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Items 1 - 19 of 19 |
One page. |
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Preschool outcome in children born very prematurely and cared for according to the Newborn Individualized Developmental Care and Assessment Program (NIDCAP).
Westrup B, Bohm B, Lagercrantz H, Stjernqvist K.
Neonatal Programme, Department of Woman and Child Health, Astrid Lindgren Children's Hospital, Karolinska Institute, Stockholm, Sweden. bjorn.westrup@ks.se
AIM: Care based on the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) has been reported to exert a positive impact on the development of prematurely born infants. The aim of the present investigation was to determine the effect of such care on the development at preschool age of children born with a gestational age of less than 32 wk. METHODS: All surviving infants in a randomised controlled trial with infants born at a postmenstrual age less than 32 wk (11 in the NIDCAP group and 15 in the control group) were examined at 66.3 (6.0) mo corrected for prematurity [mean (SD)]. In the assessment we employed the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) for cognition, Movement Assessment Battery for Children (Movement ABC) for motor function, subtests of the NEPSY test battery for attention and distractibility, and the WHO definitions of impairment, disability and handicap. Exact binary logistic regression was employed. RESULTS: There were no significant differences between the intervention group in Full-Scale IQ 93.4 (14.2) [mean (SD)] versus the control group 89.6 (27.2), Verbal IQ 93.6 (16.4) versus 93.7 (26.8) or Performance IQ 94.3 (14.7) versus 86.3 (24.8). In the NIDCAP group 8/13 (62%) survived without disability and for the children with conventional care this ratio was 7/19 (37%). The corresponding ratios for surviving without mental retardation were 10/13 (77%) and 11/19 (58%), and for surviving without attention deficits 10/13 (77%) and 10/19 (53%). Overall, the differences were not statistically significant, although the odds ratio for surviving with normal behaviour was statistical significant after correcting for group imbalances in gestational age, gender, growth retardation and educational level of the parents. CONCLUSION: Our trial suggests a positive impact by NIDCAP on behaviour at preschool age in a sample of infants born very prematurely. However, due to problems of recruitment less than half of the anticipated subjects were included in the study, which implies a low power and calls for caution in interpreting our findings. Larger trials in different cultural contexts are warranted.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15188978 [PubMed - indexed for MEDLINE]
The effect of critical care outreach on postoperative serious adverse events.
Story DA, Shelton AC, Poustie SJ, Colin-Thome NJ, McNicol PL.
Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Victoria, Australia. david.story@austin.org.au
We proposed that critical care outreach would decrease the incidence of postoperative serious adverse events and so conducted a sequential cohort study with a surveillance-only phase (baseline) followed by an intervention phase. We studied high-risk patients in a large Australian hospital. A critical care qualified nurse reviewed patients for the first three days after return to the general wards. During the intervention phase the nurse intervened in patient care where appropriate. We examined the incidence of 11 categories of serious adverse events per 100 patients during the first three days on the general wards during the surveillance and intervention phases. The surveillance phase had 319 patients and the intervention phase 345 patients. In a subgroup analysis, there were four myocardial infarctions per 100 patients in the surveillance phase and seven per 100 patients during the intervention phase (95% confidence interval: 1-7 infarctions per 100 patients increase). For the other 10 serious adverse events there were 19 per 100 patients in the surveillance phase and 11 per 100 patients in the intervention phase (95% confidence interval: 4-11 serious adverse events per 100 patients decrease). Outreach may have led to greater detection of myocardial infarctions while reducing the incidence of other serious adverse events.
PMID: 15270966 [PubMed - indexed for MEDLINE]
Evidence-based medicine in the ICU: important advances and limitations.
Vincent JL.
Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium. jlvincen@ulb.ac.be
Evidence-based medicine (EBM) is an important strategy for assessing the vast amounts of published data and applying them appropriately to our patients. However, in intensive care medicine, there is a shortage of "gold standard" randomized controlled trial evidence to support (or not support) therapeutic decisions. In addition, even when well-conducted randomized trials have been performed, we are still left with unanswered questions. In the last 5 years, several clinical trials have yielded positive results with a number of interventions being shown to improve outcomes. Here, we will outline the limitations and advances of EBM in intensive care medicine, by discussing the key findings in the last few years from studies of therapeutic agents for ICU patients.
PMID: 15302748 [PubMed - indexed for MEDLINE]
Blood conservation for critically ill patients.
Fowler RA, Rizoli SB, Levin PD, Smith T.
Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. rob.fowler@sw.ca
Anemia may be the most common illness of critically ill patients. The majority of critically ill patients are anemic at admission to the intensive care unit (ICU), and hemoglobin concentrations typically decline during the first 3 days of ICU stay. Hemoglobin continues to decline for patients with sepsis and higher severity of illness. This patient population may be at particular risk of adverse consequences of anemia given the cardiovascular, respiratory, and metabolic compromise frequently encountered during critical illness. The etiology of anemia of critical illness is multifactorial, resulting from phlebotomy, gastrointestinal bleeding, coagulation disorders, blood loss from vascular procedures, renal failure, nutritional deficiencies,bone marrow suppression, and impaired erythropoietin response.
Publication Types:
PMID: 15135468 [PubMed - indexed for MEDLINE]
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Transfusion in the cardiac patient.
Spahn DR, Dettori N, Kocian R, Chassot PG.
Department of Anesthesiology, University Hospital Lausanne (CHUV), CH-1011 Lausanne, Switzerland. donat.spahn@chuv.hospvd.ch
Transfusion guidelines in patients with coexisting cardiac diseases are similar to the ones in patients without such comorbidity, in that allogeneic blood transfusions most often are indicated at hemoglobin levels of less than 6.0 g/dL and hardly ever at hemoglobin levels greater than 10 g/dL. In the hemoglobin range of 6 to 10 g/dL, signs of impaired oxygenation should serve as transfusion indications, and such signs may be reached at higher hemoglobin values than in healthy patients. An inadequate oxygenation may become manifest globally in the form of a general hemodynamic instability with a tendency to hypotension and tachycardia despite normovolemia or an oxygen extraction of greater than 50%. An inadequate oxygenation in the form of myocardial ischemia may be manifested by new ST-segment depressions of greater than 0.1 mV, new ST-segment elevations greater than 0.2 mV, or new wall motion abnormalities in transesophageal echocardiography. Institutional guidelines also should consider local logistic characteristics such as the level of knowledge of physician and nurse staff caring for patients and the level of surveillance possible justifying eventually higher hemoglobin transfusion triggers, particularly in the postoperative period.
Publication Types:
PMID: 15135465 [PubMed - indexed for MEDLINE]
Comment on:
Obesity-related excess mortality rate in an adult intensive care unit: a risk-adjusted matched cohort study.
O'Brien JM.
Publication Types:
PMID: 15343043 [PubMed - indexed for MEDLINE]
7: id: 15343039 Error occurred: Document retrieval error: document is empty
Comment on:
Further considerations regarding the effects of physical restraint in the intensive care unit.
Happ MB.
Publication Types:
PMID: 15343038 [PubMed - indexed for MEDLINE]
Comment on:
Evidence-based approach to family care in the intensive care unit: why can't we just be decent?
Harvey MA.
Publication Types:
PMID: 15343037 [PubMed - indexed for MEDLINE]
Comment in:
Postoperative troponin-T predicts prolonged intensive care unit length of stay following cardiac surgery.
Baggish AL, MacGillivray TE, Hoffman W, Newell JB, Lewandrowski KB, Lee-Lewandrowski E, Anwaruddin S, Siebert U, Januzzi JL.
Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
OBJECTIVE: To evaluate the use of postoperative cardiac troponin T (cTnT) for the prediction of prolonged intensive care unit length of stay following cardiac surgery. DESIGN: Prospective, single-center, observational cohort study of patients following cardiac surgical procedures. The enrollment period was from October through December 2000. Patients were enrolled on admission to the intensive care unit and followed until hospital discharge. SETTING: The cardiac surgical intensive care unit of the Massachusetts General Hospital. PATIENTS: A total of 222 consecutive patients were enrolled. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Perioperative clinical factors and serum concentrations of cTnT measured every 8 hrs after surgery were recorded. These clinical factors and the results of serum cTnT measurement were correlated with the need for prolonged intensive care unit length of stay (defined as >24 hrs). Univariable analysis identified factors predictive of prolonged intensive care unit length of stay. Stepwise logistic regression identified independent predictors of prolonged intensive care unit length of stay. Multiple linear regression was used to explore the direct relationship between cTnT concentrations at several postoperative time points and intensive care unit length of stay. At each time point assessed, cTnT concentrations from patients requiring a prolonged intensive care unit length of stay were significantly higher (all p <.001) than in those individuals with normal length of stay. In contrast, creatine kinase isoenzymes were not significantly different between patients with normal or prolonged intensive care unit length of stay. Multivariable analysis demonstrated that an immediate postoperative cTnT concentration > or =1.58 ng/mL was the strongest predictor of a prolonged intensive care unit length of stay (odds ratio, 5.6; 95% confidence interval, 2.9-10.8). Multiple linear regression analysis revealed that intensive care unit length of stay increased by 0.32 days with each incremental 1.0 ng/mL increase in cTnT measured at 18-24 hrs postprocedure. CONCLUSIONS: Elevated postoperative cTnT concentrations can prospectively identify patients requiring prolonged intensive care unit length of stay after cardiac surgery.
PMID: 15343014 [PubMed - indexed for MEDLINE]
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A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia.
Campbell ML, Guzman JA.
Palliative Care Service, Detroit Receiving Hospital, Detroit, MI, USA.
OBJECTIVES: To compare usual care with a proactive case-finding approach for critically ill patients with terminal dementia using an inpatient palliative care service. DESIGN: Prospective comparison to historical control. SETTING: Urban, university-affiliated hospital. PATIENTS: Total of 52 men and women with end-stage dementia, 26 subjects in each control and intervention group. INTERVENTIONS: Proactive case-finding by the palliative care service was done to offer early assistance to the intensive care unit staff about the treatment of patients with terminal dementia. Results were compared with data obtained retrospectively. MEASUREMENTS AND MAIN RESULTS: Measurements included age, gender, Acute Physiology and Chronic Health Evaluation Score, Therapeutic Intervention Scoring System, mortality, intensive care unit and hospital lengths of stay, frequency, timing, and goals of do-not-resuscitate orders. The proactive, case-finding approach decreased hospital and medical intensive care unit length of stay. More important, a proactive palliative intervention decreased the time between identification of the poor prognosis and the establishment of do-not-resuscitate goals, decreased the time terminal demented patients remained in the intensive care unit, and reduced the use of nonbeneficial resources, thus reducing patient burden and the cost of care while having the potential to afford the patient and family increased comfort and psychoemotional support. CONCLUSIONS: Proactive interventions from a palliative care consultant within this subset of patients improved end-of-life care and decreased use of superfluous resources.
PMID: 15343010 [PubMed - indexed for MEDLINE]
Comment in:
Half the family members of intensive care unit patients do not want to share in the decision-making process: a study in 78 French intensive care units.
Azoulay E, Pochard F, Chevret S, Adrie C, Annane D, Bleichner G, Bornstain C, Bouffard Y, Cohen Y, Feissel M, Goldgran-Toledano D, Guitton C, Hayon J, Iglesias E, Joly LM, Jourdain M, Laplace C, Lebert C, Pingat J, Poisson C, Renault A, Sanchez O, Selcer D, Timsit JF, Le Gall JR, Schlemmer B; FAMIREA Study Group.
Intensive Care Unit of the Saint-Louis Teaching Hospital and University of Paris 7, Assistance Publique-Hopitaux de Paris, Paris, France.
OBJECTIVE: To evaluate the opinions of intensive care unit staff and family members about family participation in decisions about patients in intensive care units in France, a country where the approach of physicians to patients and families has been described as paternalistic. DESIGN: Prospective multiple-center survey of intensive care unit staff and family members. SETTING: Seventy-eight intensive care units in university-affiliated hospitals in France. PATIENTS: We studied 357 consecutive patients hospitalized in the 78 intensive care units and included in the study starting on May 1, 2001, with five patients included per intensive care unit. INTERVENTIONS: We recorded opinions and experience about family participation in medical decision making. Comprehension, satisfaction, and Hospital Anxiety and Depression Scale scores were determined in family members. MEASUREMENTS AND MAIN RESULTS: Poor comprehension was noted in 35% of family members. Satisfaction was good but anxiety was noted in 73% and depression in 35% of family members. Among intensive care unit staff members, 91% of physicians and 83% of nonphysicians believed that participation in decision making should be offered to families; however, only 39% had actually involved family members in decisions. A desire to share in decision making was expressed by only 47% of family members. Only 15% of family members actually shared in decision making. Effectiveness of information influenced this desire. CONCLUSION: Intensive care unit staff should seek to determine how much autonomy families want. Staff members must strive to identify practical and psychological obstacles that may limit their ability to promote autonomy. Finally, they must develop interventions and attitudes capable of empowering families.
Publication Types:
PMID: 15343009 [PubMed - indexed for MEDLINE]
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Simulation as a teaching strategy for nursing education and orientation in cardiac surgery.
Rauen CA.
Simulation Laboratory, Georgetown University, School of Nursing and Health Studies, Washington, D.C., USA.
PMID: 15206295 [PubMed - indexed for MEDLINE]
Comment in:
Mastering temporary invasive cardiac pacing.
Overbay D, Criddle L.
Oregon Health & Science University, Portland, Ore., USA.
Competent management of patients with an invasive temporary pacemaker is an important skill for nurses who provide care for critically ill patients with cardiac disease. Such management requires familiarity with normal cardiovascular anatomy and physiology, conduction system defects, and rhythm interpretation. With an understanding of the basic concepts of rate, output, chambers, sensitivity, and capture, pacing can be done with ease. Care of patients with a temporary invasive pacemaker requires monitoring cardiac tissue and hemodynamic status, observing for changes that would indicate the need for modifications in the pacemaker settings. Nursing interventions include physical assessment, care of the insertion site, routine threshold testing, and management of the pulse generator.
Publication Types:
PMID: 15206293 [PubMed - indexed for MEDLINE]
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Disaster nursing. New frontiers for critical care.
Cox E, Briggs S.
Emergency Department, Massachusetts General Hospital, Boston, Mass., USA.
PMID: 15206292 [PubMed - indexed for MEDLINE]
Comment on:
Placement of endotracheal and tracheostomy tubes.
Pate MF.
Publication Types:
PMID: 15206291 [PubMed - indexed for MEDLINE]
Comment on:
The role of institutional review boards.
Ashcraft AS.
Publication Types:
PMID: 15206289 [PubMed - indexed for MEDLINE]
Comment on:
NEOPAIN: a question of survival.
Pechlaner C.
Publication Types:
PMID: 15302186 [PubMed - indexed for MEDLINE]
Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit.
Sadowski R, Dechert RE, Bandy KP, Juno J, Bhatt-Mehta V, Custer JR, Moler FW, Bratton SL.
Department of Critical Care Support Services, University of Michigan Health System, 200 East Hospital Dr, F5815 Box 0208, Ann Arbor, MI 48109, USA. rsadowsk@umich.edu
OBJECTIVE: Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs. METHODS: Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program. RESULTS: From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation. CONCLUSIONS: We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.
PMID: 15342831 [PubMed - in process]
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