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Am J Crit Care 2002 Sep;11(5):480-1
School of Nursing, University of California, San Francisco, USA.
PMID: 12233974, UI: 22218995
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Am J Crit Care 2002 Sep;11(5):415-29; quiz 430-1
Department of Physiological Nursing, University of California, San Francisco, USA.
BACKGROUND: Research is limited on analgesic practices associated with the commonly performed procedures of turning, inserting central venous catheters, removing wound drains, changing dressings on nonburn wounds, suctioning the trachea, and removing femoral sheaths. OBJECTIVES: To determine types of analgesics administered for procedures, the prevalence and amounts of drugs given, and factors predictive of analgesic administration. METHODS: Pain was assessed before and immediately after procedures. Analgesic, sedative, and anesthetic agents administered within 1 hour before and/or during each procedure were noted RESULTS: A total of 5957 adult patients at 164 national and 5 international sites participated. Pain intensity increased at the time of procedure for all procedures. More than 63% of patients received no analgesics. Less than 20% received opiates; mean total dose of opiate was 6.44 mg (SD, 8.96 mg). Only 10% of patients received combination therapy. Factors associated with the likelihood of receiving opiates were pain intensity before a procedure, femoral sheath removal, being white, and the duration of a procedure. Patients less likely to receive opiates had a medical diagnosis or were having tracheal suctioning. Only 14.5% of the variance in the amount of opiate administered was explained by factors entered into multiple regression models. Type of procedure was the only significant predictor of amount of opiate administered. CONCLUSIONS: Most patients were not intentionally medicated even though pain intensity increased during their procedure. When used, analgesic amounts were low, and combination therapy was infrequent. Clinical trials are needed to evaluate optimal pain management for patients undergoing procedures.
PMID: 12233967, UI: 22218988
Am J Crit Care 2002 Sep;11(5):412, 414
Publication Types:
PMID: 12233966, UI: 22218987
Am J Crit Care 2002 Sep;11(5):408-10
PMID: 12233965, UI: 22218986
Anaesth Intensive Care 2002 Aug;30(4):507-29
PMID: 12553315, UI: 22437688
Clin Chest Med 2002 Dec;23(4):707-15
Yale Occupational and Environmental Medicine Program, Yale University School of Medicine, 135 College Street, Room 392, New Haven, CT 06510, USA. peter.rabinowitz@yale.edu
Recent events have underscored the importance of proper diagnosis and management of patients with inhalation injury. Clinicians who care for individuals who have sustained inhalation damage to their respiratory tract need to take a careful exposure history and be alert to possibilities of delayed effects and clinical deterioration. Although supportive care and prevention remain the cornerstone of current approaches to this condition, better understanding of the mechanisms of cellular injury and repair may lead to improved treatments in the future.
PMID: 12512160, UI: 22400882
Crit Care Clin 2002 Oct;18(4):841-54, ix
Medical Intensive Care Unit, Department of Medicine and Anesthesiology, West Virginia University Health Science Center, 3306 HSS, 100 Medical Center Drive, Morgantown, WV 26506, USA. hdedhia@hsc.wvu.edu
Rheumatoid arthritis (RA) is a systemic, debilitating disease characterized by chronic polyarticular inflammation that leads to erosion of joint and bones and to significant extra-articular, systemic, and cardiopulmonary manifestations. RA affects the patient's psychologic and social well-being as well as physical activity. The economical burden is high. Patients with RA may be admitted to the ICU for a variety of problems and present unique challenges to all physicians, including intensivists. This article discusses the basic pathophysiology and clinical manifestations of RA and the extra-articular disorders that bring these patients to an ICU. The management of these patients in ICU is discussed, with emphasis on airway management and outcome.
PMID: 12422843, UI: 22306311
Crit Care Clin 2002 Oct;18(4):819-39
Department of Medicine, Louisiana State University Health Sciences Center, 1901 Perdido Street, New Orleans, LA 70112, USA.
Pulmonary arterial hypertension is common in patients with SSc. Fig. 1 shows the diagnostic and therapeutic approach to PAH in SSc. Doppler echocardiography may suggest the diagnosis, but RHC is necessary to confirm PAH and to measure vasoreactivity. Therapy is directed at the underlying connective tissue disease. Vasoreactive patients often benefit from therapy with high-dose calcium-channel [figure: see text] blockers, but most patients are not vasoreactive. Intravenous epoprostenol and oral endothelin-1 receptor antagonists improve hemodynamic measurements and symptoms in SSc-associated PAH. The therapy of right ventricular failure is focused on vasodilators, inotropes, and diuretics with careful attention to avoiding systemic hypotension. The scleroderma pulmonary-renal syndrome and the scleroderma renal crisis are distinct syndromes with different clinical presentations, histopathologic manifestations, treatments, and outcomes. The scleroderma pulmonary renal syndrome is an autoimmune vasculitis of kidney and lung associated with normal blood pressure. Treatment is supportive, and prognosis is dismal. In contrast, scleroderma renal crisis is associated with systemic hypertension, onion skinning of afferent arterioles, and response to ACE inhibition and renal replacement therapy. Pericardial effusions are common but only occasionally lead to tamponade. Esophageal dysmotility is often associated with aspiration, leading to pulmonary fibrosis, pneumonia, or ARDS. Diffuse bowel involvement may result in pseudo-obstruction, bacterial overgrowth, or malabsorption. Prokinetic agents, antibiotics, and parenteral nutrition may be required.
PMID: 12418443, UI: 22306310
Crit Care Clin 2002 Oct;18(4):749-65
Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, GPF 80, Houston, TX 77030, USA.
The intensivist should be aware of the upper airway manifestations of the common rheumatologic disorders which may lead to ICU admission or which may potentially pose a problem during airway management. Information should be obtained from the patient, the patient's family, and the patient's primary physician, if possible. One should be fully prepared with various options in case a problem arises with an airway. Equipment for managing a difficult airway should be available. Alternate methods of managing the airway (e.g., the laryngeal mask airway, fiberoptic scopes, and the WU Scope) (Achi Corporation, Fremont, CA) are of great help in dealing with airway problems. The potential for cervical spine instability exists in patients with rheumatologic disorders. Intubating with care and avoiding spinal movement both seem to be more important than any particular mode of intubation in preserving neurologic function. One should make a concentrated and serious effort to be as gentle as possible and to avoid even minimal trauma to the mucosa in these patients, because they are at risk for mucosal edema and subsequent postextubation stridor. In cases of stridor, helium-oxygen mixtures may be of help and may eliminate the need for reintubation. When difficulty in establishing an airway is anticipated, it is prudent to attempt airway control in the operating room with surgical assistance standing by should cervical tracheotomy is required.
PMID: 12418439, UI: 22306306
Intensive Care Med 2003 Jan 31;
Bloomsbury Institute of Intensive Care Medicine, Jules Thorn BuildingMiddlesex Hospital, Mortimer St, W1T 3AA, London, UK.
[Record supplied by publisher]
OBJECTIVE. Methicillin-resistant Staphylococcus aureus (MRSA) is a major problem in intensive care units in most countries. Despite recommendations for screening and isolation of patients with MRSA our perception has been that there is little uniformity in approach in ICUs besides adherence to basic infection control procedures. We thus sought to identify MRSA prevalence and the variation of infection control policy across intensive care units in England. DESIGN AND SETTING. Postal questionnaire with telephone follow-up in English intensive care units. MEASUREMENTS AND RESULTS. Responses were obtained from 217 (96%) ICUs. Marked variation in practice was noted in terms of patient screening, staff screening, infection control procedures, isolation or cohorting of colonised/infected patients, and ward discharge policy. Point prevalence data showed that 16.2% of ICU patients were known to be colonised or infected with MRSA. There was a regional bias, but no difference was noted between high and low prevalence regions in terms of unit demographics or infection control policies. CONCLUSIONS. This study highlights the lack of consistent policy across English ICUs regarding isolation, screening and discharge practices for MRSA. Prospective studies are urgently needed to determine best practice.
PMID: 12560869
Intensive Care Med 2003 Jan 30;
Unite de Droit Medical et d'Ethique CliniqueInstitut Universitaire de Medecine Legale, 9 av. de Champel, 1211, Geneva 4, Switzerland.
OBJECTIVE. We examined whether health care workers would wake an intubated patient whose preferences are not known, and whether attitudes are influenced by how health care workers themselves would like to be treated if they were in the patient's place. DESIGN, SETTING, AND SUBJECTS. Convenience sample of 90 participants at a postgraduate lecture to anesthesiologists and related professions. Participants filled out questionnaires after a case presentation followed by two commentaries, one arguing against, the other for waking a 49-year-old intubated patient suffering from a large, intratracheal, poorly differentiated metastatic squamous cell carcinoma of the lungs. The patient was not aware of the diagnosis and poor prognosis and had not expressed any preferences. RESULTS. Participants were almost equally divided between the two alternatives. Significant differences were found between professions concerning the willingness not to wake the patient (19.8% of nurses vs. 45% of physicians and others). There was a strong correlation between the preferences of the health care worker for her-/himself and what he/she would do if in charge of the patient. CONCLUSIONS. Our study shows that attitudes of health care workers towards waking and informing an intubated patient in the intensive care unit about a hopeless situation differ. Educational programs should ensure that physicians and nurses, especially when discussing and deciding withdrawal of vital support, are aware of theses differences and realize that their own behavior can be influenced by their own preferences if themselves in the patient's situation.
PMID: 12557077