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Acta Paediatr 2002;91(3):262-263.
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PMID: 12422849, UI: 22308542
Other Formats:
Ann Intern Med 2002 Nov 19;137(10):814-22
New York Presbyterian Hospital, New York, New York, USA. bef7@columbia.edu
PMID: 12435218, UI: 22322666
Br J Anaesth 2002 Dec;89(6):873-81
Addenbrooke's Hospital NHS Trust, Hills Road, Cambridge CB2 2QQ, UK.
[Medline record in process]
BACKGROUND: Doctors have long been considered at risk of occupational stress. METHODS: A postal survey of all members of the Intensive Care Society using validated instruments. RESULTS: Eight-five per cent of members returned questionnaires and 70% were eligible for the study. Twenty-nine per cent were suffering General Health Questionnaire-12 (GHQ-12) identified distress and 12% Symptom Checklist-Depression (SCL-D) defined depression. There were no significant age or sex differences between staff suffering distress or depression and those who did not. Dissatisfaction with career correlated highly with both distress and depression (P<0.01). Twenty doctors (3%) were bothered by suicidal thoughts. The most stressful aspects of work were bed allocation, being over-stretched, effect of hours of work and stress on personal/family life, and compromising standards when resources are short. Logistic regression revealed mental health problems were predicted by five stressors: 'lack of recognition of one's own contribution by others'; 'too much responsibility at times'; 'effect of stress on personal/family life'; 'keeping up to date with knowledge'; and 'making the right decision alone'. CONCLUSIONS: Nearly one in three ICU doctors appeared distressed (GHQ), and one in 10 depressed (SCL-D); this is no greater than that reported in other specialities. Perceived stressors reveal some key areas of concern for the employer and the specialty.
PMID: 12453932, UI: 22340778
Br J Anaesth 2002 Sep;89(3):526; discussion 526-7
PMID: 12402741, UI: 22291115
Br J Anaesth 2002 Sep;89(3):373-5
PMID: 12402713, UI: 22291087
Br J Anaesth 2002 Oct;89(4):537-40
PMID: 12393351, UI: 22280433
Chest 2002 Oct;122(4):1428-35
Laboratorio Analisi Chimico Cliniche 1, Azienda Ospedaliera Spedali Civili, 25125 Brescia, Italy. panteghi@bshosp.unibs.it
New biomarkers, such as cardiac troponins, have a major role to play for cost-effective management of individuals with acute chest pain and suspected coronary syndrome, and the laboratory is now poised to assume a vital role in assessing damage and determining prognosis. The redefined biochemical criterion proposed to classify acute coronary syndrome patients presenting with ischemic symptoms as patients with myocardial infarction is heavily predicated on an increased troponin concentration in blood. In an era of evidence-based medicine, we can no longer overlook the diagnostic and prognostic benefits provided by the measurement of these highly sensitive and specific proteins.
PMID: 12377875, UI: 22265216
Chest 2002 Oct;122(4):1389-99
Reanimation polyvalente, Hopital Saint-Joseph, 46 rue Henri Huchard, 75018 Paris, France.
STUDY OBJECTIVE: To investigate the role of oropharyngeal and cutaneous commensal microorganisms (OCCs) as a cause of ventilator-associated pneumonia (VAP). DESIGN: Retrospective analysis of the medical and microbiological records. SETTING: One medical-surgical ICU. PATIENTS: All VAP episodes recorded during a 10-year period were reviewed. All patients with suspected VAP underwent bronchoscopy with protected-specimen brush (PSB) sampling and BAL before any change in antibiotic therapy was made. OCC-VAP was defined as VAP with significant growth in quantitative cultures (PSB yielded > or = 10(3) cfu/mL and/or BAL yielded > or = 10(4) cfu/mL) of OCCs only. Three experts reviewed the episodes. Exposed patients (ie, those with OCC-VAP) and unexposed patients (ie, patients without VAP) matched on condition severity at ICU admission and mechanical ventilation duration were compared. RESULTS: Twenty-nine episodes in 28 patients with > or = 10(4) cfu/mL OCCs in BAL fluid and/or > or = 10(3) cfu/mL OCCs in PSB specimens were found. All patients in these episodes had new radiologic lung infiltrates, with 26 episodes involving purulent tracheal aspirates, 23 episodes involving temperatures > or = 38.5 degrees C, and 18 episodes involving > or = 11,000 leukocytes/ microL. The main OCCs found were non-beta-hemolytic Streptococcus spp (n = 12), Neisseria spp (n = 7), and coagulase-negative Staphylococcus spp (n = 6). Other possible reasons for fever and the presence of new chest infiltrates were found in 20 and 17 patients, respectively. Histologic evidence of pneumonia was found in 2 of the 10 patients who died. The three experts agreed on the diagnosis for 23 patients. In the OCC-VAP group only, the mean (+/- SD) logistic organ dysfunction (LOD) scores increased significantly (LOD score, 2 +/- 4; p = 0.008) during the 3 days before bronchoscopy, and ICU stay duration was longer than in the unexposed group. The exposed/unexposed study found no difference in mortality. CONCLUSION: OCCs may behave like classic nosocomial pathogens in critically ill patients.
PMID: 12377870, UI: 22265211
Chest 2002 Oct;122(4):1382-8
Multidisciplinary ICU, Regional Hospital La Carita, 6600 Locarno, Switzerland.
STUDY OBJECTIVES: The potential clinical benefits of pressure-controlled ventilation (PCV) over volume-controlled ventilation (VCV) in patients with acute lung injury (ALI) or ARDS still remain debated. We compared PCV with VCV in patients with ALI/ARDS with respect to the following physiologic end points: (1) gas exchange and airway pressures, and (2) CT scan intrapulmonary gas distribution at end-expiration. DESIGN: Prospective, observational study. SETTING: A multidisciplinary ICU in a nonuniversity, acute-care hospital. PATIENTS: Ten patients with ALI or ARDS (9 men and 1 woman; age range, 17 to 80 years). INTERVENTIONS: Sequential ventilation in PCV and VCV with a constant inspiratory/expiratory ratio, tidal volume, respiratory rate, and total positive end-expiratory pressure; measurement of gas exchange and airway pressures; and achievement of CT sections at lung base, hilum, and apex for the quantitative analysis of lung densities and of aerated vs nonaerated zones. RESULTS: PaO(2), PaCO(2), and PaO(2)/fraction of inspired oxygen ratio levels did not differ between PCV and VCV. Peak airway pressure (Ppeak) was significantly lower in PCV compared with VCV (26 +/- 2 cm H(2)O vs 31 +/- 2 cm H(2)O; p < 0.001; mean +/- SEM). The surface areas of the nonaerated zones as well as the total areas at each section level were unchanged in PCV compared with VCV, except at the apex level, where there was a significantly greater nonaerated area in VCV (11 +/- 2 cm(2) vs 9 +/- 2 cm(2); p < 0.05). The total mean CT number of each lung (20 lungs from 10 patients) was similar in the two modes, as were the density values at the basal and apical levels; the hilum mean CT number was - 442 +/- 28 Hounsfield units (HU) in VCV and - 430 +/- 26 HU in PCV (p < 0.005). CONCLUSIONS: These data show that PCV allows the generation of lower Ppeaks through the precise titration of the lung distending pressure, and might be applied to avoid regional overdistension by means of a more homogeneous gas distribution.
PMID: 12377869, UI: 22265210
Chest 2002 Oct;122(4):1377-81
Department of Critical Care Medicine, St. John's Mercy Medical Center, St. Louis University, Tower B 4006, 621 South New Ballas Road, St. Louis, MO 63141, USA. trotsj@stlo.smhs.com
STUDY OBJECTIVES: To determine the patency of standard and modified Portex tracheostomy tubes inserted by the percutaneous dilatational technique. DESIGN: Prospective observational study. SETTING: Medical-surgical ICUs in a tertiary care community hospital. PATIENTS: Medical-surgical ICU patients requiring tracheostomy. INTERVENTIONS: Consecutive medical-surgical ICU patients requiring tracheostomy were eligible for the study. Percutaneous tracheostomy tubes were inserted using the percutaneous dilatational technique with bronchoscopic guidance. The study population consisted of the following two groups: group 1 (receiving the standard Portex Per-fit percutaneous tracheostomy tube); and group 2 (receiving the modified Portex Per-fit percutaneous tracheostomy tube). Patients underwent daily fiberoptic evaluation to assess tracheostomy tube patency following the first 72 h after the tracheostomy tube placement. Demographic data and clinical signs or symptoms of airway obstruction were recorded. Measurements and results: Thirty-seven patients received the standard percutaneous tracheostomy tube (group 1), and 17 patients received the modified percutaneous tracheostomy tube (group 2). Partial tracheostomy tube occlusion (> 25%) was observed in 21 of 37 group 1 patients (57%) and in 1 of 17 group 2 patients (6%; p < 0.005). Fifteen of 37 group 1 patients (41%) and none of the group 2 patients sustained a > or = 40% occlusion of the distal tracheostomy tube opening (p < 0.005). One patient from group 1 had clinical manifestations of tracheostomy tube obstruction. None of the patients in group 2 experienced signs or symptoms of airway obstruction. CONCLUSIONS: The standard Portex Per-fit percutaneous tracheostomy tubes used in this study were associated with partial airway obstruction. Modifications of the standard Portex percutaneous tracheostomy tube markedly decreased the airway obstruction. Due to the findings in this study, the authors recommend abandoning the continued use of the Portex Per-fit percutaneous tracheostomy tube in its current configuration and replacing it with the modified tracheostomy tube described in this study.
PMID: 12377868, UI: 22265209
Chest 2002 Oct;122(4):1370-6
Division of Cardiology, Department of Internal Medicine, University of Michigan Health Systems, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
BACKGROUND: Patients hospitalized in medical ICUs (MICUs) with acute noncardiac illnesses have an undefined prevalence of underlying cardiovascular abnormalities. Because of the acuteness of illness, the need for frequent concurrent mechanical ventilation, and the nature of the underlying diseases, routine cardiac examination may be suboptimal for identifying concurrent cardiac abnormalities. PURPOSE: The purpose of this study was to utilize transthoracic echocardiography and Doppler echocardiography interrogation to identify the range and prevalence of occult cardiac abnormalities that may be present in patients admitted to an MICU. METHODS: Over a 12-month period, 500 consecutive patients who had been admitted to the MICU of a large university tertiary care center underwent complete two-dimensional echocardiography and Doppler scanning within 18 h of admission. The final study population comprised 467 patients. No study subject had been admitted to the MICU for a primary cardiac diagnosis. Cardiovascular abnormalities were prospectively defined, and all echocardiograms were interpreted independently by blinded observers. Both MICU and overall mortality rates as well as length of stay were compared to the presence or absence of cardiac abnormalities. RESULTS: One or more cardiac abnormalities was noted in 169 patients (36%). The average (+/-SD) age of patients in the study was 52 +/- 17 years (age range, 17 to 100 years), and the average age was 57 +/- 18 years (age range, 18 to 93 years) in patients with underlying cardiac abnormalities. A single cardiac abnormality was noted in 103 patients (22%), two cardiac abnormalities were noted in 34 patients (7.2%), and three or more cardiac abnormalities were noted in 32 patients (6.8%). Based on subsequent requests for cardiac diagnostic studies, 67 patients (14.3%) were clinically suspected of having significant cardiovascular abnormalities, 39 of whom (58%) had one or more cardiac abnormalities on seen on echocardiography. Cardiac abnormalities were unsuspected in 130 of 169 patients (77%) and were only noted at the time they underwent surveillance echocardiography. Although there was no correlation between the presence of cardiac abnormalities and mortality, both MICU and hospital length of stay were increased in patients with cardiac abnormalities. CONCLUSION: A significant proportion of patients admitted to an MICU with noncardiac illness have underlying cardiac abnormalities, which can be detected with surveillance echocardiography at the time of admission. Cardiac abnormalities were associated with an increased length of stay but not with increased mortality.
PMID: 12377867, UI: 22265208
Chest 2002 Oct;122(4):1200-7
Division of Emergency Medicine, University of Alberta, 1G1.50 WMC, 8440-112th Street, Edmonton, AB, T6G 2B7 Canada. ahtravers@shaw.ca
OBJECTIVES: To determine the benefit of IV beta(2)-agonists for severe acute asthma treated in the emergency department (ED). METHODS: Randomized controlled trials were identified using EMBASE, MEDLINE, and CINAHL; the Cochrane Airways Review Group database; hand searching; bibliographies; pharmaceutical companies; and author contact. Studies where IV beta(2)-agonists were compared to placebo and/or existing standards of care were considered. Where appropriate, trials were combined using odds ratios (ORs) or weighted mean differences with 95% confidence intervals (CIs). RESULTS: From 746 identified references, 55 potentially relevant articles were identified and 15 articles were included. All trials were performed outside North America and were published prior to 1997. Three main treatment strategies were reviewed: strategy 1 (three articles), IV beta(2)-agonists with inhaled beta(2)-agonists vs inhaled beta(2)-agonists; strategy 2 (six articles), IV beta(2)-agonists alone vs inhaled beta(2)-agonists; and strategy 3 (six articles), IV beta(2)-agonists vs IV methylxanthines. Compared to all treatments, IV beta(2)-agonist use did not lead to clinical or statistical significant differences in vital signs, pulmonary functions, laboratory measures, adverse effects, or clinical success. Although statistically nonsignificant, seven methodologically strong studies demonstrated that peak expiratory flows and heart rates were unchanged following beta(2)-agonist use compared to all other treatments at 60 min (8.3 L/min [95% CI, 17.6 to 34.2] and 3.65 beats/min [95% CI, 2.9 to 10.2], respectively), with an increased risk of adverse effects (OR, 1.98; 95% CI, 0.5 to 8.2). CONCLUSIONS: Evidence is lacking to support the use of IV beta(2)-agonists in ED patients with severe acute asthma. Moreover, the clinical benefit appears questionable, while the potential clinical risks are obvious. The only recommendations for IV beta-(2)agonist use should be in those patients in whom inhaled therapy is not feasible, or in the context of a controlled clinical trial comparing IV beta(2)-agonists with standard care vs standard care alone.
PMID: 12377842, UI: 22265183
Chest 2002 Oct;122(4):1121-3
PMID: 12377830, UI: 22265171
Crit Care Med 2002 Oct;30(10):2338-45
Wilford Hall Medical Center, Pulmonary/Critical Care Medicine, Lackland AFB, Texas, USA.
OBJECTIVE: To review minimally invasive cardiac output monitoring devices currently available for use in the intensive care unit. DATA SOURCES: Medline search from 1966 to present plus cited reference studies and abstracts from available product literature. STUDY SELECTION: Selection criteria included published reports and abstracts comparing the accuracy of minimally invasive cardiac output monitors to a "gold standard." DATA SYNTHESIS: Many reports have been published on the accuracy of individual minimally invasive cardiac output monitors, but cumulative data reviewing each type of monitor have not been synthesized and made available to the clinician. CONCLUSIONS: Emerging noninvasive or minimally invasive means of cardiac output monitoring are based on varied physiologic principles and can be used for following hemodynamic trends. Each of these methods has advantages and disadvantages; it is important for the clinician to understand the strengths and limitations of each device to effectively use the information derived.
PMID: 12394965, UI: 22280803
Intensive Care Med 2002 Dec;28(12):1822-4
Epidemiology Discipline, School of Public Health, University of Texas Health Science Center at Houston, 1100 North Stanton Street, Suite 110, El Paso, Texas 79902, USA, zmulla@utep.edu
OBJECTIVE. To determine the clinical epidemiology of invasive group A streptococcal disease (IGASD) and identify predictors of admissions into an intensive care unit (ICU). DESIGN. A cross-sectional study. SETTING. Retrospective review of data. PATIENTS. A total of 204 patients hospitalized throughout the state of Florida, United States, between August 1996 and August 2000 for IGASD. INTERVENTION. None. MEASUREMENTS AND RESULTS. Prevalence odds ratios for ICU admissions were calculated for several demographic and clinical variables. The prevalence of ICU admissions was lower among patients 69 years of age or older compared to younger patients (odds ratio=0.43, 90% confidence interval: 0.23-0.83). The odds ratio associated with the presence of necrotizing fasciitis was 6.98 (90% confidence interval: 3.13-15.58). CONCLUSION. In this analysis of patients hospitalized for IGASD, the presence of necrotizing fasciitis was the strongest factor associated with admissions into an ICU.
PMID: 12447530, UI: 22336208
Intensive Care Med 2002 Dec;28(12):1797-803
Paediatric Intensive Care Unit, Vrije Universiteit Medical center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
OBJECTIVE. To assess and compare the structure, organisation, management, and staffing in different paediatric intensive care units (PICUs) in Europe. DESIGN. Descriptive study. SETTING. A questionnaire was sent to physicians in PICUs. Physician's names were obtained from the membership list of the European Society of Paediatric and Neonatal Intensive Care. INTERVENTIONS. None. PARTICIPANTS. Physicians from 92 European PICUs. MEASUREMENTS AND MAIN RESULTS. Responses were obtained from 92 PICUs (60% of those surveyed, 64% of hospitals with PICUs). A blank response was obtained in <2% of the questions. Considerable diversity in structure, organisation, staffing, and management in European PICUs was found. Significant differences were observed in unit size, which ranged from 2-56 (average: 8-10) beds/unit. In several - predominantly German-speaking - countries paediatric and neonatal intensive care beds are frequently combined in single units. Most European PICUs (98%) had at least part-time coverage by a paediatric intensivist; 78% had 24-h intensivist coverage. Specialized PICU nurses were present in 98% of European PICUs, and most (75%) had 24-h physician coverage by a physician with no responsibilities outside the PICU. CONCLUSIONS. Data obtained in our survey demonstrate the substantial structural, organisational management, and staff diversity of paediatric ICUs. Most European PICUs employ specialized PICU nurses and have at least part time coverage by paediatric intensivists.
PMID: 12447526, UI: 22336204
J Trauma 2002 Oct;53(4):765-9
Department of Orthopaedic and Trauma Surgery, Medical School of Hannover, Germany.
PMID: 12394881, UI: 22281825
JAMA 2002 Nov 6;288(17):2151-62
Department of Critical Care Medicine, Hopkins University, Baltimore, Md, USA.
CONTEXT: Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear. OBJECTIVE: To evaluate the association between ICU physician staffing and patient outcomes. DATA SOURCES: We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001). STUDY SELECTION: We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU. DATA SYNTHESIS: We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment. CONCLUSIONS: High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS.
PMID: 12413375, UI: 22302376
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Pediatrics 2002 Dec;110(6):1245
Department of Pediatrics, Division of Neonatology, A-0126, Medical Center North, Vanderbilt University Medical Center, Nashville, TN 37232-2370, USA. brian.carter@mcmail.vanderbilt.edu
PMID: 12456925, UI: 22345119