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Items 1 - 26 of 26 |
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Neonatal staff and advanced practice nurses' perceptions of bereavement/end-of-life care of families of critically ill and/or dying infants.
Engler AJ, Cusson RM, Brockett RT, Cannon-Heinrich C, Goldberg MA, West MG, Petow W.
University of Connecticut School of Nursing, Storrs, Conn, USA.
BACKGROUND: Parents need compassionate care when an infant dies. Nurses can provide such care and possibly facilitate grieving, yet often have inadequate preparation in bereavement/end-of-life care. OBJECTIVE: To describe neonatal nurses' perceptions of bereavement/end-of-life care of families of critically ill and/or dying infants. METHODS: A cross-sectional, descriptive, correlational mailed survey design was used. The 55-item Bereavement End-of-Life Attitudes About Care: Neonatal Nurses Scale containing 4 sections (comfort, roles, involvement, and demographics) was mailed to 240 hospitals in the United States. RESULTS: The final response rate was 52% (190 completed data sets from 125 hospitals). Respondents were comfortable with many aspects of bereavement/end-of-life care. Comfort and roles scores correlated significantly with number of years as a neonatal intensive care nurse. Respondents agreed about many important aspects of their roles with patients' families, especially the importance of providing daily support to the families. Most respondents identified caring for a dying infant, the actual death of an infant, and language or cultural differences as influential factors in the level of their involvement with families. CONCLUSIONS: Education on bereavement/end-of-life care could affect nurses' comfort with caring for families of critically ill and/or dying infants. Additional education on cultural competence would be helpful. Educators must promote the inclusion of content on bereavement/end-of-life care in nursing curricula. Finally, researchers must focus more attention on factors that promote and inhibit bereavement/end-of-life care of families of critically ill and/or dying infants.
PMID: 15568654 [PubMed - indexed for MEDLINE]
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Perceptions of physicians, nurses, and respiratory therapists about the role of acute care nurse practitioners.
Hoffman LA, Happ MB, Scharfenberg C, DiVirgilio-Thomas D, Tasota FJ.
University of Pittsburgh School of Nursing, Pittsburgh, Pa., USA.
BACKGROUND: Information about the contributions of acute care nurse practitioners to medical management teams in critical care settings is limited. OBJECTIVE: To examine contributions of acute care nurse practitioners to medical management of critically ill patients from the perspectives of 3 disciplines: medicine, respiratory care, and nursing. METHODS: Attending physicians, respiratory therapists, and nurses in 2 intensive care units were asked to list 3 advantages and 3 disadvantages of collaborative care provided by acute care nurse practitioners. Qualitative methods (coding/constant comparative analysis) were used to identify common themes and subthemes. Overall response rate was 35% (from 69% for attending physicians to 26% for nurses). RESULTS: Responses were grouped into 4 main themes: accessibility, competence/knowledge, care coordination/communication, and system issues. Acute care nurse practitioners were valued for their accessibility, expertise in routine daily management of patients, and ability to meet patient/family needs, especially for "long-stay" patients. Also, they were respected for their commitment to providing quality care and for their communication skills, exemplified through teaching of nursing staff, patient/family involvement, and fluency in weaning protocols. Physicians valued acute care nurse practitioners' continuity of care, patient/family focus, and commitment. Nurses valued their accessibility, commitment, and patient/family focus. Respiratory therapists valued their accessibility, commitment, and consistency in implementing weaning protocols. CONCLUSION: Responses reflected unique advantages of acute care nurse practitioners as members of medical management teams in critical care settings. Despite perceptions of the acute care nurse practitioner's role as medically oriented, the themes reflect a clear nursing focus.
PMID: 15568653 [PubMed - indexed for MEDLINE]
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Equivalence of the bioimpedance and thermodilution methods in measuring cardiac output in hospitalized patients with advanced, decompensated chronic heart failure.
Albert NM, Hail MD, Li J, Young JB.
Division of Nursing, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
BACKGROUND: An accurate and reliable noninvasive method for determining cardiac output/cardiac index would be valuable for patients with acutely decompensated advanced systolic heart failure. OBJECTIVES: To determine whether a correlation exists for cardiac output and index determined by using bioimpedance and thermodilution in patients with acutely decompensated complex heart failure and if differences between results with the 2 methods could be explained by the patients' advanced condition. METHODS: Cardiac output and index were determined by using bioimpedance and thermodilution in 33 patients. Echocardiographic and electrocardiographic data were assessed to determine if differences between results with the 2 methods could be explained by the patients' advanced condition. Concordance correlation coefficients and Bland-Altman agreement between methods were calculated. RESULTS: Four patients were excluded from analysis because reliable measurements could not be obtained; the remaining 29 patients constituted the study population. Mean cardiac outputs determined by thermodilution and bioimpedance were 5.48 and 5.40 L/min, respectively (rhoc = 0.89, P < .001), and mean cardiac indexes were 2.67 and 2.65 (rhoc = 0.82, P < .001). Mean bias (limits of agreement) between data pairs was 0.08 (-0.18 to 0.35) L/min (P = .52) for cardiac output and 0.03 (-0.097 to 0.16; P = .61) for cardiac index. Six data pairs (21%) had an absolute percent difference greater than 15%. Of these, 50% had a higher thermodilution value. CONCLUSION: Determinations of cardiac output and index by both methods were significantly correlated. Mean bias between the 2 methods was small, suggesting clinical utility for bioimpedance in patients with complex decompensated heart failure.
PMID: 15568652 [PubMed - indexed for MEDLINE]
Comment on:
Impact factor, impact, and smoke and mirrors.
Mannino DM.
Publication Types:
PMID: 15699080 [PubMed - indexed for MEDLINE]
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Transoesophageal echocardiography in anaesthesia and intensive care medicine.
Walker MB.
PMID: 15766361 [PubMed - in process]
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Pressure ulcer prevention in intensive care - a randomised control trial of two pressure-relieving devices.
Theaker C, Kuper M, Soni N.
Intensive Care Unit, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.
Summary Pressure sores are a potential complication of intensive care. Modern methods of pressure sore prevention centre around the use of pressure-relieving devices. Few studies exist that confirm the effectiveness of these devices. This study evaluates the effectiveness of two devices, the Hill-Rom Duo((R)) mattress and the KCI TheraPulse((R)). High-risk patients were randomly assigned to receive one of two devices. We excluded those patients who had pressure sores upon admission. Those patients that did develop a pressure sore had their wound digitally photographed and graded by two independent tissue viability nurses. Sixty-two patients were included (30 TheraPulse((R)) , 32 Duo((R))). Nine developed a pressure sore (6 Duo((R)), 3 TheraPulse((R))). No statistical differences between the two devices could be found. The longer a patient was nursed on a device, the greater the risk of pressure sore development. Despite the use of these devices, pressure sores can still develop in the Intensive Care patient population.
PMID: 15766343 [PubMed - in process]
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Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: a prospective observational study of ward and intensive care unit based care*.
Gordon AC, Oakervee HE, Kaya B, Thomas JM, Barnett MJ, Rohatiner AZ, Lister TA, Cavenagh JD, Hinds CJ.
Department of Anaesthesia and Intensive Care, Barts and The London Queen Mary's School of Medicine and Dentistry, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
Summary To determine the incidence and outcome of critical illness amongst the total population of hospital patients with haematological malignancy (including patients treated on the ward as well as those admitted to the intensive care unit), consecutive patients with haematological malignancy were prospectively studied. One hundred and one of the 1437 haemato-oncology admissions (7%) in 2001 were complicated by critical illness (26% of all new referrals). Fifty-four (53%) of these critically ill patients survived to leave hospital and 33 (34%) were still alive after 6 months. The majority (77/101) were not admitted to the intensive care unit but were managed on the ward, often with the assistance of the intensive care team. Independent risk factors for dying in hospital included hepatic failure (odds ratio 5.3, 95% confidence intervals 1.3-21.2) and central nervous system failure (odds ratio 14.5, 95% confidence intervals 1.7-120.5). No patient with four or more organ failures or a Simplified Acute Physiology Score II >/= 65 survived to leave hospital. There was close agreement between actual and predicted mortality with increasing Simplified Acute Physiology Score II for all patients, including those not admitted to intensive care.
PMID: 15766336 [PubMed - in process]
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Quality of life before and after intensive care.
Cuthbertson BH, Scott J, Strachan M, Kilonzo M, Vale L.
Clinical Senior Lecturer, Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen.
Summary Quality of life is often thought to be poor before and after intensive care unit admission. The aim of this study was to investigate changes in quality of life before and after intensive care. A prospective cohort study of 300 consecutive patients admitted to intensive care was performed in a Scottish Teaching Hospital. Quality of life was assessed premorbidly and 3, 6 and 12 months after intensive care admission for surviving patients using SF-36 as well as EQ-5D scores at 12 months. The median value for age was 60.5 years and for APACHE II score, 18. The mean length of stay was 6.7 days. SF-36 physical component scores decreased from premorbid values at 3 months (p = 0.05) and then returned to premorbid values at 12 months (p < 0.001). The mean physical scores were below the population norm at all time points but the mean mental scores were similar or higher than these population norms. Patients who died after intensive care discharge had lower quality of life scores than did survivors (all p < 0.01). Poor premorbid quality of life was demonstrated and appears to reduce after ICU discharge. For survivors there was a slow increase in physical quality of life to premorbid levels by the end of the first year but these remained lower than in the general population. ICU patients experience a considerable longer-term burden of ill health.
PMID: 15766335 [PubMed - in process]
[Intestinal malperfusion in critical care patients]
[Article in German]
Knichwitz G, Kruse C, van Aken H.
Klinik fur Anasthesiologie und operative Intensivmedizin, Universitatsklinikum Munster. knichwi@uni-muenster.de
Due to the bowel's poor tolerance of hypoxia, intestinal malperfusion presents as a grave disease with high mortality. The intensivist is confronted with this condition in association with other underlying diseases, in the course of surgery, during application of medication or associated with invasive therapy. In a critical care setting, the non-occlusive mesenteric ischemia (NOMI) is of increasing importance. Since critical care patients often lack clinical symptoms, special attention is required and one main factor of the patient's prognosis is early diagnosis. This review summarizes pathophysiology and diagnostic aspects and the range of therapeutic and preventive measures.
Publication Types:
PMID: 15480516 [PubMed - indexed for MEDLINE]
Treatment of pulmonary hypertension in the general adult intensive care unit: a role for oral sildenafil?
Ng J, Finney SJ, Shulman R, Bellingan GJ, Singer M, Glynne PA.
Department of Critical Care, University College London Hospitals, Mortimer Street, London W1T 3AA, UK.
Use of inhaled nitric oxide for treatment of pulmonary hypertension in adult critical illness is limited by its mode of delivery and high costs, prompting evaluation of alternative therapies. We report the use of oral sildenafil in a patient with severe secondary pulmonary hypertension and right ventricular dysfunction. Following reduction in mean pulmonary artery pressure and pulmonary vascular resistance with inhaled nitric oxide, crossover to sildenafil therapy maintained control of pulmonary hypertension, facilitating discontinuation of respiratory and cardiovascular organ support. The relative pulmonary vascular specificity of oral sildenafil, and its low cost, makes it an attractive therapeutic alternative to inhaled nitric oxide, and warrants further study.
PMID: 15764630 [PubMed - as supplied by publisher]
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Measurement of intra-abdominal pressure in intensive care units in the United Kingdom: a national postal questionnaire study{dagger}
Ravishankar N, Hunter J.
Department of Anaesthetics and Intensive Care, Gloucester Royal Hospital, Gloucester GL1 3NN, UK.
BACKGROUND: To explore the attitudes of intensivists in the UK to intra-abdominal pressure (IAP) measurement and abdominal compartment syndrome (ACS) and to determine current practice. METHODS: A postal questionnaire study addressed to the lead clinician in the intensive care unit was sent to hospitals in the UK with a general surgical service. RESULTS: Completed questionnaires were received from 137 of the 207 hospitals surveyed (66.2% response rate). Only 1.5% of the respondents (n=2) had no prior knowledge of intra-abdominal hypertension and ACS. IAP had been measured on some occasion by 75.9% (n=104) of the respondents, always by the intravesical route. Among those intensive care units that measured IAP, in 93.2% (n=97) it was only measured when there was a suspicion of the development of ACS; 3.8% of units (n=4) measured IAP on all patients who had undergone an emergency laparotomy, and 2.9% (n=3) measured IAP only in those who had undergone emergency laparotomy associated with massive fluid resuscitation. There was major disparity in the frequency of IAP measurement and when to recommend abdominal decompression. CONCLUSIONS: Despite widespread awareness of IAH and the ACS, many intensive care units never measure the IAP. When it is measured, the intravesical route is used exclusively. No consensus exists on optimal timing of measurement or when decompressive laparotomy should be performed.
PMID: 15764629 [PubMed - as supplied by publisher]
Waking the dying: must we always attempt to involve critically ill patients in end-of-life decisions?
Tonelli MR.
Box 356522, University of Washington Medical Center, Seattle, WA 98195-6522, USA. tonelli@u.washington.edu
Many critically ill persons are unable to participate in medical decision making, due, at least in part, to medications administered to provide sedation and analgesia. Such patients may retain the ability to participate to some degree in medical decisions if these medications can be reduced or eliminated. Decisions regarding the withdrawal of support, in particular, highlight the ethical complexities surrounding the participation of the critically ill patient. An appeal to the principle of autonomy would seem to demand that in all such cases attempts must be made to involve the patient; however, under certain circumstances arousing a dying patient to inform them of their imminent demise runs counter to the principle of beneficence in health care. A casuistic approach to this apparent dilemma identifies the ethically relevant aspects of such cases and allows for the development of specific criteria for judging the appropriateness of attempting to involve a critically ill patient directly in decision making. Patient comfort, prognosis, and prior preferences carry significant ethical weight. In cases in which a sedated, critically ill person cannot be aroused without causing significant pain and suffering, has a very poor prognosis, and in which prior unambiguous directives or current family/surrogate consensus exists that withdrawal of support would be preferred by the patient, the author argues that no ethical obligation to attempt to involve the patient in medical decisions exists.
Publication Types:
PMID: 15706007 [PubMed - indexed for MEDLINE]
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Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training.
Lorin S, Heffner J, Carson S.
The Mount Sinai Medical Center, Box 1232, One Gustave L. Levy Place, New York, NY 10029-6574, USA. scott.lorin@mountsinai.org
STUDY OBJECTIVE: To evaluate the attitudes and perceptions of internal medicine residents regarding pulmonary and critical care medicine (PCCM) training. DESIGN: Prospective study. SETTING: Three university hospitals. METHODS: An eight-page survey was distributed and collected between March 1, 2002, and June 30, 2002. All internal medicine or internal medicine/pediatric residents training at the three institutions were eligible for the study. RESULTS: One hundred seventy-eight residents in internal medicine from an eligible pool of 297 residents returned the survey (61% response rate). PCCM accounted for only 3.4% of the career choices. Forty-one percent of the residents seriously considered a pulmonary and/or critical care fellowship during their residency. Of these residents, 23.5% found the combination of programs the more attractive option, while 2.8% found pulmonary alone and 14.5% found critical care alone more attractive. Key factors associated with a higher resident interest in PCCM subspecialty training included more weeks in the ICU (p = 0.008), more role models in PCCM (3.02 +/- 0.78 vs 3.45 +/- 0.78, p = 0.0004), and resident observations of a greater sense of satisfaction among PCCM faculty (3.07 +/- 0.82 vs 3.33 +/- 0.82, p = 0.04) and fellows (3.05 +/- 0.69 vs 3.31 +/- 0.86, p = 0.03) [mean +/- SD]. The five most commonly cited attributes of PCCM fellowship that would attract residents to the field included intellectual stimulation (69%), opportunities to manage critically ill patients (51%), application of complex physiologic principles (45%), number of procedures performed (31%), and academically challenging rounds (29%). The five most commonly cited attributes of PCCM that would dissuade residents from the field included overly demanding responsibilities with lack of leisure time (54%), stress among faculty and fellows (45%), management responsibilities for chronically ill patients (30%), poor match of career with resident personality (24%), and treatment of pulmonary diseases (16%). CONCLUSIONS: Internal medicine residents have serious reservations about PCCM as a career choice. Our survey demonstrated that a minority of US medical graduates actually would choose PCCM as a career, which suggests that efforts to expand PCCM training capacity might result in vacant fellowship slots. To promote greater interest in PCCM training, efforts are needed to improve the attractiveness of PCCM and address the negative lifestyle perceptions of residents.
Publication Types:
PMID: 15706006 [PubMed - indexed for MEDLINE]
The meaning of acid-base abnormalities in the intensive care unit: part III -- effects of fluid administration.
Morgan TJ.
Adult Intensive Care, Mater Misericordiae Hospitals, Brisbane, Australia. thomas_morgan@mater.org.au
Stewart's quantitative physical chemical approach enables us to understand the acid-base properties of intravenous fluids. In Stewart's analysis, the three independent acid-base variables are partial CO2 tension, the total concentration of nonvolatile weak acid (ATOT), and the strong ion difference (SID). Raising and lowering ATOT while holding SID constant cause metabolic acidosis and alkalosis, respectively. Lowering and raising plasma SID while clamping ATOT cause metabolic acidosis and alkalosis, respectively. Fluid infusion causes acid-base effects by forcing extracellular SID and ATOT toward the SID and ATOT of the administered fluid. Thus, fluids with vastly differing pH can have the same acid-base effects. The stimulus is strongest when large volumes are administered, as in correction of hypovolaemia, acute normovolaemic haemodilution, and cardiopulmonary bypass. Zero SID crystalloids such as saline cause a 'dilutional' acidosis by lowering extracellular SID enough to overwhelm the metabolic alkalosis of ATOT dilution. A balanced crystalloid must reduce extracellular SID at a rate that precisely counteracts the ATOT dilutional alkalosis. Experimentally, the crystalloid SID required is 24 mEq/l. When organic anions such as L-lactate are added to fluids they can be regarded as weak ions that do not contribute to fluid SID, provided they are metabolized on infusion. With colloids the presence of ATOT is an additional consideration. Albumin and gelatin preparations contain ATOT, whereas starch preparations do not. Hextend is a hetastarch preparation balanced with L-lactate. It reduces or eliminates infusion related metabolic acidosis, may improve gastric mucosal blood flow, and increases survival in experimental endotoxaemia. Stored whole blood has a very high effective SID because of the added preservative. Large volume transfusion thus causes metabolic alkalosis after metabolism of contained citrate, a tendency that is reduced but not eliminated with packed red cells. Thus, Stewart's approach not only explains fluid induced acid-base phenomena but also provides a framework for the design of fluids for specific acid-base effects.
PMID: 15774079 [PubMed - in process]
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Clinical review: Acid-base abnormalities in the intensive care unit -- part II.
Kaplan LJ, Frangos S.
Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, Connecticut, USA. Lewis.Kaplan@yale.edu
Acid-base abnormalities are common in the critically ill. The traditional classification of acid-base abnormalities and a modern physico-chemical method of categorizing them will be explored. Specific disorders relating to mortality prediction in the intensive care unit are examined in detail. Lactic acidosis, base excess, and a strong ion gap are highlighted as markers for increased risk of death.
PMID: 15774078 [PubMed - in process]
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Clinical review: Vasculitis on the intensive care unit -- part 2: treatment and prognosis.
Semple D, Keogh J, Forni L, Venn R.
Worthing Hospital, Worthing, UK. david.semple@wash.nhs.uk
The second part of this review addresses the treatment and prognosis of the vasculitides Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome and polyarteritis nodosa. Treatment regimens consist of an initial remission phase with aggressive immunosuppression, followed by a more prolonged maintenance phase using less toxic agents and doses. This review focuses on the initial treatment of fulminant vasculitis, the mainstay of which remains immunosuppression with steroids and cyclophosphamide. For Wegener's granulomatosis and microscopic polyangiitis plasma exchange can be considered for first-line therapy in patients with acute renal failure and/or pulmonary haemorrhage. Refractory disease is rare and is usually due to inadequate treatment. The vasculitides provide a particular challenge for the critical care team. Particular aspects of major organ support related to these conditions are discussed. Effective treatment has revolutionized the prognosis of these conditions. However, mortality is still approximately 50% for those requiring admission to intensive care unit. Furthermore, there is a high morbidity associated with both the diseases themselves and the treatment.
PMID: 15774077 [PubMed - in process]
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Bench-to-bedside review: Ventilator strategies to reduce lung injury -- lessons from pediatric and neonatal intensive care.
Vitali SH, Arnold JH.
Department of Anesthesia and Critical Care Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA.
As in the adult with acute lung injury and acute respiratory distress syndrome, the use of lung-protective ventilation has improved outcomes for neonatal lung diseases. Animal models of neonatal respiratory distress syndrome and congenital diaphragmatic hernia have provided evidence that 'gentle ventilation' with low tidal volumes and 'open-lung' strategies of using positive end-expiratory pressure or high-frequency oscillatory ventilation result in less lung injury than do the traditional modes of mechanical ventilation with high inflating pressures and volumes. Although findings of retrospective studies in infants with respiratory distress syndrome, congenital diaphragmatic hernia, and persistent pulmonary hypertension of the newborn have been similar to those of the animal studies, prospective, randomized, controlled trials have yielded conflicting results. Successful clinical trial design in these infants and in children with acute lung injury/acute respiratory distress syndrome will require an appreciation of the data supporting the modern ventilator management strategies for infants with lung disease.
PMID: 15774075 [PubMed - in process]
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Patients' recollections of experiences in the intensive care unit may affect their quality of life.
Granja C, Lopes A, Moreira S, Dias C, Costa-Pereira A, Carneiro A; JMIP Study Group.
Medical Intensive Care Unit, Hospital Pedro Hispano, Matosinhos, Portugal. cristinagranja@oninet.pt
INTRODUCTION: We wished to obtain the experiences felt by patients during their ICU stay using an original questionnaire and to correlate the memories of those experiences with health-related quality of life (HR-QOL). METHODS: We conducted a prospective study in 10 Portuguese intensive care units (ICUs). Six months after ICU discharge, an original questionnaire on experiences of patients during their ICU stay, the recollection questionnaire, was delivered. HR-QOL was evaluated simultaneously, with the EQ-5D questionnaire. Between 1 September 2002 and 31 March 2003 1433 adult patients were admitted. ICU and hospital mortalities were 21% and 28%, respectively. Six months after ICU discharge, 464 patients completed the recollection questionnaire. RESULTS: Thirty-eight percent of the patients stated they did not remember any moment of their ICU stay. The ICU environment was described as friendly and calm by 93% of the patients. Sleep was described as being good and enough by 73%. The experiences reported as being more stressful were tracheal tube aspiration (81%), nose tube (75%), family worries (71%) and pain (64%). Of respondents, 51% experienced dreams and nightmares during their ICU stay; of these, 14% stated that those dreams and nightmares disturb their present daily life and they exhibit a worse HR-QOL. Forty-one percent of patients reported current sleep disturbances, 38% difficulties in concentrating in current daily activities and 36% difficulties in remembering recent events. More than half of the patients reported more fatigue than before the ICU stay. Multiple and linear regression analysis showed that older age, longer ICU stay, higher Simplified Acute Physiology Score II, non-scheduled surgery and multiple trauma diagnostic categories, present sleep disturbances, daily disturbances by dreams and nightmares, difficulties in concentrating and difficulties in remembering recent events were independent predictors of worse HR-QOL. Multicollinearity analysis showed that, with the exception of the correlation between admission diagnostic categories and length of ICU stay (0.47), all other correlations between the independent variables and coefficient estimates included in the regression models were weak (below 0.30). CONCLUSION: This study suggests that neuropsychological consequences of critical illness, in particular the recollection of ICU experiences, may influence subsequent HR-QOL.
PMID: 15774056 [PubMed - in process]
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Intensive care unit-acquired urinary tract infections in a regional critical care system.
Laupland KB, Bagshaw SM, Gregson DB, Kirkpatrick AW, Ross T, Church DL.
Department of Critical Care Medicine, Center for Anti-microbial Resistance, Calgary Health Region, Calgary Laboratory Services, and University of Calgary, Calgary, Alberta, Canada. kevin.laupland@calgaryhealthregion.ca
INTRODUCTION: Few studies have evaluated urinary tract infections (UTIs) specifically acquired within intensive care units (ICUs), and the effect of such infections on patient outcome is unclear. The objectives of this study were to describe the occurrence, microbiology, and risk factors for acquiring UTIs in the ICU and to determine whether these infections independently increase mortality. METHODS: A surveillance cohort study was conducted among all adults admitted to multi-system and cardiovascular surgery ICUs in the Calgary Health Region (CHR, population about 1 million) between 1 January 2000 and 31 December 2002. RESULTS: During the 3 years, 4465 patients were admitted 4915 times to a CHR ICU for 48 hours or more. A total of 356 ICU-acquired UTIs (defined as at least 105 colony-forming units/ml of one or two organisms 48 hours or more after ICU admission) occurred among 290 (6.5%) patients, yielding an overall incidence density of ICU-acquired UTIs of 9.6 per 1000 ICU days. Four bacteremic/fungemic ICU-acquired UTIs occurred (0.1 per 1000 ICU days). Development of an ICU-acquired UTI was more common in women (relative risk [RR] 1.58; 95% confidence interval [CI] 1.43-1.75; P < 0.0001) and in medical (9%) compared with non-cardiac surgical (6%), and cardiac surgical patients (2%). The most common organisms isolated were Escherichia coli (23%), Candida albicans (20%), and Enterococcus species (15%). Antibiotic-resistant organisms were identified among 14% isolates. Although development of an ICU-acquired UTI was associated with significantly higher crude in-hospital mortality (86/290 [30%] vs. 862/4167 [21%]; RR = 1.43; 95% CI 1.19-1.73; P < 0.001); an ICU-acquired UTI was not an independent predictor for death. CONCLUSIONS: Development of an ICU-acquired UTI is common in critically ill patients. Although a marker of increased morbidity associated with critical illness, it is not a significant attributable cause of mortality.
PMID: 15774051 [PubMed - in process]
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Initial distribution volume of glucose can be approximated using a conventional glucose analyzer in the intensive care unit.
Ishihara H, Nakamura H, Okawa H, Takase H, Tsubo T, Hirota K.
Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki-Shi, Japan. ishihara@cc.hirosaki-u.ac.jp
INTRODUCTION: We previously reported that initial distribution volume of glucose (IDVG) reflects central extracellular fluid volume, and that IDVG may represent an indirect measure of cardiac preload that is independent of the plasma glucose values present before glucose injection or infusion of insulin and/or vasoactive drugs. The original IDVG measurement requires an accurate glucose analyzer and repeated arterial blood sampling over a period of 7 min after glucose injection. The purpose of the present study was to compare approximated IDVG, derived from just two blood samples, versus original IDVG, and to test whether approximated IDVG is an acceptable alternative measure of IDVG in the intensive care unit. METHODS: A total of 50 consecutive intensive care unit patients were included, and the first IDVG determination in each patient was analyzed. Glucose (5 g) was injected through the central venous line to calculate IDVG. Original IDVG was calculated using a one-compartment model from serial incremental arterial plasma glucose concentrations above preinjection using a reference glucose analyzer. Approximated IDVG was calculated from glucose concentrations in both plasma and whole blood, using a combined blood gas and glucose analyzer, drawn at two time points: immediately before glucose injection and 3 min after injection. Subsequently, each approximated IDVG was calculated using a formula we proposed previously. RESULTS: The difference (mean +/- standard deviation) between approximated IDVG calculated from plasma samples and original IDVG was -0.05 +/- 0.54 l, and the difference between approximated IDVG calculated from whole blood samples and original IDVG was -0.04 +/- 0.61 l. There was a linear correlation between approximated and original IDVG (r2 = 0.92 for plasma samples, and r2 = 0.89 for whole blood samples). CONCLUSION: Our findings demonstrate that there was good correlation between each approximated IDVG and original IDVG, although the two measures are not interchangeable. This suggests that approximated IDVG is clinically acceptable as an alternative calculation of IDVG, although approximated and original IDVGs are not equivalent; plasma rather than whole blood measurements are preferable.
PMID: 15774047 [PubMed - in process]
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Practice of sedation and analgesia in German intensive care units: results of a national survey.
Martin J, Parsch A, Franck M, Wernecke KD, Fischer M, Spies C.
Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hospital am Eichert, Goppingen, Germany. joerg.martin@email.de
INTRODUCTION: Sedation and analgesia are provided by using different agents and techniques in different countries. The goal is to achieve early spontaneous breathing and to obtain an awake and cooperative pain-free patient. It was the aim of this study to conduct a survey of the agents and techniques used for analgesia and sedation in intensive care units in Germany. METHODS: A survey was sent by mail to 261 hospitals in Germany. The anesthesiologists running the intensive care unit were asked to fill in the structured questionnaire about their use of sedation and analgesia. RESULTS: A total of 220 (84%) questionnaires were completed and returned. The RAMSAY sedation scale was used in 8% of the hospitals. A written policy was available in 21% of hospitals. For short-term sedation in most hospitals, propofol was used in combination with sufentanil or fentanyl. For long-term sedation, midazolam/fentanyl was preferred. Clonidine was a common part of up to two-thirds of the regimens. Epidural analgesia was used in up to 68%. Neuromuscular blocking agents were no longer used. CONCLUSION: In contrast to the US 'Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult', our survey showed that in Germany different agents, and frequently neuroaxial techniques, were used.
PMID: 15774043 [PubMed - in process]
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Reducing interns' work hours led to fewer attentional failures and serious medical errors in intensive care units.
Sarani B, Alarcon LH.
Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
PMID: 15774040 [PubMed - in process]
Comment in:
Intensivists: providing primary care for critically ill patients.
Dorman T.
Publication Types:
PMID: 15699853 [PubMed - indexed for MEDLINE]
Comment on:
Effect of closed unit policy and appointing an intensivist in a developing country.
Topeli A, Laghi F, Tobin MJ.
Medical Intensive Care Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey.
OBJECTIVE: We hypothesized that a dual strategy--instituting a closed intensive care unit (ICU) policy and simultaneously appointing an intensivist--would improve patient outcome in a university hospital of a developing country and that the benefit would increase over time. DESIGN: Data were prospectively collected over 5 months before the policy change (open policy) and over an initial 6 mos (early closed policy) and subsequent 12 mos (late closed policy) after the policy change. SETTING: The study was conducted at a medical ICU of a university hospital in Turkey. PATIENTS: Two hundred patients were recruited during open policy, 149 during early closed policy, and 210 during late closed policy. MEASUREMENTS AND RESULTS: Instituting a closed policy and simultaneously appointing a critical care specialist was associated with the admission of sicker patients and more frequent use of invasive procedures. Compared with open policy, patients were approximately 4.5 times more likely to survive their hospital stay during early closed policy (p < .001) and approximately five times more likely during late closed policy (p < .0001). Among patients receiving mechanical ventilation, hospital mortality was lower during the early (57%) and late closed periods (59%) than during open period (91%; p < .01). In multivariate analysis, open policy, mechanical ventilation, central venous catheterization, sepsis, and higher Acute Physiology and Chronic Health Evaluation II score each independently predicted mortality. The change in policy resulted in the admission of progressively sicker patients over time and increased the use of mechanical ventilation and central venous catheters. CONCLUSION: A dual strategy of closed policy and simultaneously appointing an intensivist fostered admission of sicker patients and improved the survival of patients requiring admission to an ICU of a developing country.
Publication Types:
PMID: 15699831 [PubMed - indexed for MEDLINE]
The Groningen protocol--euthanasia in severely ill newborns.
Verhagen E, Sauer PJ.
Pediatrics Department at University Medical Center Groningen, Groningen, The Netherlands.
PMID: 15758003 [PubMed - indexed for MEDLINE]
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[Reduction of pressure sores during prone positioning of ventilated intensive care patients by the prone-head support system: a pilot study]
[Article in German]
Prebio M, Katz-Papatheophilou E, Heindl W, Gelbmann H, Burghuber OC.
Intensivstation, 1. Lungenabteilung, Otto-Wagner-Spital, Wien, Osterreich. michael.prebio@wienkav.at
OBJECTIVE: Prone positioning in patients with adult respiratory distress syndrome is a well-known method to improve oxygenation. The aim of our study was to evaluate a new device for prone positioning, the prone-head support system (PHS system), with regard to reduction of cutaneous pressure sores. METHODS: In a pilot study we randomized 8 patients with ARDS in two groups: 180 degrees standard prone positioning (group without mask) and prone positioning with the PHS system (group with mask). The PHS system consists of a facemask support, which is connected to an adapted air suspension bed. The patients of both groups were intermittently proned for several days. We evaluated the pressure sores on head and neck before turning the patients prone for the first time and after each period of prone positioning. We documented the quantity, the size, the type and the localization of the pressure sores. RESULTS: There was no significant difference in the mean duration of prone positioning (27.1+/-14.7 hours in the group with mask versus 24.5+/-18.7 h in the group without mask). In the group with mask there were 1.5+/-0.8 new pressure sores by each proning, whereas in the group without mask there were 2.37+/-1.6 new pressure sores, which was lower, but not significantly. The overall area of pressure sores (798 mm2 versus 3184 mm2, p=0.004), the area of pressure sores per patient (199.5+/-104.7 mm2 versus 796+/-478 mm2, p=0.03) and the increase of the area of pressure sores per proning (79.8+/-52.0 mm2 versus 398.0+/-214.3 mm2, p=0.004) were significantly lower in the group with mask in comparison to the group without mask. The lips were the most effected localization in both groups. The pressure sores in the group with mask were less severe and showed a homogenous distribution in comparison to the group without mask. Blisters dominated in the group with mask in comparison to erosions, necrosis and ulcers in the group without mask. CONCLUSION: The PHS system with its face mask is able to reduce the extent and the severity of pressure sores in patients ventilated in prone position. Controlled randomized studies with large study populations seem justified.
PMID: 15773424 [PubMed - in process]
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