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Acta Paediatr 2002;91(4):424-9
New South Wales Neonatal Intensive Care Units' Data Collection, School of Women's and Children's Health, University of New South Wales, Australia. lee.sutton@perinatal.usyd.edu.au
The aim of this population-based, case-control, cohort study was to report inter-rater reliability between the New South Wales Neonatal Intensive Care Unit Data Collection (NICUS) audit nurses' collection of SNAP (OS) and a research nurse's SNAP data as the audit SNAP (AS). The study was carried out in Sydney and four large rural/urban health areas in New South Wales (NSW), Australia. The subjects--182 singleton term infants with no major congenital anomalies--were admitted to a tertiary neonatal intensive care unit (NICU) for mechanical ventilation. SNAP data were collected on the 182 case infants, born between 1 January and 31 December 1996, by clinical audit officers in the nine tertiary NICUs in NSW. The research officer conducted an audit of the original SNAP score on all infants. The data were examined using Pearson's correlation coefficient, weighted kappa, a plot of difference in SNAP against mean SNAP and Wilcoxon's signed rank sum test. Pearson's correlation coefficient between the OS and AS data was 0.80. Median (interquartile range) SNAP was 13 (9,19) for the OS and 14 (10,20) for the AS. Weighted kappa was highest for highest heart rate, paO2, temperature (degrees C), oxygenation index, haematocrit, platelet count, lowest serum sodium, lowest blood glucose and seizure. In 17 (9%) infants, OS and AS differed by > or = 10, 14 because of an original data collection error, 1 data entry error, 1 audit error and 1 for both data collection and data entry errors. Conclusion: If SNAP is to be incorporated into any routine NICU data collection, it should be audited regularly on a sample of records. It is important to standardize and adhere to strict definitions for parameters before the collection of SNAP data.
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PMID: 12061358, UI: 22056246
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Acta Paediatr 2002;91(4):415-23
The objectives of this population-based, case-control cohort study were to describe the use of the score of neonatal acute physiology (SNAP) as a measure of illness severity in mechanically ventilated term infants, to compare the SNAP scores of the different diagnostic groups, to assess the contribution of the individual SNAP items to the overall SNAP severity category, and to assess SNAP as a predictor of mortality and neonatal intensive care unit (NICU) resource utilization (length of stay (LOS) and duration of ventilation (LOV)). The study was carried out in Sydney and four large rural/urban health areas in New South Wales, Australia. The subjects--182 singleton term infants with no major congenital anomalies--were admitted to a tertiary NICU for mechanical ventilation. Highest mean (SD) SNAP scores occurred in infants ventilated for meconium aspiration (18 (9)), and perinatal asphyxia (17 (9)), compared with pulmonary hypertension (14 (6)) and respiratory distress syndrome (13 (5)). The individual SNAP items that contributed most to SNAP moderate and severe categories were blood gas items, creatinine, urine output, blood glucose, and seizures. Predictors of death included total SNAP score, individual SNAP items (urine output, pH, Oxygenation Index (OI)), 5-min Apgar, gestational age >40 wk, growth restriction, and ventilation for asphyxia/apnoea. SNAP alone was not a good predictor of NICU resource utilization (LOS, LOV) in term infants. The best predictors were LOV for LOS, and a combination of SNAP and the reason for ventilation for LOV. Conclusion: SNAP is a useful measure of severity of illness in sick term neonates admitted to a tertiary NICU. This measure can be used to predict neonatal morbidity and mortality, and to some extent NICU resource utililization.
PMID: 12061357, UI: 22056245
Acta Paediatr 2002;91(3):318-22; discussion 262-3
Department of Woman and Child Health, Karolinska Institute, Stockholm, Sweden. biorn.westrup@telia.com
It has been proposed that the developmentally supportive care of very-low-birthweight (VLBW) infants provided by the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) can improve the infants' opportunities for rest and sleep. The aim of the present study was to determine whether quiet sleep (QS) in VLBW infants is affected by NIDCAP care. Twenty-two infants with a gestational age of <32 wk at birth randomly received either NIDCAP (n = 11) or conventional care (n = 11). These two groups were comparable (mean (SD)) with respect to birthweight (1021 (240) vs 913 (362)g, respectively) and gestational age (27.1 (1.7) vs 26.4 (1.8) wk). The infants in the NIDCAP group were cared for in a separate room by a group of specially trained nurses and subjected to weekly NIDCAP observations until they reached a postconceptional age (PCA) of 36 wk. Quiet sleep (QS) was assessed from 24-h amplitude-integrated EEGs recorded at 32 and 36 wk of PCA. The percentage of time [mean (SD)] spent in QS at 32 wk of PCA was 33.5 (2.6) % for the NIDCAP group and 33.3 (6.9) % for the control infants (ns). At 36 wk, the corresponding values were 24.5 (3.2) % and 25.7 (4.7) %, respectively (ns). The number of QS periods/24 h decreased equally in both groups in association with maturation: from 24.6 (3.3) to 16.8 (1.8) and from 25.0 (5.8) to 17.5 (3.3), at 32 wk, and 36 wk of PCA, respectively (NS). CONCLUSIONS: There were no indications of increased QS at 32 or 36 wk of postconceptional age among VLBW infants who received care based on NIDCAP.
PMID: 12022306, UI: 22016996
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Am J Respir Crit Care Med 2002 Oct 1;166(7):905-6
PMID: 12359641, UI: 22245958
Anaesthesia 2002 Oct;57(10):1029
PMID: 12358966, UI: 22246016
Anaesthesia 2002 Oct;57(10):1028-9
PMID: 12358965, UI: 22246015
Anaesthesist 2002 Sep;51(9):754-9
Department of Anesthesiology, University of Florida, USA. jgravens@anest2.ufl.edu
The specialty of anesthesiology has made extraordinary advances in anesthesia safety. Yet, anesthetic mortality and morbidity continue to be far from tolerable. Efforts to enhance safety in anesthesia must include adherence to explicit and implicit safety standards, must make use of equipment that offers modern safety features, must seek to detect and correct developing safety threats as early as possible and must have a structured system to analyze problems and to institute remedies to prevent their recurrence.
PMID: 12232648, UI: 22217081
Chest 2002 Oct;122(4):1116-8
PMID: 12377828, UI: 22265169
Crit Care Clin 2002 Apr;18(2):421-40
Boston University School of Medicine, Renal Section, Evans Biomedical Research Center, 5th Floor, 650 Albany Street, Boston, MA 02465, USA. ldember@bu.edu
The metabolic abnormalities associated with chronic renal failure and complications of the dialysis procedure present unique challenges in critical care medicine. Understanding how renal failure impacts the development and management of cardiovascular disease, bleeding tendencies, infection, and malnutrition is necessary to provide optimal care for these patients. The recognition of ESRD as a state of chronic inflammation and increased oxidative stress ultimately should lead to more effective treatment approaches for several of the comorbid conditions common in this patient population.
PMID: 12053841, UI: 22049713
Intensive Care Med 2002 Jul;28(7):820-1
PMID: 12349818, UI: 22237254
Intensive Care Med 2002 Jul;28(7):936-42
Dept. of Surgical Intensive Care, Erasmus MC Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. gyssens@bacl.azr.nl
BACKGROUND: As aminoglycosides show concentration-dependent killing, once-daily aminoglycoside (ODA) regimens have been instituted. Data on experience with ODA regimens in critically ill patients are limited. OBJECTIVES: 1) To evaluate the ODA-program in critically ill patients; 2) to describe the pharmacokinetics of aminoglycosides (gentamicin and tobramycin); and 3) to assess the incidence of nephrotoxicity associated with an ODA regimen in this specific of group patients. DESIGN: A prospective, descriptive study. SETTING: Eighteen-bed surgical and 12-bed medical intensive care unit in a referral centre. PATIENTS: Eighty-nine critically ill patients with a suspected or confirmed infection for which gentamicin or tobramycin was indicated and a creatinine clearance > 30 ml/min were monitored. One hundred and nine pharmacokinetic profiles were gathered. INTERVENTIONS: A first dose of 7 mg/kg/24 h of gentamicin or tobramycin was given to every patient independent of renal function. Subsequent doses were chosen on the basis of the pharmacokinetic results of the first dose. MEASUREMENTS: Serum samples were collected 1 h and 6 h after start of the aminoglycoside infusion. All samples were assayed by using immunofluorescence. Pharmacokinetic parameters were estimated using a one-compartment model. RESULTS: The volume of distribution of aminoglycosides was significantly higher in critical ill patients with septic shock than in those without. Consequently, the maximum concentration reached was significantly lower in patients with septic shock. In P. aeruginosa infections the mean (SD) estimated Cmax/MIC ratio was 10.3 (3.3). In n = 17 (49%) of the patients treated > 24 h ( n = 35), a dose adjustment or lengthening of interval was necessary. The recommended dosing interval based on the Hartford Hospital nomogram and one-serum concentration at 6 h was correct in only 62% of all cases. Signs of renal impairment occurred in n = 12 (14%) of the patients; in all survivors renal function recovered completely and no haemofiltration was needed. CONCLUSIONS: An ODA-regimen of 7 mg/kg produced Cmax/MIC ratios > 10 in the majority of critically ill patients in our population. Septic shock and renal dysfunction caused an aberrant pharmacokinetic profile of aminoglycosides in these patients. Therefore, individual therapeutic drug monitoring is warranted. Signs of renal impairment were common in the presence of shock, but appeared to be reversible.
PMID: 12122533, UI: 22117573
Intensive Care Med 2002 Jul;28(7):925-9
Department of Cardiology, Pneumology, and Angiology, Medical Clinic and Policlinic B, Heinrich Heine University, Moorenstrasse 5, Dusseldorf, Germany. hennersdorf@med.uni-duesseldorf.de
OBJECTIVE: To evaluate whether ibutilide can convert atrial fibrillation or flutter in patients in whom amiodarone has failed. DESIGN AND SETTING: Clinical study in a university hospital intensive care unit (ICU). PATIENTS: Twenty-six patients were studied, in whom atrial fibrillation or flutter persisted for a maximum of 6 h at maximum. Patients were monitored continuously during the arrhythmia. Medical conversion was necessary due to symptomatic or hemodynamic causes. INTERVENTIONS: All patients initially received amiodarone (150 mg i.v.) and after 2 h of persistent arrhythmia ibutilide (1 mg or, without success and body weight > 70 kg, 2 mg i.v.). Before the administration of ibutilide 1 g magnesium was administered, and high normal levels of potassium serum levels were achieved (4.5-5.0 mmol/l). RESULTS. After amiodarone atrial flutter persisted in 73% and atrial fibrillation in 27% of patients. After ibutilide the QT interval was prolonged from 327 +/- 61 to 387 +/- 62 ms. The QTc interval increased from 456 +/-32 to 461 +/- 66 ms. Conversion to normal sinus rhythm was achieved in 22 of 27 of cases. Nonsustained torsade de pointes tachycardia was seen in three patients (11%). No patient showed sustained ventricular tachycardia. Patients with proarrhythmic effects were characterized by a decreased left ventricular function. CONCLUSIONS: In ICU patients ibutilide led to conversion to sinus rhythm in 81.5% of patients in whom amiodarone was unsuccessful. Nonsustained tachycardias were seen in 11%; sustained ventricular tachycardia was not seen. Ibutilide seems to be well suitable for conversion of recent onset atrial fibrillation or flutter and had no severe side effects in this study population.
PMID: 12122531, UI: 22117571
Intensive Care Med 2002 Jul;28(7):917-24
Department of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, Canada M5G 1X5.
OBJECTIVES: Controversy over the optimal intravenous fluid for volume resuscitation continues unabated. Our objectives were to characterize the demographics of physicians who prescribe intravenous colloids and determine factors that enter into their decision to choose a colloid. DESIGN: Questionnaire with 61 items. PARTICIPANTS AND SETTING: Ten percent ( n = 364) of frequent intravenous fluid prescribers in the province of Ontario, Canada. RESULTS: The response rate was 74%. Colloid use in the past year was reported by 79% of the responding physicians. Important reasons for choosing a colloid included blood loss and manipulation of oncotic pressure. Physicians tended to prefer either albumin or pentastarch, but no important reasons were found for choosing between the two. Albumin with or without crystalloid was preferred in 5/13 scenarios by more than 50% of the respondents, whereas pentastarch was not favored by more than 50% of respondents in any scenario. Physicians practising in critical care areas and teaching hospitals generally preferred pentastarch to albumin. Physicians reporting pentastarch as representing greater than 90% of total colloid use were more likely to have been visited by a drug detailer for pentastarch than those who used less synthetic colloid (54 vs 22%, p < 0.001).CONCLUSIONS: The majority of physicians surveyed prescribe colloid products and the reported use of albumin and pentastarch has a bimodal distribution. Although albumin appeared to be preferred in more clinical niches, most physicians did not state reasons for choosing between products. Marketing, specialty, location of practice and clinical scenario appear to play significant roles in the utilization of colloid products.
PMID: 12122530, UI: 22117570
Thorax 2002 Oct;57 Suppl 2:II8-II14
Imperial College School of Medicine, Royal Brompton Hospital, London SW3 6LY, UK.
PMID: 12364705, UI: 22251414