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Clinical approach to the critically ill, morbidly obese patient.
El-Solh AA.
Department of Medicine, University at Buffalo School of Medicine and Biomedical Sciences, New York, USA. solh@buffalo.edu
Publication Types:
PMID: 14982823 [PubMed - indexed for MEDLINE]
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The ethical relevance of the standard of care in the design of clinical trials.
Miller FG, Silverman HJ.
Department of Clinical Bioethics, National Institutes of Health, Bethesda, MD 20892-1156, USA. fmiller@nih.gov
Publication Types:
PMID: 14701713 [PubMed - indexed for MEDLINE]
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Anaesthesia and intensive care a-z. An encyclopaedia of principles and practice.
O'Regan M.
PMID: 15023134 [PubMed - in process]
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[Artificial neural networks. Theory and applications in anesthesia, intensive care and emergency medicine]
[Article in German]
Traeger M, Eberhart A, Geldner G, Morin AM, Putzke C, Wulf H, Eberhart LH.
Klinik fur Innere Medizin, Kreiskrankenhaus Gunzburg.
Artificial neural networks (ANN) are constructed to simulate processes of the central nervous system of higher creatures. An ANN consists of a set of processing units (nodes) which simulate neurons and are interconnected via a set of "weights" (analogous to synaptic connections in the nervous system) in a way which allows signals to travel through the network in parallel. The nodes (neurons) are simple computing elements. They accumulate input from other neurons by means of a weighted sum. If a certain threshold is reached the neuron sends information to all other connected neurons otherwise it remains quiescent. One major difference compared with traditional statistical or rule-based systems is the learning aptitude of an ANN. At the very beginning of a training process an ANN contains no explicit information. Then a large number of cases with a known outcome are presented to the system and the weights of the inter-neuronal connections are changed by a training algorithm designed to minimise the total error of the system. A trained network has extracted rules that are represented by the matrix of the weights between the neurons. This feature is called generalisation and allows the ANN to predict cases that have never been presented to the system before. Artificial neural networks have shown to be useful predicting various events. Especially complex, non-linear, and time depending relationships can be modelled and forecasted. Furthermore an ANN can be used when the influencing variables on a certain event are not exactly known as it is the case in financial or weather forecasts. This article aims to give a short overview on the function of ANN and their previous use and possible future applications in anaesthesia, intensive care, and emergency medicine.
Publication Types:
PMID: 14992094 [PubMed - indexed for MEDLINE]
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[Assessment of volume responsiveness in mechanically ventilated patients]
[Article in German]
Reuter DA, Goetz AE, Peter K.
Klinik fur Anasthesiologie, Klinikum der Universitat Munchen, Grosshadern-Innenstadt.
Monitoring and management of intravascular volume status is of crucial importance in critically ill patients. Hypovolemia, induced by hemorrhage or pathologic fluid shifts in the presence of systemic inflammation, is frequently the cause for hemodynamic instability and hypotension. This deficit of central blood volume leads to a reduction in biventricular cardiac preload. With respect to the Frank-Starling mechanism, this causes an alteration in left ventricular stroke volume. If this reduction in stroke volume cannot be compensated by an increase in heart rate, this finally results in a decline of cardiac output. In this clinical situation fluid loading is the treatment of choice. However, insufficient peripheral vascular resistance and thus reduced cardiac afterload as well as impaired myocardial contractility also have to be taken in account to be causative for hypotension. Potential hazards of fluid loading specifically in the latter situation include pulmonary edema, worsening of pulmonary gas exchange and myocardial failure. Thus, prediction of fluid responsiveness, i.e. the prediction of the hemodynamic response to fluid loading is of utmost importance in critically ill patients. Several conventional parameters of systemic hemodynamic monitoring such as the cardiac filling pressures CVP and PAOP, the estimation of the left ventricular end-diastolic area (LVEDA) by echocardiography and measurement of central blood volumes as the right-ventricular end-diastolic volume (RVEDV) or the global end-diastolic volume (GEDV) by thermodilution are frequently used for preload monitoring. Further, functional preload parameters such as the left ventricular stroke volume variation (SW), describing the specific interactions of the heart and the lungs under mechanical ventilation, have been recently proposed to be useful for predicting fluid responsiveness. Thus, it is the aim of the present article to analyze these different concepts of hemodynamic monitoring regarding their usefulness and clinical applicability to predict fluid responsiveness at the bedside.
Publication Types:
PMID: 14992086 [PubMed - indexed for MEDLINE]
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The value of functional hemodynamic parameters in hemodynamic monitoring of ventilated patients.
Perel A.
Publication Types:
PMID: 14992085 [PubMed - indexed for MEDLINE]
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[Pneumocystis carinii infections in a pediatric intensive care unit: a retrospective study 1980-2002]
[Article in French]
Richard N, Stamm D, Floret D.
Service de reanimation pediatrique polyvalente, hopital Edouard-Herriot, Lyon, France. sylvie.platon@chu-lyon.fr
OBJECTIVE: The objective of this study was to ascertain the clinical and epidemiological characteristics of Pneumocystis carinii pneumonia (PCP) cases admitted to the Pediatric Intensive Care Unit (PICU). PATIENTS AND METHODS: A retrospective study was carried out for the 10 PCP cases admitted to the PICU from 1980 to 2002. The variables studied were: age, sex, PRISM, underlying diseases, immunological status, clinical manifestations, radiology, response to therapy and clinical follow up. RESULTS: Age of the patients varied between 5 months and 15 years and 4 months and there were 7 females and 3 males. Underlying diseases included: AIDS (3 cases), renal transplant (2 cases), West syndrom (1 case), cancer (4 cases). All presented an acute respiratory failure and 8/10 needed mechanical ventilation (mean duration: 14 days). All were treated by trimethoprim-sulfamethoxazole and 6/10 received steroids. Only one child died. CONCLUSION: PCP is rare and affects mainly immunocompromized children who exhibit ARDS. Steroids treatment is now considered as an useful therapeutic adjuvant. A preventive treatment should be administred to children at risk.
PMID: 15022778 [PubMed - in process]
Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: a feasibility study.
Happ MB, Roesch TK, Garrett K.
School of Nursing, University of Pittsburgh, PA 15261, USA.
BACKGROUND: The inability to speak during mechanical ventilation is recognized as a terrifying and isolating experience that is related to feelings of panic, insecurity, anger, worry, fear, sleep disturbances, and stress among critically ill patients. Alternative methods of communicating with temporarily nonspeaking patients in the intensive care unit (ICU) have received little study. Although electronic voice output communication aids (VOCAs) are available for disabled children and adults, the effectiveness of VOCA systems with adult medical ICU patients who may have multisystem illness, prolonged intubation, and longer ICU stays has not been explored. OBJECTIVES: The purpose of this pilot study was to describe (1) the characteristics of intubated MICU patients who use VOCAs, (2) the usage patterns (message categories, frequency, assistance required), (3) communication quality (ease, user satisfaction), and (4) barriers to communication with VOCAs. METHODS: This pilot study used participant observation, semi-structured interviews, questionnaires, and clinical record review in a complementary design to obtain data on communication events and VOCA use with 11 critically ill adults. RESULTS: Study participants, 45.5 +/- 16.0 years of age with 13 +/- 1.9 years of education and moderately severe illness (APACHE III=27.5 +/- 16.1), used the VOCA for 5.7 +/- 4.6 days. Ease of Communication Scale measurements showed significantly less difficulty with communication after device use (t>2.62; P=.047). Almost half (n=5) of the participants demonstrated some independent use of the device. VOCAS were used in one quarter of observed communication events. Patients used VOCAs most often to communicate with family visitors and initiated communication interactions more often when VOCAs were used than when communicating by other nonvocal methods. Poor device positioning, deterioration in patient condition, staff time constraints, staff unfamiliarity with device, and complex message screens were primary barriers to VOCA use. CONCLUSIONS: This study showed that use of VOCAs is possible with selected critically ill adults and may contribute to greater ease of communication during respiratory tract intubation particularly with family members. Further clinical research using control or comparison groups is needed.
PMID: 15024374 [PubMed - in process]
What is the daily practice of mechanical ventilation in pediatric intensive care units? A multicenter study.
Farias JA, Frutos F, Esteban A, Flores JC, Retta A, Baltodano A, Alia I, Hatzis T, Olazarri F, Petros A, Johnson M.
Unidad de Cuidados Intensivos Pediatricos, Hospital de Ninos R Gutierrez, B de Irigoyen 49, 1834, Temperley Bs. As, Argentina.
OBJECTIVE. To describe the daily practice of mechanical ventilation (MV), and secondarily, its outcome in pediatric intensive care units (PICUs). DESIGN. Prospective cohort of infants and children who received MV for at least 12 h. SETTING. Thirty-six medical surgical PICUs. PATIENTS. All consecutive patients admitted to the PICUs during 2-month period. MEASUREMENTS AND MAIN RESULTS. Of the 1893 patients admitted, 659 (35%) received MV for a median time of 4 days (25th percentile, 75%: 2, 6). Median of age was 13 months (25th percentile, 75%: 5, 48). Common indications for MV were acute respiratory failure (ARF) in 72% of the patients, altered mental status in 14% of the patients, and ARF on chronic pulmonary disease in 10% of the patients. Median length of stay in the PICUs was 8 days (25th percentile, 75%: 5, 13). Overall mortality rate in the PICUs was 15% (confidence interval 95%: 13-18) for the entire population, 50% (95% CI: 25-74) in patients who received MV because of acute respiratory distress syndrome, 24% (95% CI: 16-35) in patients who received MV for altered mental status and 16% (95% CI: 9-29) in patients who received MV for ARF on chronic pulmonary disease. CONCLUSION. One in every 3 patients admitted to the PICUs requires ventilatory support. The ARF was the most common reason for MV, and survival of unselected infants and children receiving MV for more than 12 h was 85%.
PMID: 15029473 [PubMed - as supplied by publisher]
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Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit.
Denton M, Wilcox MH, Parnell P, Green D, Keer V, Hawkey PM, Evans I, Murphy P.
Department of Microbiology, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
An outbreak of Acinetobacter baumannii colonization and infection occurred in 19 patients over a 14-month period during 1998-1999 on a neurosurgical intensive care unit. During efforts to control the outbreak a significant correlation was observed between the number of environmental isolates of A. baumannii obtained during each monthly screening and the number of patients with A. baumannii colonization/infection in the same calendar month [Formula: see text] Use of 1000 ppm hypochlorite solution and the introduction of new cleaning protocols reduced the number of environmental isolates. Failure to maintain low levels of environmental contamination with A. baumannii resulted in increases in patient colonization. This study showed that high standards of cleaning play an integral role in controlling outbreaks of A. baumannii in the intensive care unit setting.
PMID: 15019221 [PubMed - in process]
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Investigation of an outbreak of multidrug-resistant Acinetobacter baumannii in trauma intensive care unit.
El Shafie SS, Alishaq M, Leni Garcia M.
Department of Laboratory Medicine and Pathology, Division of Microbiology, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar.
Between January and June 2002, an outbreak of multidrug-resistant Acinetobacter baumannii occurred in a trauma intensive care unit (TICU) at the Hamad Medical Corporation, Qatar. The outbreak involved 21 patients whose infection/colonization was hospital acquired. All the strains were resistant to all tested antibiotics except amikacin. An A. baumannii strain with a similar antibiogram was isolated from the environment, equipment and hands of healthcare workers (HCWs). The technique of open suctioning probably resulted in aerosilization and contamination of the immediate patient environment. This allowed the hands of HCWs to be contaminated with the outbreak strain, with subsequent transmission to other patients and their environment. Lack of proper hand hygiene between patients and equipment contact facilitated this transmission. A review of hand hygiene practices, extensive environmental cleaning, a closed suctioning system, education and review of other infection-control practices, contributed to the termination of the outbreak.
PMID: 15019220 [PubMed - in process]
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Ward nurses' evaluation of critical care outreach.
Richardson A, Burnand V, Colley H, Coulter C.
Critical Care, Level 2 Anaesthetic Department, Freeman Hospital, High Heaton, Newcastle-upon-Tyne NE7 7DN. annette.richardson@nuth.northy.nhs.uk
Following the recommendation to introduce critical care outreach, two different models on two hospital sites were introduced within a large teaching Trust. To establish ward nurses' views and opinions of important components of the two outreach models, a questionnaire survey was undertaken involving 134 ward nurses on the awareness of outreach, accessibility of outreach and usage of outreach. The results identified a high level of user satisfaction amongst ward nurses. Awareness of critical care outreach and how to access the service within a hospital site was good, with little differences between the two different models. Outreach was found to provide ward nurses with better skills, more knowledge, advice and support. Providing a 24-h service and continual critical care education and training opportunities are the suggested ways to improve outreach in the future.
Publication Types:
PMID: 14871007 [PubMed - indexed for MEDLINE]
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[Levosimendan in cardiology and intensive care medicine]
[Article in German]
Delle Karth G, Heinz G.
Abteilung Kardiologie/Intensivstation 13H3, Universitatsklinik fur Innere Medizin II, Wien, Osterreich. georg.delle-karth@univie.ac.at
Levosimendan (LS) is a new calcium sensitizer that exerts positive inotropic effects without increasing intracellular cAMP or Ca2+ at therapeutic doses and therefore may avoid major limitations of beta-adrenergic agents. LS also causes arteriolar and venous dilation by opening potassium channels on vascular smooth muscle cells. In addition, LS does not increase myocardial oxygen demand and may exert anti-stunning effects. LS itself has a short elimination half life but has shown to have active metabolites with elimination half lives up to 80 hours. Three hemodynamic studies show that at recommended doses LS increases cardiac output by 8-30% and reduces pulmonary capillary wedge pressure by 11-28% in heart failure patients. Systemic vascular resistance falls significantly and blood pressure tends to decline. The hemodynamic effects are not attenuated by concomitant beta-blocker medication. Two large randomized studies on patients with chronic and acute congestive heart failure found a decrease in mortality with LS. In the LIDO trial there was a 52.9% survival benefit at day 31 when compared with patients receiving dobutamine. In the RUSSLAN trial, the survival benefit approached 40% at day 14 after start of treatment compared to placebo. Experience in the ICU setting is limited but LS therapy in postoperative low output failure and cardiogenic shock seems to be feasible and LS is a promising agent in the inotropic armamentarium. LS has a favourable side effect profile and is approved for 24-hour use in congestive heart failure. It may cause hypotension due to vasodilation, and this effect may be aggravated by inadequate preload conditions. Further morbidity and mortality studies are required to confirm the encouraging data from the LIDO and RUSSLAN trial but already the existing data support LS as the inotropic agent of choice in patients with worsening heart failure and a systolic arterial blood pressure beyond 90 mmHg.
PMID: 15030117 [PubMed - in process]
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