Acta Paediatr 2002;91(2):212-7
Department of Neonatology, Wilhelmina Children's Hospital, UMC Utrecht, The Netherlands. l.devries@wkz.a-zu.nl
[Medline record in process]
Posthaemorrhagic ventricular dilatation (PHVD) in very preterm infants carries a poor prognosis. As earlier studies have failed to show a benefit of early intervention, it is recommended that PHVD be first treated when head circumference is rapidly increasing and/or when symptoms of raised intracranial pressure develop. Infants with PHVD, admitted to 5 of the 10 Dutch neonatal intensive care units were studied retrospectively, to investigate whether there was a difference in the time of onset of treatment of PHVD and, if so, whether this was associated with a difference in the requirement of a ventriculo-peritoneal (VP) shunt and/or neurodevelopmental outcome. The surviving infants with a gestational age <34 wk, born between 1992 and 1996, diagnosed as having a grade III haemorrhage according to Papile on cranial ultrasound and who developed PHVD were included in the study. PHVD was defined as a ventricular index (VI) exceeding the 97th percentile according to Levene (1981), and severe PHVD as a VI crossing the p 97 + 4 mm line. Ninety-five infants met the entry criteria. Intervention was not deemed necessary in 22 infants, because of lack of progression. In 31 infants lumbar punctures (LP) were done before the p 97 + 4 mm line was crossed (early intervention). In 20/31 infants, stabilization occurred. In 9 a subcutaneous reservoir was placed, with subsequent stabilization in 6. In 5/31 infants a VP shunt was eventually inserted. In 42 infants treatment was started once the p 97 + 4 mm line was crossed (late intervention). In 30 infants LPs were performed and in 17 of these a VP shunt was eventually inserted. In 11 infants a subcutaneous reservoir was immediately inserted and in 8 of these infants a VP shunt was needed. In one infant a VP shunt was immediately inserted, without any other form of treatment. Infants with late intervention crossed the p 97 + 4 mm earlier (p 0.03) and needed a shunt (26/42; 62%) more often than those with early intervention (5/31; 16%). Early LP was associated with a strongly reduced risk of VP-shunting (odds ratio = 0.22, 95% confidence interval: 0.08-0.62). The number of infants who developed a moderate or severe handicap was also higher (11/42; 26%) in the late intervention group, compared with those not requiring any intervention (3/22; 14%) or treated early (5/31; 16%). CONCLUSION: In this retrospective study, infants receiving late intervention required shunt insertion significantly more often than those treated early. A randomized prospective intervention study, comparing early and late drainage, is required to further assess the role of earlier intervention.
PMID: 11952011, UI: 21948499
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Acta Paediatr 2002;91(2):203-11
Department of Paediatrics, Aalborg University Hospital, Denmark. U19091@aas.nja.dk
Transcutaneous bilirubin (TcB) was measured with a new bilirubinometer, BiliCheck, in 261 jaundiced infants in the neonatal intensive care unit (NICU) [gestational age (GA) 25-43 wk] (group 1) and in 227 healthy jaundiced term and near-term infants (GA 35-43 wk) (group 2). Imprecision of a single determination of TcB measured on the forehead [TcB(h)], expressed as 1 standard deviation, was 15-18 micromol l(-1). No statistically significant difference between intraoperator and interoperator imprecision was found. There was a good correlation between TcB(h) and total serum bilirubin (TSB) in both groups of infants, although TcB(h) was on average lower than TSB. In the NICU infants, TcB(h), other things being equal, was lower in males than in females, and decreased with increasing postnatal age, for the same TSB level. In the infants in both groups who had a GA > or = 35 wk, sick infants had a higher TcB(h) than healthy infants for the same TSB level. The differences were statistically significant, but small and of minor clinical significance. Blood haemoglobin concentration, GA and ethnic origin were not found to influence TcB(h), i.e. BiliCheck corrects sufficiently for these factors. In all 488 infants, TcB was measured at four different body sites. Measurements on the forehead and sternum [TcB(s)] correlated well with TSB, while measurements on the knee and foot correlated less well. In the NICU infants TcB(h) predicted TSB statistically significantly better than TcB(s), while in the healthy term and near-term infants TcB(h) and TcB(s) predicted TSB equally well. Therefore, the preferable body site for measurement of TcB under routine conditions is the forehead. By retrospective analysis of the data, a screening model is presented whereby TcB(h) can be used to screen infants who require phototherapy. We found that using screening limits for TcB(h), which are 70% of the currently used phototherapy limits for TSB, 80% of blood samples in healthy term and near-term infants, and 42% of NICU infants with GA > or = 32 wk, could be avoided. CONCLUSION: BiliCheck is suitable for screening both NICU and healthy newborn infants with jaundice, with regard to the need for phototherapy. The authors recommend using a TcB(h) limit which is 70% of the currently recommended TSB limits for phototherapy, to decide whether TSB needs to be measured.
PMID: 11952010, UI: 21948498
Am J Crit Care 2002 Jan;11(1):57-64
The Ohio State University College of Nursing, Columbus, USA.
BACKGROUND: Anxiety activates the sympathetic nervous system and hypothalamic-pituitary-adrenal axis and may increase morbidity and mortality in vulnerable critical care patients. Despite the adverse effects of anxiety, little is known about critical care nurses 'practices for assessing anxiety. OBJECTIVE: To determine the importance that critical care nurses place on evaluating anxiety and to describe clinical indicators used to assess anxiety. METHODS: Twenty-five hundred members of the American Association of Critical-Care Nurses received the Critical Care Nurse Anxiety Identification and Management Survey and were asked to rate the importance of anxiety assessment, to rate the importance of 61 anxiety indicators, and to select and rank the 5 most important anxiety indicators. RESULTS: Seven hundred eighty-three completed surveys (31.6%) were returned by female (92.0%), white (88.6%) staff nurses (74.2%) who practiced critical care nursing 32.5 hours (SD, 12.3 hours) weekly. Nearly three quarters (71.3%) of respondents thought that anxiety assessment is very important. Only 2 indicators, agitation and patients' verbalization of anxiety, were rated as very important to anxiety assessment. Thirty-nine indicators rated as important primarily included measurable physiological changes and observable behaviors. The top 5 anxiety indicators were agitation, increased blood pressure, increased heart rate, patients' verbalization of anxiety, and restlessness. CONCLUSION: Important indicators of anxiety included observable behaviors and measurable physiological changes. Reliance on these criteria may produce an inaccurate and incomplete anxiety evaluation in vulnerable patients and lead to poorer outcomes. A comprehensive, systematic anxiety assessment tool for valid and reproducible evaluation of patients' anxiety is needed.
PMID: 11789483, UI: 21642834
Am J Crit Care 2002 Jan;11(1):9-10
Publication Types:
PMID: 11785563, UI: 21642825
Am J Crit Care 2002 Jan;11(1):7-9
PMID: 11785559, UI: 21642824
Am J Crit Care 2002 Jan;11(1):34-7
Winston-Salem Cardiology Associates, NC, USA.
BACKGROUND: Positioning patients is a key component of nursing care and can affect their morbidity and mortality. The Centers for Disease Control and Prevention recommend that patients receiving mechanical ventilation have the head of the bed elevated 30 degrees to 45 degrees to prevent nosocomial pneumonia. However, use of higher backrest positions for critically ill patients is not common nursing practice. Backrest elevation may be affected by the accuracy of nurses' estimates of patients' positions. OBJECTIVES: To determine the difference between nurses' estimates of bed angles and measured bed angles and to describe the relationship between nurses' characteristics and the accuracy of their estimates. METHODS: A convenience sample of 67 nurses attending the 1999 American Association of Critical-Care Nurses National Teaching Institute and Critical Care Exposition in New Orleans, La. Each subject provided demographic information and estimated 3 bed angles. The angles were preselected by using a random number table. Summary statistics were used and were categorized according to the demographic information provided by participants. Estimated angles were correlated with measured angles, and accuracies in estimating angles were correlated with demographic characteristics. RESULTS: Nurses were accurate in estimating bed angles (correlation, 0.8488). Demographic information, including sex, age, years of practice, years of critical care practice, basic education, highest educational level, and present position had no relationship to accuracy. CONCLUSIONS: Nurses are able to estimate backrest elevation accurately. Other explanations are needed to understand why recommendations for backrest elevation are not used in practice.
PMID: 11785555, UI: 21642831
Am J Crit Care 2002 Jan;11(1):27-33
Georgetown University, School of Nursing and Health Studies, Washington, DC, USA.
BACKGROUND: Tobacco dependence is the leading preventable cause of death in the United States, yet healthcare professionals are not adequately educated on how to help patients break the deadly cycle of tobacco dependence. OBJECTIVE: To assess the content and extent of tobacco education in the curricula of acute care nurse practitioner programs in the United States. METHODS: A survey with 13 multiple-choice items was distributed to the coordinators of 72 acute care nurse practitioner programs. The survey was replicated and modifiedfrom previous research on tobacco dependence curricula in undergraduate medical education. RESULTS: Fifty programs (83%) responded to the survey. Overall, during an entire course of study, 70% of the respondents reported that only between 1 and 3 hours of content on tobacco dependence was covered. Seventy-eight percent reported that students were not required to teach smoking-cessation techniques to patients, and 94% did not provide opportunities for students to be certified as smoking-cessation counselors. Sixty percent reported that the national guidelines for smoking cessation were not used as a curriculum reference for tobacco content. CONCLUSIONS: The majority of acute care nurse practitioner programs include brief tobacco education. More in-depth coverage is required to reduce tobacco dependence. Acute care nurse practitioners are in a prime position to intervene with tobacco dependence, especially when patients are recovering from life-threatening events. National recommendations for core tobacco curricula and inclusion of tobacco questions on board examinations should be developed and implemented.
PMID: 11785554, UI: 21642830
Am J Crit Care 2002 Jan;11(1):19-26
Indiana University School of Nursing, Bloomington, USA.
BACKGROUND: Critical care nurses provide care to acutely ill patients, yet little is known about the early socialization processes of new nurses to critical care units from the nurses' perspectives. OBJECTIVES: To explore the early socialization processes of critical care nurses. METHODS: A grounded theory design was used to generate a local theory of how critical care nurses experience socialization. Interviews and journals of participants (N = 10) during the first 4 to 5 months of the socialization experiences were collected. Preceptors were interviewed to triangulate data. Orientation materials and field notes were examined. RESULTS: A process of 5 phases was uncovered: the prodrome, welcome to the unit, disengagement/testing, on my own, and reconciliation. Participants experienced difficulty while being evaluated by preceptors early in the orientation process because of changing expectations. Participants also expressed disappointment in their level of comfort at the end of the orientation. The theory termed "navigating the challenge" explains the nature of the changing expectations that new critical care nurses face during their socialization process. CONCLUSIONS: This exploratory study defines the phases that new critical care nurses experience during the early socialization process. Phase-specific recommendations are made on the basis of the results of the study.
PMID: 11785553, UI: 21642829
Am J Crit Care 2002 Jan;11(1):14-6
PMID: 11785552, UI: 21642828
Am J Crit Care 2002 Jan;11(1):10
PMID: 11785551, UI: 21642827
BMJ 2002 Mar 30;324(7340):753
PMID: 11923147, UI: 21920304
Br J Anaesth 2002 Feb;88(2):188-92
Department of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, UK.
BACKGROUND: There is renewed interest in the use of induced hypothermia as a method of neuroprotection both intraoperatively and in the intensive care management of severe brain injury. In this study we have investigated the effects of hypothermia on brain tissue oxygenation in patients with severe head injury. METHODS: Thirty patients with severe head injury (Glasgow coma score <8) were monitored with a multimodal sensor inserted into the brain which measures tissue PO2, PCO2, pH and temperature in addition to routine monitoring. Patients were cooled to a minimum of 33 degrees C when clinically indicated. RESULTS: For all 30 patients brain and systemic temperature correlated well (r=0.96). Brain temperature was consistently higher than systemic temperature by 0.41 +/- 0.26 degrees C (confidence limits). Brain tissue PO2 decreased with hypothermia, with a significant reduction below 35 degrees C (P<0.05). CONCLUSIONS: These results emphasize the advantage of measuring brain temperature directly, and suggest that decreasing brain temperature below 35 degrees C may impair brain tissue oxygenation.
PMID: 11878653, UI: 21867434
Crit Care Nurse 2002 Apr;22(2):80, 83-94, 96-9
Department of Emergency Medicine, Oregon Health Sciences University, Portland, Ore., USA.
PMID: 11961945, UI: 21958070
Crit Care Nurse 2002 Apr;22(2):100-13
Acute and Specialty Care Division, Medical Intensive Care Unit, University of Virginia Health System, Charlottesville, Va., USA.
Clinical research remains a desired goal of the profession. Unfortunately, the methods we have traditionally used to spark the interest and commitment of clinicians have not been universally accepted or successful in attaining our goal. Although nothing is inherently wrong with journal club meetings, research forums, and partnering with academicians, these methods of inspiring research rarely do so. Partially, that failure is because a leader, perhaps a cheerleader, is needed, someone who is willing to teach, support, coach, and call to task the clinicians who wish to "do" clinical research. As noted by Hanneman, the presence of a unit-based expert is necessary for the "catalytic conversion" of others: "Expert nurses methodically build non-expert nurse expertise through flexible, context dependent strategies." The mentor must understand the abilities, the background, and the time commitments of the clinicians so that the support is appropriate for the task. For example, an academician friend who wished to do some research "partnering" with some clinicians in a practice area of interest thought that the main role of the clinicians would be as data collectors. In this collision of philosophies and understanding, the clinicians, who wanted the academician to "show them" how to do the research and teach them at each step, were angered by the academician's perspective of their potential to contribute to the research process. The project was not successful because neither the clinicians nor the academician understood the perspective or expectations of the other. For clinical research to thrive and prosper, indeed to become part of what we do in practice, we must learn from the clinicians who can tell us what works and what does not. The comments of the clinicians recorded in Table 1 are filled with advice, should we choose to listen. Clinical research is part of what our MICU does. The clinicians are proud of their accomplishments, and some are now mentoring others in the process. The success of the program can easily be duplicated in other settings. I hope that we begin to acknowledge the power of teaching research as part of clinical practice and start to reward and acknowledge our clinicians for their involvement.
PMID: 11961932, UI: 21958071
JAMA 2002 Apr 3;287(13):1638-9
PMID: 11926875, UI: 21925086
JAMA 2002 Mar 27;287(12):1513-5
PMID: 11911737, UI: 21909838
Respir Care 2002 Mar;47(3):334-46; discussion 346-7
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA. whurford@partners.org
Treatment of anxiety and delirium, provision of adequate analgesia, and, when necessary, amnesia in critically ill patients is humane and may reduce the incidence of post-traumatic stress disorders. Injudicious use of sedatives and paralytics to produce a passive and motionless patient, however, may prolong weaning and length of stay in the intensive care unit. This report reviews indications and choices for pharmacologic treatment of anxiety, delirium, agitation, and provision of anesthesia in critically ill patients. The choice of pharmacologic agents is made difficult by complex or poorly understood pharmacokinetics, drug actions, and adverse effects in critically ill patients. Advantages, adverse effects, and limitations of drug treatment, including use of neuromuscular blocking drugs and use of sedatives and analgesia during the withdrawal of life-sustaining measures are reviewed.
PMID: 11874611, UI: 21864983
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