Ultimo Aggiornamento: 27 Gennaio 2004

1: Am J Crit Care. 2004 Jan;13(1):25-33; discussion 34.

Oral health and care in the intensive care unit: state of the science.

Munro CL, Grap MJ.

School of Nursing, Virginia Commonwealth University, Richmond, Va., USA.

Oral health is influenced by oral microbial flora, which are concentrated in
dental plaque. Dental plaque provides a microhabitat for organisms and an
opportunity for adherence of the organisms to either the tooth surface or other
microorganisms. In critically ill patients, potential pathogens can be cultured
from the oral cavity. These microorganisms in the mouth can translocate and
colonize the lung, resulting in ventilator-associated pneumonia. The importance
of oral care in the intensive care unit has been noted in the literature, but
little research is available on mechanical or pharmacological approaches to
reducing oral microbial flora via oral care in critically ill adults. Most
research in oral care has been directed toward patients' comfort; the
microbiological and physiological effects of tooth brushing in the intensive
care unit have not been reported. Although 2 studies indicated reductions in
rates of ventilator-associated pneumonia in cardiac surgery patients who
received chlorhexidine before intubation and postoperatively, the effects of
chlorhexidine in reducing ventilator-associated pneumonia in other populations
of critically ill patients or its effect when treatment with the agent initiated
after intubation have not been reported. In addition, no evaluation of the
effectiveness of pharmacological and mechanical interventions relative to each
other or in combination has been published. Additional studies are needed to
develop and test best practices for oral care in critically ill patients.

PMID: 14735645 [PubMed - in process]

2: Am J Crit Care. 2004 Jan;13(1):24.

Oral care in the intensive care unit.

Trieger N.

Publication Types:
EditorialPMID: 14735644 [PubMed - in process]

3: Arch Dis Child. 2004 Feb;89(2):176-80.

Correlation of simultaneously obtained capillary, venous, and arterial blood
gases of patients in a paediatric intensive care unit.

Yildizdas D, Yapicioglu H, Yilmaz HL, Sertdemir Y.

Cukurova University, Faculty of Medicine, Department of Pediatrics, Pediatric
Intensive Care Unit, 01330, Adana, Turkey. rdy90@hotmail.com

AIMS: To investigate the correlation of pH, partial pressure of oxygen (PO2),
partial pressure of carbon dioxide (PCO2), base excess (BE), and bicarbonate
(HCO3) between arterial (ABG), venous (VBG), and capillary (CBG) blood gases.
METHODS: Patients admitted to the paediatric intensive care unit (PICU) in
Cukurova University between August 2000 and February 2002 were enrolled.
RESULTS: A total of 116 simultaneous venous, arterial, and capillary blood
samples were obtained from 116 patients (mean age 56.91 months, range 15 days to
160 months). Eight (7%) were neonates. Sixty six (57%) were males. pH, PCO2, BE,
and HCO3 were all significantly correlated in ABG, VBG, and CBG. Correlation in
PO2 was also significant, but less so. Correlation between pH, PCO2, PO2, BE,
and HCO3 was similar in the presence of hypothermia, hyperthermia, and prolonged
capillary refilling time. In hypotension, correlation in PO2 between VBG and CBG
was similar but disappeared in ABG-VBG and ABG-CBG. CONCLUSIONS: There is a
significant correlation in pH, PCO2, PO2, BE, and HCO3 among ABG, VBG, and CBG
values, except for a poor correlation in PO2 in the presence of hypotension.
Capillary and venous blood gas measurements may be useful alternatives to
arterial samples for patients who do not require regular continuous blood
pressure recordings and close monitoring of PaO2. We do not recommend CBG and
VBG for determining PO2 of ABG.

PMID: 14736638 [PubMed - in process]

4: Arch Dis Child. 2004 Feb;89(2):170-5.

Outcome of children with neuromuscular disease admitted to paediatric intensive
care.

Yates K, Festa M, Gillis J, Waters K, North K.

Department of Paediatric Intensive Care, The Children's Hospital at Westmead,
Sydney, Australia.

AIMS: To determine the outcome of children with neuromuscular disease (NMD)
following admission to a tertiary referral paediatric intensive care (PICU).
METHODS: All children with chronic NMD whose first PICU admission was between
July 1986 and June 2001 were followed up from their first PICU admission to time
of study. The outcomes recorded were death in or outside of PICU, duration of
PICU admission, artificial ventilation during admission and following discharge
from PICU, and readmission to PICU. RESULTS: Over 15 years, 28 children were
admitted on 69 occasions. Sixteen (57%) children had more than one admission.
The median duration of PICU admission was 4 days (range 0.5-42). Twenty three
per cent of unplanned admissions resulted in the commencement of respiratory
support that was continued after discharge from the PICU. Severity of functional
impairment was not associated with longer duration of stay or higher PRISM
scores. Ten children (36%) died, with four (14%) deaths in the PICU. A higher
proportion of children with severe limitation of function were among children
that died compared to survivors. CONCLUSION: Most children with NMD admitted to
the PICU recover and are discharged without the need for prolonged invasive
ventilation. However, in this group of children, the use of non-invasive home
based ventilation is common and they are likely to require further PICU
admission.

PMID: 14736637 [PubMed - in process]

5: Crit Care Med. 2003 Dec;31(12):2815.

Comment on:
Crit Care Med. 2003 Jun;31(6):1831-8.Prone position: not yet justified in neurologic injury.

Zygun DA.

Publication Types:
Comment
LetterPMID: 14668626 [PubMed - indexed for MEDLINE]

6: Crit Care Med. 2003 Dec;31(12):2808-9.

Comment on:
Crit Care Med. 2003 Dec;31(12):2752-63.Look before you leap.

Chao DC, Scheinhorn DJ.

Publication Types:
Comment
EditorialPMID: 14668622 [PubMed - indexed for MEDLINE]

7: Crit Care Med. 2003 Dec;31(12):2807-8.

Comment on:
Crit Care Med. 2003 Dec;31(12):2742-51.Improving survival for sepsis: on the cutting edge.

Rello J, Rodriguez A.

Publication Types:
Comment
Editorial
Review
Review, TutorialPMID: 14668621 [PubMed - indexed for MEDLINE]

8: Crit Care Med. 2003 Dec;31(12):2805-6.

Comment on:
Crit Care Med. 2003 Dec;31(12):2734-41.Who benefits from pulmonary artery catheterization?

Leibowitz AB.

Publication Types:
Comment
Editorial
Review
Review, TutorialPMID: 14668620 [PubMed - indexed for MEDLINE]

9: Crit Care Med. 2003 Dec;31(12):2752-63.

Comment in:
Crit Care Med. 2003 Dec;31(12):2808-9.Implementation of an institutional program to improve clinical and financial
outcomes of mechanically ventilated patients: one-year outcomes and lessons
learned.

Burns SM, Earven S, Fisher C, Lewis R, Merrell P, Schubart JR, Truwit JD, Bleck
TP; University of Virginia Long Term Mechanical Ventilation Team.

University of Virginia School of Nursing, University of Virginia,
Charlottesville, VA 22908, USA.

OBJECTIVE: To determine the effect of an institutional approach to the care of
patients requiring mechanical ventilation for longer than three consecutive days
in five adult intensive care units (ICU) on clinical and financial outcomes.
DESIGN: A multidisciplinary team was selected from five adult ICUs to design the
approach. Planning occurred from August 1999 to September 2000. The process was
called outcomes management (OM) and included an evidence-based clinical pathway,
protocols for weaning and sedation use, and the selection of four advanced
practice nurses (called outcomes managers) to manage and monitor the program.
SETTING: The project was completed in a 550-bed mid-Atlantic academic medical
center. The ICUs included the following: coronary care, medical ICU,
neuroscience ICU, surgical trauma ICU, and thoracic cardiovascular ICU.
PATIENTS: The sample included 595 pre-OM patients and 510 post-OM patients
mechanically ventilated for greater than three consecutive days. INTERVENTIONS:
Full implementation of the OM approach occurred in March 2001. Retrospective
baseline (18 months pre-OM) and prospective (12 months OM) clinical and
financial data were compared. MEASUREMENTS AND MAIN RESULTS: Statistically
significant differences in clinical outcomes were demonstrated in the managed
patients compared with those managed before the institutional approach. Outcomes
include ventilator duration (median days declined from ten to nine; p =.0001),
ICU length of stay (median days declined from 15 to 12; p =.0008), hospital
length of stay (median days declined from 22 to 20; p =.0001), and mortality
rate (declined from 38% to 31%, p =.02). More than 3,000,000 US dollars cost
savings were realized in the OM group. CONCLUSIONS: This institutional approach
to the care of patients ventilated >3 days improved all clinical and financial
outcomes of interest. To date, few similar initiatives have demonstrated similar
results. The approach and lessons learned in this process improvement project
may be helpful to other institutions attempting to improve outcomes in this
vulnerable population.

Publication Types:
Evaluation StudiesPMID: 14668611 [PubMed - indexed for MEDLINE]

10: Crit Care Med. 2003 Dec;31(12):2734-41.

Comment in:
Crit Care Med. 2003 Dec;31(12):2805-6.Relationship of pulmonary artery catheter use to mortality and resource
utilization in patients with severe sepsis.

Yu DT, Platt R, Lanken PN, Black E, Sands KE, Schwartz JS, Hibberd PL, Graman
PS, Kahn KL, Snydman DR, Parsonnet J, Moore R, Bates DW; AMCC Sepsis Project
Working Group.

Division of General Medicine, Department of Medicine, Brigham and Women's
Hospital, Harvard Medical School, Boston, MA, USA.

OBJECTIVE: To examine the relationship of pulmonary artery catheter (PAC) use to
patient outcomes, including mortality rate and resource utilization, in patients
with severe sepsis in eight academic medical centers. DESIGN: Case-control,
nested within a prospective cohort study. SETTING: Eight academic tertiary care
centers. PATIENTS: Stratified random sample of 1,010 adult admissions with
severe sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main
outcome measures were in-hospital mortality, total hospital charge, and length
of stay (LOS) for patients with and without PAC use. The case-matched subset of
patients included 141 pairs managed with and without the use of a PAC. The
mortality rate was slightly but not statistically significantly lower among the
PAC use group compared with those not using a PAC (41.1% vs. 46.8%, p =.34).
Even this trend disappeared after we adjusted for the Charlson comorbidity score
and sepsis-specific Acute Physiology and Chronic Health Evaluation (APACHE) III
(adjusted odds ratio, 1.02; 95% confidence interval, 0.61-1.72). In linear
regression models adjusted for the Charlson comorbidity score, sepsis-specific
APACHE III, surgical status, receipt of a steroid before sepsis onset, presence
of a Hickman catheter, and preonset LOS, no significant differences were found
for total hospital charges (139,207 US dollars vs. 148,190, adjusted mean
comparing PAC and non-PAC group, p =.57), postonset LOS (23.4 vs. 26.9 days,
adjusted mean, p =.32), or total LOS in intensive care unit (18.2 vs. 18.8 days,
adjusted mean, p =.82). CONCLUSIONS: Among patients with severe sepsis, PAC
placement was not associated with a change in mortality rate or resource
utilization, although small nonsignificant trends toward lower resource
utilization were present in the PAC group.

PMID: 14668609 [PubMed - indexed for MEDLINE]

11: Crit Care Med. 2003 Dec;31(12):2727-33.

Comment in:
Crit Care Med. 2003 Dec;31(12):2804-5.Decrease in PaCO2 with prone position is predictive of improved outcome in acute
respiratory distress syndrome.

Gattinoni L, Vagginelli F, Carlesso E, Taccone P, Conte V, Chiumello D, Valenza
F, Caironi P, Pesenti A; Prone-Supine Study Group.

Istituto di Anestesia e Rianimazione, Universita degli Studi di Milano, Ospedale
Policlinico, Milan, Italy. gattinon@policlinico.mi.it

OBJECTIVE: To determine whether gas exchange improvement in response to the
prone position is associated with an improved outcome in acute lung injury
(ALI)/acute respiratory distress syndrome (ARDS). DESIGN: Retrospective analysis
of patients in the pronation arm of a controlled randomized trial on prone
positioning and patients enrolled in a previous pilot study of the prone
position. SETTING: Twenty-eight Italian and two Swiss intensive care units.
PATIENTS: We studied 225 patients meeting the criteria for ALI or ARDS.
INTERVENTIONS: Patients were in prone position for 10 days for 6 hrs/day if they
met ALI/ARDS criteria when assessed each morning. Respiratory variables were
recorded before and after 6 hrs of pronation with unchanged ventilatory
settings. MEASUREMENTS AND MAIN RESULTS: We measured arterial blood gas
alterations to the first pronation and the 28-day mortality rate. The
independent risk factors for death in the general population were the Pao2/Fio2
ratio (odds ratio, 0.992; confidence interval, 0.986-0.998), the minute
ventilation/Paco2 ratio (odds ratio, 1.003; confidence interval, 1.000-1.006),
and the concentration of plasma creatinine (odds ratio, 1.385; confidence
interval, 1.116-1.720). Pao2 responders (defined as the patients who increased
their Pao2/Fio2 by > or =20 mm Hg, 150 patients, mean increase of 100.6 +/- 61.6
mm Hg [13.4 +/- 8.2 kPa]) had an outcome similar to the nonresponders (59
patients, mean decrease -6.3 +/- 23.7 mm Hg [-0.8 +/- 3.2 kPa]; mortality rate
44% and 46%, respectively; relative risk, 1.04; confidence interval, 0.74-1.45,
p =.65). The Paco2 responders (defined as patients whose Paco2 decreased by > or
=1 mm Hg, 94 patients, mean decrease -6.0 +/- 6 mm Hg [-0.8 +/- 0.8 kPa]) had an
improved survival when compared with nonresponders (115 patients, mean increase
6 +/- 6 mm Hg [0.8 +/- 0.8 kPa]; mortality rate 35.1% and 52.2%, respectively;
relative risk, 1.48; confidence interval, 1.07-2.05, p =.01). CONCLUSION:
ALI/ARDS patients who respond to prone positioning with reduction of their Paco2
show an increased survival at 28 days. Improved efficiency of alveolar
ventilation (decreased physiologic deadspace ratio) is an important marker of
patients who will survive acute respiratory failure.

PMID: 14668608 [PubMed - indexed for MEDLINE]

12: Crit Care Med. 2003 Dec;31(12):2719-26.

Comment in:
Crit Care Med. 2003 Dec;31(12):2802-3.Prone position and positive end-expiratory pressure in acute respiratory distress
syndrome.

Gainnier M, Michelet P, Thirion X, Arnal JM, Sainty JM, Papazian L.

Service de Reanimation Medicale, Hopitax Sud, Marseille, France.

OBJECTIVE: To determine whether positive end-expiratory pressure (PEEP) and
prone position present a synergistic effect on oxygenation and if the effect of
PEEP is related to computed tomography scan lung characteristic. DESIGN:
Prospective randomized study. SETTING: French medical intensive care unit.
PATIENTS: Twenty-five patients with acute respiratory distress syndrome.
INTERVENTIONS: After a computed tomography scan was obtained, measurements were
performed in all patients at four different PEEP levels (0, 5, 10, and 15 cm
H2O) applied in random order in both supine and prone positions. MEASUREMENTS
AND MAIN RESULTS: Analysis of variance showed that PEEP (p <.001) and prone
position (p <.001) improved oxygenation, whereas the type of infiltrates did not
influence oxygenation. PEEP and prone position presented an additive effect on
oxygenation. Patients presenting diffuse infiltrates exhibited an increase of
Pao2/Fio2 related to PEEP whatever the position, whereas patients presenting
localized infiltrates did not have improved oxygenation status when PEEP was
increased in both positions. Prone position (p <.001) and PEEP (p <.001) reduced
the true pulmonary shunt. Analysis of variance showed that prone position (p
<.001) and PEEP (p <.001) reduced the true pulmonary shunt. The decrease of the
shunt related to PEEP was more pronounced in patients presenting diffuse
infiltrates. A lower inflection point was identified in 22 patients (88%) in
both supine and prone positions. There was no difference in mean lower
inflection point value between the supine and the prone positions (8.8 +/- 2.7
cm H2O vs. 8.4 +/- 3.4 cm H2O, respectively). CONCLUSIONS: PEEP and prone
positioning present additive effects. The prone position, not PEEP, improves
oxygenation in patients with acute respiratory distress syndrome with localized
infiltrates.

Publication Types:
Clinical Trial
Randomized Controlled TrialPMID: 14668607 [PubMed - indexed for MEDLINE]

13: Intensive Care Med. 2004 Jan 15 [Epub ahead of print]

Prediction of mortality in an Indian intensive care unitComparison between
APACHE II and artificial neural networks.

Nimgaonkar A, Karnad DR, Sudarshan S, Ohno-Machado L, Kohane I.

Children's Hospital Informatics Program, Ender's Building, 5th Floor, 320
Longwood Avenue, Boston, Massachusetts, USA.

OBJECTIVE. To compare hospital outcome prediction using an artificial neural
network model, built on an Indian data set, with the APACHE II (Acute Physiology
and Chronic Health Evaluation II) logistic regression model. DESIGN. Analysis of
a database containing prospectively collected data. SETTING.
Medical-neurological ICU of a university hospital in Mumbai, India. SUBJECTS.
Two thousand sixty-two consecutive admissions between 1996 and1998.
INTERVENTIONS. None. MEASUREMENTS AND RESULTS. The 22 variables used to obtain
day-1 APACHE II score and risk of death were recorded. Data from 1,962 patients
were used to train the neural network using a back-propagation algorithm. Data
from the remaining 1,000 patients were used for testing this model and comparing
it with APACHE II. There were 337 deaths in these 1,000 patients; APACHE II
predicted 246 deaths while the neural network predicted 336 deaths. Calibration,
assessed by the Hosmer-Lemeshow statistic, was better with the neural network
(H=22.4) than with APACHE II (H=123.5) and so was discrimination (area under
receiver operating characteristic curve =0.87 versus 0.77, p=0.002). Analysis of
information gain due to each of the 22 variables revealed that the neural
network could predict outcome using only 15 variables. A new model using these
15 variables predicted 335 deaths, had calibration (H=27.7) and discrimination
(area under receiver operating characteristic curve =0.88) which was comparable
to the 22-variable model ( p=0.87) and superior to the APACHE II equation (
p<0.001). CONCLUSION. Artificial neural networks, trained on Indian patient
data, used fewer variables and yet outperformed the APACHE II system in
predicting hospital outcome.

PMID: 14727015 [PubMed - as supplied by publisher]