Acta Paediatr 2002;91(4):453-8
Neonatal Intensive Care Unit, Hospital de Pediatria, Centro Medico Nacional Siglo XXI, Mexico DF, Mexico.
[Medline record in process]
AIM: To determine the agreement rates between clinical and autopsy diagnoses in a neonatal intensive care unit (NICU), distinguishing between the main diagnosis and cause of death. METHODS: Clinical and autopsy records of 75 infants who died in two consecutive years in the NICU (autopsy rate 42.6%) of a pediatric hospital in Mexico City were reviewed. RESULTS: Ninety-two percent of main clinical diagnoses were confirmed by autopsy. Four conditions (congenital cardiopathy, prematurity, specific congenital syndromes and hyaline membrane disease) accounted for more than two-thirds of diagnoses. However, for cause of death, the global agreement was only 50%. The most common conditions considered by clinicians (77%) and pathologists (56%) to be the causes of death were cardiogenic, septic or mixed shocks. Additionally, clinicians omitted 34 relevant conditions in 30 (40.0%) patients, and 21 of these conditions possibly played a role in the deaths of 17 (22.7%) patients. The most frequently omitted diagnosis was pneumonia, in 9 (26.5%) patients. Omissions were not related to gestational age, age at death, days as an inpatient, or gender. CONCLUSION: Despite a high agreement rate in the main diagnoses, notable imprecisions were present regarding cause of death and antemortem overlooking of potentially fatal conditions, confirming the useful role of autopsy to verify clinical diagnoses and suggesting that differentiation between the main diagnosis and cause of death should be carried out in future studies.
PMID: 12061363, UI: 22056251
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Acta Paediatr 2002;91(4):367-8
Department of Neonatal Medicine, University of Nottingham, UK. neil.marlow@nottingham.ac.uk
PMID: 12061346, UI: 22056234
BMJ 2002 Jun 8;324(7350):1386-9
Problem: Need for improved sedation strategy for adults receiving ventilator support. Design: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative. Background and setting: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. Key measures for improvement: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. Strategies for change: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. Effects of change: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. Lessons learnt: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.
PMID: 12052813, UI: 22047167
BMJ 2002 Jun 8;324(7350):1353
New York.
PMID: 12052795, UI: 22047149
Crit Care Clin 2002 Apr;18(2):289-308, vi
Section of Nephrology, Tulane University Health Sciences Center, New Orleans, LA 70131, USA.
Metabolic acidosis is a common occurrence in critically ill patients. Understanding the pathological mechanisms underlying the generation of protons will enable the clinician to quickly recognize these disorders and establish an acceptable treatment strategy. This article presents a logical approach to metabolic acidosis.
PMID: 12053835, UI: 22049707
Crit Care Clin 2002 Apr;18(2):223-47
Division of Nephrology and Hypertension, University of California, San Diego Medical Center, 8342, 200 West Arbor Drive, San Diego, CA 92103, USA.
Acute renal failure in the ICU is a clinically diverse entity. Consequently, the indications for initiation of dialysis therapy are varied. In general, the indications are solute control, volume control, or both. A variety of dialysis modalities are available; however, there is no consensus as to the optimal modality for any particular group of patients. A careful understanding of the particular benefits, limitations, and potential complications of each modality coupled with a thorough assessment of the individual patient's need formulate the basis for dialysis modality selection. In certain circumstances, the more conventional intermittent therapies are sufficient, whereas in other settings, CRRT techniques are advantageous. The impact of modality selection on outcome remains an area of significant controversy. Future studies in which more uniformity within specific subgroups of patients with ARF is sought may shed light on the optimal modality for a particular patient group. Newer therapies aimed at more optimal and more specific blood purification may prove promising in the management of complex critically ill patients with ARF and other comorbid conditions.
PMID: 12053832, UI: 22049704
Crit Care Med 2002 May;30(5):1180-1
Publication Types:
PMID: 12006834, UI: 22001093
Crit Care Med 2002 May;30(5):1178-9
PMID: 12006833, UI: 22001092
Crit Care Med 2002 May;30(5):1166-8
PMID: 12006825, UI: 22001084
Crit Care Med 2002 May;30(5):1165-6
PMID: 12006824, UI: 22001083
J Paediatr Child Health 2002 Apr;38(2):151-5
Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia. nyboo@mail.hukm.ukm.my
OBJECTIVE: To compare the rates of decrease in serum bilirubin levels in severely jaundiced healthy term infants given oral or intravenous fluid supplementation during phototherapy. METHODS: A randomized controlled study was carried out in the neonatal intensive care unit (NICU) of Hospital Universiti Kebangsaan Malaysia over a 12-month period. Fifty-four healthy term infants with severe hyperbilirubinemia were randomized to receive either solely enteral feeds (n = 27) or both enteral and intravenous (n = 27) fluid during phototherapy. RESULTS: There were no significant differences in the mean birthweight, mean gestational age, ethnic distribution, gender distribution, modes of delivery and types of feeding between the two groups. Similarly, there was no significant difference in the mean indirect serum bilirubin (iSB) level at the time of admission to the NICU between the enteral (359 +/- 69 micromol/L [mean +/- SD]) and intravenous group (372 +/- 59 micromol/L; P = 0.4). The mean rates of decrease in iSB during the first 4 h of phototherapy were also not significantly different between the enteral group (10.4 +/- 4.9 micromol/L per h) and intravenous group (11.2 +/- 7.4 micromol/L per h; P = 0.6). There was no significant difference in the proportion of infants requiring exchange transfusion (P = 0.3) nor in the median duration of hospitalization (P = 0.7) between the two groups. No infant developed vomiting or abdominal distension during the study period. CONCLUSION: Severely jaundiced healthy term infants had similar rates of decrease in iSB levels during the first 4 h of intensive phototherapy, irrespective of whether they received oral or intravenous fluid supplementation. However, using the oral route avoided the need for intravenous cannulae and their attendant complications.
PMID: 12030996, UI: 22028351
J Paediatr Child Health 2002 Apr;38(2):146-50
Department of Newborn Care, Royal Hospital for Women, Randwick, Australia.
OBJECTIVES: To determine if premedication reduces the time and number of attempts by junior medical staff to achieve nasotracheal intubation in neonates. The experimental design was a non-blinded randomized controlled pilot trial. The setting was a perinatal centre in a university teaching hospital. METHODS: Twenty infants (within the ranges of 25-40 weeks gestation, 650-3660 g and 1 h to 81 days of age) requiring semi-urgent intubation were randomized to either premedication with morphine, atropine and suxamethonium, or to awake intubation. RESULTS: There were no significant differences between the two groups in regard to prior intubation experience of the staff or infant weight or gestation. The intubation procedure, including intervening events, to completion was significantly faster in premedicated infants (median 60 s vs 595 s; P = 0.002) who were intubated at a younger postnatal age. It took twice as many attempts to intubate a conscious infant (median 2 vs 1; P = 0.010). There was a greater decrease in heart rate from the baseline in the unpremedicated group (mean 68 b.p.m. vs 29 b.p.m.; P = 0.017), but decreases in oxygen saturation were not different. Blood was observed in the oral and nasal passages after intubation in five of the awake infants and in one of the premedicated infants. CONCLUSIONS: The use of premedication reduces the total time and number of attempts taken to achieve successful nasotracheal intubation of neonates by junior medical staff under supervision.
PMID: 12030995, UI: 22028350
Thorax 2002 May;57(5):452-8
Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0130, USA.
An understanding of the epidemiology of ALI/ARDS and the effects of treatment have been hampered by the lack of a uniform definition of the syndrome. Various definitions have been proposed, and these are reviewed with particular attention to how changes in definition have affected our understanding of the natural history and treatment options for the condition.
PMID: 11978926, UI: 21975833
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