Ultimo Aggiornamento: 13 Gennaio 2004

1: Anaesthesia. 2003 Dec;58(12):1204-9.

Who to report to the coroner? A survey of intensive care unit directors and Her
Majesty's Coroners in England and Wales.

Booth SA, Wilkins ML, Smith JM, Park GR.

Department of Anaesthesia, Addenbrooke's Hospital, Hills Road, Cambridge CB2
2QQ, UK.

We performed a postal survey to assess the ability of intensive care unit
directors and Her Majesty's Coroners to recognise deaths that should be reported
to the local coroner. The survey questionnaire consisted of 12 hypothetical case
scenarios. Coroners were significantly better at identifying reportable deaths
than intensive care unit directors (median correct recognition scores of 11
(interquartile range 9.25-11) vs. 8 (interquartile range 7-10), respectively, p
< 0.01). Deaths associated with an accident, medical treatments, industrial
disease, neglect and substance abuse were significantly under-reported by
intensive care unit directors (p < 0.01). Results show that significant numbers
of deaths on intensive care units in England and Wales may not be being referred
for further investigation, and that wide variation in local coroners' practices
exists. Improvements in postgraduate medicolegal education about deaths
reportable to a coroner are required. National regulations need to be more
detailed and standardised so that regional variation is eliminated.

PMID: 14705685 [PubMed - indexed for MEDLINE]

2: Br J Anaesth. 2003 Dec;91(6):815-9.

Constipation and its implications in the critically ill patient.

Mostafa SM, Bhandari S, Ritchie G, Gratton N, Wenstone R.

Intensive Therapy Unit, Royal Liverpool University Hospital, Prescot Street,
Liverpool, L7 8XP, UK. Fred.Mostafa@rlbuht.nhs.uk

BACKGROUND: Motility of the lower gut has been little studied in intensive care
patients. METHOD: We prospectively studied constipation in an intensive care
unit of a university hospital, and conducted a national survey to assess the
generalizability of our findings. RESULTS: Constipation occurred in 83% of the
patients. More constipated patients (42.5%) failed to wean from mechanical
ventilation than non-constipated patients (0%), P<0.05. The median length of
stay in intensive care and the proportion of patients who failed to feed
enterally were greater in constipated than non-constipated patients (10 vs 6.5
days and 27.5 vs 12.5%, respectively (NS)). The survey found similar
observations in other units. Delays in weaning from mechanical ventilation and
enteral feeding were reported by 28 and 48% of the units surveyed, respectively.
CONCLUSIONS: Constipation has implications for the critically ill.

Publication Types:
Multicenter StudyPMID: 14633751 [PubMed - indexed for MEDLINE]

3: Br J Anaesth. 2003 Dec;91(6):810-4.

Implicit memory formation in sedated ICU patients after cardiac surgery.

Clark J, Voss L, Barnard J, Sleigh J.

Department of Anaesthetics and Intensive Care, University of Auckland, Waikato
Clinical School, Hamilton, New Zealand.

BACKGROUND: Recent research into memory formation under sedation has generated
conflicting results. We investigated explicit and implicit memory in ICU
patients during moderate to deep propofol sedation following cardiac surgery.
METHODS: Two different methods of memory testing were used; (1).
free-association (F-A) word-pair testing (n=33) to test conceptual implicit
memory and (2). process dissociation procedure (PDP) (n=26) to detect perceptual
implicit and explicit memory. One hour after surgery, whilst sedated, the F-A
group received one of two lists of 10 category-exemplar word-pairs through
headphones, while the PDP group was presented with one of two lists of 16
five-letter words. When awake and co-operative, the F-A group was tested using
F-A testing, and the PDP group was tested using the PDP. RESULTS: The F-A group
had a mean (SD) correct response rate of 7 (9)% for the target list, and 9 (8)%
for the distractor list. The PDP group had a mean (SD) correct response rate of
11 (14) and 10 (13)% for the inclusion and exclusion lists, respectively, with
mean correct response rates of 13 (14)% for both the corresponding distractor
lists. Neither group showed any significant differences between their responses
and a list of distractor words (Wilcoxon tests). CONCLUSION: We found no
evidence for memory formation in post-cardiac surgery patients under moderate to
deep propofol sedation.

PMID: 14633750 [PubMed - indexed for MEDLINE]

4: Chest. 2003 Dec;124(6 Suppl):357S-363S.

Prevention of venous thromboembolism in the ICU.

Geerts W, Selby R.

Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

BACKGROUND: Although venous thromboembolism (VTE) is an important cause of
morbidity and mortality in critical care unit patients, the risk of VTE and its
prevention have been poorly characterized in this population. Evidence-based
thromboprophylaxis guidelines are also not available for these critically ill
patients. OBJECTIVES: To review the prevalence of VTE, to summarize the
available clinical trials of thromboprophylaxis, and to outline a practical
approach to the prevention of VTE in critical care unit patients. METHODS:
Systematic review of the relevant literature. RESULTS: Most patients in critical
care units have at least one major risk factor for VTE, and many patients have
multiple risk factors. Objectively confirmed deep-vein thrombosis (DVT) rates
varied from 13 to 31% among the four prospective studies in which critical care
unit patients did not receive prophylaxis. We were able to identify only three
randomized trials of thromboprophylaxis conducted in critical care units. The
results of these studies suggest that both low-dose heparin and
low-molecular-weight heparin are efficacious in preventing DVT compared with no
prophylaxis. Fourteen studies reported that compliance with some form of
thromboprophylaxis occurred in 33 to 100% of critically ill patients.
CONCLUSIONS: There is a paucity of data assessing the risks and prevention of
VTE in critical care settings. Selection of prophylaxis for these challenging
patients involves a consideration of the thromboembolic and bleeding risks, both
of which may vary in the same patient from day to day.

Publication Types:
Review
Review, AcademicPMID: 14668418 [PubMed - indexed for MEDLINE]

5: Chest. 2003 Dec;124(6 Suppl):347S-348S.

Advances and contemporary issues in prophylaxis for deep vein thrombosis.

Hirsh J.

McMaster University, Hamilton, Ontario, Canada. jhirsh@thrombosis.hhscr.org

PMID: 14668416 [PubMed - indexed for MEDLINE]

6: Chest. 2003 Dec;124(6):2384-7.

A 74-year-old man with bilateral pulmonary opacities and rapidly progressive
renal failure.

Maimon N, Abu-Shakra M, Sion-Vardi N, Almog Y.

Medical Intensive Care Unit, and the Department of Medicine D, Soroka University
Medical Center, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva,
Israel.

Publication Types:
Case ReportsPMID: 14665525 [PubMed - indexed for MEDLINE]

7: Chest. 2003 Dec;124(6):2363-7.

Intracardiac (superior vena cava/right atrial) ECGs using saline solution as the
conductive medium for the proper positioning of the Shiley hemodialysis
catheter: is it not time to forego [correction of forgo] the postinsertion chest
radiograph?

Madias JE.

Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY
11373, USA. madiasj@nychhc.org

Hemodialysis (HD) is often administered in critical care areas to patients with
chronic renal failure as a continuation of the HD they are receiving on an
ambulatory basis, and to patients who develop such a need for the first time or
may require HD only transiently. The double-lumen Shiley central venous catheter
(SCVC), inserted via the brachiocephalic veins, is often employed for HD, and it
is customary to obtain a chest radiograph to ensure proper positioning of the
tip of the SCVC within the superior vena cava (SVC) or high right atrium (RA).
This practice is implemented to evaluate for complications stemming from the
insertion of the SCVC and subsequent mishaps due to low positioning of the tip
of the catheter in the RA or right ventricle. Intracardiac ECGs obtained via a
saline solution-filled SCVC as the conductive medium can be easily recorded
serially and periprocedurally to ensure proper positioning of the tip of the
SCVC in the SVC or high RA based on the evaluation of the appearance and
amplitude of atrial depolarization, thus rendering chest radiographs redundant.

PMID: 14665521 [PubMed - indexed for MEDLINE]

8: Chest. 2003 Dec;124(6):2267-74.

Underrecognition of preexisting cognitive impairment by physicians in older ICU
patients.

Pisani MA, Redlich C, McNicoll L, Ely EW, Inouye SK.

Department of Internal Medicine, Yale University School of Medicine, 333 Cedar
Street, PO Box 208057, New Haven, CT 06520-8057, USA. Margaret.Pisani@yale.edu

OBJECTIVES: Cognitive impairment increases with age, as do many serious
illnesses requiring intensive care. Little is known, however, about physician
recognition of preexisting cognitive impairment in the ICU and which patient
factors may play a role in physician recognition. DESIGN: Cross-sectional
comparative study. SETTING: Urban university teaching hospital. PARTICIPANTS: A
total of 165 patients aged > or =65 years who were admitted to the medical ICU.
MEASUREMENTS: Two previously validated proxy measures of cognitive impairment,
the modified Blessed dementia rating scale and the informant questionnaire on
cognitive decline in the elderly. Physician interviews and medical record
abstraction were used to evaluate the recognition of cognitive impairment.
RESULTS: The prevalence of preexisting cognitive impairment in the ICU was 37%.
Attending physicians were unaware of the preexisting cognitive impairment in 53%
of cases, and intern physicians were unaware in 59% of cases. The recognition of
preexisting cognitive impairment increased as the severity of the cognitive
impairment increased. Two independent risk factors were identified that were
significantly associated with the increased recognition of preexisting cognitive
impairment (ie, impairment in activities of daily living or being admitted to
the ICU from a nursing home). If both were present, preexisting cognitive
impairment was 13 times more likely to be recognized. CONCLUSIONS: A substantial
number of older ICU patients have preexisting cognitive impairment on admission
to the ICU, and ICU physicians caring for these patients are unaware of this
cognitive impairment in the majority of cases. Future research is needed to
identify outcomes related to preexisting cognitive impairment and to improve its
recognition.

PMID: 14665510 [PubMed - indexed for MEDLINE]

9: Chest. 2003 Dec;124(6):2256-60.

The effect of vasopressin on gastric perfusion in catecholamine-dependent
patients in septic shock.

van Haren FM, Rozendaal FW, van der Hoeven JG.

Department of Intensive Care Medicine, Jeroen Bosch Hospital, PO Box 90153, 5200
ME 's-Hertogenbosch, the Netherlands. fvharen@planet.nl

OBJECTIVE: To study the effect of continuous infusion of vasopressin on the
splanchnic circulation in patients with severe septic shock. DESIGN: Prospective
clinical study. SETTING: ICU in a teaching hospital. PATIENTS: Eleven
consecutive patients with documented septic shock who remained hypotensive
despite norepinephrine infusion at a rate > or =0.2 microg/kg/min.
INTERVENTIONS: Insertion of a gastric tonometry catheter, and continuous
infusion of vasopressin 0.04 U/min during 4 h. Measurements and main results:
Difference between gastric and arterial CO(2) partial pressure (P[g-a]CO(2)
gap), mean arterial pressure, and cardiac index were recorded at baseline and
after 15 min, 30 min, 60 min, 120 min, and 240 min. RESULTS: The median
P(g-a)CO(2) gap increased from 5 mm Hg at baseline to 19 mm Hg after 4 h (p =
0.022). Mean arterial pressure increased from 61 +/- 13 mm Hg at baseline to 68
+/- 9 mm Hg after 4 h (p = 0.055). No significant changes in cardiac index were
noted. CONCLUSIONS: In norepinephrine-dependent patients in septic shock,
continuous infusion of low-dose vasopressin results in a significant increase of
the P(g-a)CO(2) gap compatible with GI hypoperfusion.

Publication Types:
Clinical TrialPMID: 14665508 [PubMed - indexed for MEDLINE]

10: Chest. 2003 Dec;124(6):2239-43.

Incidence, etiology, and outcome of nosocomial pneumonia in ICU patients
requiring percutaneous tracheotomy for mechanical ventilation.

Rello J, Lorente C, Diaz E, Bodi M, Boque C, Sandiumenge A, Santamaria JM.

Critical Care Department, Joan XXIII University Hospital, University Rovira &
Virgili, Carrer Dr Mallafre Guasch 4, 43007 Tarragona, Spain. jrc@hjxxiii.scs.es

OBJECTIVE: To determine the epidemiology of pneumonia in patients with
tracheotomy receiving short-term mechanical ventilation. DESIGN: Observational
prospective study. SETTING: A 14-bed medical-surgical ICU. SUBJECTS: Ninety-nine
critically ill acute patients requiring percutaneous dilatational tracheotomy
for mechanical ventilation. INTERVENTIONS: Tracheal aspirate obtained 48 h
before tracheotomy. MEASUREMENTS AND MAIN RESULTS: Eighteen patients (18.1%)
acquired pneumonia (median of 7 days after tracheotomy). Pseudomonas aeruginosa
was the most frequently identified pathogen, found in eight of the episodes
(four not documented by prior tracheal colonization), followed by other
Gram-negative bacilli. The development of ventilator-associated pneumonia (VAP)
was not anticipated by any clinical variable. A positive tracheal aspirate (TA)
culture result obtained before tracheotomy was associated with a risk of
acquiring pneumonia of 19.7%, whereas sterile TA cultures were associated with a
risk of 14.3% (p > 0.20). VAP prolonged ICU stay or the ventilation period for a
median of 19 days and 15 days, respectively. Overall mortality was 34.3%, but
the presence of VAP did not increase the mortality rate. CONCLUSIONS:
Percutaneous tracheotomy in patients receiving short-term mechanical ventilation
predisposes to pneumonia. Pneumonia was associated with prolonged ventilation
and ICU stay, but was not associated with increased mortality. Pseudomonas is a
common pathogen after tracheotomy, and this observation should be considered in
selecting an antibiotic regimen, because TA obtained prior to the tracheotomy
often failed to identify this pathogen.

PMID: 14665506 [PubMed - indexed for MEDLINE]

11: Clin Chest Med. 2003 Dec;24(4):763-73.

Improving care for patients dying in the intensive care unit.

Rubenfeld GD, Curtis JR.

Division of Pulmonary and Critical Care Medicine, Harborview Medical Center,
University of Washington, 325 Ninth Avenue, Seattle, WA 98104-2499, USA.
nodrog@u.washington.edu

It is impossible for ICU clinicians to avoid caring for dying patients and their
families. For many, this is an extremely rewarding aspect of their clinical
practice. There is ample evidence that there is room to improve the care of
patients who are near death in the ICU. Despite the considerable holes in our
knowledge about optimal care of dying critically ill patients, there is
considerable agreement on the general principles of caring for these patients
and about how to measure the outcomes of palliative care in the ICU. Practical
approaches to improving the quality of end-of-life care exist and should be
implemented.

Publication Types:
Review
Review, TutorialPMID: 14710703 [PubMed - indexed for MEDLINE]

12: Clin Chest Med. 2003 Dec;24(4):751-62.

Prognostication and intensive care unit outcome: the evolving role of scoring
systems.

Herridge MS.

University Health Network, Department of Medicine, University of Toronto,
Toronto, ON, Canada. margaret.herridge@uhn.on.ca

Prognostic scoring systems remain important in clinical practice. They enable us
to characterize our patient populations with robust measures for predicted
mortality. This allows us to audit our own experience in the context of
institutional quality control measures and facilitates, albeit imperfectly,
comparisons across units and patient populations. Practically, they provide an
objective means to characterize case-mix and this helps to quantify resource
needs when negotiating with hospital administrators for funding. Prognostic
scores also help to stratify patient populations for research purposes. To be
used accurately and effectively, one must have a good understanding of the
limitations that are intrinsic to these prognostic systems. It is important to
understand the details of their derivation and validation. The population of
patients that is used to develop the models may not be relevant to your patient
population. The model may have been derived several years before and may no
longer reflect current practice patterns and treatment. These models may become
obsolete over time. As with all scoring systems, there are potential problems
with misclassification and more serious, systematic error, in data collection.
One needs to rigorously adhere to guidelines about how these data are to be
collected and processed; the persons who collect the data require regular
updates and ongoing training. In their current form, the systems should not be
used to prognosticate in individual patients, nor should they be used to define
medical futility. The prognostic models should be viewed as being in evolution.
Many patient and ICU characteristics that seem to have an important impact on
mortality have yet to be incorporated into any of the current models. As an
example, these may include the genetic characteristics of the patients and the
ICU's organizational structure and process of care [51, 52]. Because the organ
dysfunction measures are able to be obtained daily they give a much more
complete understanding of the patient's entire ICU course as opposed to the
initial 24-hour period. Daily scores also help to capture the intensity of
resource use and may help us gain a better understanding of what is truly
ICU-acquired organ dysfunction. These measures may also be used for research to
better characterize the natural history and course of a certain disease group or
population. Also, they may be used in innovative ways to predict ICU mortality
and post-ICU long-term morbidity. These current and developing applications will
help us to further understand the link between ICU severity of illness and
long-term morbidity as we move beyond survival as the sole measure of ICU
outcome.

Publication Types:
Review
Review, TutorialPMID: 14710702 [PubMed - indexed for MEDLINE]

13: Clin Chest Med. 2003 Dec;24(4):739-49, viii.

Guidelines in the intensive care unit.

Sinuff T, Cook DJ.

Department of Medicine, McMaster University, Room 3W10, 1200 Main Street West,
Hamilton, ON L9H 6Z6, Canada. sinufft@mcmaster.ca

The recent movement toward standardization of critical care practice is
associated with a growth in the use of guidelines and protocols. Although
complex, the process of guideline development, implementation, evaluation, and
maintenance can be systematic. Guideline implementation can improve the
processes and outcomes of care; however, guideline adherence represents a major
challenge to their success. The quality of the growing number of practice
guidelines in critical care is important to assess and several useful
instruments are available for this purpose.

Publication Types:
Review
Review, TutorialPMID: 14710701 [PubMed - indexed for MEDLINE]

14: Clin Chest Med. 2003 Dec;24(4):727-37.

Cognitive impairment in the intensive care unit.

Pisani MA, McNicoll L, Inouye SK.

Department of Internal Medicine, Yale University School of Medicine, 333 Cedar
Street, New Haven, CT 06520-8057, USA. margaret.pisani@yale.edu

Delirium is a frequent complication in older patients in the ICU and often
persists beyond their ICU stay. Delirium in older persons in the ICU is a
dynamic and complex process. There is a high prevalence of pre-existing
cognitive impairment in patients who are admitted to the medical ICU. This
pre-existing cognitive impairment is an important predisposing risk factor for
the development of delirium during and after the ICU stay. Given the high rates
of delirium in the ICU that range from 50% to 80% (see references [27, 28, 34]),
future studies are urgently needed to examine risk factors for delirium in the
ICU setting, such as examining the impact of psychoactive medication use on
delirium rates and persistence in the ICU setting. Moreover, studies that
examine the impact of delirium prevention in the ICU on rates of delirium,
duration and persistence of delirium, and long-term cognitive and functional
outcomes post-ICU stay are greatly needed.

Publication Types:
Review
Review, TutorialPMID: 14710700 [PubMed - indexed for MEDLINE]

15: Clin Chest Med. 2003 Dec;24(4):713-25.

Management of agitation in the intensive care unit.

Siegel MD.

Pulmonary and Critical Care Section, Yale University School of Medicine, Medical
Intensive Care Unit, Yale-New Haven Hospital, New Haven, CT, USA.
mark.siegel@yale.edu

Although the effective evaluation and management of agitated patients often
receives less attention than other aspects of critical illness, it is among the
most important and rewarding challenges that face critical care physicians. Key
features of effective management include a thorough, organized search for
potentially dangerous and correctable causes; a sound understanding of the
pharmacology of analgesics and sedatives; and keeping a steady eye on
appropriate management goals. In turn, the reward for excellent care will be
shorter lengths of stay, more rapid liberation from mechanical ventilation,
improved cognition, cost savings, and, perhaps, improved survival.

Publication Types:
Review
Review, AcademicPMID: 14710699 [PubMed - indexed for MEDLINE]

16: Clin Chest Med. 2003 Dec;24(4):645-69.

A rational approach to the evaluation and treatment of the infected patient in
the intensive care unit.

Avecillas JF, Mazzone P, Arroliga AC.

Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation,
9500 Euclid Avenue, Cleveland, OH 44195, USA.

Critically ill patients are at increased risk of acquiring nosocomial
infections. A thorough clinical evaluation and the selection of appropriate
diagnostic techniques are important elements in the evaluation of these
patients. Nonetheless, this selection process can be difficult because of the
wide spectrum of disease that is seen in the ICU and the lack of standardized
studies that have evaluated the different diagnostic methods that are available.
Many different antimicrobials are available for the treatment of ICU-acquired
infections. Most antimicrobial regimens have not been evaluated in large-scale,
prospective, randomized trials. Until this information is available, the
clinician must make an effort to be familiar with the different clinical and
epidemiologic variables that can be used to stratify patients at the moment of
selecting antimicrobial therapy. The information provided in this article, used
in association with good clinical judgment, will help the critical care
physician provide optimal initial management of the infected patient in the ICU.

Publication Types:
Review
Review, AcademicPMID: 14710696 [PubMed - indexed for MEDLINE]

17: Clin Chest Med. 2003 Dec;24(4):549-60.

Hemodynamic monitoring in the intensive care unit.

Pinsky MR.

Department of Critical Care Medicine, Bioengineering and Anesthesiology,
University of Pittsburgh School of Medicine, 606 Scaife Hall, 3550 Terrace
Street, Pittsburgh, PA 15261, USA. pinskymr@ccm.upmc.edu

Hemodynamic monitoring is a diagnostic tool. Because hemodynamic monitoring
often requires invasive procedures, it can be associated with an increased
incidence of untoward events. Like any diagnostic tool, its ability to improve
outcome will be primarily related to the survival benefit enjoyed by specific
therapies that can only be given without complications based on their use.
Presently, few specific treatment plans fit into this category. The diagnostic
accuracy of preload responsiveness is markedly improved by the use of arterial
pulse pressure or stroke volume variation, neither of which require pulmonary
arterial catheterization. The field of hemodynamic monitoring is rapidly
evolving and will probably continue to evolve at this rapid pace over the next 5
to 10 years as new technologies, information management systems, and our
understanding of the pathophysiology of critical illness progresses.

Publication Types:
Review
Review, TutorialPMID: 14710690 [PubMed - indexed for MEDLINE]

18: Crit Care Med. 2003 Dec;31(12 Abstr Suppl):A1-150.

Abstracts of the 33rd Critical Care Congress. Orlando, Florida, USA. February
20-25, 2004.

[No authors listed]

Publication Types:
Congresses
OverallPMID: 14708562 [PubMed - indexed for MEDLINE]

19: Crit Care Med. 2004 Jan;32(1):295-6.

Are we ready to monitor for delirium in the intensive care unit?

Tanios MA, Epstein SK, Teres D.

Publication Types:
Comment
EditorialPMID: 14707599 [PubMed - in process]

20: Crit Care Med. 2004 Jan;32(1):291-3.

Age and functional status as determinants of intensive care unit outcome: sound
basis for health policy or tip of the outcomes iceberg.

Szalados JE.

Publication Types:
Comment
EditorialPMID: 14707597 [PubMed - in process]

21: Crit Care Med. 2004 Jan;32(1):126-30.

Oral decontamination is cost-saving in the prevention of ventilator-associated
pneumonia in intensive care units.

van Nieuwenhoven CA, Buskens E, Bergmans DC, van Tiel FH, Ramsay G, Bonten MJ.

Department of Surgery, Atrium Heerlen, The Netherlands.

OBJECTIVE: Although the development of ventilator-associated pneumonia (VAP) is
assumed to increase costs of intensive care unit stay, it is unknown whether
prevention of VAP by means of oropharyngeal decontamination is cost-effective.
Because of wide ranges of individual patient costs, crude cost comparisons did
not show significant cost reductions. DESIGN: Based on actual cost data of 181
individual patients included in a former randomized clinical trial,
cost-effectiveness of prevention of VAP was determined using a decision model
and univariate sensitivity analyses, and bootstrapping was used to assess the
impact of variability in the various outcomes. DATA SOURCE: Published data on
prevention of VAP by oropharyngeal decontamination, which resulted in a relative
risk for VAP of 0.45, with a baseline rate of VAP of 29% among control patients.
The mean costs of the intervention were 351 dollars per patient (32 dollars per
patient per day). All other costs were derived from the hospital administrative
database for all individual patients. RESULTS OF BASE-CASE ANALYSIS: Prevention
of VAP led to mean total costs of 16,119 dollars and 18,268 dollars for patients
without preventive measures administered. Thus, costs were saved and instances
of VAP were prevented. Similar results were observed in terms of overall
survival. RESULTS OF SENSITIVITY ANALYSIS: Prevention of VAP remains cost-saving
if the relative risk for VAP because of intervention is <0.923, the costs of the
intervention are less than 2,500 dollars, and the prevalence of VAP without
intervention is >4%. Bootstrapping confirmed that, with about 80% certainty,
oropharyngeal decontamination results in prevention of VAP and simultaneously
saves costs. In terms of a survival benefit, the results are less evident; the
results indicate that with only about 60% certainty can we confirm that
oropharyngeal decontamination would result in a survival benefit and
simultaneously save costs. CONCLUSIONS: This study provides strong evidence that
prevention of VAP by means of oropharyngeal decontamination is cost-effective.

PMID: 14707570 [PubMed - in process]

22: Crit Care Med. 2004 Jan;32(1):106-12.

Current opinions regarding the importance, diagnosis, and management of delirium
in the intensive care unit: a survey of 912 healthcare professionals.

Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, Dittus RS,
Bernard GR.

Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN,
USA. wes.ely@vanderbilt.edu

OBJECTIVE: Recently published clinical practice guidelines of the Society of
Critical Care Medicine recommend monitoring for the presence of delirium in all
mechanically ventilated patients because of the potential for adverse outcomes
associated with this comorbidity, yet little is known about healthcare
professionals' opinions regarding intensive care unit delirium or how they
manage this organ dysfunction. The aim of this survey was to assess the medical
community's beliefs and practices regarding delirium in the intensive care unit.
DESIGN: Survey administration was conducted both without a delirium definition
(phase 1) and then with a definition of delirium (phase 2). SETTING: Critical
care meetings and continuing medical education/board review courses from October
2001 to July 2002. PARTICIPANTS: A convenience sample of physicians (n = 753),
nurses (n = 113), pharmacists (n = 13), physician assistants (n = 12),
respiratory care practitioners (n = 8), and others (n = 13). INTERVENTIONS:
Survey. MEASUREMENTS AND MAIN RESULTS: Participants completed 912 of the
surveys. The majority (68%) of respondents thought that >25% of adult
mechanically ventilated patients experience delirium. Delirium was considered a
significant or very serious problem in the intensive care unit by 92% of
healthcare professionals, yet underdiagnosis was acknowledged by 78%. Only 40%
reported routinely screening for delirium, and only 16% indicated using a
specific tool for delirium assessment. Delirium was considered important in the
outcome of elderly and young patients by 89% and 60% of the respondents,
respectively (p <.0001). The most serious complications these professionals
associated with delirium were prolonged mechanical ventilation, self-injury, and
respiratory difficulties. Delirium was treated with haloperidol by 66% of the
respondents, with lorazepam by 12%, and with atypical antipsychotics by <5%.
More than 55% administered haloperidol and lorazepam at daily doses of < or =10
mg, but some used >50 mg/day of either medication. CONCLUSIONS: Most healthcare
professionals consider delirium in the intensive care unit a common and serious
problem, although few actually monitor for this condition and most admit that it
is underdiagnosed. Data from this survey point to a disconnect between the
perceived significance of delirium in the intensive care unit and current
practices of monitoring and treatment.

PMID: 14707567 [PubMed - in process]

23: Crit Care Med. 2004 Jan;32(1):100-5.

Complicated acute myocardial infarction requiring mechanical ventilation in the
intensive care unit: prognostic factors of clinical outcome in a series of 157
patients.

Lesage A, Ramakers M, Daubin C, Verrier V, Beynier D, Charbonneau P, du Cheyron
D.

Department of Medical Intensive Care, Caen University Hospital, France.

OBJECTIVE: To determine prognostic factors associated with death in patients
with complicated acute myocardial infarction requiring mechanical ventilation.
DESIGN: Retrospective chart-based analysis. SETTING: A 22-bed medical intensive
care unit in a university hospital. PATIENTS: A total of 157 consecutive
patients with acute myocardial infarction requiring endotracheal intubation and
mechanical ventilation admitted to an intensive care unit during a 6-yr period.
INTERVENTIONS: Coronary reperfusion strategy within 12 hrs following symptom
onset. MEASUREMENTS AND MAIN RESULTS: Clinical characteristics at admission of
survivors (n = 77) and nonsurvivors (n = 80) were similar regarding
demographics, medical history, and Glasgow Coma Scale score. Twenty-eight-day
intensive care unit mortality rate was 51%. The following criteria were higher
for nonsurvivors: Simplified Acute Severity Score II, 79 +/- 18 vs. 64 +/- 17 (p
<.0001); Acute Physiology and Chronic Health Evaluation (APACHE) II, 33 +/- 13
vs. 25 +/- 6 (p <.0001); incidence of cardiogenic shock (p =.0085) and failing
organs (p <.0001); coronary artery disease extension (p =.045); and delay
between symptom onset and coronary reperfusion (p =.0348). Nonsurvivors also had
higher serum urea and creatinine and lower urine output, arterial pH, and left
ventricular ejection fraction (p <.05). Mortality rate was higher in patients
with PaO2/FiO2 ratio <200 than in patients with PaO2/FiO2 ratio >200 at
admission (log-rank, 5.016; p =.0251). By multivariate analysis, only three
factors were independently associated with death: APACHE II >29 (odds ratio,
1.132; 95% confidence interval, 1.013-1.265, p =.0287), serum creatinine >180
micromol/L (odds ratio, 6.151; 95% confidence interval, 1.446-26.166, p =.0139),
and initial left ventricular ejection fraction <0.4 (odds ratio, 1.121; 95%
confidence interval, 1.049-1.347, p =.0316). Overall, good discrimination was
achieved for the risk score model (c-index, 0.852). CONCLUSIONS: We confirmed
the high mortality rate of patients admitted to an intensive care unit with
acute myocardial infarction requiring mechanical ventilation. In these patients,
the main risk factors for death found, namely high APACHE II, early development
of acute renal failure, and low resting left ventricular function, reflected the
severity of the myocardial infarction.

PMID: 14707566 [PubMed - in process]

24: Crit Care Med. 2004 Jan;32(1):70-6.

Using population death rate to predict rate of admissions to the intensive care
unit.

Carroll GC, Herbert DA.

Department of Anesthesiology, Kaiser Permanente Hayward/Fremont Medical Center,
CA 94538-2398, USA. gil.carroll@kp.org

OBJECTIVE: To determine whether the intensive care unit (ICU) admission rates of
new health plan members can be predicted by the mortality of non-ICU-treated
members. DESIGN: Retrospective study of health records. PATIENTS: Five
sequential cohorts of new health plan members (298,974 members) seen at any of
three tertiary care medical centers of a health maintenance organization in
northern California who joined the health plan during the first quarter of 1994,
1995, 1996, 1997, or 1998 and retained membership for > or =1 yr. SETTING: Three
medical centers in northern California. INTERVENTIONS: None. MEASUREMENTS AND
MAIN RESULTS: We measured rates of ICU admission, death, and mechanical
ventilation among cohort members. ICU admission rate varied between hospitals
and over time but was predicted by non-ICU mortality-ICU admission rate = 0.83 x
non-ICU mortality-and was linear throughout its range. In no hospital or time
period was a higher mortality associated with fewer ICU admissions. Seventeen
percent of population deaths occurred among ICU patients and did not differ
among medical centers. CONCLUSIONS: A single linear equation predicted ICU
admission rate from death rate of non-ICU-treated patients among cohorts of new
members. ICU admission rates can be predicted from a measure of population
illness burden, such as the mortality of non-ICU-treated patients. It may be
possible to extend this analysis to other hospitals and health care systems to
evaluate the adequacy of ICU services provided.

PMID: 14707561 [PubMed - in process]

25: Crit Care Med. 2004 Jan;32(1):53-60.

Effect of an intensive care unit rotating empiric antibiotic schedule on the
development of hospital-acquired infections on the non-intensive care unit ward.

Hughes MG, Evans HL, Chong TW, Smith RL, Raymond DP, Pelletier SJ, Pruett TL,
Sawyer RG.

Department of Surgery, University of Virginia, Charlottesville 22908, USA.

OBJECTIVE: We have previously shown that a rotating empirical antibiotic
schedule could reduce infectious mortality in an intensive care unit (ICU). We
hypothesized that this intervention would decrease infectious complications in
the non-ICU ward to which these patients were transferred. DESIGN: Prospective
cohort study. SETTING: An ICU and the ward to which the ICU patients were
transferred at a university medical center. PATIENTS: All patients treated on
the general, transplant, or trauma surgery services who developed
hospital-acquired infection while on the non-ICU wards. INTERVENTIONS: A 2-yr
study consisting of 1-yr non-protocol-driven antibiotic use and 1-yr quarterly
rotating empirical antibiotic assignment for patients treated in the ICU from
which a portion of the patients were transferred. MEASUREMENTS AND MAIN RESULTS:
There were 2,088 admissions to the non-ICU wards during the nonrotation year and
2,183 during the ICU rotation year. Of these patients, 407 hospital-acquired
infections were treated during the nonrotation year and 213 were treated during
the ICU rotation (19.7 vs. 9.8 infections/100 admissions, p <.0001). During the
ICU rotation year a decrease in the rate of resistant Gram-positive and
resistant Gram-negative infections on the non-ICU wards occurred (2.5 vs. 1.6
infections/100 admissions, p =.04; 1.0 vs. 0.4 infections/100 admissions, p
=.03). Subgroup analysis revealed that the decrease in resistant infections on
the wards was due to a reduction in resistant Gram-positive and resistant
Gram-negative infections among non-ICU ward patients admitted initially from
areas other than the ICU implementing the antibiotic rotation (e.g., home, other
ward, or a different ICU) (1.8 vs. 0.5 infections/100 admissions, p =.0001; 0.7
vs. 0.2 infections/100 admissions, p =.02), not due to differences for those
transferred to the ward from the rotation ICU (10.4 vs. 9.7 infections/100
admissions, p = 1.0; 4.3 vs. 1.9 infections/100 admissions, p =.3). No
differences in infection-related mortality were detected. CONCLUSIONS: An
effective rotating empirical antibiotic schedule in an ICU is associated with a
reduction in infectious morbidity (hospital-acquired and resistant
hospital-acquired infection rates) on the non-ICU wards to which patients are
transferred.

PMID: 14707559 [PubMed - in process]

26: Crit Care Med. 2004 Jan;32(1):31-8.

Effect of a multiple-site intensive care unit telemedicine program on clinical
and economic outcomes: an alternative paradigm for intensivist staffing.

Breslow MJ, Rosenfeld BA, Doerfler M, Burke G, Yates G, Stone DJ, Tomaszewicz P,
Hochman R, Plocher DW.

VISICU, Baltimore, MD 21224, USA. mbreslow@visicu.com

OBJECTIVE: To examine whether a supplemental remote intensive care unit (ICU)
care program, implemented by an integrated delivery network using a commercial
telemedicine and information technology system, can improve clinical and
economic performance across multiple ICUs. DESIGN: Before-and-after trial to
assess the effect of adding the supplemental remote ICU telemedicine program.
SETTING: Two adult ICUs of a large tertiary care hospital. PATIENTS: A total of
2,140 patients receiving ICU care between 1999 and 2001. INTERVENTIONS: The
remote care program used intensivists and physician extenders to provide
supplemental monitoring and management of ICU patients for 19 hrs/day (noon to 7
am) from a centralized, off-site facility (eICU). Supporting software, including
electronic data display, physician note- and order-writing applications, and a
computer-based decision-support tool, were available both in the ICU and at the
remote site. Clinical and economic performance during 6 months of the remote
intensivist program was compared with performance before the intervention.
MEASUREMENTS AND MAIN RESULTS: Hospital mortality for ICU patients was lower
during the period of remote ICU care (9.4% vs. 12.9%; relative risk, 0.73; 95%
confidence interval [CI], 0.55-0.95), and ICU length of stay was shorter (3.63
days [95% CI, 3.21-4.04] vs. 4.35 days [95% CI, 3.93-4.78]). Lower variable
costs per case and higher hospital revenues (from increased case volumes)
generated financial benefits in excess of program costs. CONCLUSIONS: The
addition of a supplemental, telemedicine-based, remote intensivist program was
associated with improved clinical outcomes and hospital financial performance.
The magnitude of the improvements was similar to those reported in studies
examining the impact of implementing on-site dedicated intensivist staffing
models; however, factors other than the introduction of off-site intensivist
staffing may have contributed to the observed results, including the
introduction of computer-based tools and the increased focus on ICU performance.
Although further studies are needed, the apparent success of this on-going
multiple-site program, implemented with commercially available equipment,
suggests that telemedicine may provide a means for hospitals to achieve quality
improvements associated with intensivist care using fewer intensivists.

PMID: 14707557 [PubMed - in process]

27: Intensive Care Med. 2004 Feb;30(2):254-9. Epub 2004 Jan 09.

Validation of the new Intensive Care Nursing Scoring System (ICNSS).

Pyykko AK, Ala-Kokko TI, Laurila JJ, Miettunen J, Finnberg M, Hentinen M.

Department of Nursing and Health Administration, PL 5300, University of Oulu,
90014, Oulu, Finland, anita.pyykko@diak.fi

OBJECTIVES. To validate a new Intensive Care Nursing Scoring System (ICNSS).
DESIGN. Retrospective data collection. SETTING. Adult 19-bed intensive care unit
(ICU) in a tertiary care university hospital. PATIENTS. A total of 1,538 patient
records of which 30 documents were included in the validation. MEASUREMENTS AND
RESULTS. Data included admission scores of the Acute Physiology and Chronic
Health Evaluation II (APACHE II) and the Simplified Acute Physiology Scores II
(SAPS II), daily Therapeutic Intervention Scores (TISS) and ICNSS scores. Data
were compared using Spearman's correlation, t-test and chi-square test. Receiver
operating characteristics (ROC) curve analysis was used to assess the ability of
ICNSS and TISS to predict mortality. Intra-class correlation, percentage
agreement and kappa statistics were used to test the validity of given scores.
Nursing workload assessment using ICNSS showed that medical and
emergency-operated patients caused a greater nursing workload than electively
operated patients ( p<0.001). Six variables of the sub-scale that described
vital function nursing accounted for 27.4% of the variation of SAPS II and for
37% of the variation of APACHE II. The ICNSS sub-scale of vital function nursing
accounted for a ROC area of 0.91. In the validity of the given ICNSS scores,
kappa was 0.81 and weighted kappa 0.82. CONCLUSIONS. Nursing workload varied
between the different admission types. ICNSS explained a similar percentage of
the variation of the admission scores of APACHE II and SAPSS II as TISS and
discriminated between non-survivors and survivors. ICNSS is a suitable nursing
workload instrument to be used with the TISS score.

PMID: 14714105 [PubMed - in process]

28: J Hosp Infect. 2004 Jan;56(1):77-8.

Ralstonia pickettii outbreak associated with contaminated distilled water used
for respiratory care in a paediatric intensive care unit.

Kendirli T, Ciftci E, Ince E, Incesoy S, Guriz H, Aysev AD, Tutar E, Yavuz G,
Dogru U.

Publication Types:
LetterPMID: 14706279 [PubMed - in process]

29: N Engl J Med. 2003 Dec 25;349(26):2565-7; author reply 2565-7.

Comment on:
N Engl J Med. 2003 Sep 18;349(12):1123-32.Withdrawal of mechanical ventilation.

Rady MY.

Publication Types:
Comment
LetterPMID: 14699648 [PubMed - indexed for MEDLINE]

30: Nurs Crit Care. 2003 Sep-Oct;8(5):203-8.

Designing a grounded theory study: some practicalities.

McCallin AM.

School of Nursing, Faculty of Health and Community. Otago Polytechnic, Dunedin,
New Zealand. mccallin@ihug.co.nz

Grounded theory is an interpretative research methodology frequently used by
social science researchers seeking to discover the underlying social processes
shaping interaction. The methodology is useful to create knowledge about the
behavioural patterns of a group. The aim of this paper was to discuss some
practical issues that the prospective grounded theory researcher planning a
small-scale project may consider. Discussion focuses on the basic premises,
choosing a version of grounded theory, the research problem, the purpose of
study, the research question and the place of the literature in a study. The
specific skills required of the grounded theory researcher are considered and
some cautions are exercised. The paper may assist student researchers in a
critical care setting and may be of interest to their supervisors and
experienced. grounded theory researchers.

PMID: 14653527 [PubMed - indexed for MEDLINE]

31: Nurs Crit Care. 2003 Sep-Oct;8(5):197-202.

Neonatal end-of-life care in Sweden.

Lundqvist A, Nilstun T, Dykes AK.

Department of Medical Ethics, University of Lund, Lund, Sweden.
anita.lundqvist@omv.lu.se

A survey was carried out of Swedish neonatal end-of-life regarding practice
before birth, at birth, during dying and after death using a descriptive
questionnaire with close-ended questions and individual comments. The practice
in 32 of 38 neonatal units, as described by the head nurse or the registered
nurses, was largely similar. Respectful treatment of both the neonate and the
parents during neonatal end-of-life care was indicated. Differences were found
in pre-natal care concerning the information about the risks of pre-term birth,
the opportunity for parents to view a pre-term neonate and meet its family, as
well as a social worker. Practice directly after birth was also different. A
little less than half of the units answered that they gave a description of the
seriously ill neonate to the parents before the first visit to the ward.
Practice during dying indicated that only a few units permitted the neonate to
die at home.

Publication Types:
Multicenter StudyPMID: 14653526 [PubMed - indexed for MEDLINE]

32: Nurs Crit Care. 2003 Sep-Oct;8(5):185-6.

Critical care research.

Gelling L.

Publication Types:
EditorialPMID: 14653524 [PubMed - indexed for MEDLINE]

33: Pediatrics. 2003 Dec;112(6 Pt 1):1460-1; author reply 1460-1.

Comment on:
Pediatrics. 2002 Dec;110(6):1177-81.Continuous propofol infusion in 142 critically ill children.

Markovitz BP.

Publication Types:
Comment
LetterPMID: 14654635 [PubMed - indexed for MEDLINE]

34: Pediatrics. 2003 Dec;112(6 Pt 1):1420-1.

Comment on:
Pediatrics. 2003 Dec;112(6 Pt 1):1283-9.The difficulty of diagnosing ventilator-associated pneumonia.

Baltimore RS.

Department of Pediatrics, Yale University School of Medicine, New Haven, CT
06520-8064, USA. robert.baltimore@yale.edu

Publication Types:
CommentPMID: 14654620 [PubMed - indexed for MEDLINE]

35: Pediatrics. 2003 Dec;112(6 Pt 1):1415-9.

Comment on:
Pediatrics. 2002 Sep;110(3):615-6.Resolving our uncertainty about oxygen therapy.

Cole CH, Wright KW, Tarnow-Mordi W, Phelps DL; Pulse Oximetry Saturation Trial
for Prevention of Retinopathy of Prematurity Planning Study Group.

Division of Newborn Medicine, The Floating Hospital for Children, Tufts
University School of Medicine, Boston, MA 02111, USA. ccole@tufts-nemc.org

Publication Types:
CommentPMID: 14654618 [PubMed - indexed for MEDLINE]

36: Pediatrics. 2003 Dec;112(6 Pt 1):1242-7.

Proficiency of pediatric residents in performing neonatal endotracheal
intubation.

Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH.

Department of Pediatrics, University of Texas Health Science Center at San
Antonio, 78229, USA.

OBJECTIVE: Current guidelines of the Accreditation Council for Graduate Medical
Education have restricted the amount of intensive care experience obtained
during pediatric residency. The impact on performing procedures has not been
evaluated. To determine the current level of competency in 1 common procedure,
we investigated the proficiency of pediatric residents in performing neonatal
endotracheal intubation during the academic years 1998-1999 and 2000-2001.
METHODS: Indication for intubation, number of attempts, and achievement of
success were recorded by the respiratory therapist present for the procedure.
Each intubation was scored according to the attempt on which intubation was
successful. Indications for intubation were categorized as respiratory failure,
delivery room resuscitation, and meconium-stained amniotic fluid. Competency was
defined as a successful intubation occurring on the first or second attempt
>or=80% of the time. Intubation scores were compared between residents at
various stages of training and analyzed by multivariate logistic regression
analysis for significance. Comparisons were then performed to determine
percentage success with confidence intervals. We also surveyed previous
graduates of the training program not included in the observations for this
study and asked them to indicate how frequently they perform intubation in
current practice and to assess their own competence in the procedure. RESULTS: A
total of 449 resident procedures were observed during the study periods: 192 by
postgraduate year 1 (PGY-1) residents, 126 by PGY-2 residents, and 131 by PGY-3
residents. A total of 35% (160 of 449) of intubation procedures were never
successful by pediatric house officers. Intubation was successful on the first
or second attempt for 50% of PGY-1 residents (95% confidence interval [CI]:
42.6-56.8), 55% of PGY-2 residents (95% CI: 46-63.5), and 62% of PGY-3 residents
(95% CI: 53.9-70.7). The third-year residents exhibited a significantly higher
likelihood of performing a successful intubation compared with first-year
residents. The first-year residents in 1998-1999 showed no improvement by their
third year in 2000-2001. Surveys were sent to 56 graduates of our residency
program (1998-2000). Completed surveys were received from 31 (66%) of 47. A
total of 71% of the respondents are practicing general pediatrics, and 36%
attend deliveries or perform intubations. A total of 87% reported that their
level of confidence with endotracheal intubation was good or excellent after
completion of residency training. CONCLUSIONS: We provide objective and
subjective data concerning the proficiency of pediatric residents in performing
neonatal endotracheal intubation. None of our resident groups met the specified
definition of technical competence, although there was improvement with
advancing training level in bivariate analyses. However, graduates of our
training program felt confident with their intubation skills in contrast to our
objective findings. As exposure to these important skills becomes limited,
methods to ensure attainment of technical competency during training may need to
be redefined.

PMID: 14654592 [PubMed - indexed for MEDLINE]