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Anaesthesia 2003 Mar;58(3):261-5
University Department of Anaesthesia and Intensive Care, Nottingham City Hospital, UK.
Cerebral dysfunction in sepsis is common in critically ill adults. However, little is known of the effects of sepsis on cerebral haemodynamics. We studied 12 sedated and ventilated patients in whom sepsis had been established for > 24 h. Transcranial Doppler measurements of the middle cerebral artery flow velocity were made at normocapnia, then hypocapnia (-1 kPa) and hypercapnia (+1 kPa). From these data, cerebrovascular reactivity to carbon dioxide was calculated. Variables indicating disease severity, systemic cardiovascular status and outcome were also recorded. We found significant changes in cerebrovascular reactivity to carbon dioxide. Only three of 12 patients had a cerebrovascular reactivity to carbon dioxide in the normal range; seven patients had a reduced cerebrovascular reactivity to carbon dioxide, whereas in two patients it was raised. In this smaD sample, we could not find any trend of association between altered cerebrovascular reactivity to carbon dioxide and severity of illness, cardiovascular status or outcome. This study suggests that established sepsis profoundly affects the vascular tone and reactivity, not only of the systemic circulation, but also of the cerebral vasculature.
PMID: 12638565, UI: 22525036
Other Formats:
Ann Intern Med 2003 Mar 18;138(6):502-5
Department of Medicine, Center for Vaccine Development, University of Maryland School of Medicine, 685 West Baltimore Street, HSF 480, Baltimore, Maryland 21201, USA. across@umn.edu
Despite the advances in supportive care and the availability of potent antimicrobial agents, mortality from sepsis, a leading cause of death in intensive care units, has not improved. Over the last decade, clinical trials with numerous adjunctive therapies, including antiendotoxin antibodies and inhibitors of the inflammatory response, have yielded disappointing results. Recently, treatment with recombinant human activated protein C reduced mortality 6% compared with controls. Given the likelihood that many processes in the complex pathophysiology of sepsis are simultaneously activated, it is unlikely that therapy directed at any one of them, as has been done in the past, will dramatically improve survival. Rather, a combination of therapies directed at many arms of the septic process, much like the strategy used for cancer and HIV infection, is required. Given the likelihood that sepsis represents an excessive innate immune response to microbial products, vigorous attempts must be made to develop rapid assays that reflect the level of innate immune activation. Such assays could be used to identify patients who would benefit from therapy and to monitor their response so that overtreatment does not completely abrogate host defense mechanisms and render these patients susceptible to fatal infection. It is now time to test a new therapeutic paradigm based on an improved understanding of the pathophysiology of the septic process and the recognition that we may have reached the limits of adjunctive monotherapy.
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PMID: 12639085, UI: 22526004
Clin Chest Med 2003 Mar;24(1):103-22
Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Box 3221, Durham, NC 27710, USA. rocha002@mc.duke.edu
Venous thromboembolism frequently complicates the management of patients with severe medical and surgical illnesses. Because the diagnosis of VTE is especially challenging in critically ill patients, the focus of intensivists should be on characterization of risk factors and the appropriate choice of VTE prophylaxis. LDUH or LMHW is the preferred choice for VTE prophylaxis in ICU patients. Mechanical methods of prophylaxis should be reserved for patients with a high risk for bleeding. The effectiveness of mechanical methods and of combined strategies of prevention and the clinically important outcomes of therapy need to be explored further in critically ill patients. Few diagnostic strategies have been assessed in ICU patients with suspected PE. Ventilation-perfusion lung scans remain a pivotal diagnostic test but retain the same limitations in critically ill patients as seen in other patient populations. Newer noninvasive techniques, such as spiral CT associated with imaging of the extremities, are gaining more wide-spread use, but, thus far, pulmonary angiography remains the most reliable technique to confirm or exclude PE in patients with respiratory failure. A consensus must be reached regarding the most appropriate combination of tests for adequate and cost-effective diagnosis of VTE. Further investigation of diagnostic strategies that include adequate consideration of clinical diagnosis using standardized models and noninvasive imaging are warranted.
PMID: 12685059, UI: 22572098
Crit Care Med 2003 Apr;31(4):1277-8
[Medline record in process]
PMID: 12682505, UI: 22568171
Crit Care Med 2003 Apr;31(4):1226-34
OBJECTIVETo examine neuropsychological function, depression, and quality of life 6 months after discharge in patients who received mechanical ventilation in the intensive care unit.DESIGNProspective cohort study.SETTINGTertiary care, medical and coronary intensive care unit of a university-based medical center.STUDY POPULATIONA total of 275 consecutive, mechanically ventilated patients from a medical intensive care unit were prospectively followed. At 6 months, 157 were alive, of whom 41 (26%) returned for extensive follow-up testing.MEASUREMENT AND MAIN RESULTSNeuropsychological testing and assessment of depression and quality of life were performed at 6-month follow-up. Seven of 41 patients were excluded from further analysis due to preexisting cognitive impairment determined via surrogate interviews using the Modified Blessed Dementia Rating Scale and a review of medical records. On the basis of strict criteria derived from normative data, we found that 11 of 34 patients (32%) were neuropsychologically impaired. Impairment was generally diffuse but occurred primarily in areas of psychomotor speed, visual and working memory, verbal fluency, and visuo-construction. The rate of neuropsychological deficits in the study population was markedly higher than population norms for mild dementia. Scores on the Geriatric Depression Scale-Short Form were significantly more abnormal in the neuropsychologically impaired group than in the nonimpaired group at hospital discharge (p =.04) and at 6-month follow-up (p =.02), and clinically significant depression was found in 27% of impaired subjects at hospital discharge and in 36% at 6-month follow-up. No differences were observed between groups in quality of life as measured with the Short Form Health Survey-12 at discharge or 6-month follow-up.CONCLUSIONSProlonged neuropsychological impairment is common among survivors of the medical intensive care unit and occurs with greater than anticipated frequency when compared with relevant normative data. Future investigations are warranted to elucidate the nature of the association between critical illness, neuropsychological impairment, depression, and decreased quality of life.
PMID: 12682497, UI: 22568163
Crit Care Med 2003 Apr;31(4):1175-82
OBJECTIVETo measure patients' risk for acquiring antibiotic-resistant microorganisms associated with intensive care unit admission.DESIGNProspective, observational study.SETTINGTen public hospitals including one university medical center.PATIENTSConsecutive patients admitted to ten intensive care units.INTERVENTIONSSerial patient surveillance cultures were screened for vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus (MRSA), ceftazidime-resistant Gram-negative bacilli (CR-GNB), Acute Physiology and Chronic Health Evaluation II score, and antibiotic and medical device exposures.MEASUREMENTS AND MAIN RESULTSA total of 1,697 patient admissions in ten intensive care units were enrolled. The overall carriage rate of antibiotic-resistant bacteria at intensive care unit entry was 12.1% for MRSA, 14% for CR-GNB and 4.7% for both. At discharge from the intensive care unit, new carriage of MRSA, CR-GNB, and both was found in 11.1%, 14.2%, and 2.4% of the patients, respectively. The acquisition rates in the individual units correlated highly and positively with proportion of patients with carriage at intensive care unit entry for both MRSA (n = 10, Pearson's r =.89, p < 0.001) and CR-GNB (n = 10, Pearson's r =.92, p < 0.001). By logistic regression, severity of illness (odds ratio, 1.4), length of stay (odds ratio, 1.7), use of penicillins (odds ratio, 1.9), and number of antibiotics (odds ratio, 1.2) and medical devices (odds ratio, 1.2) were independently associated with intensive care unit acquisition of MRSA. In comparison, variables independently associated with intensive care unit acquisition of CR-GNB were Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.5), number of antibiotics (odds ratio, 1.1), and artificial airway (odds ratio, 1.5).CONCLUSIONSThese data suggest that hospitalization in the intensive care unit introduces significant risk to patients in terms of transmission of MRSA and/or CR-GNB. This risk seems to be influenced strongly by the proportion of patients with colonization at intensive care unit admission and is associated with severity of illness, length of stay, and exposures to antibiotics and medical devices.
PMID: 12682490, UI: 22568156
Crit Care Med 2003 Apr;31(4):1026-30
OBJECTIVETo assess the value of clinical and/or radiographic prognostic indices in predicting the clinical course and outcome of patients with acute pancreatitis, in the intensive care unit.DESIGNRetrospective, single institution review.SETTINGAn adult medical and surgical intensive care unit in a public, urban teaching hospital.PATIENTSPatients with acute pancreatitis requiring intensive care unit admission between January 1, 1997 and June 30, 2000.INTERVENTIONSStandard care.MEASUREMENTS AND MAIN RESULTSA total of 477 patients were hospitalized with the diagnosis of acute pancreatitis. Of these, 28 patients (6%) were admitted to the intensive care unit. Ranson's, Imrie scores, Acute Physiologic and Chronic Health Evaluation (APACHE) II and III scores, simplified acute physiology scores, and multiple organ dysfunction scores were tabulated at 1, 2, 3, 7, and 14 days after intensive care unit admission. Abdominal computed tomography was available for review for 24 of the 28 patients (86%), where the mean Balthazar's computed tomography index was 4.5 +/- 0.4 (range = 2 to 10). Hospital mortality rate for the intensive care unit patients was 14% (4 of 28). The intensive care unit length of stay ranged from 1 to 79 days (mean 15 days, median 5 days). Fifty-seven percent of the patients developed organ dysfunction, and 36% of the patients required mechanical ventilatory support, ranging in duration from 1 to 70 days. Infectious morbidity occurred in 43% of patients. Thirty-six percent of the patients required operative intervention for intraabdominal complications. APACHE II scores at 7 days after intensive care unit admission correlated closely with ventilator days (r2 =.90; p =.003) and correlated with the occurrence of infectious complications (r2 =.71; p =.02). Patient age, APACHE III, simplified acute physiology scores, multiple organ dysfunction scores, Ranson, Imrie, computed tomography, and APACHE II scores before day 7 did not closely correlate with the occurrence of adverse clinical outcome.CONCLUSIONSThe clinical course and outcomes of intensive care unit patients with acute pancreatitis can be highly variable. An APACHE II score <10 during the initial 48 hrs correlated with mild pancreatitis and uncomplicated intensive care unit course; however, multifactorial prognosticators were not useful for the early identification of patients who developed complications or required extended intensive care unit care.
PMID: 12682467, UI: 22568133
Crit Care Med 2003 Apr;31(4):1006-11
OBJECTIVEQuality assurance techniques applied within the healthcare industry have been widely used and are intended to improve patient outcomes. Two methods that have been utilized are incident reporting and medical chart review (MCR). The objectives for this study were to evaluate facilitated incident monitoring (FIM) and MCR in the intensive care setting.DESIGNCross-sectional comparison of prospective FIM and retrospective MCR.SETTINGTertiary, 12-bed, closed intensive care unit (ICU) in Australia providing adult and pediatric intensive care to surgical, medical, trauma, and retrieval patients.PATIENTSPatients present or admitted to the ICU during the 2-month study period.MEASUREMENT AND MAIN RESULTSDuring the study period, there were 176 admissions involving 164 patients. A total of 100 FIM reports, of which 70 related to care provided by the ICU team, identified 221 incidents. There were 30 FIM reports that described adverse events, of which only one related to ICU team care. Potential of harm was estimated to be minimal in 49% and significant in 51%; 84% of incidents were considered preventable. Important contextual information was provided, including evidence for the importance of system factors. MCR identified 132 adverse events involving 48% of charts, and 47 related to ICU team care. Common adverse events included nosocomial infections, aspiration, neurologic compromise, respiratory arrest, delayed diagnosis, and treatment. Twenty percent of adverse events were considered preventable, and in 41%, there was evidence of system causation.CONCLUSIONFIM provided more contextual information about incidents and identified a larger number and higher proportion of preventable problems than MCR, but FIM identified few iatrogenic infections, problems with pain management, or problems leading to ICU admission. FIM is easily incorporated into the clinical routine. This study suggests that incident monitoring may be more useful for identifying quality problems, and it could be supplemented by selective audits and focused MCR to detect problems not reported well by FIM.
PMID: 12682464, UI: 22568130
Crit Care Med 2003 Apr;31(4 Suppl):S296-9
Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium.
OBJECTIVES: To summarize the prevalence of various forms of acute respiratory failure in acutely ill patients and review the major factors involved in the outcome of these patients. DATA SOURCES AND SELECTION: MEDLINE search for published studies reporting the prevalence or outcome for patients with acute respiratory failure and cited reference studies and abstracts from a recent international meeting in the intensive care medicine field. DATA SYNTHESIS AND EXTRACTION: From the selected articles, information was obtained regarding the prevalence of acute respiratory failure, including acute respiratory distress syndrome and acute lung injury as defined by the North American-European Consensus Conference, the outcome, and the factors influencing mortality rates in this population of patients. CONCLUSIONS: The prevalence of acute respiratory failure varies according to the definition used and the population studied. Nonsurvivors of acute respiratory distress syndrome die predominantly of respiratory failure in <20% of cases. The relatively high mortality rates of acute lung injury/acute respiratory distress syndrome are primarily related to the underlying disease, the severity of the acute illness, and the degree of organ dysfunction.
PMID: 12682455, UI: 22568121
Crit Care Med 2003 Mar;31(3):992-3
PMID: 12627029, UI: 22513549
Crit Care Med 2003 Mar;31(3):988-9
PMID: 12627026, UI: 22513546
Crit Care Med 2003 Mar;31(3):987-8
PMID: 12627025, UI: 22513545
Crit Care Med 2003 Mar;31(3):986-7
PMID: 12627024, UI: 22513544
Crit Care Med 2003 Mar;31(3):980-1
PMID: 12627020, UI: 22513540
Crit Care Med 2003 Mar;31(3):956-9
University of Texas-Houston Medical School, Department of Medicine, Division of General Internal Medicine, USA.
OBJECTIVE: To measure and compare critical care physicians' and nurses' attitudes about teamwork. DESIGN: Cross-sectional surveys. SETTING: Eight nonsurgical intensive care units in two teaching and four nonteaching hospitals in the Houston, TX, metropolitan area. SUBJECTS: Physicians and nurses who worked in the intensive care units. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty subjects (90 physicians and 230 nurses) responded to the survey. The response rate was 58% (40% for physicians and 71% for nurses). Only 33% of nurses rated the quality of collaboration and communication with the physicians as high or very high. In contrast, 73% of physicians rated collaboration and communication with nurses as high or very high. By using factor analysis, we developed a seven-item teamwork scale. Multivariate analysis of variance of the items yielded an omnibus ( [7, 163] = 8.37; p <.001), indicating that physicians and nurses perceive their teamwork climate differently. Analysis of individual items revealed that relative to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received. CONCLUSIONS: Critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other. As evidenced by individual item content, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills. These findings may be the result of the differences in status/authority, responsibilities, gender, training, and nursing and physician cultures.
PMID: 12627011, UI: 22513531
Crit Care Med 2003 Mar;31(3):946-55
Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Section of Critical Care Medicine, Cooper Health System, Camden 08103, USA. Dellinger-Phil@cooperhealth.edu
PMID: 12627010, UI: 22513530
Crit Care Med 2003 Mar;31(3):776-80
Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Jena, Germany.
OBJECTIVE: Opioid analgesia impairs gastrointestinal motility. Enteral administration of naloxone theoretically allows selective blocking of intestinal opioid receptors caused by extensive presystemic metabolism. Therefore, we studied the effect of enteral naloxone on the amount of gastric tube reflux, the frequency of pneumonia, and the time until first defecation in mechanically ventilated patients with fentanyl analgesia. DESIGN: Prospective, randomized, double-blinded study. SETTING: University hospital intensive care unit. PATIENTS: Eighty-four mechanically ventilated, fentanyl-treated patients without gastrointestinal surgery or diseases. INTERVENTIONS: Patients were assigned to receive 8 mg naloxone or placebo four times daily via a gastric tube during fentanyl administration. MEASUREMENTS AND MAIN RESULTS: Thirty-eight patients received naloxone and 43 placebo; three patients were excluded because of protocol violation. Median gastric tube reflux volume (54 vs. 129 mL, p =.03) and frequency of pneumonia (34% vs. 56%, p =.04) were significantly lower in the naloxone group. In both groups, time until first defecation, ventilation time, and length of intensive care unit stay did not differ. There was no difference in fentanyl requirements between the naloxone and the placebo group (7 vs. 6.5 microg/kg/hr, p =.15). CONCLUSIONS: Our results provide evidence that the administration of enteral opioid antagonists in ventilated patients with opioid analgesia might be a simple-and possibly preventive-treatment of increased gastric tube reflux and reduces frequency of pneumonia.
PMID: 12626983, UI: 22513503
Crit Care Med 2003 Mar;31(3 Suppl):S178-81
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
PMID: 12626965, UI: 22513485
Crit Care Med 2003 Mar;31(3 Suppl):S172-7
Center for the Study of Bioethics, Medical College of Wisconsin, Milwaukee 53226, USA.
PMID: 12626964, UI: 22513484
Crit Care Med 2003 Mar;31(3 Suppl):S167-71
Phoebe R. Berman Bioethics Institute, Johns Hopkins University, Baltimore, MD, USA. mwilliam@jhmi.edu
Clinician-investigators face challenges in conducting research on critically ill patients when they have do-not-resuscitate orders, advance directives, or are in need of end-of-life care. Potential conflicts of interest for clinician-investigators include either financial stakes or academic and reputational stakes. The dual roles for intensive care unit physician or nurse clinician-investigators as healthcare professionals and scientists also present conflicts of interest, as does the dual purpose for the physical plant of the intensive care unit, which simultaneously serves as a site for patient care and a site for clinical research. Intensive care unit patients who become human research subjects also have dual roles that present conflict or confusion that can result in the therapeutic misconception. There are no scientifically or ethically sound reasons to exclude patients from participation in critical care research based on the presence of an advance directive or do-not-resuscitate order, as it would create a biased study sample that does not reflect the critically ill patient population, and it would treat a large group of potential research subjects differently from others without justification. There are four values in tension for critical care clinician-investigators in relation to patients/human research subjects: curative intent, palliative intent, research, and fiduciary obligations. A patient's decision to participate in research does not relieve clinician-investigators of their obligation to serve patient/human research subject's interests, even when doing so involves decisions to limit or withdraw life-sustaining interventions or withdraw the patient/human research subject from research. Critical care research involving patients with advance directives or do-not-resuscitate status is both possible and desirable because it is just, respects patient autonomy, and results in study populations that better reflect the clinical population in all respects.
PMID: 12626963, UI: 22513483
Crit Care Med 2003 Mar;31(3 Suppl):S143-52
Department of Anesthesia, University of Pennsylvania, Philadelphia 19104-4283, USA. kofkea@uphs.upenn.edu
Quality improvement (QI) activities have been done as long as medicine has been practiced and are integral to safety and efficacy of patient care. The 20th century witnessed sophisticated advances of QI methods, with concurrent advances in research ethics. The suggestion that some interventional QI activities resemble research has led to a complex conundrum, with disparate forces driving for improvement and maintenance of patient care quality vs. the societal mandate to control healthcare costs. In the middle of these conflicting priorities are QI systems charged with effecting cost-effective and efficacious healthcare processes. Given the advances in research ethics, substantially grounded in the Nuremberg Code, and the increasing resemblance of interventional QI activities to research, the concern is raised of widespread and systematic Nuremberg Code violations occurring under the guise of QI in health care. Moreover, evidence is cited to suggest that if this is the case, then such activities may be subject to litigation or prosecutorial action. The ethical and legal foundations exist to support the systematic practice of informing patients of their participation in some types of QI procedures.
PMID: 12626960, UI: 22513480
Crit Care Nurse 2003 Feb;23(1):77-80
University of Virginia Health Sciences Center, Division of Gastroenterology/Department of Nutrition Services in Charlottesville, VA, USA.
Nutrition support is a hotly debated topic in most intensive care units. Is enteral nutrition or TPN best? Is gastric or small-bowel feeding safer? Are specialized formulas needed? These are only some of the issues, and the fact remains that there is a paucity of clear, solid data. Folklore has become the standard of practice in many areas of medicine; it is richly found in nutrition support. We must be careful not to get caught up in the trappings of our beliefs about nutrition support. Instead, we must continue to evaluate our own practices and fine-tune our skills of clinical assessment and common sense.
PMID: 12640963, UI: 22528212
Crit Care Nurse 2003 Feb;23(1):73-6
MSN/MHA Program, School of Nursing, University of NC at Charlotte, NC, USA.
PMID: 12640962, UI: 22528211
Crit Care Nurse 2003 Feb;23(1):53-5
Idaho State University College of Pharmacy, Pocatello, Idaho, USA.
PMID: 12640959, UI: 22528208
Crit Care Nurse 2003 Feb;23(1):31-50; quiz 51-2
St. Joseph Hospital, Augusta, Ga., USA.
PMID: 12640958, UI: 22528207
Crit Care Nurse 2003 Feb;23(1):14-5
PMID: 12640955, UI: 22528204
Intensive Care Med 2003 Apr 9;
Intensive Care Unit and Trauma Center, Nord Hospital AP-HM, Marseilles University Hospital System, Marseilles School of Medicine, 13915, Marseille cedex 20, France.
[Record supplied by publisher]
OBJECTIVE. To determine the risk factors for catheter-associated urinary tract infection in a polyvalent intensive care unit (ICU). DESIGN AND SETTING. Prospective cohort study in a 16-bed polyvalent ICU in a French university hospital. INTERVENTIONS. Prospective patient surveillance of patients included in two successive studies of two urine drainage systems. MEASUREMENTS AND RESULTS. Bacteriuria occurrence in 553 ICU patients requiring a bladder catheter for longer than 48 h. The following variables were analyzed as possible risk factors: age, sex, severity score at admission, diagnosis on admission, duration of bladder catheterization, length of ICU stay, prior exposure to antibiotics, and system of urine drainage. The frequency of catheter-associated bacteriuria was 9.6%. From the multivariate analysis, five independent risk factors were determined: sex female, length of ICU stay, use of an antimicrobial therapy, severity score at admission, and duration of catheterization. CONCLUSIONS. In our study the drainage system did not influence the occurrence of bacteriuria. To decrease the rate of catheter-associated bacteriuria in polyvalent ICU patients removal of the bladder catheter must be performed as soon as possible.
PMID: 12684747