slow. Much of the reluctance to use these drugs is based on their associated incidence of hemorrhagic complications, which is several-fold greater than with use of conventional anticoagulants. With the introduction of second-generation thrombolytic agents, made possible through successes in recombinant DNA technology and chemical modifications of previously available compounds, increased fibrin specificity has been achieved and has been translated into increased clinical efficacy and safety. These results will likely improve as innovative regimens using dose modifications or multiple agents with combined synergy are developed. An appreciation of basic coagulation and the pharmacology of anticoagulants and thrombolytic agents is necessary to maximize the benefits of currently available medications, to develop new treatment strategies, and to minimize potential hemorrhagic complications.

Minimal resection with curative intent for bronchogenic carcinoma was performed at our institutions in 15 patients from 1977 to 1987. All patients were stage I (T1N0 or T2N0). The five-year actuarial survival was 77 percent. The median length of follow-up for patients remaining alive was 41 months. There was a 6 percent (n = 1) local recurrence rate and a 27 percent (n = 3) distant recurrence rate. Both survival and recurrence rates are similar for minimal resection and for that being reported for lobectomy and pneumonectomy for stage I bronchogenic carcinoma. In our series, both median length of operating time and median length of postoperative hospital stay was less for those patients undergoing minimal resection for stage I bronchogenic carcinoma than for those undergoing lobectomy or pneumonectomy. Minimal resection can be considered as an acceptable treatment for bronchogenic carcinoma when technically possible in selected patients.

Postinfluenza toxic shock syndrome is a recently described entity that results from a respiratory tract infection with toxin-producing Staphylococcus aureus following an episode of influenza or influenzalike illness. This report describes a 19-year-old man who developed an influenza B respiratory infection complicated by staphylococcal pneumonia and toxic shock syndrome. The patient improved rapidly with specific antibiotic therapy, emphasizing the importance of considering this otherwise highly lethal syndrome in any individual who becomes critically ill after an initial influenzalike illness.

Although widely used, pericardial fluid cytology has not been adequately validated. We pooled 22 new cases with 71 previously reported cases having both fluid cytology and pericardial histopathologic examination. Cytology was correct in 87 of 93 cases (diagnostic accuracy, 94 percent). Sensitivity was 87 percent and specificity was 100 percent.

A 62-year-old woman presented with a history of hoarseness. Although stable for ten years, she recently showed signs of deterioration. Investigations revealed left vocal cord paralysis and a large left atrial tumor displacing the left pulmonary artery under the arch of the aorta. The lesion was removed and the normal aortopulmonary window on computed tomography (CT) scan was restored. On review of the literature, this case appears to be the first to suggest that myxomas cause recurrent laryngeal nerve palsy through direct effects.

Transbronchial biopsy and transbronchial needle aspiration greatly increase the utility of bronchoscopy in the diagnosis of a variety of disease processes. Transbronchial needle aspiration has brought into focus the importance of good cytopathologic support. The addition of histologic specimens (for light and electron microscopy) with the newer large-bore needles may further increase the utility of transbronchial needle aspiration. Both techniques are limited, in part, by the lack of distal tip deflection of the sampling instrument for steering accurately to peripheral masses. Tip deflection may have been partly responsible for the good yields reported for the double-hinged curet on small nodules, although the bronchographic map was also a factor. A steerable brush was described several years ago, but it was somewhat difficult to accurately maneuver, and long-term results were never reported. As yet, no easy answer is available for this problem. In the future, new generations of ultrathin bronchoscopes may permit much more accurate placement of sampling devices in the periphery of the lung and will represent an exciting diagnostic advance.

Thrombolytic therapy in AMI restores infarct artery patency, preserves LV function, and decreases hospital mortality. Although hemorrhagic complications including stroke can occur, the incidence of stroke is not increased compared with control groups. Aspirin must be administered as soon as possible to inhibit platelet function, and an adjunctive role for early beta-blocker therapy may be important. Acute cardiac catheterization and coronary angioplasty need not be routinely performed in stable patients after tPA therapy, but should be considered in unstable patients. Two trials suggest that aggressive use of coronary angioplasty or bypass graft surgery before hospital discharge to preserve infarct artery patency and to prevent postinfarction ischemia is associated with an important improvement in long-term prognosis. Thrombolytic therapy should be considered standard care for patients whose ischemic chest pain lasts 20 min to at least 6 h in duration and who have an injury current on their ECG unless they are at increased risk for bleeding. The need for and timing of cardiac catheterization, coronary angioplasty, and surgical revascularization after AMI requires further evaluation.