Distribution by Scientific Domains
Distribution within Medical Sciences

Kinds of ICU

  • adult icu
  • general icu
  • surgical icu

  • Terms modified by ICU

  • icu admission
  • icu nurse
  • icu patient
  • icu stay

  • Selected Abstracts

    Rhabdomyolysis and brain ischemic stroke in a heroin-dependent male under methadone maintenance therapy

    W.-Y. Hsu
    Objective:, There are several complications associated with heroin abuse, some of which are life-threatening. Methadone may aggravate this problem. Method:, A clinical case description. Results:, A 33-year-old man presented with rhabdomyolysis and cerebral ischemic stroke after intravenous heroin. He had used heroin since age 20, and had used 150 mg methadone daily for 6 months. He was found unconsciousness at home and was sent to our hospital. In the ER, his opiate level was 4497 ng/ml. In the ICU, we found rhabdomyolysis, acute renal failure and acute respiratory failure. After transfer to an internal ward, we noted aphasia and weakness of his left limbs. After MRI, we found cerebral ischemic infarction. Conclusion:, Those using methadone and heroin simultaneously may increase risk of rhabdomyolysis and ischemic stroke. Patients under methadone maintenance therapy should be warned regarding these serious adverse events. Hypotheses of heroin-related rhabdomyolysis and stroke in heroin abusers are discussed. [source]

    Mechanical ventilation for respiratory failure in children with severe neurological impairment: is it futile medical treatment?

    Aim, To assess outcome for children with severe neurological impairment receiving invasive mechanical ventilation for respiratory failure. Method, Medical charts for all such children treated in our intensive care unit (ICU) between January 2003 and July 2008 were reviewed. Outcomes were compared with those for children with moderate neurological impairment. Results, Twenty-two children with severe neurological impairment were included (nine females, 13 males; median age 7y 10mo; range 4mo,17y). The median duration of mechanical ventilation was 16 days. Six children had an uneventful 1-year survival, the others required reintubation or readmission to the ICU, or died. Eleven children were still alive 1 year after discharge from the ICU. Nine patients died of respiratory failure. None of the children in the severe group died of a heart defect. Eleven children with moderate neurological impairment were included (eight females, three males; median age 1y 1mo, range 4mo,13y). Four children had an uneventful 1-year survival. Eight children were still alive 1 year after discharge from the ICU. Two of the three non-survivors died of their heart defects. Interpretation, Mechanical ventilation for respiratory failure in children with severe neurological impairment is complex and associated with limited survival. However, it cannot be regarded as futile medical treatment. Further studies are urgently needed for the rational guidance of clinical decision-making. [source]

    Potential use of insulin as an anti-inflammatory drug

    Paresh Dandona
    Abstract Acute hyperglycemia worsens morbidity and mortality in critically ill patients. The control of hyperglycemia with insulin improves clinical outcomes in patients with a stay of more than 3,5 days in the intensive care unit (ICU) and in coronary artery bypass graft (CABG) patients. However, clinical benefits of insulin infusion have not been seen consistently in patients with acute coronary syndromes. Since all previous studies in the ICU have centered on the normalization of glycemia, we still do not know whether insulin exerts beneficial effects over and above those observed with reduction of blood glucose concentrations. The regimens used in acute coronary syndromes infuse fixed doses of insulin with high rates of glucose and are usually associated with hyperglycemia; this may neutralize the beneficial effects of insulin. In this article, we discuss data demonstrating an anti-inflammatory effect of insulin and a pro-inflammatory effect of glucose. We provide a mechanistic justification for the benefits of maintaining euglycemia with insulin infusions in the hospitalized patients. To investigate the clinical benefits of the anti-inflammatory effects of insulin, we also suggest further investigations directed toward optimization of insulin infusion regimens to determine whether restoration of glucose levels toward normal with higher infusion rates and concentrations of insulin will lead to further improvement in outcomes in the critical care and acute coronary syndromes. Drug Dev Res 69:101,110, 2008 © 2008 Wiley-Liss, Inc. [source]

    Trauma Team Activation Criteria as Predictors of Patient Disposition from the Emergency Department

    Michael A. Kohn MD
    Many trauma centers use mainly physiologic, first-tier criteria and mechanism-related, second-tier criteria to determine whether and at what level to activate a multidisciplinary trauma team in response to an out-of-hospital call. Some of these criteria result in a large number of unnecessary team activations while identifying only a few additional patients who require immediate operative intervention. Objectives: To separately evaluate the incremental predictive value of individual first-tier and second-tier trauma team activation criteria for severe injury as reflected by patient disposition from the emergency department (ED). Methods: This was a prospective cohort study in which activation criteria were collected prospectively on all adult patients for whom the trauma team was activated during a five-month period at an urban, Level 1 trauma center. Severe injury disposition ("appropriate" team activation) was defined as immediate operative intervention, admission to the intensive care unit (ICU), or death in the ED. Data analysis consisted of recursive partitioning and multiple logistic regression. Results: Of the 305 activations for the mainly physiologic first-tier criteria, 157 (51.5%) resulted in severe injury disposition. The first-tier criterion that caused the greatest increase in "inappropriate" activations for the lowest increase in "appropriate" activations was "age > 65." Of the 34 additional activations due to this criterion, seven (20.6%) resulted in severe injury disposition. Of the 700 activations for second-tier, mechanism-related criteria, 54 (7.7%) resulted in ICU or operating room admissions, and none resulted in ED death. The four least predictive second-tier criteria were "motorcycle crash with separation of rider,""pedestrian hit by motor vehicle,""motor vehicle crash with rollover," and "motor vehicle crash with death of occupant." Of the 452 activations for these four criteria, only 18 (4.0%) resulted in ICU or operating room admission. Conclusions: The four least predictive second-tier, mechanism-related criteria added little sensitivity to the trauma team activation rule at the cost of substantially decreased specificity, and they should be modified or eliminated. The first-tier, mainly physiologic criteria were all useful in predicting the need for an immediate multidisciplinary response. If increased specificity of the first-tier criteria is desired, the first criterion to eliminate is "age > 65." [source]

    Association between Insurance Status and Admission Rate for Patients Evaluated in the Emergency Department

    Jennifer Prah Ruger PhD
    Abstract Objectives: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. Methods: This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for underinsured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. Results: Compared with the other insured group, underinsured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed underinsured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Underinsured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. Conclusions: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference. [source]

    Heightened levels of circulating 20S proteasome in critically ill patients

    G. A. Roth
    Abstract Background, Recently, circulating proteasome core particles (20S proteasome) have been suggested as a marker of cell damage and immunological activity in autoimmune diseases. Aberrant leucocyte activation and increased lymphocyte apoptosis with consecutive T-cell unresponsiveness is deemed to play a pivotal role in the sepsis syndrome. Moreover sepsis-induced muscle proteolysis mainly reflects ubiqutin proteasome-dependent protein degradation. We therefore sought to investigate serum levels of 20S proteasome in critical ill patients. Material and methods, Case,control-study at a university hospital intensive care unit; 15 patients recruited within 24,48 h of diagnosis of sepsis, 13 trauma patients recruited within 24 h of admission to the ICU, a control group of 15 patients who underwent abdominal surgery, and 15 healthy volunteers. ELISA was used to measure the concentration of 20S proteasome in the sera of the patients and controls. Data are given as mean ± SEM. Mann,Whitney U -test was used to calculate significance and a P -value of 0·05 was considered to be statistically significant. Results, Marked increase of 20S proteasome was detected in the sera of septic patients (33 551 ± 10 034 ng mL,1) as well as in trauma patients (29 669 ± 5750 ng mL,1). In contrast, significantly lower concentrations were found in the abdominal surgery group (4661 ± 1767 ng mL,1) and in the healthy control population (2157 ± 273 ng mL,1). Conclusion, Detection of 20S proteasome may represent a novel marker of immunological activity and muscle degradation in sepsis and trauma patients, and may be useful in monitoring the clinical effect of proteasome-inhibitors. [source]

    Altered pharmacology in the intensive care unit patient

    Giovanni Zagli
    Abstract Critically ill patients, not infrequently present alterations of physiological parameters that determine the success/failure of therapeutic interventions as well as the final outcome. Sepsis and polytrauma are two of the most common and complex syndromes occurring in Intensive Care Unit (ICU) and affect drug absorption, disposition, metabolism and elimination. Pharmacological management of ICU patients requires consideration of the unique pharmacokinetics associated with these clinical conditions and the likely occurrence of drug interaction. Rational adjustment in drug choice and dosing contributes to the appropriateness of treatment of those patients. [source]

    Pharmacological treatment of sepsis

    Armand R.J. Girbes
    Abstract The incidence of sepsis, the combination of a systemic inflammatory response syndrome and documented infection, is as high as up to 95 cases per 100,000 people per year. The understanding of the pathophysiology of sepsis has much increased over the last 20 years. However, sepsis combined with shock is still associated with a high mortality rate varying from 35 to 55%. Causative treatment, source control and antibiotics started as soon as possible, are the cornerstone of therapy in combination with symptomatic treatment in the ICU. The pharmacological interventions, including fluid resuscitation, vasoactive drugs and adjunctive drugs such as steroids, activated protein C are discussed. The possible beneficial role of strict glucose control is also addressed. Since many drug intervention studies were negative, lessons should be learned from earlier experiences for future trials. Source control and level of intensive care should be eliminated as confounders. [source]

    Prospective evaluation of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) in a surgical intensive care unit: Technique and results of the Fantoni tracheostomy

    Ralf Konopke MD
    Abstract Background. Controversy surrounds the safety and practicality of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) compared with other percutaneous methods. Methods. We used the Fantoni tracheostomy for 245 patients in our intensive care unit (ICU) over a period of 3 years 6 months and conducted a prospective analysis. Results. We are able to report a low incidence of complications (1.2%) with the Fantoni procedure. Advantages of the method are reduced tissue trauma and optimal adaptation of the stoma to the cannula, leading to less stomal bleeding and fewer infectious complications. We observed no procedure-related mortality. Under mandatory bronchoscopic control, proper puncture location and cannula placement are ensured, which prevents tracheal wall injury and paratracheal placement of the cannula. Conclusions. Our experience shows that the major advantage of the use of the Fantoni tracheostomy is the retrograde dilatation of the stoma, which prevents serious complications compared with other techniques. © 2005 Wiley Periodicals, Inc. Head Neck28: 355,359, 2006 [source]

    Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of Life

    Amber E. Barnato
    Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. Data Source. The 1985,1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [source]

    How Do Mothers Feel About Their Very Low Birth Weight Infants?

    Development of a New Measure
    The early relationship between a mother and her very low birth weight (VLBW; <1.5 kg) infant may be difficult to evaluate. Therefore, we aimed to develop a useful and practical method to describe a mother's early relationship with her VLBW infant. Mothers (mean age=27 years, 46% married) of 119 singleton VLBW infants (mean BW=1,056 g, mean GA=28 weeks) admitted to the neonatal ICU at Rainbow Babies and Children's Hospital completed a novel questionnaire regarding their feelings about their infant at 3 weeks' postnatal age, and at 35 weeks', 40 weeks' (term), and 4 months' postmenstrual ages. Factor analysis of initial interview data was used to construct subscales to measure unique domains hypothesized to underpin the beginning maternal,infant relationship. Three subscales were identified: (a) The Worry subscale focuses on the mother's concerns about her infant's current medical condition and future development, (b) the Enjoyment subscale examines the mother's positive feelings about and responsiveness to her infant, and (c) the Separation Anxiety subscale examines the mother's mental anxiety about being physically separated from her infant. Statistical and clinical validation of the subscales produced positive supporting evidence that the subscales are a meaningful measure of the mother,infant relationship. We have developed a unique and practical measure for describing the early mother,VLBW infant relationship. [source]

    An audit of the use of granulocyte colony-stimulating factor in septic shock

    D. P. Stephens
    Abstract Background:,Granulocyte colony-stimulating factor (G-CSF) stimulates the production of neutrophils and modulates the function and activity of developing and mature neutrophils. In septic shock, the immune system can be considered one of the failing organ systems.G-CSF improves immune function and may be a useful adjunctive therapy in patients with septic shock. Aim:,To evaluate the introduction of G-CSF as an adjunct to our standard treatment for community-acquired septic shock. Methods:,We performed a prospective data collection and analysis to determine whether the addition of G-CSF to our standard treatment for community-acquired septic shock was associated with improved hospital outcome, compared with an historical cohort ofsimilar patients. We included all patients admitted to the Intensive Care Unit (ICU) with community-acquired septic shock between December 1998 and March 2000. Patients received 300 µg G-CSF intravenously daily for 10 days in addition to ourstandard treatment for community-acquired septic shock. G-CSF was discontinued early if the patient was discharged from ICU before10 days or if the absolute neutrophil count exceeded 75 × 106/mL. Results:,A total of 36 patients with community-acquired septic shock, an average Apache 2 score of 26.7, and a predictedmortality of 0.79, were treated with G-CSF from December 1998 to March 2000. Hospital mortality was 31% compared with an historical cohort of 11 similar patients with a hospital mortality of 73% (P = 0.018). In the subgroup of patients with melioidosis septic shock, the hospital survival improved from 5% to 100% (P < 0.0001). No significant adverse events occurred as a result of the administration of G-CSF. Conclusion:,G-CSF is a safe adjunctive therapy in community-acquired septic shock and may be associated with improved outcome. The use of G-CSF in septic shock should undergo further investigation to define subgroups of patients who may benefit from G-CSF. The use of G-CSF in patients with septic shock due to Burkholderia pseudomallei is recommended. (Intern Med J 2002; 32: 143,148) [source]

    Early predictability of the need for tracheotomy after admission to ICU: an observational study

    D. P. VEELO
    Background: The goal of this study was to explore the ability of professional judgment to predict the need for tracheotomy early among intensive care unit (ICU) patients. Methods: Prospective study using daily questionnaires among ICU physicians in a mixed medical,surgical ICU. The prediction of tracheotomy was by a visual analogue scale (VAS, from 1 to 10, with 1 representing ,absolutely no need for tracheotomy' and 10 representing ,pertinent need for tracheotomy') during ICU stay until tracheal extubation or tracheotomy. For the purpose of this study, a VAS score ,8 was considered a positive prediction for tracheotomy. Results: A total of 476 questionnaires were retrieved for 75 patients (6.4±5.2 questionnaires per patient), of which 11 patients finally proceeded with a tracheostomy. At first assessment (mean of 2.4±0.8 days after ICU admittance), ICU physicians predicted the need for tracheotomy 3.0 (2.0,6.0) higher VAS points for patients who were finally tracheotomized (P<0.01). Patients with a positive prediction had a 5.4 (1.2,24.1) higher chance of receiving tracheotomy (P=0.03). Considering the median VAS score over a maximum of 10 days before tracheotomy, ICU physicians scored tracheotomized patients significantly higher from day 8 onwards. When comparing ICU physicians, fellows and residents separately, only staff physicians scored a significant difference in the VAS score (P<0.05). Conclusion: ICU physicians are able to differentiate between patients in need for tracheotomy from those who do not, within 2 days from admittance. The closer the time to the actual intervention, the better the physicians are able to predict this decision. [source]

    Early predictors of morbidity and mortality in trauma patients treated in the intensive care unit

    Background: We investigated the incidence and severity of post-injury morbidity and mortality in intensive care unit (ICU)-treated trauma patients. We also identified risk factors in the early phase after injury that predicted the later development of complications. Methods: A prospective observational cohort study design was used. One hundred and sixty-four adult patients admitted to the ICU for more than 24 h were included during a 21-month period. The incidence and severity of morbidity such as multiple organ failure (MOF), acute lung injury (ALI), severe sepsis and 30-day post-injury mortality were calculated and risk factors were analyzed with uni- and multivariable logistic regression analysis. Results: The median age was 40 years, the injury severity score was 24, the new injury severity score was 29, the acute physiology and chronic health evaluation II score was 15, sequential organ failure assessment maximum was 7 and ICU length of stay was 3.1 days. The incidences of post-injury MOF were 40.2%, ALI 25.6%, severe sepsis 31.1% and 30-day mortality 10.4%. The independent risk factors differed to some extent between the outcome parameters. Age, severity of injury, significant head injury and massive transfusion were independent risk factors for several outcome parameters. Positive blood alcohol was only a predictor of MOF, whereas prolonged rescue time only predicted death. Unexpectedly, injury severity was not an independent risk factor for mortality. Conclusions: Although the incidence of morbidity was considerable, mortality was relatively low. Early post-injury risk factors that predicted later development of complications differed between morbidity and mortality. [source]

    Prospective cohort study comparing sequential organ failure assessment and acute physiology, age, chronic health evaluation III scoring systems for hospital mortality prediction in critically ill cirrhotic patients

    Y-C Chen
    Summary The aim of the study was to evaluate the usefulness of sequential organ failure assessment (SOFA) and acute physiology, age, chronic health evaluation III (APACHE III) scoring systems obtained on the first day of intensive care unit (ICU) admission in predicting hospital mortality in critically ill cirrhotic patients. The study enrolled 102 cirrhotic patients consecutively admitted to ICU during a 1-year period. Twenty-five demographic, clinical and laboratory variables were analysed as predicators of survival. Information considered necessary to calculate the Child,Pugh, SOFA and APACHE III scores on the first day of ICU admission was also gathered. Overall hospital mortality was 68.6%. Multiple logistic regression analysis revealed that mean arterial pressure, SOFA and APACHE III scores were significantly related to prognosis. Goodness-of-fit was good for the SOFA and APACHE III models. Both predictive models displayed a similar degree of the best Youden index (0.68) and overall correctness (84%) of prediction. The SOFA and APACHE III models displayed good areas under the receiver,operating characteristic curve (0.917 ± 0.028 and 0.912 ± 0.029, respectively). Finally, a strong and significant positive correlation exists between SOFA and APACHE III scores for individual patients (r2 = 0.628, p < 0.001). This investigation confirms the grave prognosis for cirrhotic patients admitted to ICU. Both SOFA and APACHE III scores are excellent tools to predict the hospital mortality in critically ill cirrhotic patients. The overall predictive accuracy of SOFA and APACHE III is superior to that of Child,Pugh system. The role of these scoring systems in describing the dynamic aspects of clinical courses and allocating ICU resources needs to be clarified. [source]

    Acute kidney injury with renal replacement therapy in trauma patients

    Background: Acute kidney injury (AKI) with renal replacement therapy (RRT) is rare in trauma patients. The primary aim of the study was to assess incidence, mortality and chronic RRT dependency in this patient group. Methods: Adult trauma patients with AKI receiving RRT at a regional trauma referral center over a 12-year period were retrospectively reviewed. Results: Population-based incidence of post-traumatic AKI with RRT was 1.8 persons per million inhabitants per year (p.p.m./year) [95% confidence the interval (CI) 1.5,2.1 p.p.m./year]. In trauma patients admitted to hospital, incidence was 0.5, (95% CI 0.3,0.7,) of those treated in intensive care unit (ICU), it was 8.3% (95% CI 5.9,10.8%). The median age was 46 years. Odds ratio (OR) for post-traumatic AKI requiring RRT was higher in males than in females in general population (OR 5.6, 95% CI 2.2,14.0), and in trauma patients admitted to hospital (OR 4.4, 95% CI 1.9,10.3) and ICU (OR 4.5, 95% CI 1.9,10.7). The in-hospital mortality rate was 24% (95% CI 11,37%), 3-month mortality 36% (95% CI 21,51%) and 1-year mortality 40% (95% CI 25,55%). Age was a risk factor for death after 1 year, with 57% (95% CI 7,109%) increased risk for each 10 years added. None of the survivors was dialysis-dependent 3 months or 1 year after trauma. Conclusion: AKI in trauma patients requiring RRT was rare in this single-center study. More males than females were affected. Mortality was modest, and renal recovery was excellent as none of the survivors became dependent on chronic RRT. [source]

    Continuous glucose monitoring by intravenous microdialysis

    Background: The conflicting results from studies over tight glucose control in intensive care unit (ICU) patients ask for a continuous on-line real-time glucose monitoring in future. Here, intravenous microdialysis was tested in ICU patients and healthy volunteers. Primary aims were technical feasibility and accuracy. Methods: A microdialysis catheter was inserted into a peripheral vein. ICU patients (n=10) were studied for up to 5 days. Healthy volunteers (n=6) were studied on one occasion. Recordings were monitored during 70 min each 24-h period to allow for an estimate of variability over time. Microdialysis glucose and lactate were compared with plasma glucose and whole blood lactate. Results are presented as medians (quartiles) of the differences between microdialysis and plasma concentrations over each of the 70-min recording periods. Results: Out of the included ICU patients, no exclusions or early terminations were due to failure of the microdialysis catheter. The concordance was highly variable. The difference of medians over the recording periods differed by ,34% (,40, ,16) in patients and ,22% (,31, ,15) for the volunteers. In contrast, the overall variability within the individual measurement periods was low. Conclusion: Technical feasibility was good, but the accuracy was not sufficient and the variability between the recording periods was high without calibrations. The non-availability of suitable peripheral veins was a problem in many patients screened but not included in the study. Intravenous microdialysis to obtain continuous on-line real-time glucose monitoring is technically feasible, but accuracy needs to be improved. [source]

    Effect of epidural dexmedetomidine on intraoperative awareness and post-operative pain after one-lung ventilation

    Background: During combined general and regional anaesthesia, it is difficult to use autonomic signs to assess whether wakefulness is suppressed adequately. We compared the effects of a dexmedetomidine,bupivacaine mixture with plain bupivacaine for thoracic epidural anaesthesia on intraoperative awareness and analgesic benefits, when combined with superficial isoflurane anaesthesia (<0.05 maximum alveolar concentration) in patients undergoing thoracic surgery with one-lung ventilation (OLV). Methods: Fifty adult male patients were randomly assigned to receive either epidural dexmedetomidine 1 ,g/kg with bupivacaine 0.5% (group D) or bupivacaine 0.5% alone (group B) after induction of general anaesthesia. Gasometric, haemodynamic and bispectral index values were recorded. Post-operative verbal rating score for pain and observer's assessment of alertness/sedation scale were determined by a blinded observer. Results: Dexmedetomidine reduced the use of supplementary fentanyl during surgery. Patients in group B consumed more analgesics and had higher pain scores after operation than patients of group D. The level of sedation was similar between the two groups in the ICU. Two patients (8%) in group B reported possible intraoperative awareness. There was a limited decrease in PaO2 at OLV in group D compared with group B (P<0.05). Conclusion: In thoracic surgery with OLV, the use of epidural dexmedetomidine decreases the anaesthetic requirements significantly, prevents awareness during anaesthesia and improves intraoperative oxygenation and post-operative analgesia. [source]

    The Richmond Agitation-Sedation Scale: translation and reliability testing in a Swedish intensive care unit

    Background: Awareness about adequate sedation in mechanically ventilated patients has increased in recent years. The use of a sedation scale to continually evaluate the patient's response to sedation may promote earlier extubation and may subsequently have a positive effect on the length of stay in the intensive care unit (ICU). The Richmond Agitation-Sedation Scale (RASS) provides 10 well-defined levels divided into two different segments, including criteria for levels of sedation and agitation. Previous studies of the RASS have shown it to have strong reliability and validity. The aim of this study was to translate the RASS into Swedish and to test the inter-rater reliability of the scale in a Swedish ICU. Methods: A translation of the RASS from English into Swedish was carried out, including back-translation, critical review and pilot testing. The inter-rater reliability testing was conducted in a general ICU at a university hospital in the south of Sweden, including 15 patients mechanically ventilated and sedated. Forty in-pair assessments using the Swedish version of the RASS were performed and the inter-rater reliability was tested using weighted , statistics (linear weighting). Result: The translation of the RASS was successful and the Swedish version was found to be satisfactory and applicable in the ICU. When tested for inter-rater reliability, the weighed , value was 0.86. Conclusion: This study indicates that the Swedish version of the RASS is applicable with good inter-rater reliability, suggesting that the RASS can be useful for sedation assessment of patients mechanically ventilated in Swedish general ICUs. [source]

    Long-term effect of the ICU-diary concept on quality of life after critical illness

    Background: Critically ill patients often spend time in the intensive care unit (ICU) either unconscious or sedated. On recovery, they are often in a state of confusion with memory loss that may be associated with a longstanding reduction in health-related quality of life (QoL). We hypothesised that the ICU-diary concept could improve their QoL by filling in their memory gaps. Methods: A non-randomised, prospective study in a non-academic eight-bedded general ICU. A group of patients (n=38) were selected to receive the ICU-diary concept (keeping a diary with photos while on the ICU plus a follow-up meeting) when a long and complicated course was expected. Health-related QoL at 6, 12, 24 and 36 months was compared with a group that did not receive the ICU-diary (n=224). The Medical Outcomes Study 36-Item Short-Form (SF-36) was used to measure health-related QoL. Multiple regression models adjusted for age, sex, illness severity, pre-existing disease and diagnostic category was used to analyse the effects of the ICU-diary concept at 6 months, and changes over time were analysed using repeated measures MANOVA. Results: Crude and adjusted scores for two dimensions of SF-36 (general health and vitality) and the physical component summary score were significantly higher at 6 months in the ICU-diary group (P<0.05) and some of the effects remained during the 3-year follow-up period (P<0.05). Conclusion: The ICU-diary concept was associated with improved health-related QoL during the 3-year follow-up period after a critical illness. The effect of this intervention needs to be confirmed in a larger randomised study. [source]

    Nursing Diagnoses in a Brazilian Intensive Care Unit

    Amália De Fátima Lucena
    PURPOSE.,To identify the nursing diagnoses and their most frequent related factors or risk factors in patients admitted to an intensive care unit (ICU). METHOD.,Descriptive cross-sectional study with information from 991 admissions to an ICU during a 6-month period. FINDINGS.,Sixteen nursing diagnoses resulting from hospitalization were most frequently identified; six had percentages greater than 40% with 29 related/risk factors. The resulting averages were 6.9 diagnoses per hospitalization and 1.2 related/risk factors per nursing diagnoses. CONCLUSIONS.,The nursing diagnoses identified seemed to be common to the clinical practice of nursing and their fundamental related/risk factors to precise clinical judgment, thus providing a basis for interventions for a desired outcome. PRACTICE IMPLICATIONS.,The findings have contributed to the development of the standardized nursing language usage in Brazilian nursing practices. Diagnósticos de Enfermagem em uma Unidade de Terapia Intensiva Brasileira OBJETIVO.,Identificar os diagnósticos de enfermagem e os seus fatores relacionados/risco mais freqüentemente estabelecidos aos pacientes internados numa unidade de terapia intensiva (UTI). MÉTODO.,Estudo descritivo, transversal, com informações de 991 admissões numa UTI, durante seis meses. RESULTADOS.,Dezesseis diagnósticos de enfermagem foram mais freqüentes, seis deles com percentuais acima de 40% por internação e com 29 fatores relacionados ou de risco. As médias foram de 6,9 diagnósticos de enfermagem por internação e 1,2 fatores relacionados ou de risco por diagnóstico de enfermagem. CONCLUSÕES.,Os diagnósticos de enfermagem identificados parecem ser comuns à prática clínica de enfermagem e os seus fatores relacionados ou de risco fundamentais ao julgamento clínico preciso, que subsidia à escolha da intervenção para um resultado esperado. IMPLICAÇÕES PARA A PRÁTICA.,Os resultados têm colaborado para o desenvolvimento do uso da linguagem padronizada de enfermagem no Brasil. [source]

    Nursing-Sensitive Outcome Implementation and Reliability Testing in a Tertiary Care Setting

    Julia G. Behrenbeck
    PURPOSE To describe the NOC outcomes most relevant for specialty nursing practice and in selected field sites representing the continuum of care; to assess the adequacy of measures (reliability, validity, sensitivity, specificity, practicality); and to describe the linkages among nursing diagnoses, interventions, and outcomes in clinical decision making. METHODS Data were collected on 434 patients during the 12-month data collection period at a tertiary care center: cardiac surgery intensive care (n= 76), cardiac transplant unit (n= 153), and medical unit (n= 205). Medical diagnoses of patients on the two cardiac units were related to cardiac disease. Medical diagnoses of patients on the medical unit were extremely varied (ranging from e.g., gout to pneumonia). Data were collected on 65 separate outcome labels for a total of 633 ratings. FINDINGS In the cardiac transplant ICU, data were collected on 42 outcomes: 30 had an average interrater reliability of ,85%, and 16 had an absolute agreement interrater reliability of ,85%. In the cardiac surgery ICU, data were collected on 30 outcomes: 25 had an average interrater reliabilty of ,85%, 6 had an absolute agreement interrater of ,85%. In the medical unit, data were collected on 45 outcomes: 41 had an average interrater reliability of ,85%, 14 had an absolute agreement interrater reliability of ,85%. Four outcomes have been implemented into the documentation system for all patients: Tissue Integrity: Skin and Mucous Membranes, Mobility Level, Knowledge: Disease Process, and Coping. CONCLUSIONS Overall, nursing staff were very positive about having the opportunity to participate in nursing research. Staff were able to think about the relative status of their patient and how nursing care contributes to the patient's recovery. They appreciated the opportunity to discuss this with a colleague during the interrater exercise. Increased familiarity with NOC allows staff members to determine which outcomes comprise core nursing-sensitive outcomes for their clinical setting. [source]

    A Computerized Nursing Process Support System in Brazil

    Maria da Graça Oliveira Crossetti
    BACKGROUND Hospital de Clinicas de Porto Alegre introduced the nursing process model as the basis for nursing practice at the hospital more than 20 years ago. A computerized nursing order system based on nursing diagnoses was introduced. The strategies used in the development of the system included establishment of Nursing Diagnosis Work Groups in 1998; systematic analysis of nursing processes based on the work of existing studies, the NANDA taxonomy in 1999; development and implementation of a data collection instrument to analyze the nursing diagnosis process; training of all nursing staff during 1999,2000; meetings between analysts and nursing staff to articulate the nursing process needs the system would be required to support; pilot implementation of the computerized nursing process system in the ICU in February 2000; and hospital-wide implementation in December 2000. The system supports nursing diagnoses and orders. It was developed in-house by the information systems group at the hospital and is implemented as an Oracle database accessed in client server mode over a Windows NT-based Ethernet network. The system is part of the hospital's larger clinical information management system. MAIN CONTENT POINTS The patient care module includes medical orders and nursing orders. On entering the nursing orders module, the user selects a patient and the system presents a list all current orders completed and pending. These orders can be examined, updated, and reprinted, and new daily nursing orders can also be input at this time. The "new order" screen provides the user with any previous orders to ensure consistency in nursing care. New nursing orders are prepared based on the patient history, physical exam, and daily evaluations. Required interventions are identified based on changes in the patient's "basic human needs." This process can be realized through two distinct paths through the nursing care module: one associated with diagnoses and the other with signs and symptoms. A nurse with more clinical experience and knowledge of diagnostic reasoning will opt to develop orders based on diagnoses. After the diagnosis and associated etiology is input, the system generates a list of possible interventions for selection. The duration and frequency of the intervention can then be specified and the order individualized to a patient's particular needs. Less experienced nurses and students will develop nursing orders based on a patient's signs and symptoms. The system generates a list of diagnoses, etiology, and associated basic human needs in response to the signs and symptoms input. The nurse selects the appropriate diagnoses and etiology and the system generates the list of nursing intervention options. Nurses following either path are required to confirm their orders. They then have the option of developing other orders for the same patient until all that patient's basic human needs have been addressed. The orders can be printed but also remain in the system for nursing staff to implement. CONCLUSIONS The application of systematic, evidence-based methods in nursing care results in improved quality of service that conforms to individual patients' basic human needs. [source]

    Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosis

    J. HOLM
    Background: Adequate monitoring of the hemodynamic state is essential after cardiac surgery and is vital for medical decision making, particularly concerning hemodynamic management. Unfortunately, commonly used methods to assess the hemodynamic state are not well documented with regard to outcome. Mixed venous oxygen saturation (SvO2) was therefore investigated after cardiac surgery. Methods: Detailed data regarding mortality were available on all patients undergoing aortic valve replacement for isolated aortic stenosis during a 5-year period in the southeast region of Sweden (n=396). SvO2 was routinely measured on admission to the intensive care unit (ICU) and registered in a database. A receiver operating characteristics (ROC) analysis of SvO2 in relation to post-operative mortality related to cardiac failure and all-cause mortality within 30 days was performed. Results: The area under the curve (AUC) was 0.97 (95% CI 0.96,1.00) for mortality related to cardiac failure (P=0.001) and 0.76 (95% CI 0.53,0.99) for all-cause mortality (P=0.011). The best cutoff for mortality related to cardiac failure was SvO2 53.7%, with a sensitivity of 1.00 and a specificity of 0.94. The negative predictive value was 100%. The best cutoff for all-cause mortality was SvO2 58.1%, with a sensitivity of 0.75 and a specificity of 0.84. The negative predictive value was 99.4%. Post-operative morbidity was also markedly increased in patients with a low SvO2. Conclusion: SvO2, on admission to the ICU after surgery for aortic stenosis, demonstrated excellent sensitivity and specificity for post-operative mortality related to cardiac failure and a fairly good AUC for all-cause mortality, with an excellent negative predictive value. [source]

    Impact of the post-World War II generation on intensive care needs in Norway

    J. H. LAAKE
    Background: A high birth rate during the first two decades following World War II has increased the proportion of elderly people in present-day society and, consequently, the demand for health-care services. The impact on intensive care services may become dramatic because the age distribution of critically ill patients is skewed towards the elderly. We have used registry data and population statistics to forecast the demand for intensive care services in Norway up until the year 2025. Methods: Data collected by the Norwegian intensive care registry (NIR), showing the age distribution in Norwegian intensive care units (ICU) during the years 2006 and 2007, were used with three different Norwegian prognostic models of population growth for the years 2008,2025 to compute the expected increase in intensive care unit bed-days (ICU bed-days). Results: The elderly were overrepresented in Norwegian ICUs in 2006,2007, with patients from 60 to 79 years of age occupying 44% of ICU bed-days. Population growth from 2008 to 2025 was estimated to be from 11.1 to 26.4%, depending on the model used. Growth will be much larger in the age group 60,79 years. Other factors kept unchanged, this will result in an increase in the need for intensive care (ICU bed-days) of between 26.1 and 36.9%. Conclusion: The demand for intensive care beds will increase markedly in Norwegian hospitals in the near future. This will have serious implications for the planning of infrastructure, education of health care personnel, as well as financing of our health care system. [source]

    Promoting peaceful death in the intensive care unit in Thailand

    W. Kongsuwan rn
    Background:, Having a peaceful death is a common wish among Thai people. Thai culture and religious beliefs offer practical ways to enhance having a peaceful death. Dying in an intensive care unit (ICU) is unnatural and oftentimes painful for the patient and their loved ones. Promoting a peaceful death is one of the least understood yet critical roles of nurses who practise in ICUs. Purpose:, To explore the ways that ICU nurses in Thailand could promote peaceful death and to attempt a definition of the concept of ,peaceful death'. Method:, Data were generated from ICU nurses' descriptions of peaceful death. These were given during in-depth telephone interviews, tape-recorded and analysed using the grounded theory method of analysis. Findings:, ICU nurses promote peaceful death through a three-dimensional process: awareness of dying; creating a caring environment; and promoting end-of-life care. Conclusions:, The study provided opportunities for nurses to understand and influence the practice of promoting peaceful death in ICUs in Thailand. Further research is needed to enhance the practices and processes necessary for promoting peaceful death among ICU patients. It is anticipated that this will advance policy changes in nursing care processes in Thailand. [source]

    Unexpected cardiovascular collapse from massive air embolism during endoscopic retrograde cholangiopancreatography

    K. M. GOINS
    A 72 year-old woman with cholangiocarcinoma presented for endoscopic retrograde cholangio pancreatography (ERCP) for diagnostic intraductal endoscopy under GETA. During the technically difficult procedure the patient became suddenly hypoxic, hypotensive, bradycardic, and progressed to PEA code (ETCO2 5 mmHg). ACLS was initiated. Transesophageal echo demonstrated massive right heart air accumulation; abdominal X-Ray showed air filled bile ducts. Central access was obtained, a pulmonary artery catheter floated, and 30 ml of air aspirated from the RV. Within 5 minutes pulses returned; the patient was transferred to the ICU. MRI revealed two watershed infarcts in the right frontal lobe. The patient fully recovered and returned a month later for an uneventful ERCP. [source]

    Improved outcome after trauma care in university-level intensive care units

    Background: Centralized trauma care has been shown to be associated with improved patient outcome. We compared the outcomes of trauma patients in relation to the size of the intensive care unit (ICU) using a large Finnish database. Methods: A national prospectively collected ICU data registry was used for analysis. All adult trauma admissions excluding isolated head trauma and burns registered from July 1999 to December 2006 were analyzed. Data from 22 ICUs were available. The non-university-affiliated units were categorized according to the number of beds and referral population as small, mid size and large. Acute physiology and chronic health evaluation (APACHE II)- and sequential organ failure assessment (SOFA)-adjusted mortalities were compared between the units. Results: There were 2067 trauma admissions that fulfilled the inclusion criteria; 38% were treated in the university hospitals, 26% in large non-teaching ICUs, 20% in mid size ICUs and 15% in small ICUs. The crude hospital mortality was 5.6%, being 4.7% in university ICU and 6.6% in mid size ICU. In two subgroup analyses of severely ill trauma patients with APACHE II points >25 or SOFA score >8 points, respectively, hospital mortality was significantly lower in university ICUs. Conclusions: University-level hospitals were associated with better outcomes with critically ill trauma patients. These results can be used in planning future organization of trauma patient care in Finland. [source]

    Quality of cardiopulmonary resuscitation on manikins: on the floor and in the bed

    Background: In general, in-hospital resuscitation is performed in a bed and out-of-hospital resuscitation on the floor. The surface under the patient may affect the cardiopulmonary resuscitation (CPR) quality; therefore, we evaluated CPR quality (the percentage of chest compressions of correct depth) and rescuer's fatigue (the mean compression depth minute by minute) when CPR is performed on a manikin on the floor or in the bed. Methods: Forty-four simulated cardiac arrest scenarios of 10 min were treated by intensive care unit (ICU) nurses in pairs using a 30 : 2 chest compression-to-ventilation ratio. The rescuer who performed the compressions was changed every 2 min. CPR was randomly performed either on the floor or in the bed without a backboard; in both settings, participants kneeled beside the manikin. Results: A total number of 1060 chest compressions, 44% with correct depth, were performed on the floor; 1068 chest compressions were performed in the bed, and 58% of these were the correct depth. These differences were not significant between groups. The mean compression depth during the scenario was 44.9±6.2 mm (mean±SD) on the floor and 43.0±5.9 mm in the bed (P=0.3). The mean chest compression depth decreased over time on both surfaces (P<0.001), indicating rescuer fatigue, but this change was not different between the groups (P=0.305). Conclusions: ICU nurses perform chest compression as effectively on the floor as in the bed. The mean chest compression depth decreases over time, but the surface had no significant effect. [source]

    Non-invasive ventilation in do-not-intubate patients: five-year follow-up on a two-year prospective, consecutive cohort study

    H.-H. BÜLOW
    Background: End-of-life decisions are common in intensive care units (ICUs), and increasingly, non-invasive ventilation (NIV) is used as a ceiling of ventilatory care. However, little is known about the outcome following that decision. Methods: An observational, single-center, retrospective, follow-up study with no interventions, on ICU patients treated with NIV and a do-not-intubate (DNI) order. The patients were followed until a 5-year survival rate could be calculated. Results: One hundred and fifty-seven patients were treated with NIV during 2002 and 2003, and among 38 a DNI order was in effect. Of the 38 DNI patients, 11 died in the ICU, 16 died on the ward and 11 survived the hospital stay. Five of these 11 survivors died within 6 months, two died after 2.7 and 3.3 years, respectively, but four were still alive after 5 years. The long-term (>6 months) survivors have, surprisingly only been admitted to the hospital 0,2 times a year , and seldom with the need for ICU treatment. Conclusions: According to this study, and previous ones, it seems worthwhile treating DNI patients with NIV. Twenty-five to 35% leave the hospital alive, every 6th patient lives for at least 1 year, and this paper shows that 10% may survive for 5 years or more. However, only chronic obstructive pulmonary disease and chronic heart failure patients (both with a concomitant low APACHE score) seem to have a reasonable outcome, and patients should be informed about this. So far, no study has investigated the quality of life of these survivors. [source]