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Assessment of anxiety in intensive care patients by using the Faces Anxiety Scale.
McKinley S, Stein-Parbury J, Chehelnabi A, Lovas J.
Royal North Shore Hospital, Sydney, New South Wales, Australia.
BACKGROUND: Anxiety is difficult to detect in patients receiving mechanical ventilation because clinical signs are confounded and patients often cannot respond to validated anxiety measures. Most patients can respond to the single-item Faces Anxiety Scale. OBJECTIVES: To assess the validity of the Faces Anxiety Scale, the frequency and severity of state anxiety, and correlates of anxiety in intensive care patients. METHODS: A research assistant made a single clinical judgment of anxiety in the range of 1 to 10 on the basis of patients' nonverbal responses (ie, nods) to 9 questions about mood and their physical and behavioral signs. Patients then responded to the Faces Anxiety Scale. Demographic, clinical, and pharmacological data were obtained from the patients' charts. RESULTS: Mean age of the 106 patients was 61 years; 62% were men. Admission diagnoses were cardiovascular in 26% of patients, respiratory in 26%, trauma in 18%, neurological in 12%, gastrointestinal in 12%, and other in 6%. At the time of anxiety assessment, 89% were receiving mechanical ventilation. The correlation between patients' self-reports of anxiety on the Anxiety Faces Scale and the research assistant's assessments was 0.64 (P <.001). Some anxiety was reported by 85% of patients (mean level 2.9; SD 1.2). Anxiety levels were lower in patients who had recently received sedatives or opioids but were not related to heart rate or blood pressure. CONCLUSIONS: The Faces Anxiety Scale is a valid means of measuring anxiety in intensive care patients. Anxiety is common in these patients and is often moderate to severe.
PMID: 15043242 [PubMed - in process]
Controlled normothermia in neurologic intensive care.
Marion DW.
Department of Neurological Surgery, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.
Preclinical studies of cerebral ischemia and trauma find increased brain tissue injury and worsened functional outcomes if the brain temperature exceeds 39 degrees C. Several retrospective studies of patients with new-onset stroke, intracerebral hemorrhage, or subarachnoid hemorrhage support these observations. However, fever is very common among these patients early after the onset of their disease, particularly if they are in the ICU for a week or more, and brain temperatures are likely to be as much as 2 degrees C higher than rectal temperatures. Finally, intravascular temperature modulation has been shown to be more effective for preventing fever than conventional methods, such as antipyretic medications or surface-cooling techniques. Further study is needed to establish if such better control of temperature will lead to improved outcomes.
PMID: 15043227 [PubMed - in process]
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Pioneering contributions of Peter Safar to intensive care and the founding of the Society of Critical Care Medicine.
Weil MH, Shoemaker WC.
Institute of Critical Care Medicine, Palm Springs, CA, USA.
PMID: 15043226 [PubMed - in process]
Development of a risk assessment tool for deliberate self-extubation in intensive care patients.
Moons P, Sels K, De Becker W, De Geest S, Ferdinande P.
Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium.
OBJECTIVE. To develop a risk stratification scheme for deliberate self-extubation in intensive care patients. DESIGN. A nested case-control study. SETTING. Four surgical ICUs, one medical ICU, one coronary care unit, and one emergency department of a tertiary care center. MEASUREMENT. In a 3-month period, the number of ventilation periods, ventilation days, and unplanned extubations were recorded. Potential determinants of unplanned extubation were assessed with a translated (English to Dutch) and modified version of the "Unplanned Extubation Data Collection Tool." PATIENTS. Clinical and demographic characteristics and circumstances of the 26 unplanned extubations were compared with those of 48 randomly selected control patients who did not experience unplanned extubation. RESULTS. The incidence of unplanned extubation was 4.2%, corresponding to 0.68 unplanned extubations per 100 ventilation days. The incidence was substantially lower at surgical ICUs (2.6%) compared with that at medical ICU/CCUs (9.5%). Multiple logistic regression analysis revealed that patients with a low sedation level (Bloomsbury Sedation Score) and a higher degree of consciousness (Glasgow Coma Scale) were at higher risk for deliberate self-extubation. The explained variance of this model including these factors was 67.3%. CONCLUSION. Based on the risk factors identified, a risk assessment tool was developed. Systematic administration of the Bloomsbury Sedation Score and the Glasgow Coma Scale, and the use of the stratification scheme, allows identification of patients at risk. Appropriate reduction of sedative drugs during weaning, a timely extubation, and increased surveillance in patients identified to be at risk are possible interventions to diminish the number of unplanned extubations.
PMID: 15045169 [PubMed - as supplied by publisher]
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Surveillance of antimicrobial use and antimicrobial resistance in intensive care units (SARI): 1. Antimicrobial use in German intensive care units.
Meyer E, Schwab F, Jonas D, Rueden H, Gastmeier P, Daschner FD.
Institute of Environmental Medicine and Hospital Epidemiology, Freiburg University Hospital, Hugstetter Strasse 55, 79106, Freiburg, Germany.
OBJECTIVE. To study antimicrobial use for benchmarking and ensuring quality of antimicrobial treatment and to identify risk factors associated with the high use of antimicrobials in German intensive care units (ICUs) through implementation of the SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in ICUs) system. DESIGN. Prospective, unit-based surveillance on antimicrobial use from February, 2000, until June, 2002. The data are standardised by use of the defined daily dose (DDD) for each antimicrobial defined by the WHO and by calculating use per 1000 patient days. SETTING. The data were obtained from 35 German ICUs and stratified by type of ICU (medical, surgical, interdisciplinary). RESULTS. To date, the project covers a total of 266,013 patient days in 744 reported ICU months and 354,356 DDDs. Mean antimicrobial use density (AD) was 1,332 DDD/1000 patient days and was correlated with length of stay. Penicillins with beta-lactamase inhibitor (AD 338.3) and quinolones (155.5) were the antimicrobial group with the highest ADs. Comparison with US ICARE (Intensive Care Antimicrobial Resistance Epidemiology)/AUR (Antimicrobial Use and Resistance) data revealed a higher AD for glycopeptides and 3rd generation cephalosporins in ICARE/AUR ICUs, but a higher AD for carbapenems in German SARI ICUs regardless of the type of ICU. In the multivariate analysis, length of stay was an independent risk factor for an AD above the 75% percentile of the total amount of antimicrobials used (OR 1.96 per day); likewise, for the AD above the 75% percentile of carbapenems (OR 1.90 per day) and penicillins with extended spectrum (OR 2.01 per day). High use of glycopeptides and quinolones (AD >75% percentile) correlated with central venous catheter (CVC) rate (OR 1.14 per CVC day per 100 patient days and 1.16, respectively). CONCLUSION. The SARI data on antimicrobials serve ICUs as a benchmark by which to improve the quality of antimicrobial drug administration and for international comparison.
PMID: 15045167 [PubMed - as supplied by publisher]
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Helicobacter pylori in intensive care.
Van Der Voort PH, Zandstra DF, Tytgat GN.
Department of Intensive Care, Medical Centre Leeuwarden, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands.
PMID: 15042287 [PubMed - as supplied by publisher]
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Variation in intensive care unit outcomes by day of week: no weak-end.
Bell CM, Scales DC.
Department of Medicine, St. Michael's Hospital, 30 Bond Street, M5B 1W8, Toronto, Ontario, Canada.
PMID: 15034649 [PubMed - as supplied by publisher]
Comment on:
Supply and demand of organs for donation.
Park G.
Publication Types:
- Comment
- Editorial
- Review
- Review, Tutorial
PMID: 14716477 [PubMed - indexed for MEDLINE]
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A comparative evaluation of thermodilution and partial CO2 rebreathing techniques for cardiac output assessment in critically ill patients during assisted ventilation.
Rocco M, Spadetta G, Morelli A, Dell'Utri D, Porzi P, Conti G, Pietropaoli P.
Department of Anesthesiology and Intensive Care, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy. monica.rocco@uniroma1.it
OBJECTIVE: To evaluate the reliability and clinical value of partial noninvasive CO2 (NICO2) rebreathing technique for measuring cardiac output compared with standard thermodilution in a group of intensive care nonpostoperative patients. DESIGN AND SETTING: Clinical investigation in a university hospital ICU. PATIENTS: Twelve mechanically ventilated patients with high (n=6) and low (n=6) pulmonary shunt fractions. MEASUREMENTS AND RESULTS: Thirty-six paired measurements of cardiac output were carried out with NICO2 and thermodilution in patients ventilated in pressure-support mode and sedated with a sufentanil continuous infusion to obtain a Ramsay score value of 2. The mean cardiac output was: thermodilution 7.27+/-2.42 l/min; NICO2 6.10+/-1.66 l/min; r2 was 0.62 and bias -1.2 l/min+/-1.5. Mean values of cardiac output were similar in the low shunt group (Qs/Qt < 20), with r2=0.90 and a bias of 0.01 l/min+/-0.4; conversely, in the high pulmonary shunt group (Qs/Q > 35%) the mean was 9.32+/-1.23 l/min with thermodilution and a mean NICO2CO value was 6.97+/-1.53 l/min, with r2 of 0.38 and a bias of -2.3 l+/-1.2 min. CONCLUSIONS. The partial CO2 rebreathing technique is reliable in measuring cardiac output in nonpostoperative critically ill patients affected by diseases causing low levels of pulmonary shunt, but underestimates it in patients with shunt higher than 35%.
Publication Types:
PMID: 14652718 [PubMed - indexed for MEDLINE]
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Tissue Doppler imaging estimation of pulmonary artery occlusion pressure in ICU patients.
Combes A, Arnoult F, Trouillet JL.
Reanimation Medicale,Institut de Cardiologie, AP-HP, Hopital Pitie-Salpetriere, 47 Boulevard de l'Hopital, 75013 Paris, France. alain.combes@psl.ap-hop-paris.fr
OBJECTIVE: Earlier reports suggested that transthoracic (TTE) determination of the ratio of mitral inflow E wave velocity to early diastolic mitral annulus velocity (E/E') measured by tissue Doppler imaging (TDI) closely approximates PAOP in cardiac patients. However, the value of E/E' for PAOP assessment in ICU patients has not been evaluated. This study assessed whether the E/E' ratio provides an accurate estimation of pulmonary artery occlusion pressure (PAOP) in mechanically ventilated ICU patients. DESIGN AND SETTING: Prospective, open, clinical study in the ICU of a university hospital. PATIENTS: Twenty-three consecutive mechanically ventilated patients. INTERVENTIONS: Volume expansion in 14 patients. MEASUREMENTS AND RESULTS: Doppler TTE or TEE mitral inflow and TDI mitral annulus velocities were determined and compared with PAOP measured using a Swan-Ganz catheter. Of all the Doppler variables studied the best correlations were observed between PAOP and the lateral (r=0.84) and medial (r=0.76) annulus E/E' ratio and remained highly significant when the analysis was restricted to TEE (r=0.91 and 0.86) or TTE (r=0.73 and 0.61). The sensitivities and specificities of estimating PAOP at 15 mmHg or higher were, respectively, 86% and 81% for lateral E/E' above 7.5 and 76% and 80% for medial E/E' above 9. PAOP changes after volume expansion (700+/-230 ml) were limited and accurately assessed by repeated E/E' determinations. CONCLUSIONS: In mechanically ventilated ICU patients TTE or TEE E/E' determinations using TDI closely approximate PAOP.
Publication Types:
PMID: 14634723 [PubMed - indexed for MEDLINE]
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A novel method for insertion of post-pyloric feeding tubes at the bedside without endoscopic or fluoroscopic assistance: a prospective study.
Slagt C, Innes R, Bihari D, Lawrence J, Shehabi Y.
Department of Anaesthesiology, General Hospital De Heel, Zaans Medical Center, P.O. Box 210, 1500 EE Zaandam, The Netherlands. slagt.c@deheel.nl
OBJECTIVE: To assess a novel method, adapted from already published literature, for bedside placement of nasojejunal feeding tubes using erythromycin, air insufflation of the stomach and continuous ECG guidance. DESIGN AND SETTING: Prospective study in a tertiary teaching hospital. PATIENTS AND PARTICIPANTS: 40 consecutive patients who required enteral nutrition and mechanical ventilation for at least 48 h. INTERVENTIONS: Erythromycin (200 mg) was administered intravenously 30 min prior to the insertion of the feeding tube. The post-pyloric feeding tube was then inserted into the stomach and 500 ml air insufflated. Stomach ECG was performed, and during further insertion of the tube the QRS complex was continuously monitored for a change in polarity, suggesting passage across the midline through the pylorus. At the end of the procedure aspirate was obtained from the feeding tube and checked for alkaline pH. Exact tube position was determined by abdominal radiography. MEASUREMENTS AND RESULTS: In 88% of cases the feeding tubes were post-pyloric, with a median time to insertion of 15 min (range 7-75). No major complications were seen in 52 attempts. Change in QRS polarity had 94% sensitivity in predicting post-pyloric tip placement. Of the 32 alkaline pH aspirates 31 were post-pyloric. CONCLUSIONS: This procedure is safe, effective and could be performed in a short time period within the confines of the intensive care unit without endoscopic assistance.
PMID: 14615841 [PubMed - indexed for MEDLINE]
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The prognostic value of transcranial Doppler studies in children with moderate and severe head injury.
Trabold F, Meyer PG, Blanot S, Carli PA, Orliaguet GA.
Department of Anesthesiology and Critical Care, Hopital de Bicetre, Le Kremlin Bicetre, Assistance Publique-Hopitaux de Paris, Universite Paris XI, 63 rue Gabriel Peri, 94276 Le Kremlin-Bicetre, France.
OBJECTIVE: To assess the potency of transcranial Doppler (TCD) to predict prognosis in children with moderate and severe head trauma. DESIGN AND SETTING: Prospective single-center study in a level I pediatric trauma center. PATIENTS: Thirty-six consecutive patients with a prehospital diagnosis of moderate or severe head trauma admitted over a 6-month period. INTERVENTIONS: On arrival in the emergency room, TCD was performed and peak systolic velocities, end-diastolic velocity and time-averaged mean velocity in the middle cerebral artery were recorded. Pulsatility and resistance index were calculated. The Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS) were also calculated. Patient neurological outcome was determined using the Glasgow Outcome Scale (GOS) at discharge from hospital. GOS 1-2 were considered as "good prognosis" (group 1) and GOS 3-5 were considered as "poor prognosis" (group 2). RESULTS. Compared with group 1 patients, group 2 patients had a significantly lower mean GCS (5+/-3 vs 8+/-4, p<0.05) and PTS (2+/-2 vs 5+/-2), and a higher mean ISS (32+/-8 vs 19+/-11, p<0.05). An end-diastolic velocity less than 25 cm/s and a pulsatility index more than 1.31 were associated with a poor prognosis (p<0.05). CONCLUSION: In children with moderate and severe head trauma, our data suggest an association between the results of TCD assessment on arrival in the emergency room and the outcome at discharge from the hospital.
Publication Types:
PMID: 14600812 [PubMed - indexed for MEDLINE]
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Is there a place for granulocyte colony-stimulating factor in non-neutropenic critically ill patients?
Azoulay E, Delclaux C.
Intensive Care Unit, Saint Louis Teaching Hospital, 1 Avenue Claude Vellefaux, 75010 Paris, France. elie.azoulay@sls.ap-hop-paris.fr
Immunoparalysis, characterised by impairments in neutrophil and monocyte/macrophage function, is common in critically ill patients. The theoretical ability of granulocyte colony-stimulating factor (G-CSF) to improve the functions of both neutrophils and monocytes/macrophages provides a rationale for G-CSF therapy in non-neutropenic critically ill patients with infection or a high risk of nosocomial infection. The expression of the receptors that mediate G-CSF effects in neutrophils and monocytes/macrophages is regulated by bacterial products, cytokines and endogenous G-CSF levels, accounting for the variables effects of G-CSF on the neutrophil functions of critically ill patients. This variability should be taken into account when designing studies on the use of G-CSF in ICU-patients. Studies are still needed to identify the subset of patients who may benefit from G-CSF therapy.
Publication Types:
PMID: 14593456 [PubMed - indexed for MEDLINE]
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