About Entrez
NCBI Toolbar
Text Version
Entrez PubMed
Overview
Help |
FAQ
Tutorials
New/Noteworthy
E-Utilities
PubMed Services
Journals Database
MeSH Database
Single Citation Matcher
Batch Citation Matcher
Clinical Queries
Special Queries
LinkOut
My NCBI
Related Resources
Order Documents
NLM Mobile
NLM Catalog
NLM Gateway
TOXNET
Consumer Health
Clinical Alerts
ClinicalTrials.gov
PubMed Central
|
|
| Display Show |
 |
|
|
A framework for ethical decision making in neonatal intensive care.
Baumann-Holzle R, Maffezzoni M, Bucher HU.
Dialogue Ethics, Zurich, Switzerland.
Intensive care for neonates with high risks of severe impairment and the possibility of a prolonged dying process represents a frequent ethical issue in neonatal units. The aim of this paper is to present a framework for structured decision making that has been developed in a neonatal intensive care unit and to demonstrate its impact on the healthcare team and on survival of critically ill neonates. This framework attempts to integrate the best interests of the infants and their parents, the possibilities of high-tech neonatal intensive care interventions, and the perspective of the nurses and doctors. An external evaluation of 84 sessions over 3 y revealed a beneficial effect on the quality of the decision-making process itself and on the quality of the teamwork in the unit. Survival time was shorter (median 2 d, interquartile range 1-7 d) in 26 infants that died after structured decision making compared with 26 controls matched for gestational age, malformation and intracranial haemorrhage (median 7 d, interquartile range 4-15 d).Conclusion: The introduction of this framework for structured decision making involving doctors and nurses improved the quality of the teamwork. It shortened futile intensive care, and thereby suffering for both infants and parents.
PMID: 16421039 [PubMed - in process]
Life-threatening pulmonary hypertension and right ventricular failure complicating calcium and phosphate replacement in the intensive care unit.
Felton TW, McCormick BA, Finfer SR, Fisher MM.
Intensive Therapy Unit, Royal North Shore Hospital, St. Leonards, Sydney, Australia. timothyfelton@doctors.org.uk
A 43-year-old man developed septic shock and acute lung injury after surgery to drain an ischiorectal abscess. In the intensive care unit he initially improved but developed severe hypoxaemia, right ventricular failure and pulmonary hypertension 90 min after receiving intravenous calcium gluconate and potassium phosphate, best explained by the formation of a calcium-phosphate precipitant that resulted in aggregate anaphylaxis. His rapid deterioration and lack of response to conventional therapies necessitated support with extracorporeal membrane oxygenation that was life saving. This adverse event has altered local practice regarding calcium and phosphate replacement and has implications for all intensive care units.
PMID: 16409342 [PubMed - in process]
Should premedication be used for semi-urgent or elective intubation in neonates?
Byrne E, MacKinnon R.
St Mary's Hospital, Manchester, UK.
Publication Types:
PMID: 16371384 [PubMed - indexed for MEDLINE]
Comment in:
Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial.
Honrubia T, Garcia Lopez FJ, Franco N, Mas M, Guevara M, Daguerre M, Alia I, Algora A, Galdos P.
Unidad de Epidemiologia Clinica, Hospital Universitario Puerta de Hierro, San Martin de Porres, 4, 28035 Madrid, Spain.
STUDY OBJECTIVE: Noninvasive mechanical ventilation (NIMV) is beneficial for patients with acute respiratory failure (ARF) when added to medical treatment. However, its role as an alternative to conventional mechanical ventilation (CMV) remains controversial. Our aim was to compare the efficacy and resource consumption of NIMV against CMV in patients with ARF. DESIGN: A randomized, multicenter, controlled trial. SETTING: Seven multipurpose ICUs. PATIENTS: Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation. INTERVENTION: The noninvasive group received ventilation through a face mask in pressure-support mode plus positive end-expiratory pressure; the conventional group received ventilation through a tracheal tube. MEASUREMENTS AND RESULTS: Avoidance of intubation, mortality, and consumption of resources were the outcome variables. Thirty-one patients were assigned to the noninvasive group, and 33 were assigned to the conventional group. In the noninvasive group, 58% patients were intubated, vs 100% in the conventional group (relative risk reduction, 43%; p < 0.001). Stratification by type of ARF gave similar results. In the ICU, death occurred in 23% and 39% (p = 0.09) and complications occurred in 52% and 70% (p = 0.07) in the noninvasive and conventional groups, respectively. There were no differences in length of stay. The Therapeutic Intervention Score System-28, but not the direct nursing activity time, was lower in the noninvasive group during the first 3 days. CONCLUSIONS: NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes. There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay.
Publication Types:
PMID: 16354864 [PubMed - indexed for MEDLINE]
-
Comment in:
Introduction of a 14-hour work shift model for housestaff in the medical ICU.
Afessa B, Kennedy CC, Klarich KW, Aksamit TR, Kolars JC, Hubmayr RD.
Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA. afessa.bekele@mayo.edu
STUDY OBJECTIVE: To describe the outcomes of switching housestaff from a traditional model of "long-call" every 4 days to a 14-h work-shift model in a medical ICU (MICU) over a 5-week pilot period. DESIGN: Retrospective comparison of a 5-week pilot period for a 14-h work-shift model vs a 4-month period for the traditional model. SETTING: The MICU of a tertiary medical center. PARTICIPANTS: A total of 626 patients admitted to the MICU and 34 internal medicine residents taking care of them. INTERVENTIONS: None. MEASUREMENTS: Severity-adjusted patient outcomes, housestaff performance on end-of-rotation examinations, and scheduled duty hours during the 5-week 14-h work-shift pilot period compared to a 16-week traditional nonpilot work period. RESULTS: There were no statistically significant differences in patients' adjusted mortality rates, hospital lengths of stay, or housestaff performance on end-of-rotation knowledge assessment examinations between the pilot and nonpilot periods. During the pilot period, each resident was scheduled to work for an average of 61.3 h weekly, and each fellow for 65.3 h weekly. In comparison, each resident and fellow was scheduled to work for an average of 73.3 h weekly during the nonpilot period. CONCLUSIONS: The 14-h work shift is a feasible option for housestaff rotation in the MICU. Although the power of our study to detect significant differences in mortality, length of stay, and educational outcomes was low, there was no evidence of compromised patient care or housestaff education associated with the 14-h shift model over the course of this 5-week pilot study.
PMID: 16354863 [PubMed - indexed for MEDLINE]
-
Comment on:
A shift for the better.
Lilly CM, Landrigan CP.
Publication Types:
PMID: 16354844 [PubMed - indexed for MEDLINE]
Gram-negative bacterial surgical site infection and intensive care unit patients.
Lee JT.
Publication Types:
PMID: 16421807 [PubMed - in process]
Use of prophylactic fluconazole in a neonatal intensive care unit: efficacy is similar to that described in adult high-risk surgical patients.
Manzoni P, Farina D, Leonessa M, Priolo C, Gomirato G.
Neonatology and Hospital NICU, Azienda Ospedaliera Regina Margherita, Turin, Italy. paolomanzoni@hotmail.com.
PMID: 16420658 [PubMed - as supplied by publisher]
-
Changes in appetite related gut hormones in intensive care unit patients: a pilot cohort study.
Nematy M, O'flynn JE, Wandrag L, Brynes AE, Brett SJ, Patterson M, Ghatei MA, Bloom SR, Frost GS.
Phd Student, Nutrition and Dietetic Research Group, Imperial College, Hammersmith Hospitals NHS Trust, Du Cane Road, London W12 0HS, UK. m.nematy@imperial.ac.uk.
ABSTRACT : INTRODUCTION : The nutritional status of patients in the intensive care unit (ICU) appears to decline not only during their stay in the ICU but also after discharge from the ICU. Recent evidence suggests that gut released peptides, such as ghrelin and peptide YY (PYY) regulate the initiation and termination of meals and could play a role in the altered eating behaviour of sick patients. The aim of this study was to assess the patterns of ghrelin and PYY levels during the stay of ICU patients in hospital. METHODS : Sixteen ICU patients (60 +/- 4.7 years, body mass index (BMI) 28.1 +/- 1.7 kg/m2 (mean +/- standard error of the mean)) underwent fasting blood sample collections on days 1, 3, 5, 14, 21 and 28 of their stay at Hammersmith and Charing Cross Hospitals. Changes in appetite and biochemical and anthropometric markers of nutritional status were recorded. A comparison was made to a group of 36 healthy volunteers matched for age and BMI (54.3 +/- 2.9 years, p = 0.3; BMI 25.8 +/- 0.8 kg/m2 p = 0.2). RESULTS : Compared to healthy subjects, ICU patients exhibited a significantly lower level of ghrelin (day one 297.8 +/- 76.3 versus 827.2 +/- 78.7 pmol/l, p < 0.001) during their stay in the ICU. This tended to rise to the normal level during the last three weeks of hospital stay. Conversely, ICU patients showed a significantly higher level of PYY (day one 31.5 +/- 9.6 versus 11.3 +/- 1.0 pmol/l, p < 0.05) throughout their stay in the ICU and on the ward, with a downward trend to the normal level during the last three weeks of stay. CONCLUSIONS : Results from our study show high levels of PYY and low levels of ghrelin in ICU patients compared to healthy controls. There appears to be a relationship between the level of these gut hormones and nutritional intake.
PMID: 16420657 [PubMed - as supplied by publisher]
-
The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low.
Graat ME, Choi G, Wolthuis EK, Korevaar JC, Spronk PE, Stoker J, Vroom MB, Schultz MJ.
Medical student, Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. m.e.graat@amc.uva.nl.
ABSTRACT : INTRODUCTION : The clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care for intensive care unit (ICU) patients. METHOD : This was a prospective observational study conducted in a 28-bed, mixed medical-surgical ICU of a university hospital. RESULTS : Over a 5-month period, 2,457 daily routine CXRs were done in 754 consecutive ICU patients. The majority of these CXRs did not reveal any new predefined major finding. In only 5.8% of daily routine CXRs (14.3% of patients) was one or more new and unexpected abnormality encountered, including large atelectases (24 times in 20 patients), large infiltrates (23 in 22), severe pulmonary congestion (29 in 25), severe pleural effusion (13 in 13), pneumothorax/pneumomediastinum (14 in 13), and malposition of the orotracheal tube (32 in 26). Fewer than half of the CXRs with a new and unexpected finding were ultimately clinically relevant; in only 2.2% of all daily routine CXRs (6.4% of patients) did these radiologic abnormalities result in a change to therapy. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily routine CXRs and the effect of new and unexpected CXR findings on daily care. CONCLUSION : In the ICU, daily routine CXRs seldom reveal unexpected, clinically relevant abnormalities, and they rarely prompt action. We propose that this diagnostic examination be abandoned in ICU patients.
PMID: 16420655 [PubMed - as supplied by publisher]
-
Survival methods, including those using competing risk analysis, are not appropriate for intensive care unit outcome studies.
Schoenfeld D.
Professor of Medicine, Harvard Medical School, Massachusetts General Hospital Biostatistics Center, Staniford Street, Boston, MA 02114, USA. dschoenfeld@partners.org.
ABSTRACT : The preferred analysis for studies of mortality among patients treated in an intensive care unit should compare the proportions of patients who died during hospitalization. Studies that look for prognostic covariates should use logistic regression. Survival methods, such as the proportional hazards model, or methods based on competing risk analysis are not appropriate because prolonged survival among patients that die during their hospitalization does not benefit the patient and, therefore, should not be measured in the statistical analysis.
Publication Types:
PMID: 16420653 [PubMed - as supplied by publisher]
Serious Errors in Intensive Care.
Rothschild JM, Landrigan CP, Bates DW.
Brigham and Women's Hospital, Boston, MA.
PMID: 16424769 [PubMed - as supplied by publisher]
-
Serious errors in intensive care.
Henneman EA, Gawlinski A.
School of Nursing, University of Massachusetts, Amherst, MA (Henneman) UCLA Healthcare and School of Nursing, Los Angeles, CA (Gawlinski).
PMID: 16424765 [PubMed - in process]
-
Intensive care unit sedation: Waking up clinicians to the gap between research and practice.
Devlin JW, Tanios MA, Epstein SK.
Northeastern University School of Pharmacy Tufts-New England Medical Center Boston, MA (Devlin) Saint Mary Medical Center University of California Los Angeles Long Beach, CA Caritas-St. Elizabeth's Medical Center Tufts University School of Medicine Boston, MA (Tanios) Caritas-St. Elizabeth's Medical Center Tufts University School of Medicine Boston, MA (Epstein).
PMID: 16424748 [PubMed - as supplied by publisher]
-
Antibiotic cycling in intensive care units: The value of organized chaos?
Bonten MJ, Weinstein RA.
Departments of Internal Medicine & Infectious Diseases; Eijkman Winkler Institute for Microbiology & Infectious Diseases; Julius Center for Health Sciences and Primary Care; University Medical Center; Utrecht, The Netherlands (Bonten) Division of Infectious Diseases; John Stroger Hospital of Cook County and Rush Medical School; Chicago, IL (Weinstein).
PMID: 16424744 [PubMed - as supplied by publisher]
-
Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection.
Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G.
From the University Medical Center (BJK, GP) and Department of Pharmacy Practice & Science (BLE), College of Pharmacy, the University of Arizona; Shands at the University of Florida (MEA); and University of Arizona, College of Medicine, Department of Pediatrics and Steele Memorial Children's Research Center (AAT).
OBJECTIVE:: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. DESIGN:: Prospective, direct observation study. SETTING:: Tertiary care academic medical center. PATIENTS:: Patients in a medical/surgical intensive care unit. INTERVENTIONS:: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS:: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). CONCLUSIONS:: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.
PMID: 16424723 [PubMed - as supplied by publisher]
-
Improved nurse job satisfaction and job retention with the transition from a "mandatory consultation" model to a "semiclosed" surgical intensive care unit: A 1-year prospective evaluation.
Haut ER, Sicoutris CP, Meredith DM, Sonnad SS, Reilly PM, Schwab CW, Hanson CW, Gracias VH.
From the Department of Surgery, The Johns Hopkins University School of Medicine (ERH), Baltimore, MD; the Division of Traumatology and Surgical Critical Care (VHG, PMR, CWS), Department of Surgery (SSS), and the Department of Anesthesia (CWH), The University of Pennsylvania School of Medicine, Philadelphia; and Department of Nursing, The Hospital of the University of Pennsylvania (CPS, DMM), Philadelphia, PA.
OBJECTIVE:: The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS). DESIGN:: Prospective longitudinal survey. SETTING:: Tertiary-care university hospital. SUBJECTS:: SICU staff nurses. INTERVENTIONS:: Change from mandatory consultation to semiclosed SICU. MEASUREMENTS AND MAIN RESULTS:: We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p < .05). Hospital spending on agency nurses decreased significantly (p = .0098). The yearly nurse job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p < .0001). CONCLUSIONS:: Nurse job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.
PMID: 16424719 [PubMed - as supplied by publisher]
-
Effects of prolonged intensive care unit stay on quality of life and long-term survival after transthoracic esophageal resection.
Cense HA, Hulscher JB, de Boer AG, Dongelmans DA, Tilanus HW, Obertop H, Sprangers MA, van Lanschot JJ.
From the Department of Surgery (HAC, JBFH, HO, JJBvL), Coronel Institute (AGEMdB), Department of Intensive Care Medicine (DAD), and Department of Medical Psychology (MAGS), Academic Medical Center, Amsterdam, The Netherlands; and the Department of Surgery (HWT, HO, HAC), Erasmus Medical Center, Rotterdam, The Netherlands.
OBJECTIVE:: There are few prospective data on the effects of prolonged intensive care unit stay on the quality of life and long-term survival of a homogeneous patient population. Therefore, the aims of this prospective study were a) to describe the quality of life in patients after having a transthoracic esophageal resection; and b) to analyze the influences of a prolonged intensive care unit stay on quality of life and survival in patients after esophageal cancer resection who survived to hospital discharge. DESIGN:: Prospective study. SETTING:: Medical center. PATIENTS:: The study population consisted of 109 patients undergoing a transthoracic resection for adenocarcinoma of the middistal esophagus or gastric cardia between April 1994 and February 2000. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: A comparison was made between patients staying </=5 days vs. >/=6 days in the intensive care unit and also </=2 days vs. >/=14 days. Quality of life was assessed in all patients by mailed self-report questionnaires at baseline (preoperatively), at 5 wks, and at 3, 6, 9, 12, 18, 24, 30, and 36 months after surgery. Daily physical, emotional, and social functioning was assessed with the generic Medical Outcome Studies Short Form-20. Disease-specific quality of life was measured by an adapted Rotterdam Symptom Check List. Quality of life data were gathered between July 1994 and March 2003. Five of the 109 patients died in the hospital and were excluded from the analysis. All five of them were in the intensive care unit >/=6 days. Of the remaining 104 patients, 92 provided baseline scores. The data of the 92 patients were used for the quality of life analyses. For the clinicopathologic and survival analysis, the data of 104 hospital survivors were used. Patients spent a median of 5.5 days (range 0-71) in the intensive care unit. The Medical Outcome Studies Short Form-20 and the Rotterdam Symptom Check List measurements showed no clear differences in long-term quality of life between patients after a short vs. a prolonged postoperative intensive care unit period. The median overall survival in all patients was 2.0 yrs (range 0.1-8.0). Median overall survival in patients staying in the intensive care unit </=5 days was 1.9 yrs (range 0.3-7.4 yrs) vs. 2.7 yrs (range 0.9-7.2 yrs) in patients staying >/=6 days (p = .9, log-rank test). Median overall survival in patients staying in the intensive care unit </=2 days was 1.7 yrs (range 1.2-2.6 yrs) vs. 2.0 yrs (range 0.2-3.8 yrs) in patients staying >/=14 days (p = .74, log-rank test). CONCLUSIONS:: For patients who survived to hospital discharge after transthoracic esophagectomy, there was no difference in long-term quality of life or survival between those submitted to the intensive care unit for a short period vs. a long period.
PMID: 16424714 [PubMed - as supplied by publisher]
-
Sepsis in European intensive care units: Results of the SOAP study.
Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D; on behalf of the Sepsis Occurrence in Acutely Ill Patients Investigators.
From the Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium (J-LV, YS); Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel (CLS); Department of Anesthesiology and Intensive Care, S. Giovanni Battista Hospital, University of Turin, Italy (VMR); Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Jena, Germany (KR); Department of Anesthesiology and Intensive Care, Vivantes-Klinikum Neukolln, Berlin, Germany (HG); Department for Intensive Care, Hospital de St, Antonio dos Capuchos, Lisbon, Portugal (RM); Department of Intensive Care, Saint-Joseph Hospital, Paris, France (JC); Department of Intensive Care, Saint-Louis Hospital, Paris, France (J-RLG); and Department of Anesthesiology and Intensive Care, Centre Hospitalier Universitaire Lariboisiere, Paris, France (DP).
OBJECTIVE:: To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units. DESIGN:: Cohort, multiple-center, observational study. SETTING:: One hundred and ninety-eight intensive care units in 24 European countries. PATIENTS:: All new adult admissions to a participating intensive care unit between May 1 and 15, 2002. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Demographic data, comorbid diseases, and clinical and laboratory data were collected prospectively. Patients were followed up until death, until hospital discharge, or for 60 days. Of 3,147 adult patients, with a median age of 64 yrs, 1,177 (37.4%) had sepsis; 777 (24.7%) of these patients had sepsis on admission. In patients with sepsis, the lung was the most common site of infection (68%), followed by the abdomen (22%). Cultures were positive in 60% of the patients with sepsis. The most common organisms were Staphylococcus aureus (30%, including 14% methicillin-resistant), Pseudomonas species (14%), and Escherichia coli (13%). Pseudomonas species was the only microorganism independently associated with increased mortality rates. Patients with sepsis had more severe organ dysfunction, longer intensive care unit and hospital lengths of stay, and higher mortality rate than patients without sepsis. In patients with sepsis, age, positive fluid balance, septic shock, cancer, and medical admission were the important prognostic variables for intensive care unit mortality. There was considerable variation between countries, with a strong correlation between the frequency of sepsis and the intensive care unit mortality rates in each of these countries. CONCLUSIONS:: This large pan-European study documents the high frequency of sepsis in critically ill patients and shows a close relationship between the proportion of patients with sepsis and the intensive care unit mortality in the various countries. In addition to age, a positive fluid balance was among the strongest prognostic factors for death. Patients with intensive care unit acquired sepsis have a worse outcome despite similar severity scores on intensive care unit admission.
PMID: 16424713 [PubMed - as supplied by publisher]
-
Comparison of antimicrobial cycling and mixing strategies in two medical intensive care units.
Martinez JA, Nicolas JM, Marco F, Horcajada JP, Garcia-Segarra G, Trilla A, Codina C, Torres A, Mensa J.
From the Departments of Infectious Diseases (JAM, JPH, JM), Medical Intensive Care Unit (JMN, GGS), Microbiology Laboratory (FM), Unit for Evaluation, Supporting and Prevention (AT), Pharmacy (CC), and Respiratory Intensive Care Unit-ICPTC (AT). Hospital Clinic, IDIBAPS -University of Barcelona. Spain.
OBJECTIVE:: To compare a mixing vs. a cycling strategy of use of anti-Pseudomonas antibiotics on the acquisition of resistant Gram-negative bacilli in the critical care setting. DESIGN:: Prospective, open, comparative study of two strategies of antibiotic use. SETTING:: Two medical intensive care units of a university hospital. PATIENTS:: A total of 346 patients admitted for >/=48 hrs to two separate medical intensive care units during an 8-month period. INTERVENTIONS:: Patients, who according to the attending physician's judgment required an anti-Pseudomonas regimen, were assigned to receive cefepime/ceftazidime, ciprofloxacin, a carbapemen, or piperacillin-tazobactam in this order. "Cycling" was accomplished by prescribing one of these antibiotics during 1 month each. "Mixing" was accomplished by using the same order of antibiotic administration on consecutive patients. Interventions were carried out during two successive 4-month periods, starting with mixing in one unit and cycling in the other. MEASUREMENTS AND MAIN RESULTS:: Swabbing of nares, pharynx, and rectum and culture of respiratory secretions were obtained thrice weekly. The main outcome variable was the proportion of patients acquiring enteric or nonfermentative Gram-negative bacilli resistant to the antibiotics under intervention. The scheduled cycling of antibiotics was only partially successful. Although the expected antibiotic was the most prevalent anti-Pseudomonas agent used within the corresponding period, it never accounted for >45% of all anti-Pseudomonas antimicrobials administered. During mixing, a significantly higher proportion of patients acquired a strain of Pseudomonas aeruginosa resistant to cefepime (9% vs. 3%, p = .01), and there was a trend toward a more frequent acquisition of resistance to ceftazidime (p = .06), imipenem (p = .06), and meropenem (p = .07). No differences in the rate of acquisition of potentially resistant Gram-negative bacilli or incidence of intensive care unit-acquired infections and infections due to particular organisms were observed. CONCLUSIONS:: In critically ill medical patients, a strategy of monthly rotation of anti-Pseudomonas beta-lactams and ciprofloxacin may perform better than a strategy of mixing in the acquisition of P. aeruginosa resistant to selected beta-lactams.
PMID: 16424711 [PubMed - as supplied by publisher]
-
Comment on:
Raising mean arterial pressure in patients with septic shock.
Giovanni L, Filippo B, Stefania D, Martina C.
Publication Types:
PMID: 16374202 [PubMed - indexed for MEDLINE]
-
Comment on:
An excellent pharmacokinetic profile can actually act as a double-edged sword.
Hui M.
Publication Types:
PMID: 16374201 [PubMed - indexed for MEDLINE]
-
Comment on:
Quality improvement: best evidence in clinical practice and clinical evidence of best practice.
Cook DA.
Publication Types:
PMID: 16374198 [PubMed - indexed for MEDLINE]
-
Comment on:
Clinical skills in acute care: a role for simulation training.
Murray D.
Publication Types:
PMID: 16374192 [PubMed - indexed for MEDLINE]
-
Comment on:
Intensive insulin therapy: of harm and health, of hypes and hypoglycemia.
Polderman KH, Girbes AR.
Publication Types:
PMID: 16374189 [PubMed - indexed for MEDLINE]
-
Comment on:
Focusing on caregivers of the critically ill: beyond illness into recovery.
Kleinpell RM.
Publication Types:
PMID: 16374187 [PubMed - indexed for MEDLINE]
-
Comment on:
Effectiveness of prolonged glucocorticoid treatment in acute respiratory distress syndrome: the right drug, the right way?
Meduri GU, Chrousos GP.
Publication Types:
PMID: 16374183 [PubMed - indexed for MEDLINE]
-
Comment on:
Sepsis in an aging population.
Paz HL, Martin AA.
Publication Types:
PMID: 16374182 [PubMed - indexed for MEDLINE]
-
Comment on:
Finding out what we do in the ICU.
Levy MM.
Rhode Island Hospital, Intensive Care Unit, Providence, RI, USA.
Publication Types:
PMID: 16374179 [PubMed - indexed for MEDLINE]
-
Pressure-flow signatures of central-airway mucus plugging.
Zamanian M, Marini JJ.
University of Minnesota, Minneapolis-St. Paul, MN, USA.
SETTING: Medical Intensive Care Unit of Regions Hospital, a University of Minnesota-affiliated teaching hospital. PATIENT: Mechanically ventilated woman with status asthmaticus and acute respiratory failure. INTERVENTION: Observations of airway pressure and flow tracings before and after bronchoscopic inspection and airway lavage. MAIN RESULTS: Four newly observed signs were recorded that may serve to identify occult central airway mucus plugging in the ventilated asthmatic patient.
Publication Types:
PMID: 16374178 [PubMed - indexed for MEDLINE]
-
Elevated growth-arrest-specific protein 6 plasma levels in patients with severe sepsis.
Borgel D, Clauser S, Bornstain C, Bieche I, Bissery A, Remones V, Fagon JY, Aiach M, Diehl JL.
Inserm U428, Service d'Hematologie Biologique A, Hopital Europeen Georges Pompidou, Paris, France. delphine.borgel@univ-paris5.fr
OBJECTIVE: Growth-arrest-specific protein 6 (Gas6), an intracellular protein released by apoptotic cells, has been detected in normal plasma. As the Gas6 system has been implicated in mouse susceptibility to sepsis, and as leukocyte apoptosis is thought to play a major role in the physiopathology of human severe sepsis, we studied Gas6 plasma levels and possibly related variables in patients with severe sepsis. DESIGN: Matched case-control study. SETTING: Adult intensive care unit in a university hospital. PATIENTS: Thirty patients with severe sepsis, 30 patients with organ failure not related to infection, and 30 healthy subjects matched for age and gender. INTERVENTIONS: Blood draw. MEASUREMENTS AND MAIN RESULTS: Gas6 plasma levels were quantified using enzyme-linked immunosorbent assay. Whole-blood gas6 messenger RNA levels were measured by quantitative real-time polymerase chain reaction. Gas6 plasma levels were elevated (110 ng/mL [75, 139]; median values [interquartile range]) in severe sepsis patients compared with organ failure patients (85 ng/mL [56, 101]) and healthy subjects (54 ng/mL [49, 68]). In patients with severe sepsis, this increase correlated with the Acute Physiology and Chronic Health Evaluation II severity score, the organ failure Organ Dysfunction and Infection (ODIN) score, and the existence of a septic shock. Gas6 messenger RNA levels were increased in patients with severe sepsis and correlated specifically with the monocyte count. CONCLUSIONS: In severe sepsis, the recently described anti-apoptotic protein Gas6 was found at high levels in plasma and correlated well with the degree of organ dysfunction.
PMID: 16374177 [PubMed - indexed for MEDLINE]
-
Comment in:
Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills.
Steadman RH, Coates WC, Huang YM, Matevosian R, Larmon BR, McCullough L, Ariel D.
Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
OBJECTIVE: To determine whether full-scale simulation (SIM) is superior to interactive problem-based learning (PBL) for teaching medical students acute care assessment and management skills. DESIGN: Randomized controlled trial. SETTING: Simulation center at a U.S. medical school. SUBJECTS: Thirty-one fourth-year medical students in a week-long acute care course. INTERVENTIONS: After institutional review board approval and informed consent, eligible students were randomized to either the SIM or PBL group. On day 1, all subjects underwent a simulator-based initial assessment designed to evaluate their critical care skills. Two blinded investigators assessed each student using a standardized checklist. Subsequently, the PBL group learned about dyspnea in a standard PBL format. The SIM group learned about dyspnea using the simulator. To equalize simulator education time, the PBL group learned about acute abdominal pain on the simulator, whereas the SIM group used the PBL format. On day 5, each student was tested on a unique dyspnea scenario. MEASUREMENTS AND MAIN RESULTS: Mean initial assessment and final assessment checklist scores and their change for the SIM and PBL groups were compared using the Student's t-test. A p < .05 was considered significant. The SIM and PBL groups had similar mean (PBL 0.44, SIM 0.47, p = .64) initial assessment scores (earned score divided by maximum score) and were deemed equivalent. The SIM group performed better than the PBL group on the final assessment (mean, PBL 0.53, SIM 0.72, p < .0001). When each student's change in score (percent correct on final assessment minus percent correct on the initial assessment) was compared, SIM group students performed better (mean improvement, SIM 25 percentage points vs. PBL 8 percentage points, p < .04) CONCLUSIONS: For fourth-year medical students, simulation-based learning was superior to problem-based learning for the acquisition of critical assessment and management skills.
Publication Types:
PMID: 16374169 [PubMed - indexed for MEDLINE]
-
Comment in:
Current issues in critical care of the human immunodeficiency virus-infected patient.
Morris A, Masur H, Huang L.
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
OBJECTIVE: To provide current information on the epidemiology of human immunodeficiency virus (HIV)-infected patients admitted to the intensive care unit during the era of combination antiretroviral therapy and to review issues related to the administration of antiretroviral therapy that are relevant to the intensivist. DESIGN: Review of literature related to intensive care of HIV-infected patients. RESULTS: Overall mortality of HIV-infected patients in the intensive care unit has decreased in the era of combination antiretroviral therapy, and patients are more commonly admitted with non-HIV-related illnesses. Use of antiretroviral therapy in the intensive care unit is difficult but may be associated with improved outcomes. CONCLUSIONS: HIV-infected patients are less likely to be admitted to the intensive care unit with opportunistic infections but more likely to be admitted with problems unrelated to HIV infection or with conditions related to antiretroviral therapy. With current management strategies, more patients survive intensive care unit admission. Intensivists need to be familiar with antiretroviral therapy to recognize life-threatening toxicities unique to these drugs; to avoid drug interactions, which are extremely common and potentially life-threatening; and to avoid enhancing HIV drug resistance, an occurrence that could have devastating consequences for the patient following intensive care unit discharge.
Publication Types:
PMID: 16374154 [PubMed - indexed for MEDLINE]
-
Comment in:
The effect of age on the development and outcome of adult sepsis.
Martin GS, Mannino DM, Moss M.
Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Emory University, USA.
OBJECTIVE: Sepsis is an increasingly common and lethal medical condition that occurs in people of all ages. The influence of age on sepsis risk and outcome is incompletely understood. We sought to determine the independent effect of age on the incidence, severity, and outcome of adult sepsis. DESIGN: Longitudinal observational study using national hospital discharge data. SETTING: Approximately 500 geographically separated nonfederal acute care hospitals in the United States. PATIENTS: Patients were 10,422,301 adult sepsis patients hospitalized over 24 yrs, from 1979 to 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Incident sepsis cases were age adjusted and characterized by demographics, sources and types of infection, comorbid medical conditions, and hospital discharge status. Elderly patients (> or = 65 yrs of age) accounted for 12% of the U.S. population and 64.9% of sepsis cases, yielding a relative risk of 13.1 compared with younger patients (95% confidence interval, 12.6-13.6). Elderly patients were more likely to have Gram-negative infections, particularly in association with pneumonia (relative risk, 1.66; 95% confidence interval, 1.63-1.69) and to have comorbid medical conditions (relative risk, 1.99; 95% confidence interval, 1.92-2.06). Case-fatality rates increased linearly by age; age was an independent predictor of mortality in an adjusted multivariable regression (odds ratio, 2.26; 95% confidence interval, 2.17-2.36). Elderly sepsis patients died earlier during hospitalization, and elderly survivors were more likely to be discharged to a nonacute health care facility. CONCLUSIONS: The incidence of sepsis is disproportionately increased in elderly adults, and age is an independent predictor of mortality. Compared with younger sepsis patients, elderly nonsurvivors of sepsis die earlier during hospitalization and elderly survivors more frequently require skilled nursing or rehabilitative care after hospitalization. These findings have implications for patient care and health care resource prioritization and provide insights for expanded scientific investigations and potential patient interventions.
PMID: 16374151 [PubMed - indexed for MEDLINE]
-
X-ray crystallography and structural biology.
Yaffe MB.
Department of Biology, Center for Cancer Research, Cambridge, MA, USA.
Publication Types:
PMID: 16340415 [PubMed - indexed for MEDLINE]
-
Molecular biology for today's practicing intensivist.
Angus DC, Fink MP.
Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
PMID: 16340403 [PubMed - indexed for MEDLINE]
-
Acute care surgery.
Bosse MJ, Tornetta P, Sanders R, Swiontkowski MF, Russell TA.
Publication Types:
PMID: 16374305 [PubMed - indexed for MEDLINE]
| Display Show |
|
|