Critically Ill Patients Research Papers (original) (raw)

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- Nursing, Adolescent, Medicine, Energy Metabolism

Background: With the goal of optimizing tissue perfusion and maintaining adequate oxygen delivery, nurses play an important role in monitoring oxygenation and ventilation. Nursing practices may affect oxygen saturation in critically ill patients. Aim of study was to determine the relationship between nursing practices and oxygen desaturation in critically ill patients. A descriptive research design was used in this study. Setting: The study was conducted at the Critical Care Units (CCUs) of two selected Hospitals at Makah Al-Mukaramah, KSA. Subjects; a convenience sample of 100 newly admitted critically ill patients were included in the study. Tool of data collection was the relationship between nursing practices and oxygen desaturation in critically ill patients' tool. It consists of two parts: Part 1; nursing practices observation checklists and part 2; oxygen saturation monitoring record. Results: It was noted that in 67% of observations, patients had their position changed by nurses once per shift, no patients had oxygen during suctioning. In addition, there were significant correlation between oxygen saturation during, and after bathing (r .403, p.000, r .342, p .000). From the results of this study it can be concluded that the nursing practices mainly suctioning, positioning and bathing affect oxygen desaturation in critically ill patients. There were significant relationships between oxygen desaturation and the procedures performed as oxygen saturation decreased during and after certain performed procedures especially suctioning. Recommendations: Protocols should be developed regarding oxygen desaturation in critically ill patients. Adequate supervision should be provided on nurses during their practice.

- by Hayam I Asfour
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- Nursing, Critical Care Nursing, Monitoring, Hemodynamic Monitoring

Introducción: El mantenimiento del equilibrio hidroelectrolítico es esencial para el buen funcionamiento del organismo. Existen situaciones en las que se producen desequilibrios en los líquidos corporales, originando sobrecargas de fluidos, y sus consecuentes problemas asociados. Los pacientes con esta problemática, pueden beneficiarse de la administración de fármacos parenterales en el menor volumen posible. Los pacientes en estado crítico suelen requerir un gran número de fármacos por vía intravenosa, y altas dosis de éstos a diluir en grandes cantidades de suero. Por todo ello, parece útil buscar una estrategia de optimización de la administración de los fármacos parenterales. Objetivo: Revisar y recopilar datos referentes a volúmenes mínimos de dilución. Además de las vías de administración, reconstitución, diluyentes compatibles, tiempos de infusión. Método: Se incluyeron en el estudio aquellos principios activos utilizados con más frecuencia en pacientes críticos. Se realizó una búsqueda en varias fuentes de información: fichas técnicas de las especialidades farmacéuticas, Handbook on Injectable Drugs, Trissel L., American Society Healh-System Pharmacists, 15thEd., 2009, Thomson Micromedex ® Healthcare series, o vía telefónica con el laboratorio fabricante del producto. Resultados: Los resultados se muestran en forma de tabla. Se revisaron 65 especialidades farmacéuticas. Conclusiones: Consideramos útil la recopilación de estos datos para optimizar la administración parenteral en pacientes críticos o que requieran una terapia restrictiva en fluidos ya que la información ha tenido que ser recopilada de distintas fuentes no encontrándose siempre en la ficha técnica.

- by Quimico Farmaceutico
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- Critically Ill Patients

insulin-like activity or of transforming growth factor-a, which is thought to interact with the epidermal growth factor receptor. 3 Insulin level was normal in the present patient but we do not know if the present patient had a relative insuline resistance. We believe that other etiopathologic or stimulating factors, which are unknown, yet may play a role in the development of AN, as in the present case.

- by Mesiha Ekim
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- Pediatrics, Dialysis, Child, Alanine Aminotransferase

Introduction: The weakness acquired in the UCI is a condition that appears often in the critical patient, causing deficiencies in their physical and functional state. The early mobilization has proved to be safe and feasible demonstrating an improvement in the muscular strength and functionality of the patient during his stay in the ICU. Objectives: To describe the benefit of early mobilization in relation to muscle strength and functionality of critical patients upon discharge from the ICU. Material and methods: A retrospective, observational and descriptive study was conducted in the period from June to December of 2017, with a convenience sample of patients admitted to the ICU who were under mechanical ventilation and sedation, registration was obtained in the clinical files of muscle strength, functionality and mobility after the withdrawal of sedation and previous discharge of the patient, and the changes found were recorded. Results: A sample of 8 patients was obtained, of which 25% of the patients met the criterion of weakness

Introduction: Daily bed-baths are usually provided for most critically ill patients to improve patient hygiene, promote comfort and improve health outcomes. Critically ill patients are at greater risk for skin colonization and infection with multidrug-resistant organisms. Therefore, it is important to provide critically ill patient with effective personal hygiene especially bed-bath as poor hygiene may increase the risk of infection. The decision for bed-bath depends on the judgment of the caring nurse. The aim of this work was to describe bed-bath practices in intensive care units. Methods: A descriptive design was used. Sixty intensive care unit nurses were involved. Tool: "Bed-bath practices of critically ill patients' assessment sheet" was used to collect data. Results: More than three quarters of nurses, 79% had improper bed-bath practices. The gap for safe bed-bath practices between nurses' current bed-bath practices and the bed-bath evidence-based recommendations is wide (83%). Nurses' self-reported reasons that hinder safe bed-bath practices were financial resources, followed by lack of equipment, no policy, lack of knowledge, and workload. Conclusions: Although, bed-bath is a routine nursing procedure, critical care nurses in the current study had poor skills and knowledge regarding it. The factors affecting bed-bath practice are financial resources, lack of equipment, no policy, lack of knowledge and workload. In-service training program should be conducted for nurses regarding putting priority of nursing care, determining timing and frequency for the bed-bath.

- by Hayam Asfour
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- Nursing Care, ICU Nursing, Critically Ill Patients

Among critically ill patients, several physio-pathological processes such as global and local hypo-perfusion, hypoxia, endothelial injury and acidosis have been associated with the production and release of large amounts of reactive oxygen species (ROS) in a non regulated fashion. Although in physiologic conditions ROS influence intracellular processes and participate in the defense against infectious organism, in critically ill conditions they are associated with potential oxidative damage over cellular structures and with persistent activation of the inflammatory response. Mechanisms associated with oxidative damage are activation of the macrophage-monocyte system and neutrophils, ischemia-reperfusion events and intracellular ROS production. Endogenous compounds, mainly enzymes, and dietary components act as antioxidant. Several studies show that in critically ill patients increase levels of ROS or reduction of antioxidant levels are related to disease severity. In animal models of critical diseases, antioxidant therapy has shown to reduce mortality. Nevertheless, there are few studies in humans that only show improvements in hemodynamic variables, reduction in inflammatory mediators levels, decreases in oxidized compounds and that suggest a lower incidence of multiple organ failure (Rev Méd Chile 2006; 134: 649-56). (Key words: Multiple organ failure; Oxidative stress; Reactive oxygen specias) Recibido el 15 de julio, 2005. Aceptado el 29 de noviembre, 2005.

- by Max Andresen
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- Reactive Oxygen Species, Disease Severity, Animal Model, Enzyme

Background. Sustained low-efficiency daily dialysis (SLEDD) is an increasingly popular renal replacement therapy for intensive care unit (ICU) patients. SLEDD has been previously reported to provide good solute control and haemodynamic stability. However, continuous renal replacement therapy (CRRT) is considered superior by many ICU practitioners, due first to the large amounts of convective clearance achieved and second to the ability to deliver treatment independently of nephrology services. We report on a program of sustained low-efficiency daily diafiltration (SLEDD-f ) delivered autonomously by ICU nursing personnel, and benchmark solute clearance data with recently published reports that have provided dose-outcome relationships for renal replacement therapy in this population.

- by Chia-Chu Chang
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- Kinetics, Acute kidney injury, Acute renal failure, Prospective studies
- by Jorge Sinclair
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- Nursing, Evidence Based Medicine, Medicine, Critical Care

Background: Colonization with Methicillin-Resistant Staphylococcus Aureus (MRSA) is independently is associated with mortality in critically ill adults. Tea tree has broad bactericidal activity. Clinical evidence supports its efficacy in eradicating MRSA, but there are no published data on its role in preventing MRSA colonization. The aim of the study: To determine whether the daily use of 5% tea tree oil compared with standard care (soap and water) had a lower incidence of Methicillin-Resistant Staphylococcus Aureus colonization.

Background: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life threatening clinical conditions seen in critically ill patients with diverse underlying illnesses. Lung injury may be perpetuated by ventilation strategies that do not limit lung volumes and airway pressures. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing pressure and volume-limited (PVL) ventilation strategies with more traditional mechanical ventilation in adults with ALI and ARDS. Methods and Findings: We searched Medline, EMBASE, HEALTHSTAR and CENTRAL, related articles on PubMed TM , conference proceedings and bibliographies of identified articles for randomized trials comparing PVL ventilation with traditional approaches to ventilation in critically ill adults with ALI and ARDS. Two reviewers independently selected trials, assessed trial quality, and abstracted data. We identified ten trials (n = 1,749) meeting study inclusion criteria. Tidal volumes achieved in control groups were at the lower end of the traditional range of 10-15 mL/kg. We found a clinically important but borderline statistically significant reduction in hospital mortality with PVL [relative risk (RR) 0.84; 95% CI 0.70, 1.00; p = 0.05]. This reduction in risk was attenuated (RR 0.90; 95% CI 0.74, 1.09, p = 0.27) in a sensitivity analysis which excluded 2 trials that combined PVL with open-lung strategies and stopped early for benefit. We found no effect of PVL on barotrauma; however, use of paralytic agents increased significantly with PVL (RR 1.37; 95% CI, 1.04, 1.82; p = 0.03). Conclusions: This systematic review suggests that PVL strategies for mechanical ventilation in ALI and ARDS reduce mortality and are associated with increased use of paralytic agents.

Background: To determine practices of Turkish anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill. Methods: An anonymous questionnaire consisting of 18 questions was mailed to 439 members of the Turkish Society of Anaesthesiology and Reanimation. Results: Three hundred and 69 questionnaires were returned (84% response). Over 90% of the respondents indicated that they were Muslim. We found that 66% of respondents had initiated written or oral do-not-resuscitate orders, most frequently after discussion with colleagues (82%). Conclusions: While a number of similarities were found between Turkish anaesthesiologists and those from other countries, some specific differences could be identified, particularly related to consensus decision-making and sharing information with other providers and the value of Ethics Committees in the decision-making process.

- by A. Günerli
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- Decision Making, Anesthesiology, Medical Ethics, Turkey

Objective: To review the cardiovascular effects of spontaneous breathing and mechanical ventilation in healthy and pathological states. Data sources: A review of articles published in peer-reviewed journals from 1966 to 1998 and identified through a MEDLINE search on cardiopulmonary interaction. Summary of review: Respiration has a hydraulic influence upon cardiovascular function. Pulmonary and cardiac pathology alter this interaction. Spontaneous inspiration increases right ventricular (RV) preload and left ventricular (LV) afterload. Mechanical ventilation with positive pressure (MV) reduces LV preload and afterload. The influence of MV upon the cardiovascular system (CVS), particularly in critically ill patients, depends upon the mode of ventilation and the pre-existing cardiac and respiratory status. The influence of these factors is reviewed. Consideration of these parameters will enable the clinician to predict the likely effect of MV and develop strategies to minimise adverse events. Conclusions: Mechanical ventilation has an adverse effect upon the CVS in healthy subjects and in patients with pulmonary pathology, particularly in the presence of preload-dependent LV dysfunction or afterload-induced RV dysfunction. Mechanical ventilation may benefit cardiac function in patients with respiratory failure and afterload-dependent or exercise-induced LV dysfunction. (Critical Care and Resuscitation 1999; 1: 388-399)

- by Romain Gaudy and +1
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- Medicine, Critically Ill Patients

Introduction: One of the complications of intensive care unit (ICU) admission is neuromuscular dysfunction because of critical illness, which may lead to disuse atrophy. Many of critically ill patients have severe muscle weakness, which has been termed ICU-acquired weakness (ICU-AW). ICU-AW has many consequences on patients' outcome. The aim of the study was to determine contributing factors for occurrence of acquired muscle weakness in intensive care units. Setting: The study was conducted in four general ICUs in two selected Hospitals in Makkah in KSA. Subjects: Hundred patients were included in the study. Materials and Method: Tool one: factors contributing to ICU-AW assessment tool. Tool two: indicators of ICU-AW in critically ill patients. Results: Forty-two patients were diagnosed ICU-AW. Differences between the ICU-AW group and the no ICU-AW group in, sex, diagnosis on admission and APACHE II were not statistically significant. Age in the ICU-AW group was higher than in no ICU-AW group [59±14 vs. 53±11 years, p = .0183] which was significant statistical difference. Conclusion: The contributing factors for ICU-AW are immobility, patients' age, level of consciousness, parenteral nutrition, and glucocorticoid & insulin therapy.

- by Hayam I Asfour
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- ICU Nursing, Critically Ill Patients, ICU acquired weakness

- by Hayam Asfour
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- Nursing, Medicine, Critical Care Nursing, Monitoring

Objective: To assess the predictive ability of preillness and illness variables, impact of care, and discharge variables on the post-intensive care mortality. Setting and patients: 5,805 patients treated with high intensity of care in 89 ICUs in 12 European countries (EURICUS-I study) surviving ICU stay. Methods: Case-mix was split in training sample (logistic regression model for post-ICU mortality: discrimination assessed by area under ROC curve) and in testing sample. Time to death was studied by Cox regression model validated with bootstrap sampling on the unsplit case-mix. Results: There were 5,805 high-intensity patients discharged to ward and 423 who died in hospital. Significant odds ratios were observed for source of admission, medical/surgical unscheduled admission, each year age, each SAPSII point, each consecutive day in high-intensity treatment, and each NEMS point on the last ICU day. Time to death in ward was significantly shortened by different source of admission; age over 78 years, medical/unscheduled surgical admission; SAPSII score without age, comorbidity and type of admis-sion over 16 points; more than 2 days in high-intensity treatment; all days spent in high treatment; respiratory, cardiovascular, and renal support at discharge; and last ICU day NEMS higher than 27 points Conclusions: Worse outcome is associated with the physiological reserve before admission in the ICU, type of illness, intensity of care required, and the clinical stability and/or the grade of nursing dependence at discharge.

- by Giovanni Mistraletti and +2
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- Model validation, Cox Regression, INTENSIVE CARE, Clinical Sciences

Critically ill new born babies admitted at the Neonatal Intensive Care Unit (NICU) are extremely tiny and vulnerable to external disturbance. Smart Jacket proposed in this paper is the vision of a wearable unobtrusive continuous monitoring system realized by body sensor networks (BSN) and wireless communication. The smart jacket aims for providing reliable health monitoring as well as a comfortable

- by loe feijs
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- Computer Science, Pediatrics, Aesthetics, Textiles

- by Hayam Asfour
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- ICU Nursing, Critically Ill Patients, ICU acquired weakness

Sonographic patterns of brain injury in the term and near-term infant are quite different from those in the premature infant. Although periventricular leukomalacia and germinal matrix hemorrhage are rarely seen in term infants, selective neuronal injury, parasagittal infarction, focal stroke, diffuse hypoxic-ischemic injury, and deep parenchymal hemorrhages are more common lesions. In addition, congenital brain tumors, hamartomatous lesions, such as hemimegalencephaly, and tuberous sclerosis can mimic ischemic and hemorrhagic injury. Sonography remains an important tool in the initial evaluation of intracranial abnormalities in critically ill term and near-term infants. An understanding of the differences in etiology, sonographic patterns, and limitations of sonography in the term infant is essential for accurate and effective diagnoses in this age group.

- by George Taylor and +1
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- Brain Tumor, Skull, Pediatric radiology, Brain injury

Cardiac depression is well known in severe sepsis and septic shock. Our aim was to investigate the incidence of myocardial ischaemia as shown by cardiac troponin I (cTnI) levels in patients with septic shock and to evaluate the correlation with myocardial dysfunction measured by echocardiography. The study was performed in the paediatric intensive care unit in Dicle University Hospital, Turkey, between January 2001 and December 2002. Patients in septic shock, with a mean age of 6.4 +/- 2.8 months, were simultaneously submitted to a two-dimensional echocardiogram and biochemical investigation on admission. The mean serum cTnI level of the patients was 3.1 +/- 2.6 ng/ml (0.01-9.80 ng/ml) and the mean LVEF value was calculated as 48% +/- 11%. 21 patients (75%) had a cTnI level >/=0.6 ng/ml, and 15 patients (54%) had a LVEF <0.5. For cTnI levels >/=0.6 ng/ml, sensitivity and specificity were 93.3% and 46.2%, and positive and negative predictive values were 66.7% and 85.7% respe...

- by MEKİ BİLİCİ
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- Echocardiography, Septic Shock, Left Ventricular Assist Device, Infant

Objective: A lack of intensive care units beds in Israel results
in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study’s objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit. Design: A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department
and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of
discharge. Setting: Five acute care hospitals. Patients: A total of 749 newly deteriorated patients. Interventions: None. Measurements and Main Results: Crude survival of patients in
and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0–3 days) relative to regular departments (p .0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients. Conclusions: Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive
care unit triage decisions should be targeted at maximizing
intensive care unit benefit by early admitting patients deteriorating on hospital wards.

- by George Mnatzaganian and +1
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- Mortality, Intensive Care Medicine, Critically Ill Patients

The provision of nutrition and hydration to newborn infants is considered fundamental care. For premature and critically ill newborns, similar considerations generally hold true. Nutrition may be provided for these infants using assisted measures such as parenteral nutrition or tube feedings. However, for some newborn infants the provision of medically assisted nutrition may be a more complicated issue. In particular, the goals of nutrition need to be clearly elaborated for newborns with lethal conditions or for whom appropriately administered intensive care is unsuccessful in sustaining life. These infants may benefit from palliative measures of care and a limitation or withdrawal of burdensome or nonbeneficial interventions. This article explores issues pertinent to deciding and communicating the appropriate withdrawal of medically assisted nutrition and implementing palliative comfort measures.

- by Brian Carter
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- Medical Ethics, Medical and Research ethics, Emotions, INTENSIVE CARE

IMPORTANCE Evidence supporting the choice of intravenous colloid vs crystalloid solutions for management of hypovolemic shock remains unclear. OBJECTIVE To test whether use of colloids compared with crystalloids for fluid resuscitation alters mortality in patients admitted to the intensive care unit (ICU) with hypovolemic shock. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial stratified by case mix (sepsis, trauma, or hypovolemic shock without sepsis or trauma). Therapy in the Colloids Versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was open label but outcome assessment was blinded to treatment assignment. Recruitment began in February 2003 and ended in August 2012 of 2857 sequential ICU patients treated at 57 ICUs in France, Belgium, North Africa, and Canada; follow-up ended in November 2012. INTERVENTIONS Colloids (n = 1414; gelatins, dextrans, hydroxyethyl starches, or 4% or 20% of albumin) or crystalloids (n = 1443; isotonic or hypertonic saline or Ringer lactate solution) for all fluid interventions other than fluid maintenance throughout the ICU stay. MAIN OUTCOMES AND MEASURES The primary outcome was death within 28 days. Secondary outcomes included 90-day mortality; and days alive and not receiving renal replacement therapy, mechanical ventilation, or vasopressor therapy. RESULTS Within 28 days, there were 359 deaths (25.4%) in colloids group vs 390 deaths (27.0%) in crystalloids group (relative risk [RR], 0.96 [95% CI, 0.88 to 1.04]; P = .26). Within 90 days, there were 434 deaths (30.7%) in colloids group vs 493 deaths (34.2%) in crystalloids group (RR, 0.92 [95% CI, 0.86 to 0.99]; P = .03). Renal replacement therapy was used in 156 (11.0%) in colloids group vs 181 (12.5%) in crystalloids group (RR, 0.93 [95% CI, 0.83 to 1.03]; P = .19). There were more days alive without mechanical ventilation in the colloids group vs the crystalloids group by 7 days (mean: 2.1 vs 1.8 days, respectively; mean difference, 0.30 [95% CI,

- by Xavier Forceville
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- Biology, Survival Analysis, Treatment Outcome, Medicine
- by Seyda Besen and +1
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- Nursing, Electroencephalography, Adolescent, Medicine

The heart and lungs work closely to meet the tissues' oxygen demands. If the balance between oxygen demand and supply becomes disturbed in critical illness, tissue hypoxia and cell death can rapidly result. An essential part of critical care is to maintain cardiopulmonary function with the help of pharmacotherapy, fluid management, and respiratory support. Paradoxically, interventions aimed at improving the function of one system can sometimes have undesirable eVects on the other and, although the pulmonary consequences of cardiac disease are well recognised, the influences of changes in pulmonary physiology on cardiac function are less well appreciated.

- by Graeme Duke
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- Interaction, Peer Review, Critical Care, Child

Medical intensivists make heterogenous decisions using pulmonary artery catheter (PAC) data in medical intensive care unit patients. The object was to determine if cardiologists given PAC data from critically ill cardiology patients make uniform management choices. A survey questionnaire containing 3 coronary care unit (CCU) clinical vignettes was designed and mailed to board-certified cardiologists who are members of the American College of Cardiology. Twenty board-certified medical intensivists were also asked to complete the vignettes. Each vignette contained PAC data and one-half of the surveys contained echocardiographic (ECHO) information. Every respondent was asked to select 1 of 6 interventions for each vignette. In 2 of 3 vignettes 1 intervention was selected by more than 70% of cardiologists. In the third vignette, 1 intervention was selected by more than 50% of cardiologists. For each vignette, 1 intervention was selected by at least 75% of medical intensivists. There was no significant difference in the distribution of management choices between the ECHO and the non-ECHO subgroups. There is relative homogeneity in selecting an intervention based on PAC data among cardiologists and medical intensivists in CCU patients and is probably due to patient-related factors. The presence of ECHO information did not change the intervention selected. Cardiology patients may represent an ideal group in which to evaluate PAC efficacy.

- by Dan Fintel
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- Nursing, Cardiology, Decision Making, Medicine

Background: Mechanically ventilating is frequently performed life-saving procedure in the emergency room (ER). With the duration of stay of ventilated patients in ERs rising, it is critical for emergency physicians to have a firm grasp on procedures for optimizing mechanical ventilation and minimizing consequences. Numerous positively pressured ventilation techniques are available; they are derived from different permutations of triggered volume-and pressure-cycled ventilations and supply ventilation at a variety of rates, pressures and volumes. Inadequate ventilatory treatment may result in significant respiratory and extrapulmonary injury that may go undetected. Objective: The aim of this review article was to highlight mechanical ventilation in critically ill patients in ICU. Conclusion: Non-invasive ventilation is an excellent first-line therapy for hypoxemic or hypercapnic respiratory failure in critically ill patients, failure of non-invasive ventilation necessitates introduction of intubation and invasive mechanical ventilation as second line therapy.

- by fawzy badawy
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- Medicine, Mechanical Ventilation, Critically Ill Patients

The aim of the study was to assess the outcome after esophageal replacement using gastric pull-up performed in critically ill neonates with esophageal atresia (EA) and tracheoesophageal fistula. Methods: During 1998 to 2005, gastric transposition was performed in 27 neonates (mean birth weight, 2.32 kg [1.86-3.0 kg]; mean age, 6.08 days) for post-EA and tracheoesophageal fistula leaks in 17, long gap in 6, and pure EA in 4, using transhiatal route in all. Pyloromyotomy as the drainage procedure was added for all 27 neonates. Patients were followed up at 3, 6, and 12 months for clinical evaluation, gastric clearance, duodenogastric reflux, and gastric pressure profile. Results: Six neonates had ongoing serious chest infection, 3 had lung collapse, and 2 had associated congenital heart disease. Postoperative elective ventilation was provided to all neonates for 2 to 40 days (mean, 10.6 days). Nine neonates developed postoperative leaks in the neck; all healed spontaneously before discharge. Mean hospital stay was 32.6 days (range, 9-87 days). Four newborns died on postoperative days 9, 13, 15, and 29 because of existing severe sepsis in 3 and major congenital heart disease in 1. Functional evaluations were done at 3, 6, and 12 months postoperatively. Values at 6 months revealed normal gastric emptying in 16 of 23, presence of duodenal gastric reflux in 11 of 23, and mass contractions with significant rise in intragastric pressure after bolus feeds in 16 of 23 cases. Values at 12 months revealed normal gastric emptying in 14 of 20, presence of duodenal gastric reflux in 8 of 20, and mass contractions with significant rise in intragastric pressure after bolus feeds in 13 (65%) of 20 cases. Conclusion: Gastric transposition could be a lifesaving alternative to diversion, even in the critically ill newborns after major leaks. However, it requires technical surgical expertise and an effective pain relief and neonatal intensive care.

- by shilpa sharma
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- Medicine, Pediatric Surgery, Pediatric, Newborn Infant

Background: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. Purpose: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. Methods: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. Results: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. Conclusions: Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

- by Susan Tarlo
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- Algorithms, Health Promotion, Asthma, Health Policy

EETING THE HEALTH CARE needs of the American people in the coming decades requires accurate forecasts of likely requirements, not only in terms of dollars, but also in terms of staffing and facilities. Unfortunately, such forecasts are difficult because many factors influence health care delivery. One factor likely to increase demand for services is the aging of the US population. During the next 30 years, Medicare enrollment will grow by more than 50%. 1 Because the elderly consume considerable health care resources, demand for medical services is expected to outpace other indices of the economy. 2 This increased demand might be offset by other factors, such as the growth of managed care. It is argued that physicians create part of the demand for their services. 3,4 One influential study found managed care plans, by carefully screening physician services, lowered demand for specialist care. 5 Because of anticipated growth in managed care, the Council on Graduate Medical Education predicted specialists would now be oversupplied. 5,6 Concern over such potential changes in physician requirements generated other forecasts of the physician labor market in the 1990s. 3,5-9 Not all studies reached the same conclusion and some

- by John Popovich, Jr.
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- Epidemiology, Evaluation, Evolution, Public Health

BACKGROUND: Clinical signs and symptoms of sepsis are nonspecific and often indistinguishable from those of nonseptic critical illness. This ambiguity frequently delays the diagnosis of sepsis until culture results can confirm the presence or absence of an infectious organism. Lymphocyte phenotyping can be conducted rapidly and may provide information on the presence of infection before culture results are available. In this study, we hypothesized that lymphocyte phenotype can distinguish between septic and nonseptic critical illness. STUDY DESIGN: C57Bl/6 mice were subjected to either P aeruginosa pneumonia or lipopolysaccharide-induced acute lung injury (ALI). Animals were sacrificed 24 hours postinjury and splenic lymphocytes were harvested. Additionally, 13 patients in a surgical ICU were enrolled in the study. Whole blood was obtained and lymphocytes were isolated by density gradient centrifugation. Lymphocyte phenotype was identified through flow cytometry after labeling lymphocytes for CD3, CD4, CD8, CD20, CD40, CD69, and CD86 with fluorochrome-conjugated antibodies.

- by Tejal Brahmbhatt and +1
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- Mice, Sepsis, Clinical Sciences, Immunophenotyping

กระบวนการหยาเครื่องชวยหายใจที่เหมาะสมในผูปวยวิกฤตมีความสําคัญในการสงเสริมใหผูปวยหยาเครื่อง ไดสําเร็จ หลักฐานเกี่ยวกับแนวปฏิบัติทางการพยาบาลเพื่อสงเสริมความสําเร็จในการหยาเครื่องสําหรับผูปวยที่ใช เครื่องชวยหายใจชนิด Bird’s respirator มีคอนขางจํากัด การศึกษาครั้งนี้เปนการวิจัยกึ่งทดลอง เพื่อศึกษาผลของ โปรแกรมสงเสริมความสําเร็จการหยาเครื่องชวยหายใจตอความสําเร็จในการหยาเครื่องในผูปวยวิกฤตอายุรกรรม ซึ่งพัฒนาโปรแกรมขึ้นจากหลักฐานเชิงประจักษ กลุมตัวอยางเปนผูปวยวิกฤตอายุรกรรมชายที่ใชเครื่องชวยหายใจ ชนิด Bird’s respirator ที่ไดรับการคัดเลือกตามคุณสมบัติที่กําหนด จํานวน 44 คน แบงออกเปนกลุมควบคุมที่ได รับการพยาบาลตามปกติ และกลุมทดลองที่ไดรับการพยาบาลตามโปรแกรมสงเสริมความสําเร็จการหยาเครื่องชวย หายใจ กลุมละ 22 คน ผลการวิจัย พบวา ผูปวยกลุมที่ไดรับโปรแกรมสงเสริมความสําเร็จการหยาเครื่องชวยหายใจ มีคาสัดสวน ความสําเร็จในการหยาเครื่องชวยหายใจมากเปน 3.86 เทาของกลุมที่ไดรับการดูแลตามปกติ (RR = 3.86, 95% Conﬁ dent Interval [CI] 1.09, 13.66) สรุปผลการวิจัยไดวา โปรแกรมสงเสริมความสําเร็จการหยาเครื่องชวยหายใจ ชวยเพิ่มความสําเร็จในการหยาเครื่องชวยหายใจชนิดฺ Bird’s respirator ในผูปวยวิกฤตอายุรกรรมชาย

Background Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output < 0.5 ml/kg/h) in acutely ill patients and its association with the need for renal replacement therapy (RRT) and outcome. Methods International observational study. All adult (> 16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. Results Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay ...

- by Jan Manak
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- Acute kidney injury, Mortality, Medicine, Critical Care
- by Varsha Gharpure
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- Adolescent, Medicine, Child, Infant

During empirical management, particularly in the critically ill, under-treatment with less sensitive antibiotics would lead to loss of valuable time, spread of infection, increase in morbidity and mortality and delayed recovery; whereas, antibiotic abuse would lead to antibiotic resistance and higher treatment cost. 2,3 Because antimicrobial resistance among pathogens varies from ABSTRACT Background: Knowledge of antibiotic sensitivity patterns in the critically ill would lead to better outcomes by refinement of empirical therapy. The aim of the study was to analyze the antibiotic sensitivity patterns of pathogens in the critically ill. Methods: Retrospective analytical study of 267 culture samples from critically ill patients was done. Data was collected from hospital medical records department and analyzed. Results: In case of community-acquired infections, carbapenems and piperacillin-tazobactam had high efficacy for UTI; carbapenems, aminoglycosides and levofloxacin had intermediate efficacy for pneumonia; aminoglycosides, piperacillin-tazobactam, carbapenems and quinolones had intermediate efficacy for soft tissue infections; and linezolid and vancomycin had high efficacy for blood borne sepsis of unknown source. In case of hospital acquired infections, carbapenems and aztreonam had intermediate efficacy for UTI; aminoglycosides had intermediate efficacy for blood borne sepsis of unknown source and aminoglycosides had high efficacy for CLABSI. Only colistin and tigecycline demonstrated high efficacy for VAP. Colistin and tigecycline showed high efficacy for community and hospital acquired UTI, pneumonia and soft tissue infections as well as gram negative CLABSI and hospital acquired blood borne sepsis of unknown source. Conclusions: The study shows that in critically ill, in general, carbapenems are fast losing their efficacy. Colistin and tigecycline are effective even against MDR pathogens in their spectrum. Fluoroquinolones and cephalosporins have poor efficacy overall to be recommended for empirical therapy. Piperacillin-tazobactam is not satisfactory for many critical infections. Amikacin has variable efficacy. Linezolid, vancomycin and teicoplanin are highly active against MRSA and Enterococcus infections.

- by Raquel Ramos
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- Medical Sciences, Biostatistics, Medicine, Efficacy

Background: Intensive care has a strong impact on health-related quality of life (HRQOL). The specific impact of cardiac arrest in non-shockable rhythm is poorly known. Patients and methods: We gathered patients included in two randomized controlled trials (AWARE and HYPE-RION). The HYPERION trial included ICU-treated non-shockable cardiac arrest patients. The AWARE study included ICU patients requiring mechanical ventilation. We compared the 3-months HRQOL of these patients to those of a large sample of the French general population. Physical and mental dimension were compared. Multivariable linear regression was used to pick up factors associated with HRQOL. Results: 72 and 307 patients of the HYPERION and the AWARE studies were compared to 20,574 French controls. ICU patients evidenced lower scores in all the SF-36 dimensions compared to the controls. Similar scores were observed in both HYPERION and AWARe trials. The physical component score was lower in patients from the HYPERION trial compared to those from the AWARE trials and to controls (38.6 [29.6-47.8], 35.4 [27.5-46.4] vs. 53.0 [46.0-56.7], p < 0.001). After adjustment for age and gender, HYPERION and AWARE trial status were associated wit lower physical component score. Conclusion: Health-related quality of life of unshockable cardiac arrest survivors evaluated at 3 months was similar to ICU survivors and significantly lower than in individuals from general population, especially in the physical dimensions.

- by Nadia Aissaoui
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- Mental Health, Quality of life, Biology, Medicine

Total anomalous pulmonary venous connection is a relatively uncommon congenital cardiac anomaly. When there is obstruction to pulmonary venous drainage or severe pulmonary hypertension due to increased pulmonary blood flow, the patient is usually critically ill and the diagnosis is unambiguous. However, in some patients the symptoms may be mild and often overlap with those of other noncardiac diseases. Tachypnea, failure to thrive, and mild cyanosis are the most frequently reported symptoms. In our patient population, we encountered a frequent observation by parents that the child had an alteration in voice which we elected to refer to as dysphonia for the purpose of this study. We retrospectively reviewed all patients with total anomalous pulmonary venous connection who were evaluated at our institution from January 1996 to January 1999 and found that 27% of patients had dysphonia as a presenting complaint to their primary care provider. We hypothesize that the etiology of this phenomenon lies in the possible compression of the left recurrent laryngeal nerve in the vicinity of the dilated pulmonary artery and the left vertical vein.

- by Usha Krishnan
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- Pulmonary Hypertension, Pediatric Cardiology, India, Congenital Heart Defects
- by Cheri White
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- Nursing, Pain, Procedures, Intensive Care Unit

This study was conducted to determine the effect of meal disturbance on blood glucose level of the critically ill patients and to simulate the control algorithm previously developed using in-silico works. The study is significant so as to reduce the mortality rate of critically ill patients who usually encounter hyperglycaemia or/and hypoglycaemia while in
treatment. The meal intake is believed to affect the blood glucose regulation and causes the hyperglycaemia to occur. Critically ill patients receive their meal through parenteral and enteral nutrition. Furthermore, by using in-silico works, time consumed and resources needed for
clinical evaluation of the patients can be reduced. Hovorka model was employed in which the simulation study was carried out using MATLAB on the virtual patient and it was being compared with actual patient in which the data were provided by Institut Jantung Negara (IJN).
Based on the simulation, the disturbance on enteral glucose supplied had affected the blood glucose level of the patient; however, it remained unchanged for the parenteral glucose. To reduce the occurrence of hypoglycaemia and hyperglycaemia, the patient was injected with 30
g/hr and 10 g/hr of enteral glucose, respectively. In conclusion, the disturbance of meal received can be controlled through in-silico works.

- by Apostolos Armaganidis
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- Critical Care, Adipose tissue, Critically Ill Patients
- by Nikitas Nikitas
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- Critical Care, Critically Ill Patients

Introduction: Daily bed-baths are usually provided for most critically ill patients to improve patient hygiene, promote comfort and improve health outcomes. Critically ill patients are at greater risk for skin colonization and infection with multidrug-resistant organisms. Therefore, it is important to provide critically ill patient with effective personal hygiene especially bed-bath as poor hygiene may increase the risk of infection. The decision for bed-bath depends on the judgment of the caring nurse. The aim of this work was to describe bed-bath practices in intensive care units. Methods: A descriptive design was used. Sixty intensive care unit nurses were involved. Tool: " Bed-bath practices of critically ill patients' assessment sheet " was used to collect data. Results: More than three quarters of nurses, 79% had improper bed-bath practices. The gap for safe bed-bath practices between nurses' current bed-bath practices and the bed-bath evidence-based recommendations is wide (83%). Nurses' self-reported reasons that hinder safe bed-bath practices were financial resources, followed by lack of equipment, no policy, lack of knowledge, and workload. Conclusions: Although, bed-bath is a routine nursing procedure, critical care nurses in the current study had poor skills and knowledge regarding it. The factors affecting bed-bath practice are financial resources, lack of equipment, no policy, lack of knowledge and workload. In-service training program should be conducted for nurses regarding putting priority of nursing care, determining timing and frequency for the bed-bath.

- by Hayam I Asfour
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- Nursing Care, ICU Nursing, Critically Ill Patients, basic care

- by Giovanni Mistraletti
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- Critically Ill Patients