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Am J Crit Care 2002 Jul;11(4):378-86; quiz 387-8
Department of Physiological Nursing, University of California, San Francisco, USA.
The electrocardiogram continues to be the gold standard for the diagnosis of cardiac arrhythmias and acute myocardial ischemia. The treatment of arrhythmias in critical care units has become less aggressive during the past decade because research indicates that antiarrhythmic agents can be proarrhythmic, causing malignant ventricular arrhythmias such as torsade de pointes. However, during the same period, the treatment of acute myocardial ischemia has become more aggressive, with the goal of preventing or interrupting myocardial infarction by using new antithrombotic and antiplatelet agents and percutaneous coronary interventions. For this reason, critical care nurses should learn how to use ST-segment monitoring to detect acute ischemia, which is often asymptomatic, in patients with acute coronary syndromes. Because the electrocardiographic lead must be facing the localized ischemic zone of the heart to depict the telltale signs of ST-segment deviation, the challenge is to find ways to monitor patients continuously for ischemia without using an excessive number of electrodes and lead wires. The current trend is to use reduced lead set configurations in which 5 or 6 electrodes, placed at convenient places on the chest, are used to construct a full 12-lead electrocardiogram. Nurse scientists at the University of California, San Francisco, School of Nursing are at the forefront in developing and assessing the diagnostic accuracy of these reduced lead set electrocardiograms.
PMID: 12102439, UI: 22096752
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Am J Crit Care 2002 Jul;11(4):369-77
Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA.
BACKGROUND: As older persons in the intensive care unit increasingly require long-term mechanical ventilation, accurate indications of readiness for weaning from ventilatory support are needed to avoid premature extubation. OBJECTIVE: To describe temporal changes in pulmonary and systemic variables in older adults receiving long-term mechanical ventilation. METHODS: After 3 days of unsuccessful attempts at weaning from ventilatory support, 10 trauma and surgical patients more than 60 years old were monitored daily. Previously reported predictors of the duration of mechanical ventilation and weaning outcome were measured, including hemodynamic and gas exchange variables, oxygen cost of breathing, and the score on the Burns Weaning Assessment Program. RESULTS: The 6 patients who could be weaned from ventilatory support were younger (median age, 71.5 years) than the 4 patients who could not be weaned (median age, 80 years). Patients who could be weaned were ready for weaning by day 11 of their stay in the intensive care unit and required an additional 5.5 days of mechanical ventilation; those who could not be weaned were not ready for weaning until day 17. All patients initially had increases in oxygen consumption during weaning; those who were successfully weaned had decreases before extubation. Respiratory rate, maximal inspiratory pressure, the ratio of Pao2 to fraction of inspired oxygen, and mean arterial pressure were higher in patients who could be weaned, and oxygen cost of breathing and central venous pressure were lower CONCLUSION: Further study of weaning in older adults is warranted.
PMID: 12102438, UI: 22096751
Am J Crit Care 2002 Jul;11(4):363-8
School of Nursing, University of Central Florida, Orlando, USA.
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PMID: 12102437, UI: 22096750
Anaesth Intensive Care 2002 Dec;30(6):815
[Medline record in process]
PMID: 12500528, UI: 22388944
Anaesth Intensive Care 2002 Dec;30(6):786-93
Department of Paediatric Intensive Care, Children's Hospital at Westmead, Locked Bag 4001, Westmead, N.S.W. 2124.
Despite the risk of propofol infusion syndrome, a rare but often fatal complication of propofol infusion in ventilated children and possibly adults, propofol infusion remains in use in paediatric intensive care units (PICU). This questionnaire study surveys the current pattern of use of this sedative infusion in Australian and New Zealand PICUs. Thirty-three of the 45 paediatric intensive care physicians surveyed (73%), from 12 of the 13 intensive care units, returned completed questionnaires. The majority of practitioners (82%) use propofol infusion in children in PICU, the main indication being for short-term sedation in children requiring procedures. 39% of respondents consider propofol infusion useful in ventilated children requiring longer-term sedation. 67% of paediatric intensivists use maximum infusion doses that may be considered dangerously high (> or = 10 mg/kg/h). Nineteen per cent use propofol infusion for prolonged periods (> 72 hours). A smaller proportion (15%) of respondents indicate that they may use both higher doses and prolonged periods of infusion, a practice likely to lead to a greater chance of serious adverse events. Knowledge of local protocols for the use of propofol infusion is associated with a significantly greater level of monitoring for possible adverse events. We suggest that national guidelines for the use of propofol infusion in children should be developed. These should include clear indications and contraindications to its use, a maximum dose rate and maximum period of infusion, with a ceiling placed on the cumulative dose given and clearly stated minimum monitoring requirements.
PMID: 12500519, UI: 22388935
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Arch Dis Child 2003 Jan;88(1):46-52
Department of Paediatric Intensive Care, Guy's Hospital, London SE1 9RT, UK. Shane.Tibby@gstt.sthames.nhs.uk
Systolic cardiac function results from the interaction of four interdependent factors: heart rate, preload, contractility, and afterload. Heart rate can be quantified easily at the bedside, while preload estimation has traditionally relied on invasive pressure measurements, both central venous and pulmonary artery wedge. These have significant clinical limitations; however, adult literature has highlighted the superiority of several novel preload measures. Measurement of contractility and afterload is difficult; thus in clinical practice the bedside assessment of cardiac function is represented by cardiac output. A variety of techniques are now available for cardiac output measurement in the paediatric patient. This review summarises cardiac function and cardiac output measurement in terms of methodology, interpretation, and their contribution to the concepts of oxygen delivery and consumption in the critically ill child.
PMID: 12495962, UI: 22383397
Arch Pediatr 2002 Oct;9(10):1064-9
Unite Protegee A, clinique de pediatrie, hopital Jeanne-de-Flandre, CHRU de Lille, 59037 Lille, France. jhdalle@yahoo.fr
As a result of major progresses in anti-cancer treatment, many children with malignancy have to be admitted to an intensive care unit. Therefore it has become a necessity for paediatric oncologists and haematologists and paediatric intensive care physicians to work together. What are the current tools to guide their discussion and decision? There are few useful published studies about the outcome of oncology paediatric patients admitted to intensive care unit. Due to the very specificity of paediatric oncology it is difficult to extrapolate from the available adult studies. Legislative texts specify the limits of the debate but feed it little. Philosophers concentrate on the risk of therapeutic doggedness and the right to dye with dignity. The oncology paediatric patients may be sent to an intensive care unit at different steps of their diseases: at the time of diagnosis, during the curative treatment, or after treatment failure. For each step, there is a need for a wide debate between oncologists, intensivists, nurses, psychologists, and the child's family in order to define the most consensual decisions. The development of validated prognostic scores for this particular population will be very helpful for the decision making. As frequently as possible the decision should be anticipated before the transfer of the child to the intensive care unit.
PMID: 12462840, UI: 22351223
Chest 2002 Nov;122(5):1727-36
Division of Pulmonary and Critical Care, Department of Medicine, Stanford University, Stanford, CA 94305-5236, USA.
Sepsis is a common cause of morbidity and death in critically ill patients, and blood culture samples are often drawn in an effort to identify a responsible pathogen. Blood culture results are usually negative, however, and even when positive are sometimes difficult to interpret. Distinguishing between true bacteremia and a false-positive blood culture result is important, but complicated by a variety of factors in the ICU. False-positive culture results are costly because they often prompt more diagnostic testing and more antibiotic prescriptions, and increase hospital length of stay. A number of factors influence the yield of blood cultures in critically ill patients, including the use of antibiotics, the volume of blood drawn, the frequency with which culture samples are drawn, and the site from which the culture samples are taken. Skin preparation techniques, handling of the cultures in the microbiology laboratory, and the type of blood culture system employed also influence blood culture yield. Attempts to identify predictors of true bacteremia in critically ill patients have been disappointing. In this review, we discuss factors that influence blood culture yield in critically ill patients, suggest ways to improve yield, and discuss true bacteremia vs false-positive blood culture results. We also discuss the costs and consequences of false-positive blood culture results, and list noninfectious causes of fever in the ICU.
PMID: 12426278, UI: 22313200
Intensive Care Med 2002 Sep;28(9):1273-5
Department of General, Visceral, Vascular and Thoracic Surgery, Charite Campus Mitte, Humboldt University, Campus Charite Mitte, Schumanstrasse 20/21, 10117 Berlin, Germany. tido.junghans@charite.de
OBJECTIVE: The purpose of this study was to compare the judgment of intravascular volume based either on conventional monitoring or on the data of COLD measurement. DESIGN: Single-blinded, observational study.Setting: Intensive care unit (ICU). PATIENTS: Ten consecutive patients after upper gastrointestinal tract surgery for carcinoma. MEASUREMENTS AND RESULTS: Judgments ( n=59) about intravascular volume (hypo-, iso- or hypervolemic) were given twice a day until the 2nd postoperative day by two physicians. Physician A's judgment was based on conventional monitoring and physician B's judgment on COLD monitoring. Both were blinded for each other's judgment. The inter-rater agreement between A and B was analyzed using the weighted kappa statistic. Both physicians gave a recommendation about the volume therapy during the following 12 h. The therapeutic regimen, including volume therapy, was defined by physician A. The inter-rater-agreement regarding intravascular volume was poor (overall weighted kappa =0.095). The sum of absolute differences between A and B in their recommendation about infusion administration reached a median of 4,875 ml per patient. CONCLUSIONS: The poor inter-rater agreement between the two physicians and the consecutive difference in the infusion therapy may have clinical consequences and should be evaluated in further studies. These data cannot confirm which decision strategy should be preferred.
PMID: 12209276, UI: 22198381
J Hosp Infect 2003 Jan;53(1):31-8
The Pediatric Infectious Disease Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
We describe an outbreak of Acinetobacter baumannii in a neonatal intensive care unit (NICU), and our investigation to determine the source and mode of transmission and identify the population at risk. A case (infected infant) was defined as a patient hospitalized in the NICU during the outbreak period, with clinical signs of sepsis and isolation of A. baumannii. In colonized infants, A. baumannii was isolated from body surfaces without signs of infection. Infected infants were separated and treated by a different medical team. Cultures were taken from working surfaces and along the infant's admission passage from the delivery room to the NICU. The outbreak strain was identified by pulsed-field gel electrophoresis (PFGE). Nine cases and eight colonized infants met the definition criteria. Cases were younger than colonized infants with regard to gestational age and age of diagnosis and had lower birthweights (P<0.01). The outbreak strain was only isolated from hygroscopic bandages used on skin under the ventilation tube and umbilical catheters. Discontinuing the use of the bandages put an end to the outbreak. We conclude that a rapid and thorough investigation of the environment during an outbreak of A. baumannii is essential to finding the source of the infection, and that hygroscopic bandages may be a source of such outbreaks.
PMID: 12495683, UI: 22384435
J Hosp Infect 2003 Jan;53(1):25-30
Division of Neonatal Intensive Care, Bambino Gesu Children's Hospital, Rome, Italy
The clinical records a years cohort of 280 newborn infants consecutively hospitalized for 48h or more in our neonatal intensive-care unit (NICU) were reviewed. Information on the infants' conditions during the first 12h of life, and on the procedures used in the NICU, were collected. Statistical significance was tested by univariate analysis with the chi(2) test and by multivariate logistic regression analysis with the software program SPSS (Version 10). Over the one-year period reviewed, 90 hospital-acquired infections (HAIs) were contracted; 55 (19.6%) of infants had at least one infection during their stay. The overall in-hospital mortality was 7.1%, and mortality was higher in infants in whom at least one infection developed than in non-infected infants (12.7 vs. 5.8% P=0.13). Very low birthweight infants (VLBW<1501g) who had more severe clinical conditions on admission [clinical risk index for babies (CRIB) score >/=5] had an almost two-fold higher risk of contracting a HAI. In the multivariate regression analysis, the onset of a HAI was strongly associated with a low gestational age and the presence of an intravascular catheter. HAIs frequently complicate hospitalization in NICUs and are associated with increased mortality. Our findings also suggest that CRIB could be predictive for the risk of infection in VLBW infants.
PMID: 12495682, UI: 22384434
J Hosp Infect 2003 Jan;53(1):6-13
Nosocomial Infection Control Department, Hospital das Cli;nicas, Brazil
The objective of this study is to describe infections in a specialized burns intensive care unit from 1993 to 1999. The criteria for admission to the unit are: children with burns involving at least 10% or adults with burns involving at least 20% of total body surface; burns affecting face, perineum or feet; suspected or proven airway injury; electric or chemical burns; age less than one year or above 50; or pre-existing disease with any extent of burns. Surveillance of hospital-acquired infection was prospective. Hospital-acquired infection criteria used were those modified from the Centers for Disease Control and Prevention. Diagnosis of infection using skin biopsy was not done. Over the study period, 320 patients were admitted to our burns intensive care unit. One hundred and seventy-five (55%) developed 388 hospital-acquired infections. The rate for vascular catheter-associated bloodstream infections was 34 per 1000 central line-days. The rate of ventilator associated pneumonia was 26 infections per 1000 ventilator-days. Primary bloodstream was the most common infection with 189 episodes (49%); followed by 83 burn wound infections (21%) and 56 pneumonias (14%). In 76% of these infections and in 97% of the primary bloodstream infections, aetiological agents were identified. The micro-organisms causing infections were S taphylococcus aureus (24%), Pseudomonas aeruginosa (18%),Acinetobacter spp. (14%) and coagulase-negative staphylococci (12%). Candida spp. caused 8% of infections. Gram-positive and Gram-negative organisms exhibited resistance to most antimicrobial agents used for therapy. During the first three days of hospitalization in the burns intensive care unit there were eight infections caused by S. aureus and three of these were resistant to oxacillin. These data provide background information regarding extensive burn patients on which decisions for control and prevention of hospital-acquired infections can be made.
PMID: 12495679, UI: 22384431
Pediatrics 2003 Jan;111(1):80-6
Department of Plastic and Reconstructive Surgery, University of Innsbruck and Ludwig-Boltzmann Institute for Quality Control in Plastic Surgery, Innsbruck, Austria. christian.rainer@chello.at
OBJECTIVE: During intensive care of newborns, a number of invasive techniques may be necessary for resuscitation. The margin of safety between effective treatment and iatrogenic damage is narrow. The objective of this study was to identify and discuss iatrogenic damage in females resulting from treatment of pneumothorax and to give neonatologists anatomically based advice for prevention. PATIENTS AND METHODS: We report 2 female patients (aged 13 and 16 years) born prematurely in whom breast deformity occurred caused by drainage of multiple pneumothoraces during intensive care. In an additional anatomic study, both hemithoraces of 5 newborn female cadavers (n = 10) were dissected to measure the extension of the breast tissue. RESULTS: The anatomic investigations in newborns demonstrate that breast tissue extends vertically from the second or third rib to the sixth rib and from close to the sternal edge medially, almost to the anterior axillary line laterally. CONCLUSION: Psychological distress and corrective surgery because of deformed breasts in adolescent girls who have undergone drainage of pneumothoraces as newborns can be avoided by placing the skin incision in the anterior axillary line, maintaining a distance of 4 to 5 cm inferior to the nipple, and by inserting the chest drain through the fifth or sixth intercostal space during neonatal treatment.
PMID: 12509558, UI: 22397904
Thorax 2003 Jan;58(1):81-8
Intensive Care Unit, John Radcliffe Hospital, Oxford OX3 9DU, UK.
Most deaths from acute asthma occur outside hospital, but the at-risk patient may be recognised on the basis of prior ICU admission and asthma medication history. Patients who fail to improve significantly in the emergency department should be admitted to an HDU or ICU for observation, monitoring, and treatment. Hypoxia, dehydration, acidosis, and hypokalaemia render the severe acute asthmatic patient vulnerable to cardiac dysrrhythmia and cardiorespiratory arrest. Mechanical ventilation may be required for a small proportion of patients for whom it may be life saving. Aggressive bronchodilator (continuous nebulised beta agonist) and anti-inflammatory therapy must continue throughout the period of mechanical ventilation. Recognised complications of mechanical ventilation include hypotension, barotrauma, and nosocomial pneumonia. Low ventilator respiratory rates, long expiratory times, and small tidal volumes help to prevent hyperinflation. Volatile anaesthetic agents may produce bronchodilation in patients resistant to beta agonists. Fatalities in acute asthmatics admitted to HDU/ICU are rare.
PMID: 12511728, UI: 22400208