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Items 1 - 20 of 20 |
One page. |
Permanent pacemakers and implantable defibrillators: considerations for intensivists.
McPherson CA, Manthous C.
Department of Internal Medicine, Bridgeport Hospital and Yale University School of Medicine, Bridgeport, Connecticut 06610, USA.
Pacemakers and cardioverter-defibrillators are implanted in patients with cardiovascular disease for an ever-increasing array of indications. Intensivists provide care frequently for patients who have these devices, and thus, they must be familiar with common problems and nuances that may contribute to critical illness. Close collaboration of the critical care physician and cardiologist/electrophysiologist assures that pacemakers and defibrillators are tuned to optimize the hemodynamic milieu of critically ill patients. Many recent advances in the sophistication of implanted devices are reviewed herein.
Publication Types:
PMID: 15297272 [PubMed - indexed for MEDLINE]
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Critical care use during the course of serious illness.
Iwashyna TJ.
Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia 19103, USA. iwashyna@alumni.Princeton.edu
Despite its expense and importance, it is unknown how common critical care use is. We describe longitudinal patterns of critical care use among a nationally representative cohort of elderly patients monitored from the onset of common serious illnesses. A retrospective population-based cohort study of elderly patients in fee-for-service Medicare is used, with 1,108,060 Medicare beneficiaries at least 68 years of age and newly diagnosed with serious illnesses: 1 of 9 malignancies, stroke, congestive heart failure, hip fracture, or myocardial infarction. Medicare inpatient hospital claims from diagnosis until death (65.1%) or fixed-right censoring (more than 4 years) were reviewed. Distinct hospitalizations involving critical care use (intensive care unit or critical care unit) were counted and associated reimbursements were assessed; repeated use was defined as five or more such hospitalizations. Of the cohort, 54.9% used critical care at some time after diagnosis. Older patients were much less likely to ever use critical care (odds ratio, 0.31; comparing patients more than 90 years old with those 68-70 years old), even after adjustment. A total of 31,348 patients (2.8%) were repeated users of critical care; they accounted for 3.6 billion dollars in hospital charges and 1.4 billion dollars in Medicare reimbursement. We conclude that critical care use is common in serious chronic illness and is not associated solely with preterminal hospitalizations. Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs.
PMID: 15271691 [PubMed - indexed for MEDLINE]
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B-Type natriuretic peptide and the prediction of outcome in patients admitted to intensive care.
Cuthbertson BH, Patel RR, Croal BL, Barclay J, Hillis GS.
Clinical Senior Lecturer, Medical School, University of Aberdeen, Scotland.
Summary B-type natriuretic peptide is known to predict outcome in congestive cardiac failure and myocardial infarction. We aimed to determine whether measurement of B-type natriuretic peptide would predict hospital mortality in patients admitted to an intensive care unit. We conducted a prospective observational cohort study in 78 consecutive patients. Demographics, clinical details and clinical outcomes were recorded. Admission and 24 h B-type natriuretic peptide and cardiac troponin I levels were measured. B-type natriuretic peptide and cardiac troponin I levels taken on intensive care admission and 24 h after admission did not accurately predict hospital mortality for all patients, including patients with severe sepsis or septic shock (all p > 0.05). B-type natriuretic peptide levels were higher in patients with severe sepsis and septic shock (p = 0.02), in patients >/= 65 years (p = 0.04) and in patients with raised creatinine >/= 110 mumol.l(-1) (p = 0.02). We concluded that B-type natriuretic peptide, measured soon after admission to intensive care, does not usefully predict outcome after intensive care.
PMID: 15601267 [PubMed - in process]
Comment on:
A response to 'The effect of critical care outreach on postoperative serious adverse events', Story DA, Shelton AC, Poustie SJ, Colin-Thome NJ and McNicol PL, Anaesthesia 2004; 59: 762-6.
Sartain JB.
Publication Types:
PMID: 15479350 [PubMed - indexed for MEDLINE]
Comment on:
A response to 'Abdominal muscle action during expiration can impair pressure controlled ventilation', Prasad CV and Drummond GB, Anaesthesia 2004; 59: 715-8.
Ireland T.
Publication Types:
PMID: 15479345 [PubMed - indexed for MEDLINE]
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Long-term outcomes in survivors from critical illness.
Wu A, Gao F.
Publication Types:
PMID: 15479309 [PubMed - indexed for MEDLINE]
[Therapeutic hypothermia after traumatic brain injury or subarachnoid hemorrhageCurrent practices of German anaesthesia departments in intensive care.]
[Article in German]
Himmelseher S, Werner C.
Klinik fur Anaesthesiologie, Klinikum rechts der Isar, Technische Universitat Munchen, Munchen, s.himmelseher@lrz.tu-muenchen.de.
BACKGROUND. We aimed to explore current practices in use of therapeutic hypothermia after traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH) in intensive care of adults. METHODS. Questionnaires were sent to anaesthesia department chairs in German hospitals with neurosurgical care in January 2004 with a survey focussing on cooling procedures, temperature measurement, depth and duration of hypothermia, and rewarming after therapy. RESULTS. 99 (67%) questionnaires on TBI and 95 (64%) on SAH could be analysed. Hypothermia was used in 39% after TBI and 18% after SAH. Its aims were neuroprotection in approximately 45% and control of refractory intracranial hypertension in approximately 50%. However, in most cases (69% TBI, 59% SAH) hypothermia was used in less than a quarter of patients treated. A criterion for hypothermia was severe disease in approximately 40% and refractory intracranial hypertension in approximately 50%. Temperatures were targeted to 36-34 degrees C in 77% after TBI and 88% after SAH. In more than 80%, bladder temperatures were measured. For induction of hypothermia, surface cooling was applied in approximately 90%. The duration of hypothermia was 24-48 h in 62% after TBI and 29% after SAH. Cooling was orientated at the intracranial pressure (ICP) in 31% after TBI and 47% after SAH, and was used for more than 48 h in approximately 25%. After hypothermia was stopped, a rewarming rate of 0.5 degrees C/h was applied in 38% after TBI and 53% after SAH. In approximately 35%, rewarming was orientated at the ICP, and in 33% after TBI and 24% after SAH, it was performed over 24 h. After SAH, spontaneous rewarming was used in 24%. CONCLUSION. Therapeutic hypothermia is used in 39% after TBI and 18% after SAH in the intensive care of German anaesthesia departments. There is no standard in management, and there is wide variation in practices of duration of cooling and rewarming. For patients' benefit, evidence-based recommendations on therapeutic hypothermia should be published by the appropriate medical societies in the German language.
PMID: 15597156 [PubMed - in process]
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[Anesthesia and intensive care medicine--status report. XIIIth International Symposium on Anesthesia in Heidelberg, March 19-21, 2004]
[Article in German]
Bopp C, Plachky J, Hofer S, Graf BM, Weigand MA.
Klinik fur Anasthesiologie, Universitatsklinikum Heidelberg. Christian.Bopp@med.uni-heidelberg.de
Publication Types:
PMID: 15221113 [PubMed - indexed for MEDLINE]
Prophylaxis or preemptive therapy of invasive candidiasis in the intensive care unit?
Ostrosky-Zeichner L.
University of Texas Health Science Center at Houston, Houston, TX.
PMID: 15599171 [PubMed - in process]
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Cycling empirical antimicrobial agents to prevent emergence of antimicrobial-resistant Gram-negative bacteria among intensive care unit patients.
Warren DK, Hill HA, Merz LR, Kollef MH, Hayden MK, Fraser VJ, Fridkin SK.
From the Department of Medicine (DKW, LRM, MHK, VJF), Washington University School of Medicine, St. Louis, MO; Division of Healthcare Quality Promotion (HAH) and Division of Bacterial and Mycotic Diseases (SKF), National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA; and Department of Medicine (MKH), Rush University Medical Center, Chicago, IL.
OBJECTIVE:: To determine the impact of the rotation of antimicrobial agents on the rates of infection, intestinal colonization, and acquisition with antimicrobial-resistant Gram-negative bacteria. DESIGN:: Pre- and postintervention design. SETTING:: A 19-bed, medical intensive care unit. PATIENTS:: Individuals admitted to the study unit for >48 hrs. INTERVENTIONS:: After a 5-month baseline observation period, four classes of antimicrobial agents with Gram-negative activity were cycled at 3- to 4-month intervals for 24 months. MEASUREMENTS AND MAIN RESULTS:: The primary outcome was the acquisition rate of antimicrobial resistance among Enterobacteriaceae and Pseudomonas aeruginosa obtained from rectal swab cultures performed on admission, weekly during the patients' stay, and at discharge. Rates and microbiology of nosocomial bloodstream infections and ventilator-associated pneumonia were also compared between baseline and cycling periods. The cycling program resulted in a significant change in prescribing practices; the predominant agent used changed with each cycle. Among study patients who were not already colonized with a resistant organism, the rate of acquisition of enteric colonization with bacteria resistant to any of the target drugs remained stable during the cycling period for P. aeruginosa (relative rate, 0.96; 95% confidence Interval, 0.47-2.16) and Enterobacteriaceae (relative rate, 1.57; 95% confidence interval, 0.80-3.43). Hospital-wide, P. aeruginosa from routine clinical cultures resistant to the target drugs increased during the cycling period. The proportion of Gram-negative bacteria isolated from cases of nosocomial bloodstream infection (29% baseline vs. 26% cycling; p = .11) and ventilator-associated pneumonia (80% vs. 41%; p = .06) did not significantly differ. CONCLUSIONS:: In this study, antimicrobial cycling did not result in a significant change in enteric acquisition of resistant Gram-negative bacteria among intensive care unit patients.
PMID: 15599150 [PubMed - as supplied by publisher]
Comment on:
Do not suction above the cuff.
van Saene HK, Ashworth M, Petros AJ, Sanchez M, de la Cal MA.
Publication Types:
PMID: 15483436 [PubMed - indexed for MEDLINE]
Comment on:
Albumin versus crystalloid solutions for the critically ill and injured.
Weil MH, Tang W.
Publication Types:
PMID: 15483432 [PubMed - indexed for MEDLINE]
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Prevention of stress ulceration: current trends in critical care.
Daley RJ, Rebuck JA, Welage LS, Rogers FB.
Pharmacotherapy Department, Fletcher Allen Health Care, Burlington, VT, USA.
OBJECTIVE: To identify the level of current intensivist's knowledge regarding risk assessment and intensive care unit (ICU) clinical practice pertaining to stress-related mucosal bleeding, including pharmacologic approaches for stress ulcer prevention. DESIGN: A nationwide survey of critical care physicians. STUDY POPULATION: Two thousand random physician members of the Society of Critical Care Medicine. MEASUREMENTS AND MAIN RESULTS: The response rate was 519 (26%) of 2000, with data analysis from 501 (25.1%) usable surveys. Respondents were affiliated with internal medicine (44.3%), surgery (42.3%), and anesthesiology (12.6%). Gut ischemia was indicated as the perceived major cause of stress ulceration (59.7%). The estimated incidence of clinically important bleeding was 2% or less by 62% of respondents; however, 28.6% of physicians surveyed initiate stress ulcer prophylaxis in all ICU patients, regardless of bleeding risk. Respiratory failure was most frequently indicated as a reason for stress ulcer prophylaxis (68.6%), followed by shock/hypotension (49.4%), sepsis (39.4%), and head injury/major neurologic insult (35.2%). The first-line agents selected for stress ulcer prophylaxis include histamine-2 receptor antagonists (63.9%), followed by proton pump inhibitors (23.1%), and sucralfate (12.2%). Concern for nosocomial pneumonia was regarded as more prevalent with antisecretory therapies in those who chose sucralfate (61%) as initial therapy compared with overall respondents (26.9%) (p < .001). CONCLUSIONS: The majority of intensivists surveyed recognize stress-related mucosal bleeding as a relatively infrequent event; however, implementation of a stress ulcer prophylaxis risk stratification scheme for ICU patients is necessary. Histamine-2 receptor antagonists are consistently perceived as appropriate initial agents, although proton pump inhibitors have become first-line therapy in an increasing percentage of critical care patients, despite limited data regarding their use in this population.
PMID: 15483408 [PubMed - indexed for MEDLINE]
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New regulations for the care of the critically ill patients in Italy.
Zamperetti N, Conti G.
Publication Types:
PMID: 15292985 [PubMed - indexed for MEDLINE]
Comment on:
Intra-hospital transport of critically ill patients: minimising risk.
Shirley PJ, Bion JF.
Publication Types:
PMID: 15197442 [PubMed - indexed for MEDLINE]
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Morphologic characteristics of central pulmonary thromboemboli predict haemodynamic response in massive pulmonary embolism.
Podbregar M, Voga G, Krivec B.
Department for Intensive Internal Medicine, General Hospital Celje, Oblakova 5, 3000 Celje, Slovenia. Matej.Podbregar@guest.arnes.si
OBJECTIVE: On hospital admission, the morphology of the central pulmonary artery thromboemboli is an independent predictor of 30-day mortality in patients with massive pulmonary embolism (MPE). This may be due to the differential susceptibility of thromboemboli to thrombolysis. The aim of this study was to assess haemodynamic response to treatment in patients with MPE and morphologically different thromboemboli. DESIGN: Prospective observational study. SETTING: An 11-bed closed medical ICU at a 860-bed community general hospital. PATIENTS: Twelve consecutive patients with shock or hypotension due to MPE and central pulmonary thromboemboli detected by transesophageal echocardiography who were treated with thrombolysis between January 2000 through April 2002. PROCEDURES: Patients were divided into two groups according to the characteristics of detected central pulmonary thromboemboli: group 1, thrombi with one or more long, mobile parts; and group 2, immobile thrombi. Urokinase infusion was terminated when mixed venous oxygen saturation was stabilized above 60% for 15 min. RESULTS: At 2 h, the total pulmonary vascular resistance index was reduced more in group 1 than group 2 [from 27+/-12 mmHg/(l.min.m(2)) to 14+/-6 mmHg/(l.min.m(2)) (-52%) vs 27+/-8 mmHg/(l.min.m(2)) to 23+/-10 mmHg/(l.min.m(2)) (-15%), respectively, P=0.04]. In group 1 thrombolysis was terminated earlier than group 2 (89+/-40 min vs 210+/-62 min, respectively, P= 0.0024). The cumulative dose of urokinase used in group 1 was lower than group 2 (1.7+/-0.3 M i.u. vs 2.7+/-0.5 M i.u., respectively, P= 0.023). CONCLUSION: Haemodynamic stabilization is achieved faster in patients with mobile central thromboemboli detected by transesophageal echocardiography during MPE.
PMID: 15197440 [PubMed - indexed for MEDLINE]
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Combination enteral and parenteral nutrition in critically ill patients: harmful or beneficial? A systematic review of the evidence.
Dhaliwal R, Jurewitsch B, Harrietha D, Heyland DK.
Department of Medicine, Queen's University, Kingston, Ontario, Canada.
OBJECTIVE: A combination of enteral (EN) and parenteral nutrition (PN) is often used as a strategy to optimize nutritional intake in critically ill patients; however, the effects of this intervention on clinically important outcomes have not been widely studied. This paper systematically reviewed studies that compare EN + PN to enteral nutrition (EN) alone in critically ill patients. METHODS: We searched bibliographic databases, personal files, and relevant reference lists to identify randomized controlled trials that compared combination EN + PN to EN alone. RESULTS: Only five studies met the inclusion criteria. In all these studies PN was started at the same time as EN in the experimental group. When the results of these trials were aggregated, EN + PN had no significant effect on mortality. There was no difference between the two groups in rates of infectious complications, length of hospital stay, or ventilator days. CONCLUSIONS: In critically ill patients who are not malnourished and have an intact gastrointestinal tract, starting PN at the same time as EN provides no benefit in clinical outcomes over EN alone. More research is needed to determine the effects of combination EN + PN on clinical outcomes in critically ill patients who are poorly intolerant to EN.
Publication Types:
PMID: 15185069 [PubMed - indexed for MEDLINE]
Comment on:
The ICNSS: incorporating family care into nursing workload assessment.
Olson D.
Publication Types:
PMID: 15160238 [PubMed - indexed for MEDLINE]
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Street drug abuse leading to critical illness.
Mokhlesi B, Garimella PS, Joffe A, Velho V.
Division of Pulmonary and Critical Care, Cook County Hospital and Rush Medical Center, 1901 West Harrison Street, Suite 2818 B, Chicago, IL 60612, USA. Babak_Mokhlesi@rush.edu
Critical care physicians are frequently confronted with intoxicated patients who have used street drugs. In the last decade there has been an upward trend in the use of these substances, particularly amongst adolescents and young adults in large urban areas. In excess quantities all street drugs can lead to critical illness. Early and appropriate medical attention by emergency medicine physicians and intensivists can improve outcomes. In this review article we intend to familiarize critical care physicians with the most common street drugs such as amphetamines, ecstasy, cocaine, gamma hydroxybutyrate, opioids, and phencyclidine.
Publication Types:
PMID: 14999443 [PubMed - indexed for MEDLINE]
Practice variability in management of acute respiratory distress syndrome: bringing evidence and clinician education to the bedside using a web-based teaching tool.
Belda TE, Gajic O, Rabatin JT, Harrison BA.
Department of Anesthesiology, Mayo Clinic, 200 First Street SW, 2-114 Old Marian Hall, Rochester MN 55905, USA. belda.thomas@mayo.edu.
BACKGROUND: Clinical practice often lags behind publication of evidence-based research and national consensus guidelines. OBJECTIVE: To assess practice variability in the clinical management of acute respiratory distress syndrome (ARDS) and test an evidence-based, online clinician-education tool designed to improve intensive-care clinicians' understanding of current evidence about ARDS management. METHODS: We surveyed 117 intensive care clinicians (16 critical care physician specialists, 28 resident physicians, 50 critical care nurses, and 23 respiratory therapists) with an online questionnaire in our tertiary academic institution. Fifty of the original respondents (12 residents, 26 critical care nurses, and 12 respiratory therapists) also responded to a repeat survey that included context-sensitive hypertext links to a summary of critically appraised primary articles regarding ARDS management, to determine if the responses changed after the clinicians had read the evidence-based summary information. RESULTS: Critical care physician specialists were most likely to choose the low-tidal-volume (low-VT) ventilation strategy and protocol-based ventilator weaning and were least likely to choose neuromuscular blockade or parenteral nutrition (p < 0.05). In a paired comparison, individual respondents were more likely to choose treatment options that are based on stronger evidence (low-VT, daily interruption in sedation, and protocol weaning [p < 0.01]). We also reviewed the medical records of 100 patients who were mechanically ventilated for > 48 h, during the 6 months before and after the survey, from which we identified 45 ARDS patients. Following the clinician-education intervention, ARDS patients were less likely to receive potentially injurious high-VT ventilation (mean day-3 VT 10.3 +/- 2.3 mL/kg before vs 8.9 +/- 1.7 mL/kg after, p = 0.02). CONCLUSION: Web-based teaching tools are useful to educate intensive-care practitioners and to promote evidence-based practice. Copyright 2004 Daedalus Enterprises
PMID: 15329172 [PubMed - indexed for MEDLINE]
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