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Risk of Posttraumatic Stress Symptoms in Family Members of Intensive Care Unit Patients.
Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larche J.
Service de Reanimation Medicale, Hopital Saint-Louis, Paris, France.
Rationale: ICU admission of a relative is a stressful event that may cause symptoms of posttraumatic stress disorder (PTSD). Objectives: Factors associated with these symptoms need to be identified. Methods: For patients admitted to 21 ICUs from March to November 2003, we studied the family member with the main potential decision-making role. Measurements: Ninety days after ICU discharge or death, family members completed the Impact of Event Scale (which evaluates the severity of posttraumatic stress reactions), Hospital Anxiety and Depression Scale, and 36-item Short-Form General Health Survey, during a telephone interview. Linear regression was used to identify factors associated with the risk of posttraumatic stress symptoms. Main results: Interviews were obtained for family members of 284 (62%) of the 459 eligible patients. Posttraumatic stress symptoms consistent with a moderate to major risk of PTSD were found in 94 (33.1%) family members. Higher rates were noted among family members who felt information was incomplete in the ICU (48.4%), who shared in decision-making (47.8%), whose relative died in the ICU (50%), whose relative died after end-of-life decisions (60%), and who shared in end-of-life decisions (81.8%). Severe posttraumatic stress reaction was associated with increased rates of anxiety and depression and decreased quality of life. Conclusion: Posttraumatic stress reaction consistent with a high risk of PTSD is common in family members of ICU patients and is the rule among those who share in end-of-life decisions. Research is needed to investigate PTSD rates and to devise preventive and early-detection strategies.
PMID: 15665319 [PubMed - as supplied by publisher]
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Survey of intensive care nurses' knowledge relating to the pulmonary artery catheter.
Johnston IG, Jane R, Fraser JF, Kruger P, Hickling K.
Primary Base-Gold Coast Hospital, Queensland.
In 2003 there was an increase in the use of pulmonary artery catheters in Australia from 12,000 to 16,000 units in intensive care and peri-operative care. This survey of intensive care nurses in five intensive care units in Queensland addressed knowledge of use, safety and complications of the pulmonary artery catheter, using a previously validated 31 question multiple choice survey. One hundred and thirty-nine questionnaires were completed, a response rate of 46%. The mean score was 13.3, standard deviation +/-4.2 out of a total of 31 (42.8% correct). The range was 4 to 25. Scores were significantly higher in those participants with more ICU experience, higher nursing grade, a higher self-assessed level of knowledge and greater frequency of PAC supervision. There was no significant correlation between total score and hospital- or university-based education, or total score and public or private hospital participants. Fifty-one per cent were unable to correctly identify the significant pressure change as the catheter is advanced from the right ventricle to the pulmonary artery.
PMID: 15675218 [PubMed - in process]
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Successful use of ECMO in adults with life-threatening infections.
MacLaren G, Pellegrino V, Butt W, Preovolos A, Salamonsen R.
Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria.
Two cases of critically ill patients who received extracorporeal membrane oxygenation (ECMO) using different forms of circuitry and for different indications are presented. Both patients had life-threatening infections with septic shock and were not able to be supported by conventional means. The first patient had staphylococcal septicaemia and received venoarterial ECMO for circulatory failure. The second patient had psittacosis and received venovenous ECMO for respiratory failure. We discuss the expanding indications for this technology and the role it has to play in adult intensive care.
Publication Types:
- Case Reports
- Review
- Review of Reported Cases
PMID: 15535500 [PubMed - indexed for MEDLINE]
Randomised controlled cross-over comparison of continuous positive airway pressure through the Hamilton Galileo ventilator with a Drager CF 800 device.
Sutton PJ, Perkins CL, Giles SP, McAuley DF, Gao F.
Intensive Care Unit, Birmingham Heartlands Hospital, Birmingham Heartlands and Solihull NHS Trust (Teaching), Bordesley Green East, Birmingham, B9 5SS, England.
In this controlled, randomised cross-over trial on 26 intensive care patients, we compared the effects on haemodynamic and respiratory profiles of continuous positive airway pressure delivered through the Hamilton Galileo ventilator or a Drager CF 800 device. We also compared the nursing time saved using the two approaches when weaning patients from mechanical ventilation. We did not find significant differences in haemodynamics, respiratory rate, physiological dead space, oxygen saturation and carbon dioxide production between the continuous positive airway pressure generated by the Galileo and Drager machines. However, there was a 10-fold reduction in nursing time using the Galileo ventilator compared with the Drager generator. We conclude that continuous positive airway pressure delivered through the Galileo ventilator is as efficient as a Drager device but consumes less nursing time.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15601276 [PubMed - indexed for MEDLINE]
Reliability of PRISM and PIM scores in paediatric intensive care.
van Keulen JG, Polderman KH, Gemke RJ.
Department of Pediatrics, VU University Medical Center, Amsterdam, Netherlands.
AIMS: To assess the reliability of mortality risk assessment using the Paediatric Risk of Mortality (PRISM) score and the Paediatric Index of Mortality (PIM) in daily practice. METHODS: Twenty seven physicians from eight tertiary paediatric intensive care units (PICUs) were asked to assess the severity of illness of 10 representative patients using the PRISM and PIM scores. Physicians were divided into three levels of experience: intensivists (>3 years PICU experience, n = 12), PICU fellows (6-30 months of PICU experience, n = 6), and residents (<6 months PICU experience, n = 9). This represents all large PICUs and about half of the paediatric intensivists and PICU fellows working in the Netherlands. RESULTS: Individual scores and predicted mortality risks for each patient varied widely. For PRISM scores the average intraclass correlation (ICC) was 0.51 (range 0.32-0.78), and the average kappa score 0.6 (range 0.28-0.87). For PIM scores the average ICC was 0.18 (range 0.08-0.46) and the average kappa score 0.53 (range 0.32-0.88). This variability occurred in both experienced and inexperienced physicians. The percentage of exact agreement ranged from 30% to 82% for PRISM scores and from 28 to 84% for PIM scores. CONCLUSION: In daily practice severity of illness scoring using the PRISM and PIM risk adjustment systems is associated with wide variability. These differences could not be explained by the physician's level of experience. Reliable assessment of PRISM and PIM scores requires rigorous specific training and strict adherence to guidelines. Consequently, assessment should probably be performed by a limited number of well trained professionals.
PMID: 15665184 [PubMed - indexed for MEDLINE]
The future of critical care.
Angus DC.
The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, 604 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA. angusdc@upmc.edu
Critical care has become an important part of the health care system; however, it still is provided in a heterogeneous, and likely suboptimal, fashion. Future challenges will include providing an adequate workforce; ensuring critical care is delivered to the right patients at the right time; converting advances in our understanding of the biology of critical illness into improved care and outcomes; and partnering successfully with patients, families, and society in forging the critical care of the future.
Publication Types:
PMID: 15579359 [PubMed - indexed for MEDLINE]
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Can regulation improve safety in critical care?
Marinelli AM.
Medical Intensive Care Unit and Respiratory Care Services, West Suburban Hospital, One Erie Court, Suite #3000, Oak Park, IL 60302, USA. threemm4me@aol.com
This article examines national and state safety practice initiatives, including the Centers for Medicare and Medicaid Services quality focus, federal and state outcomes reporting, and consumer access to outcomes data. The efforts of national and regional legislators and health care institutions to create regulations for staffing and technology to reduce medical errors is reviewed. The potential of a unified cooperative effort from all stakeholders to implement the above initiatives to improve intensive care unit safety practices is discussed.
Publication Types:
PMID: 15579358 [PubMed - indexed for MEDLINE]
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Management of the critically ill patient in the emergency department: focus on safety issues.
Goldstein RS.
Department of Emergency Medicine, North Shore/Long Island Jewish Research Institute, North Shore University Hospital, 350 Community Drive, Manhasset, NY 11030, USA. rgoldsteinmd@yahoo.com
The management of the critically ill patient in the emergency department (ED) is an evolving process. Currently there is sufficient evidence substantiating the central role of the ED in the management of critically ill patients. Understanding the tremendous impact ED physicians have in the care of critically ill patients will serve as an impetus for emergency medicine residents to pursue critical care specialty. With the continuous increment of critically ill patients presenting to EDs throughout the country, the nationwide shortage of critical care physicians, and the limited availability of intensive care unit eds throughout hospital systems, there will be an increased focus on managing these patients in the ED. As the field of emergency medicine continues to mature, the ED physician must take notice of the potential risk areas within the management of the critically ill patient to continue to improve these patients' short- and long-term survival.
Publication Types:
PMID: 15579354 [PubMed - indexed for MEDLINE]
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The electronic medical record, safety, and critical care.
Bria WF 2nd, Shabot MM.
Department of Internal Medicine, University of Michigan Medical School, 1500 East Medical Center Drive, 3916 Taubman Center, Ann Arbor, MI 48109-0360, USA. wbria@umich.edu
The goal of this article is to introduce the elements of the Electronic Medical Record as they pertain to critical care medicine including order communications and decision support.
Publication Types:
PMID: 15579353 [PubMed - indexed for MEDLINE]
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Critical care organization.
Chang SY, Multz AS, Hall JB.
Department of Medicine, New York University School of Medicine, North Shore University Hospital, 300 Community Drive, 4 Levitt Manhasset, NY 11030, USA. schang2@nshs.edu
The organizational structure of critical care services likely affects the quality of patient care, and ultimately, patient outcomes. Based on the available data, the ideal intensive care unit would be a closed-unit staffed by dedicated intensivists. Whether or not around-the-clock intensivist staffing is necessary, however, is debatable. Because financial realities preclude all units from being ideal, alternative strategies for organization must be explored.
Publication Types:
PMID: 15579352 [PubMed - indexed for MEDLINE]
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An irreplaceable safety culture.
Render ML, Hirschhorn L.
Department of Medicine, Division of Pulmonary/Critical Care, University of Cincinnati College of Medicine, 3200 Vine Street, Cincinnati, OH 45220, USA. marta.render@med.va.gov
Intensive care unit (ICU) clinicians are sources of errors and of resilience. When they learn how to juggle many competing goals, remain vigilant, and tell safety stories--all in the context of changing technologies and demand--they can create safe settings of care. Other strategies (eg, using computerized tools and implementing safety procedures) are important, but alone they are not sufficient. An ICU needs a safety culture that is rooted in a committed leadership, the acknowledgment that error is inevitable, a reporting system, and continuous learning. The all too common norm, "no harm no foul," is an obstacle. ICU leaders can use a campaign strategy to spread the safety practices that sustain a safety culture. They should attend to the political, marketing, and military aspects of such campaigns and recognize that people's time and attention are limited and built projects from existing ongoing pilots. Pilots can compete for people's attention; it has pull when it exemplifies a moral idea, simplifies work, and gives the health care professional more control and feedback. Under these conditions, the campaign will release individuals' passions and add energy and insight to the campaign itself.
Publication Types:
PMID: 15579351 [PubMed - indexed for MEDLINE]
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Failure mode and effects analysis application to critical care medicine.
Duwe B, Fuchs BD, Hansen-Flaschen J.
Department of Medicine, Hospital of the University of Pennsylvania, 873 Maloney Building, 3400 Spruce Street, Philadelphia, PA 19104, USA.
In July 2001, the United States Joint Commission on Accreditation of Health care Organizations adopted a new leadership standard that requires department heads in health care organizations to perform at least one Failure Mode and Effects Analysis (FMEA) every year. This proactive approach to error prevention has proven to be highly effective in other industries, notably aerospace, but remains untested in acute care hospitals. For several reasons, the intensive care unit (ICU) potentially is an attractive setting for early adoption of FMEA; however, successful implementation of FMEA in ICUs is likely to require strong, effective leadership and a sustained commitment to prevent errors that may have occurred rarely or never before in the local setting. This article describes FMEA in relation to critical care medicine and reviews some of the attractive features together with several potential pitfalls that are associated with this approach to error prevention in ICUs.
Publication Types:
PMID: 15579350 [PubMed - indexed for MEDLINE]
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Defining and measuring patient safety.
Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL.
Department of Anesthesiology & Critical Care Medicine, Surgery and Health Policy & Management, The Johns Hopkins University School of Medicine, 901 South Bond Street, Suite 318, Baltimore, MD 21231, USA. ppronovo@jhmi.edu
Despite the growing demand for improved safety in health care, debate remains regarding the magnitude of the problem and the degree to which harm is preventable. To a great extent, this debate stems from variation in the definition and methods for measuring safety, its "shadow" error, and the degree of preventability. This article reviews the definition of safety and error, discusses approaches to measuring safety, and provides a framework for investigating incidents that unveils how the systems under which care is delivered may contribute to adverse incidents.
Publication Types:
PMID: 15579349 [PubMed - indexed for MEDLINE]
Comment on:
Affordable health care.
Moss RE.
Publication Types:
PMID: 15599184 [PubMed - indexed for MEDLINE]
Comment on:
Metabolic acidosis.
Rosival V.
Publication Types:
PMID: 15599180 [PubMed - indexed for MEDLINE]
Comment on:
Dynamic assessment of pulmonary edema.
Evgenov OV.
Publication Types:
PMID: 15599176 [PubMed - indexed for MEDLINE]
Comment on:
Keeping a cool head: How to induce and maintain hypothermia.
Polderman KH.
Publication Types:
PMID: 15599175 [PubMed - indexed for MEDLINE]
Comment on:
Clinical implications of a validated scoring system for disseminated intravascular coagulation.
Heslet L.
Publication Types:
- Comment
- Editorial
- Validation Studies
PMID: 15599168 [PubMed - indexed for MEDLINE]
Comment on:
Continuous versus bilevel positive airway pressure in acute cardiogenic pulmonary edema? A good question!
Mehta S.
Publication Types:
PMID: 15599167 [PubMed - indexed for MEDLINE]
Comment on:
Bispectral Index monitoring for assessment of level of consciousness in brain-injured patients: the journey continues.
Fodale V, Pratico C.
Publication Types:
PMID: 15599166 [PubMed - indexed for MEDLINE]
Comment on:
Substantiating the concerns about recombinant human activated protein C use in sepsis.
Deans KJ, Minneci PC, Banks SM, Natanson C, Eichacker PQ.
Publication Types:
PMID: 15599164 [PubMed - indexed for MEDLINE]
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Carboxyhemoglobin formation as an unexpected side effect of inhaled nitric oxide therapy in severe acute respiratory distress syndrome.
Rusca M, Oddo M, Schaller MD, Liaudet L.
Division of Critical Care, Department of Internal Medicine, University Hospital, Lausanne, Switzerland.
OBJECTIVE: To report an unexpected cause of carboxyhemoglobinemia associated with inhaled nitric oxide therapy in severe acute respiratory distress syndrome. DESIGN: Case report. SETTING: Medical critical care unit at Lausanne University Hospital. PATIENT: One female patient with acute respiratory distress syndrome treated with inhaled nitric oxide, who developed a simultaneous increase in blood methemoglobin and carboxyhemoglobin. CONCLUSIONS: Potential pathophysiologic mechanisms linking acute respiratory distress syndrome, inhaled nitric oxide, methemoglobin, and carboxyhemoglobin are discussed. Since carboxyhemoglobin has a negative influence on oxygen-carrying capacity, this effect may potentially offset the beneficial influence (if any) of inhaled nitric oxide on arterial PO2. This observation does not support the use of inhaled nitric oxide in the treatment of acute respiratory distress syndrome.
Publication Types:
PMID: 15599162 [PubMed - indexed for MEDLINE]
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Management of the critically ill patient with severe acute pancreatitis.
Nathens AB, Curtis JR, Beale RJ, Cook DJ, Moreno RP, Romand JA, Skerrett SJ, Stapleton RD, Ware LB, Waldmann CS.
University of Washington, Seattle, WA, USA.
OBJECTIVE: Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP). DATA SOURCES AND METHODS: An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis. DATA SYNTHESIS: There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas. CONCLUSIONS: This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.
Publication Types:
- Consensus Development Conference
- Review
PMID: 15599161 [PubMed - indexed for MEDLINE]
Comment in:
Clinical trial of a novel surface cooling system for fever control in neurocritical care patients.
Mayer SA, Kowalski RG, Presciutti M, Ostapkovich ND, McGann E, Fitzsimmons BF, Yavagal DR, Du YE, Naidech AM, Janjua NA, Claassen J, Kreiter KT, Parra A, Commichau C.
Neurological Intensive Care Unit, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA. sam@columbia.edu
OBJECTIVE: To compare the efficacy of a novel water-circulating surface cooling system with conventional measures for treating fever in neuro-intensive care unit patients. DESIGN: Prospective, unblinded, randomized controlled trial. SETTING: Neurologic intensive care unit in an urban teaching hospital. PATIENTS: Forty-seven patients, the majority of whom were mechanically ventilated and sedated, with fever > or =38.3 degrees C for >2 consecutive hours after receiving 650 mg of acetaminophen. INTERVENTIONS: Subjects were randomly assigned to 24 hrs of treatment with a conventional water-circulating cooling blanket placed over the patient (Cincinnati SubZero, Cincinnati OH) or the Arctic Sun Temperature Management System (Medivance, Louisville CO), which employs hydrogel-coated water-circulating energy transfer pads applied directly to the trunk and thighs. MEASUREMENTS AND MAIN RESULTS: Diagnoses included subarachnoid hemorrhage (60%), cerebral infarction (23%), intracerebral hemorrhage (11%), and traumatic brain injury (4%). The groups were matched in terms of baseline variables, although mean temperature was slightly higher at baseline in the Arctic Sun group (38.8 vs. 38.3 degrees C, p = .046). Compared with patients treated with the SubZero blanket (n = 24), Arctic Sun-treated patients (n = 23) experienced a 75% reduction in fever burden (median 4.1 vs. 16.1 C degrees -hrs, p = .001). Arctic Sun-treated patients also spent less percent time febrile (T > or =38.3 degrees C, 8% vs. 42%, p < .001), spent more percent time normothermic (T < or =37.2 degrees C, 59% vs. 3%, p < .001), and attained normothermia faster than the SubZero group median (2.4 vs. 8.9 hrs, p = .008). Shivering occurred more frequently in the Arctic Sun group (39% vs. 8%, p = .013). CONCLUSION: The Arctic Sun Temperature Management System is superior to conventional cooling-blanket therapy for controlling fever in critically ill neurologic patients.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15599159 [PubMed - indexed for MEDLINE]
Comment in:
Assessment of preemptive treatment to prevent severe candidiasis in critically ill surgical patients.
Piarroux R, Grenouillet F, Balvay P, Tran V, Blasco G, Millon L, Boillot A.
Department of Parasitology-Mycology, University Hospital, Besancon, France.
OBJECTIVE: To assess the efficacy of a preemptive antifungal therapy in preventing proven candidiasis in critically ill surgical patients. DESIGN: Before/after intervention study, with 2-yr prospective and 2-yr historical control cohorts. SETTING: Surgical intensive care unit (SICU) in a university-affiliated hospital. PATIENTS: Nine hundred and thirty-three patients, 478 in the prospective group and 455 in the control group, with SICU stay > or =5 days. INTERVENTIONS: During the prospective period, systematic mycological screening was performed on all patients admitted to the SICU, immediately at admittance and then weekly until discharge. A corrected colonization index was used to assess intensity of Candida mucosal colonization. Patients with corrected colonization index > or =0.4 received early preemptive antifungal therapy (fluconazole intravenously: loading dose 800 mg, then 400 mg/day for 2 wks). MEASUREMENTS AND MAIN RESULTS: End points of this study were the frequency of proven candidiasis, especially SICU-acquired candidiasis. During the retrospective period, 32 patients of 455 (7%) presented with proven candidiasis: 22 (4.8%) were imported and 10 (2.2%) were SICU-acquired cases. During the prospective period, 96 patients with corrected colonization index > or =0.4 of 478 received preemptive antifungal treatment and only 18 cases (3.8%) of proven candidiasis were diagnosed; all were imported infections. Candida infections occurred more frequently in the control cohort (7% vs. 3.8%; p = .03). Incidence of SICU-acquired proven candidiasis significantly decreased from 2.2% to 0% (p < .001, Fisher test). Incidence of proven imported candidiasis remained unchanged (4.8% vs. 3.8%; p = .42). No emergence of azole-resistant Candida species (especially Candida glabrata, Candida krusei) was noted during the prospective period. CONCLUSIONS: Targeted preemptive strategy may efficiently prevent acquisition of proven candidiasis in SICU patients. Further studies are being performed to assess cost-effectiveness of this strategy and its impact on selection of azole-resistant Candida strains on a long-term basis.
Publication Types:
PMID: 15599149 [PubMed - indexed for MEDLINE]
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Removal of linezolid by conventional intermittent hemodialysis, sustained low-efficiency dialysis, or continuous venovenous hemofiltration in patients with acute renal failure.
Fiaccadori E, Maggiore U, Rotelli C, Giacosa R, Parenti E, Picetti E, Sagripanti S, Manini P, Andreoli R, Cabassi A.
Dipartimento di Clinica Medica, Nefrologia, & Scienze della Prevenzione, Universita degli Studi di Parma, Parma, Italy.
OBJECTIVE: To study the removal of linezolid, a new oxazolidinone antibiotic, by renal replacement therapy in patients with acute renal failure. DESIGN: Prospective, single-dose pharmacokinetic study. SETTING: Renal intensive care unit of a tertiary university hospital. PATIENTS: Fifteen critically ill patients with oliguric acute renal failure on renal replacement therapy (seven males, mean age 72.3 yrs, range 60-94; Acute Physiology and Chronic Health Evaluation II score 24.9, range 18-36; mechanical ventilation ten of 15). INTERVENTIONS: All patients received 600 mg of intravenous linezolid before starting renal replacement therapy, which consisted of intermittent hemodialysis lasting 3-4 hrs in eight patients, sustained low-efficiency dialysis lasting 8 hrs in five patients, and continuous venovenous hemofiltration lasting 10.5-12 hrs in two patients. MEASUREMENTS AND MAIN RESULTS: Linezolid concentrations were measured by liquid chromatography/mass spectrometry methods on serum and dialysate/ultrafiltrate samples. At the start of renal replacement therapy, serum levels averaged 11.91 mg/L (range 5.49-21.52) and dropped at the end to levels <4 mg/dL (90% minimum inhibitory concentration values for Staphylococcus aureus) in three of eight patients on hemodialysis, three of five patients on sustained low-efficiency dialysis, and two of two patients on continuous venovenous hemofiltration. Mean removal of the drug was 193.7 mg with hemodialysis (32.3% of the dose administered), 205 mg with sustained low-efficiency dialysis (33.9%), and 74.8 mg (12.4%) and 105 (17.5%) mg following a continuous venovenous hemofiltration session lasting 10.5 and 12 hrs, respectively. CONCLUSIONS: In patients with acute renal failure, serum levels of linezolid can be reduced to the subtherapeutic range following renal replacement therapy.
PMID: 15599148 [PubMed - indexed for MEDLINE]
Comment in:
Cerebral microdialysis of patients with severe traumatic brain injury exhibits highly individualistic patterns as visualized by cluster analysis with self-organizing maps.
Nelson DW, Bellander BM, Maccallum RM, Axelsson J, Alm M, Wallin M, Weitzberg E, Rudehill A.
Department of Anaesthesiology and Intensive care, Karolinska University Hospital, Stockholm Sweden.
OBJECTIVE: To analyze patterns of cerebral microdialysis in patients with traumatic brain injury and, with a neural network methodology, investigate pattern relationships to intracranial pressure and cerebral perfusion pressure. DESIGN: Retrospective. SETTING: University hospital, adult neurosurgical intensive care unit. PATIENTS: Twenty-six patients with severe traumatic brain injury. All consecutive traumatic brain injured patients (Glasgow Coma Scale < or =8) with microdialysis monitoring, analyzing glutamate, lactate, pyruvate, and glucose in both penumbral and nonpenumbral tissue. INTERVENTIONS: None; patients received the unit's standard neurointensive care procedure. MEASUREMENTS AND MAIN RESULTS: We used 2084 hrs of complete microdialysis data sets (eight markers) to train Kohonen self-organizing maps. The self-organizing map algorithm is a data-clustering method that reduces high-dimensional information to a two-dimensional representation on a grid (map), retaining local relationships in the data. Maps were colored (overlaid) for intracranial pressure, cerebral perfusion pressure, and outcome, to explore relationships with underlying microdialysis patterns. The maps exhibited a striking clustering of patients, with unique microdialysis patterns that were recognizable throughout the analysis period. This also held true for most microdialysis patterns characteristic of ischemia. These patients with ischemic patterns can have good outcomes, suggesting a disparity between microdialysis values and severity of traumatic brain injury. CONCLUSION: Using an artificial neural network-like clustering technique, Kohonen self-organizing maps, we have shown that cerebral microdialysis, in traumatic brain injury, exhibits strikingly individualistic patterns that are identifiable throughout the analysis period. Because patients form their own clusters, microdialysis patterns, during periods of increased intracranial pressure or decreased cerebral perfusion pressure, will be found within these clusters. Consequently, no common pattern of microdialysis can be seen among patients within the range of our data. We suggest that these individualistic patterns reflect not only metabolic states of traumatic brain injury but also local gradients seen with small volume sampling. Future investigation should focus on relating these patterns, and movement within and from clusters, to metabolic states of the complex pathophysiology of traumatic brain injury.
PMID: 15599147 [PubMed - indexed for MEDLINE]
Comment in:
Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator.
Mayo PH, Hackney JE, Mueck JT, Ribaudo V, Schneider RF.
Beth Israel Medical Center, University Hospital and Manhattan Campus for the Albert Einstein College of Medicine, New York, NY, USA.
OBJECTIVES: Patient simulation is emerging as a training technique in the field of medicine. It has particular application in training responses to high-risk, low-frequency clinical events, of which a typical example is in-hospital cardiac arrest. A critical element of response by the cardiac arrest team is initial airway management. In teaching hospitals, medical interns are first responders to in-hospital cardiac arrests. Our objective was to design and test a program using a computer-controlled patient simulator to train medical interns and demonstrate their competence in initial airway management. DESIGN: Prospective, randomized, controlled, unblinded trial. SETTING: Internal medicine residency training program in an urban teaching hospital. PARTICIPANTS: All 50 starting internal medicine interns in July 2002, all Advanced Cardiac Life Support certified in June 2002. INTERVENTIONS: All interns were tested in initial airway management skills and then were randomly assigned to receive either immediate or delayed individualized training using a computer-controlled patient simulator. The computer-simulated training process consisted of a scenario of respiratory arrest. The interns were challenged with the scenario twice following testing. The interns were debriefed extensively and given hands-on training by the attending using the simulator until they achieved perfect performance. MEASUREMENTS AND MAIN RESULTS: Initial airway management was divided into specific scorable steps. Individual step scores and total scores were recorded for each intern on initial and repeat testing. For 10 months following simulator training, intern airway management skills were scored in actual patient airway events. Despite recent Advanced Cardiac Life Support training and certification, all starting medical interns demonstrated poor airway management skills. The immediate training group showed significant improvement in initial airway management when tested before and 4 wks after training. In contrast, the delayed training group showed no significant improvement. Direct observation of interns in actual initial airway events revealed excellent clinical performance. CONCLUSIONS: Individualized training of medical interns using a computer-controlled patient simulator is an effective means of achieving and measuring competence in initial airway management skills. The improvement appears to be transferable to the bedside of real patients.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15599146 [PubMed - indexed for MEDLINE]
Comment in:
Prospective validation of the International Society of Thrombosis and Haemostasis scoring system for disseminated intravascular coagulation.
Bakhtiari K, Meijers JC, de Jonge E, Levi M.
Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, The Netherlands.
OBJECTIVES: A diagnosis of disseminated intravascular coagulation (DIC) is hampered by the lack of an accurate diagnostic test. Based on the retrospective analysis of studies in patients with DIC, a scoring system (0-8 points) using simple and readily available routine laboratory tests has been proposed. The aim of this study was to prospectively validate this scoring system and assess its feasibility, sensitivity, and specificity in a consecutive series of intensive care patients. DESIGN: Prospective cohort of intensive care patients. SETTING: Adult intensive care unit in a tertiary academic center. PATIENTS: Consecutive patients with a clinical suspicion of disseminated intravascular coagulation. INTERVENTIONS: Patients were followed during their admission to the intensive care unit, and the DIC score was calculated every 48 hrs and compared with a "gold standard" based on expert opinion. In addition, an activated partial thromboplastin time (aPTT) waveform analysis, which has been reported to be a good predictor for the absence or presence of DIC, was performed. MEASUREMENTS AND MAIN RESULTS: We analyzed 660 samples from 217 consecutive patients. The prevalence of DIC was 34%. There was a strong correlation between an increasing DIC score and 28-day mortality (for each 1-point increment in the DIC score, the odds ratio for mortality was 1.25). The sensitivity of the DIC score was 91% and the specificity 97%. An abnormal aPTT waveform was seen in 32% of patients and correlated well with the presence of DIC (sensitivity 88%, specificity 97%). In 19% of patients, the aPTT waveform-based diagnosis of DIC preceded the diagnosis based on the scoring system. CONCLUSIONS: A diagnosis of DIC based on a simple scoring system, using widely available routine coagulation tests, is sufficiently accurate to make or reject a diagnosis of DIC in intensive care patients with a clinical suspicion of this condition. An aPTT waveform analysis is an interesting and promising tool to assist in the diagnostic management of DIC.
Publication Types:
PMID: 15599145 [PubMed - indexed for MEDLINE]
Comment in:
Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema.
Park M, Sangean MC, Volpe Mde S, Feltrim MI, Nozawa E, Leite PF, Passos Amato MB, Lorenzi-Filho G.
Division of Emergency Medicine), Heart Institute (InCor), Hospital das Clinicas, University of Sao Paulo, Brazil. mpark@uol.com.br
OBJECTIVE: To compare the effects of oxygen, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (bilevel-PAP) on the rate of endotracheal intubation in patients with acute cardiogenic pulmonary edema. DESIGN: Randomized, controlled trial. SETTING: Tertiary hospital emergency room. PATIENTS: We randomly assigned 80 patients with severe cardiogenic acute pulmonary edema into three treatment groups. Patients were followed for 60 days after the randomization. INTERVENTIONS: Oxygen applied by face mask, CPAP, and bilevel-PAP. MEASUREMENTS AND MAIN RESULTS: The rate of endotracheal intubation as well as vital signs and blood gases was recorded during the first 24 hrs. Mortality was evaluated at 15 days, at 60 days, and at hospital discharge. Complications related to respiratory support were evaluated before hospital discharge. Treatment with CPAP or bilevel-PAP resulted in significant improvement in the PaO2/FiO2 ratio, subjective dyspnea score, and respiratory and heart rates compared with oxygen therapy. Endotracheal intubation was necessary in 11 of 26 patients (42%) in the oxygen group but only in two of 27 patients (7%) in each noninvasive ventilation group (p = .001). There was no increase in the incidence of acute myocardial infarction in the CPAP or bilevel-PAP groups. Mortality at 15 days was higher in the oxygen than in the CPAP or bilevel-PAP groups (p < .05). Mortality up to hospital discharge was not significantly different among groups (p = .061). CONCLUSIONS: Compared with oxygen therapy, CPAP and bilevel-PAP resulted in similar vital signs and arterial blood gases and a lower rate of endotracheal intubation. No cardiac ischemic complications were associated with either of the noninvasive ventilation strategies.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15599144 [PubMed - indexed for MEDLINE]
Comment in:
Bispectral Index monitoring correlates with sedation scales in brain-injured patients.
Deogaonkar A, Gupta R, DeGeorgia M, Sabharwal V, Gopakumaran B, Schubert A, Provencio JJ.
Department of Anesthesiology, The Cleveland Clinic Foundation, Cleveland, OH, USA.
OBJECTIVE: Monitoring critically ill, brain-injured patients with a decreased level of consciousness is challenging. Our goal is to determine in this population the correlation between the Bispectral Index (BIS) and three commonly used sedation agitation scales: the Richmond Agitation-Sedation Scale (RASS), the Sedation-Agitation Scale (SAS) and the Glasgow Coma Scale (GCS) scores. DESIGN: Prospective, single-blinded observational study. SETTING: Eight-bed neurology-neurosurgery intensive care unit at the Cleveland Clinic Foundation. PATIENTS: Thirty critically ill patients admitted to the neurointensive care unit with primary brain injury and a decreased level of consciousness. MEASUREMENTS AND MAIN RESULTS: Patients were prospectively evaluated for level of consciousness using the RASS, SAS, and GCS every hour and simultaneously were monitored continuously with a BIS monitor for 6 hrs. A Spearman's correlation coefficient was used to correlate the BIS scores with clinical scales. In 15 patients monitored with the newer BIS XP version, the BIS values correlated significantly with the RASS (R2 = .810; p < .0001), SAS (R2 = .725; p < .0001), and GCS (R2 = .655; p < .0001). In 15 patients monitored with the older BIS 2.1.1 software, the correlation was as follows: for RASS, R2 = .30 (p < .008), for SAS: R2 = .376 (p < .001), and for GCS: R2 = .274 (p < .015). This correlation was maintained in patients who received sedative medications. CONCLUSIONS: A statistically significant correlation existed between BIS values and the RASS, SAS, and GCS scores in critically ill brain-injured patients, with and without sedation. The newer BIS XP software package may be a useful adjunctive tool in objective assessment of level of consciousness in brain-injured patients.
Publication Types:
PMID: 15599143 [PubMed - indexed for MEDLINE]
Year in review in intensive care medicine, 2004. II. Brain injury, hemodynamic monitoring and treatment, pulmonary embolism, gastrointestinal tract, and renal failure.
Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R, Vallet B.
Intensive Care Medicine Unit, Western General Hospital, Edinburgh, UK.
PMID: 15678311 [PubMed - in process]
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Prognosis of patients with systemic rheumatic diseases admitted to the intensive care unit.
Moreels M, Melot C, Leeman M.
Departments of Intensive Care Medicine and Internal Medicine, Erasme University Hospital, Lennik Road 808, 1070, Brussels, Belgium, marc.leeman@ulb.ac.be.
OBJECTIVE: To determine prognostic factors in patients with systemic rheumatic diseases admitted to the intensive care unit (ICU) and to examine whether the observed mortality rate is predicted using the Acute Physiology And Chronic Health Assessment II (APACHE II) score.DESIGN AND SETTING: Retrospective study with historical controls in a 31-bed medicosurgical ICU at a university hospital.PATIENTS AND PARTICIPANTS: Seventy-one patients admitted to the ICU for an acute illness related to a systemic rheumatic disease and/or its treatment and 353 ICU control patients.RESULTS: Systemic rheumatic diseases were mainly rheumatoid arthritis and vasculitides. In-hospital mortality rate was 28/71 (39%), including 23 patients who died in the ICU. Multivariable logistic regression showed that poor prior health status (Berdit's classification), APACHE II score, and admission for infection were associated with mortality, whereas prior use of immunosuppressive agents was not. APACHE II score at admission was higher in nonsurvivors (22+/-9) than in survivors (17+/-5) (p<0.01). The standard mortality ratio, i.e., the ratio between observed and predicted mortality, was 1.7 in the 71 study patients and 1.0 in the 353 control patients (p<0.0001).CONCLUSIONS: In patients with systemic rheumatic diseases admitted to the ICU for at least 48 h, poor prior chronic health status, APACHE II score, and infection were prognostic factors for in-hospital mortality. SMR was higher than in a control ICU population.
PMID: 15678307 [PubMed - as supplied by publisher]
Comment in:
Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study.
Cepeda JA, Whitehouse T, Cooper B, Hails J, Jones K, Kwaku F, Taylor L, Hayman S, Cookson B, Shaw S, Kibbler C, Singer M, Bellingan G, Wilson AP.
Department of Clinical Microbiology, University College London Hospitals, London W1T 4 JF, UK.
BACKGROUND: Hospital-acquired infection due to meticillin-resistant Staphylococcus aureus (MRSA) is common within intensive-care units. Single room or cohort isolation of infected or colonised patients is used to reduce spread, but its benefit over and above other contact precautions is not known. We aimed to assess the effectiveness of moving versus not moving infected or colonised patients in intensive-care units to prevent transmission of MRSA. METHODS: We undertook a prospective 1-year study in the intensive-care units of two teaching hospitals. Admission and weekly screens were used to ascertain the incidence of MRSA colonisation. In the middle 6 months, MRSA-positive patients were not moved to a single room or cohort nursed unless they were carrying other multiresistant or notifiable pathogens. Standard precautions were practised throughout. Hand hygiene was encouraged and compliance audited. FINDINGS: Patients' characteristics and MRSA acquisition rates were similar in the periods when patients were moved and not moved. The crude (unadjusted) Cox proportional-hazards model showed no evidence of increased transmission during the non-move phase (0.73 [95% CI 0.49-1.10], p=0.94 one-sided). There were no changes in transmission of any particular strain of MRSA nor in handwashing frequency between management phases. INTERPRETATION: Moving MRSA-positive patients into single rooms or cohorted bays does not reduce crossinfection. Because transfer and isolation of critically ill patients in single rooms carries potential risks, our findings suggest that re-evaluation of isolation policies is required in intensive-care units where MRSA is endemic, and that more effective means of preventing spread of MRSA in such settings need to be found.
Publication Types:
PMID: 15664224 [PubMed - indexed for MEDLINE]
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