Anaesthesia 2002 Apr;57(4):405
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PMID: 11949647, UI: 21946120
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Anaesthesia 2002 Apr;57(4):413
PMID: 11940006, UI: 21937626
Anaesthesia 2002 Apr;57(4):404-5
PMID: 11940000, UI: 21937620
Anaesthesia 2002 Apr;57(4):365-8
Department of Anaesthetics and Intensive Care and Research and Development Co-ordinator, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries DG1 4AP, UK. p.jefferson@dgri.scot.nhs.uk
A questionnaire was sent to 288 critical care units in the UK to assess the use of portable ultrasound machines to assist central vein cannulation. There was a 58% response rate. Ultrasound guidance was used by 36 (21.6%) units for central vein cannulation. Of these, only four (11.1%) used it routinely and 25 (69.4%) used it when faced with a difficult vein cannulation. Half of the units with ultrasound facilities may be using it suboptimally. Of those units not using ultrasound for central vein cannulation, 70 (53%) said it was because of lack of equipment and 51 (38.9%) did not think that it was necessary. Overall, over half of the units did not audit complications of central vein cannulation.
PMID: 11939995, UI: 21937615
Crit Care Med 2002 Apr;30(4):949-52
PMID: 11940785, UI: 21938054
Crit Care Med 2002 Apr;30(4):729-32
PMID: 11940736, UI: 21938005
JAMA 2002 May 8;287(18):2432
University of Pittsburgh School of Medicine, Pittsburgh, Pa.
[Medline record in process]
PMID: 11988066, UI: 21984332
Pediatrics 2002 May;109(5):878-86
Department of Pediatrics and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
OBJECTIVES: Does predictive power for outcomes of neonatal intensive care unit (NICU) patients get better with time? Or does it get worse? We determined the predictive power of Score for Neonatal Acute Physiology (SNAP) scores and clinical intuitions as a function of day of life (DOL) for newborn infants admitted to our NICU. METHODS: We identified 369 infants admitted to our NICU during 1996-1997 who required mechanical ventilation. We calculated SNAP scores on DOL 1, 3, 4, 5, 7, 10, 14, 21, 28, and weekly thereafter until either death or extubation. We also asked nurses, residents, fellows, and attendings on each day of mechanical ventilation: "Do you think this child is going to live to go home to their family, or die before hospital discharge?" RESULTS: Two thousand twenty-eight SNAP scores were calculated for 285 infants. On DOL 1, SNAP for nonsurvivors (24 +/- 8.7 [standard deviation]) was significantly higher than SNAP for survivors (13 +/- 6.1). However, this difference diminished steadily and by DOL 10 was no longer statistically significant (12.7 +/- 4.9 vs 10.0 +/- 4.8). On each NICU day, at all ranges of SNAP scores, there were at least as many infants who would ultimately survive as would die. Consequently, the positive predictive value of any SNAP value for subsequent mortality was <0.5 on all NICU days. Prediction profiles were obtained for 230 ventilated infants reflecting over 11 000 intuitions obtained on 2867 patient days. One hundred fifty-seven (81%) of 192 survivor profiles displayed consistent accurate prediction profiles-at least 90% of their NICU ventilation days were characterized by 100% prediction of survival. Twenty-five (13%) of 192 surviving infants survived somewhat unexpectedly; that is, after at least 1 day characterized by at least 1 estimate of "death." Thirty-three (60%) of the 55 nonsurvivors died before DOL 10. Eighty-two percent of the prediction profiles for these early dying infants were homogeneous, dismal, and accurate. Twenty-two (40%) of the 55 nonsurvivors died after DOL 10. Seventeen (78%) of these 22 late-dying infants were predicted to live by many observers on many hospital days. Sixty-one (30%) of 230 profiled patients had at least 1 NICU day characterized by at least 1 prediction of death; 26/61 (43%) of these patients were incorrectly predicted; that is, they survived. Seventeen infants who were predicted to die during but survived nonetheless were assessed neurologically at 1 year. Fourteen (82%) of these 17 were not neurologically normal-8 were clearly abnormal, 1 suspicious, and 5 had died. CONCLUSIONS: If absolute certainty about mortality is the only criterion that can justify a decision to withhold or withdraw life-sustaining treatment in the NICU, these data would make such decisions difficult on the first day of life, and increasingly problematic thereafter. However, if we acknowledge that medicine is inevitably an inexact science and that clinical predictions can never be perfect, we can ask the more interesting question of whether good but less-than-perfect predictions of imprecise but ethically relevant clinical outcomes can still be useful. We think that they can-and that they must.
PMID: 11986450, UI: 21982882
Pediatrics 2002 May;109(5):758-64
Division of Infectious Diseases, Departments of Pediatrics and Internal Medicine, Washington University School of Medicine, St Louis, Missouri.
OBJECTIVES: To determine the rates, risk factors, and outcomes of ventilator-associated pneumonia in pediatric intensive care unit (PICU) patients. METHODS: A prospective cohort study was conducted at the St Louis Children's Hospital PICU on all patients who were admitted to the PICU from September 1, 1999, to May 31, 2000, except those who died within 24 hours, were >/=18 years of age, or were neonatal intensive care unit patients on extracorporeal membrane oxygenation. The primary outcome measured was the development of ventilator-associated pneumonia. Secondary outcomes were death and hospital and PICU length of stay. Multiple logistic regression analysis was performed to determine independent predictors for ventilator-associated pneumonia. RESULTS: There were 34 episodes of ventilator-associated pneumonia in 30 patients of 911 admissions (3.3%) and 595 (5.1%) mechanically ventilated patients. The mean ventilator-associated pneumonia rate was 11.6/1000 ventilator days. By logistic regression analysis, genetic syndrome (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.01-5.46), reintubation (OR: 2.71; 95% CI: 1.18-6.21), and transport out of the PICU (OR: 8.90; 95% CI: 3.82-20.74) independently predicted ventilator-associated pneumonia. CONCLUSIONS: Ventilator-associated pneumonia occurs at significant rates among mechanically ventilated PICU patients and is associated with processes of care. Additional studies are necessary to develop interventions to prevent ventilator-associated pneumonia.
PMID: 11986433, UI: 21982865
Thorax 2002 Mar;57(3):267-71
Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK. S.V.Baudouin@ncl.ac.uk
Severe community acquired pneumonia carries a high mortality. Early recognition of the severity of the illness, rapid and appropriate resuscitation, targeted antibiotic treatment, and the critical care support of multiple failing organ systems are all important in this group of patients. Only by improving all these aspects of care is it likely that survival will increase.
PMID: 11867834, UI: 21857137
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