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Diagnosis and management of gastro-oesophageal reflux in preterm infants in neonatal intensive care units.
Dhillon AS, Ewer AK.
Department of Neonatology, Birmingham Women's Hospital, Edgbaston, Birmingham, UK. amritdhillon@hotmail.com
AIM: There is relatively little published information regarding gastro-oesophageal reflux (GOR) in preterm infants, therefore the aim of this study was to elucidate the incidence of GOR and management regimes employed for this condition in major neonatal intensive care units (NICUs). METHODS: A standard questionnaire was sent to consultants in 77 level II (or secondary) and III (or tertiary) NICUs. RESULTS: Seventy-eight percent of consultants responded. Of babies born in these units, 40% were less than 34 wk gestational age and the estimated incidence of GOR in this group was 22%. GOR was diagnosed on a clinical basis alone in 42% of units, 8% used clinical features and/or investigations, and 50% used clinical features plus investigations and/or therapeutic trials. Intra-oesophageal pH monitoring was available in 93% of units but used regularly in only 32% of suspected cases. Common treatment strategies for diagnosed GOR included non-drug options--body positioning (98%) and placement on a slope (96%); and drugs--H2-receptor antagonists (100%), feed thickeners (98%), antacids (96%), prokinetic agents (79%), proton-pump inhibitors (65%) and dopamine-receptor antagonists (53%). However, the frequency with which all of these treatments were used varied widely between units. Surgery was required in only 1% of cases. CONCLUSIONS: GOR is perceived to be a common condition in preterm infants but the lack of published evidence relating to the management of GOR in preterm infants is reflected in the wide variation in diagnostic and treatment strategies used in major NICUs. It is clear that randomized, controlled trials to evaluate appropriate and effective treatments are needed.
PMID: 14989446 [PubMed - in process]
Comment on:
Critical care outreach team's effect on patient outcome: other conclusions are possible.
Subbe CP.
Publication Types:
PMID: 14764507 [PubMed - indexed for MEDLINE]
Comment on:
Critical care outreach team's effect on patient outcome: more information is needed.
Parker MR.
Publication Types:
PMID: 14764506 [PubMed - indexed for MEDLINE]
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Nutritional support of the critically ill and injured patient.
Slone DS.
Trauma Critical Care Section, Swedish Medical Center, 499 East Hamden Avenue, Suite 380, Englewood, CO 80110, USA. sue.slone@healthonecares.com
The understanding of the importance of nutrition, particularly in the critically ill patient, is based on the known physiologic consequences of malnutrition. It includes respiratory muscle function, cardiac function, the coagulation cascade balance, electrolyte and hormonal balance, and renal function. Nutrition affects emotional and behavioral responses, functional recovery, and the overall cost of health care. The need to identify and treat the malnourished or potentially malnourished patient is a critical aspect of patient management. Much is known of catabolic and hypermetabolic state caused by trauma and burns. The response to injury needs to be mediated. There is much to learn about the intervention of that response through adjuvant nutritional therapy.
Publication Types:
PMID: 14979334 [PubMed - indexed for MEDLINE]
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Critical concepts in abdominal injury.
Todd SR.
Division of General Surgery, The University of Texas at Houston, 6431 Fannin Street, Suite 4.162, Houston, TX 77030, USA. samual.todd@uth.tmc.edu
Missed intra-abdominal injuries are among the most frequent causes of potentially preventable trauma deaths. The evaluation and management of abdominal trauma is dependant on multiple factors, including mechanism of injury, location of injury, hemodynamic status of the patient, neurologic status of the patient, associated injuries, and institutional resources.
Publication Types:
PMID: 14979333 [PubMed - indexed for MEDLINE]
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Damage control surgery.
Schreiber MA.
Division of Trauma and Critical Care, Oregon Health & Science University, 3181 SW Sam Jackson Road, Mail Code L223A, Portland, OR 97239, USA. schreibm@ohsu.edu
Damage control is a staged approach to severely injured patients predicated on treatment priorities. Initially, life-threatening injuries are addressed expediently, and procedures are truncated. Normal physiology is restored in the ICU, and patients subsequently are returned to the operating room for definitive management. This strategy breaks the bloody vicious cycle and results in improved outcomes. Novel technologies like CAVR and rFVIIa contribute to the effectiveness of damage control.
Publication Types:
PMID: 14979332 [PubMed - indexed for MEDLINE]
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Management of post traumatic respiratory failure.
Michaels AJ.
Trauma Service, Legacy Emanuel Hospital and Health Center, 2801 North Gantenbein Avenue, Suite 130, Portland, OR 97227, USA. amichael@lhs.org
Acute respiratory distress syndrome (ARDS) is a severe and common complication of major trauma. The most important early management principle is to identify the inciting event and remove the ongoing insult aggressively. It is important to immediately resuscitate the patients and prepare them for a complex and difficult hospitalization. Avoiding secondary insults is the cornerstone of supportive care, and this is based primarily on aggressive immune surveillance, full nutrition, and unrelenting oxygen delivery. The use of aggressive immune surveillance, nutritional support, and fluid management is critical to support ventilator management for oxygenation and ventilation. In general, although essential, the ventilator has great potential for harm in patients who are compromised seriously with ARDS. Physicians must establish reasonable therapeutic goals based on oxygen delivery rather than arbitrary normal values of blood gas measurement. The impact of the ventilator should be limited with regard to aspiratory pressure, tidal volume, inspired oxygen, and levels of expiratory end expiratory pressure. Use of pulmonary toilet, including therapeutic bronchoscopy; patient positioning, including intermittent prone positioning, and recruitment maneuvers are useful therapeutic complements for maintaining functional residual capacity and decreasing shunt. Overall, ARDS represents a clear indication that the patient is failing to meet the demands of their stress and without prompt attention likely will die. It is a challenge and an opportunity to identify the underlying situation and to manage the patient while not causing additional harm as the patient's intrinsic resources can bring about the healing necessary to recover from the situation of extremis.
Publication Types:
PMID: 14979331 [PubMed - indexed for MEDLINE]
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Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury.
Wanek S, Mayberry JC.
Division of General Surgery, Oregon Health & Science University, Mail Code L223A, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
Blunt thoracic trauma can result in significant morbidity in injured patients. Both chest wall and the intrathoracic visceral injuries can lead to life-threatening complications if not anticipated and treated. Pain control, aggressive pulmonary toilet, and mechanical ventilation when necessary are the mainstays of supportive treatment. The elderly with blunt chest trauma are especially at risk for pulmonary deterioration in the several days postinjury and should be monitored carefully regardless of their initial presentation. Blunt thoracic trauma is also a marker for associated injuries, including severe head and abdominal injuries.
Publication Types:
PMID: 14979330 [PubMed - indexed for MEDLINE]
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Management of brain and spine injuries.
Chesnut RM.
Department of Neurotrauma and Neurosurgical Critical Care, Oregon Health & Science University, L-472, 3181 Southwest Sam Jackson Park Road, Portland, OR 97201, USA. chesnutr@ohsu.edu
For both SCI and TBI, physicians are unable to affect reversal of the cellular injuries suffered at the time of trauma directly. Unfortunately, understanding such processes is just on the horizon. Physicians do, however, have significant influence on recovery through the avoidance of secondary insults to the injured nervous system. In keeping with trauma in general, the mechanism for this is focused and coordinated multi-disciplinary care originating at the earliest contact and continuing through acute care. Aggressive and pre-emptive attention to the ABC(D)s with attention to the needs of the injured nervous system, appropriate monitoring in all patients, meticulous medical management, and prompt surgical intervention when indicated have made marked improvements in outcome, particularly in TBI. Focusing on the basics and strict attention to detail appear to be the major roles played in the care of CNS trauma.
Publication Types:
PMID: 14979328 [PubMed - indexed for MEDLINE]
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Initial management of the trauma patient.
Richards CF, Mayberry JC.
Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA. richarch@ohsu.edu
Critical care specialists should be familiar with the initial management of injured patients. Dividing the evaluation and treatment of the patient into the primary, secondary, and tertiary surveys ensures that the multiply injured patient will be managed expeditiously. The primary survey identifies the acute life-threatening problems that must be managed immediately. The secondary survey identifies the remaining major injuries and sets priorities for definitive management. The tertiary survey identifies occult injuries before they become missed injuries.
Publication Types:
PMID: 14979326 [PubMed - indexed for MEDLINE]
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EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units.
[No authors listed]
OBJECTIVE. Ten years ago 8.4% of patients in French intensive care units (ICUs) were found to have severe sepsis or shock and 56% died in the hospital. As novel therapies for severe sepsis are emerging, updated epidemiological information is required. DESIGN AND SETTING. An inception cohort study conducted in 206 ICUs of randomly selected hospitals over a 2-week period in 2001, including all patients meeting criteria for clinically or microbiologically documented severe sepsis (with >/=1 organ dysfunction). MEASUREMENTS AND RESULTS. Among 3738 admissions, 546 (14.6%) patients experienced severe sepsis or shock, of which 30% were ICU-acquired. The median age of patients was 65 years, and 54.1% had at least one chronic organ system dysfunction. The median (range) Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) at onset of severe sepsis were 48 (2-129) and 9 (1-24), respectively. Mortality was 35% at 30 days; at 2 months the mortality rate was 41.9%, and 11.4% of patients remained hospitalized. The median (range) hospital stay was 25 (0-112) days in survivors and 7 (0-90) days in non-survivors. Chronic liver and heart failure, acute renal failure and shock, SAPS II at onset of severe sepsis and 24-h total SOFA scores were the independent risk factors most strongly associated with death. CONCLUSIONS. Although the attack rate of severe sepsis in French ICUs appears to have increased over the past decade, its associated mortality has decreased, suggesting improved management of patients. Severe sepsis incurs considerable resources use, and implementation of effective management strategies and continued research efforts are needed.
PMID: 14997295 [PubMed - as supplied by publisher]
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Economies of scale in British intensive care units and combined intensive care/high dependency units.
Jacobs P, Rapoport J, Edbrooke D.
Institute of Health Economics, #1200 - 10405 Jasper Avenue, T5 J 3N4, Edmonton, Alberta, Canada.
OBJECTIVE. To estimate the relationship between size of intensive care unit and combined intensive care/high dependency units and average costs per patient day. DESIGN. Retrospective data analysis. Multiple regression of average costs on critical care unit size, controlling for teaching status, type of unit, occupancy rate and average length of stay. SETTING. Seventy-two United Kingdom adult intensive care and combined intensive care/high dependency units submitting expenditure data for the financial year 2000-2001 as part of the Critical Care National Cost Block Programme. INTERVENTIONS. None. MEASUREMENTS AND RESULTS. The main outcome measures were total cost per patient day and the following components: staffing cost, consumables cost and clinical support services costs. Nursing Whole Time Equivalents per patient day were recorded. The unit size variable has a negative and statistically significant ( p<0.05) coefficient in regressions for total, staffing and consumables cost. The predicted average cost for a seven-bed unit is about 96% of that predicted for a six-bed critical care unit. CONCLUSION. Policy makers should consider the possibility of economies of scale in planning intensive care and combined intensive care/high dependency units.
PMID: 14997294 [PubMed - as supplied by publisher]
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Assessment of peri-extubation pain by visual analogue scale in the adult intensive care unit: a prospective observational study.
Gacouin A, Camus C, Le Tulzo Y, Lavoue S, Hoff J, Signouret T, Person A, Thomas R.
Service des Maladies Infectieuses et de Reanimation Medicale, Hopital Pontchaillou, rue Henri Le Guilloux, 35000, Rennes, France.
OBJECTIVE. This prospective observational study was undertaken in order to assess pain experienced by intensive care unit patients at the time of extubation and to identify factors associated with pain of at least moderate intensity. DESIGN. Prospective observational study. SETTING. Intensive care unit at a university hospital. PATIENTS. During a 1-year period the presence, severity and clinical predictors of orofacial and/or chest pain among patients undergoing removal of endotracheal tubes was assessed. MEASUREMENTS AND RESULTS. Pain was evaluated using a visual analogue scale (VAS). Of 332 extubated patients, 203 could be evaluated. During the peri-extubation period, pain was significantly associated with a SAPS II score more than 36 ( p=0.03) and duration of mechanical ventilation (MV) of 6 days or more ( p=0.002), whereas intubation in the operating room was associated with less pain ( p=0.001). Pain of at least moderate intensity (VAS score >30 mm) was reported by 73% of patients and pain of severe intensity (VAS score >50 mm) was reported by 45% of patients. MV duration of 6 days or more was the only independent risk factor for pain of at least moderate intensity (OR 2.4, 95% CI 1.03-5.4, p=0.04). We also observed that pain had resolved 1 h after extubation in the majority of patients. CONCLUSION. Our results suggest that, in intensive care unit patients, peri-extubation pain is frequent and should be considered for treatment, especially in patients with longer intubation.
PMID: 14991103 [PubMed - as supplied by publisher]
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