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ICU transport: interhospital transport of critically ill patient with dedicated intensive care ventilator.
van Lieshout EJ, Vroom MV, Fuchs BD, Reily D.
Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands 1100 DD. vanlieshout@amc.nl.
PMID: 15706022 [PubMed - in process]
Clinical review: Vasculitis on the intensive care unit - part 1: diagnosis.
Semple D, Keogh J, Forni L, Venn R.
Specialist Registrar Renal Medicine, Worthing Hospital, Worthing, UK. david.semple@wash.nhs.uk.
The first part of this review addresses the diagnosis and differential diagnosis of the primary vasculitides Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome and polyarteritis nodosa. Prompt diagnosis and treatment of these conditions ensures an optimal prognosis. The development of assays for antineutrophil cytoplasmic antibodies has aided the diagnosis of Wegener's granulomatosis and microscopic polyangiitis. However, even in cases where there is high clinical likelihood that these conditions are present, up to 20% may be antibody negative, whereas alternative diagnoses may be antibody positive. The final diagnosis rests on a balance of clinical, laboratory, radiological and histological features. The exclusion of alternative diagnoses is important in assuring appropriate therapy. Particular attention is paid to the more fulminant presentations of these conditions and the role of the critical care physician in their diagnosis and management.
PMID: 15693990 [PubMed - in process]
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The use of bispectral index monitors in paediatric intensive care.
Playfor SD.
Consultant Paediatric Intensivist, Honorary Clinical Lecturer in Paediatric Intensive Care Medicine, Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Manchester, UK. Stephen.playfor@cmmc.nhs.uk.
The bispectral index (BIS) is a processed neurophysiological electroencephalographic parameter that may be used to evaluate the depth of sedation in critically ill children. Triltsch and colleagues attempted to correlate BIS scores with a commonly used clinical sedation scoring system. They were able to demonstrate good correlation during deep sedation and in cases where the electrical impedance of the BIS electrodes was lowest. Studies have shown only moderate degrees of correlation between BIS scores and clinical sedation scoring systems. There is currently insufficient evidence to recommend routine monitoring of BIS scores in critically ill children.
Publication Types:
PMID: 15693977 [PubMed - in process]
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Bispectral index versus COMFORT score to determine the level of sedation in paediatric intensive care unit patients: a prospective study.
Triltsch AE, Nestmann G, Orawa H, Moshirzadeh M, Sander M, Grosse J, Genahr A, Konertz W, Spies CD.
Department of Medical Statistics and Clinical Epidemiology, Campus Benjamin Franklin, Charite University Hospital Berlin, Berlin, Germany. andreas.triltsch@charite.de
INTRODUCTION: Most clinicians give sedatives and analgesics according to their professional experience and the patient's estimated need for sedation. However, this approach is prone to error. Inadequate monitoring of sedation and analgesia may contribute to adverse outcomes and complications. With this in mind, data obtained continuously using nonstimulating methods such as bispectral index (BIS) may have benefits in comparison with clinical monitoring of sedation. The aim of this prospective observational trial was to evaluate the use of electroencephalographic (EEG) BIS for monitoring sedation in paediatric intensive care unit (PICU) patients. METHODS: Forty paediatric patients (<18 years) were sedated for mechanical ventilation in a cardiac surgical and general PICU. In each paediatric patient BIS and COMFORT score were obtained. The study protocol did not influence ongoing PICU therapy. BIS and corresponding COMFORT score were collected three times for each patient. Measurements with the best starting EEG impedances were analyzed further. Deep sedation was defined as a COMFORT score between 8 and 16, and light sedation as a score between 17 and 26. Biometric and physiological data, and Pediatric Risk of Mortality III scores were also recorded. RESULTS: There was a good correlation (Spearman's rho 0.651; P = 0.001) between BIS and COMFORT score in the presence of deep sedation and low starting impedance. Receiver operating characteristic (ROC) analysis revealed best discrimination between deep and light sedation at a BIS level of 83. CONCLUSION: In the presence of deep sedation, BIS correlated satisfactorily with COMFORT score results if low EEG impedances were guaranteed.
PMID: 15693968 [PubMed - in process]
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Differentiating midazolam over-sedation from neurological damage in the intensive care unit.
McKenzie CA, McKinnon W, Naughton DP, Treacher D, Davies G, Phillips GJ, Hilton PJ.
Senior Lecturer, School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK. D.P.Naughton@bton.ac.uk.
INTRODUCTION: Midazolam is used routinely to sedate patients in the intensive care unit (ICU). We suspected that midazolam over-sedation was occurring in the ICU of the Guy's and St. Thomas' Trust and that it could be difficult to differentiate this from underlying neurological damage. A sensitive assay for detecting midazolam and 1-hydroxymidazolam glucuronide (1-OHMG) in serum was developed and applied in the clinical setting. METHODS: In the present study we evaluated a series of cases managed in a mixed medical, surgical and trauma ICU. Serum was collected from 26 patients who received midazolam, were 'slow to wake' and in whom there was suspicion of neurological damage. Patient outcome was followed in terms of mortality, neurological recovery and neurological damage on discharge. RESULTS: Out of 26 patients, 13 had detectable serum levels of midazolam and/or 1-OHMG after a median of 67 hours (range 36-146 hours) from midazolam cessation. Of these 13 patients in whom midazolam/1-OHMG was detectable, 10 made a full neurological recovery. Of the remaining 13 patients with no detectable midazolam/1-OHMG, three made a full neurological recovery; 10 patients were subsequently found to have suffered neurological damage (P < 0.002), eight of whom died and two were discharged from the ICU with profound neurological damage. CONCLUSION: These findings confirm that prolonged sedation after midazolam therapy should be considered in the differential diagnosis of neurological damage in the ICU. This can be reliably detected by the assay method described. The effects of midazolam/1-OHMG persist days after administration of midazolam has ceased. After prolonged sedation has been excluded in this patient group, it is highly likely that neurological damage has occurred.
PMID: 15693964 [PubMed - in process]
Reexamining quinolone use in the intensive care unit: Use them right or lose the fight against resistant bacteria.
Niederman MS.
Department of Medicine; SUNY at Stony Brook; Department of Medicine; Winthrop-University Hospital; Mineola, NY.
PMID: 15699851 [PubMed - in process]
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First-generation fluoroquinolone use and subsequent emergence of multiple drug-resistant bacteria in the intensive care unit.
Nseir S, Di Pompeo C, Soubrier S, Delour P, Lenci H, Roussel-Delvallez M, Onimus T, Saulnier F, Mathieu D, Durocher A.
From the Intensive Care Unit (SN, SS, PD, HL, TO, FS, DM, AD) and the Bacteriology Laboratory (MR-D), Calmette Hospital, Regional University Centre, Lille, France; and the Medical Assessment Laboratory, Lille II University, Lille, France (SN, CdP, SS, TO, FS, AD).
OBJECTIVE:: The objective of this study was to determine the relationship between fluoroquinolone (FQ) use and subsequent emergence of multiple drug-resistant bacteria (MRB) in the intensive care unit (ICU). DESIGN:: The authors conducted a prospective observational cohort study and a case control study. SETTING:: The study was conducted in a 30-bed ICU. METHODS:: All immunocompetent patients hospitalized for >48 hrs who did not receive antibiotics before ICU admission were eligible during a 15-month period. Routine MRB screening was performed at ICU admission and weekly thereafter. This screening included tracheal aspirate and nasal, anal, and axilla swabs. Univariate and multivariate analyses were used to determine risk factors for MRB emergence in the ICU. In addition, a case control study was performed to determine whether FQ use is associated with subsequent emergence of MRB. RESULTS:: Two hundred thirty-nine patients were included; 108 ICU-acquired MRB were isolated in 77 patients. FQ use and longer duration of antibiotic treatment were identified as independent risk factors for MRB occurrence (odds ratio [95% confidence interval [CI] = 3.3 [1.7-6.5], 1.1 [1.0-1.2]; p < .001; respectively). One hundred thirty-five (56%) patients received FQ; matching was successful for 72 (53%) of them. Number of MRB (40 vs. 15 per 1,000 ICU days; p = .019) and percentage of patients with MRB (40% vs. 22%; OR [95% CI] = 1.5 [1.0-2.4]; p = .028) were significantly higher in cases than in controls. Although methicillin-resistant Staphylococcus aureus (26% vs. 12%; OR [95% CI] = 1.6 [.6-2.9]; p = .028) and extending-spectrum beta-lactamase-producing Gram-negative bacilli (11% vs. 1%; OR [95% CI] = 4.7 [0.7-30.2]; p = .017) rates were higher in cases than in controls, ceftazidime or imipenem-resistant Pseudomonas aeruginosa (15% vs. 8%), Acinetobacter baumannii (1% vs. 5%), and Stenotrophomonas maltophilia (2% vs. 1%) rates were similar (p > .05) in case and control patients. CONCLUSION:: FQ use and longer duration of antibiotic treatment are independently associated with MRB emergence. Reducing antimicrobial treatment duration and restricting FQ use could be suggested to control MRB spread in the ICU.
PMID: 15699829 [PubMed - as supplied by publisher]
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Society of Critical Care Medicine, 34th Critical Care Congress. Phoenix, Arizona, USA, January 15-19, 2005. Abstracts.
[No authors listed]
Publication Types:
PMID: 15622024 [PubMed - indexed for MEDLINE]
Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation.
Malerba G, Romano-Girard F, Cravoisy A, Dousset B, Nace L, Levy B, Bollaert PE.
Service d'aide medicale urgente, Centre Hospitalier Universitaire, 54035, Nancy Cedex, France.
OBJECTIVE: To study the factors associated with relative adrenocortical deficiency in mechanically ventilated, critically ill patientsDESIGN AND SETTING: Prospective observational study in a multidisciplinary ICU of a university-affiliated teaching hospitalPATIENTS: Sixty-two consecutive, acutely ill patients needing mechanical ventilation for more than 24 h.MEASUREMENTS AND RESULTS: A high-dose short corticotropin test 24 h after endotracheal intubation. Relative adrenocortical deficiency ("nonresponder" group of patients) was defined by a rise in cortisol less than 90 microg/l after stimulation. Twenty-seven patients were classified as nonresponders and 35 as responders. On univariate analysis nonresponders were more often men, had lower mean arterial pressure, required vasoactive agents more often, had lower creatinine clearance, higher SAPS II, higher organ dysfunction scores, and received etomidate as a single bolus for endotracheal intubation more often than responders. On multivariate analysis, only etomidate administration was related to relative adrenocortical deficiency (OR 12.21; 95% CI 2.99-49.74) while female gender was protective (OR 0.13; 95% CI 0.03-0.57).CONCLUSIONS: A single bolus infusion of etomidate could be a major risk factor for the development of relative adrenocortical deficiency in ICU patients for at least 24 h after administration. Female gender is an independent protective factor.
PMID: 15703896 [PubMed - as supplied by publisher]
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Clinical outcome of immunonutrition in a heterogeneous intensive care population.
Kieft H, Roos AN, van Drunen JD, Bindels AJ, Bindels JG, Hofman Z.
Department of Intensive Care, Isala Clinics (Location Sophia), Dr. van Heesweg 2, 8025 AB, Zwolle, The Netherlands, h.kieft@isala.nl.
OBJECTIVE: To study the effect of a high-protein enteral formula enriched with arginine, glutamine, and antioxidants and containing omega3 fatty acids and a mixture of fibers, on the clinical outcome of a heterogeneous intensive care (ICU) population. DESIGN AND SETTING: A randomized, prospective, double blind, controlled, two-center clinical trial in two intensive care units in The Netherlands. PATIENTS AND PARTICIPANTS: A total of 597 adult ICU patients expected to require enteral tube feeding for more than 2 days were randomized to receive immunonutrition or an isocaloric control formula. INTERVENTIONS: Patients received either the immunonutrition or the control feed. MEASUREMENTS AND RESULTS: Intention-to-treat and per-protocol analyses showed no statistically significant difference in clinical outcome parameters between the two groups. Results of the intention-to-treat analysis in control vs. immunonutrition were: median ICU length of stay in days, 8.0 (IQR 5.0-16.0) vs. 7.0 (4.0-14.0); median hospital length of stay in days, 20.0 (IQR 10.0-34.0) vs. 20.0 (10.0-35.0); median days of ventilation, 6.0 (IQR 3.0-12.0) vs. 6.0 (IQR 3.0-12.0); ICU mortality, 26.8% vs. 28.2%; in-hospital mortality, 36.4% vs. 38.5%; infectious complications, 41.7% vs. 43.0% CONCLUSIONS: The results of this largest randomized, controlled trial found that in the general ICU population immunonutrition has no beneficial effect on clinical outcome parameters. These results are consistent with the literature that is currently available.
PMID: 15703894 [PubMed - as supplied by publisher]
Comment on:
Comment on "Effects on skeletal muscle of intravenous glutamine supplementation to ICU patients" by Tjader et al.
O'Leary MJ, Coakley JH.
Publication Types:
PMID: 15232681 [PubMed - indexed for MEDLINE]
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The European Union Directive and the protection of incapacitated subjects in research: an ethical analysis.
Silverman HJ, Druml C, Lemaire F, Nelson R; European Union Directive.
School of Medicine, University of Maryland, 10 South Pine Street, Baltimore, MD 21201, USA. hsilverm@medicine.umaryland.edu
OBJECTIVE: We perform an ethical analysis of European Union Directive 2001/20/EC on the simplification and harmonization of guidelines regarding good clinical practice in the conduct of clinical trials involving drugs. BACKGROUND: The Directive provides guidance on protecting incapacitated subjects who participate in drug clinical trials. Such guidance promotes society's obligations of beneficence because the participation of incapacitated subjects in research is crucial in advancing the understanding and treatment of serious diseases. The Directive requires proxy consent for incapacitated subjects which adheres to the principle of respect for persons. The Directive also recommends additional safeguards to further protect subjects against exploitation and harm. These include respect for the assent and dissent of incapacitated subjects and the "necessity" and "subject-condition" requirements. RESULTS: While these essential protection mechanisms are commendable, the Directive fails to endorse other safeguards that have been recommended by other research ethics guidelines, especially for riskier research. The Directive's silence regarding research in the emergency setting frustrates the principle of beneficence because the lack of guidance might prove to be a barrier for the conduct of such potentially beneficial research. CONCLUSIONS: We conclude that the European Directive fails in many respects to promote several important ethical principles in research involving incapacitated subjects.
PMID: 15232680 [PubMed - indexed for MEDLINE]
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Clinician discomfort with life support plans for mechanically ventilated patients.
Griffith L, Cook D, Hanna S, Rocker G, Sjokvist P, Dodek P, Marshall J, Levy M, Varon J, Finfer S, Jaeschke R, Buckingham L, Guyatt G; Level of Care Investigators; Canadian Critical Care Trials Group.
Department of Clinical Epidemiology, Medical Center, McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada. griffith@mcmaster.ca
OBJECTIVE: To examine the incidence and predictors of clinician discomfort with life support plans for ICU patients. DESIGN AND SETTING: Prospective cohort in 13 medical-surgical ICUs in four countries. PATIENTS: 657 mechanically ventilated adults expected to stay in ICU at least 72 h. MEASUREMENTS AND RESULTS: Daily we documented the life support plan for mechanical ventilation, inotropes and dialysis, and clinician comfort with these plans. If uncomfortable, clinicians stated whether the plan was too technologically intense (the provision of too many life support modalities or the provision of any modality for too long) or not intense enough, and why. At least one clinician was uncomfortable at least once for 283 (43.1%) patients, primarily because plans were too technologically intense rather than not intense enough (93.9% vs. 6.1%). Predictors of discomfort because plans were too intense were: patient age, medical admission, APACHE II score, poor prior functional status, organ dysfunction, dialysis in ICU, plan to withhold dialysis, plan to withhold mechanical ventilation, first week in the ICU, clinician, and city. CONCLUSIONS: Clinician discomfort with life support perceived as too technologically intense is common, experienced mostly by nurses, variable across centers, and is more likely for older, severely ill medical patients, those with acute renal failure, and patients lacking plans to forgo reintubation and ventilation. Acknowledging the sources of discomfort could improve communication and decision making.
Publication Types:
PMID: 15221128 [PubMed - indexed for MEDLINE]
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Effect of polymyxin B-immobilized fiber on bone resorption in patients with sepsis.
Nakamura T, Kawagoe Y, Matsuda T, Koide H.
Department of Medicine, Shinmatsudo Central General Hospital, Chiba, Japan.
OBJECTIVE: To analyze the effects of polymyxin B-immobilized fiber (PMX-F) on bone resorption in septic patients. DESIGN AND SETTING: Observational prospective study in intensive care units of a general hospital. PATIENTS AND PARTICIPANTS: 25 patients with severe sepsis and 20 healthy controls. MEASUREMENTS AND RESULTS: Septic patients were randomly assigned to two groups: PMX-F treatment group (n=15) and conventional treatment group (n=10). Total pyridinium crosslink pyridinoline (PYD) and deoxypyridinoline (DPD) in urine were determined by modified high-performance liquid chromatography. Nitric oxide production was assessed by measuring the ratio of the nitric oxide breakdown products to urinary creatinine (NOx/Cr). Plasma endotoxin levels were determined by endospecy test. The blood albumin, ionized calcium, and parathyroid hormone were also measured. PMX-F treatment was performed twice separated by 24 h. Urinary NOx/Cr, PYD/Cr, and DPD/Cr were significantly increased in septic patients compared with those in healthy controls. Blood ionized calcium in septic patients was lower than in healthy controls, while parathyroid hormone levels in septic patients were higher than in healthy controls (P<0.01). PMX-F treatment reduced plasma endotoxin, urinary NOx/Cr, PYD/Cr, DPD/Cr, and serum parathyroid hormone levels and increased blood ionized calcium significantly; however, conventional treatment did not affect these levels. CONCLUSIONS: Septic patients increased nitric oxide production and bone resorption, and PMX-F treatment is effective in reducing nitric oxide levels and bone resorption markers.
Publication Types:
PMID: 15197430 [PubMed - indexed for MEDLINE]
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Increased plasma levels of pro-brain natriuretic peptide in patients with cardiovascular complications following off-pump coronary artery surgery.
Kerbaul F, Collart F, Giorgi R, Oddoze C, Lejeune PJ, Guidon C, Caus T, Bellezza M, Gouin F.
Departement d'Anesthesie-Reanimation Adulte, Groupe Hospitalier de La Timone, 13385 Marseille Cedex 05, France. fkerbaul@yahoo.fr
OBJECTIVE: To compare N-terminal pro-brain natriuretic peptide (NT-pro-BNP), procalcitonin (PCT), and troponin I (Tn I) concentrations during and after coronary artery surgery in patients with or without cardiovascular complications. DESIGN AND SETTING: Prospective, comparative study of 12 months in the cardiovascular intensive care unit in a university hospital. PATIENTS: 60 adult patients undergoing coronary artery bypass grafting with the off-pump technique. MEASUREMENTS AND RESULTS: Plasma NT-pro-BNP, PCT, and Tn I levels were measured before and immediately after the end of operation and on PODs 1, and 2 and 3. We defined complicated postoperative course as myocardial infarction, cardiogenic shock, arrhythmias, congestive heart failure, and death occurring after the fourth postoperative hour. Receiver operating characteristic (ROC) curve cutoff values were used to assess the ability of the three markers to predict future cardiac events. The area under ROC curve (AUC) using NT-pro-BNP to detect a cardiovascular complicated course was 0.780 at the preoperative time and 0.850 at the end of surgery. A preoperative NT-pro-BNP value of 397 pg/ml had a sensitivity of 76%, specificity of 67%, and accuracy of 74% for predicting a subsequent cardiovascular complication. An immediate postoperative NT-pro-BNP value of 430 pg/ml had a sensitivity of 80%, specificity of 77%, and accuracy of 76%. Patients with preoperative NT-pro-BNP levels less than 275 pg/ml had an excellent postoperative prognosis. Other two markers were less appropriate. CONCLUSIONS: NT-pro-BNP levels measured before and immediately after off-pump coronary artery bypass seem to be predictive of postoperative cardiac events.
PMID: 15138672 [PubMed - indexed for MEDLINE]
Use of enteral vancomycin for the control of methicillin-resistant Staphylococcus aureus in intensive care units.
Humphreys H, Smyth EG.
Department of Clinical Microbiology, Royal College of Surgeons in Ireland Education and Research Centre, Smurfit Building, Beaumont Hospital, P.O. Box 9063, Dublin 9, Ireland.
Publication Types:
PMID: 15694985 [PubMed - in process]
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Control of an outbreak of multi-drug-resistant Acinetobacter baumannii in an intensive care unit and a surgical ward.
Pimentel JD, Low J, Styles K, Harris OC, Hughes A, Athan E.
Department of Microbiology, Pathcare Consulting Pathologists, P.O. Box 1088, Geelong, Vic. 3220, Australia; Infection Prevention Service, Barwon Health, Geelong, Vic, Australia.
We describe an outbreak of multi-drug-resistant Acinetobacter baumannii (MRAB) that occurred in an intensive care unit (ICU) and a surgical ward from December 2003 to March 2004. Mapping patient movements on a timeline indicated that the outbreak was confined to these two areas. Investigation by the hospital's infection prevention service found that a possible source of spread was improper cleaning methods used on respiratory equipment. Pulsed-field gel electrophoresis analysis of available isolates indicated the presence of two distinct strains. One strain was seen in patients from the ICU and the other strain was seen in the surgical ward patients. Cleaning and environmental decontamination as well as staff education were implemented to halt further immediate spread. The deficiencies identified during the investigation were also resolved. The final outcome was the successful termination of this outbreak.
PMID: 15694983 [PubMed - in process]
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Investigation of a nosocomial outbreak of Acinetobacter baumannii producing PER-1 extended-spectrum beta-lactamase in an intensive care unit.
Jeong SH, Bae IK, Kwon SB, Lee K, Yong D, Woo GJ, Lee JH, Jung HI, Jang SJ, Sung KH, Lee SH.
Department of Laboratory Medicine and Graduate School of Public Health, Kosin University College of Medicine, Busan, Republic of Korea; Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Republic of Korea.
We investigated an outbreak of Acinetobacter baumannii in an adult intensive care unit of Kosin University Gospel Hospital in Busan, Republic of Korea. The outbreak involved 10 cases of infection by A. baumannii producing PER-1 extended-spectrum beta-lactamase over a seven-month period, and was caused by a single pulsed-field gel electrophoresis clone. The epidemic isolates were characterized by slight synergy between clavulanic acid and cefepime. Isoelectric focusing of crude bacterial extracts detected two nitrocefin-positive bands with pI values of 8.0 and 5.3. Polymerase chain reaction amplification and characterization of the amplicons by restriction analysis and direct sequencing indicated that the epidemic isolates carried a bla(PER-1) determinant. The epidemic isolates were characterized by a multidrug-resistant phenotype that remained unchanged over the outbreak, including penicillins, beta-lactam/beta-lactamase inhibitor, extended-spectrum cephalosporins and monobactams. Isolation of infected patients and appropriate carbapenem therapy were successful in ending the outbreak. Our report indicates that the bla(PER-1) resistance determinant may become an emerging therapeutic problem.
PMID: 15694982 [PubMed - in process]
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Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit.
Tvedt C, Bukholm G.
Institute of Clinical Epidemiology and Molecular Biology, Akershus University Hospital, 1474 Nordbyhagen, Norway.
This study involved observation of hand-hygiene behaviour and evaluation of the effect of alcohol-based hand disinfection and handwashing with plain liquid soap on microbial flora. The study was performed in a combined medical and surgical intensive care unit. We demonstrated a crude compliance of hand hygiene of 50.4%, which was only performed adequately in 20.8% of cases. Of this group, handwashing and hand-disinfection procedures were performed properly 34.0% and 71.6% of the time, respectively. Hand samples for bacteriological examinations with the glove juice method demonstrated that whilst handwashing was sensitive to the way in which hand hygiene was performed, alcohol-based hand disinfection was less sensitive to such performance. Our study demonstrated that alcohol-based hand disinfection is a robust hand-hygiene method with many advantages in a practical setting. It is very feasible for use in hospital wards.
PMID: 15694980 [PubMed - in process]
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Handwashing in the intensive care unit: a big measure with modest effects.
Silvestri L, Petros AJ, Sarginson RE, de la Cal MA, Murray AE, van Saene HK.
Emergency Department and Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Vittorio Veneto 171, 34170 Gorizia, Italy.
Handwashing is widely accepted as the cornerstone of infection control in the intensive care unit. Nosocomial infections are frequently viewed as an indicator of poor compliance of handwashing. The aim of this review is to evaluate the effectiveness of handwashing on infection rates in the intensive care unit, and to analyse the failure of handwashing. A literature search identified nine studies that evaluated the impact of handwashing or hand hygiene on infection rates, and demonstrated a low level of evidence for the efforts to control infection with handwashing. Poor compliance cannot be blamed as the only reason for the failure of handwashing to control infection. Handwashing on its own does not abolish, but only reduces transmission, as it is dependent on the bacterial load on the hand of healthcare workers. Finally, recent studies, using surveillance cultures of throat and rectum, have shown that, under ideal circumstances, handwashing can only influence 40% of all intensive care unit infections. A randomised clinical trial with the intensive care as randomisation unit is required to support handwashing as the cornerstone of infection control.
PMID: 15694973 [PubMed - in process]
Comment in:
Who should pay for intensive behavioural intervention in autism? A parent's view.
Couper J.
Department of Paediatrics, Women's and Children's Hospital, University of Adelaide, South Australia 5006, Australia. jennifer.couper@adelaide.edu.au
The evidence that early intensive behavioural intervention (IBI) is effective for young children with autism has persuaded parents worldwide to finance and advocate for IBI. Intensive behavioural intervention uses applied behavioural analysis to address the deficits of autism with an individualized and systematic approach. Communication, social, cognitive and adaptive gains are seen in the majority of children; a sizeable minority can catch up to near normal functioning, under ideal conditions. However there is not universal acceptance amongst professionals that IBI is the most proven intervention. What level of evidence is required for Australian states to provide adequate public funds for IBI?
PMID: 15367153 [PubMed - indexed for MEDLINE]
Comment on:
Intensive behavioural intervention in autism.
Prior M.
Publication Types:
PMID: 15367140 [PubMed - indexed for MEDLINE]
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Diagnosis of Acid-base derangements and mortality prediction in the trauma intensive care unit: the physiochemical approach.
Martin M, Murray J, Berne T, Demetriades D, Belzberg H.
From the Division of Trauma and Critical Care, Department of Surgery, Los Angeles County Hospital/University of Southern California Medical Center, Los Angeles, California.
BACKGROUND:: Conventional measures such as anion gap and base deficit can be inadequate for defining and managing complex acid-base derangements. Physiochemical analysis is an alternative approach based on the principles of electroneutrality and conservation of mass, and may be more accurate for defining the presence and type of acidosis and unmeasured anions. METHODS:: We retrospectively analyzed 2,152 sets of laboratory data from 427 trauma patients admitted to the intensive care unit. All data sets included simultaneous measurements of an arterial blood gas with base deficit (BD), serum electrolytes, albumin, lactate, and a calculated anion gap (AG). Physiochemical analysis was used to calculate the corrected anion gap (AGcorr), the apparent strong ion difference, the effective strong ion difference, the strong ion gap (SIG), and the base deficit corrected for unmeasured anions (BDua). Statistical analysis comparing AG and BD to the physiochemical measures was performed on all data and the subset of admission laboratory data only (n = 427). RESULTS:: Unmeasured anions as defined by an elevated SIG were present in 92% of patients (mean SIG, 5.9 +/- 3.3), whereas hyperlactatemia and hyperchloremia were present in only 18% and 21%, respectively. The physiochemical approach yielded a different clinical interpretation of the acid-base status than the conventional approach in 597 (28%) of the data sets. Lactate level was more strongly correlated with the physiochemical measures of SIG (r = 0.48) and AGcorr (r = 0.47) than with the conventional measures of AG (r = 0.24) and BD (r = 0.36, p < 0.01 for all). Both admission BD and BDua were significantly elevated in nonsurvivors, and logistic regression analysis for prediction of mortality revealed an area under the curve of 0.70 for BDua (p < 0.01) versus 0.65 for BD (p < 0.01). AGcorr and SIG did not differentiate survivors from nonsurvivors in the group as a whole. However, analysis of patients with a normal admission lactate level (n = 322) demonstrated a significant difference between survivors and nonsurvivors in SIG (7 vs. 5, p = 0.009), BDua (-4.2 vs. -2.0, p = 0.004), and AGcorr (21 vs. 19, p = 0.04), whereas the conventional measures of BD and AG showed no significant discriminatory ability. CONCLUSION:: Unmeasured anions are the most common component of metabolic acidosis in trauma intensive care unit patients. The physiochemical approach can significantly alter the acid-base diagnosis compared with conventional measures. The SIG, AGcorr, and BDua may be particularly helpful in predicting acid-base derangements and mortality in patients with normal serum lactate levels.
PMID: 15706182 [PubMed - in process]
Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial.
Squadrone V, Coha M, Cerutti E, Schellino MM, Biolino P, Occella P, Belloni G, Vilianis G, Fiore G, Cavallo F, Ranieri VM; Piedmont Intensive Care Units Network (PICUN).
Dipartimento di Anestesia, Azienda Ospedaliera S.Giovanni Battista-Molinette, Universita di Torino, Italy.
CONTEXT: Hypoxemia complicates the recovery of 30% to 50% of patients after abdominal surgery; endotracheal intubation and mechanical ventilation may be required in 8% to 10% of cases, increasing morbidity and mortality and prolonging intensive care unit and hospital stay. OBJECTIVE: To determine the effectiveness of continuous positive airway pressure compared with standard treatment in preventing the need for intubation and mechanical ventilation in patients who develop acute hypoxemia after elective major abdominal surgery. DESIGN AND SETTING: Randomized, controlled, unblinded study with concealed allocation conducted between June 2002 and November 2003 at 15 intensive care units of the Piedmont Intensive Care Units Network in Italy. PATIENTS: Consecutive patients who developed severe hypoxemia after major elective abdominal surgery. The trial was stopped for efficacy after 209 patients had been enrolled. INTERVENTIONS: Patients were randomly assigned to receive oxygen (n = 104) or oxygen plus continuous positive airway pressure (n = 105). MAIN OUTCOME MEASURES: The primary end point was incidence of endotracheal intubation; secondary end points were intensive care unit and hospital lengths of stay, incidence of pneumonia, infection and sepsis, and hospital mortality. RESULTS: Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). CONCLUSION: Continuous positive airway pressure may decrease the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 15687314 [PubMed - indexed for MEDLINE]
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