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Nursing practice and civic professionalism.
Day L.
Department of Physiological Nursing, University of California, School of Nursing, San Francisco, USA.
PMID: 16120895 [PubMed - indexed for MEDLINE]
Use of complementary and alternative therapies: a national survey of critical care nurses.
Tracy MF, Lindquist R, Savik K, Watanuki S, Sendelbach S, Kreitzer MJ, Berman B.
University of Minnesota Medical Center, University of Minnesota School of Nursing, Minneapolis, MN, USA.
BACKGROUND: Demand for complementary and alternative therapies is increasing and is affecting all healthcare settings, including critical care. METHODS: A random sample of members of the American Association of Critical-Care Nurses was surveyed to determine the members' attitudes, knowledge, perspectives, and use of complementary and alternative therapies. RESULTS: Most of the 726 respondents were using one or more complementary and alternative therapies in practice. The most common therapies used were diet, exercise, relaxation techniques, and prayer. A majority of the nurses had some knowledge of more than half of the 28 therapies listed on the survey, and a majority desired additional training for 25 therapies. Respondents generally required more evidence judged as essential to use or recommend conventional therapy than to use or recommend complementary and alternative therapies. Nurses viewed complementary and alternative therapies positively overall, were open to use of the therapies, and perceived them as legitimate and beneficial to patients. Nurses judged the therapies helpful for treatment of a variety of symptoms. A majority of nurses desired an increase in the availability of the therapies for patients, patients' families, and nursing staff. Nurses' professional use of the therapies was related to having more knowledge of them, perceiving benefits of them, total number of therapies they recommended to patients, personal use, and affiliation with a mainstream religion. CONCLUSIONS: Educational programs that provide information about use of complementary and alternative therapies and the underlying evidence base most likely will increase the appropriate use of the therapies to achieve desired outcomes.
PMID: 16120892 [PubMed - indexed for MEDLINE]
Providing end-of-life care to patients: critical care nurses' perceived obstacles and supportive behaviors.
Beckstrand RL, Kirchhoff KT.
Brigham Young University, Provo, Utah, USA.
BACKGROUND: Critical care nurses care for dying patients daily. The process of dying in an intensive care unit is complicated, and research on specific obstacles that impede delivery of end-of-life care and/or supportive behaviors that help in delivery of end-of-life care is limited. OBJECTIVE: To measure critical care nurses' perceptions of the intensity and frequency of occurrence of (1) obstacles to providing end-of-life care and (2) supportive behaviors that help in providing end-of-life care in the intensive care unit. METHODS: An experimental, posttest-only, control-group design was used. A national, geographically dispersed, random sample of members of the American Association of Critical-Care Nurses was surveyed. RESULTS: The response rate was 61.3%, 864 usable responses from 1409 eligible respondents. The highest scoring obstacles were frequent telephone calls from patients' family members for information, patients' families who did not understand the term lifesaving measures, and physicians disagreeing about the direction of a dying patient's care. The highest scoring supportive behaviors were allowing patients' family members adequate time alone with patients after death, providing peaceful and dignified bedside scenes after death, and teaching patients' families how to act around a dying patient. CONCLUSIONS: The biggest obstacles to appropriate end-of-life care in the intensive care unit are behaviors of patients' families that remove nurses from caring for patients, behaviors that prolong patients' suffering or cause patients pain, and physicians' disagreement about the plan of care.
PMID: 16120891 [PubMed - indexed for MEDLINE]
Improving oral care in patients receiving mechanical ventilation.
Cutler CJ, Davis N.
Clinical Excellence Department, Advocate Health Care, Oak Brook, IL, USA.
BACKGROUND: Comprehensive oral care is an evidence-based prevention strategy to reduce the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation. Until recently, no comprehensive guidelines or standards existed to define necessary tasks, methods, and frequency of oral care to provide patients with optimal results. OBJECTIVES: To observe current practice of, define best practice for, and measure compliance with standardized comprehensive oral care. METHODS: This observational study was part of a larger research study performed at 5 acute care hospitals. Time blocks of 4 hours were randomized over 8 intensive care units and the 7 days of the week. Baseline data were collected before implementation of multifaceted education on an oral-cleansing protocol; interventional data were collected afterward. RESULTS: Oral care practices were observed for 253 patients. During the baseline period, oral cleansing was primarily via suction swabs. Toothbrushing and moisturizing of the oral tissues were not observed. Only 32% of the patients had suctioning to manage oral secretions. During the interventional period, 33% of patients had their teeth brushed, 65% had swab cleansing, and 63% had a moisturizer applied to the oral mucosal tissues. A total of 61% had management of oral secretions; 38% had oropharyngeal suctioning via a special catheter. CONCLUSIONS: Implementation of an evidence-based oral cleansing protocol improved the care of patients receiving mechanical ventilation. Multifaceted education and implementation strategies motivated staff to increase oral care practices.
PMID: 16120890 [PubMed - indexed for MEDLINE]
Frequency of oral care and positioning of patients in critical care: a replication study.
Hanneman SK, Gusick GM.
Center for Nursing Research, University of Texas School of Nursing at Houston, TX, USA.
BACKGROUND: Oral care and head-of-bed elevation are interventions to decrease risk of aspiration pneumonia in hospitalized patients. In a previous study, nurses' self-reports of how often they performed oral care did not match documented provision of such care. OBJECTIVES: To replicate the original study and estimate instrument reliability. METHODS: A cross-sectional design was used, and survey data from nursing personnel and bedside observational data from 9 intensive care units were collected. RESULTS: A total of 181 surveys (47%) were returned, and data were collected from 436 bedsides. Reported frequencies of oral care and use of oral care products differed between nonintubated and intubated patients (P< .001). The mean documented frequency of oral care for nonintubated patients was 1.8 (SD 1.5); self-reported frequency was 3 (SD 2.4). The mean documented frequency of oral care for intubated patients was 3.3 (SD 1.8); self-reported frequency was 4.2 (SD 2.1). Documented oral care frequency differed by unit (P = .006) and intubation status (P < .001). Mean observed head-of-bed position was 38 degrees (SD 24 degrees ) for nonintubated patients and 23 degrees (SD 12 degrees ) for intubated patients (P < .001). Intubation status, but not unit, affected observed head-of-bed position (P < .001). Three survey items had adequate reliability evidence (r = 0.70). Interrater reliability for bedside data collection was 96% or greater. CONCLUSIONS: Despite inadequate estimates of survey reliability, findings generally were comparable to results of the original study; nurses report more frequent oral care than is documented. Intensive care nurses elevate the head of patients' beds in accordance with self-reports.
PMID: 16120889 [PubMed - indexed for MEDLINE]
Cloxacillin versus vancomycin for presumed late-onset sepsis in the Neonatal Intensive Care Unit and the impact upon outcome of coagulase negative staphylococcal bacteremia: a retrospective cohort study.
Lawrence SL, Roth V, Slinger R, Toye B, Gaboury I, Lemyre B.
ABSTRACT: BACKGROUND: Coagulase negative staphylococcus (CONS) is the main cause of late-onset sepsis in Neonatal Intensive Care Units (NICU). Although CONS rarely causes fulminant sepsis, vancomycin is frequently used as empiric therapy. Indiscriminate use of vancomycin has been linked to the emergence of vancomycin resistant organisms. The objective of this study was to compare duration of CONS sepsis and mortality before and after implementation of a policy of selective vancomycin use and compare use of vancomycin between the 2 time periods. METHODS: A retrospective study was conducted of infants over or equal to 4 days old, experiencing signs of sepsis with a first positive blood culture for CONS, during two 12-month periods. Late-onset sepsis was treated empirically with vancomycin and gentamicin during period 1, and cloxacillin and gentamicin during period 2. The confidence interval method was used to assess non-inferiority of the outcomes between the two study groups. RESULTS: There were 45 episodes of CONS sepsis during period 1 and 37 during period 2. Duration of sepsis was similar between periods (hazard ratio of 1.00, 95%CI: 0.64, 1.57). One death during period 2 was possibly related to CONS sepsis versus none in period 1. Vancomycin was used in 97.8% of episodes in period 1 versus 81.1% of episodes in period 2. CONCLUSION: Although we failed to show non-inferiority of duration of sepsis in the cloxacillin and gentamicin group compared to the vancomycin and gentamicin group, duration of sepsis was clinically similar. Restricting vancomycin for confirmed cases of CONS sepsis resistant to oxacillin appears effective and safe, and significantly reduces vancomycin use in the NICU.
PMID: 16375769 [PubMed - as supplied by publisher]
Comment on:
Draining all pleural effusions in the intensive care unit?
Spronk PE, ten Hove W, Schultz MJ.
Publication Types:
PMID: 16374205 [PubMed - indexed for MEDLINE]
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Comment on:
Grading the evidence for shortened intensive care unit stays after cardiac operations.
Johnson RG.
Publication Types:
PMID: 16374186 [PubMed - indexed for MEDLINE]
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Comment on:
Out of intense complexities, intense simplicities emerge: AIDS in the intensive care unit.
Franklin C, Weinstein RA.
Publication Types:
PMID: 16374184 [PubMed - indexed for MEDLINE]
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Comment in:
Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team.
Curtis JR, Cook DJ, Wall RJ, Angus DC, Bion J, Kacmarek R, Kane-Gill SL, Kirchhoff KT, Levy M, Mitchell PH, Moreno R, Pronovost P, Puntillo K.
University of Washington, Seattle, Washington, USA.
OBJECTIVE: Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a "how-to" guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit. DATA SOURCES AND METHODS: The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on "quality improvement" and "critical care or intensive care" and searched online for additional resources. DATA SYNTHESIS AND OVERVIEW: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview. CONCLUSIONS: This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families.
Publication Types:
PMID: 16374176 [PubMed - indexed for MEDLINE]
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Comment in:
Predisposing factors for hypoglycemia in the intensive care unit.
Vriesendorp TM, van Santen S, DeVries JH, de Jonge E, Rosendaal FR, Schultz MJ, Hoekstra JB.
Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands.
OBJECTIVE: The introduction of strict glycemic control in the intensive care unit has increased the risk for hypoglycemia. In this study we examined the association between predefined circumstances and the occurrence of hypoglycemia in the intensive care unit. DESIGN:: Retrospective cohort study. SETTING: Academic medical center. PATIENTS: All episodes of hypoglycemia (glucose value <45 mg/dL) in our intensive care unit between September 2002 and September 2004 were identified. Presence of predefined circumstances previously associated with hypoglycemia was scored around the moment of hypoglycemia using a patient data management system and in-hospital charts. Patients with a first hypoglycemic event were contrasted to controls from the same cohort, who were matched for time since admission, to correct for the effect of length of stay. Data were analyzed using conditional logistic regression analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 2,272 patients, 156 (6.9%) experienced at least one episode of hypoglycemia. Continuous venovenous hemofiltration with bicarbonate-based substitution fluid (odds ratio [OR], 14; 95% confidence interval [CI], 1.8-106), a decrease of nutrition without adjustment for insulin infusion (OR, 6.6; 95% CI, 1.9-23), diabetes mellitus (OR, 2.6; 95% CI, 1.5-4.7), insulin use (OR, 5.3; 95% CI, 2.8-11), sepsis (OR, 2.2; 95% CI, 1.2-4.1), and inotropic support (OR, 1.8; 95% CI, 1.1-2.9) were associated with hypoglycemia. Simultaneous octreotide and insulin use (OR, 6.0; 95% CI, 0.72-50) may also be associated with hypoglycemia. Gastric residual during enteral nutrition without adjusting insulin infusion, liver failure, continuous venovenous hemofiltration with lactate-based substitution fluid, diminished glomerular filtration rate, dose diminishment of glucocorticoids or catecholamines, and use of beta-blocking agents were not associated with hypoglycemia. Adjusting for age, gender, and Acute Physiology and Chronic Health Evaluation II score at admission did not materially change ORs. CONCLUSION: Use of bicarbonate-based substitution fluid during continuous venovenous hemofiltration, a decrease of nutrition without adjustment for insulin infusion, a prior diagnosis of diabetes mellitus, sepsis, and need for inotropic support were found to be associated with hypoglycemia. Simultaneous use of insulin and octreotide may be associated with hypoglycemia.
PMID: 16374162 [PubMed - indexed for MEDLINE]
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Comment in:
Short-stay intensive care after coronary artery bypass surgery: randomized clinical trial on safety and cost-effectiveness.
van Mastrigt GA, Heijmans J, Severens JL, Fransen EJ, Roekaerts P, Voss G, Maessen JG.
Department of Clinical Epidemiology and Medical Technology Assessment, University Hospital Maastricht, Maastricht, Netherlands.
OBJECTIVE: To evaluate the safety and cost-effectiveness of short-stay intensive care (SSIC) treatment for low-risk coronary artery bypass patients. DESIGN: Randomized clinical equivalence trial. SETTING: University Hospital Maastricht, the Netherlands. PATIENTS: Low-risk coronary artery bypass patients. INTERVENTIONS: A total of 600 patients were randomly assigned to undergo either SSIC treatment (8 hrs of intensive care treatment) or control treatment (care as usual, overnight intensive care treatment). MEASUREMENTS: The primary outcome measures were intensive care readmissions and total hospital stay. The secondary outcome measures were total hospital costs, quality of life, postoperative morbidity, and mortality. Hospital costs consisted of the cost of hospital admission or admissions and outpatient costs. MAIN RESULTS: The difference in intensive care readmission between the two groups of 1.13% was very small and not significantly different (p = .241; 95% confidence interval, -0.9% to 2.9%). The total hospital stay (p = .807; 95% confidence interval, 1.2 to -0.4) and postoperative morbidity were comparable between the groups. The SSIC group's quality of life improved more compared with the control group's quality of life (p = .0238; 95% confidence interval, 0.0012 to 0.0464). The total hospital costs for SSIC were significantly lower (95% confidence interval, -1,581 to -174) compared with those for the control group (4,625 and 5,441, respectively). The estimated incremental cost-effectiveness ratio (cost/delta quality-adjusted life months) thus showed the dominance of SSIC. Bootstrap and sensitivity analyses confirm the robustness of the study findings. CONCLUSIONS: Compared with usual care, SSIC is a safe and cost-effective approach. SSIC can be considered as an alternative for conventional postoperative intensive care treatment for low-risk coronary artery bypass graft patients.
Publication Types:
PMID: 16374158 [PubMed - indexed for MEDLINE]
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Comment in:
Pharmacokinetics and total elimination of meropenem and vancomycin in intensive care unit patients undergoing extended daily dialysis.
Kielstein JT, Czock D, Schopke T, Hafer C, Bode-Boger SM, Kuse E, Keller F, Fliser D.
Department of Medicine, Division of Nephrology, Medical School Hannover, Hannover, Germany.
OBJECTIVE: Extended daily dialysis (EDD) combines the advantage of both intermittent hemodialysis and continuous renal replacement therapy: excellent detoxification accompanied by cardiovascular tolerability. The aim of this study was to evaluate pharmacokinetics of meropenem and vancomycin in critically ill patients with renal failure undergoing EDD. DESIGN: Prospective clinical study. SETTING: Surgical intensive care unit in a tertiary care center. PATIENTS: We studied intensive care patients with anuric acute renal failure being treated with EDD and receiving meropenem (n = 10) or vancomycin (n = 10) therapy. INTERVENTIONS: The antibiotics were administered 6 hrs (1.0 g meropenem) or 12 hrs (1.0 g vancomycin) before EDD was started in order to study the pharmacokinetics before and during EDD. In addition to the application of different methods to calculate pharmacokinetic parameters, the total dialysate concentration of both drugs was measured. RESULTS: Based on the amount of the drug recovered from the collected spent dialysate, the fraction of drug removed by one dialysis treatment was 18% for meropenem and 26% for vancomycin. Dosing regimes for intermittent hemodialysis and continuous renal replacement therapy cannot be used for critically ill patients treated with EDD. CONCLUSION: Our data suggest that patients treated with EDD by means of a high-flux dialyzer (polysulphone; surface area, 1.3 m; blood and dialysate flow, 160 mL/min; EDD time, 480 mins) and current dosing regimens run the risk of being significantly underdosed, which may have detrimental effects on critically ill patients with life-threatening infections. The exact dose has to be tailored according to weight and severity of illness as well as the current minimal inhibitory concentration against the incriminated bacteria. Whenever possible, therapeutic drug monitoring should be performed.
Publication Types:
PMID: 16374156 [PubMed - indexed for MEDLINE]
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Comment on:
Controlling antibiotic-resistant bacteria: what's an intensivist to do?
Weinstein RA, Bonten MJ.
Publication Types:
PMID: 16215421 [PubMed - indexed for MEDLINE]
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Comment on:
Evolving paradigms in the management of severe traumatic brain injury.
Stevens RD, Bhardwaj A.
Publication Types:
PMID: 16215404 [PubMed - indexed for MEDLINE]
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Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care.
Rubinson L, Nuzzo JB, Talmor DS, O'Toole T, Kramer BR, Inglesby TV.
The Working Group on Emergency Mass Critical Care was convened by the Center for Biosecurity of the University of Pittsburgh Medical Center and the Society of Critical Care Medicine to provide recommendations to hospital and clinical leaders regarding the delivery of critical care services in the wake of a bioterrorist attack resulting in hundreds or thousands of critically ill patients. In these conditions, traditional hospital and clinical care standards in general, and critical care standards in particular, likely could no longer be maintained, and clinical guidelines for U.S. hospitals facing these situations have not been developed. The Working Group offers recommendations for this situation.
PMID: 16215397 [PubMed - indexed for MEDLINE]
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Comment in:
Red blood cell 2,3-diphosphoglycerate concentration and in vivo P50 during early critical illness.
Ibrahim Eel D, McLellan SA, Walsh TS.
Department of Anaesthetics, Critical Care, and Pain Medicine, The University of Edinburgh, Royal Infirmary, Little France, Edinburgh, Scotland.
OBJECTIVE: To measure red blood cell 2,3-diphosphoglycerate (RBC 2,3-DPG) concentrations in early critical illness; to investigate factors associated with high or low RBC 2,3-DPG levels; to calculate in vivo P50 in patients with early critical illness; and to explore the relationship between RBC 2,3-DPG and intensive care mortality. DESIGN: Prospective cohort study. SETTING: General medical-surgical intensive care unit (ICU) of a major Scottish teaching hospital. PATIENTS: One-hundred eleven critically ill patients during the first 24 hrs in the ICU with no history of chronic hematologic disorders or RBC transfusion within 24 hrs and 34 age- and sex-matched healthy reference subjects. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured RBC 2,3-DPG concentration, plasma biochemistry values, and arterial blood gas parameters. On average, RBC 2,3-DPG was lower among critically ill patients than controls (mean [sd], 14.1 [6.3] vs. 16.7 [3.7] mumol/g hemoglobin; p = .004) and had a wider range of values (patients, 3.2-32.5 mumol/g hemoglobin; reference group, 9.1-24.3). Regression analysis indicated a strong independent association between plasma pH and RBC 2,3-DPG (B, 32.15 [95% confidence interval, 19.07-46.22], p < .001) and a weak association with plasma chloride (B, -0.196 [95% confidence interval, -0.39 to -0.01], p = .044) but not with hemoglobin or other measured biochemical parameters. The mean calculated in vivo P50 level was normal (3.8 kPa) but varied widely among patients (range, 2.0-5.5 kPa). RBC 2,3-DPG concentration was similar for ICU survivors and nonsurvivors. CONCLUSIONS: RBC 2,3-DPG concentrations vary widely among critically ill patients. Acidosis is associated with lower RBC 2,3-DPG concentrations, but anemia is not associated with a compensatory increase in RBC 2,3-DPG early in critical illness. Lower RBC 2,3-DPG concentrations during the first 24 hrs of intensive care are not associated with higher ICU mortality.
PMID: 16215378 [PubMed - indexed for MEDLINE]
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Comment in:
Transcutaneous PCO2 monitoring in critically ill adults: clinical evaluation of a new sensor.
Bendjelid K, Schutz N, Stotz M, Gerard I, Suter PM, Romand JA.
Surgical Intensive Care Unit, Department of Anesthesiology, Pharmacology and Surgical Intensive Care, Geneva University Hospitals, Geneva, Switzerland.
OBJECTIVE: In critically ill patients, arterial blood gas analysis is the gold standard for evaluating systemic oxygenation and carbon dioxide partial pressure. A new miniaturized carbon dioxide tension Pco2-Spo2 single sensor (TOSCA, Linde Medical Sensors AG, Basel, Switzerland) continuously and noninvasively (transcutaneously) monitors both Paco2 and oxygen saturation by pulse oximetry (Spo2). The present study was designed to investigate the usability and the accuracy of this device in critically ill patients. DESIGN: Prospective clinical investigation. SETTING: A 20-bed, university-affiliated, surgical intensive care unit. PATIENTS: Patients admitted after major surgery, multiple trauma, or septic shock equipped with an arterial catheter. INTERVENTIONS: The heated (42 degrees C) sensor was fixed at the earlobe using an attachment clip. Transcutaneous Pco2 (TcPco2) measurements were correlated with Paco2 values (measured using a blood gas analyzer). In addition, the differences between Paco2 and TcPco2 values were evaluated using the method of Bland-Altman. MEASUREMENTS AND MAIN RESULTS: We studied 55 patients, aged 18-80 (mean 57 +/- 15) yrs. A total of 417 paired measurements were compared. Correlation between TcPco2 and Paco2 was r = .86 (p < .01) in the Paco2 range of 24-101 mm Hg. Mean bias (+/-sd) between the two methods of measurement (Bland-Altman analysis) was 1.2 +/- 6.0 mm Hg with TcPco2 slightly overestimating arterial carbon dioxide tension. Nineteen percent of the measured values were outside of the acceptable clinical range of agreement of +/-7.5 mm Hg. CONCLUSIONS: The present study suggests that Paco2 can be acceptably assessed by measuring TcPco2 using the TOSCA Pco2-Spo2 sensor.
Publication Types:
PMID: 16215371 [PubMed - indexed for MEDLINE]
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Clinical and economic consequences of ventilator-associated pneumonia: a systematic review.
Safdar N, Dezfulian C, Collard HR, Saint S.
Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, 600 Highland Avenue, Madison, WI 53792, USA. ns2@medicine.wisc.edu
BACKGROUND: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in critically ill patients. The clinical and economic consequences of VAP are unclear, with a broad range of values reported in the literature OBJECTIVE: To perform a systematic review to determine the incidence of VAP and its attributable mortality rate, length of stay, and costs. DATA SOURCE: Computerized PUBMED and MEDLINE search supplemented by manual searches for relevant articles, limited to articles published after 1990. STUDY SELECTION: English-language observational studies and randomized trials that provided data on the incidence of VAP were included. Matched cohort studies were included for calculation of attributable mortality rate and length of stay. DATA EXTRACTION: Data were extracted on patient population, diagnostic criteria for VAP, incidence, outcome, type of intensive care unit, and study design. DATA SYNTHESIS: The cumulative incidence of VAP was calculated by combining the results of several studies using standard formulas for combining proportions, in which the weighted average and variance are calculated. Results from studies comparing intensive care unit and hospital mortality due to VAP, additional length of stay, and additional days of mechanical ventilation were pooled using a random effects model, with assessment of heterogeneity. RESULTS: Our findings indicate a) between 10% and 20% of patients receiving >48 hrs of mechanical ventilation will develop VAP; b) critically ill patients who develop VAP appear to be twice as likely to die compared with similar patients without VAP (pooled odds ratio, 2.03; 95% confidence interval, 1.16-3.56); c) patients with VAP have significantly longer intensive care unit lengths of stay (mean = 6.10 days; 95% confidence interval, 5.32-6.87 days); and d) patients who develop VAP incur > or = USD $10,019 in additional hospital costs. CONCLUSIONS: Ventilator-associated pneumonia occurs in a considerable proportion of patients undergoing mechanical ventilation and is associated with substantial morbidity, a two-fold mortality rate, and excess cost. Given these findings, strategies that effectively prevent VAP are urgently needed.
Publication Types:
PMID: 16215368 [PubMed - indexed for MEDLINE]
The contribution of withholding or withdrawing care to newborn mortality.
Barton L, Hodgman JE.
Division of Newborn Medicine, Department of Pediatrics, Keck School of Medicine, University of Southern California, Women's & Children's Hospital, Los Angeles, California, USA. barton@usc.edu
OBJECTIVE: We sought to determine the contribution of withholding or withdrawing care to neonatal mortality in our hospital over a 10-year period from 1993 through 2002. BACKGROUND: Although not initiating or withholding intensive care for certain newborns has been practiced openly for the past 25 years, little information has been published concerning the results of these practices on neonatal mortality. DESIGN AND METHODS: All infants who were born in our hospital and remained in the hospital until their death were evaluated for the care they received at the time of birth and near the time of their death. The contribution of not initiating care or withdrawing care to the neonatal mortality rates in our hospital was determined. Information was obtained directly from the patients' charts as well as the neonatal database and monthly neonatal mortality and morbidity review. Other information, if needed, was obtained from the monthly ethics committee reviews of all nursery deaths. Information was collected relating to birth weight, gestational age, diagnosis, time of death, and year of death. Hospital and neonatal unit protocols were evaluated to determine how closely they were followed. RESULTS: During the 10-year period, 380 deaths (0.8%) of a total of 47820 live births occurred in our hospital. Care was not initiated or was withdrawn in close to 72% of those deaths; total care until death occurred in 28%. Total care for infants who died over the 10-year period decreased markedly as care not initiated or care withdrawn increased. Most of this increase in not initiating care and in withdrawal of care was in the smaller of the extremely low birth weight infants. CONCLUSIONS: The majority of nursery deaths of infants born in our hospital occurred as the result of selected noninitiating of care or as a result of withdrawing care in infants not responding or considered to have a futile outcome. Only slightly more than one quarter of the infants received total care until the time of death.
PMID: 16322175 [PubMed - indexed for MEDLINE]
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Project 27/28: inquiry into quality of neonatal care and its effect on the survival of infants who were born at 27 and 28 weeks in England, Wales, and Northern Ireland.
Acolet D, Elbourne D, McIntosh N, Weindling M, Korkodilos M, Haviland J, Modder J, Macintosh M; Confidential Enquiry Into Maternal and Child Health.
Confidential Enquiry into Maternal and Child Health (CEMACH) Central Office, London NW1 5SD, United Kingdom. dominique.acolet@cemach.org.uk
OBJECTIVE: To identify variations in standards of neonatal care in the first week of life that might have contributed to deaths in infants who were born at 27 and 28 weeks' gestation. METHODS: A case-control study was conducted of infants who were born at 27 and 28 weeks' gestation in England, Wales, and Northern Ireland during a 2-year period. Cases were neonatal deaths; control subjects were randomly selected survivors at day 28. Main outcome measures were failures of prespecified standards of care or deficiencies in care reported by regional panels assessing anonymized medical records. RESULTS: Failures of standards of care relating to ventilatory support (adjusted odds ratio [OR]: 3.29; 95% confidence interval [CI]: 1.97-5.49), cardiovascular support (OR: 2.37; 95% CI :1.36-4.13), and thermal care (OR: 1.71; 95% CI: 1.21-2.43) were associated with neonatal death. Frequencies of unmet resuscitation standards (range: 3%-46%) and of delays in surfactant administration (range: 38%-40%) were similar in cases and control subjects. Panels identified significantly more deficiencies in all aspects of neonatal care in cases with the exception of the management of infection. Stratification by clinical condition of infants at birth showed a stronger association between overall standard of care and death when infants were in a good condition at birth. CONCLUSIONS: Our findings suggest an association between quality of neonatal care and neonatal deaths, most marked for early thermal care and ventilatory and cardiovascular support. Poor overall quality of care was more strongly associated with deaths when the infant was in a good condition at birth.
PMID: 16322171 [PubMed - indexed for MEDLINE]
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Relationship between significant perinatal events and migraine severity.
Maneyapanda SB, Venkatasubramanian A.
Department of Ecology and Evolutionary Biology, Princeton University, Princeton, New Jersey, USA.
OBJECTIVE: Nociceptive neuronal circuits are formed during embryonic and postnatal times, so insult during these periods may result in long-term alterations to pain circuitry via synaptic plasticity. One possible long-term result of plasticity is central hyperexcitability, which is suspected to be involved in chronic headache. This study aimed to establish whether there is an association between early pain experiences and the experience of migraines in later childhood. METHODS: In a retrospective study, we examined the charts of 280 pediatric migraineurs at the Division of Pediatric Neurology at Robert Wood Johnson Medical School and documented their perinatal history and migraine characteristics. RESULTS: Analysis revealed that there was a significant relationship between patients who had been in the NICU at birth and the type of pain medication prescribed when compared with patients who had not been in the NICU (chi2 test, chi2(2) = 23.304; N = 30250). Findings also suggested that pediatric migraine patients who had been in the NICU at birth had a significantly earlier age of onset of their migraines (chi2 +/- SD = 7.83 +/- 3.23; N = 30) when compared with patients who did not remain in the NICU (chi2 +/- SD = 9.68 +/- 3.57; N = 250; Kolmogorov-Smirnov Test, chi2 = 10.699). CONCLUSION: On the basis of these findings, we speculate that pain experience as a neonate, through neuronal plasticity and resulting central hyperexcitability, can alter the later experience of pain. However, this observational study cannot validate these links. Other potential explanations that work either synergistically or alone include other forms of stimulation and greater parental vigilance that may occur when neonates spend time in the NICU. This study would prompt additional development of a larger prospective study to establish a link between early pain experience and subsequent pain syndromes and also future investigation into the treatment of pain in neonates as a preventive measure for avoiding long-lasting neuronal alterations.
PMID: 16199683 [PubMed - indexed for MEDLINE]
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