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Anaesth Intensive Care 2002 Jun;30(3):386
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PMID: 12075655, UI: 22070883
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Anaesth Intensive Care 2002 Jun;30(3):348-54
Intensive Care Facility, Royal Brisbane Hospital, Queensland, Australia.
This review discusses the issues to be considered in establishing new or extending existing high dependency unit (HDU) services. A defined high dependency service becomes cost-effective when patient care requires more than one nurse for three patients. Professional guidelines for HDUs vary and there are no national accreditation criteria. Casemix and service delivery specifications for the HDU need to be defined and agreed upon within the institution. Establishing a new HDU service requires changes to care delivery. Many potential HDU patients are currently managed in general wards or in the intensive care unit. The service should be discussed widely and marketed within the institution, and the development of defined working relationships with the ICU and primary care teams on the wards is mandatory.
PMID: 12075644, UI: 22070872
Anaesth Intensive Care 2002 Jun;30(3):295-307
Department of Electrical and Electronic Engineering, The University of Western Australia, Nedlands.
A closed-loop control system was constructed for automatic intravenous infusion of insulin to control blood sugar levels (BSL) in critically ill patients. We describe the development of the system. A total of nine subjects were recruited to clinically test the control system. In the patients who underwent closed-loop control of BSL, the controller managed to control only one patient's glycaemia without any manual intervention. The average BSL attained during closed-loop control approached the target range of 6-10 mmol/l, and had less deviation than when BSL had been maintained manually. We conclude that closed-loop BSL control using a sliding scale algorithm is feasible. The main deficiency in the current system is unreliability of the subcutaneous glucose sensor when used in this setting. This deficiency mandates high vigilance during use of the system as it is being developed.
PMID: 12075636, UI: 22070864
Anaesth Intensive Care 2002 Jun;30(3):289-94
Royal Brisbane Hospital, Queensland.
Survival of bone marrow transplant recipients requiring mechanical ventilation is poor but improving. This study reports a retrospective audit of all haematopoietic stem cell transplant (HSCT) recipients requiring mechanical ventilation at an Australian institution over a period spanning 11 years from 1988 to 1998. Recipients of autologous transplants are significantly less likely to require mechanical ventilation than recipients of allogeneic transplants. Of 50 patients requiring mechanical ventilation, 28% survived to discharge from the intensive care unit, 20% to 30 days post-ventilation, 18% to discharge from hospital and 12% to six months post-ventilation. Risk factors for mortality in the HSCT recipient requiring mechanical ventilation include renal, hepatic and cardiovascular insufficiency and greater severity of illness. Mechanical ventilation of HSCT recipients should not be regarded as futile therapy.
PMID: 12075635, UI: 22070863
Anaesthesia 2003 Jan;58(1):84-6
Burnley Health Care Trust Burnley BB10 2 PQ, UK.
[Medline record in process]
PMID: 12492670, UI: 22380320
Anaesthesia 2002 Nov;57(11):1094-7
Department of Intensive Care, University Medical Centre Nijmegen, PO Box 9100, 6500 HB Nijmegen, The Netherlands. b.fikkers@icstaf.azn.nl
We assessed the peri-operative, early and late complications in 100 percutaneous tracheostomies performed with the Blue Rhino trade mark kit. The success rate was 98%. Peri-operative complications occurred in 30 patients. Six major complications occurred; these included bleeding which required surgical exploration (n = 3), and pneumothoraces (n = 2) and one false passage. Cannula insertion was made easier by blunt dissection of the cervical tissues anterior to the trachea. The median duration of the procedure was 8.5 min, which is significantly longer than other authors' results. Only one major complication occurred while the patient was cannulated (serious bleeding requiring exploration). Finally, in a single patient a tracheal stenosis occurred as a major late complication which eventually was treated by a successful tracheal resection. Percutaneous tracheostomy with the Blue Rhino trade mark kit is safe with a low incidence of major complications.
PMID: 12392457, UI: 22280174
Br J Anaesth 2003 Jan;90(1):39-42
Department of Clinical Neurophysiology, Addenbrookes Hospital, Cambridge, UK. Department of Anaesthesia, University of Cambridge, Cambridge, UK Department of Clinical Neurophysiology, Box 124, Addenbrookes Hospital, Cambridge CB2 2QQ, UK. E-mail: sjb80@cam.ac.uk
[Record supplied by publisher]
BACKGROUND: The relationship between changes in intracranial pressure and incidence of subclinical seizures in patients requiring neurological intensive care is not fully understood. The aim of this study was to investigate if acute increases in intracranial pressure were accompanied by subclinical seizures. METHODS: We prospectively studied 17 intensive care patients (11 male, aged 3-66 yr) who were selected from 85 patients requiring intracranial pressure measurement. Patients were selected to have a 30 min, 16-channel electroencephalogram (EEG) recorded when intracranial pressure remained increased despite preliminary treatments. RESULTS: Diagnoses included head injury, intracranial haemorrhage, subarachnoid haemorrhage and sagittal sinus thrombosis. All patients had at least one acute episode of intracranial pressure increase. Pressures ranged from 90 to 440 mm H(2)O. Encephalopathic features (delta/theta rhythms and burst suppression) were noted on all EEGs. No seizure activity was recorded. CONCLUSIONS: We conclude from this pilot study that seizures are an uncommon cause of acute raised intracranial pressure. To determine whether raised intracranial pressure causes seizures, long-term monitoring in a large cohort of intensive care patients would be necessary, studying patients with similar diagnoses and ages. Br J Anaesth 2003; 90: 39-42
PMID: 12488376
Crit Care Med 2002 Dec;30(12):2752-2756
OBJECTIVE To determine if propylene glycol accumulates in children receiving continuous lorazepam infusion and, if accumulation occurs, to determine if it is associated with significant laboratory abnormalities.DESIGN Prospective study.SETTING A tertiary care pediatric intensive care unit.PATIENTS Eleven intubated pediatric intensive care patients receiving continuous lorazepam infusion for sedation.INTERVENTIONS Propylene glycol accumulation was determined by comparing concentrations at baseline, after 48 hrs, and at end of therapy. Laboratory abnormalities were determined by comparing serum lactate and osmolar gap at baseline, after 48 hrs, and at end of therapy. Correlation between the cumulative dose of lorazepam received and the propylene glycol concentration measured at the end of therapy was determined.MEASUREMENTS AND MAIN RESULTS Patients aged 1-15 months were studied. Lorazepam infusion rates ranged from 0.1 to 0.33 mg.kg.hr and lasted 3-14 days. Propylene glycol accumulated significantly in patients receiving continuous infusion of lorazepam. The propylene glycol concentration increased during the study from 86 +/- 93 &mgr;g/mL at baseline to 763 +/- 660 &mgr;g/mL at the end of the study ( =.038). A statistically significant correlation between the cumulative dose of lorazepam received and propylene glycol concentration at the end of therapy was demonstrated ( =.65, <.005). However, the propylene glycol accumulation was not associated with significant laboratory abnormalities. Neither serum lactate concentrations nor osmolar gap were significantly elevated over baseline.CONCLUSION Propylene glycol accumulated significantly in pediatric intensive care patients receiving continuous lorazepam infusion, and propylene glycol concentration correlated with the cumulative lorazepam dose the patient received. However, significant laboratory abnormalities due to propylene glycol accumulation were not observed.
PMID: 12483068
Crit Care Med 2002 Dec;30(12):2636-8
OBJECTIVE To assess the added value of surveying patients after discharge from the intensive care unit.DESIGN Prospective cohort study.SETTING Medical intensive care unit of a large teaching hospital.PATIENTS All patients admitted to the intensive care unit for 48 hrs or more from October 1995 to November 1997.MEASUREMENTS AND MAIN RESULTS We prospectively surveyed 1,068 patients during their intensive care unit stay and for 5 days after intensive care unit discharge. We detected 554 intensive care unit-acquired infections, yielding an infection rate of 70.7 per 1,000 patient days. Of these, only 31 infections (5.6%) in 27 patients were detected after intensive care unit discharge. If postdischarge surveillance was targeted on patients who had had a central vascular catheter while in the intensive care unit, only one infected patient would have been missed, but only 554 out of 889 would have been followed up (sensitivity, 96.2%; specificity, 38.7%; negative predictive value, 99.7%).CONCLUSIONS Surveillance of all patients discharged from the medical intensive care unit is not recommended, as it is resource demanding and allows the detection of few additional infections. However, targeted postdischarge surveillance could be a rational alternative, and selection criteria need to be refined and validated.
PMID: 12483051, UI: 22370596
JAMA 2002 Dec 4;288(21):2732-40
Departments of Medicine and Anesthesiology, Dartmouth-Hitchcock Medical Center, Section of Pulmonary and Critical Care Medicine (3D), 1 Medical Center Dr, Lebanon, NH 03756, USA. thomas.j.prendergast@hitchcock.org
The technology and expertise of critical care practice support patients through life-threatening illnesses. Most recover; some die quickly; others, however, linger--neither improving nor acutely dying, alive but with a dwindling capacity to recover from their injury or illness. Management of these patients is often dominated by the question: Is it appropriate to continue life-sustaining therapy? Patients rarely participate in these pivotal discussions because they are either too sick or too heavily sedated. As a result, the decision often falls to the family or the surrogate decision maker, in consultation with the medical team. Decisions of such import are emotionally stressful and are often a source of disagreement. Failure to resolve such disagreements may create conflict that compromises patient care, engenders guilt among family members, and creates dissatisfaction for health care professionals. However, the potential for strained communications is mitigated if clinicians provide timely clinical and prognostic information and support the patient and family with aggressive symptom control, a comfortable setting, and continuous psychosocial support. Effective communication includes sharing the burden of decision making with family members. This shift from individual responsibility to patient-focused consensus often permits the family to understand, perhaps reluctantly and with great sadness, that intensive caring may involve letting go of life-sustaining interventions.
PMID: 12460097, UI: 22350021
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Thorax 2002 Nov;57(11):986-91
Department of Intensive Care Medicine, University College London Hospitals, The Middlesex Hospital, London, UK. j.goldstone@ucl.ac.uk
The study of patients being weaned from mechanical ventilation has offered new insights into the physiology of respiratory failure. Assessment of the balance between respiratory muscle strength, work and central drive is essential if difficulty in weaning occurs, and optimisation of these elements may improve the success of weaning. Psychological support of patients and the creation of units specialising in weaning have also resulted in a higher success rate.
PMID: 12403884, UI: 22292249