WorldWideScience

Sample records for patients requiring critical

  1. Energy Requirements in Critically Ill Patients

    Science.gov (United States)

    2018-01-01

    During the management of critical illness, optimal nutritional support is an important key for achieving positive clinical outcomes. Compared to healthy people, critically ill patients have higher energy expenditure, thereby their energy requirements and risk of malnutrition being increased. Assessing individual nutritional requirement is essential for a successful nutritional support, including the adequate energy supply. Methods to assess energy requirements include indirect calorimetry (IC) which is considered as a reference method, and the predictive equations which are commonly used due to the difficulty of using IC in certain conditions. In this study, a literature review was conducted on the energy metabolic changes in critically ill patients, and the implications for the estimation of energy requirements in this population. In addition, the issue of optimal caloric goal during nutrition support is discussed, as well as the accuracy of selected resting energy expenditure predictive equations, commonly used in critically ill patients.

  2. Energy Requirements in Critically Ill Patients.

    Science.gov (United States)

    Ndahimana, Didace; Kim, Eun-Kyung

    2018-04-01

    During the management of critical illness, optimal nutritional support is an important key for achieving positive clinical outcomes. Compared to healthy people, critically ill patients have higher energy expenditure, thereby their energy requirements and risk of malnutrition being increased. Assessing individual nutritional requirement is essential for a successful nutritional support, including the adequate energy supply. Methods to assess energy requirements include indirect calorimetry (IC) which is considered as a reference method, and the predictive equations which are commonly used due to the difficulty of using IC in certain conditions. In this study, a literature review was conducted on the energy metabolic changes in critically ill patients, and the implications for the estimation of energy requirements in this population. In addition, the issue of optimal caloric goal during nutrition support is discussed, as well as the accuracy of selected resting energy expenditure predictive equations, commonly used in critically ill patients.

  3. Nutritional requirements of the critically ill patient.

    Science.gov (United States)

    Chan, Daniel L

    2004-02-01

    The presence or development of malnutrition during critical illness has been unequivocally associated with increased morbidity and mortality in people. Recognition that malnutrition may similarly affect veterinary patients emphasizes the need to properly address the nutritional requirements of hospitalized dogs and cats. Because of a lack in veterinary studies evaluating the nutritional requirements of critically ill small animals, current recommendations for nutritional support of veterinary patients are based largely on sound clinical judgment and the best information available, including data from experimental animal models and human studies. This, however, should not discourage the veterinary practitioner from implementing nutritional support in critically ill patients. Similar to many supportive measures of critically ill patients, nutritional interventions can have a significant impact on patient morbidity and may even improve survival. The first step of nutritional support is to identify patients most likely to benefit from nutritional intervention. Careful assessment of the patient and appraisal of its nutritional needs provide the basis for a nutritional plan, which includes choosing the optimal route of nutritional support, determining the number of calories to provide, and determining the composition of the diet. Ultimately, the success of the nutritional management of critically ill dogs and cats will depend on close monitoring and frequent reassessment.

  4. Nitrogen Balance and Protein Requirements for Critically Ill Older Patients

    Directory of Open Access Journals (Sweden)

    Roland N. Dickerson

    2016-04-01

    Full Text Available Critically ill older patients with sarcopenia experience greater morbidity and mortality than younger patients. It is anticipated that unabated protein catabolism would be detrimental for the critically ill older patient. Healthy older subjects experience a diminished response to protein supplementation when compared to their younger counterparts, but this anabolic resistance can be overcome by increasing protein intake. Preliminary evidence suggests that older patients may respond differently to protein intake than younger patients during critical illness as well. If sufficient protein intake is given, older patients can achieve a similar nitrogen accretion response as younger patients even during critical illness. However, there is concern among some clinicians that increasing protein intake in older patients during critical illness may lead to azotemia due to decreased renal functional reserve which may augment the propensity towards worsened renal function and worsened clinical outcomes. Current evidence regarding protein requirements, nitrogen balance, ureagenesis, and clinical outcomes during nutritional therapy for critically ill older patients is reviewed.

  5. Caloric requirement of the critically ill septic patient

    International Nuclear Information System (INIS)

    Shizgal, H.M.; Martin, M.F.

    1988-01-01

    The caloric requirement of the critically ill septic patient was determined by measuring body composition, by multiple isotope dilution, before and at 2-wk intervals while receiving total parenteral nutrition (TPN) in 86 septic and 57 nonseptic malnourished patients. All patients received a TPN solution containing 25% dextrose and 2.75% crystalline amino acids. The body composition of the nonseptic patients, who received 51.9 +/- 1.5 kcal/kg.day, improved significantly, while that of the septic patients, receiving 46.8 +/- 1.1 kcal/kg.day was only maintained. The relationship between caloric intake and the restoration of a malnourished body cell mass (BCM) was determined for each group by correlating, using multiple linear regression, the mean daily change in the BCM with the caloric intake and the nutritional state, as determined by body composition. According to the resultant regressions, an intake of 35.1 and 50.7 kcal/kg.day was required to maintain the BCM of the septic and nonseptic patients, respectively. To restore a depleted BCM, caloric intakes in excess of this amount are required

  6. Successful intraosseous infusion in the critically ill patient does not require a medullary cavity.

    LENUS (Irish Health Repository)

    McCarthy, Gerard

    2012-02-03

    OBJECTIVES: To demonstrate that successful intraosseous infusion in critically ill patients does not require bone that contains a medullary cavity. DESIGN: Infusion of methyl green dye via standard intraosseous needles into bones without medullary cavity-in this case calcaneus and radial styloid-in cadaveric specimens. SETTING: University department of anatomy. PARTICIPANTS: Two adult cadaveric specimens. MAIN OUTCOME MEASURES: Observation of methyl green dye in peripheral veins of the limb in which the intraosseous infusion was performed. RESULTS: Methyl green dye was observed in peripheral veins of the chosen limb in five out of eight intraosseous infusions into bones without medullary cavity-calcaneus and radial styloid. CONCLUSIONS: Successful intraosseous infusion does not always require injection into a bone with a medullary cavity. Practitioners attempting intraosseous access on critically ill patients in the emergency department or prehospital setting need not restrict themselves to such bones. Calcaneus and radial styloid are both an acceptable alternative to traditional recommended sites.

  7. Insulin requirements in non-critically ill hospitalized patients with diabetes and steroid-induced hyperglycemia.

    Science.gov (United States)

    Spanakis, Elias K; Shah, Nina; Malhotra, Keya; Kemmerer, Terri; Yeh, Hsin-Chieh; Golden, Sherita Hill

    2014-04-01

    Steroid-induced hyperglycemia is common in hospitalized patients with diabetes mellitus. Guidelines for glucose management in this setting are lacking. We conducted a retrospective chart review of non-critically ill patients with diabetes receiving steroids, hospitalized from January 2009 to October 2012. Fifty-eight patients were identified from 247 consults. Multivariable linear regression was used to assess median daily insulin requirements of normoglycemic patients compared with hyperglycemic patients. Of the 58 total patients included in our study, 20 achieved normoglycemia during admission (patient-day weighted mean blood glucose [PDWMBG] level = 154 ± 16 mg/dL) and 38 remained hyperglycemic (PDWMBG level = 243 ± 39 mg/dL; P < 0.001). There were no differences between the 2 patient groups in age, sex, race, body weight, renal function, HbA1c level, glucose-altering medications, diabetes type, or disease duration. Following multivariable adjustment, compared with hyperglycemic patients, normoglycemic patients required similar units of basal insulin (median interquartile range [IQR])(23.6 [17.9, 31.2] vs 20.1 [16.5, 24.4]; P = 0.35); higher units of nutritional insulin (45.5 [34.2, 60.4] vs 20.1 [16.4, 24.5]; P < 0.001]; and lower units of correctional insulin (5.8 [4.1, 8.1] vs 13.0 [10.2, 16.5]; P < 0.001]). Patients achieving normoglycemia required a significantly lower percentage of correction insulin (total daily dose [TDD]: 7.4% vs 23.4%; P < 0.001) and a higher percentage of nutritional insulin (TDD: 58.1% vs 36.2%; P <0.001) than hyperglycemic patients. There was no difference in the TDD per kilogram, TDD per milligram hydrocortisone dose, or TDD per milligram hydrocortisone dose per kilogram weight between the 2 groups. The data suggest that non-critically ill patients with hyperglycemia receiving steroids require a higher percentage of TDD insulin therapy as nutritional insulin to achieve normoglycemia.

  8. Outcome and prognostic factors of critically ill patients with acute renal failure requiring continuous renal replacement therapy

    Directory of Open Access Journals (Sweden)

    Aldawood Abdulaziz

    2010-01-01

    Full Text Available Continuous renal replacement therapy (CRRT has proved to be beneficial for the treatment of critically ill patients with acute renal failure (ARF. The aim of this study is to determine the outcome and identify the predictors of mortality of critically ill patients treated with CRRT for ARF in the intensive care unit (ICU. This prospective cohort study of critically ill patients with ARF requiring CRRT admitted to the ICU was carried out at a tertiary care hospital in Saudi Arabia from 2002 to 2008. A total of 644 of 7173 patients with ARF required CRRT were studied. About 9% of the ARF patients required CRRT and comprised mainly those with medical causes, carrying a mortality of 64%. Multivariate analysis found high serum creatinine as an independent factor for better outcome and requirement of mechanical ventilation (MV as an independent factor for worse outcome. In our cohort study, ARF requiring CRRT in the ICU was associated with a high mortality.

  9. Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy.

    Science.gov (United States)

    Marshall, Mark R; Golper, Thomas A; Shaver, Mary J; Alam, Muhammad G; Chatoth, Dinesh K

    2002-03-01

    Continuous renal replacement therapies have practical and theoretical advantages compared with conventional intermittent hemodialysis in hemodynamically unstable or severely catabolic patients with acute renal failure (ARF). Sustained low-efficiency dialysis (SLED) is a hybrid modality introduced July 1998 at the University of Arkansas for Medical Sciences that involves the application of a conventional hemodialysis machine with reduced dialysate and blood flow rates for 12-hour nocturnal treatments. Nine critically ill patients with ARF were studied during a single SLED treatment to determine delivered dialysis dose and the most appropriate model for the description of urea kinetics during treatment. Five patients were men, mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 28.9 and mean weight was 92.5 kg. Kt/V was determined by the reference method of direct dialysate quantification (DDQ) combined with an equilibrated postdialysis plasma water urea nitrogen (PUN) concentration and four other methods that were either blood or dialysate based, single or double pool, or model independent (whole-body kinetic method). Solute removal indices (SRIs) were determined from net urea removal and urea distribution volume supplied from DDQ (reference method) and by mass balance using variables supplied from blood-based formal variable-volume single-pool (VVSP) urea kinetic modeling. Equivalent renal urea clearances (EKRs) were calculated from urea generation rates and time-averaged concentrations for PUN based on weekly mass balance with kinetic variables supplied by either DDQ (reference method) or formal blood-based VVSP modeling. Mean Kt/V determined by the reference method was 1.40 and not significantly different when determined by formal VVSP modeling, DDQ using an immediate postdialysis PUN, or the whole-body kinetic method. Correction of single-pool Kt/V by a Daugirdas rate equation did not yield plausible results. Mean SRI and EKR by the

  10. The critically ill injured patient.

    Science.gov (United States)

    Cereda, Maurizio; Weiss, Yoram G; Deutschman, Clifford S

    2007-03-01

    Patients admitted to the ICU after severe trauma require frequent procedures in the operating room, particularly in cases where a damage control strategy is used. The ventilatory management of these patients in the operating room can be particularly challenging. These patients often have severely impaired respiratory mechanics because of acute lung injury and abdominal compartment syndrome. Consequently, the pressure and flow generation capabilities of standard anesthesia ventilators may be inadequate to support ventilation and gas exchange. This article presents the problems that may be encountered in patients who have severe abdominal and lung injuries, and the current management concepts used in caring for these patients in the critical care setting, to provide guidelines for the anesthetist faced with these patients in the operating room.

  11. Determination of the energy requirements in mechanically ventilated critically ill elderly patients in different BMI groups using the Harris–Benedict equation

    Directory of Open Access Journals (Sweden)

    Pi-Hui Hsu

    2018-04-01

    Full Text Available Background: Due to studies on calorie requirement in mechanically ventilated critically ill elderly patients are few, and indirect calorimetry (IC is not available in every intensive care unit (ICU. The aim of this study was to compare IC and Harris–Benedict (HB predictive equation in different BMI groups. Methods: A total of 177 mechanically ventilated critically ill elderly patients (≧65 years old underwent IC for measured resting energy expenditure (MREE. Estimated calorie requirement was calculated by the HB equation, using actual body weight (ABW and ideal body weight (IBW separately. Patients were divided into four BMI groups. One-way ANOVA and Pearson's correlation coefficient were used for statistical analyses. Results: The mean MREE was 1443.6 ± 318.2 kcal/day, HB(ABW was 1110.9 ± 177.0 kcal/day and HB(IBW was 1101.5 ± 113.1 kcal/day. The stress factor (SFA = MREE ÷ HB(ABW was 1.43 ± 0.26 for the underweight, 1.30 ± 0.27 for the normal weight, 1.20 ± 0.19 for the overweight, and 1.20 ± 0.31 for the obese. The SFI (SFI = MREE ÷ HB(IBW was 1.24 ± 0.24 for the underweight, 1.31 ± 0.26 for the normal weight, 1.36 ± 0.21 for the overweight, and 1.52 ± 0.39 for the obese. MREE had significant correlation both with REE(ABW = HB(ABW × SFA (r = 0.46; P < 0.0001 and REE(IBW = HB(IBW × SFI (r = 0.43; P < 0.0001. Conclusion: IC is the best accurate method for assessing calorie requirement of mechanically ventilated critically ill elderly patients. When IC is not available, using the predictive HB equation is an alternative choice. Calorie requirement can be predicted by HB(ABW × 1.20–1.43 for critically ill elderly patients according to different BMI groups, or using HB(IBW × 1.24–1.52 for patients with edema, ascites or no available body weight data. Keywords: Body Mass Index, Elderly critical care, Harris–Benedict equation, Indirect calorimetry

  12. Improving outcomes for hospital patients with critical bleeding requiring massive transfusion: the Australian and New Zealand Massive Transfusion Registry study methodology.

    Science.gov (United States)

    Oldroyd, J C; Venardos, K M; Aoki, N J; Zatta, A J; McQuilten, Z K; Phillips, L E; Andrianopoulos, N; Cooper, D J; Cameron, P A; Isbister, J P; Wood, E M

    2016-10-06

    The Australian and New Zealand (ANZ) Massive Transfusion (MT) Registry (MTR) has been established to improve the quality of care of patients with critical bleeding (CB) requiring MT (≥ 5 units red blood cells (RBC) over 4 h). The MTR is providing data to: (1) improve the evidence base for transfusion practice by systematically collecting data on transfusion practice and clinical outcomes; (2) monitor variations in practice and provide an opportunity for benchmarking, and feedback on practice/blood product use; (3) inform blood supply planning, inventory management and development of future clinical trials; and (4) measure and enhance translation of evidence into policy and patient blood management guidelines. The MTR commenced in 2011. At each participating site, all eligible patients aged ≥18 years with CB from any clinical context receiving MT are included using a waived consent model. Patient information and clinical coding, transfusion history, and laboratory test results are extracted for each patient's hospital admission at the episode level. Thirty-two hospitals have enrolled and 3566 MT patients have been identified across Australia and New Zealand between 2011 and 2015. The majority of CB contexts are surgical, followed by trauma and gastrointestinal haemorrhage. Validation studies have verified that the definition of MT used in the registry correctly identifies 94 % of CB events, and that the median time of transfusion for the majority of fresh products is the 'product event issue time' from the hospital blood bank plus 20 min. Data linkage between the MTR and mortality databases in Australia and New Zealand will allow comparisons of risk-adjusted mortality estimates across different bleeding contexts, and between countries. Data extracts will be examined to determine if there are differences in patient outcomes according to transfusion practice. The ratios of blood components (e.g. FFP:RBC) used in different types of critical bleeding will also

  13. Critical Review of NOAA's Observation Requirements Process

    Science.gov (United States)

    LaJoie, M.; Yapur, M.; Vo, T.; Templeton, A.; Bludis, D.

    2017-12-01

    NOAA's Observing Systems Council (NOSC) maintains a comprehensive database of user observation requirements. The requirements collection process engages NOAA subject matter experts to document and effectively communicate the specific environmental observation measurements (parameters and attributes) needed to produce operational products and pursue research objectives. User observation requirements documented using a structured and standardized manner and framework enables NOAA to assess its needs across organizational lines in an impartial, objective, and transparent manner. This structure provides the foundation for: selecting, designing, developing, acquiring observing technologies, systems and architectures; budget and contract formulation and decision-making; and assessing in a repeatable fashion the productivity, efficiency and optimization of NOAA's observing system enterprise. User observation requirements are captured independently from observing technologies. Therefore, they can be addressed by a variety of current or expected observing capabilities and allow flexibility to be remapped to new and evolving technologies. NOAA's current inventory of user observation requirements were collected over a ten-year period, and there have been many changes in policies, mission priorities, and funding levels during this time. In light of these changes, the NOSC initiated a critical, in-depth review to examine all aspects of user observation requirements and associated processes during 2017. This presentation provides background on the NOAA requirements process, major milestones and outcomes of the critical review, and plans for evolving and connecting observing requirements processes in the next year.

  14. Dependency in Critically Ill Patients

    Directory of Open Access Journals (Sweden)

    Rumei Yang

    2016-03-01

    Full Text Available By necessity, critically ill patients admitted to intensive care units (ICUs have a high level of dependency, which is linked to a variety of negative feelings, such as powerlessness. However, the term dependency is not well defined in the critically ill patients. The concept of “dependency” in critically ill patients was analyzed using a meta-synthesis approach. An inductive process described by Deborah Finfgeld-Connett was used to analyze the data. Overarching themes emerged that reflected critically ill patients’ experience and meaning of being in dependency were (a antecedents: dependency in critically ill patients was a powerless and vulnerable state, triggered by a life-threatening crisis; (b attributes: the characteristic of losing “self” was featured by dehumanization and disembodiment, which can be alleviated by a “self”-restoring process; and (c outcomes: living with dependency and coping with dependency. The conceptual model explicated here may provide a framework for understanding dependency in critically ill patients.

  15. Governing Critical ICT: Elements that Require Attention

    NARCIS (Netherlands)

    Luiijf, H.A.M.; Klaver, M.H.A.

    2015-01-01

    With respect to critical information and communication technologies (ICT), nations most often declare their national critical infrastructure to include telecommunication services and in some cases critical services offered by key Internet Service Providers (ISP). This paper debates whether nations,

  16. Pharmacokinetics of linezolid in critically ill patients.

    Science.gov (United States)

    Sazdanovic, Predrag; Jankovic, Slobodan M; Kostic, Marina; Dimitrijevic, Aleksandra; Stefanovic, Srdjan

    2016-06-01

    Linezolid is an oxazolidinone antibiotic active against Gram-positive bacteria, and is most commonly used to treat life-threatening infections in critically ill patients. The pharmacokinetics of linezolid are profoundly altered in critically ill patients, partly due to decreased function of vital organs, and partly because life-sustaining drugs and devices may change the extent of its excretion. This article is summarizes key changes in the pharmacokinetics of linezolid in critically ill patients. The changes summarized are clinically relevant and may serve as rationale for dosing recommendations in this particular population. While absorption and penetration of linezolid to tissues are not significantly changed in critically ill patients, protein binding of linezolid is decreased, volume of distribution increased, and metabolism may be inhibited leading to non-linear kinetics of elimination; these changes are responsible for high inter-individual variability of linezolid plasma concentrations, which requires therapeutic plasma monitoring and choice of continuous venous infusion as the administration method. Acute renal or liver failure decrease clearance of linezolid, but renal replacement therapy is capable of restoring clearance back to normal, obviating the need for dosage adjustment. More population pharmacokinetic studies are necessary which will identify and quantify the influence of various factors on clearance and plasma concentrations of linezolid in critically ill patients.

  17. Therapeutic Plasma Exchange in Critically Ill Children Requiring Intensive Care.

    Science.gov (United States)

    Cortina, Gerard; McRae, Rosemary; Chiletti, Roberto; Butt, Warwick

    2018-02-01

    To characterize the clinical indications, procedural safety, and outcome of critically ill children requiring therapeutic plasma exchange. Retrospective observational study based on a prospective registry. Tertiary and quaternary referral 30-bed PICU. Forty-eight critically ill children who received therapeutic plasma exchange during an 8-year period (2007-2014) were included in the study. Therapeutic plasma exchange. A total of 48 patients underwent 244 therapeutic plasma exchange sessions. Of those, therapeutic plasma exchange was performed as sole procedure in 193 (79%), in combination with continuous renal replacement therapy in 40 (16.4%) and additional extracorporeal membrane oxygenation in 11 (4.6%) sessions. The most common admission diagnoses were hematologic disorders (30%), solid organ transplantation (20%), neurologic disorders (20%), and rheumatologic disorders (15%). Complications associated with the procedure occurred in 50 (21.2%) therapeutic plasma exchange sessions. Overall, patient survival from ICU was 82%. Although patients requiring therapeutic plasma exchange alone (n = 31; 64%) had a survival rate of 97%, those with additional continuous renal replacement therapy (n = 13; 27%) and extracorporeal membrane oxygenation (n = 4; 8%) had survival rates of 69% and 50%, respectively. Factors associated with increased mortality were lower Pediatric Index of Mortality 2 score, need for mechanical ventilation, higher number of failed organs, and longer ICU stay. Our results indicate that, in specialized centers, therapeutic plasma exchange can be performed relatively safely in critically ill children, alone or in combination with continuous renal replacement therapy and extracorporeal membrane oxygenation. Outcome in children requiring therapeutic plasma exchange alone is excellent. However, survival decreases with the number of failed organs and the need for continuous renal replacement therapy and extracorporeal membrane oxygenation.

  18. Rhabdomyolysis in Critically Ill Surgical Patients.

    Science.gov (United States)

    Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana

    2016-07-27

    Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic "Mother Teresa" in Skopje, Macedonia, from January 1 st till December 31 st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI.

  19. Necessidades proteicas, morbidade e mortalidade no paciente grave: fundamentos e atualidades Protein requirements, morbidity and mortality in critically ill patients: fundamentals and applications

    Directory of Open Access Journals (Sweden)

    Haroldo Falcão Ramos da Cunha

    2013-03-01

    nutritional therapy for critically ill patients may help to reduce mortality. The purpose of this study was to review some of the nutrition therapy principles related to protein metabolism, evaluate the main assertions of the guidelines of specialty societies and review the recent studies that address these issues using critical insights from the authors' clinical experience.

  20. Critical requirements of the SSTR method

    International Nuclear Information System (INIS)

    Gold, R.

    1975-08-01

    Discrepancies have been reported in absolute fission rate measurements observed with Solid State Tract Recorders (SSTR) and fission chambers which lie well outside experimental error. As a result of these comparisons, the reliability of the SSTR method has been seriously questioned, and the fission chamber method has been advanced for sole use in absolute fission rate determinations. In view of the absolute accuracy already reported and well documented for the SSTR method, this conclusion is both surprising and unfortunate. Two independent methods are highly desirable. Moreover, these two methods more than compliment one another, since certain in-core experiments may be amenable to either but not both techniques. Consequently, one cannot abandon the SSTR method without sacrificing crucial advantages. A critical reappraisal of certain aspects of the SSTR method is offered in the hope that the source of the current controversy can be uncovered and a long term beneficial agreement between these two methods can therefore be established. (WHK)

  1. Physiotherapy in critically ill patients

    Directory of Open Access Journals (Sweden)

    N. Ambrosino

    2011-11-01

    Full Text Available Prolonged stay in Intensive Care Unit (ICU can cause muscle weakness, physical deconditioning, recurrent symptoms, mood alterations and poor quality of life.Physiotherapy is probably the only treatment likely to increase in the short- and long-term care of the patients admitted to these units. Recovery of physical and respiratory functions, coming off mechanical ventilation, prevention of the effects of bed-rest and improvement in the health status are the clinical objectives of a physiotherapy program in medical and surgical areas. To manage these patients, integrated programs dealing with both whole-body physical therapy and pulmonary care are needed.There is still limited scientific evidence to support such a comprehensive approach to all critically ill patients; therefore we need randomised studies with solid clinical short- and long-term outcome measures. Resumo: Uma estadia prolongada na Unidade de Cuidados Intensivos (UCI pode causar fraqueza muscular, descondicionamento físico, sintomas recorrentes, alterações de humor e má qualidade de vida.A fisioterapia é, provavelmente, o único tratamento com potencial para aumentar nos cuidados a curto e longo prazo aos pacientes internados nestas unidades. A recuperação das funções físicas e respiratórias, retirar a ventilação mecânica, prevenção de efeitos do repouso na cama e melhoria do estado de saúde são objectivos clínicos de um programa de fisioterapia nas áreas médicas e cirúrgicas. Para tratar estes pacientes, são necessários programas integrados que englobem tanto a fisioterapia global como os cuidados respiratórios necessários.A evidência científica para apoiar esta abordagem abrangente para todos os doentes críticos é ainda limitada; portanto, são necessários estudos aleatorizados com medidas de resultados a curto e longo prazo. Keywords: Rehabilitation, Mechanical ventilation, Physiotherapy, Weaning, Palavras-chave: Reabilitação, Ventilação mec

  2. Traceability of Software Safety Requirements in Legacy Safety Critical Systems

    Science.gov (United States)

    Hill, Janice L.

    2007-01-01

    How can traceability of software safety requirements be created for legacy safety critical systems? Requirements in safety standards are imposed most times during contract negotiations. On the other hand, there are instances where safety standards are levied on legacy safety critical systems, some of which may be considered for reuse for new applications. Safety standards often specify that software development documentation include process-oriented and technical safety requirements, and also require that system and software safety analyses are performed supporting technical safety requirements implementation. So what can be done if the requisite documents for establishing and maintaining safety requirements traceability are not available?

  3. Requirements for reflection in the critical care environment

    Directory of Open Access Journals (Sweden)

    Celia J. Filmalter

    2015-03-01

    Full Text Available Background: Reflection is recognised as an important method for practice development. The importance of reflection is well documented in the literature, but the requirements for reflection remain unclear. Objectives: To explore and describe the requirements for reflection in the critical care environment as viewed by educators of qualified critical care nurses. Method: A focus group interview was conducted to explore and describe the views of educators of qualified critical care nurses regarding requirements for reflection in the critical care environment. Results: The themes that emerged from the focus group were buy-in from stakeholders –management, facilitators and critical care nurses, and the need to create an environment where reflection can occur. Conclusion: Critical care nurses should be allowed time to reflect on their practice and be supported by peers as well as a facilitator in a non-intimidating way to promote emancipatorypractice development.

  4. in Critically Ill Patients: Success and Limits

    Directory of Open Access Journals (Sweden)

    Filippo Mariano

    2011-01-01

    Full Text Available Citrate anticoagulation has risen in interest so it is now a real alternative to heparin in the ICUs practice. Citrate provides a regional anticoagulation virtually restricted to extracorporeal circuit, where it acts by chelating ionized calcium. This issue is particularly true in patients ongoing CRRT, when the “continuous” systemic anticoagulation treatment is per se a relevant risk of bleeding. When compared with heparin most of studies with citrate reported a longer circuit survival, a lower rate of bleeding complications, and transfused packed red cell requirements. As anticoagulant for CRRT, the infusion of citrate is prolonged and it could potentially have some adverse effects. When citrate is metabolized to bicarbonate, metabolic alkalosis may occur, or for impaired metabolism citrate accumulation leads to acidosis. However, large studies with dedicated machines have indeed demonstrated that citrate anticoagulation is well tolerated, safe, and an easy to handle even in septic shock critically ill patients.

  5. Oral hygiene care in critically ill patients

    African Journals Online (AJOL)

    2007-11-19

    Nov 19, 2007 ... conditions, treatment interventions, equipment, and the patient's inability to attend to his or her ... practices for a critically ill patient include assessment of the oral cavity, brushing the teeth, moisturising the lips and mouth and ...

  6. [Observation of critically ill patients

    DEFF Research Database (Denmark)

    Fuhrmann, L.; Hesselfeldt, R.; Lippert, A.

    2009-01-01

    . MATERIAL AND METHODS: Prospective observational study at Herlev Hospital, Copenhagen, Denmark. Study personnel measured vital signs on all patients present on five wards during the evening and night and interviewed nursing staff about patients with abnormal vital signs. Subsequently, patient records were...

  7. Nuclear data requirements for accelerator driven sub-critical systems

    Indian Academy of Sciences (India)

    The development of accelerator driven sub-critical systems (ADSS) require significant amount of new nuclear data in extended energy regions as well as for a variety of new materials. This paper reviews these perspectives in the Indian context.

  8. When Serious Project Management is a Critical Business Requirement

    Science.gov (United States)

    Jansma, P. A.; Gibby, L.; Chambers, C.; Joines, J.; Egger, R.

    2000-01-01

    When serious project management is a critical business requirement, project managers need to integrate cost, schedule and technical scope of work across the project, and apply earned value management (EVM).

  9. Oxygen supplementation for critically ill patients

    DEFF Research Database (Denmark)

    Barbateskovic, M; Schjørring, O L; Jakobsen, J C

    2018-01-01

    . The objective of this systematic review is to critically assess the evidence of randomised clinical trials on the effects of higher versus lower inspiratory oxygen fractions or targets of arterial oxygenation in critically ill adult patients. METHODS: We will search for randomised clinical trials in major......BACKGROUND: In critically ill patients, hypoxaemia is a common clinical manifestation of inadequate gas exchange in the lungs. Supplemental oxygen is therefore given to all critically ill patients. This can result in hyperoxaemia, and some observational studies have identified harms with hyperoxia...... in international guidelines despite lack of robust evidence of its effectiveness. To our knowledge, no systematic review of randomised clinical trials has investigated the effects of oxygen supplementation in critically ill patients. This systematic review will provide reliable evidence to better inform future...

  10. [Medicines reconciliation in critically ill patients].

    Science.gov (United States)

    Lopez-Martin, C; Aquerreta, I; Faus, V; Idoate, A

    2014-01-01

    Medicines reconciliation plays a key role in patient safety. However, there is limited data available on how this process affects critically ill patients. In this study, we evaluate a program of reconciliation in critically ill patients conducted by the Intensive Care Unit's (ICU) pharmacist. Prospective study about reconciliation medication errors observed in 50 patients. All ICU patients, excluding patients without regular treatment. Reconciliation process was carried out in the first 24h after ICU admission. Discrepancies were clarified with the doctor in charge of the patient. We analyzed the incidence of reconciliation errors, their characteristics and gravity, the interventions made by the pharmacist and their acceptance by physicians. A total of 48% of patients showed at least one reconciliation error. Omission of drugs accounted for 74% of the reconciliation errors, mainly involving antihypertensive drugs (33%). An amount of 58% of reconciliation errors detected corresponded to severity category D. Pharmacist made interventions in the 98% of patients with discrepancies. A total of 81% of interventions were accepted. The incidence and characteristics of reconciliation errors in ICU are similar to those published in non-critically ill patients, and they affect drugs with high clinical significance. Our data support the importance of the stablishment of medication reconciliation proceedings in critically ill patients. The ICU's pharmacist could carry out this procedure adequately. Copyright © 2013 Elsevier España, S.L. and SEMICYUC. All rights reserved.

  11. Lateral positioning for critically ill adult patients.

    Science.gov (United States)

    Hewitt, Nicky; Bucknall, Tracey; Faraone, Nardene M

    2016-05-12

    Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes. To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals. We included randomized and quasi-randomized trials examining effects of

  12. The incretin effect in critically ill patients

    DEFF Research Database (Denmark)

    Nielsen, Signe Tellerup; Janum, Susanne; Krogh-Madsen, Rikke

    2015-01-01

    INTRODUCTION: Patients admitted to the intensive care unit often develop hyperglycaemia, but the underlying mechanisms have not been fully described. The incretin effect is reduced in patients with type 2 diabetes. Type 2 diabetes and critical illness have phenotypical similarities, such as hyper...

  13. Melatonin Secretion Pattern in Critically Ill Patients

    DEFF Research Database (Denmark)

    Boyko, Yuliya; Holst, René; Jennum, Poul

    2017-01-01

    effect of remifentanil on melatonin secretion. We found that the risk of atypical sleep compared to normal sleep was significantly lower (p REM) sleep was only observed during the nonsedation period. We found preserved diurnal pattern of melatonin...... secretion in these patients. Remifentanil did not affect melatonin secretion but was associated with lower risk of atypical sleep pattern. REM sleep was only registered during the period of nonsedation.......Critically ill patients have abnormal circadian and sleep homeostasis. This may be associated with higher morbidity and mortality. The aims of this pilot study were (1) to describe melatonin secretion in conscious critically ill mechanically ventilated patients and (2) to describe whether melatonin...

  14. Glucose metabolism in critically ill patients

    DEFF Research Database (Denmark)

    Nielsen, Signe Tellerup; Krogh-Madsen, Rikke; Møller, Kirsten

    2015-01-01

    glucose (BG). This is taken advantage of in the treatment of patients with T2DM, for whom GLP-1 analogs have been introduced during the recent years. Infusion of GLP-1 also lowers the BG level in critically ill patients without causing severe hypoglycemia. The T2DM and critical illness share similar......, stimulates insulin secretion and inhibits glucagon release both in healthy individuals and in patients with type 2 diabetes (T2DM). Compared to insulin, GLP-1 appears to be associated with a lower risk of severe hypoglycemia, probably because the magnitude of its insulinotropic action is dependent on blood...

  15. Recent and proposed changes in criticality alarm system requirements

    International Nuclear Information System (INIS)

    Putman, V.L.

    1998-01-01

    Various changes in criticality alarm system (CAS) requirements of American Nuclear Society (ANS) standards, US Department of Energy (DOE) orders, US Nuclear Regulatory Commission (NRC) regulations and guidance, and Occupational Safety and Health Administration (OSHA) standards or regulations were approved or proposed in the last 5 yr. Many changes interpreted or clarified existing requirements or accommodated technological or organizational developments. However, some changes could substantively affect CAS programs, including several changes originally thought to be editorial. These changes are discussed here

  16. Critical thinking in patient centered care.

    Science.gov (United States)

    Mitchell, Shannon H; Overman, Pamela; Forrest, Jane L

    2014-06-01

    Health care providers can enhance their critical thinking skills, essential to providing patient centered care, by use of motivational interviewing and evidence-based decision making techniques. The need for critical thinking skills to foster optimal patient centered care is being emphasized in educational curricula for health care professions. The theme of this paper is that evidence-based decision making (EBDM) and motivational interviewing (MI) are tools that when taught in health professions educational programs can aid in the development of critical thinking skills. This paper reviews the MI and EBDM literature for evidence regarding these patient-centered care techniques as they relate to improved oral health outcomes. Comparisons between critical thinking and EBDM skills are presented and the EBDM model and the MI technique are briefly described followed by a discussion of the research to date. The evidence suggests that EBDM and MI are valuable tools; however, further studies are needed regarding the effectiveness of EBDM and MI and the ways that health care providers can best develop critical thinking skills to facilitate improved patient care outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.

  17. Definition of areas requiring criticality alarm annunciation and emergency control

    International Nuclear Information System (INIS)

    Hobson, J.M.

    1988-01-01

    The design of fissile material handling at British Nuclear Fuels plc requires the provision of a criticality incident detection system unless a specific case for omission can be formally made. Where such systems are provided, the 100 mSv contour resulting from a reference criticality incident must be restricted to an area of administrative control within which it is reasonably practicable to provide alarm annunciation and for which emergency arrangements can be defined. For typical reprocessing plant applications, the definition of these areas, and their restriction by provision of shielding where necessary, potentially requires a very large number of three dimensional neutron transport calculations in complex geometries. However, by considering the requirements and nature of this assessment, simple generic methods have been developed and justified. Consequently, rapid and inexpensive assessments of control areas can be carried out

  18. The optimal blood glucose level for critically ill adult patients.

    Science.gov (United States)

    Lv, Shaoning; Ross, Paul; Tori, Kathleen

    2017-09-01

    Glycaemic control is recognized as one of the important aspects in managing critically ill patients. Both hyperglycaemia and hypoglycaemia independently increase the risk of patient mortality. Hence, the identification of optimal glycaemic control is of paramount importance in the management of critically ill patients. The aim of this literature review is to examine the current status of glycaemic control in critically ill adult patients. This literature review will focus on randomized controlled trials comparing intensive insulin therapy to conventional insulin therapy, with an objective to identify optimal blood glucose level targets for critically ill adult patients. A literature review was conducted to identify large randomized controlled trials for the optimal targeted blood glucose level for critically ill adult patients published since 2000. A total of eight studies fulfilled the selection criteria of this review. With current human and technology resources, the results of the studies support commencing glycaemic control once the blood glucose level of critically ill patients reaches 10 mmol/L and maintaining this level between 8 mmol/L and 10 mmol/L. This literature review provides a recommendation for targeting the optimal blood glucose level for critically ill patients within moderate blood glucose level target range (8-10 mmol/L). The need for uniformed glucometrics for unbiased reporting and further research for optimal blood glucose target is required, especially in light of new technological advancements in closed-loop insulin delivery and monitoring devices. This literature review has revealed a need to call for consensus in the measurement and reporting of glycaemic control using standardized glucometrics. © 2017 British Association of Critical Care Nurses.

  19. Critical Business Requirements Model and Metrics for Intranet ROI

    OpenAIRE

    Luqi; Jacoby, Grant A.

    2005-01-01

    Journal of Electronic Commerce Research, Vol. 6, No. 1, pp. 1-30. This research provides the first theoretical model, the Intranet Efficiency and Effectiveness Model (IEEM), to measure intranet overall value contributions based on a corporation’s critical business requirements by applying a balanced baseline of metrics and conversion ratios linked to key business processes of knowledge workers, IT managers and business decision makers -- in effect, closing the gap of understanding...

  20. Critical analysis of radiologist-patient interaction.

    Science.gov (United States)

    Morris, K J; Tarico, V S; Smith, W L; Altmaier, E M; Franken, E A

    1987-05-01

    A critical incident interview technique was used to identify features of radiologist-patient interactions considered effective and ineffective by patients. During structured interviews with 35 radiology patients and five patients' parents, three general categories of physician behavior were described: attention to patient comfort, explanation of procedure and results, and interpersonal sensitivity. The findings indicated that patients are sensitive to physicians' interpersonal styles and that they want physicians to explain procedures and results in an understandable manner and to monitor their well-being during procedures. The sample size of the study is small; thus further confirmation is needed. However, the implications for training residents and practicing radiologists in these behaviors are important in the current competitive medical milieu.

  1. Ethics research in critically ill patients.

    Science.gov (United States)

    Estella, A

    2018-05-01

    Research in critical care patients is an ethical obligation. The ethical conflicts of intensive care research arise from patient vulnerability, since during ICU admission these individuals sometimes lose all or part of their decision making capacity and autonomy. We therefore must dedicate effort to ensure that neither treatment (sedation or mechanical ventilation) nor the disease itself can affect the right to individual freedom of the participants in research, improving the conditions under which informed consent must be obtained. Fragility, understood as a decrease in the capacity to tolerate adverse effects derived from research must be taken into account in selecting the participants. Research should be relevant, not possible to carry out in non-critical patients, and a priori should offer potential benefits that outweigh the risks that must be known and assumable, based on principles of responsibility. Copyright © 2018 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

  2. Antithrombin III for critically ill patients

    DEFF Research Database (Denmark)

    Allingstrup, Mikkel; Wetterslev, Jørn; Ravn, Frederikke B

    2016-01-01

    Background: Critical illness is associated with uncontrolled inflammation and vascular damage which can result in multiple organ failure and death. Antithrombin III (AT III) is an anticoagulant with anti-inflammatory properties but the efficacy and any harmful effects of AT III supplementation...... in critically ill patients are unknown. This review was published in 2008 and updated in 2015.  Objectives: To examine: 1. The effect of AT III on mortality in critically ill participants. 2. The benefits and harms of AT III. We investigated complications specific and not specific to the trial intervention......, bleeding events, the effect on sepsis and disseminated intravascular coagulation (DIC) and the length of stay in the intensive care unit (ICU) and in hospital in general.  Search methods: We searched the following databases from inception to 27 August 2015: Cochrane Central Register of Controlled Trials...

  3. Infections in critically ill burn patients.

    Science.gov (United States)

    Hidalgo, F; Mas, D; Rubio, M; Garcia-Hierro, P

    2016-04-01

    Severe burn patients are one subset of critically patients in which the burn injury increases the risk of infection, systemic inflammatory response and sepsis. The infections are usually related to devices and to the burn wound. Most infections, as in other critically ill patients, are preceded by colonization of the digestive tract and the preventative measures include selective digestive decontamination and hygienic measures. Early excision of deep burn wound and appropriate use of topical antimicrobials and dressings are considered of paramount importance in the treatment of burns. Severe burn patients usually have some level of systemic inflammation. The difficulty to differentiate inflammation from sepsis is relevant since therapy differs between patients with and those without sepsis. The delay in prescribing antimicrobials increases morbidity and mortality. Moreover, the widespread use of antibiotics for all such patients is likely to increase antibiotic resistance, and costs. Unfortunately the clinical usefulness of biomarkers for differential diagnosis between inflammation and sepsis has not been yet properly evaluated. Severe burn injury induces physiological response that significantly alters drug pharmacokinetics and pharmacodynamics. These alterations impact antimicrobials distribution and excretion. Nevertheless the current available literature shows that there is a paucity of information to support routine dose recommendations. Copyright © 2016. Publicado por Elsevier España, S.L.U.

  4. Analyzing Software Requirements Errors in Safety-Critical, Embedded Systems

    Science.gov (United States)

    Lutz, Robyn R.

    1993-01-01

    This paper analyzes the root causes of safety-related software errors in safety-critical, embedded systems. The results show that software errors identified as potentially hazardous to the system tend to be produced by different error mechanisms than non- safety-related software errors. Safety-related software errors are shown to arise most commonly from (1) discrepancies between the documented requirements specifications and the requirements needed for correct functioning of the system and (2) misunderstandings of the software's interface with the rest of the system. The paper uses these results to identify methods by which requirements errors can be prevented. The goal is to reduce safety-related software errors and to enhance the safety of complex, embedded systems.

  5. Nosocomial pneumonia in critically ill patients

    Directory of Open Access Journals (Sweden)

    Dandagi Girish

    2010-01-01

    Full Text Available The care of critically ill patients in the intensive care unit (ICU is a primary component of modern medicine. ICUs create potential for recovery in patients who otherwise may not have survived. However, they may suffer from problems associated with of nosocomial infections. Nosocomial infections are those which manifest in patients 48 hours after admission to hospital. Nosocomial infections are directly related to diagnostic, interventional or therapeutic procedures a patient undergoes in hospital, and are also influenced by the bacteriological flora prevailing within a particular unit or hospital. Urinary tract infections are the most frequent nosocomial infection, accounting for more than 40% of all nosocomial infections. Critical care units increasingly use high technology medicine for patient care, hemodynamic monitoring, ventilator support, hemodialysis, parenteral nutrition, and a large battery of powerful drugs, particularly antibiotics to counter infection. It is indeed a paradox that the use of high-tech medicine has brought in its wake the dangerous and all too frequent complication of nosocomial infections

  6. The critically ill obstetric patient - Recent concepts

    Directory of Open Access Journals (Sweden)

    Anjan Trikha

    2010-01-01

    Full Text Available Obstetric patients admitted to an Intensive Care Unit (ICU present a challenge to an intensivist because of normal physiological changes associated with pregnancy and puerperium, the specific medical diseases peculiar to pregnancy and the need to take care of both the mother and the foetus. Most common causes of admission to an ICU for obstetric patients are eclampsia, severe preeclampsia, haemorrhage, congenital and valvular heart disease, septic abortions, severe anemia, cardiomyopathy and non-obstetric sepsis. The purpose of this review is to present the recent concepts in critical care management of obstetric patients with special focus mainly on ventilatory strategies, treatment of shock and nutrition. The details regarding management of individual diseases would not be discussed as these would be beyond the purview of this article. In addition, some specific issues of importance while managing such patients would also be highlighted.

  7. Hyperglycemia and mortality in critically ill patients

    International Nuclear Information System (INIS)

    Rezvanfar, M.R.; Dalvandy, M.; Emami, A.R.; Rafiee, M.; Eshratee, B.

    2009-01-01

    To analyze the relation between serum glucose concentration and hospital outcome across the critically ill patients. A single-centre, retrospective study was performed at surgical and medical intensive care unit. Admission glucose, mean morning glucose, mean glucose, maximal glucose and time-averaged glucose levels were calculated for each patient. The time-averaged hyperglycemia was defined as the area under the curve above the upper limit of normal, divided by the total length of stay. Of 300 patients with a median stay of 16 days, the mortality rate was 32%. Mean fasting glucose was 121 mg/dl in survivors versus 160 mg/dl in non survivors (P=0.001). Mean admission glucose was 127 mg/dl in survivors versus 142 mg/dl in non survivors (0.03). Median time-averaged hyperglycemia was 4 mg/dl in survivors versus 17.5 mg/dl in non survivors (P < 0.006). The area under the receiver operator characteristic (ROC) curve was 0.59 for time-averaged glucose and 0.73 for mean fasting glucose. Whereas time-averaged hyperglycemia is a useful assessment for glucose control in critically ill patients, it has no priority to admission glucose and mean fasting glucose for outcome prediction. (author)

  8. Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes

    Science.gov (United States)

    Chou, Deng-Wei; Wu, Shu-Ling; Chung, Kuo-Mou; Han, Shu-Chen; Cheung, Bruno Man-Hon

    2016-01-01

    OBJECTIVES: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential. PMID:27759843

  9. Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes

    Directory of Open Access Journals (Sweden)

    Deng-Wei Chou

    Full Text Available OBJECTIVES: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%. The most common computed tomographic findings included a feeding vessel sign (90%, peripheral nodules without cavities (80% or with cavities (65%, and peripheral wedge-shaped opacities (75%. The most common primary source of infection was liver abscess (40%, followed by pneumonia (25%. The two most frequent causative pathogens were Klebsiella pneumoniae (50% and Staphylococcus aureus (35%. Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential.

  10. [Evaluation and treatment of the critically ill cirrhotic patient].

    Science.gov (United States)

    Fernández, Javier; Aracil, Carles; Solà, Elsa; Soriano, Germán; Cinta Cardona, Maria; Coll, Susanna; Genescà, Joan; Hombrados, Manoli; Morillas, Rosa; Martín-Llahí, Marta; Pardo, Albert; Sánchez, Jordi; Vargas, Victor; Xiol, Xavier; Ginès, Pere

    2016-11-01

    Cirrhotic patients often develop severe complications requiring ICU admission. Grade III-IV hepatic encephalopathy, septic shock, acute-on-chronic liver failure and variceal bleeding are clinical decompensations that need a specific therapeutic approach in cirrhosis. The increased effectiveness of the treatments currently used in this setting and the spread of liver transplantation programs have substantially improved the prognosis of critically ill cirrhotic patients, which has facilitated their admission to critical care units. However, gastroenterologists and intensivists have limited knowledge of the pathogenesis, diagnosis and treatment of these complications and of the prognostic evaluation of critically ill cirrhotic patients. Cirrhotic patients present alterations in systemic and splanchnic hemodynamics, coagulation and immune dysfunction what further increase the complexity of the treatment, the risk of developing new complications and mortality in comparison with the general population. These differential characteristics have important diagnostic and therapeutic implications that must be known by general intensivists. In this context, the Catalan Society of Gastroenterology and Hepatology requested a group of experts to draft a position paper on the assessment and treatment of critically ill cirrhotic patients. This article describes the recommendations agreed upon at the consensus meetings and their main conclusions. Copyright © 2015 Elsevier España, S.L.U. y AEEH y AEG. All rights reserved.

  11. Phenytoin pharmacokinetics in critically ill trauma patients.

    Science.gov (United States)

    Boucher, B A; Rodman, J H; Jaresko, G S; Rasmussen, S N; Watridge, C B; Fabian, T C

    1988-12-01

    Preliminary data have suggested that phenytoin systemic clearance may increase during initial therapy in critically ill patients. The objectives for this study were to model the time-variant phenytoin clearance and evaluate concomitant changes in protein binding and urinary metabolite elimination. Phenytoin was given as an intravenous loading dose of 15 mg/kg followed by an initial maintenance dose of 6 mg/kg/day in 10 adult critically ill trauma patients. Phenytoin bound and unbound plasma concentrations were determined in 10 patients and urinary excretion of the metabolite p-hydroxyphenyl phenylhydantoin (p-HPPH) was measured in seven patients for 7 to 14 days. A Michaelis-Menten one-compartment model incorporating a time-variant maximal velocity (Vmax) was sufficient to describe the data and superior to a conventional time-invariant Michaelis-Menten model. Vmax for the time-variant model was defined as V'max + Vmax delta (1 - e(-kindt)). Vmax infinity is the value for Vmax when t is large. The median values (ranges) for the parameters were Km = 4.8 (2.6 to 20) mg/L, Vmax infinity = 1348 (372 to 4741) mg/day, and kind = 0.0115 (0.0045 to 0.132) hr-1. Phenytoin free fraction increased in a majority of patients during the study period, with a binding ratio inversely related to albumin. Measured urinary p-HPPH data were consistent with the proposed model. A loading and constant maintenance dose of phenytoin frequently yielded a substantial, clinically significant fall in plasma concentrations with a pattern of apparently increasing clearance that may be a consequence of changes in protein binding, induction of metabolism, or the influence of stress on hepatic metabolic capacity.

  12. Clinical use of lactate monitoring in critically ill patients

    NARCIS (Netherlands)

    J. Bakker (Jan); M.W.N. Nijsten (Maarten); T.C. Jansen (Tim)

    2013-01-01

    textabstractIncreased blood lactate levels (hyperlactataemia) are common in critically ill patients. Although frequently used to diagnose inadequate tissue oxygenation, other processes not related to tissue oxygenation may increase lactate levels. Especially in critically ill patients, increased

  13. Remifentanil in critically ill cardiac patients

    Directory of Open Access Journals (Sweden)

    Ruggeri Laura

    2011-01-01

    Full Text Available Remifentanil has a unique pharmacokinetic profile, with a rapid onset and offset of action and a plasmatic metabolism. Its use can be recommended even in patients with renal impairment, hepatic dysfunction or poor cardiovascular function. A potential protective cardiac preconditioning effect has been suggested. Drug-related adverse effects seem to be comparable with other opioids. In cardiac surgery, many randomized controlled trials demonstrated that the potential benefits of the use of remifentanil not only include a profound protection against intraoperative stressful stimuli, but also rapid postoperative recovery, early weaning from mechanical ventilation, and extubation. Remifentanil shows ideal properties of sedative agents being often employed for minimally invasive cardiologic techniques, such as transcatheter aortic valve implantation and radio frequency treatment of atrial flutter, or diagnostic procedures such as transesophageal echocardiography. In intensive care units remifentanil is associated with a reduction in the time to tracheal extubation after cessation of the continuous infusion; other advantages could be more evident in patients with organ dysfunction. Effective and safe analgesia can be provided in case of short and painful procedures (i.e. chest drain removal. In conclusion, thanks to its peculiar properties, remifentanil will probably play a major role in critically ill cardiac patients.

  14. Air Transportation of Critically Ill Patients

    Directory of Open Access Journals (Sweden)

    E. P. Rodionov

    2008-01-01

    Full Text Available During the Napoleonic wars, balloon evacuation of the wounded was the first to be made in the history when Paris was being defended. In the USA, casualty helicopters are being used in 20% of cases on evacuating the victims from the accident scene and in 80% during interhospital transportation. Russia also shows an ambiguous approach to employing air medical service — from the wide use of air transportation in the country’s regions that are difficult of access to its almost complete refusal in the regions with the well-developed transportation system. Long-distance transportation of critically ill patients by chartered or commercial planes is the reality of our time. In each region, continuing specialized teams of qualified medical workers who have a good knowledge of altitude pathophysiology and handle the obligatorily certified equipment should be created on the basis of large-scale medical centers.

  15. Ventilator Technologies Sustain Critically Injured Patients

    Science.gov (United States)

    2012-01-01

    Consider this scenario: A soldier has been critically wounded in a sudden firefight in a remote region of Afghanistan. The soldier s comrades attend to him and radio for help, but the soldier needs immediate medical expertise and treatment that is currently miles away. The connection between medical support for soldiers on the battlefield and astronauts in space may not be immediately obvious. But when it comes to providing adequate critical care, NASA and the military have very similar operational challenges, says Shannon Melton of NASA contractor Wyle Integrated Science and Engineering. Melton works within Johnson Space Center s Space Medicine Division, which supports astronaut crew health before, during, and after flight. In space, we have a limited number of care providers, and those providers are not always clinicians with extensive medical training. We have limited room to provide care, limited consumables, and our environment is not like that of a hospital, she says. The Space Medicine Division s Advanced Projects Group works on combining the expertise of both clinicians and engineers to develop new capabilities that address the challenges of medical support in space, including providing care to distant patients. This field, called telemedicine, blends advanced communications practices and technologies with innovative medical devices and techniques to allow caregivers with limited or no medical experience to support a patient s needs. NASA, just by its nature, has been doing remote medicine since the beginning of the Space Program, says Melton, an engineer in the Advanced Projects Group. Since part of NASA s mandate is to transfer the results of its technological innovation for the benefit of the public, the Agency has worked with doctors and private industry to find ways to apply the benefits of space medicine on Earth. In one such case, a NASA partnership has resulted in new technologies that may improve the quality of emergency medicine for wounded

  16. Critical Infrastructure Awareness Required by Civil Emergency Planning

    NARCIS (Netherlands)

    Luiijf, H.A.M.; Klaver, M.H.A.

    2005-01-01

    Modern societies are increasingly dependent on a set of critical products and services which comprise the Critical Infrastructure (CI). This makes Critical infrastructures increasingly important as a planning factor in case of emergencies. For that reason, we studied a number of emergencies and a

  17. Continuous oscillation: outcome in critically ill patients.

    Science.gov (United States)

    Traver, G A; Tyler, M L; Hudson, L D; Sherrill, D L; Quan, S F

    1995-09-01

    To compare turning by an oscillating bed to standard 2-hour turning. Outcomes were survival, length of stay (LOS), duration of mechanical ventilation, and incidence of pneumonia. One hundred and three intensive care patients were randomly assigned to standard turning or turning by an oscillating bed. Data, collected at baseline, daily for 7 days, and then three times weekly until study discharge, included demographics, initial Acute Physiology and Chronic Health Evaluation (APACHE II) score, ventilatory/gas exchange parameters, indicators of pneumonia, nursing measures, and chest roentgenograph. There were no significant differences for LOS, duration of ventilation, nor incidence of pneumonia. Higher survival for subjects on the oscillating bed reached borderline significance (P = .056) for subjects with APACHE II greater than or equal to 20. Longitudinal data were analyzed using the random effects model. No differences in ventilatory or gas exchange parameters were identified. Among subjects who developed pneumonia there was a significantly higher respiratory score (nursing acuity scale) for subjects on the oscillating bed. In selected critically ill patients oscillating therapy may improve survival and improve airway clearance. The frequency and degree of turning needed to prevent complications and improve outcome remains unclear. These newer beds should be used with discrimination so as to not increase hospital costs unnecessarily.

  18. Enteral nutrition therapy for critically ill adult patients; critical review and algorithm creation.

    Science.gov (United States)

    Araújo-Junqueira, L; De-Souza, Daurea A

    2012-01-01

    Undernutrition directly affects critically ill patient's clinical outcome and mortality rates. Interdisciplinar algorithm creation aiming to optimize the enteral nutrition therapy for critically ill adult patients. Pubmed, SciELO, Scholar Google, Web of Science, Scopus, with research of these key words: protocols, enteral nutrition, nutritional support, critical care, undernutrition, fasting. Intensive Care Unit, Hospital de Clínicas, Federal University of Uberlándia, MG, Brazil. Were established in the algorithm a following sequential steps: After a clinical-surgical diagnosis, including the assessment of hemodynamic stability, were requested passage of a feeding tube in post-pyloric position and a drainage tube in gastric position. After hemodynamic stability it should be done the nutritional status diagnosis, calculated nutritional requirements, as well as chosen formulation of enteral feeding. Unless contraindicated, aiming to increase tolerance was started infusion with small volumes (15 ml/h) of a semi-elemental diet, normocaloric, hypolipidic (also hyperproteic, with addition of glutamine). To ensure infusion of the diet, as well as the progressive increase of infusion rates, the patient was monitored for moderate or severe intestinal intolerance. The schedule and infusion rates were respected and diet was not routinely suspended for procedures and diagnostic tests, unless indicated by the medical team. For nutrition therapy success it is essential routine monitoring and extensive interaction between the professionals involved. Nutritional conducts should be reevaluated and improved, seeking complete and specialized care to the critically ill patients. Adherence to new practices is challenging, though instruments such as protocols and algorithms help making information more accessible and comprehensible.

  19. [Fish oil containing lipid emulsions in critically ill patients: Critical analysis and future perspectives].

    Science.gov (United States)

    Manzanares, W; Langlois, P L

    2016-01-01

    Third-generation lipid emulsions (LE) are soybean oil sparing strategies with immunomodulatory and antiinflammatory effects. Current evidence supporting the use of intravenous (i.v) fish oil (FO) LE in critically ill patients requiring parenteral nutrition or receiving enteral nutrition (pharmaconutrient strategy) mainly derives from small phase ii clinical trials in heterogenous intensive care unit patient's population. Over the last three years, there have been published different systematic reviews and meta-analyses evaluating the effects of FO containing LE in the critically ill. Recently, it has been demonstrated that i.v FO based LE may be able to significantly reduce the incidence of infections as well as mechanical ventilation days and hospital length of stay. Nonetheless, more robust evidence is required before giving a definitive recommendation. Finally, we strongly believe that a dosing study is required before new phase iii clinical trials comparing i.v FO containing emulsions versus other soybean oil strategies can be conducted. Copyright © 2015 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

  20. Should we mobilise critically ill patients? A review.

    LENUS (Irish Health Repository)

    O'Connor, Enda D

    2009-12-01

    Neuromuscular weakness, a frequent complication of prolonged bed rest and critical illness, is associated with morbidity and mortality. Mobilisation physiotherapy has widespread application in patients hospitalised with non-critical illness.

  1. Regulatory considerations for computational requirements for nuclear criticality safety

    International Nuclear Information System (INIS)

    Bidinger, G.H.

    1995-01-01

    As part of its safety mission, the U.S. Nuclear Regulatory Commission (NRC) approves the use of computational methods as part of the demonstration of nuclear criticality safety. While each NRC office has different criteria for accepting computational methods for nuclear criticality safety results, the Office of Nuclear Materials Safety and Safeguards (NMSS) approves the use of specific computational methods and methodologies for nuclear criticality safety analyses by specific companies (licensees or consultants). By contrast, the Office of Nuclear Reactor Regulation approves codes for general use. Historically, computational methods progressed from empirical methods to one-dimensional diffusion and discrete ordinates transport calculations and then to three-dimensional Monte Carlo transport calculations. With the advent of faster computational ability, three-dimensional diffusion and discrete ordinates transport calculations are gaining favor. With the proper user controls, NMSS has accepted any and all of these methods for demonstrations of nuclear criticality safety

  2. Pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients.

    OpenAIRE

    Chin, T W; Vandenbroucke, A; Fong, I W

    1995-01-01

    Current dosage regimens of trimethoprim-sulfamethoxazole used to treat Pneumocystis carinii pneumonia in AIDS patients have been based on data from healthy subjects or patients without AIDS. The clearance and absorption characteristics of the drugs may potentially be different between patients with and without AIDS. This study was conducted to assess the pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients treated for P. carinii pneumonia. P...

  3. Assessing burden in families of critical care patients.

    Science.gov (United States)

    Kentish-Barnes, Nancy; Lemiale, Virginie; Chaize, Marine; Pochard, Frédéric; Azoulay, Elie

    2009-10-01

    To provide critical care clinicians with information on validated instruments for assessing burden in families of critical care patients. PubMed (1979-2009). We included all quantitative studies that used a validated instrument to evaluate the prevalence of, and risk factors for, burden on families. We extracted the descriptions of the instruments used and the main results. Family burden after critical illness can be detected reliably and requires preventive strategies and specific treatments. Using simple face-to-face interviews, intensivists can learn to detect poor comprehension and its determinants. Instruments for detecting symptoms of anxiety, depression, or stress can be used reliably even by physicians with no psychiatric training. For some symptoms, the evaluation should take place at a distance from intensive care unit discharge or death. Experience with families of patients who died in the intensive care unit and data from the literature have prompted studies of bereaved family members and the development of interventions aimed at decreasing guilt and preventing complicated grief. We believe that burden on families should be assessed routinely. In clinical studies, using markers for burden measured by validated tools may provide further evidence that effective communication and efforts to detect and to prevent symptoms of stress, anxiety, or depression provide valuable benefits to families.

  4. Does gender influence outcomes in critically ill patients?

    OpenAIRE

    Angele, Martin K; Pratschke, Sebastian; Chaudry, Irshad H

    2012-01-01

    Investigators continue to debate whether gender plays any role in patient outcome following injury/critical illness. We submit that age and hormonal milieu at the time of injury, rather than gender, are the critical factors influencing patient outcome under those conditions.

  5. Highlighting the gap between critical outcomes requirements and built environment education in South Africa

    CSIR Research Space (South Africa)

    Ampofo-Anti, NL

    2007-06-01

    Full Text Available This paper aims to highlight the discrepancies between current built environment education and Critical Outcomes requirements of the South African National Qualifications Framework (NQF)...

  6. Critical Service Learning across Two Required Marketing Classes

    Science.gov (United States)

    Crutchfield, Tammy Neal

    2017-01-01

    Business service learning projects have the potential to be a state-of-the-art instructional laboratory to teach and apply theory and make a substantial impact on the community. In this article, the author presents a service learning project that is embedded in two consecutive required courses of the marketing major and has been conducted and…

  7. Patients' opinions on outcomes following critical illness

    DEFF Research Database (Denmark)

    Nedergaard, H K; Haberlandt, T; Reichmann, P D

    2018-01-01

    BACKGROUND: Our aim was to explore which outcomes are most important to patients following ICU-discharge, and to explore whether intensive care unit (ICU)-nurses and anesthesiologists are aware of patients' priorities. METHODS: First, interviews with adult ICU-survivors were conducted until data......, fatigue, and decreased walking distance. The top three for ICU-nurses (54 participants) were: fatigue, difficulties concentrating, sadness/depression, and for anesthesiologists (17 participants): fatigue, difficulties in activities of daily living, and lack of physical strength. CONCLUSION: Patients chose......-ICU discharge) rated the items, as did ICU-nurses and anesthesiologists. RESULTS: A total of 32 patients participated (44% women, medians: age 70.5, time since discharge 179 days, length of stay in ICU 9 days, APACHEII 19.5). The three most important outcomes defined by patients were: lack of physical strength...

  8. Predicting recovery from acute kidney injury in critically ill patients

    DEFF Research Database (Denmark)

    Itenov, Theis S; Berthelsen, Rasmus Ehrenfried; Jensen, Jens-Ulrik

    2018-01-01

    these patients. DESIGN: Observational study with development and validation of a risk prediction model. SETTING: Nine academic ICUs in Denmark. PARTICIPANTS: Development cohort of critically ill patients with AKI at ICU admission from the Procalcitonin and Survival Study cohort (n = 568), validation cohort.......1%. CONCLUSION: We constructed and validated a simple model that can predict the chance of recovery from AKI in critically ill patients....

  9. Diversity requirements for safety critical software-based automation systems

    International Nuclear Information System (INIS)

    Korhonen, J.; Pulkkinen, U.; Haapanen, P.

    1998-03-01

    System vendors nowadays propose software-based systems even for the most critical safety functions in nuclear power plants. Due to the nature and mechanisms of influence of software faults new methods are needed for the safety and reliability evaluation of these systems. In the research project 'Programmable automation systems in nuclear power plants (OHA)' various safety assessment methods and tools for software based systems are developed and evaluated. This report first discusses the (common cause) failure mechanisms in software-based systems, then defines fault-tolerant system architectures to avoid common cause failures, then studies the various alternatives to apply diversity and their influence on system reliability. Finally, a method for the assessment of diversity is described. Other recently published reports in OHA-report series handles the statistical reliability assessment of software based (STUK-YTO-TR 119), usage models in reliability assessment of software-based systems (STUK-YTO-TR 128) and handling of programmable automation in plant PSA-studies (STUK-YTO-TR 129)

  10. Arterial carboxyhemoglobin level and outcome in critically ill patients.

    Science.gov (United States)

    Melley, Daniel D; Finney, Simon J; Elia, Androula; Lagan, Anna L; Quinlan, Gregory J; Evans, Timothy W

    2007-08-01

    Arterial carboxyhemoglobin is elevated in patients with critical illness. It is an indicator of the endogenous production of carbon monoxide by the enzyme heme oxygenase, which modulates the response to oxidant stress. The objective was to explore the hypothesis that arterial carboxyhemoglobin level is associated with inflammation and survival in patients requiring cardiothoracic intensive care. Prospective, observational study. A cardiothoracic intensive care unit. All patients admitted over a 15-month period. None. Arterial carboxyhemoglobin, bilirubin, and standard biochemical, hematologic, and physiologic markers of inflammation were measured in 1,267 patients. Associations were sought between levels of arterial carboxyhemoglobin, markers of the inflammatory response, and clinical outcome. Intensive care unit mortality was associated with lower minimum and greater maximal carboxyhemoglobin levels (p carboxyhemoglobin was associated with an increased risk of death from all causes (odds risk of death, 0.391; 95% confidence interval, 0.190-0.807; p = .011). Arterial carboxyhemoglobin correlated with markers of the inflammatory response. Both low minimum and high maximum levels of arterial carboxyhemoglobin were associated with increased intensive care mortality. Although the heme oxygenase system is protective, excessive induction may be deleterious. This suggests that there may be an optimal range for heme oxygenase-1 induction.

  11. Providing care for critically ill surgical patients: challenges and recommendations.

    Science.gov (United States)

    Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M

    2013-07-01

    Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.

  12. Pharmacokinetics of Intravenous Posaconazole in Critically Ill Patients.

    Science.gov (United States)

    Sime, Fekade B; Stuart, Janine; Butler, Jenie; Starr, Therese; Wallis, Steven C; Pandey, Saurabh; Lipman, Jeffrey; Roberts, Jason A

    2018-06-01

    To date, there is no information on the intravenous (i.v.) posaconazole pharmacokinetics for intensive care unit (ICU) patients. This prospective observational study aimed to describe the pharmacokinetics of a single dose of i.v. posaconazole in critically ill patients. Patients with no history of allergy to triazole antifungals and requiring systemic antifungal therapy were enrolled if they were aged ≥18 years, central venous access was available, they were not pregnant, and they had not received prior posaconazole or drugs interacting with posaconazole. A single dose of 300 mg posaconazole was administered over 90 min. Total plasma concentrations were measured from serial plasma samples collected over 48 h, using a validated chromatographic method. The pharmacokinetic data set was analyzed by noncompartmental methods. Eight patients (7 male) were enrolled with the following characteristics: median age, 46 years (interquartile range [IQR], 40 to 51 years); median weight, 68 kg (IQR, 65 to 82 kg); and median albumin concentration, 20 g/liter (IQR, 18 to 24 g/liter). Median (IQR) pharmacokinetic parameter estimates were as follows: observed maximum concentration during sampling period ( C max ), 1,702 ng/ml (1,352 to 2,141 ng/ml); area under the concentration-time curve from zero to infinity (AUC 0-∞ ), 17,932 ng · h/ml (13,823 to 27,905 ng · h/ml); clearance (CL), 16.8 liters/h (11.1 to 21.7 liters/h); and volume of distribution ( V ), 529.1 liters (352.2 to 720.6 liters). The V and CL were greater than 2-fold and the AUC 0-∞ was 39% of the values reported for heathy volunteers. The AUC 0-∞ was only 52% of the steady-state AUC 0-24 reported for hematology patients. The median of estimated average steady-state concentrations was 747 ng/ml (IQR, 576 to 1,163 ng/ml), which is within but close to the lower end of the previously recommended therapeutic range of 500 to 2,500 ng/ml. In conclusion, we observed different pharmacokinetics of i.v. posaconazole in

  13. Continuous infusion of antibiotics in critically ill patients.

    Science.gov (United States)

    Smuszkiewicz, Piotr; Szałek, Edyta; Tomczak, Hanna; Grześkowiak, Edmund

    2013-02-01

    Antibiotics are the most commonly used drugs in intensive care unit patients and their supply should be based on pharmacokinetic/pharmacodynamic rules. The changes that occur in septic patients who are critically ill may be responsible for subtherapeutic antibiotic concentrations leading to poorer clinical outcomes. Evolving in time the disturbed pathophysiology in severe sepsis (high cardiac output, glomerular hyperfiltration) and therapeutic interventions (e.g. haemodynamically active drugs, mechanical ventilation, renal replacement therapy) alters antibiotic pharmacokinetics mainly through an increase in the volume of distribution and altered drug clearance. The lack of new and efficacious drugs and increased bacterial resistance are current problems of contemporary antibiotic therapy. Although intermittent administration is a standard clinical practice, alternative methods of antibiotic administration are sought, which may potentialise effects and reduce toxicity as well as contribute to inhibition of bacterial resistance. A wide range of studies prove that the application of continuous infusion of time-dependent antibiotics (beta-lactams, glycopeptides) is more rational than standard intermittent administration. However, there are also studies which do not confirm the advantage of one method over the other. In spite of controversy the continuous administration of this group of antibiotics is common practice, because the results of both studies point to the higher efficacy of this method in critically ill patients. Authors reviewed the literature to determine whether any clinical benefits exist for administration of time-dependent antibiotics by continuous infusion. Definite specification of the clinical advantage of administration this way over standard dosage requires a large-scale multi-centre randomised controlled trial.

  14. Initial ventilator settings for critically ill patients

    OpenAIRE

    Kilickaya, Oguz; Gajic, Ognjen

    2013-01-01

    The lung-protective mechanical ventilation strategy has been standard practice for management of acute respiratory distress syndrome (ARDS) for more than a decade. Observational data, small randomized studies and two recent systematic reviews suggest that lung protective ventilation is both safe and potentially beneficial in patients who do not have ARDS at the onset of mechanical ventilation. Principles of lung-protective ventilation include: a) prevention of volutrauma (tidal volume 4 to 8 ...

  15. Coronary Artery Disease in critical patients of Iran

    International Nuclear Information System (INIS)

    Zahra, P.M.; Azizollah, A.S.; Masoud, R.; Hamed, S.

    2012-01-01

    Objective: To identify the risk factors for Coronary Artery Diseases (CAD), such as hypertension, hyperlipidaemia, smoking, age, obesity, immobility and diabetes mellitus, in critical patients of Sistan-Baluchistan (SB), Iran. Methods: This cross-sectional research was performed in 2006. The sampling method was convenience, and involved 616 hospitalised patients in the CCUs of hospitals of Sistan-Baluchistan province. Data was collected by structured interview and a checklist which included personal characteristics and risk factors like lifestyles as well as biochemical and physiological factors for CAD. SPSS software, Chi-square and exact fisher tests were used for analysis. Results: Frequency of risk factors among patients with CAD was found to be high in the study area. Also, the results showed that the prevalence of some risk factors, such as diabetes mellitus 198 (32.5%), hypertension 266 (43.7%) and obesity 131 (22.9%), was significantly higher in women than men. Besides, there was a significant relationship between smoking, 317(52.3%) and low mobility 503 (83.3%), with gender (p=0.001). Conclusion: Clinical and para-clinical data indicated that the adult population has a high level of CAD risk factors in the Sistan-Baluchistan province which may require urgent steps to address national control measures regarding CAD. Implementation of a prevention programme is necessary in order to reduce the risk factors. Also, health education is necessary, specially for women. (author)

  16. Preload assessment and optimization in critically ill patients.

    Science.gov (United States)

    Voga, Gorazd

    2010-01-01

    Preload assessment and optimization is the basic hemodynamic intervention in critically ill. Beside clinical assessment, non-invasive or invasive assessment by measurement of various pressure or volume hemodynamic variables, are helpful for estimation of preload and fluid responsiveness. The use of dynamic variables is useful in particular subgroup of critically ill patients. In patients with inadequate preload, fluid responsiveness and inadequate flow, treatment with crystalloids or colloids is mandatory. When rapid hemodynamic response is necessary colloids are preferred.

  17. The meaning of social support for the critically ill patient.

    Science.gov (United States)

    Hupcey, J E

    2001-08-01

    Social support has been shown to be important for the critically ill patient. However, what constitutes adequate support for these patients has not been investigated. Thus, the purpose of this qualitative study was to investigate patients' perceptions of their need for and adequacy of the social support received while they were critically ill. Thirty adult patients who were critical during some point of their stay in the intensive care unit (ICU) stay were interviewed, once stable. Interviews were tape-recorded and began with an open-ended question regarding the ICU experience. This was followed by open-ended focused questions regarding social support, such as 'Who were your greatest sources of social support while you were critically ill?' 'What did they do that was supportive or unsupportive?' Data were analyzed according to Miles and Huberman (1994). The categories that emerged were need for social support based on patient perceptions (not number of visitors), quality of support (based on perceptions of positive and negative behaviors of supporters) and lack of support. This study found that quality of support was more important than the actual number of visitors. Patients with few visitors may have felt supported, while those with numerous visitors felt unsupported. Patients who felt unsupported also were more critical of the staff and the care they received. Nurses need to individually assess patients regarding their need for support, and assist family/friends to meet these needs.

  18. Unilateral mydriasis secondary to ipratropium bromide in a critically ill patient

    Directory of Open Access Journals (Sweden)

    Luciano Santana-Cabrera

    2012-01-01

    Full Text Available Unilateral dilated pupil in a critical patient under sedation is an important clinical sign that requires prompt evaluation. An exhaustive assessment must be performed, including neurological examination and imaging tests, and pharmacological causes must be ruled out. We describe a case of unilateral fixed dilated pupil secondary to the administration of a nebulized cholinergic antagonist, ipratropium bromide, in an unconscious patient.

  19. Criticality Safety Evaluation of Standard Criticality Safety Requirements #1-520 g Operations in PF-4

    Energy Technology Data Exchange (ETDEWEB)

    Yamanaka, Alan Joseph Jr. [Los Alamos National Lab. (LANL), Los Alamos, NM (United States)

    2017-10-13

    Guidance has been requested from the Nuclear Criticality Safety Division (NCSD) regarding processes that involve 520 grams of fissionable material or less. This Level-3 evaluation was conducted and documented in accordance with NCS-AP-004 (Ref. 1), formerly NCS-GUIDE-01. This evaluation is being written as a generic evaluation for all operations that will be able to operate using a 520-gram mass limit. Implementation for specific operations will be performed using a Level 1 CSED, which will confirm and document that this CSED can be used for the specific operation as discussed in NCS-MEMO-17-007 (Ref. 2). This Level 3 CSED updates and supersedes the analysis performed in NCS-TECH-14-014 (Ref. 3).

  20. Nutritional Support of the Critically Ill Pediatric Patient: Foundations and Controversies

    Directory of Open Access Journals (Sweden)

    Iván José Ardila Gómez

    2017-04-01

    Full Text Available Critically ill children require nutritional support that will give them nutritional and non-nutritional support to successfully deal with their disease. In the past few years, we have been able to better understand the pathophysiology of critical illness, which has made possible the establishment of nutritional strategies resulting in an improved nutritional status, thus optimizing the pediatric intensive care unit (PICU stay and decreasing morbidity and mortality. Critical illness is associated with significant metabolic stress. It is crucial to understand the physiological response to stress to create nutritional recommendations for critically ill pediatric patients in the PICU.

  1. Patient autonomy and informed consent in critically lll

    Directory of Open Access Journals (Sweden)

    Todorović Zoran M.

    2017-01-01

    Full Text Available Patient autonomy has been a cornerstone of contemporary clinical ethics since the Nuremberg trial, especially in American school of bioethics. Topic: Patient autonomy has been defined in the Nuremberg Code, and re-defined in the Declaration of Helsinki, Belmont Report and Barcelona Declaration. Founders and followers of the rights-oriented bioethics (for example, Hellegers, Beauchamp and Childers have established and promoted the patient autonomy as the main principle of bio(medical ethics since 1970s. However, there is a lot of controversy surrounding such a principle, especially in vulnerable patients. We aimed at evaluating the real meaning and value of patient autonomy in critical care settings regarding the communication between health workers and their patients and families. Conclusion: Protection of patients autonomy in critically ill is a complex issue. Careful benefit-risk assessment is needed in order to find the most appropriate way of obtaining the informed consent, proxy consent or to omit or delay it.

  2. Daptomycin experience in critical care patients: results from a registry.

    Science.gov (United States)

    Brown, Jack E; Fominaya, Cory; Christensen, Keith J; McConnell, Scott A; Lamp, Kenneth C

    2012-04-01

    Vancomycin is often the drug of choice in critically ill patients with gram-positive infections, although circumstances often prevent its use. In these situations, clinicians are frequently left with limited data regarding alternative agents. To describe patients with reported sepsis receiving daptomycin in a critical care unit. This multicenter, noncomparative, noninterventional study identified patients in critical care units, using the Cubicin Outcomes Registry and Experience (CORE) 2005-2009 registry. A descriptive account of patient characteristics, infectious etiology, outcomes at the end of daptomycin therapy, and 30-day mortality is reported. Nonevaluable patients were excluded from the efficacy analysis but included in the safety analysis. We identified 128 patients, 98 (77%) of whom were evaluable for efficacy. Patient characteristics for the efficacy population were 55 (56%) males, 30 (31%) aged 66 years or older, 38 (39%) had creatinine clearance less than 30 mL/min, and 27 (28%) were on dialysis. Common underlying diseases included acute or chronic renal failure 44 (45%), hypertension 40 (41%), and diabetes 27 (28%). Seventy-two (73%) patients were bacteremic. The most common pathogens found were methicillin-resistant Staphylococcus aureus (32%), vancomycin-resistant Enterococcus faecium (21%), and coagulase-negative staphylococci (20%). Prior to daptomycin, antibiotics were used in 84 (86%) patients, most commonly vancomycin (65/84; 77%). The median (range) initial daptomycin dose was 6 mg/kg (3-10) and duration of 10 days (1-58). Overall success rate was 70% (31% cured; 39% improved). Twelve adverse events possibly related to daptomycin were reported in 9 of 128 (7%) patients in the safety population; 4 of these in 4 (3%) patients were serious. The mortality rate within 30 days of completing daptomycin was 42 of 128 (33%) patients. These data provide preliminary results on the use of daptomycin in critically ill patients with complicated conditions

  3. Low but Sufficient Anidulafungin Exposure in Critically Ill Patients

    NARCIS (Netherlands)

    van Wanrooy, Marjolijn J. P.; Rodgers, Michael G. G.; Uges, Donald R. A.; Arends, Jan P.; Zijlstra, Jan G.; Werf, van der Tjip S.; Kosterink, Jos G. W.; Alffenaar, Jan-Willem C.

    The efficacy of anidulafungin is driven by the area under the concentration-time curve (AUC)/MIC ratio. Patients in intensive care may be at risk for underexposure. In critically ill patients with an invasive Candida infection, the anidulafungin exposure and a possible correlation with disease

  4. Is refeeding syndrome relevant for critically ill patients?

    Science.gov (United States)

    Koekkoek, Wilhelmina A C; Van Zanten, Arthur R H

    2018-03-01

    To summarize recent relevant studies regarding refeeding syndrome (RFS) in critically ill patients and provide recommendations for clinical practice. Recent knowledge regarding epidemiology of refeeding syndrome among critically ill patients, how to identify ICU patients at risk, and strategies to reduce the potential negative impact on outcome are discussed. RFS is a potentially fatal acute metabolic derangement that ultimately can result in marked morbidity and even mortality. These metabolic derangements in ICU patients differ from otherwise healthy patients with RFS, as there is lack of anabolism. This is because of external stressors inducing a hypercatabolic response among other reasons also reflected by persistent high glucagon despite initiation of feeding. Lack of a proper uniform definition complicates diagnosis and research of RFS. However, refeeding hypophosphatemia is commonly encountered during critical illness. The correlations between risk factors proposed by international guidelines and the occurrence of RFS in ICU patients remains unclear. Therefore, regular phosphate monitoring is recommended. Based on recent trials among critically ill patients, only treatment with supplementation of electrolytes and vitamins seems not sufficient. In addition, caloric restriction for several days and gradual increase of caloric intake over days is recommendable.

  5. CSER 95-003: Exemption from Criticality Alarm System requirement for 232-Z building

    International Nuclear Information System (INIS)

    Nirider, L.T.; Miller, E.M.

    1995-01-01

    This CSER establishes an exemption for 232-Z from the requirement for a Criticality Alarm System, because the formation of a critical configuration is not a credible event for any circumstance involving the cleaning out and removal of the Burning Hood and associated equipment

  6. Plasmapheresis and other extracorporeal filtration techniques in critical patients.

    Science.gov (United States)

    Daga Ruiz, D; Fonseca San Miguel, F; González de Molina, F J; Úbeda-Iglesias, A; Navas Pérez, A; Jannone Forés, R

    2017-04-01

    Plasmapheresis is an extracorporeal technique that eliminates macromolecules involved in pathological processes from plasma. A review is made of the technical aspects, main indications in critical care and potential complications of plasmapheresis, as well as of other extracorporeal filtration techniques such as endotoxin-removal columns and other devices designed to eliminate cytokines or modulate the inflammatory immune response in critical patients. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

  7. Milrinone for cardiac dysfunction in critically ill adult patients

    DEFF Research Database (Denmark)

    Koster, Geert; Bekema, Hanneke J; Wetterslev, Jørn

    2016-01-01

    INTRODUCTION: Milrinone is an inotrope widely used for treatment of cardiac failure. Because previous meta-analyses had methodological flaws, we decided to conduct a systematic review of the effect of milrinone in critically ill adult patients with cardiac dysfunction. METHODS: This systematic...... trials were at high risk of bias, and none reported the primary composite outcome SAE. Fourteen trials with 1611 randomised patients reported mortality data at maximum follow-up (RR 0.96; 95% confidence interval 0.76-1.21). Milrinone did not significantly affect other patient-centred outcomes. All...... analyses displayed statistical and/or clinical heterogeneity of patients, interventions, comparators, outcomes, and/or settings and all featured missing data. DISCUSSION: The current evidence on the use of milrinone in critically ill adult patients with cardiac dysfunction suffers from considerable risks...

  8. Advances in Biomarkers in Critical Ill Polytrauma Patients.

    Science.gov (United States)

    Papurica, Marius; Rogobete, Alexandru F; Sandesc, Dorel; Dumache, Raluca; Cradigati, Carmen A; Sarandan, Mirela; Nartita, Radu; Popovici, Sonia E; Bedreag, Ovidiu H

    2016-01-01

    The complexity of the cases of critically ill polytrauma patients is given by both the primary, as well as the secondary, post-traumatic injuries. The severe injuries of organ systems, the major biochemical and physiological disequilibrium, and the molecular chaos lead to a high rate of morbidity and mortality in this type of patient. The 'gold goal' in the intensive therapy of such patients resides in the continuous evaluation and monitoring of their clinical status. Moreover, optimizing the therapy based on the expression of certain biomarkers with high specificity and sensitivity is extremely important because of the clinical course of the critically ill polytrauma patient. In this paper we wish to summarize the recent studies of biomarkers useful for the intensive care unit (ICU) physician. For this study the available literature on specific databases such as PubMed and Scopus was thoroughly analyzed. Each article was carefully reviewed and useful information for this study extracted. The keywords used to select the relevant articles were "sepsis biomarker", "traumatic brain injury biomarker" "spinal cord injury biomarker", "inflammation biomarker", "microRNAs biomarker", "trauma biomarker", and "critically ill patients". For this study to be carried out 556 original type articles were analyzed, as well as case reports and reviews. For this review, 89 articles with relevant topics for the present paper were selected. The critically ill polytrauma patient, because of the clinical complexity the case presents with, needs a series of evaluations and specific monitoring. Recent studies show a series of either tissue-specific or circulating biomarkers that are useful in the clinical status evaluation of these patients. The biomarkers existing today, with regard to the critically ill polytrauma patient, can bring a significant contribution to increasing the survival rate, by adapting the therapy according to their expressions. Nevertheless, the necessity remains to

  9. Causes of death in critically ill multiple sclerosis patients.

    Science.gov (United States)

    Karamyan, A; Brandtner, H; Grinzinger, S; Chroust, V; Bacher, C; Otto, F; Reisp, M; Hauer, L; Sellner, J

    2017-10-01

    Patients with multiple sclerosis (MS) experience higher mortality rates as compared to the general population. While the risk of intensive care unit (ICU) admission is also reported to be higher, little is known about causes of death CoD in critically ill MS patients. To study the causes of death (CoD) in the series of critically ill patients with MS verified by autopsy. We reviewed hospital electronic charts of MS patients treated at the neurological ICU of a tertiary care hospital between 2000 and 2015. We compared clinical and pathological CoD for those who were autopsied. Overall, 10 patients were identified (seven female; median age at death 65 years, range 27-80), and six of them were autopsied. The median MS duration prior to ICU admission was 27.5 years (range 1-50), and the median EDSS score at the time of ICU admission was 9 (range 5-9.5). The median length of ICU stay was 3 days (range 2-213). All the individuals in our series had experienced respiratory insufficiency during their ICU stay. The autopsy examination of brain tissue did not reveal evidences of MS lesions in one patient. In another patient, Lewy bodies were found on brain immunohistochemistry. Mortality in critically ill MS patients is largely driven by respiratory complications. Sporadic disparities between clinical and pathological findings can be expected. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  10. Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU

    NARCIS (Netherlands)

    Droogh, Joep M; Kruger, H. L.; Ligtenberg, Jack J M; Zijlstra, Jan G

    2012-01-01

    BACKGROUND: Transporting critically ill ICU patients by standard ambulances, with or without an accompanying physician, imposes safety risks. In 2007 the Dutch Ministry of Public Health required that all critically ill patients transferred between ICUs in different hospitals be transported by a

  11. Cytokines in chronically critically ill patients after activity and rest.

    Science.gov (United States)

    Winkelman, Chris; Higgins, Patricia A; Chen, Yea Jyh Kathy; Levine, Alan D

    2007-04-01

    Inflammation, a common problem for patients in the intensive care unit (ICU), frequently is associated with serious and prolonged critical illnesses. To date, no study has examined whether physical activity influences inflammatory factors in critically ill adults. The objectives of this study were to (a) examine the relationships between type and duration of physical activity and serum levels of interleukin 6 (IL-6), a proinflammatory cytokine; IL-10, an anti-inflammatory cytokine; and their ratio and (b) determine if there are associations between cytokines or their ratio and activity or outcomes. This descriptive feasibility study investigated the approaches to measuring levels of physical activity and its relationship to serum levels of IL-6 and IL-10 and the ratio between them in patients with prolonged mechanical ventilation during periods of activity and rest. Measurements included serum IL-6 and IL-10 levels, direct observation and actigraphy, and prospective chart review. Ten critically ill patients who were mechanically ventilated for an average of 10 days in a large, urban, teaching hospital were enrolled. The average ratio of IL-6 to IL-10 improved after an average of 14.7 min of passive physical activity, typically multiple in-bed turns associated with hygiene. IL-6, IL-10, and their ratio were not associated with patient outcomes of weaning success or length of stay. High levels of IL-6 were associated with mortality. Cytokine balance may be improved by low levels of activity among patients with prolonged critical illness. The pattern of cytokines produced after activity may improve patients' recovery from prolonged critical illness and mechanical ventilation.

  12. Predictors of maternal mortality among critically ill obstetric patients

    African Journals Online (AJOL)

    et al.,15 that absence of prenatal care was a predictor of maternal mortality in critically ill obstetric patients, the booking status in this study was not a predictor of mortality. This could be because the delay in recognition of the need for ICU care and delays in presentation could have removed the otherwise expected beneficial ...

  13. Ventilator-associated pneumonia in critically ill African patients on ...

    African Journals Online (AJOL)

    Background: Stress ulcer prophylaxis is an integral part of the care of the critically ill. Agents that alter gastric pH may predispose these patients to gastric colonisation, with subsequent pneumonia and/or sepsis. Cytoprotective agents such as sucralfate preserve gastric acidity and may be protective. Objective: To determine ...

  14. 807: melatonin secretion pattern in critically ill patients

    DEFF Research Database (Denmark)

    Boyko, Yuliya; Holst, René; Jennum, Poul Jørgen

    2016-01-01

    in over 100 patients from 0% to 54%. The project is ongoing as part of the Society of Critical Care Medicine’s ICU Liberation Collaborative. Conclusions: A multidisciplinary team based initiative to reinforce education, audit and feedback resulted in increased documentation of CAM-ICU screening rates...

  15. Decreasing the critical value of hemoglobin required for physician notification reduces the rate of blood transfusions

    Directory of Open Access Journals (Sweden)

    Larson EA

    2016-06-01

    Full Text Available Eric A Larson,1 Paul A Thompson,1,2 Zachary K Anderson,3 Keith A Anderson,4 Roxana A Lupu,1 Vicki Tigner,5 Wendell W Hoffman6,7 1Department of Internal Medicine, 2Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, 3Department of Internal Medicine, Fairview Health Services, Edina, MN, 4Department of Laboratory Medicine, Sanford School of Medicine, University of South Dakota, 5Medical Staff Services, 6Department of Infectious Disease, Sanford Health, Sanford USD Medical Center, 7Department of Infectious Disease, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USAAbstract: Red blood cell transfusions have been cited as one of the most overused therapeutic interventions in the USA. Excessively aggressive transfusion practices may be driven by mandatory physician notification of critical hemoglobin values that do not generally require transfusion. We examined the effect of decreasing the critical value of hemoglobin from 8 to 7 g/dL at our institution. Along with this change, mandatory provider notification for readings between 7 and 8 g/dL was rescinded. Transfusion rates were compared retrospectively during paired 5-month periods for patients presenting in three key hemoglobin ranges (6.00–6.99, 7.00–7.99, and 8.00–8.99 g/dL. A change in transfusion practices was hypothesized in the 7–8 g/dL range, which was no longer labeled critical and for which mandated physician calls were rescinded. Transfusion rates showed a statistically significant 8% decrease (P≤0.0001 during the 5-month period post change in our transfusion practices. This decrease in the 7.00–7.99 g/dL range was significantly greater than the 2% decrease observed in either the 6–6.99 g/dL (P=0.0017 or 8–8.99 g/dL (P≤0.0001 range. Cost savings of up to $700,000/year were extrapolated from our results showing 491 fewer units of red blood cells transfused during the 5-month post change. These cost

  16. Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients

    Directory of Open Access Journals (Sweden)

    Legriel Stéphane

    2011-08-01

    Full Text Available Abstract Background Recognizing infection is crucial in immunocompromised patients with organ dysfunction. Our objective was to assess the diagnostic accuracy of procalcitonin (PCT in critically ill immunocompromised patients. Methods This prospective, observational study included patients with suspected sepsis. Patients were classified into one of three diagnostic groups: no infection, bacterial sepsis, and nonbacterial sepsis. Results We included 119 patients with a median age of 54 years (interquartile range [IQR], 42-68 years. The general severity (SAPSII and organ dysfunction (LOD scores on day 1 were 45 (35-62.7 and 4 (2-6, respectively, and overall hospital mortality was 32.8%. Causes of immunodepression were hematological disorders (64 patients, 53.8%, HIV infection (31 patients, 26%, and solid cancers (26 patients, 21.8%. Bacterial sepsis was diagnosed in 58 patients and nonbacterial infections in nine patients (7.6%; 52 patients (43.7% had no infection. PCT concentrations on the first ICU day were higher in the group with bacterial sepsis (4.42 [1.60-22.14] vs. 0.26 [0.09-1.26] ng/ml in patients without bacterial infection, P 0.5 ng/ml had 100% sensitivity but only 63% specificity for diagnosing bacterial sepsis. The area under the receiver operating characteristic (ROC curve was 0.851 (0.78-0.92. In multivariate analyses, PCT concentrations > 0.5 ng/ml on day 1 independently predicted bacterial sepsis (odds ratio, 8.6; 95% confidence interval, 2.53-29.3; P = 0.0006. PCT concentrations were not significantly correlated with hospital mortality. Conclusion Despite limited specificity in critically ill immunocompromised patients, PCT concentrations may help to rule out bacterial infection.

  17. Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients.

    Science.gov (United States)

    Bele, Nicolas; Darmon, Michael; Coquet, Isaline; Feugeas, Jean-Paul; Legriel, Stéphane; Adaoui, Nadir; Schlemmer, Benoît; Azoulay, Elie

    2011-08-24

    Recognizing infection is crucial in immunocompromised patients with organ dysfunction. Our objective was to assess the diagnostic accuracy of procalcitonin (PCT) in critically ill immunocompromised patients. This prospective, observational study included patients with suspected sepsis. Patients were classified into one of three diagnostic groups: no infection, bacterial sepsis, and nonbacterial sepsis. We included 119 patients with a median age of 54 years (interquartile range [IQR], 42-68 years). The general severity (SAPSII) and organ dysfunction (LOD) scores on day 1 were 45 (35-62.7) and 4 (2-6), respectively, and overall hospital mortality was 32.8%. Causes of immunodepression were hematological disorders (64 patients, 53.8%), HIV infection (31 patients, 26%), and solid cancers (26 patients, 21.8%). Bacterial sepsis was diagnosed in 58 patients and nonbacterial infections in nine patients (7.6%); 52 patients (43.7%) had no infection. PCT concentrations on the first ICU day were higher in the group with bacterial sepsis (4.42 [1.60-22.14] vs. 0.26 [0.09-1.26] ng/ml in patients without bacterial infection, P 0.5 ng/ml had 100% sensitivity but only 63% specificity for diagnosing bacterial sepsis. The area under the receiver operating characteristic (ROC) curve was 0.851 (0.78-0.92). In multivariate analyses, PCT concentrations > 0.5 ng/ml on day 1 independently predicted bacterial sepsis (odds ratio, 8.6; 95% confidence interval, 2.53-29.3; P = 0.0006). PCT concentrations were not significantly correlated with hospital mortality. Despite limited specificity in critically ill immunocompromised patients, PCT concentrations may help to rule out bacterial infection.

  18. Stress, coping and presenteeism in nurses assisting critical and potentially critical patients

    Directory of Open Access Journals (Sweden)

    Juliane Umann

    2014-10-01

    Full Text Available Objective to verify the associations between stress, Coping and Presenteeism in nurses operating on direct assistance to critical and potentially critical patients. Method this is a descriptive, cross-sectional and quantitative study, conducted between March and April 2010 with 129 hospital nurses. The Inventory of stress in nurses, Occupational and Coping Questionnaire Range of Limitations at Work were used. For the analysis, the Kolmogorov-Smirnov test, correlation coefficient of Pearson and Spearman, Chi-square and T-test were applied. Results it was observed that 66.7% of the nurses showed low stress, 87.6% use control strategies for coping stress and 4.84% had decrease in productivity. Direct and meaningful relationships between stress and lost productivity were found. Conclusion stress interferes with the daily life of nurses and impacts on productivity. Although the inability to test associations, the control strategy can minimize the stress, which consequently contributes to better productivity of nurses in the care of critical patients and potentially critical.

  19. Call 4 Concern: patient and relative activated critical care outreach.

    Science.gov (United States)

    Odell, Mandy; Gerber, Karin; Gager, Melanie

    Patients can experience unexpected deterioration in their physiological condition that can lead to critical illness, cardiac arrest, admission to the intensive care unit and death. While ward staff can identify deterioration through monitoring physiological signs, these signs can be missed, interpreted incorrectly or mismanaged. Rapid response systems using early warning scores can fail if staff do not follow protocols or do not notice or manage deterioration adequately. Nurses often notice deterioration intuitively because of their knowledge of individual patients. Patients and their relatives have the greatest knowledge of patients, and can often pick up subtle signs physiological deterioration before this is identified by staff or monitoring systems. However, this ability has been largely overlooked. Call 4 Concern (C4C) is a scheme where patients and relatives can call critical care teams directly if they are concerned about a patient's condition- it is believed to be the first of its kind in the UK. A C4C feasibility project ran for six months, covering patients being transferred from the intensive care unit to general wards. C4C has the potential to prevent clinical deterioration and is valued by patients and relatives. Concerns of ward staff could be managed through project management. As it is relatively new, this field offers further opportunities for research.

  20. Patient Experience: A Critical Indicator of Healthcare Performance.

    Science.gov (United States)

    Guler, Pamela H

    2017-01-01

    Patient experience has become a critical differentiator for healthcare organizations, and it will only grow in importance as transparency and consumerism dominate the healthcare landscape. Creating and sustaining a consistently exceptional experience that promotes patient engagement and the best outcomes is far more than just "satisfying" patients, going well beyond amenities that may be provided.Perception of care experience is often shaped by methods we use to address the biopsychosocial needs of patients. Building relationships and communicating well with our patients and families are primary approaches. In a complex healthcare situation, patients may not fully understand or remember the highly clinical nature of treatment. However, they always remember how we made them feel, how we communicated with them as a team, and what interactions they experienced while in our care.Patients who are fully informed and feel connected to their caregivers are often less anxious than those who are disengaged. Informed and engaged patients are enabled to participate in their healthcare. Organizations that focus on developing an accountable culture-one that inspires caregivers to communicate in a way that connects to patients' mind, body, and spirit while leveraging standard, evidence-based patient experience practices-find that patients' perception of care, or "the patient experience," is vastly improved.Adventist Health System has embarked on a journey to patient experience excellence with a commitment to whole-person care and standard patient experience practice across the system. Recognized with several national awards, we continue to strengthen our approach toward bringing all of our campuses and patient settings to sustained high-level performance. We have found that a combination of strong, accountable leadership; a focus on employee culture; engagement of physicians; standardized patient experience practices and education; and meaningful use of patient feedback are top

  1. Critical and precious materials consumption and requirement in wind energy system in the EU 27

    International Nuclear Information System (INIS)

    Kim, Junbeum; Guillaume, Bertrand; Chung, Jinwook; Hwang, Yongwoo

    2015-01-01

    Graphical abstract: Critical and precious materials requirement in the wind energy system in the EU 27 by 2020. - Highlights: • The critical and precious materials consumption were calculated in wind energy system in the EU 27. • The future requirement of critical and precious materials was estimated in the EU 27 by 2020. • Fluorspar, silver, magnesium, indium, gold and tantalum are the mainly used and required materials. • This research approach could be applied to other industrial sectors as well as other renewable technology. - Abstract: Critical materials as well as rare earth elements and precious metals such as platinum, gold and silver are used significantly for computer hard disk drives, mobile phones, hybrid electric vehicles, batteries, renewable energy system and many other applications. It is therefore important to quantify and estimate both current stocks and flows of such materials, as well as future requirement for industries and economies. In this study, which is focused on wind energy system in the European Union (EU) 27, the current consumption and future requirement of critical and precious materials were calculated and estimated using the wind power production dataset from ecoinvent and data from National Renewable Energy Action Plan (NREAP). It is shown that fluorspar has been the most consumed material to date, and will probably be the most required material in the future. Among other critical and valuable materials, the main materials used for current wind energy system are silver, magnesium, indium, gold and tantalum. These materials will also be required significantly by 2020 for the wind energy system in the EU 27. It is argued that these results should be connected to the future energy and material policy and management

  2. Reuse-centric Requirements Analysis with Task Models, Scenarios, and Critical Parameters

    Directory of Open Access Journals (Sweden)

    Cyril Montabert

    2007-02-01

    Full Text Available This paper outlines a requirements-analysis process that unites task models, scenarios, and critical parameters to exploit and generate reusable knowledge at the requirements phase. Through the deployment of a critical-parameter-based approach to task modeling, the process yields the establishment of an integrative and formalized model issued from scenarios that can be used for requirements characterization. Furthermore, not only can this entity serve as interface to a knowledge repository relying on a critical-parameter-based taxonomy to support reuse but its characterization in terms of critical parameters also allows the model to constitute a broader reuse solution. We discuss our vision for a user-centric and reuse-centric approach to requirements analysis, present previous efforts implicated with this line of work, and state the revisions brought to extend the reuse potential and effectiveness of a previous iteration of a requirements tool implementing such process. Finally, the paper describes the sequence and nature of the activities involved with the conduct of our proposed requirements-analysis technique, concluding by previewing ongoing work in the field that will explore the feasibility for designers to use our approach.

  3. Early Glycemic Control in Critically Ill Emergency Department Patients: Pilot Trial

    Directory of Open Access Journals (Sweden)

    Cohen, Jason

    2010-02-01

    Full Text Available Objective: Glycemic control in the critically ill intensive care unit (ICU patient has been shown to improve morbidity and mortality. We sought to investigate the effect of early glycemic control in critically ill emergency department (ED patients in a small pilot trial.Methods: Adult non-trauma, non-pregnant ED patients presenting to a university tertiary referral center and identified as critically ill were eligible for enrollment on a convenience basis. Critical illness was determined upon assignment for ICU admission. Patients were randomized to either ED standard care or glycemic control. Glycemic control involved use of an insulin drip to maintain blood glucose levels between 80-140 mg/dL. Glycemic control continued until ED discharge. Standard patients were managed at ED attending physician discretion. We assessed severity of illness by calculation of APACHE II score. The primary endpoint was in-hospital mortality. Secondary endpoints included vasopressor requirement, hospital length of stay, and mechanical ventilation requirement.Results: Fifty patients were randomized, 24 to the glycemic group and 26 to the standard care cohort. Four of the 24 patients (17% in the treatment arm did not receive insulin despite protocol requirements. While receiving insulin, three of 24 patients (13% had an episode of hypoglycemia. By chance, the patients in the treatment group had a trend toward higher acuity by APACHE II scores. Patient mortality and morbidity were similar despite the acuity difference.Conclusion: There was no difference in morbidity and mortality between the two groups. The benefit of glycemic control may be subject to source of illness and to degree of glycemic control, or have no effect. Such questions bear future investigation. [West J Emerg Med. 2010; 11(1:20-23].

  4. Antithrombin III for critically ill patients

    DEFF Research Database (Denmark)

    Allingstrup, Mikkel; Wetterslev, Jørn; Ravn, Frederikke B

    2016-01-01

    PURPOSE: Antithrombin III (AT III) is an anticoagulant with anti-inflammatory properties. We assessed the benefits and harms of AT III in critically ill patients. METHODS: We searched from inception to 27 August 2015 in CENTRAL, MEDLINE, EMBASE, CAB, BIOSIS and CINAHL. We included randomized...... participants). However, for all other outcome measures and analyses, the results did not reach statistical significance. CONCLUSIONS: There is insufficient evidence to support AT III substitution in any category of critically ill participants including those with sepsis and DIC. AT III did not show an impact...

  5. Nutritional risk assessment in critically ill cancer patients: systematic review

    Science.gov (United States)

    Fruchtenicht, Ana Valéria Gonçalves; Poziomyck, Aline Kirjner; Kabke, Geórgia Brum; Loss, Sérgio Henrique; Antoniazzi, Jorge Luiz; Steemburgo, Thais; Moreira, Luis Fernando

    2015-01-01

    Objective To systematically review the main methods for nutritional risk assessment used in critically ill cancer patients and present the methods that better assess risks and predict relevant clinical outcomes in this group of patients, as well as to discuss the pros and cons of these methods according to the current literature. Methods The study consisted of a systematic review based on analysis of manuscripts retrieved from the PubMed, LILACS and SciELO databases by searching for the key words “nutritional risk assessment”, “critically ill” and “cancer”. Results Only 6 (17.7%) of 34 initially retrieved papers met the inclusion criteria and were selected for the review. The main outcomes of these studies were that resting energy expenditure was associated with undernourishment and overfeeding. The high Patient-Generated Subjective Global Assessment score was significantly associated with low food intake, weight loss and malnutrition. In terms of biochemical markers, higher levels of creatinine, albumin and urea were significantly associated with lower mortality. The worst survival was found for patients with worse Eastern Cooperative Oncologic Group - performance status, high Glasgow Prognostic Score, low albumin, high Patient-Generated Subjective Global Assessment score and high alkaline phosphatase levels. Geriatric Nutritional Risk Index values < 87 were significantly associated with mortality. A high Prognostic Inflammatory and Nutritional Index score was associated with abnormal nutritional status in critically ill cancer patients. Among the reviewed studies that examined weight and body mass index alone, no significant clinical outcome was found. Conclusion None of the methods reviewed helped to define risk among these patients. Therefore, assessment by a combination of weight loss and serum measurements, preferably in combination with other methods using scores such as Eastern Cooperative Oncologic Group - performance status, Glasgow Prognostic

  6. The Role of Time-Limited Trials in Dialysis Decision Making in Critically Ill Patients.

    Science.gov (United States)

    Scherer, Jennifer S; Holley, Jean L

    2016-02-05

    Technologic advances, such as continuous RRT, provide lifesaving therapy for many patients. AKI in the critically ill patient, a fatal diagnosis in the past, is now often a survivable condition. Dialysis decision making for the critically ill patient with AKI is complex. What was once a question solely of survival now is nuanced by an individual's definition of quality of life, personal values, and short- and long-term prognoses. Clinical evaluation of AKI in the critically ill is multifaceted. Treatment decision making requires consideration of the natural evolution of the patient's AKI within the context of the global prognosis. Situations are often marked by prognostic uncertainty and clinical unknowns. In the face of these uncertainties, establishment of patient-directed therapies is imperative. A time-limited trial of continuous RRT in this setting is often appropriate but difficult to execute. Using patient preferences as a clinical guide, a proper time-limited trial requires assessment of prognosis, elicitation of patient values, strong communication skills, clear documentation, and often, appropriate integration of palliative care services. A well conducted time-limited trial can avoid interprofessional conflict and provide support for the patient, family, and staff. Copyright © 2016 by the American Society of Nephrology.

  7. Critical care admission of South African (SA surgical patients: Results of the SA Surgical Outcomes Study

    Directory of Open Access Journals (Sweden)

    David Lee Skinner

    2017-05-01

    Full Text Available Background. Appropriate critical care admissions are an important component of surgical care. However, there are few data describing postoperative critical care admission in resource-limited low- and middle-income countries. Objective. To describe the demographics, organ failures, organ support and outcomes of non-cardiac surgical patients admitted to critical care units in South Africa (SA. Methods. The SA Surgical Outcomes Study (SASOS was a 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 government-funded hospitals. All patients admitted to critical care units during this study were included for analysis. Results. Of the 3 927 SASOS patients, 255 (6.5% were admitted to critical care units; of these admissions, 144 (56.5% were planned, and 111 (43.5% unplanned. The incidence of confirmed or strongly suspected infection at the time of admission was 35.4%, with a significantly higher incidence in unplanned admissions (49.1 v. 24.8%, p<0.001. Unplanned admission cases were more frequently hypovolaemic, had septic shock, and required significantly more inotropic, ventilatory and renal support in the first 48 hours after admission. Overall mortality was 22.4%, with unplanned admissions having a significantly longer critical care length of stay and overall mortality (33.3 v. 13.9%, p<0.001. Conclusion. The outcome of patients admitted to public sector critical care units in SA is strongly associated with unplanned admissions. Adequate ‘high care-dependency units’ for postoperative care of elective surgical patients could potentially decrease the burden on critical care resources in SA by 23%. This study was registered on ClinicalTrials.gov (NCT02141867.

  8. The capabilities and scope-of-practice requirements of advanced life support practitioners undertaking critical care transfers: A Delphi study

    Directory of Open Access Journals (Sweden)

    Monique Venter

    2016-11-01

    Full Text Available Background. Critical care transfers (CCT refer to the high level of care given during transport (via ambulance, helicopter or fixed-wing aircraft of patients who are of high acuity. In South Africa (SA, advanced life support (ALS paramedics undertake CCTs. The scope of ALS in SA has no extended protocol regarding procedures or medications in terms of dealing with these CCTs. Aim. The aim of this study was to obtain the opinions of several experts in fields pertaining to critical care and transport and to gain consensus on the skills and scope-of-practice requirements of paramedics undertaking CCTs in the SA setting. Methods. A modified Delphi study consisting of three rounds was undertaken using an online survey platform. A heterogeneous sample (n=7, consisting of specialists in the fields of anaesthesiology, emergency medicine, internal medicine, critical care, critical care transport and paediatrics, was asked to indicate whether, in their opinion, selected procedures and medications were needed within the scope of practice of paramedics undertaking CCTs. Results. After three rounds, consensus was obtained in 70% (57/81 of procedures and medications. Many of these items are not currently within the scope of paramedics’ training. The panel felt that paramedics undertaking these transfers should have additional postgraduate training that is specific to critical care. Conclusion. Major discrepancies exist between the current scope of paramedic practice and the suggested required scope of practice for CCTs. An extended scope of practice and additional training should be considered for these practitioners.

  9. Fluid and electrolyte disturbances in critically ill patients.

    Science.gov (United States)

    Lee, Jay Wook

    2010-12-01

    Disturbances in fluid and electrolytes are among the most common clinical problems encountered in the intensive care unit (ICU). Recent studies have reported that fluid and electrolyte imbalances are associated with increased morbidity and mortality among critically ill patients. To provide optimal care, health care providers should be familiar with the principles and practice of fluid and electrolyte physiology and pathophysiology. Fluid resuscitation should be aimed at restoration of normal hemodynamics and tissue perfusion. Early goal-directed therapy has been shown to be effective in patients with severe sepsis or septic shock. On the other hand, liberal fluid administration is associated with adverse outcomes such as prolonged stay in the ICU, higher cost of care, and increased mortality. Development of hyponatremia in critically ill patients is associated with disturbances in the renal mechanism of urinary dilution. Removal of nonosmotic stimuli for vasopressin secretion, judicious use of hypertonic saline, and close monitoring of plasma and urine electrolytes are essential components of therapy. Hypernatremia is associated with cellular dehydration and central nervous system damage. Water deficit should be corrected with hypotonic fluid, and ongoing water loss should be taken into account. Cardiac manifestations should be identified and treated before initiating stepwise diagnostic evaluation of dyskalemias. Divalent ion deficiencies such as hypocalcemia, hypomagnesemia and hypophosphatemia should be identified and corrected, since they are associated with increased adverse events among critically ill patients.

  10. Constipation and its implications in the critically ill patient.

    Science.gov (United States)

    Mostafa, S M; Bhandari, S; Ritchie, G; Gratton, N; Wenstone, R

    2003-12-01

    Motility of the lower gut has been little studied in intensive care patients. We prospectively studied constipation in an intensive care unit of a university hospital, and conducted a national survey to assess the generalizability of our findings. Constipation occurred in 83% of the patients. More constipated patients (42.5%) failed to wean from mechanical ventilation than non-constipated patients (0%), Pconstipated than non-constipated patients (10 vs 6.5 days and 27.5 vs 12.5%, respectively (NS)). The survey found similar observations in other units. Delays in weaning from mechanical ventilation and enteral feeding were reported by 28 and 48% of the units surveyed, respectively. Constipation has implications for the critically ill.

  11. Modeling of requirement specification for safety critical real time computer system using formal mathematical specifications

    International Nuclear Information System (INIS)

    Sankar, Bindu; Sasidhar Rao, B.; Ilango Sambasivam, S.; Swaminathan, P.

    2002-01-01

    Full text: Real time computer systems are increasingly used for safety critical supervision and control of nuclear reactors. Typical application areas are supervision of reactor core against coolant flow blockage, supervision of clad hot spot, supervision of undesirable power excursion, power control and control logic for fuel handling systems. The most frequent cause of fault in safety critical real time computer system is traced to fuzziness in requirement specification. To ensure the specified safety, it is necessary to model the requirement specification of safety critical real time computer systems using formal mathematical methods. Modeling eliminates the fuzziness in the requirement specification and also helps to prepare the verification and validation schemes. Test data can be easily designed from the model of the requirement specification. Z and B are the popular languages used for modeling the requirement specification. A typical safety critical real time computer system for supervising the reactor core of prototype fast breeder reactor (PFBR) against flow blockage is taken as case study. Modeling techniques and the actual model are explained in detail. The advantages of modeling for ensuring the safety are summarized

  12. Relatives to Critically Ill Patients Have No Sense of Coherence

    DEFF Research Database (Denmark)

    Laursen, Jannie; Andresen, Kristoffer; Rosenberg, Jacob

    2016-01-01

    shown that relatives do not always receive the attention they need from health professionals. There is a lack of studies that focus on relatives' satisfaction and involvement during their family members' hospitalization. Design. A mixed methods design was chosen. Methods. A quantitative study...... of the dissatisfaction, a qualitative approach was used and the in-depth interviews revealed three themes: lack of continuity and structure, responsibility of coordination, and relatives feeling left on their own with no guiding and support. Conclusion. Health professionals' key role in relation to relatives must......Aims and Objective. To investigate the relatives' satisfaction and involvement on a general surgery ward regarding the critically ill patient. Introduction. Relatives to critically ill patients are affected both physically and mentally during the hospitalization of a family member. Research has...

  13. Fluid and Electrolyte Disturbances in Critically Ill Patients

    OpenAIRE

    Lee, Jay Wook

    2010-01-01

    Disturbances in fluid and electrolytes are among the most common clinical problems encountered in the intensive care unit (ICU). Recent studies have reported that fluid and electrolyte imbalances are associated with increased morbidity and mortality among critically ill patients. To provide optimal care, health care providers should be familiar with the principles and practice of fluid and electrolyte physiology and pathophysiology. Fluid resuscitation should be aimed at restoration of normal...

  14. Critical care admission of South African (SA) surgical patients ...

    African Journals Online (AJOL)

    Critical care admission of South African (SA) surgical patients: Results of the SA Surgical Outcomes Study. D.L. Skinner, K de Vasconcellos, R Wise, T.M. Esterhuizen, C Fourie, A Goolam Mahomed, P.D. Gopalan, I Joubert, H Kluyts, L.R. Mathivha, B Mrara, J.P. Pretorius, G Richards, O Smith, M.G.L. Spruyt, R.M. Pearse, ...

  15. Procalcitonin-guided antibiotic treatment in critically ill patients.

    Science.gov (United States)

    Hohn, Andreas; Heising, Bernhard; Schütte, Jan-Karl; Schroeder, Olaf; Schröder, Stefan

    2017-02-01

    In critically ill patients, length of antibiotic treatment can be effectively guided by procalcitonin (PCT) protocols. International sepsis guidelines and guidelines on antibiotic stewardship strategies recommend PCT as helpful laboratory marker for a rational use of antibiotics. A number of studies and meta-analyses have confirmed the effectiveness of PCT-protocols for shortening antibiotic treatment without compromising clinical outcome in critically ill patients. But in clinical practice, there is still uncertainty how to interpret PCT levels and how to adjust antibiotic treatment in various infectious situations, especially in the perioperative period. This narrative review gives an overview on the application of PCT-protocols in critically ill patients with severe bacterial infections on the basis of 5 case reports and the available literature. Beside strengths and limitations of this biomarker, also varying kinetics and different maximum values with regard to the infectious focus and pathogens are discussed. PCT-guided antibiotic treatment appears to be safe and effective. Most of the studies revealed a shorter antibiotic treatment without negative clinical outcomes. Cost effectiveness is still a matter of debate and effects on bacterial resistance due to shorter treatments, possible lower rates of drug-related adverse events, or decreased rates of Clostridium difficile infections are not yet evaluated. Guidance of antibiotic treatment can effectively be supported by PCT-protocols. However, it is important to consider the limitations of this biomarker and to use PCT protocols along with antibiotic stewardship programmes and regular clinical rounds together with infectious diseases specialists.

  16. Management Issues in Critically Ill Pediatric Patients with Trauma.

    Science.gov (United States)

    Ahmed, Omar Z; Burd, Randall S

    2017-10-01

    The management of critically ill pediatric patients with trauma poses many challenges because of the infrequency and diversity of severe injuries and a paucity of high-level evidence to guide care for these uncommon events. This article discusses recent recommendations for early resuscitation and blood component therapy for hypovolemic pediatric patients with trauma. It also highlights the specific types of injuries that lead to severe injury in children and presents challenges related to their management. Copyright © 2017 Elsevier Inc. All rights reserved.

  17. An integrative review of health-related quality of life in patients with critical limb ischaemia.

    Science.gov (United States)

    Monaro, Susan; West, Sandra; Gullick, Janice

    2017-10-01

    To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life. Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation. The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al. The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia. Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required. A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients. © 2016 John Wiley & Sons Ltd.

  18. Isotopic dilution requirements for 233U criticality safety in processing and disposal facilities

    International Nuclear Information System (INIS)

    Elam, K.R.; Forsberg, C.W.; Hopper, C.M.; Wright, R.Q.

    1997-11-01

    The disposal of excess 233 U as waste is being considered. Because 233 U is a fissile material, one of the key requirements for processing 233 U to a final waste form and disposing of it is to avoid nuclear criticality. For many processing and disposal options, isotopic dilution is the most feasible and preferred option to avoid nuclear criticality. Isotopic dilution is dilution of fissile 233 U with nonfissile 238 U. The use of isotopic dilution removes any need to control nuclear criticality in process or disposal facilities through geometry or chemical composition. Isotopic dilution allows the use of existing waste management facilities, that are not designed for significant quantities of fissile materials, to be used for processing and disposing of 233 U. The amount of isotopic dilution required to reduce criticality concerns to reasonable levels was determined in this study to be ∼ 0.66 wt% 233 U. The numerical calculations used to define this limit consisted of a homogeneous system of silicon dioxide (SiO 2 ), water (H 2 O), 233 U, and depleted uranium (DU) in which the ratio of each component was varied to determine the conditions of maximum nuclear reactivity. About 188 parts of DU (0.2 wt% 235 U) are required to dilute 1 part of 233 U to this limit in a water-moderated system with no SiO 2 present. Thus, for the US inventory of 233 U, several hundred metric tons of DU would be required for isotopic dilution

  19. Amikacin treatment of Serratia septicemia in critically ill patients.

    Science.gov (United States)

    Mosquera, J M; de Villota, E D; de la Serna, J L; Diez-Balda, V; Tomás, M I; Galdos, P; Rubio, J J

    1981-09-01

    Serratia marcescens septicemia represents a serious problem in high risk critical care patients. Treatment is difficult because Serratia is usually resistant to most antibiotics. Amikacin is at present the most effective antibiotic in vitro against gentamycin-resistant Serratia, although significant loss of activity may occur in vivo in the group of compromised patients, whose ultimate prognosis may depend eventually upon other associated conditions. In this Medical ICU, 15 patients with Serratia septicemia who were treated with in vitro effective antibiotics (14 were given amikacin) had a mortality of 60%, while 5 patients who received ineffective in vitro antibiotics had a mortality of 100%. In this ICU, 80% of the Serratia isolates were resistant to gentamycin, while only 2.8% were resistant to amikacin. Because amikacin-resistant strains of Serratia have already emerged, appropriate use of this antibiotic is essential in order not to promote the selection of amikacin-resistant strains.

  20. Bilateral Diaphragmatic Paralysis in a Patient With Critical Illness Polyneuropathy

    Science.gov (United States)

    Chen, Hsuan-Yu; Chen, Hung-Chen; Lin, Meng-Chih; Liaw, Mei-Yun

    2015-01-01

    Abstract Bilateral diaphragmatic paralysis (BDP) manifests as respiratory muscle weakness, and its association with critical illness polyneuropathy (CIP) was rarely reported. Here, we present a patient with BDP related to CIP, who successfully avoided tracheostomy after diagnosis and management. A 71-year-old male presented with acute respiratory failure after sepsis adequately treated. Repeated intubation occurred because of carbon dioxide retention after each extubation. After eliminating possible factors, septic shock-induced respiratory muscle weakness was suspected. Physical examination, a nerve conduction study, and chest ultrasound confirmed our impression. Pulmonary rehabilitation and reconditioning exercises were arranged, and the patient was discharged with a diagnosis of BDP. The diagnosis of BDP is usually delayed, and there are only sporadic reports on its association with polyneuropathy, especially in patients with preserved limb muscle function. Therefore, when physicians encounter patients that are difficult to wean from mechanical ventilation, CIP associated with BDP should be considered in the differential diagnosis. PMID:26252301

  1. Trigger mechanisms of secondary sclerosing cholangitis in critically ill patients.

    Science.gov (United States)

    Leonhardt, Silke; Veltzke-Schlieker, Wilfried; Adler, Andreas; Schott, Eckart; Hetzer, Roland; Schaffartzik, Walter; Tryba, Michael; Neuhaus, Peter; Seehofer, Daniel

    2015-03-31

    In recent years the development of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has increasingly been perceived as a separate disease entity. About possible trigger mechanisms of SSC-CIP has been speculated, systematic investigations on this issue are still lacking. The purpose of this study was to evaluate the prevalence and influence of promoting factors. Temporality, consistency and biological plausibility are essential prerequisites for causality. In this study, we investigated the temporality and consistency of possible triggers of SSC-CIP in a large case series. Biological plausibility of the individual triggers is discussed in a scientific context. SSC-CIP cases were recruited retrospectively from 2633 patients who underwent or were scheduled for liver transplantation at the University Hospital Charité, Berlin. All patients who developed secondary sclerosing cholangitis in association with intensive care treatment were included. Possible trigger factors during the course of the initial intensive care treatment were recorded. Sixteen patients (68% males, mean age 45.87 ± 14.64 years) with a confirmed diagnosis of SSC-CIP were identified. Of the 19 risk factors investigated, particularly severe hypotension with a prolonged decrease in mean arterial blood pressure (MAP) to <65 mmHg and systemic inflammatory response syndrome (SIRS) were established as possible triggers of SSC-CIP. The occurrence of severe hypotension appears to be the first and most significant step in the pathogenesis. It seems that severe hypotension has a critical effect on the blood supply of bile ducts when it occurs together with additional microcirculatory disturbances. In critically ill patients with newly acquired cholestasis the differential diagnosis of SSC-CIP should be considered when they have had an episode of haemodynamic instability with a prolonged decrease in MAP, initial need for large amounts of blood transfusions or colloids, and early

  2. Patient's dignity in intensive care unit: A critical ethnography.

    Science.gov (United States)

    Bidabadi, Farimah Shirani; Yazdannik, Ahmadreza; Zargham-Boroujeni, Ali

    2017-01-01

    Maintaining patient's dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units. The aim of this study was to uncover the cultural factors that impeded maintaining patients' dignity in the cardiac surgery intensive care unit. The study was conducted using a critical ethnographic method proposed by Carspecken. Participants and research context: Participants included all physicians, nurses and staffs working in the study setting (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace. Ethical Consideration: Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained. The findings of the study fell into the following main themes: "Presence: the guarantee for giving enough attention to patients' self-esteem", "Instrumental and objectified attitudes", "Adherence to the human equality principle: value-action gap", "Paternalistic conduct", "Improper language", and "Non-interactive communication". The final assertion was "Reductionism as a major barrier to the maintaining of patient's dignity". The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches. Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships.

  3. Temporary Decompression in Critically Ill Patients: Retrospective Comparison of Ileostomy and Colostomy.

    Science.gov (United States)

    Lin, Zhi-Liang; Yu, Wen-Kui; Shi, Jia-Liang; Chen, Qi-Yi; Tan, Shan-Jun; Li, Ning

    2014-05-01

    In critically ill patients, gastrointestinal function plays an important role in multiple organ dysfunction syndrome. Patients suffering from acute lower gastrointestinal dysfunction need to be performed a temporary fecal diversion after the failure of conservative treatment. This study aims to determine which type of fecal diversion is associated with better clinical outcomes in critically ill patients. Data of critically ill patients requiring surgical decompression following acute lower gastrointestinal dysfunction between January 2008 and June 2013 were retrospectively analyzed. Comparison was made between ileostomy group and colostomy group regarding the stoma-related complications and the recovery after stoma creation. 63 patients consisted of temporary ileostomy group (n = 35) and temporary colostomy group (n = 28) were included in this study. First bowel movement and length of enteral nutrition intolerance after fecal diversion were both significantly shorter in the ileostomy group than in the colostomy group (1.70 ± 0.95 vs. 3.04 ± 1.40; p colostomy group. Both procedures provide an effective defunctioning of the distant gastrointestinal tract with a low complication incidence. We prefer a temporary ileostomy to temporary colostomy for acute lower gastrointestinal dysfunction in critically ill patients.

  4. Vitamin D deficiency is independently associated with mortality among critically ill patients

    Directory of Open Access Journals (Sweden)

    Rafael Barberena Moraes

    2015-05-01

    Full Text Available OBJECTIVE: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients. METHOD: In 135 intensive care unit (ICU patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity. RESULTS: Mortality rates were higher among patients with vitamin D levels 12 ng/mL (32.2% vs. 13.2%, with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05. There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity. CONCLUSIONS: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.

  5. Hyperglycemia in critical patients: Determinants of insulin dose choice

    Directory of Open Access Journals (Sweden)

    Aline Klitzke Paliosa

    Full Text Available Summary Objective: To identify factors that can determine the choice of intermittent subcutaneous regular insulin dose in critically ill patients with hyperglycemia. Method: Cross-sectional study in a general adult ICU with 26 beds, data collected between September and October 2014. The variables analyzed were: sex, age, previous diagnosis of diabetes mellitus, use of corticosteroids, use of lactulose, sepsis, fasting, enteral nutrition, use of dextrose 5% in water, NPH insulin prescription and blood glucose level. Patients with one or more episodes of hyperglycemia (blood glucose greater than 180 mg/dL were included as a convenience sample, not consecutively. Those with continuous insulin prescription were excluded from analysis. Results: We included 64 records of hyperglycemia observed in 22 patients who had at least one episode of hyperglycemia. The median administered subcutaneous regular human insulin was 6 IU and among the factors evaluated only blood glucose levels were associated with the choice of insulin dose administered. Conclusion: Clinical characteristics such as diet, medications and diagnosis of diabetes mellitus are clearly ignored in the decision-making regarding insulin dose to be administered for glucose control in critically ill patients with hyperglycemia.

  6. Transesophageal echocardiography as an alternative for the assessment of the trauma and critical care patient.

    Science.gov (United States)

    Rose, David D

    2003-06-01

    Transesophageal echocardiography was first described and used to monitor cardiac function in 1976. Initially adopted by cardiac anesthesiologists and cardiologists, it has gained acceptance as an important diagnostic tool in the monitoring and assessment of cardiac status in the critically ill and trauma patient population. Comparative data suggest that transesophageal echocardiography provides rapid real-time noninvasive monitoring of the critically ill and avoids the morbidity and mortality that is associated with more invasive methods of patient monitoring. In addition, transesophageal echocardiography affords the practitioner reliable cardiac filling volumes based on direct left ventricular assessment compared to pressure data that are based on indirect right ventricular and pulmonary occlusive pressures. In a healthcare environment that seeks optimum patient assessment while requiring an approach that encourages cost-effective, noninvasive, and minimal patient risk, those nurse anesthetists who work in institutions that have transesophageal echocardiographic capabilities should learn this newer technology and begin to incorporate it into their practice.

  7. Requirements on waste forms for the planned Konrad repository based on criticality calculations

    International Nuclear Information System (INIS)

    Berg, H.P.

    1988-02-01

    In the framework of the safety analyses for the planned Konrad repository it has been investigated whether a criticality incident may be possible during the operational phase or in the post-operational phase. The analysis has shown that the criticality safety is ensured by limitation of a mass concentration of the fissile material in the waste form group and by determination of a maximum permissible mass of fissile material per waste package. The resulting requirements of the waste packages, including a mixture in the cross-section of an emplacement room, are explained. (orig.) [de

  8. Argatroban versus Lepirudin in critically ill patients (ALicia): a randomized controlled trial.

    Science.gov (United States)

    Treschan, Tanja A; Schaefer, Maximilian S; Geib, Johann; Bahlmann, Astrid; Brezina, Tobias; Werner, Patrick; Golla, Elisabeth; Greinacher, Andreas; Pannen, Benedikt; Kindgen-Milles, Detlef; Kienbaum, Peter; Beiderlinden, Martin

    2014-10-25

    Critically ill patients often require renal replacement therapy accompanied by thrombocytopenia. Thrombocytopenia during heparin anticoagulation may be due to heparin-induced thrombocytopenia with need for alternative anticoagulation. Therefore, we compared argatroban and lepirudin in critically ill surgical patients. Following institutional review board approval and written informed consent, critically ill surgical patients more than or equal to 18 years with suspected heparin-induced thrombocytopenia, were randomly assigned to receive double-blind argatroban or lepirudin anticoagulation targeting an activated Partial Thromboplastin Time (aPTT) of 1.5 to 2 times baseline. In patients requiring continuous renal replacement therapy we compared the life-time of hemodialysis filters. We evaluated in all patients the incidence of bleeding and thrombembolic events. We identified 66 patients with suspected heparin-induced thrombocytopenia, including 28 requiring renal replacement therapy. Mean filter lifetimes did not differ between groups (argatroban 32 ± 25 hours (n = 12) versus lepirudin 27 ± 21 hours (n = 16), mean difference 5 hours, 95% CI -13 to 23, P = 0.227). Among all 66 patients, relevant bleeding occurred in four argatroban- versus eleven lepirudin-patients (OR 3.9, 95% CI 1.1 to 14.0, P = 0.040). In the argatroban-group, three thromboembolic events occurred compared to two in the lepirudin group (OR 0.7, 95% CI 0.1 to 4.4, P = 0.639). The incidence of confirmed heparin-induced thrombocytopenia was 23% (n = 15) in our study population. This first randomized controlled double-blind trial comparing two direct thrombin inhibitors showed comparable effectiveness for renal replacement therapy, but suggests fewer bleeds in surgical patients with argatroban anticoagulation. Clinical Trials.gov NCT00798525. Registered 25 November 2008.

  9. How do we approach thrombocytopenia in critically ill patients?

    Science.gov (United States)

    Thachil, Jecko; Warkentin, Theodore E

    2017-04-01

    A low platelet count is a frequently encountered haematological abnormality in patients treated in intensive treatment units (ITUs). Although severe thrombocytopenia (platelet count classical view for thrombocytopenia in this setting is consumption associated with thrombin-mediated platelet activation, but other concepts, including platelet adhesion to endothelial cells and leucocytes, platelet aggregation by increased von Willebrand factor release, red cell damage and histone release, and platelet destruction by the complement system, have recently been described. The management of severe thrombocytopenia is platelet transfusion in the presence of active bleeding or invasive procedure, but the risk-benefit of prophylactic platelet transfusions in this setting is uncertain. In this review, the incidence and mechanisms of thrombocytopenia in patients with ITU, its prognostic significance and the impact on organ function is discussed. A practical approach based on the authors' experience is described to guide management of a critically ill patient who develops thrombocytopenia. © 2016 John Wiley & Sons Ltd.

  10. Management of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department

    Directory of Open Access Journals (Sweden)

    Rose L

    2012-03-01

    Full Text Available Louise RoseLawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, CanadaAbstract: Patients requiring noninvasive and invasive ventilation frequently present to emergency departments, and may remain for prolonged periods due to constrained critical care services. Emergency clinicians often do not receive the same education on management of mechanical ventilation or have similar exposure to these patients as do their critical care colleagues. The aim of this review was to synthesize the evidence on management of patients requiring noninvasive and invasive ventilation in the emergency department including indications, clinical applications, monitoring priorities, and potential complications. Noninvasive ventilation is recommended for patients with acute exacerbation of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Less evidence supports its use in asthma and other causes of acute respiratory failure. Use of noninvasive ventilation in the prehospital setting is relatively new, and some evidence suggests benefit. Monitoring priorities for noninvasive ventilation include response to treatment, respiratory and hemodynamic stability, noninvasive ventilation tolerance, detection of noninvasive ventilation failure, and identification of air leaks around the interface. Application of injurious ventilation increases patient morbidity and mortality. Lung-protective ventilation with low tidal volumes based on determination of predicted body weight and control of plateau pressure has been shown to reduce mortality in patients with acute respiratory distress syndrome, and some evidence exists to suggest this strategy should be used in patients without lung injury. Monitoring of the invasively ventilated patient should focus on assessing response to mechanical ventilation and other interventions, and avoiding complications, such as ventilator-associated pneumonia. Several key aspects of management of noninvasive

  11. A CRITICAL ANALYSIS OF PATIENT SATISFACTION WITH DIABETES CARE

    Directory of Open Access Journals (Sweden)

    Cotiu Madalina-Alexandra

    2015-07-01

    Full Text Available Consumer satisfaction represents one of the core principles of marketing as it is acknowledged that organizations survive and prosper only by properly meeting the needs and wants of their customers. The same logic can be applied to the healthcare sector, especially in the current context of increased public scrutiny and funding pressure. Furthermore, research shows that patient satisfaction is linked to positive effects from both a marketing and a medical point of view. From a marketing point of view, patient satisfaction is closely linked to positive word of mouth and likelihood to recommend, while from a medical poinbt of view, research suggests that satisfied patients are more inclined toward treatment adherence, are less likely to seek another opinion elsewhere thus delaying treatment, while medical staff tend to have a higher morale. Yet, research regarding patient satisfaction with a particular illness is scarce with studies rarely building on previous results. The article takes on this challenge and aims to critically analyse several empirical studies conducted on patient satisfaction with diabetes care in order to synthesize results on particular determinants and suggest areas for further research. Diabetes is currently one of the most spread chronic disease around the world, while also affecting both old and younger patients. At the same time, it is a chronic disease characterised by the need for disease management efforts on behalf of the patients as well as high treatment adherence in order to avoid complications. It is also a costly chronic disease especially because of the numerous complications which patients may arrive to face during their struggle with this disease. In order to achieve the aim of this article we have chosen to adopt a marketing approach meaning that we see diabetes patients as clients of the medical institutions. Results show that diabetes particularities call for a broader view on patient satisfaction

  12. [Variation of muscle mass and weight in critical patient].

    Science.gov (United States)

    Valls-Matarín, J; del Cotillo-Fuente, M; Grané-Mascarell, N; Quintana, S

    2015-01-01

    Quantify the muscle mass and body weight variation in critically ill patients and to identify associated factors. A descriptive follow-up study. Data for demographic variables, body weight, fluid balance, daily kilocalories, the amount of sedation and muscle relaxants received and motor physiotherapy applied were collected. Three consecutive measurements were performed in the brachial biceps and quadriceps rectus by using ultrasound, upon admission and every 5 days until discharge. 68 patients were included. Average age was of 73.5 [57-78,5] years. The median length of stay was 9.5 [5.5 -15] days. The median 16 (SD=5.7) daily kilocalories per kg/weight, 91.2% received sedation, 44.1% received muscle relaxants and 20% received physiotherapy. The patients presented a muscle wasting of 4.9 (SD=3.9)mm, p <.001 in the brachial biceps and 5.6 (SD=4.8)mm, p <.001 in the quadriceps rectus. Regression analysis selected the length of stay and the muscle relaxants are the most influential variables in the brachial biceps muscle wasting (R2=0.4), and length of stay as the most influential in the quadriceps rectus muscle wasting (R2=0.3). Patient's mean body weight on admission was of 81.1 (SD=15)kg and 81.2 (SD=14.2)kg on discharge, p=.95. The critically ill patient presents a significant muscle waste related with the length of stay and the treatment received with muscle relaxants. Patients are being discharged with a similar body weight to which they were admitted but with a significant reduction of muscle mass. Copyright © 2014 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

  13. [The development of a portable life support device for transporting pre-hospital critically ill patients].

    Science.gov (United States)

    Song, Zhen-xing; Wu, Tai-hu; Meng, Xing-ju; Lu, Heng-zhi; Zheng, Jie-wen; Wang, Hai-tao

    2012-06-01

    To describe a portable life support device for transportation of pre-hospital patients with critical illness. The characteristics and requirements for urgent management during transportation of critically ill patients to a hospital were analyzed. With adoption of the original equipment, with the aid of staple of the art soft ware, the overall structure, its installation, fixation, freedom from interference, operational function were studied, and the whole system of life support and resuscitation was designed. The system was composed by different modules, including mechanical ventilation, transfusion, aspiration, critical care, oxygen supply and power supply parts. The system could be fastened quickly to a stretcher to form portable intensive care unit (ICU), and it could be carried by different size vehicles to provide nonstop treatment by using power supply of the vehicle, thus raising the efficiency of urgent care. With characteristics of its small size, lightweight and portable, the device is particularly suitable for narrow space and extreme environment.

  14. Postoperative Haematocrit and Outcome in Critically Ill Surgical Patients.

    Science.gov (United States)

    Lopes, Ana Martins; Silva, Diana; Sousa, Gabriela; Silva, Joana; Santos, Alice; Abelha, Fernando José

    2017-08-31

    Haematocrit has been studied as an outcome predictor. The aim of this study was to evaluate the correlation between low haematocrit at surgical intensive care unit admission and high disease scoring system score and early outcomes. This retrospective study included 4398 patients admitted to the surgical intensive care unit between January 2006 and July 2013. Acute physiology and chronic health evaluation and simplified acute physiology score II values were calculated and all variables entered as parameters were evaluated independently. Patients were classified as haematocrit if they had a haematocrit < 30% at surgical intensive care unit admission. The correlation between admission haematocrit and outcome was evaluated by univariate analysis and linear regression. A total of 1126 (25.6%) patients had haematocrit. These patients had higher rates of major cardiac events (4% vs 1.9%, p < 0.001), acute renal failure (11.5% vs 4.7%, p < 0.001), and mortality during surgical intensive care unit stay (3% vs 0.8%, p < 0.001) and hospital stay (12% vs 5.9%, p < 0.001). A haematocrit level < 30% at surgical intensive care unit admission was frequent and appears to be a predictor for poorer outcome in critical surgical patients. Patients with haematocrit had longer surgical intensive care unit and hospital stay lengths, more postoperative complications, and higher surgical intensive care unit and hospital mortality rates.

  15. Doripenem pharmacokinetics in critically ill patients receiving continuous hemodiafiltration (CHDF).

    Science.gov (United States)

    Hidaka, Seigo; Goto, Koji; Hagiwara, Satoshi; Iwasaka, Hideo; Noguchi, Takayuki

    2010-01-01

    Objectives of the prospective, open-label study were to investigate pharmacokinetics of doripenem and determine appropriate doripenem regimens during continuous hemodiafiltration (CHDF) in critically ill patients with renal failure (creatinine clearance times during one dosing interval were measured in order to calculate pharmacokinetic parameters and clearance via hemodiafiltration. Mean half-life (+/-standard deviation) of doripenem was 7.9+/-3.7 hours. Total body clearance of doripenem was 58.0+/-12.7 ml/min, including clearance of 13.5+/-1.6 ml/min via CHDF. An IV dose of 250 mg of doripenem every 12 hours during CHDF provided adequate plasma concentrations for critically ill patients with renal failure, without resulting in accumulation upon steady-state. Thus, under the conditions tested, CHDF appeared to have little effect on doripenem clearance. Therefore, the blood level of doripenem can be satisfactorily controlled by adjustment of doripenem dose and dosing interval, in accordance with residual renal function in patients receiving CHDF.

  16. Simulation experience enhances physical therapist student confidence in managing a patient in the critical care environment.

    Science.gov (United States)

    Ohtake, Patricia J; Lazarus, Marcilene; Schillo, Rebecca; Rosen, Michael

    2013-02-01

    Rehabilitation of patients in critical care environments improves functional outcomes. This finding has led to increased implementation of intensive care unit (ICU) rehabilitation programs, including early mobility, and an associated increased demand for physical therapists practicing in ICUs. Unfortunately, many physical therapists report being inadequately prepared to work in this high-risk environment. Simulation provides focused, deliberate practice in safe, controlled learning environments and may be a method to initiate academic preparation of physical therapists for ICU practice. The purpose of this study was to examine the effect of participation in simulation-based management of a patient with critical illness in an ICU setting on levels of confidence and satisfaction in physical therapist students. A one-group, pretest-posttest, quasi-experimental design was used. Physical therapist students (N=43) participated in a critical care simulation experience requiring technical (assessing bed mobility and pulmonary status), behavioral (patient and interprofessional communication), and cognitive (recognizing a patient status change and initiating appropriate responses) skill performance. Student confidence and satisfaction were surveyed before and after the simulation experience. Students' confidence in their technical, behavioral, and cognitive skill performance increased from "somewhat confident" to "confident" following the critical care simulation experience. Student satisfaction was highly positive, with strong agreement the simulation experience was valuable, reinforced course content, and was a useful educational tool. Limitations of the study were the small sample from one university and a control group was not included. Incorporating a simulated, interprofessional critical care experience into a required clinical course improved physical therapist student confidence in technical, behavioral, and cognitive performance measures and was associated with high

  17. Pharmacologic management of constipation in the critically ill patient.

    Science.gov (United States)

    Patanwala, Asad E; Abarca, Jacob; Huckleberry, Yvonne; Erstad, Brian L

    2006-07-01

    To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (MICU). Retrospective medical record review. MICU of an academic medical center. Ninety-five patients admitted to the MICU from July 1-October 31, 2004. Fifty patients satisfied the inclusion criteria. Patient-specific data such as age, weight, sex, length of MICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) II score, dietary intake, opioid intake, laxative intake, and bowel movements were recorded during the first 96 hours of admission. Logistic regression analysis was used to compare patients who did and did not have a bowel movement. Of the 50 patients, 25 did not have a bowel movement during the first 96 hours of MICU admission. Patients given a stimulant laxative (senna, bisacodyl) and/or an osmotic laxative (lactulose, milk of magnesia) were more likely to have a bowel movement (odds ratio [OR] 26.6, 95% confidence interval [CI] 3.2-221, p=0.002). Opioid intake, expressed as logarithmic morphine equivalents, was negatively associated with occurrence of a bowel movement (OR 0.76, 95% CI 0.59-0.97, p=0.027). Disease severity, as determined by APACHE II score, was also negatively associated with a bowel movement (OR 0.84, 95% CI 0.7-0.99, p=0.04). Critically ill patients have a high frequency of constipation, and opioid therapy is a significant risk factor. Routine administration of stimulant or osmotic laxatives should be considered for this patient population.

  18. Characteristics of critically ill patients in ICUs in mainland China.

    Science.gov (United States)

    Du, Bin; An, Youzhong; Kang, Yan; Yu, Xiangyou; Zhao, Mingyan; Ma, Xiaochun; Ai, Yuhang; Xu, Yuan; Wang, Yushan; Qian, Chuanyun; Wu, Dawei; Sun, Renhua; Li, Shusheng; Hu, Zhenjie; Cao, Xiangyuan; Zhou, Fachun; Jiang, Li; Lin, Jiandong; Chen, Erzhen; Qin, Tiehe; He, Zhenyang; Zhou, Lihua

    2013-01-01

    We sought to describe the demographics, case mix, interventions, and clinical outcome of critically ill patients admitted to ICUs in Mainland China. A 2-month (July 1, 2009, to August 31, 2009) prospective, observational cohort study. Twenty-two ICUs in Mainland China. Adult patients admitted to participating ICUs during the study period with an ICU length of stay >24 hrs. None. Patient characteristics, including demographics, underlying diseases, severity of illness, admission status, complications, intervention and treatment during ICU stay, and clinical outcome were recorded in case report form. The primary outcome measure was all-cause hospital mortality. Independent predictors for hospital mortality were determined with multivariate logistic regression analysis. One thousand two hundred ninety-seven patients met the inclusion criteria for the study, 821 (63.3%) were male, and mean age was 58.5 ± 19.2 yrs. Mean Acute Physiology and Chronic Health Evaluation II score was 18.0 ± 8.1, and mean Sequential Organ Failure Assessment score was 6.5 ± 3.8. One third of the patients were postoperative ICU admissions. Seven hundred sixty-five patients (59.0%) developed infections, followed by severe sepsis or septic shock (484, 37.3%), acute kidney injury (398, 30.7%), and acute lung injury/acute respiratory distress syndrome (351, 27.1%). Mechanical ventilation was used in almost three fourths of the patients, whereas any type of renal replacement therapy was used in 173 patients (13.3%). Hospital mortality was 20.3%. Multivariate logistic regression analysis found that Acute Physiology and Chronic Health Evaluation II score, solid tumor, severe sepsis/septic shock, acute lung injury/acute respiratory distress syndrome, and acute kidney injury were independent risk factors for hospital mortality. Critically ill patients in ICUs in Mainland China exhibited a case mix similar to those of Western countries, although there are significant differences in intensive care unit

  19. Minimum mass of moderator required for criticality of homogeneous low-enriched uranium systems

    Energy Technology Data Exchange (ETDEWEB)

    Jordan, W.C.; Turner, J.C.

    1992-12-01

    A parametric calculational analysis has been performed in order to estimate the minimum mass of moderator required for criticality of homogeneous low-enriched uranium systems. The analysis was performed using a version of the SCALE-4.0 code system and the 27-group ENDF/B-IV cross-section library. Water-moderated uranyl fluoride (UO{sub 2}F{sub 2} and H{sub 2}O) and hydrofluoric-acid-moderated uranium hexaflouride (UF{sub 6} and HF) systems were considered in the analysis over enrichments of 1.4 to 5 wt % {sup 235}U. Estimates of the minimum critical volume, minimum critical mass of uranium, and the minimum mass of moderator required for criticality are presented. There was significant disagreement between the values generated in this study when compared with a similar undocumented study performed in 1983 using ANISN and the Knight-modified Hansen-Roach cross sections. An investigation into the cause of the disagreement was made, and the results are presented.

  20. Minimum mass of moderator required for criticality of homogeneous low-enriched uranium systems

    Energy Technology Data Exchange (ETDEWEB)

    Jordan, W.C.; Turner, J.C.

    1992-12-01

    A parametric calculational analysis has been performed in order to estimate the minimum mass of moderator required for criticality of homogeneous low-enriched uranium systems. The analysis was performed using a version of the SCALE-4.0 code system and the 27-group ENDF/B-IV cross-section library. Water-moderated uranyl fluoride (UO[sub 2]F[sub 2] and H[sub 2]O) and hydrofluoric-acid-moderated uranium hexaflouride (UF[sub 6] and HF) systems were considered in the analysis over enrichments of 1.4 to 5 wt % [sup 235]U. Estimates of the minimum critical volume, minimum critical mass of uranium, and the minimum mass of moderator required for criticality are presented. There was significant disagreement between the values generated in this study when compared with a similar undocumented study performed in 1983 using ANISN and the Knight-modified Hansen-Roach cross sections. An investigation into the cause of the disagreement was made, and the results are presented.

  1. Comparison of sedation strategies for critically ill patients

    DEFF Research Database (Denmark)

    Hutton, Brian; Burry, Lisa D.; Kanji, Salmaan

    2016-01-01

    Background: Sedatives and analgesics are administered to provide sedation and manage agitation and pain in most critically ill mechanically ventilated patients. Various sedation administration strategies including protocolized sedation and daily sedation interruption are used to mitigate drug...... their efficacy and safety for mechanically ventilated patients. Methods: We will search the following from 1980 to March 2016: Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science. We will also search the Cochrane Library, gray literature, and the International Clinical Trials Registry Platform. We...... of interest include duration of mechanical ventilation, time to first extubation, ICU and hospital length of stay, re-intubation, tracheostomy, mortality, total sedative and opioid exposure, health-related quality of life, and adverse events. To inform our NMA, we will first conduct conventional pair...

  2. [Tissue oxygen saturation in the critically ill patient].

    Science.gov (United States)

    Gruartmoner, G; Mesquida, J; Baigorri, F

    2014-05-01

    Hemodynamic resuscitation seeks to correct global macrocirculatory parameters of pressure and flow. However, current evidence has shown that despite the normalization of these global parameters, microcirculatory and regional perfusion alterations can persist, and these alterations have been independently associated with a poorer patient prognosis. This in turn has lead to growing interest in new technologies for exploring regional circulation and microcirculation. Near infra-red spectroscopy allows us to monitor tissue oxygen saturation, and has been proposed as a noninvasive, continuous and easy-to-obtain measure of regional circulation. The present review aims to summarize the existing evidence on near infra-red spectroscopy and its potential clinical role in the resuscitation of critically ill patients in shock. Copyright © 2013 Elsevier España, S.L. and SEMICYUC. All rights reserved.

  3. Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: neurocritical patient.

    Science.gov (United States)

    Acosta Escribano, J; Herrero Meseguer, I; Conejero García-Quijada, R

    2011-11-01

    Neurocritical patients require specialized nutritional support due to their intense catabolism and prolonged fasting. The preferred route of nutrient administration is the gastrointestinal route, especially the gastric route. Alternatives are the transpyloric route or mixed enteral-parenteral nutrition if an effective nutritional volume of more than 60% cannot be obtained. Total calorie intake ranges from 20-30 kcal/kg/day, depending on the period of the clinical course, with protein intake higher than 20% of total calories (hyperproteic diet). Nutritional support should be initiated early. The incidence of gastrointestinal complications is generally higher to other critically-ill patients, the most frequent complication being an increase in gastric residual volume. As in other critically-ill patients, glycemia should be closely monitored and maintained below 150 mg/dL.

  4. Osteomyelitis in burn patients requiring skeletal fixation

    NARCIS (Netherlands)

    Barret, JP; Desai, MH; Herndon, DN

    Deep and severe burns often present with the exposure of musculoskeletal structures and severe deformities. Skeletal fixation, suspension and/or traction are part of their comprehensive treatment. Several factors put burn patients at risk for osteomyelitis, osteosynthesis material being one of them.

  5. Worldwide audit of blood transfusion practice in critically ill patients.

    Science.gov (United States)

    Vincent, Jean-Louis; Jaschinski, Ulrich; Wittebole, Xavier; Lefrant, Jean-Yves; Jakob, Stephan M; Almekhlafi, Ghaleb A; Pellis, Tommaso; Tripathy, Swagata; Rubatto Birri, Paolo N; Sakr, Yasser

    2018-04-19

    The aim was to describe transfusion practice in critically ill patients at an international level and evaluate the effects of red blood cell (RBC) transfusion on outcomes in these patients. This was a pre-planned sub-study of the Intensive Care Over Nations audit, which involved 730 ICUs in 84 countries and included all adult patients admitted between 8 May and 18 May 2012, except admissions for routine postoperative surveillance. ICU and hospital outcomes were recorded. Among the 10,069 patients included in the audit, data related to transfusion had been completed for 9553 (mean age 60 ± 18 years, 60% male); 2511 (26.3%) of these had received a transfusion, with considerable variation among geographic regions. The mean lowest hemoglobin on the day of transfusion was 8.3 ± 1.7 g/dL, but varied from 7.8 ± 1.4 g/dL in the Middle East to 8.9 ± 1.9 g/dL in Eastern Europe. Hospital mortality rates were higher in transfused than in non-transfused patients (30.0% vs. 19.6%, p < 0.001) and increased with increasing numbers of transfused units. In an extended Cox proportional hazard analysis, the relative risk of in-hospital death was slightly lower after transfusion in the whole cohort (hazard ratio 0.98, confidence interval 0.96-1.00, p = 0.048). There was a stepwise decrease in the hazard ratio for mortality after transfusion with increasing admission severity scores. More than one fourth of critically ill patients are transfused during their ICU stay, with considerable variations in transfusion practice among geographic regions. After adjustment for confounders, RBC transfusions were associated with a slightly lower relative risk of in-hospital death, especially in the most severely ill patients, highlighting the importance of taking the severity of illness into account when making transfusion decisions.

  6. Treatment of Chryseobacterium indologenes ventilator-associated pneumonia in a critically ill trauma patient.

    Science.gov (United States)

    Monteen, Megan R; Ponnapula, Supriya; Wood, G Christopher; Croce, Martin A; Swanson, Joseph M; Boucher, Bradley A; Fabian, Timothy C

    2013-12-01

    To report a case of Chryseobacterium indologenes ventilator-associated pneumonia (VAP) in a critically ill trauma patient. This report describes a 66-year-old critically ill trauma patient who developed VAP, which was caused by C indologenes. The patient was injured in a riding lawn mower accident that trapped him underwater in a pond. The patient required surgery for intra-abdominal injuries and was mechanically ventilated in the trauma intensive care unit. On hospital day 5, the patient developed signs and symptoms of VAP. A diagnosis of C indologenes VAP was confirmed based on a quantitative culture from a bronchoscopic bronchoalveolar lavage. The patient's infection was successfully treated with moxifloxacin for 2 days followed by cefepime for 7 days. Formally known as Flavobacterium indologenes, C indologenes is a Gram-negative bacillus normally found in plants, soil, foodstuffs, and fresh and marine water sources. Recently, worldwide reports of C indologenes infections in humans have been increasing, though reports from the United States are still rare. Bacteremia and pneumonia are the most commonly reported infections, and most patients are immunocompromised. The current case differs from most previous reports because this patient was in the United States and did not have any traditional immunocompromised states (eg, transplant, cancer, HIV/AIDS, or corticosteroid use). This case report demonstrates that C indologenes can cause VAP in a trauma ICU patient.

  7. Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice.

    Science.gov (United States)

    Yang, Shuofei; Wu, Xingjiang; Yu, Wenkui; Li, Jieshou

    2014-02-01

    Early enteral nutrition (EEN) in critically ill patients is associated with significant benefit as well as elevated risk of complications. Concomitant use of EEN with vasopressors has been associated with nonocclusive bowel necrosis in critically ill patients with hemodynamic instability. The decision when to initiate enteral nutrition in hemodynamically unstable patients that require vasoactive substances remains a clinical dilemma. This review summarizes the effect of EEN and vasoactive agents on gastrointestinal blood flow and perfusion in critically ill patients, based on current evidence. Animal and clinical data involving simultaneous administration of EEN and vasoactive agents for hemodynamic instability are reviewed, and the factors related to the safety and effectiveness of EEN support in this patient population are analyzed. Moreover, practical recommendations are provided. Additional randomized clinical trials are warranted to provide cutting-edge evidence-based guidance about this issue for practitioners of critical care.

  8. Prophylactic use of laxative for constipation in critically ill patients

    Directory of Open Access Journals (Sweden)

    Masri Yasser

    2010-01-01

    Full Text Available Background : This study was designed to evaluate the use of laxative prophylaxis for constipation in intensive care unit (ICU and the impact of early versus late bowel movement on patient′s outcome. Methods : The study was a prospective, randomized controlled trial in critically ill ventilated adult patients, who were expected to stay on ventilator for >72 h. Control group did not receive any intervention for bowel movement for the first 72 h, whereas interventional group received prophylactic dose of lactulose 20 cc enterally every 12 h for the first 72 h. The parameters measured during the study were admission diagnosis, age, gender, comorbid conditions, admission Simplified Acute Physiologic Score (SAPS II, sedative and narcotic agents with doses and duration, timing and tolerance of nutrition, daily assessment of bowel movement, total use of prokinetic, doses of suppositories, and enema for first bowel movement, total number of days on ventilator, weaning failures, extubation or tracheostomy, ICU length of stay, and death or discharge. Results : A total of 100 patients were enrolled, 50 patients in each control and interventional group. Mean age was 38.8 years, and both groups had male predominance. Mean SAPS II score for both was 35. Mean dose of Fentanyl (323.8 ± 108.89 mcg/h in control and 345.83 ± 94.43 mcg/h in interventional group and mean dose of Midazolam (11.1 ± 4.04 mg/h in control and 12.4 ± 3.19 mg/h in interventional group. There were only two (4% patients in control, while nine (18% patients in interventional group who had bowel movement in <72 h (P < 0.05. Mean ventilator days were 16.19, and 17.36 days in control and interventional groups, respectively. Subgroup analysis showed that the patients who moved bowel in <5 days in both groups had mean ventilator days of 18.5, whereas it was 15.88 days for the patients who moved bowel after 5 days in both groups (P< 0.05. Mean ICU days for control was 21.15 ± 10.44 and 20

  9. Secondary sclerosing cholangitis in critically ill patients: current perspectives

    Directory of Open Access Journals (Sweden)

    Gudnason HO

    2017-06-01

    Full Text Available Hafsteinn O Gudnason,1 Einar S Björnsson1,2 1Division of Gastroenterology and Hepatology, Department of Internal Medicine, Landspitali, University Hospital of Iceland, 2Faculty of Medicine, University of Iceland, Reykjavik, Iceland Abstract: Secondary sclerosing cholangitis (SSC is a term used for a group of chronic cholestatic disease affecting the intra- and/or extrahepatic biliary tree with inflammation and progressive stricture formation, which can lead to biliary cirrhosis. A newly recognized form of SSC is secondary sclerosing cholangitis in critically ill patients (SSC-CIP. Pathogenesis is believed to involve ischemic injury of intrahepatic bile ducts associated with prolonged hypotension, vasopressors administration, and/or mechanical ventilation in patients treated in the intensive care unit (ICU. Patients diagnosed with SSC-CIP have no prior history of liver disease and no known pathologic process or injury responsible for bile duct obstruction prior to ICU treatment. Reasons leading to ICU treatment are many including multitrauma, burn injury, cardiac surgery, severe pneumonia, other infections, or bleeding after abdominal surgery. Patients have in common prolonged ICU admission. SSC-CIP is associated with rapid progression to liver cirrhosis and poor survival with limited treatment options except a liver transplantation. Transplant-free survival is around 17–40 months, which is lower than in other SSC patients. During the initial stages of the disease, the clinical symptoms and biochemical profile are not specific and easily missed. Biliary casts formation may be considered pathognomonic for SSC-CIP since most patients have them in early stages of the disease. Increased awareness and early detection of the disease and its complications is considered to be crucial to improve the poor prognosis. Keywords: secondary sclerosing cholangitis, SSC-CIP, chronic cholestatic disease, sclerosing cholangitis

  10. [Patient satisfaction in hospital: critical incident technique or standardised questionnaire?].

    Science.gov (United States)

    Eckhardt-Abdulla, R; Bock, M; Bauer, M

    2008-03-01

    Questionnaires are usually used for the measurement of patient satisfaction, however, it is increasingly being recognized that the critical incident technique (CIT) also provides valuable insight. Questionnaires of the "Hamburger questionnaire on hospital stay" were distributed to 650 consecutive patients before discharge. Additionally 103 interviews were conducted in which the patients were asked to describe positive and negative incidents during their hospital stay. The results of both methods were then compared. A total of 369 patients returned the questionnaire and 103 patients participated in the interviews. The duration of a single interview was between 5 and 45 min with a mean of 12.7 min+/-10.1 min standard deviation (SD). Cronbach's alpha of the questionnaire was 0.9. A total of 424 incidents were reported, 301 of them were negative compared to 123 positive events. The questionnaires and interviews yielded partly similar and partly different results at category and subcategory levels concerning the areas of weaknesses and strengths in quality performance. The CIT was more concrete but did not give results for all aspects of quality. The CIT, but not the questionnaire, was able to detect 40/56 (71%) of the positive and 33/75 (44%) of the negative reports regarding medical performance and 25/42 (60%) of the positive and 15/51 (29.4%) of the negative reports of the performance of the nurses were revealed by the CIT and not by the questionnaires. The CIT gives valuable insights into the patient's perspective of strengths and weaknesses in hospital care, which might be overlooked by the questionnaire alone. However, the CIT is probably not suited for routine use because it is very time-consuming.

  11. PROTEIN NEEDS OF CRITICALLY ILL PATIENTS RECEIVING PARENTERAL NUTRITION.

    Science.gov (United States)

    Germano Borges de Oliveira Nascimento Freitas, Renata; Negrão Nogueira, Roberto José; Hessel, Gabriel

    2015-07-01

    assess whether the current protein intake recommendations may improve the biochemical parameters of critical patients receiving parenteral nutrition. longitudinal study with three evaluations made (during the first 72 hours, on the 7th and the 14th days of PN). The following tests were applied: albumin, C-reactive protein, prealbumin, total cholesterol, HDL, triglycerides, lymphocytes, and glutathione peroxidase. The severity was determined by SOFA. The statistical analysis included the Spearman and Mann-Whitney tests, as well as ANOVA (analysis of variance). among the 53 patients evaluated, 20 (37.74%) died. The mean calorie was 24.68 ± 9.78 kcal/kg (beginning of PN), 26.49 ± 8.89 kcal/kg (3rd to 7th days of PN), and 30.9 ± 12.19 kcal/kg (7th to 14th days of PN). The mean protein was 1.19 ± 0.44 g/kcal/kg (first 72 hours of PN), 1.29 ± 0.44 g/kcal/kg (3rd to 7th days of PN) and 1.49 ± 0.69 g/kcal/kg (7th to 14th days of PN). Prealbumin, albumin, total cholesterol and HDL were below the reference values, while the CRP levels were high. Throughout the three evaluation times, there was no a significant improvement on the levels of laboratory examinations. A strong and negative correlation was found between SOFA and prealbumin (r = -0.64, p = 0.05). the protein offer, according to the traditional recommendations, was not enough to improve the biochemical parameters of critical patients undergoing parenteral nutrition. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

  12. Reversible acute adrenal insufficiency caused by fluconazole in a critically ill patient

    Science.gov (United States)

    Krishnan, S G Santhana; Cobbs, R K

    2006-01-01

    A 38 year old man with history of obstructive sleep apnea and polycythaemia presented with hypercapnic respiratory failure that required intubation. He developed fever with infiltrates on chest radiography that required empiric antifungal therapy with fluconazole along with broad spectrum antibiotics. He developed acute adrenal insufficiency that recovered after fluconazole was stopped. It is believed that this complication of adrenal suppression attributable to fluconazole is underrecognised and it may be prudent to monitor all critically ill patients who are given fluconazole for this complication. PMID:16954446

  13. Emergency team calls for critically ill non-trauma patients in the emergency department

    DEFF Research Database (Denmark)

    Jensen, Søren Marker; Do, Hien Quoc; Rasmussen, Søren W.

    2015-01-01

    BACKGROUND: Handling critically ill patients is a complex task for Emergency Department (ED) personnel. Initial treatment is of major importance and requires adequately experienced ED doctors to initiate and decide for the right medical or surgical treatment. Our aim was, with regard to clinical...... the study period. RESULTS: A total of 109 emergency team calls were triggered (79 orange and 30 red), comprising 66 (60.6 %) men and 43 women, with a median age of 64 years. Patients presented with: 4 Airway, 27 Breathing, 41 Circulation, 31 Disability, 2 Exposure and 4 Other problems. Overall, 58/109 (53.......2 %) patients were admitted to the ICU, while 20/109 (18.3 %) patients were deemed ineligible for ICU admission. 30-day mortality was 34/109 (31.2 %), and circulatory problems were the most frequent cause of death (61.8 %, p = 0.02). Patients who died were significantly older than those who survived (p = 0...

  14. [Evolution in muscle strength in critical patients with invasive mechanical ventilation].

    Science.gov (United States)

    Via Clavero, G; Sanjuán Naváis, M; Menéndez Albuixech, M; Corral Ansa, L; Martínez Estalella, G; Díaz-Prieto-Huidobro, A

    2013-01-01

    To assess the evolution of muscle strength in critically ill patients with mechanical ventilation (MV) from withdrawal of sedatives to hospital discharge. A cohort study was conducted in two intensive care units in the Hospital Universitari de Bellvitge from November 2011 to March 2012. Consecutive patients with MV > 72h. Dependent outcome: Muscle strength measured with the Medical Research Council (MRC) scale beginning on the first day the patient was able to answer 3 out of 5 simple orders (day 1), every week, at ICU discharge and at hospital discharge or at day 60 Independent outcomes: factors associated with muscle strength loss, ventilator-free days, ICU length of stay and hospital length of stay. The patients were distributed into two groups (MRC2 (P 2 and costicosteroids. Patients with a MRC < 48 required more days with MV and a longer ICU stay. Copyright © 2013 Elsevier España, S.L. y SEEIUC. All rights reserved.

  15. Blood tranfusion in critically ill patients: state of the art.

    Science.gov (United States)

    Hajjar, Ludhmila Abrahão; Auler Junior, Jose Otávio Costa; Santos, Luciana; Galas, Filomena

    2007-08-01

    Anemia is one of the most common abnormal findings in critically ill patients, and many of these patients will receive a blood transfusion during their intensive care unit stay. However, the determinants of exactly which patients do receive transfusions remains to be defined and have been the subject of considerable debate in recent years. Concerns and doubts have emerged regarding the benefits and safety of blood transfusion, in part due to the lack of evidence of better outcomes resulting from randomized studies and in part related to the observations that transfusion may increase the risk of infection. As a result of these concerns and of several studies suggesting better or similar outcomes with a lower transfusion trigger, there has been a general tendency to decrease the transfusion threshold from the classic 10 g/dL to lower values. In this review, we focus on some of the key studies providing insight into current transfusion practices and fueling the current debate on the ideal transfusion trigger.

  16. [The interarm blood pressure difference in the critically ill patient].

    Science.gov (United States)

    Valls Matarín, Josefa; del Cotillo Fuente, Mercedes; Quintana Riera, Salvador; de la Sierra Iserte, Alejandro

    2014-02-04

    To evaluate the prevalence of a difference in systolic blood pressure (SBPd) ≥ 10 mmHg between arms in patients admitted in a Critical Care Unit and to examine the clinical characteristics associated with such blood pressure difference. Observational cross-sectional study. Two blood pressure measurements in each arm were carried out at unit admission. The firstly measured arm was chosen at random. One-hundred and sixty-eight patients were studied, with a mean age of 61 (SD=16), 67.3% male and 45% with a previous hypertension diagnosis. On admission, 27.4% presented SBPd ≥ 10 mmHg. Among them, 54% had higher SBP in the right arm and 46% in the left one. A SBPd ≥ 10 mmHg was associated with a previous hypertension diagnosis (67.4 versus 36.9%; Parms. This feature is associated with a previous hypertension diagnosis and reduced consciousness. It should be assessed in the future if the choice of a control arm would help improve patient's care as it would become a more accurate guide for hemodynamic management. Copyright © 2012 Elsevier España, S.L. All rights reserved.

  17. Patients' Perceptions of Nurses' Behaviour That Influence Patient Participation in Nursing Care: A Critical Incident Study

    Directory of Open Access Journals (Sweden)

    Inga E. Larsson

    2011-01-01

    Full Text Available Patient participation is an important basis for nursing care and medical treatment and is a legal right in many Western countries. Studies have established that patients consider participation to be both obvious and important, but there are also findings showing the opposite and patients often prefer a passive recipient role. Knowledge of what may influence patients' participation is thus of great importance. The aim was to identify incidents and nurses' behaviours that influence patients' participation in nursing care based on patients' experiences from inpatient somatic care. The Critical Incident Technique (CIT was employed. Interviews were performed with patients (=17, recruited from somatic inpatient care at an internal medical clinic in West Sweden. This study provided a picture of incidents, nurses' behaviours that stimulate or inhibit patients' participation, and patient reactions on nurses' behaviours. Incidents took place during medical ward round, nursing ward round, information session, nursing documentation, drug administration, and meal.

  18. Critical overview of the development of the optimization requirement and its implementation

    International Nuclear Information System (INIS)

    Gonzalez, A.J.

    1988-01-01

    This paper is intended to provide a critical overview of the development of the optimization requirement of the system of dose limitation recommended by the International Commission on Radiological Protection (ICRP), as well as of its implementation. The concept of optimization began to evolve in the mid-1950s and was formally introduced as a requirement for radiation protection in 1978. Recommendations on its practical implementation have been available for five years. After such a long evolution, it seems reasonable to make a critical assessment of the development of the optimization concept, and this summary paper is intended to provide such an assessment. It does not include a description of the requirement or of any method for implementing it, since it is assumed that optimization is familiar by now. The paper concentrates rather on misunderstandings of and achievements owed to optimization and explores some of their underlying causes, the intention being to draw lessons from past experience and to apply them to future developments in this area. The paper presents an outlook on some remaining policy issues that still pending solution as well as some suggestions on prioritization of implementation of optimization and on standardizing the optimization protection

  19. The impact of transport of critically ill pediatric patients on rural emergency departments in Manitoba.

    Science.gov (United States)

    Hansen, Gregory; Beer, Darcy L; Vallance, Jeff K

    2017-01-01

    Although the interfacility transport (IFT) of critically ill pediatric patients from rural to tertiary health centres may improve outcomes, the impact of IFTs on the rural referring centre is not known. The purpose of this study was to investigate how the IFT of critically ill children affects staffing and functionality of rural emergency departments (EDs) in Manitoba. In 2015, surveys were emailed to the medical directors of all 15 regional EDs within 2 hours' travel time from a tertiary pediatric hospital. The survey consisted of 9 questions that addressed baseline characteristics of the regional EDs and duration of ED staffing changes or closures due to IFT of critically ill pediatric patients. Ten surveys were received (67% response rate); a regional ED catchment population of about 130 000 people was represented. Interfacility transport caused most EDs (60%, with an average catchment population of 15 000) to close or to alter their staffing to a registered nurse only. These temporary changes lasted a cumulative total of 115 hours. Interfacility transport of critically ill pediatric patients resulted in ED closures and staffing changes in rural Manitoba. These findings suggest that long-term sustainable solutions are required to improve access to emergency care.

  20. A new approach to scoring systems to improve identification of acute medical admissions that will require critical care.

    Science.gov (United States)

    Carmichael, H A; Robertson, E; Austin, J; McCruden, D; Messow, C M; Belcher, P R

    2011-11-01

    Removal of the intensive care unit (ICU) at the Vale of Leven Hospital mandated the identification and transfer out of those acute medical admissions with a high risk of requiring ICU. The aim of the study was to develop triaging tools that identified such patients and compare them with other scoring systems. The methodology included a retrospective analysis of physiological and arterial gas measurements from 1976 acute medical admissions produced PREEMPT-1 (PRE-critical Emergency Medical Patient Triage). A simpler one for ambulance use (PREAMBLE-1 [PRE-Admission Medical Blue-Light Emergency]) was produced by the addition of peripheral oxygen saturation to a modification of MEWS (Modified Early Warning Score). Prospective application of these tools produced a larger database of 4447 acute admissions from which logistic regression models produced PREEMPT-2 and PREAMBLE-2, which were then compared with the original systems and seven other early warning scoring systems. Results showed that in patients with arterial gases, the area under the receiver operator characteristic curve was significantly higher in PREEMPT-2 (89·1%) and PREAMBLE-2 (84.4%) than all other scoring systems. Similarly, in all patients, it was higher in PREAMBLE-2 (92·4%) than PREAMBLE-1 (88·1%) and the other scoring systems. In conclusion, risk of requiring ICU can be more accurately predicted using PREEMPT-2 and PREAMBLE-2, as described here, than by other early warning scoring systems developed over recent years.

  1. Association of Gender With Outcome and Host Response in Critically Ill Sepsis Patients.

    Science.gov (United States)

    van Vught, Lonneke A; Scicluna, Brendon P; Wiewel, Maryse A; Hoogendijk, Arie J; Klein Klouwenberg, Peter M C; Ong, David S Y; Cremer, Olaf L; Horn, Janneke; Franitza, Marek; Toliat, Mohammad R; Nürnberg, Peter; Bonten, Marc M J; Schultz, Marcus J; van der Poll, Tom

    2017-11-01

    To determine the association of gender with the presentation, outcome, and host response in critically ill patients with sepsis. A prospective observational cohort study in the ICU of two tertiary hospitals between January 2011 and January 2014. All consecutive critically ill patients admitted with sepsis, involving 1,815 admissions (1,533 patients). The host response was evaluated on ICU admission by measuring 19 plasma biomarkers reflecting organ systems implicated in sepsis pathogenesis (1,205 admissions) and by applying genome-wide blood gene expression profiling (582 admissions). Sepsis patients admitted to the ICU were more frequently males (61.0%; p < 0.0001 vs females). Baseline characteristics were not different between genders. Urosepsis was more common in females; endocarditis and mediastinitis in men. Disease severity was similar throughout ICU stay. Mortality was similar up to 1 year after ICU admission, and gender was not associated with 90-day mortality in multivariate analyses in a variety of subgroups. Although plasma proteome analyses (including systemic inflammatory and cytokine responses, and activation of coagulation) were largely similar between genders, females showed enhanced endothelial cell activation; this difference was virtually absent in patients more than 55 years old. More than 80% of the leukocyte blood gene expression response was similar in male and female patients. The host response and outcome in male and female sepsis patients requiring ICU admission are largely similar.

  2. Benefit of revascularisation to critical limb ischaemia patients evaluated by a patient-oriented scoring system.

    Science.gov (United States)

    Chisci, E; Perulli, A; Iacoponi, F; Setacci, F; de Donato, G; Palasciano, G; Cappelli, A; Setacci, C

    2012-05-01

    The concept of patency and limb salvage are physician-oriented endpoints in critical limb ischaemia (CLI). These endpoints have failed to enhance function after revascularisation. The aim of this study was to create a scoring system to predict 1-year functional status and to assess the benefit to patients possible by revascularisation. During the period 2007-2009, 480 consecutive patients (mean age ± SD, 83.2 ± 8.7 years) underwent repair for CLI. Preoperative, operative and functional status characteristics and post-operative outcomes were recorded. The following patient-oriented outcomes were investigated pre- and postoperatively: basic and instrumental activities of daily living (BADL and IADL) and ambulatory and living status. Statistical analysis was performed to assess predictors of functional benefit from revascularisation. The variables significant on multivariable analysis were used to generate a scoring system to pre and postoperatively grade individual patient risk of losing baseline functional status at 1 year (CLI functional score). Ninety-three of 480 patients (19.3%) were in Rutherford class IV, 208 (43.3%) in class V and 179 (37.4%) in class VI. Surgical, endovascular and hybrid operations were performed in 108 (22.5%), 319 (66.5%) and 53 (11%) patients, respectively; mean follow-up was 408 ± 363 days. Improved or unchanged functional status was observed in 276 patients (57.5%). Preoperative mean ± SD BADL and IADL (4.26 ± 1.98 and 3.92 ± 2.69, respectively) were modified from mean values at 1-year follow-up (4.19 ± 2.06 and 4.12 ± 3, respectively) (p = 0.401 and p 80% indicates that patients are likely to lose functional abilities and require assistance for ambulation or ADL, as well as risking outcomes such as major amputation, new CLI-related hospitalisation or re-operation (p 2 cm, infection and poor tibial runoff), American Society of Anesthesiologists (ASA) score > II, previous cerebrovascular event and heart

  3. Requirement analysis of the safety-critical software implementation for the nuclear power plant

    International Nuclear Information System (INIS)

    Chang, Hoon Seon; Jung, Jae Cheon; Kim, Jae Hack; Nam, Sang Ku; Kim, Hang Bae

    2005-01-01

    The safety critical software shall be implemented under the strict regulation and standards along with hardware qualification. In general, the safety critical software has been implemented using functional block language (FBL) and structured language like C in the real project. Software design shall comply with such characteristics as; modularity, simplicity, minimizing the use of sub-routine, and excluding the interrupt logic. To meet these prerequisites, we used the computer-aided software engineering (CASE) tool to substantiate the requirements traceability matrix that were manually developed using Word processors or Spreadsheets. And the coding standard and manual have been developed to confirm the quality of software development process, such as; readability, consistency, and maintainability in compliance with NUREG/CR-6463. System level preliminary hazard analysis (PHA) is performed by analyzing preliminary safety analysis report (PSAR) and FMEA document. The modularity concept is effectively implemented for the overall module configurations and functions using RTP software development tool. The response time imposed on the basis of the deterministic structure of the safety-critical software was measured

  4. Physical and psychosocial support requirements of 1,500 patients starting radiotherapy

    Energy Technology Data Exchange (ETDEWEB)

    Kirchheiner, K.; Czajka, A.; Luetgendorf-Cacig, C.; Schmid, M.P.; Komarek, E.; Poetter, R. [Medical Univ. of Vienna, Comprehensive Cancer Center, Vienna (Austria). Dept. of Radiation Oncology; Ponocny-Seliger, E. [Sigmund Freud Private Univ. Vienna (Austria). Dept. of Psychology; Doerr, W. [Medical Univ. of Vienna, Comprehensive Cancer Center, Vienna (Austria). Dept. of Radiation Oncology; Medical Univ. of Vienna (Austria). Christian Doppler Lab. for Medical Radiation Research for Radiation Oncology

    2013-05-15

    Background. The need for psychosocial support in cancer patients is estimated in the literature at 14-50%. At the Department of Radiation Oncology, Medical University of Vienna, approximately 3,000 patients are seen annually. Due to limited staff resources, highly distressed patients need to be selected for focused support. A multidisciplinary screening questionnaire covering physical, social and psychological problems and needs was successfully implemented in clinical routine. We present the results of a representative sample of 1,500 heterogeneous cancer patients before beginning radiotherapy. Patients and methods. The prevalence rates of physical, social and psychological problems and needs were evaluated. Independent risk factors for critical psychological distress were analyzed in a multivariate logistic regression model, in order to identify vulnerable subgroups for focused psychosocial support. Results. Critical psychological distress was found in 22% of the overall cohort, of whom only 26% reported a need for psychological information. Clinically relevant pain was suffered by 31%. Patients' most frequent complaints were weakness, sleeping difficulties and exhaustion. Consequently, 40% were impaired in activities and 35% reported a requirement for support in daily life. A need for further information was expressed by 37% of patients. Significant risk factors for critical psychological distress included pain, functional status, support requirements and patient-reported symptoms. Differences in tumor type, metastases and sociodemographic variables had no impact on critical psychological distress. Conclusion. Approximately one third of all patients beginning radiotherapy have physical, social and psychological problems and should receive focused psychosocial support. Multivariate analysis reveals that patients with impaired ''physical integrity'' are at a significantly higher risk of experiencing critical psychological distress. (orig.)

  5. Physical and psychosocial support requirements of 1,500 patients starting radiotherapy

    International Nuclear Information System (INIS)

    Kirchheiner, K.; Czajka, A.; Luetgendorf-Cacig, C.; Schmid, M.P.; Komarek, E.; Poetter, R.; Ponocny-Seliger, E.; Doerr, W.; Medical Univ. of Vienna

    2013-01-01

    Background. The need for psychosocial support in cancer patients is estimated in the literature at 14-50%. At the Department of Radiation Oncology, Medical University of Vienna, approximately 3,000 patients are seen annually. Due to limited staff resources, highly distressed patients need to be selected for focused support. A multidisciplinary screening questionnaire covering physical, social and psychological problems and needs was successfully implemented in clinical routine. We present the results of a representative sample of 1,500 heterogeneous cancer patients before beginning radiotherapy. Patients and methods. The prevalence rates of physical, social and psychological problems and needs were evaluated. Independent risk factors for critical psychological distress were analyzed in a multivariate logistic regression model, in order to identify vulnerable subgroups for focused psychosocial support. Results. Critical psychological distress was found in 22% of the overall cohort, of whom only 26% reported a need for psychological information. Clinically relevant pain was suffered by 31%. Patients' most frequent complaints were weakness, sleeping difficulties and exhaustion. Consequently, 40% were impaired in activities and 35% reported a requirement for support in daily life. A need for further information was expressed by 37% of patients. Significant risk factors for critical psychological distress included pain, functional status, support requirements and patient-reported symptoms. Differences in tumor type, metastases and sociodemographic variables had no impact on critical psychological distress. Conclusion. Approximately one third of all patients beginning radiotherapy have physical, social and psychological problems and should receive focused psychosocial support. Multivariate analysis reveals that patients with impaired ''physical integrity'' are at a significantly higher risk of experiencing critical psychological distress. (orig.)

  6. Thermoluminescent dosimetry of critical organs in CT pediatric patients

    International Nuclear Information System (INIS)

    Azorin, Juan; Tabares, Musel

    2008-01-01

    This paper presents the determination of absorbed dose in critical organs of pediatric patients submitted to head computed tomography (CT) studies. This research included patients up to 16 years old submitted to head CT studies using a Siemens Somaton 16 plus multislice CT scanner. Doses were measured using locally made LiF: Mg,Cu,P + PTFE thermoluminescent dosimeters (TLD) due to its tissue equivalence and low fading. Results showed that both the organ absorbed doses and the volume computed tomography dose index (CTDI vol ) determined for simple studies were half of those obtained for contrasted studies. In the case of head three-dimensional reconstruction CT studies the CTDI vol value obtained was almost the same that the obtained for simple CT studies but the organ doses were significantly different. These results suggest that the CTDI vol value is a good indication for choosing the exposure parameters of the CT studies and is useful in the determination of the effective dose but it is not related with the organ doses. (author)

  7. [Vitamin D deficiency and morbimortality in critically ill paediatric patients].

    Science.gov (United States)

    García-Soler, Patricia; Morales-Martínez, Antonio; Rosa-Camacho, Vanessa; Lillo-Muñoz, Juan Antonio; Milano-Manso, Guillermo

    2017-08-01

    To determine the prevalence and risks factors of vitamin D deficiency, as well as its relationship with morbidity and mortality in a PICU. An observational prospective study in a tertiary children's University Hospital PICU conducted in two phases: i: cohorts study, and ii: prevalence study. The study included 340 critically ill children with ages comprising 6 months to 16 years old. Chronic kidney disease, known parathyroid disorders, and vitamin D supplementation. Total 25-hydroxyvitamin D [25(OH)D] was measured in the first 48hours of admission to a PICU. Parathormone, calcium, phosphate, blood gases, blood count, C-reactive protein, and procalcitonin were also analysed. A record was also made of demographic features, characteristics of the episode, and complications during the PICU stay. The overall prevalence rate of vitamin D deficiency was 43.8%, with a mean of 22.28 (95% CI 21.15-23.41) ng/ml. Patients with vitamin D deficiency were older (61 vs 47 months, P=.039), had parents with a higher level of academic studies (36.5% vs 20%, P=.016), were admitted more often in winter and spring, had a higher PRISM-III (6.8 vs 5.1, P=.037), a longer PICU stay (3 vs 2 days, P=.001), and higher morbidity (61.1% vs 30.4%, P<001) than the patients with sufficient levels of 25(OH)D. Patients who died had lower levels of 25(OH)D (14±8.81ng/ml versus 22.53±10.53ng/ml, P=.012). Adjusted OR for morbidity was 5.44 (95%CI; 2.5-11.6). Vitamin D deficiency is frequent in critically ill children, and it is related to both morbidity and mortality, although it remains unclear whether it is a causal relationship or it is simply a marker of severity in different clinical situations. Copyright © 2016 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

  8. Acute and long-term survival in chronically critically ill surgical patients: a retrospective observational study.

    Science.gov (United States)

    Hartl, Wolfgang H; Wolf, Hilde; Schneider, Christian P; Küchenhoff, Helmut; Jauch, Karl-Walter

    2007-01-01

    Various cohort studies have shown that acute (short-term) mortality rates in unselected critically ill patients may have improved during the past 15 years. Whether these benefits also affect acute and long-term prognosis in chronically critically ill patients is unclear, as are determinants relevant to prognosis. We conducted a retrospective analysis of data collected from March 1993 to February 2005. A cohort of 390 consecutive surgical patients requiring intensive care therapy for more than 28 days was analyzed. The intensive care unit (ICU) survival rate was 53.6%. Survival rates at one, three and five years were 61.8%, 44.7% and 37.0% among ICU survivors. After adjustment for relevant covariates, acute and long-term survival rates did not differ significantly between 1993 to 1999 and 1999 to 2005 intervals. Acute prognosis was determined by disease severity during ICU stay and by primary diagnosis. However, only the latter was independently associated with long-term prognosis. Advanced age was an independent prognostic determinant of poor short-term and long-term survival. Acute and long-term prognosis in chronically critically ill surgical patients has remained unchanged throughout the past 12 years. After successful surgical intervention and intensive care, long-term outcome is reasonably good and is mainly determined by age and underlying disease.

  9. Transfusion requirements in elective cardiopulmonary bypass surgery patients

    DEFF Research Database (Denmark)

    Sivapalan, Praleene; Bäck, Anne Caroline; Ostrowski, Sisse Rye

    2017-01-01

    Managing haemostasis in patients undergoing cardiopulmonary bypass (CPB) surgery remains a challenge. There is no established laboratory test to predict transfusion requirements in cardiac surgery. We investigated whether preoperative Thromboelastography (TEG) with Platelet Mapping Assay (PMA......) or Multiple Electrode Aggrometry (MEA) could predict transfusion requirements in patients undergoing elective coronary artery bypass grafting (CABG) or combined CABG with aortic or mitral valve replacement. We prospectively investigated 199 patients undergoing elective CABG or combined procedures. PMA and MEA...

  10. Numerical investigation on critical heat flux and coolant volume required for transpiration cooling with phase change

    International Nuclear Information System (INIS)

    He, Fei; Wang, Jianhua

    2014-01-01

    Highlights: • Five states during the transpiration cooling are discussed. • A suit of applicable program is developed. • The variations of the thickness of two-phase region and the pressure are analyzed. • The relationship between heat flux and coolant mass flow rate is presented. • An approach is given to define the desired case of transpiration cooling. - Abstract: The mechanism of transpiration cooling with liquid phase change is numerically investigated to protect the thermal structure exposed to extremely high heat flux. According to the results of theoretical analysis, there is a lower critical and an upper critical external heat flux corresponding a certain coolant mass flow rate, between the two critical values, the phase change of liquid coolant occurs within porous structure. A strongly applicable self-edit program is developed to solve the states of fluid flow and heat transfer probably occurring during the phase change procedure. The distributions of temperature and saturation in these states are presented. The variations of the thickness of two-phase region and the pressure including capillary are analyzed, and capillary pressure is found to be the main factor causing pressure change. From the relationships between the external heat flux and coolant mass flow rate obtained at different cooling cases, an approach is given to estimate the maximal heat flux afforded and the minimal coolant consumption required by the desired case of transpiration cooling. Thus the pressure and coolant consumption required in a certain thermal circumstance can be determined, which are important in the practical application of transpiration cooling

  11. Patient participation as discursive practice-A critical discourse analysis of Danish mental healthcare.

    Science.gov (United States)

    Joergensen, Kim; Praestegaard, Jeanette

    2018-04-01

    Patient participation is one of the most prevalent focus areas in the Danish healthcare debate. Patient participation is generally presented as a fundamental democratic right, and is stated in an objective language with legal requirements for healthcare professionals to ensure that patients systematically participate in their own courses of care and treatment. In the research literature, it is not clear what is meant by 'patient participation', and several discourses on patient participation exist side by side. This study explores how discourses of patient participation unfold and are at play in the articulations in official legal and political documents and patient records relating to a Danish psychiatric context. The documents and patient records have been analyzed using a Fairclough-inspired critical discourse approach which is concerned with how power is exercised through language. The research findings show that patient participation within Danish psychiatric healthcare is governed within a neoliberal discourse where underlying discourses; discourse of biomedicine, paternalism, management, evidence and ethics of care are embedded, and a discourse that seems to ascribe stigmatizing traits to mentally ill patients. © 2017 John Wiley & Sons Ltd.

  12. Patient-important outcomes in randomized controlled trials in critically ill patients: a systematic review.

    Science.gov (United States)

    Gaudry, Stéphane; Messika, Jonathan; Ricard, Jean-Damien; Guillo, Sylvie; Pasquet, Blandine; Dubief, Emeline; Boukertouta, Tanissia; Dreyfuss, Didier; Tubach, Florence

    2017-12-01

    Intensivists' clinical decision making pursues two main goals for patients: to decrease mortality and to improve quality of life and functional status in survivors. Patient-important outcomes are gaining wide acceptance in most fields of clinical research. We sought to systematically review how well patient-important outcomes are reported in published randomized controlled trials (RCTs) in critically ill patients. Literature search was conducted to identify eligible trials indexed from January to December 2013. Articles were eligible if they reported an RCT involving critically ill adult patients. We excluded phase II, pilot and physiological crossover studies. We assessed study characteristics. All primary and secondary outcomes were collected, described and classified using six categories of outcomes including patient-important outcomes (involving mortality at any time on the one hand and quality of life, functional/cognitive/neurological outcomes assessed after ICU discharge on the other). Of the 716 articles retrieved in 2013, 112 RCTs met the inclusion criteria. Most common topics were mechanical ventilation (27%), sepsis (19%) and nutrition (17%). Among the 112 primary outcomes, 27 (24%) were patient-important outcomes (mainly mortality, 21/27) but only six (5%) were patient-important outcomes besides mortality assessed after ICU discharge (functional disability = 4; quality of life = 2). Among the 598 secondary outcomes, 133 (22%) were patient-important outcomes (mainly mortality, 92/133) but only 41 (7%) were patient-important outcomes besides mortality assessed after ICU discharge (quality of life = 20, functional disability = 14; neurological/cognitive performance = 5; handicap = 1; post-traumatic stress = 1). Seventy-three RCTs (65%) reported at least one patient-important outcome but only 11 (10%) reported at least one patient-important outcome besides mortality assessed after ICU discharge. Patient-important outcomes are rarely primary

  13. Worries and concerns experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident study.

    Science.gov (United States)

    Gustafsson, Marcus; Wennerholm, Sara; Fridlund, Bengt

    2010-06-01

    Inter-hospital patient transports are required around the clock. During these transports it is the responsibility of the accompanying nurse specialists to ensure their patient's safety, while at the same time providing optimal nursing care in an unusual and often stressful situation. The aim of this study was to explore and describe the nurse specialists' cause of worries and concerns (WaC) and how they manage these. An explorative and qualitative design based on the critical incident technique was used. Interviews were conducted with 30 nurse specialists within the fields of anaesthetic, intensive and pre-hospital care in the south of Sweden. WaC felt by the nurse specialists were based on being unable to influence their work situation, or carry out their tasks as expected. Their responses to these unusual situations were resolved by using internal (acquired knowledge and experience) and external resources (consulting colleagues having different competences). A safe working environment improves the possibility to deliver a satisfactory work performance. Shared experiences and communication between colleagues should be encouraged; teamwork should be enhanced by the implementation of local and national training courses, and unambiguous work guidelines should be given. Copyright 2010 Elsevier Ltd. All rights reserved.

  14. Metformin: An Old Taboo yet a New Friend for Targeted Glucose Control in Critically Ill Patients

    Directory of Open Access Journals (Sweden)

    Sarvi Sanaie

    2016-04-01

    Full Text Available Glucose management in critically ill adults and children has always been controversial. A few recent studies mention that the use of any drug other than insulin for glucose control in intensive care unit is not recommended anymore1. Increased levels of counter-regulatory hormones and insulin resistance at organ levels contribute immensely to the emergence of hyperglycemia in these patients. Consequently, in some patients higher doses of insulin are required for the maintenance of normoglycemia and in such scenarios incidence of hypoglycemia becomes a real concern. Moreover, insulin therapy might lead to hypokalaemia and hypomagnesaemia which in turns promote insulin resistance and higher blood glucose level (BGL. All these events make insulin administration unavoidable; thereby, beginning a vicious cycle with adverse outcomes. One of therapeutic options in this scenario is using insulin sensitizing agents as an adjunct therapy for glycemic control in critically ill patients. Different studies have shown that metformin, similar to insulin, is of anti-inflammatory and antioxidant properties, improves lipid profile, decreases nursing workload and lowers the incidence of adverse effects related to high-dose insulin therapy without being associated with the increased risk of lactic acidosis or hypoglycemia2-4. Panahi et al., in their study, showed that metformin therapy in hyperglycemic critically ill patients resulted in similar outcomes with insulin thersapy5. Also, there are some studies reporting that metformin limits ischemia reperfusion injury, modulates inflammation; it consequently contributes to the survival benefits probably through increasing adenosine receptor stimulation6-8. In sepsis, there is a biphasic inflammatory response; Systemic Inflammatory Response Syndrome (SIRS, as an initial hyperinflammatory phase, and Counterregulatory anti-inflammatory response syndrome as a later hypoactive phase. Therefore, anti-inflammatory drugs like

  15. Testing to fulfill HACCP (Hazard Analysis Critical Control Points) requirements: principles and examples.

    Science.gov (United States)

    Gardner, I A

    1997-12-01

    On-farm HACCP (hazard analysis critical control points) monitoring requires cost-effective, yet accurate and reproducible tests that can determine the status of cows, milk, and the dairy environment. Tests need to be field-validated, and their limitations need to be established so that appropriate screening strategies can be initiated and test results can be rationally interpreted. For infections and residues of low prevalence, tests or testing strategies that are highly specific help to minimize false-positive results and excessive costs to the dairy industry. The determination of the numbers of samples to be tested in HACCP monitoring programs depends on the specific purpose of the test and the likely prevalence of the agent or residue at the critical control point. The absence of positive samples from a herd test should not be interpreted as freedom from a particular agent or residue unless the entire herd has been tested with a test that is 100% sensitive. The current lack of field-validated tests for most of the chemical and infectious agents of concern makes it difficult to ensure that the stated goals of HACCP programs are consistently achieved.

  16. Using operations research to plan improvement of the transport of critically ill patients.

    Science.gov (United States)

    Chen, Jing; Awasthi, Anjali; Shechter, Steven; Atkins, Derek; Lemke, Linda; Fisher, Les; Dodek, Peter

    2013-01-01

    Operations research is the application of mathematical modeling, statistical analysis, and mathematical optimization to understand and improve processes in organizations. The objective of this study was to illustrate how the methods of operations research can be used to identify opportunities to reduce the absolute value and variability of interfacility transport intervals for critically ill patients. After linking data from two patient transport organizations in British Columbia, Canada, for all critical care transports during the calendar year 2006, the steps for transfer of critically ill patients were tabulated into a series of time intervals. Statistical modeling, root-cause analysis, Monte Carlo simulation, and sensitivity analysis were used to test the effect of changes in component intervals on overall duration and variation of transport times. Based on quality improvement principles, we focused on reducing the 75th percentile and standard deviation of these intervals. We analyzed a total of 3808 ground and air transports. Constraining time spent by transport personnel at sending and receiving hospitals was projected to reduce the total time taken by 33 minutes with as much as a 20% reduction in standard deviation of these transport intervals in 75% of ground transfers. Enforcing a policy of requiring acceptance of patients who have life- or limb-threatening conditions or organ failure was projected to reduce the standard deviation of air transport time by 63 minutes and the standard deviation of ground transport time by 68 minutes. Based on findings from our analyses, we developed recommendations for technology renovation, personnel training, system improvement, and policy enforcement. Use of the tools of operations research identifies opportunities for improvement in a complex system of critical care transport.

  17. Right-Sided Pleural Effusion in a Critically Ill Stroke Patient

    Directory of Open Access Journals (Sweden)

    Alexander Bautista MD

    2014-02-01

    Full Text Available Pleural fluid collections are common in those critically ill. We report the case of a left middle cerebral artery stroke patient who developed respiratory distress and required intubation and mechanical ventilation. Although the patient’s clinical status and oxygenation improved, there was persistence of right-sided opacity in the chest radiograph. Further workup proved a right-sided pleural effusion, which was drained and managed. Following extubation, a swallow study was ordered, which led to a fluoroscopic examination that demonstrated esophageal perforation. Thoracic surgery was consulted and did a primary repair of perforation and noted non–small cell carcinoma on the perforated site.

  18. Resting energy expenditure in critically ill patients: Evaluation methods and clinical applications

    Directory of Open Access Journals (Sweden)

    Ana Cláudia Soncini Sanches

    Full Text Available Summary Patients on intensive care present systemic, metabolic, and hormonal alterations that may adversely affect their nutritional condition and lead to fast and important depletion of lean mass and malnutrition. Several factors and medical conditions can influence the energy expenditure (EE of critically ill patients, such as age, gender, surgery, serious infections, medications, ventilation modality, and organ dysfunction. Clinical conditions that can present with EE change include acute kidney injury, a complex disorder commonly seen in critically ill patients with manifestations that can range from minimum elevations in serum creatinine to renal failure requiring dialysis. The nutritional needs of this population are therefore complex, and determining the resting energy expenditure is essential to adjust the nutritional supply and to plan a proper diet, ensuring that energy requirements are met and avoiding complications associated with overfeeding and underfeeding. Several evaluation methods of EE in this population have been described, but all of them have limitations. Such methods include direct calorimetry, doubly labeled water, indirect calorimetry (IC, various predictive equations, and, more recently, the rule of thumb (kcal/kg of body weight. Currently, IC is considered the gold standard.

  19. Chest tube care in critically ill patient: A comprehensive review

    Directory of Open Access Journals (Sweden)

    Hanan Mohammed Mohammed

    2015-10-01

    Full Text Available Breathing is automatic. We don’t usually think too much about it unless we develop a problem. Lack of adequate ventilation and impairment of our respiratory system can quickly become life-threatening. There are many clinical conditions that may necessitate the use of chest tubes. When there is an accumulation of positive pressure in the chest cavity (where it should normally be negative pressure between pleurae, a patient will require chest drainage. Chest tubes may be inserted to drain body fluids or to facilitate the re-expansion of a lung. It is important for the clinician to determine the most appropriate tube size to use prior to intubation. The position of the chest tube is related to the function that the chest tube performs. When managing the care of patients who have chest tubes it is important to fully understand what to do in case problems arise. It is also important to be able to assess when the chest tube is ready to be discontinued. Nurses and other healthcare professionals who are responsible for the safe delivery of care should be knowledgeable about respiratory pathophysiology, signs of respiratory compromise, and the care and management of interventions that may be utilized to ensure adequate respiration.

  20. Nurses' perceptions of critical issues requiring consideration in the development of guidelines for professional registered nurse staffing for perinatal units.

    Science.gov (United States)

    Simpson, Kathleen Rice; Lyndon, Audrey; Wilson, Jane; Ruhl, Catherine

    2012-01-01

    To solicit input from registered nurse members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) on critical considerations for review and revision of existing nurse staffing guidelines. Thematic analysis of responses to a cross-sectional on-line survey question: "Please give the staffing task force your input on what they should consider in the development of recommendations for staffing of perinatal units." Members of AWHONN (N = 884). Descriptions of staffing concerns that should be considered when evaluating and revising existing perinatal nurse staffing guidelines. Consistent themes identified included the need for revision of nurse staffing guidelines due to requirements for safe care, increases in patient acuity and complexity, invisibility of the fetus and newborn as separate and distinct patients, difficulties in providing comprehensive care during labor and for mother-baby couplets under current conditions, challenges in staffing small volume units, and the negative effect of inadequate staffing on nurse satisfaction and retention. Participants overwhelmingly indicated current nurse staffing guidelines were inadequate to meet the needs of contemporary perinatal clinical practice and required revision based on significant changes that had occurred since 1983 when the original staffing guidelines were published. © 2012 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.

  1. Empowering Critical Thinking Skills with Computerized Patient Simulators

    Science.gov (United States)

    Farrar, Francisca Cisneros; Suggs, Leslie

    2010-01-01

    Students struggle with the mastery of critical thinking skills which are essential to their academic success. University faculty are challenged to create teaching strategies to help students build critical thinking skills. Nursing faculty at Austin Peay State University in Clarksville, Tennessee looked to research and technology for ways to…

  2. Being a fellow patient to a critically ill patient leads to feelings of anxiety - An interview study

    DEFF Research Database (Denmark)

    Laursen, Jannie; Bonnevie Lundby, Trine; Danielsen, Anne Kjaergaard

    2016-01-01

    Objectives To explore in-patients’ experiences being a fellow patient to patients who become critically ill. Design The study was designed as a qualitative phenomenological study. Setting The study was conducted in a surgical ward of a hospital in Denmark. Subjects Fifteen fellow patients...... to patients, who became critically ill. Results Three key themes emerged from the analysis of the data: patients’ interaction, anxiety, and professional support. These findings demonstrated the importance of understanding how patients experienced being a fellow patient to patients, who become critically ill......, their views on interacting with such a patient, how the patients who become critically ill influenced them, and what kind of support they needed from the health professionals. Conclusion The findings highlighted the different emotions and feelings experienced by fellow patients. It showed how the impact...

  3. [Nutritional support response in critically ill patients; differences between medical and surgical patients].

    Science.gov (United States)

    Zamora Elson, M; Serón Arbeloa, C; Labarta Monzón, L; Garrido Ramírez de Arellano, I; Lander Azcona, A; Marquina Lacueva, M I; López Claver, J C; Escós Orta, J

    2012-01-01

    To assess the nutritional response of a group of critically ill patients, as well as the differences in the response to nutritional support between medical and surgical patients. One-year long retrospective study including critically ill patients on artificial nutrition for 7 days. Throughout the first week, three nutritional biochemical controls were done that included albumin, prealbumin, transferrin, cholesterol, and electrolytes. Other data gathered were: nutritional risk index, age, gender, weight, height, APACHE, delay of onset of nutritional support, access route, predicted and real caloric intake, medical or surgical patient, hospital stay, duration of the central venous catheter, urinary tube, and/or mechanical ventilation, incidence and density of incidence of nosocomial infections. Sixty-three patients were studied, 30 (47%) medical and 33 (53%) surgical/trauma patients, with a usage of EN higher among medical patients (16/30, 53% vs. 5/33, 15%), PN higher among surgical patients (25/33, 76%), and mixed nutrition similar in both groups (5 medical and 3 surgical patients) (p = 0.001). There were no differences between medical and surgical patients regarding: both predicted and real caloric and nitrogenous intake, APACHE, delay of onset of nutrition, phosphorus, magnesium or glucose levels, mortality and incidence of nosocomial infections. There were no differences either in hospital stay or use of mechanical ventilation, although these tended to be lower in surgical patients. The baseline biochemical parameters did not show differences between both groups, although they were worse among surgical patients. These patients presented during the study period steady albumin levels with improvement in the remaining parameters, whereas medical patients showed a decrease in albumin and transferrin levels, steady prealbumin levels, and slightly improvement in cholesterol levels. We have observed higher usage of PN among surgical patients, which showed worse

  4. Pharmacokinetic/pharmacodynamic evaluation of linezolid for the treatment of staphylococcal infections in critically ill patients.

    Science.gov (United States)

    Dong, Haiyan; Xie, Jiao; Wang, Taotao; Chen, Lihong; Zeng, Xiaoyan; Sun, Jinyao; Wang, Xue; Dong, Yalin

    2016-09-01

    Several studies have demonstrated that the ideal therapeutic effect of linezolid cannot be achieved in critically ill patients with the recommended standard dosing regimen of 600 mg every 12 h (q12h). Moreover, the optimal strategy for successful treatment is still lacking. This study analysed factors influencing the efficacy of linezolid treatment and determined the target for successful treatment by logistic regression in 27 critically ill patients with staphylococcal infection who received linezolid 600 mg q12h. The results showed that only the 24-h area under the concentration-time curve to minimum inhibitory concentration (AUC24/MIC) ratio was significantly associated with staphylococcal eradication. Reaching 80% bacterial eradication required an AUC24/MIC of 120.5, defining the therapeutic target. Different dosing regimens were evaluated using Monte Carlo simulation to determine the optimal dosage strategy for linezolid. Although the probability of target attainment (PTA) was high (>99.9%) for the standard dosing regimen at MIC ≤ 1 mg/L, the PTA was almost 0 at MIC = 2 mg/L, thus the dosing regimen required adjustment. In addition, if the dosing regimen was adjusted to 600 mg every 8 h or 600 mg every 6 h, the major staphylococci (except for MRSA and MSSA) exhibited a cumulative fraction of response of >80%, showing a higher treatment success. These findings indicate that a strategy of high linezolid dosage may be needed to increase the probability of successful treatment at MIC > 1 mg/L. The role of therapeutic drug monitoring should be encouraged for optimising linezolid exposure in critically ill patients. Copyright © 2016 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.

  5. Critically Ill Patients With the Middle East Respiratory Syndrome: A Multicenter Retrospective Cohort Study.

    Science.gov (United States)

    Arabi, Yaseen M; Al-Omari, Awad; Mandourah, Yasser; Al-Hameed, Fahad; Sindi, Anees A; Alraddadi, Basem; Shalhoub, Sarah; Almotairi, Abdullah; Al Khatib, Kasim; Abdulmomen, Ahmed; Qushmaq, Ismael; Mady, Ahmed; Solaiman, Othman; Al-Aithan, Abdulsalam M; Al-Raddadi, Rajaa; Ragab, Ahmed; Al Mekhlafi, Ghaleb A; Al Harthy, Abdulrahman; Kharaba, Ayman; Ahmadi, Mashael Al; Sadat, Musharaf; Mutairi, Hanan Al; Qasim, Eman Al; Jose, Jesna; Nasim, Maliha; Al-Dawood, Abdulaziz; Merson, Laura; Fowler, Robert; Hayden, Frederick G; Balkhy, Hanan H

    2017-10-01

    To describe patient characteristics, clinical manifestations, disease course including viral replication patterns, and outcomes of critically ill patients with severe acute respiratory infection from the Middle East respiratory syndrome and to compare these features with patients with severe acute respiratory infection due to other etiologies. Retrospective cohort study. Patients admitted to ICUs in 14 Saudi Arabian hospitals. Critically ill patients with laboratory-confirmed Middle East respiratory syndrome severe acute respiratory infection (n = 330) admitted between September 2012 and October 2015 were compared to consecutive critically ill patients with community-acquired severe acute respiratory infection of non-Middle East respiratory syndrome etiology (non-Middle East respiratory syndrome severe acute respiratory infection) (n = 222). None. Although Middle East respiratory syndrome severe acute respiratory infection patients were younger than those with non-Middle East respiratory syndrome severe acute respiratory infection (median [quartile 1, quartile 3] 58 yr [44, 69] vs 70 [52, 78]; p < 0.001), clinical presentations and comorbidities overlapped substantially. Patients with Middle East respiratory syndrome severe acute respiratory infection had more severe hypoxemic respiratory failure (PaO2/FIO2: 106 [66, 160] vs 176 [104, 252]; p < 0.001) and more frequent nonrespiratory organ failure (nonrespiratory Sequential Organ Failure Assessment score: 6 [4, 9] vs 5 [3, 7]; p = 0.002), thus required more frequently invasive mechanical ventilation (85.2% vs 73.0%; p < 0.001), oxygen rescue therapies (extracorporeal membrane oxygenation 5.8% vs 0.9%; p = 0.003), vasopressor support (79.4% vs 55.0%; p < 0.001), and renal replacement therapy (48.8% vs 22.1%; p < 0.001). After adjustment for potential confounding factors, Middle East respiratory syndrome was independently associated with death compared to non-Middle East respiratory syndrome severe acute respiratory

  6. Current clinical nutrition practices in critically ill patients in Latin America: a multinational observational study.

    Science.gov (United States)

    Vallejo, Karin Papapietro; Martínez, Carolina Méndez; Matos Adames, Alfredo A; Fuchs-Tarlovsky, Vanessa; Nogales, Guillermo Carlos Contreras; Paz, Roger Enrique Riofrio; Perman, Mario Ignacio; Correia, Maria Isabel Toulson Davisson; Waitzberg, Dan Linetzky

    2017-08-25

    Malnutrition in critically ill adults in the intensive care unit (ICU) is associated with a significantly elevated risk of mortality. Adequate nutrition therapy is crucial to optimise outcomes. Currently, there is a paucity of such data in Latin America. Our aims were to characterise current clinical nutrition practices in the ICU setting in Latin America and evaluate whether current practices meet caloric and protein requirements in critically ill patients receiving nutrition therapy. We conducted a cross-sectional, retrospective, observational study in eight Latin American countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Panama, and Peru). Eligible patients were critically ill adults hospitalised in the ICU and receiving enteral nutrition (EN) and/or parenteral nutrition (PN) on the Screening Day and the previous day (day -1). Caloric and protein balance on day -1, nutritional status, and prescribed nutrition therapy were recorded. Multivariable logistic regression analysis was performed to identify independent predictors of reaching daily caloric and protein targets. The analysis included 1053 patients from 116 hospitals. Evaluation of nutritional status showed that 74.1% of patients had suspected/moderate or severe malnutrition according to the Subjective Global Assessment. Prescribed nutrition therapy included EN alone (79.9%), PN alone (9.4%), and EN + PN (10.7%). Caloric intake met >90% of the daily target in 59.7% of patients on day -1; a caloric deficit was present in 40.3%, with a mean (±SD) daily caloric deficit of -688.8 ± 455.2 kcal. Multivariable logistic regression analysis showed that combined administration of EN + PN was associated with a statistically significant increase in the probability of meeting >90% of daily caloric and protein targets compared with EN alone (odds ratio, 1.56; 95% confidence interval, 1.02-2.39; p = 0.038). In the ICU setting in Latin America, malnutrition was highly prevalent and caloric

  7. Challenges and Potential Solutions – Individualised Antibiotic Dosing at the Bedside for Critically Ill Patients: a structured review

    Science.gov (United States)

    Roberts, Jason A.; Aziz, Mohd Hafiz Abdul; Lipman, Jeffrey; Mouton, Johan W.; Vinks, Alexander A.; Felton, Timothy W.; Hope, William W.; Farkas, Andras; Neely, Michael N.; Schentag, Jerome J.; Drusano, George; Frey, Otto R.; Theuretzbacher, Ursula; Kuti, Joseph L.

    2014-01-01

    Summary Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in sub-optimal outcomes. In this paper, we review the patient- and pathogen-related challenges that contribute to inadequate antibiotic dosing and discuss how a process for individualised antibiotic therapy, that increases the accuracy of dosing, can be implemented to further optimise care for the critically ill patient. The process for optimised antibiotic dosing firstly requires determination of the physiological derangements in the patient that can alter antibiotic concentrations including altered fluid status, microvascular failure, serum albumin concentrations as well as altered renal and hepatic function. Secondly, knowledge of the susceptibility of the infecting pathogen should be determined through liaison with the microbiology laboratory. The patient and pathogen challenges can then be solved by combining susceptibility data with measured antibiotic concentration data (where possible) into a clinical dosing software. Such software uses pharmacokinetic-pharmacodynamic (PK/PD) models from critically ill patients to accurately predict the dosing requirements for the individual patient with the aim of optimising antibiotic exposure and maximising effectiveness. PMID:24768475

  8. Knowledge translation interventions for critically ill patients: a systematic review*.

    Science.gov (United States)

    Sinuff, Tasnim; Muscedere, John; Adhikari, Neill K J; Stelfox, Henry T; Dodek, Peter; Heyland, Daren K; Rubenfeld, Gordon D; Cook, Deborah J; Pinto, Ruxandra; Manoharan, Venika; Currie, Jan; Cahill, Naomi; Friedrich, Jan O; Amaral, Andre; Piquette, Dominique; Scales, Damon C; Dhanani, Sonny; Garland, Allan

    2013-11-01

    We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized

  9. [Aeromedical evacuation of critically ill patients in developing countries A retrospective study on 244 patients in Djibouti].

    Science.gov (United States)

    Bordes, J; Loheas, D; Benois, A

    2015-01-01

    The pratice of intensive care in Africa is marked by a wide variety of health care delivery. Only a few centers offer specialized intensive care units, as cardiac or neurological units. That may explain the need for aeromedical evacuations for patients whose condition exceeds local capacity. Our objective was to assess whether the proportion of patients admitted to intensive care and evacuated had increased between 1997 and 2013 in a developing country, Djibouti. We examined the activity register of Bouffard Hospital intensive care unit in Djibouti to determine the number and characteristics of patients evacuated by air ambulance during a 16 years period. From January 1997 to December 2013, a total of 244 patients were evacuated. The evacuation rate was 5.74ù of the patients admitted to the entire duration of the study. The rate of patients evacuated was not different between 1997 and 2013 (5,69ù versus 8,33ù respectively, p = 0,269). However, the rate of djiboutian evacuated patients was statistically different between 1997 and 2013 (0,96ù versus 4,46ù, p = 0,02). The main causes were severe trauma injuries, cardiovascular diseases and neurological diseases. The aeromedical evacuation of a critically ill patient in a developing country is a process requiring heavy logistics and depending on the medical skills available in the area, and financial resources that can be implemented for the patient. Our study shows that medical evacuations in favor of Djiboutian patients are marginal but are increasing over the past decade.

  10. A critical review of the data requirements for fluid flow models through fractured rock

    International Nuclear Information System (INIS)

    Priest, S.D.

    1986-01-01

    The report is a comprehensive critical review of the data requirements for ten models of fluid flow through fractured rock, developed in Europe and North America. The first part of the report contains a detailed review of rock discontinuities and how their important geometrical properties can be quantified. This is followed by a brief summary of the fundamental principles in the analysis of fluid flow through two-dimensional discontinuity networks and an explanation of a new approach to the incorporation of variability and uncertainty into geotechnical models. The report also contains a review of the geological and geotechnical properties of anhydrite and granite. Of the ten fluid flow models reviewed, only three offer a realistic fracture network model for which it is feasible to obtain the input data. Although some of the other models have some valuable or novel features, there is a tendency to concentrate on the simulation of contaminant transport processes, at the expense of providing a realistic fracture network model. Only two of the models reviewed, neither of them developed in Europe, have seriously addressed the problem of analysing fluid flow in three-dimensional networks. (author)

  11. [Prevention and management of refeeding syndrome in patients with chronic critical illness].

    Science.gov (United States)

    Chen, Jun; Fan, Chaogang

    2016-07-01

    Nutritional support is an important means to treat the patients with chronic critical illness for commonly associated malnutrition. Refeeding syndrome is a serious complication during the process, mainly manifested as severe electrolyte with hypophosphataemia being the most common. Refeeding syndrome is not uncommon but it is often ignored. In our future clinical work, we need to recognize this chinical situation and use preventative and treatment measures. According to NICE clinical nutrition guideline, we discussed the risk factors, treatment methods and preventive measures of refeeding syndrome in patients with chronic critical illness. We argued that for patients with high risk refeeding syndrome, nutritional support treatment should be initially low calorie and slowly increased to complete requirement. Circulation capacity should be recovered, fluid balance must be closely monitored and supplement of vitamins, microelement, electrolytes should be noted. After the emergence of refeeding syndrome, we should reduce or even stop the calorie intake, give an active treatment for electrolyte disorder, provide vitamin B, and maintain the functions of multiple organs.

  12. Patient Accounting Systems: Are They Fit with the Users' Requirements?

    Science.gov (United States)

    Ayatollahi, Haleh; Nazemi, Zahra; Haghani, Hamid

    2016-01-01

    A patient accounting system is a subsystem of a hospital information system. This system like other information systems should be carefully designed to be able to meet users' requirements. The main aim of this research was to investigate users' requirements and to determine whether current patient accounting systems meet users' needs or not. This was a survey study, and the participants were the users of six patient accounting systems used in 24 teaching hospitals. A stratified sampling method was used to select the participants (n = 216). The research instruments were a questionnaire and a checklist. The mean value of ≥3 showed the importance of each data element and the capability of the system. Generally, the findings showed that the current patient accounting systems had some weaknesses and were able to meet between 70% and 80% of users' requirements. The current patient accounting systems need to be improved to be able to meet users' requirements. This approach can also help to provide hospitals with more usable and reliable financial information.

  13. Patient Accounting Systems: Are They Fit with the Users' Requirements?

    Science.gov (United States)

    Ayatollahi, Haleh; Nazemi, Zahra

    2016-01-01

    Objectives A patient accounting system is a subsystem of a hospital information system. This system like other information systems should be carefully designed to be able to meet users' requirements. The main aim of this research was to investigate users' requirements and to determine whether current patient accounting systems meet users' needs or not. Methods This was a survey study, and the participants were the users of six patient accounting systems used in 24 teaching hospitals. A stratified sampling method was used to select the participants (n = 216). The research instruments were a questionnaire and a checklist. The mean value of ≥3 showed the importance of each data element and the capability of the system. Results Generally, the findings showed that the current patient accounting systems had some weaknesses and were able to meet between 70% and 80% of users' requirements. Conclusions The current patient accounting systems need to be improved to be able to meet users' requirements. This approach can also help to provide hospitals with more usable and reliable financial information. PMID:26893945

  14. Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database

    DEFF Research Database (Denmark)

    Andersen, Peter Oluf; Maaløe, Rikke; Andersen, Henning Boje

    2010-01-01

    Background Critical incident reports can identify areas for improvement in resuscitation practice. The Danish Patient Safety Database is a mandatory reporting system and receives critical incident reports submitted by hospital personnel. The aim of this study is to identify, analyse and categorize...... critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. Methods The search terms “cardiac arrest” and “resuscitation” were used to identify reports in the Danish Patient Safety Database. Identified critical incidents were then classified into categories. Results One...

  15. An effective technique for the software requirements analysis of NPP safety-critical systems, based on software inspection, requirements traceability, and formal specification

    International Nuclear Information System (INIS)

    Koo, Seo Ryong; Seong, Poong Hyun; Yoo, Junbeom; Cha, Sung Deok; Yoo, Yeong Jae

    2005-01-01

    A thorough requirements analysis is indispensable for developing and implementing safety-critical software systems such as nuclear power plant (NPP) software systems because a single error in the requirements can generate serious software faults. However, it is very difficult to completely analyze system requirements. In this paper, an effective technique for the software requirements analysis is suggested. For requirements verification and validation (V and V) tasks, our technique uses software inspection, requirement traceability, and formal specification with structural decomposition. Software inspection and requirements traceability analysis are widely considered the most effective software V and V methods. Although formal methods are also considered an effective V and V activity, they are difficult to use properly in the nuclear fields as well as in other fields because of their mathematical nature. In this work, we propose an integrated environment (IE) approach for requirements, which is an integrated approach that enables easy inspection by combining requirement traceability and effective use of a formal method. The paper also introduces computer-aided tools for supporting IE approach for requirements. Called the nuclear software inspection support and requirements traceability (NuSISRT), the tool incorporates software inspection, requirement traceability, and formal specification capabilities. We designed the NuSISRT to partially automate software inspection and analysis of requirement traceability. In addition, for the formal specification and analysis, we used the formal requirements specification and analysis tool for nuclear engineering (NuSRS)

  16. Procalcitonin increase in early identification of critically ill patients at high risk of mortality

    DEFF Research Database (Denmark)

    Jensen, Jens Ulrik; Heslet, Lars; Jensen, Tom Hartvig

    2006-01-01

    To investigate day-by-day changes in procalcitonin and maximum obtained levels as predictors of mortality in critically ill patients.......To investigate day-by-day changes in procalcitonin and maximum obtained levels as predictors of mortality in critically ill patients....

  17. Haloperidol for delirium in critically ill patients - protocol for a systematic review

    DEFF Research Database (Denmark)

    Barbateskovic, M; Kraus, S R; Collet, M O

    2018-01-01

    , relatives, and societies is considerable. The objective of this systematic review was to critically access the evidence of randomised clinical trials on the effects of haloperidol vs. placebo or any other agents for delirium in critically ill patients. METHODS: We will search for randomised clinical trials...... decision makers on the use of or future trials with haloperidol for the management of delirium in critically ill patients....

  18. Persistent lymphopenia is an independent predictor of mortality in critically ill emergency general surgical patients.

    Science.gov (United States)

    Vulliamy, P E; Perkins, Z B; Brohi, K; Manson, J

    2016-12-01

    Lymphopenia has been associated with poor outcome following sepsis, burns and trauma. This study was designed to establish whether lymphocyte count was associated with mortality in emergency general surgery (EGS) patients, and whether persistent lymphopenia was an independent predictor of mortality. A retrospective review of a prospectively compiled database of adult patients requiring ICU admission between 2002 and 2013 was performed. EGS patients with acute intra-abdominal pathology and organ dysfunction were included. Lymphocyte counts obtained from the day of ICU admission through to day 7 were examined. Multivariate logistic regression models were used to determine the relationship between persistent lymphopenia and outcome. The primary outcome measure was in-hospital mortality. The study included 173 patients, of whom 135 (78 %) had a low lymphocyte count at admission to ICU and 91 % (158/173) developed lymphopenia on at least one occasion. Lymphocyte counts were lower among non-survivors compared with survivors on each day from day 2 (0.62 vs 0.81, p = 0.03) through to day 7 (0.87 vs 1.15, p < 0.01). Patients with a persistently low lymphocyte count during the study period had significantly higher mortality when compared to patients with other lymphocyte patterns (64 vs 29 %, p < 0.01). On multivariate regression analysis, persistent lymphopenia was independently associated with increased in-hospital mortality [odds ratio 3.5 (95 % CI 1.7-7.3), p < 0.01]. Lymphopenia is commonly observed in critically ill EGS patients. Patients with persistent lymphopenia are 3.5 times more likely to die and lymphopenia is an independent predictor of increased mortality in this patient group.

  19. Sleep disturbances in critically ill patients in ICU: how much do we know?

    DEFF Research Database (Denmark)

    Boyko, Y.; Ording, H.; Jennum, Poul

    2012-01-01

    the underlying literature. There are no studies of level 1 evidence proving the positive impact of the tested interventions on the critically ill patients sleep pattern. Thus, disturbed sleep in critically ill patients with all the severe consequences remains an unresolved problem and needs further investigation.......Sleep disturbances in the intensive care unit (ICU) seem to lead to development of delirium, prolonged ICU stay, and increased mortality. That is why sufficient sleep is important for good outcome and recovery in critically ill patients. A variety of small studies reveal pathological sleep patterns...... in critically ill patients including abnormal circadian rhythm, high arousal and awakening index, reduced Slow Wave Sleep, and Rapid Eye Movement sleep. The purpose of this study is to summarise different aspects of sleep-awake disturbances, causes and handling methods in critically ill patients by reviewing...

  20. Measuring tele-ICU impact: does it optimize quality outcomes for the critically ill patient?

    Science.gov (United States)

    Goran, Susan F

    2012-04-01

    To determine the relationship between tele-ICU (intensive care unit) implementations and improvement in quality measures and patient outcomes. Tele-ICUs were designed to leverage scarce critical-care experts and promised to improve patient quality. Abstracts and peer-reviewed articles were reviewed to identify the associations between tele-ICU programmes and clinical outcomes, cost savings, and customer satisfaction. Few peer-reviewed studies are available and many variables in each study limit the ability to associate study conclusions to the overall tele-ICU programme. Further research is required to explore the impact of the tele-ICU on patient/family satisfaction. Research findings are highly dependent upon the level of ICU acceptance. The tele-ICU, in collaboration with the ICU team, can be a valuable tool for the enhancement of quality goals although the ability to demonstrate cost savings is extremely complex. Studies clearly indicate that tele-ICU nursing vigilance can enhance patient safety by preventing potential patient harm. Nursing managers and leaders play a vital part in optimizing the quality role of the tele-ICU through supportive modelling and the maximization of ICU integration. © 2012 Blackwell Publishing Ltd.

  1. Novel, Family-Centered Intervention to Improve Nutrition in Patients Recovering From Critical Illness: A Feasibility Study.

    Science.gov (United States)

    Marshall, Andrea P; Lemieux, Margot; Dhaliwal, Rupinder; Seyler, Hilda; MacEachern, Kristen N; Heyland, Daren K

    2017-06-01

    Critically ill patients are at increased risk of developing malnutrition-related complications because of physiological changes, suboptimal delivery, and reduced intake. Strategies to improve nutrition during critical illness recovery are required to prevent iatrogenic underfeeding and risk of malnutrition. The purpose of this study was to assess the feasibility and acceptability of a novel family-centered intervention to improve nutrition in critically ill patients. A 3-phase, prospective cohort feasibility study was conducted in 4 intensive care units (ICUs) across 2 countries. Intervention feasibility was determined by patient eligibility, recruitment, and retention rates. The acceptability of the intervention was assessed by participant perspectives collected through surveys. Participants included family members of the critically ill patients and ICU and ward healthcare professionals (HCPs). A total of 75 patients and family members, as well as 56 HCPs, were enrolled. The consent rate was 66.4%, and 63 of 75 (84%) of family participants completed the study. Most family members (53/55; 98.1%) would recommend the nutrition education program to others and reported improved ability to ask questions about nutrition (16/20; 80.0%). Family members viewed nutrition care more positively in the ICU. HCPs agreed that families should partner with HCPs to achieve optimal nutrition in the ICU and the wards. Health literacy was identified as a potential barrier to family participation. The intervention was feasible and acceptable to families of critically ill patients and HCPs. Further research to evaluate intervention impact on nutrition intake and patient-centered outcomes is required.

  2. Tracheostomy in special groups of critically ill patients: Who, when, and where?

    Science.gov (United States)

    Longworth, Aisling; Veitch, David; Gudibande, Sandeep; Whitehouse, Tony; Snelson, Catherine; Veenith, Tonny

    2016-01-01

    Tracheostomy is one of the most common procedures undertaken in critically ill patients. It offers many theoretical advantages over translaryngeal intubation. Recent evidence in a heterogeneous group of critically ill patients, however, has not demonstrated a benefit for tracheostomy, in terms of mortality, length of stay in Intensive Care Unit (ICU), or incidence of ventilator-associated pneumonia. It may be a beneficial intervention in articular subsets of ICU patients. In this article, we will focus on the evidence for the timing of tracheostomy and its effect on various subgroups of patients in critical care. PMID:27275076

  3. Rights of patients required in a public service ombudsman

    Directory of Open Access Journals (Sweden)

    Maristela Santini Martins

    2015-07-01

    Full Text Available Objective: analyzing the rights of patients required in a public service ombudsmen. Methods: an exploratory, descriptive study of documentary research. 109 complaint forms coming from the basic network were analyzed, related to 12 Basic Health Units located within the Southern Health Technical Supervision. Results: grouped into four categories of required rights: access to goods and services (62.4% being, access to specialized exams (28.7%, access to consultations (16.6%, referral to a specialist (5.7%, referral for urgent/emergency cases (1.3%, monitoring through home visits (7.6%, guaranteed medications (2.5%. Quality of health services (36.9% divided into: decent, considerate and respectful care (26.8%, guidance/clarification (9.6%, and public disclosure of government programs (0.6% and adequate infrastructure (0.6%. Conclusion: the rights that patients required are related to access, quality, treatment and adequate infrastructure.

  4. Information security requirements in patient-centred healthcare support systems.

    Science.gov (United States)

    Alsalamah, Shada; Gray, W Alex; Hilton, Jeremy; Alsalamah, Hessah

    2013-01-01

    Enabling Patient-Centred (PC) care in modern healthcare requires the flow of medical information with the patient between different healthcare providers as they follow the patient's treatment plan. However, PC care threatens the stability of the balance of information security in the support systems since legacy systems fall short of attaining a security balance when sharing their information due to compromises made between its availability, integrity, and confidentiality. Results show that the main reason for this is that information security implementation in discrete legacy systems focused mainly on information confidentiality and integrity leaving availability a challenge in collaboration. Through an empirical study using domain analysis, observations, and interviews, this paper identifies a need for six information security requirements in legacy systems to cope with this situation in order to attain the security balance in systems supporting PC care implementation in modern healthcare.

  5. Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients

    Science.gov (United States)

    de Mestral, Charles; Iqbal, Sameena; Fong, Nancy; LeBlanc, Joanne; Fata, Paola; Razek, Tarek; Khwaja, Kosar

    2011-01-01

    Background A multidisciplinary tracheostomy team was created in 2005 to follow critically ill patients who had undergone a tracheostomy until their discharge from hospital. Composed of a surgeon, surgical resident, respiratory therapist, speech-language pathologist and clinical nurse specialist, this team has been meeting twice a week for rounds involving patients who transitioned from the intensive care unit (ICU) to the medical and surgical wards. Our objective was to assess the impact of this multidisciplinary team on downsizing and decannulation times, on the incidence of speaking valve placement and on the incidence of tracheostomy-related complications on the ward. Methods This study was conducted at a tertiary care, level-1 trauma centre and teaching hospital and involved all patients who had received a tracheostomy during admission to the ICU from Jan. 1 to Dec. 31, 2004 (preservice group), and from Jan. 1 to Dec. 31, 2006 (postservice group). We compared the outcomes of patients who required tracheostomies in a 12-month period after the team was created with those of patients from a similar time frame before the establishment of the team. Results There were 32 patients in the preservice group and 54 patients in the post-service group. Under the new tracheostomy service, there was a decrease in incidence of tube blockage (5.5% v. 25.0%, p = 0.016) and calls for respiratory distress (16.7% v. 37.5%, p = 0.039) on the wards. A significantly larger proportion of patients also received speaking valves (67.4% v. 19.4%, p tracheostomy team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve. PMID:21443833

  6. [Metabolic control in the critically ill patient an update: hyperglycemia, glucose variability hypoglycemia and relative hypoglycemia].

    Science.gov (United States)

    Pérez-Calatayud, Ángel Augusto; Guillén-Vidaña, Ariadna; Fraire-Félix, Irving Santiago; Anica-Malagón, Eduardo Daniel; Briones Garduño, Jesús Carlos; Carrillo-Esper, Raúl

    Metabolic changes of glucose in critically ill patients increase morbidity and mortality. The appropriate level of blood glucose has not been established so far and should be adjusted for different populations. However concepts such as glucose variability and relative hypoglycemia of critically ill patients are concepts that are changing management methods and achieving closer monitoring. The purpose of this review is to present new data about the management and metabolic control of patients in critical areas. Currently glucose can no longer be regarded as an innocent element in critical patients; both hyperglycemia and hypoglycemia increase morbidity and mortality of patients. Protocols and better instruments for continuous measurement are necessary to achieve the metabolic control of our patients. Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

  7. Impact of electronic order management on the timeliness of antibiotic administration in critical care patients.

    Science.gov (United States)

    Cartmill, Randi S; Walker, James M; Blosky, Mary Ann; Brown, Roger L; Djurkovic, Svetolik; Dunham, Deborah B; Gardill, Debra; Haupt, Marilyn T; Parry, Dean; Wetterneck, Tosha B; Wood, Kenneth E; Carayon, Pascale

    2012-11-01

    To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients. We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated. The overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration. The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  8. Proliferation and differentiation of adipose tissue in prolonged lean and obese critically ill patients.

    Science.gov (United States)

    Goossens, Chloë; Vander Perre, Sarah; Van den Berghe, Greet; Langouche, Lies

    2017-12-01

    In prolonged non-obese critically ill patients, preservation of adipose tissue is prioritized over that of the skeletal muscle and coincides with increased adipogenesis. However, we recently demonstrated that in obese critically ill mice, this priority was switched. In the obese, the use of abundantly available adipose tissue-derived energy substrates was preferred and counteracted muscle wasting. These observations suggest that different processes are ongoing in adipose tissue of lean vs. overweight/obese critically ill patients. We hypothesize that to preserve adipose tissue mass during critical illness, adipogenesis is increased in prolonged lean critically ill patients, but not in overweight/obese critically ill patients, who enter the ICU with excess adipose tissue. To test this, we studied markers of adipogenesis in subcutaneous and visceral biopsies of matched lean (n = 24) and overweight/obese (n = 24) prolonged critically ill patients. Secondly, to further unravel the underlying mechanism of critical illness-induced adipogenesis, local production of eicosanoid PPARγ agonists was explored, as well as the adipogenic potential of serum from matched lean (n = 20) and overweight/obese (n = 20) critically ill patients. The number of small adipocytes, PPARγ protein, and CEBPB expression were equally upregulated (p ≤ 0.05) in subcutaneous and visceral adipose tissue biopsies of lean and overweight/obese prolonged critically ill patients. Gene expression of key enzymes involved in eicosanoid production was reduced (COX1, HPGDS, LPGDS, ALOX15, all p ≤ 0.05) or unaltered (COX2, ALOX5) during critical illness, irrespective of obesity. Gene expression of PLA2G2A and ALOX15B was upregulated in lean and overweight/obese patients (p ≤ 0.05), whereas their end products, the PPARγ-activating metabolites 15s-HETE and 9-HODE, were not increased in the adipose tissue. In vitro, serum of lean and overweight/obese prolonged critically ill

  9. Most important needs of family members of critical patients in light of the critical care family needs inventory.

    Science.gov (United States)

    Padilla Fortunatti, Cristóbal Felipe

    2014-01-01

    This work sought to identify the most important needs for family members of adult critical patients as described in the literature pursuant to the dimensions established in the "Critical Care Family Needs Inventory" (CCFNI) by Molter and Leske. A literature review was carried out by using the CCFNI instrument. The databases used were: Pubmed, CINAHL, Proquest Nursing & Allied Health Source, Proquest Psychology Journals, LILACS, Science Direct, Ovid SP, PsyicINFO, and SciELO. The following limitations for the search were identified: adult patients, articles in English and Spanish, with abstract and complete text available and which had been published from 2003 to June 2013; 15 articles were included. The family's hope on desired results and sincere communication with the healthcare staff turned out to be the most relevant needs, while the least important were related to comfort and having support structures or systems. Most of the studies were conducted in Asia and North America revealing differences in the order of importance assigned to each necessity. Certain sociodemographic and cultural characteristics impact upon how family members rank their needs; this also occurs with the nature of the most important needs for the family and the factors determining their prioritization. The articles included in this review mention the frequent interaction with the family and their holistic view of the person beyond the illness, determine that nurses are the most appropriate professionals to know and satisfy the family needs of critical patients.

  10. Most Important Needs of Family Members of Critical Patients in Light of the Critical Care Family Needs Inventory

    Directory of Open Access Journals (Sweden)

    Cristóbal Felipe Padilla Fortunatti

    2014-07-01

    Full Text Available Objective. This work sought to identify the most important needs for family members of adult critical patients as described in the literature pursuant to the dimensions established in the "Critical Care Family Needs Inventory" (CCFNI by Molter and Leske. Methodology. A literature review was carried out by using the CCFNI instrument. The databases used were: Pubmed, CINAHL, Proquest Nursing & Allied Health Source, Proquest Psychology Journals, LILACS, Science Direct, Ovid SP, PsyicINFO, and SciELO. The following limitations for the search were identified: adult patients, articles in English and Spanish, with abstract and complete text available and which had been published from 2003 to June 2013; 15 articles were included. Results. The family's hope on desired results and sincere communication with the healthcare staff turned out to be the most relevant needs, while the least important were related to comfort and having support structures or systems. Most of the studies were conducted in Asia and North America revealing differences in the order of importance assigned to each necessity. Certain sociodemographic and cultural characteristics impact upon how family members rank their needs; this also occurs with the nature of the most important needs for the family and the factors determining their prioritization. Conclusion. The articles included in this review mention the frequent interaction with the family and their holistic view of the person beyond the illness, determine that nurses are the most appropriate professionals to know and satisfy the family needs of critical patients.

  11. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients.

    Science.gov (United States)

    Bruder, Eric A; Ball, Ian M; Ridi, Stacy; Pickett, William; Hohl, Corinne

    2015-01-08

    The use of etomidate for emergency airway interventions in critically ill patients is very common. In one large registry trial, etomidate was the most commonly used agent for this indication. Etomidate is known to suppress adrenal gland function, but it remains unclear whether or not this adrenal gland dysfunction affects mortality. The primary objective was to assess, in populations of critically ill patients, whether a single induction dose of etomidate for emergency airway intervention affects mortality.The secondary objectives were to address, in populations of critically ill patients, whether a single induction dose of etomidate for emergency airway intervention affects adrenal gland function, organ dysfunction, or health services utilization (as measured by intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation, or vasopressor requirements).We repeated analyses within subgroups defined by the aetiologies of critical illness, timing of adrenal gland function measurement, and the type of comparator drug used. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; CINAHL; EMBASE; LILACS; International Pharmaceutical Abstracts; Web of Science; the Database of Abstracts of Reviews of Effects (DARE); and ISI BIOSIS Citation index(SM) on 8 February 2013. We reran the searches in August 2014. We will deal with any studies of interest when we update the review.We also searched the Scopus database of dissertations and conference proceedings and the US Food and Drug Administration Database. We handsearched major emergency medicine, critical care, and anaesthesiology journals.We handsearched the conference proceedings of major emergency medicine, anaesthesia, and critical care conferences from 1990 to current, and performed a grey literature search of the following: Current Controlled Trials; National Health Service - The National Research Register; ClinicalTrials.gov; NEAR website. We included randomized controlled

  12. The effects of implementing a nutritional support algorithm in critically ill medical patients.

    Science.gov (United States)

    Sungur, Gonul; Sahin, Habibe; Tasci, Sultan

    2015-08-01

    To determine the effect of the enteral nutrition algorithm on nutritional support in critically ill medical patients. The quasi-experimental study was conducted at a medical Intensive Care Unit of a university hospital in central Anatolia region in Turkey from June to December 2008. The patients were divided into two equal groups: the historical group was fed in routine clinical applications, while the study group was fed according to the enteral nutritional algorithm. Prior to collecting data, nurses were trained interactively about enteral nutrition and the nutritional support algorithm. The nutrition of the study group was directed by the nurses. Data were recorded during 3 days of care. SPSS 22 was used for statistical analysis. The 40 patients in the study were divided into two equal groups of 20(50%) each. The energy intake of study group was 62% of the prescribed energy requirement on the 1st, 68.5% on the 2nd and 63% on the 3rd day, whereas in the historical group 38%, 56.5% and 60% of the prescribed energy requirement were met. The consumed energy of the historical group on the 1st 2nd and 3rd day was significantly different (p=0.020). In the study group, serum total protein and albumin levels decreased significantly (pgroup, any of the serum parameters did not change. Enteral nutrition-induced complications, duration of stay in intensive care unit were not significantly different between the groups (p>0.05). The use of standard algorithms for enteral nutrition may be an effective way to meet the nutritional requirements of patients.

  13. Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients

    OpenAIRE

    Weijs, Peter JM; Looijaard, Wilhelmus GPM; Dekker, Ingeborg M; Stapel, Sandra N; Girbes, Armand R; Straaten, Heleen M Oudemans-van; Beishuizen, Albertus

    2014-01-01

    Introduction Higher body mass index (BMI) is associated with lower mortality in mechanically ventilated critically ill patients. However, it is yet unclear which body component is responsible for this relationship. Methods This retrospective analysis in 240 mechanically ventilated critically ill patients included adult patients in whom a computed tomography (CT) scan of the abdomen was made on clinical indication between 1 day before and 4 days after admission to the intensive care unit. CT s...

  14. Temporary abdominal closure in the critically ill patients with an open abdomen.

    Directory of Open Access Journals (Sweden)

    Ghodratollah Maddah

    2014-05-01

    Full Text Available The emergent abdominal surgeries from either of traumatic or non traumatic causes can result in situations in which the abdominal wall cannot initially be closed. Many techniques have been reported for temporary coverage of the exposed viscera, but the result of various techniques remains unclear. During 94 months, 19 critically ill patients whit an open abdomen underwent surgery using plastic bags (Bogotá bag. The study population comprised of 11 (57.9% male and 8 (42.1% female with an average age of 32.26+14.8 years. The main indications for temporary abdominal coverage were as follows: planned reoperation in 11 (57.9% patients, subjective judgment that the fascia closure is too tight in 6 (31.6% patient's damage control surgery in one patient (5.3% and development of abdominal compartment surgery in one patient (5.3%. Surgical conditions requiring temporary abdominal closure was severe post operative peritonitis in 9 (47.4% patients, post operative intestinal fistula in 4 (21.1% patients, post traumatic intra abdominal bleeding in 3 (15.8% patients and intestinal obstructions in 3 (15.8% patients. Length of hospitalization was 45+23.25 days and the mean total number of laparotomies was 6.2+3.75 times per patient. Three bowel fistulas occurred due to a missed injury at the time of initial operation that was discovered during changing the plastic sheet. They were unrelated to coverage technique. All of them were treated by repair of the defect and serosal patch by adjacent bowel loop. Only one (10.0% patient underwent definitive closure within 6 months of initial operation. The remaining survivor has declined to have hernia repaired. There were 4 (%21.1 early postoperative deaths that were not related to the abdominal coverage technique. Also, there were 5 (26.3% late deaths that were due to dissemination of malignancy with a mean survival time of 20.8+13 (range 2-54 months. Currently 10 patients (52.6% are alive at a follow up of 45 (range 1

  15. Transportation Network Data Requirements for Assessing Criticality for Resiliency and Adaptation Planning

    Science.gov (United States)

    2017-11-01

    This report is one of two NCST Research Report documents produced as part of a project to advance the technical modeling tools for resiliency and adaptation planning, especially those used for criticality rankings. The official final technical report...

  16. Infarct volume predicts critical care needs in stroke patients treated with intravenous thrombolysis

    Energy Technology Data Exchange (ETDEWEB)

    Faigle, Roland; Marsh, Elisabeth B.; Llinas, Rafael H.; Urrutia, Victor C. [Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD (United States); Wozniak, Amy W. [Johns Hopkins University, Department of Biostatistics, Bloomberg School of Public Health, Baltimore, MD (United States)

    2014-10-26

    Patients receiving intravenous thrombolysis with recombinant tissue plasminogen activator (IVT) for ischemic stroke are monitored in an intensive care unit (ICU) or a comparable unit capable of ICU interventions due to the high frequency of standardized neurological exams and vital sign checks. The present study evaluates quantitative infarct volume on early post-IVT MRI as a predictor of critical care needs and aims to identify patients who may not require resource intense monitoring. We identified 46 patients who underwent MRI within 6 h of IVT. Infarct volume was measured using semiautomated software. Logistic regression and receiver operating characteristics (ROC) analysis were used to determine factors associated with ICU needs. Infarct volume was an independent predictor of ICU need after adjusting for age, sex, race, systolic blood pressure, NIH Stroke Scale (NIHSS), and coronary artery disease (odds ratio 1.031 per cm{sup 3} increase in volume, 95 % confidence interval [CI] 1.004-1.058, p = 0.024). The ROC curve with infarct volume alone achieved an area under the curve (AUC) of 0.766 (95 % CI 0.605-0.927), while the AUC was 0.906 (95 % CI 0.814-0.998) after adjusting for race, systolic blood pressure, and NIHSS. Maximum Youden index calculations identified an optimal infarct volume cut point of 6.8 cm{sup 3} (sensitivity 75.0 %, specificity 76.7 %). Infarct volume greater than 3 cm{sup 3} predicted need for critical care interventions with 81.3 % sensitivity and 66.7 % specificity. Infarct volume may predict needs for ICU monitoring and interventions in stroke patients treated with IVT. (orig.)

  17. Infarct volume predicts critical care needs in stroke patients treated with intravenous thrombolysis

    International Nuclear Information System (INIS)

    Faigle, Roland; Marsh, Elisabeth B.; Llinas, Rafael H.; Urrutia, Victor C.; Wozniak, Amy W.

    2015-01-01

    Patients receiving intravenous thrombolysis with recombinant tissue plasminogen activator (IVT) for ischemic stroke are monitored in an intensive care unit (ICU) or a comparable unit capable of ICU interventions due to the high frequency of standardized neurological exams and vital sign checks. The present study evaluates quantitative infarct volume on early post-IVT MRI as a predictor of critical care needs and aims to identify patients who may not require resource intense monitoring. We identified 46 patients who underwent MRI within 6 h of IVT. Infarct volume was measured using semiautomated software. Logistic regression and receiver operating characteristics (ROC) analysis were used to determine factors associated with ICU needs. Infarct volume was an independent predictor of ICU need after adjusting for age, sex, race, systolic blood pressure, NIH Stroke Scale (NIHSS), and coronary artery disease (odds ratio 1.031 per cm 3 increase in volume, 95 % confidence interval [CI] 1.004-1.058, p = 0.024). The ROC curve with infarct volume alone achieved an area under the curve (AUC) of 0.766 (95 % CI 0.605-0.927), while the AUC was 0.906 (95 % CI 0.814-0.998) after adjusting for race, systolic blood pressure, and NIHSS. Maximum Youden index calculations identified an optimal infarct volume cut point of 6.8 cm 3 (sensitivity 75.0 %, specificity 76.7 %). Infarct volume greater than 3 cm 3 predicted need for critical care interventions with 81.3 % sensitivity and 66.7 % specificity. Infarct volume may predict needs for ICU monitoring and interventions in stroke patients treated with IVT. (orig.)

  18. A proactive transfer policy for critical patient flow management.

    Science.gov (United States)

    González, Jaime; Ferrer, Juan-Carlos; Cataldo, Alejandro; Rojas, Luis

    2018-02-17

    Hospital emergency departments are often overcrowded, resulting in long wait times and a public perception of poor attention. Delays in transferring patients needing further treatment increases emergency department congestion, has negative impacts on their health and may increase their mortality rates. A model built around a Markov decision process is proposed to improve the efficiency of patient flows between the emergency department and other hospital units. With each day divided into time periods, the formulation estimates bed demand for the next period as the basis for determining a proactive rather than reactive transfer decision policy. Due to the high dimensionality of the optimization problem involved, an approximate dynamic programming approach is used to derive an approximation of the optimal decision policy, which indicates that a certain number of beds should be kept free in the different units as a function of the next period demand estimate. Testing the model on two instances of different sizes demonstrates that the optimal number of patient transfers between units changes when the emergency patient arrival rate for transfer to other units changes at a single unit, but remains stable if the change is proportionally the same for all units. In a simulation using real data for a hospital in Chile, significant improvements are achieved by the model in key emergency department performance indicators such as patient wait times (reduction higher than 50%), patient capacity (21% increase) and queue abandonment (from 7% down to less than 1%).

  19. Early lactate clearance for predicting active bleeding in critically ill patients with acute upper gastrointestinal bleeding: a retrospective study.

    Science.gov (United States)

    Wada, Tomoki; Hagiwara, Akiyoshi; Uemura, Tatsuki; Yahagi, Naoki; Kimura, Akio

    2016-08-01

    Not all patients with upper gastrointestinal bleeding (UGIB) require emergency endoscopy. Lactate clearance has been suggested as a parameter for predicting patient outcomes in various critical care settings. This study investigates whether lactate clearance can predict active bleeding in critically ill patients with UGIB. This single-center, retrospective, observational study included critically ill patients with UGIB who met all of the following criteria: admission to the emergency department (ED) from April 2011 to August 2014; had blood samples for lactate evaluation at least twice during the ED stay; and had emergency endoscopy within 6 h of ED presentation. The main outcome was active bleeding detected with emergency endoscopy. Classification and regression tree (CART) analyses were performed using variables associated with active bleeding to derive a prediction rule for active bleeding in critically ill UGIB patients. A total of 154 patients with UGIB were analyzed, and 31.2 % (48/154) had active bleeding. In the univariate analysis, lactate clearance was significantly lower in patients with active bleeding than in those without active bleeding (13 vs. 29 %, P bleeding is derived, and includes three variables: lactate clearance; platelet count; and systolic blood pressure at ED presentation. The rule has 97.9 % (95 % CI 90.2-99.6 %) sensitivity with 32.1 % (28.6-32.9 %) specificity. Lactate clearance may be associated with active bleeding in critically ill patients with UGIB, and may be clinically useful as a component of a prediction rule for active bleeding.

  20. Secondary Sclerosing Cholangitis in Critically Ill Patients: Clinical Presentation, Cholangiographic Features, Natural History, and Outcome

    Science.gov (United States)

    Leonhardt, Silke; Veltzke-Schlieker, Wilfried; Adler, Andreas; Schott, Eckart; Eurich, Dennis; Faber, Wladimir; Neuhaus, Peter; Seehofer, Daniel

    2015-01-01

    Abstract Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an important differential diagnosis in patients presenting with cholestasis and PSC-like cholangiographic changes in endoscopic retrograde cholangiography (ERC). As a relatively newly described entity, SSC-CIP is still underdiagnosed, and the diagnosis is often delayed. The present study aims to improve the early detection of SSC-CIP and the identification of its complications. A total of 2633 records of patients who underwent or were listed for orthotopic liver transplantation at the University Hospital Charité, Berlin, were analyzed retrospectively. The clinical presentation and outcome (mean follow-up 62.7 months) of the 16 identified SSC-CIP cases were reviewed. Cholestasis was the first sign of SSC-CIP. GGT was the predominant enzyme of cholestasis. Hypercholesterolemia occurred in at least 75% of the patients. SSC-CIP provoked a profound weight loss (mean 18 kg) in 94% of our patients. SSC-CIP was diagnosed by ERC in all patients. The 3 different cholangiographic features detected correspond roughly to the following stages: (I) evidence of biliary casts, (II) progressive destruction of intrahepatic bile ducts, and (III) picture of pruned tree. Biliary cast formation is a hallmark of SSC-CIP and was seen in 87% of our cases. In 75% of the patients, the clinical course was complicated by cholangiosepsis, cholangitic liver abscesses, acalculous cholecystitis, or gallbladder perforation. SSC-CIP was associated with worse prognosis; transplant-free survival was ∼40 months (mean). Because of its high rate of serious complications and unfavorable prognosis, it is imperative to diagnose SSC-CIP early and to differentiate SSC-CIP from other types of sclerosing cholangitis. Specific characteristics enable identification of SSC-CIP. Early cooperation with a transplant center and special attention to biliary complications are required after diagnosis of SSC-CIP. PMID:26656347

  1. Improvement critical care patient safety: using nursing staff development strategies, at Saudi Arabia.

    Science.gov (United States)

    Basuni, Enas M; Bayoumi, Magda M

    2015-01-13

    Intensive care units (ICUs) provide lifesaving care for the critically ill patients and are associated with significant risks. Moreover complexity of care within ICUs requires that the health care professionals exhibit a trans-disciplinary level of competency to improve patient safety. This study aimed at using staff development strategies through implementing patient safety educational program that may minimize the medical errors and improve patient outcome in hospital. The study was carried out using a quasi experimental design. The settings included the intensive care units at General Mohail Hospital and National Mohail Hospital, King Khalid University, Saudi Arabia. The study was conducted from March to June 2012. A convenience sample of all prevalent nurses at three shifts in the aforementioned settings during the study period was recruited. The program was implemented on 50 staff nurses in different ICUs. Their age ranged between 25-40 years. Statistically significant relation was revealed between safety climate and job satisfaction among nurses in the study sample (p=0.001). The years of experiences in ICU ranged between one year 11 (16.4) to 10 years 20 (29.8), most of them (68%) were working in variable shift, while 32% were day shift only. Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on ICUs after implementing a safety program. On the heels of this improvement; nurses' total knowledge, skills and attitude were enhanced regarding patient safety dimensions. Continuous educational program for ICUs nursing staff through organized in-service training is needed to increase their knowledge and skills about the importance of improving patient safety measure. Emphasizing on effective collaborative system also will improve patient safety measures in ICUS.

  2. The Changing Role for Tracheostomy in Patients Requiring Mechanical Ventilation.

    Science.gov (United States)

    Mahmood, Kamran; Wahidi, Momen M

    2016-12-01

    Tracheostomy is performed in patients who require prolonged mechanical ventilation or have upper airway instability. Percutaneous tracheostomy with Ciaglia technique is commonly used and rivals the surgical approach. Percutaneous technique is associated with decreased risk of stomal inflammation, infection, and bleeding along with reduction in health resource utilization when performed at bedside. Bronchoscopy and ultrasound guidance improve the safety of percutaneous tracheostomy. Early tracheostomy decreases the need for sedation and intensive care unit stay but may be unnecessary in some patients who can be extubated later successfully. A multidisciplinary approach to tracheostomy care leads to improved outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

  3. Medical evaluation of the pregnant patient requiring nonobstetric surgery

    International Nuclear Information System (INIS)

    Barron, W.M.

    1985-01-01

    This article provides a summary of currently available information from a broad range of disciplines aimed at guiding the physician caring for the pregnant patient who requires nonobstetric surgery. An understanding of the anatomic and physiologic alterations that occur during pregnancy will allow such procedures to be accomplished with morbidity and mortality approaching those of nonpregnant surgical patients. The presence of the fetus does impose some restraint; however, this should rarely impair appropriate diagnosis and treatment of maternal disease. This obtains from the broad range of diagnostic and therapeutic alternatives available, and from the fact that what is beneficial for maternal health is generally best for the fetus. 64 references

  4. Servant as leader: Critical requirements for the appointment and training of retirement fund trustees

    Directory of Open Access Journals (Sweden)

    L.M. Magda Hewitt

    2017-09-01

    Full Text Available Orientation: The South African retirement fund industry ranks among the 15 largest retirement fund industries internationally, with some 8 million members and assets under management of close to R2 trillion. However, to be successful, retirement funds need good governance. Research purpose: To explore the most critical servant leadership qualities required that can serve as profile in the selection, appointment and training of retirement fund trustees (RFTs to serve on boards of trustees of retirement funds in the South African context. Motivation for the study: The South African National Treasury’s retirement reform proposal clearly articulates government’s concern for the poor governance of retirement fund assets by appointed boards of trustees and the broader implications on social and economic security in retirement. It promotes the regulation of standards relating to the minimum qualifications and expertise needed to be appointed to serve on a board of trustees (BoTs. Although the measures proposed by government to improve fund governance and the role of the RFTs are sound in principle, it does not inform the character, leadership qualities or leadership competence desired for RFTs, thus leaving the management of funds in the hands of people who must make investment decisions when they themselves are not fully committed. Research design, approach and method: The research question was addressed through an extensive literature review and a qualitative methodology using a semi-structured interview; fieldwork that included personal observations; and notes with six active, high-profile, respected, purposefully selected RFTs. An interpretive approach was adopted to provide elaborative interpretations of phenomena without having to rely on numerical measurement. Main findings: A strong similitude exists between servant leader qualities, as found in the literature, and those qualities identified and required to be appointed as a RFT. Literature

  5. ICU-acquired weakness: what is preventing its rehabilitation in critically ill patients?

    Directory of Open Access Journals (Sweden)

    Lee Christie M

    2012-10-01

    Full Text Available Abstract Intensive care unit-acquired weakness (ICUAW has been recognized as an important and persistent complication in survivors of critical illness. The absence of a consistent nomenclature and diagnostic criteria for ICUAW has made research in this area challenging. Although many risk factors have been identified, the data supporting their direct association have been controversial. Presently, there is a growing body of literature supporting the utility and benefit of early mobility in reducing the morbidity from ICUAW, but few centers have adopted this into their ICU procedures. Ultimately, the implementation of such a strategy would require a shift in the knowledge and culture within the ICU, and may be facilitated by novel technology and patient care strategies. The purpose of this article is to briefly review the diagnosis, risk factors, and management of ICUAW, and to discuss some of the barriers and novel treatments to improve outcomes for our ICU survivors.

  6. Prevention of upper gastrointestinal bleeding in critically ill Chinese patients: a randomized, double-blind study evaluating esomeprazole and cimetidine.

    Science.gov (United States)

    Lou, Wenhui; Xia, Ying; Xiang, Peng; Zhang, Liangqing; Yu, Xiangyou; Lim, Sam; Xu, Mo; Zhao, Lina; Rydholm, Hans; Traxler, Barry; Qin, Xinyu

    2018-04-20

    To assess the efficacy and safety of esomeprazole in preventing upper gastrointestinal (GI) bleeding in critically ill Chinese patients, using cimetidine as an active comparator. A pre-specified non-inferiority limit (5%) was used to compare rates of significant upper GI bleeding in this randomized, double-blind, parallel-group, phase 3 study across 27 intensive care units in China. Secondary endpoints included safety and tolerability measures. Patients required mechanical ventilation and had at least one additional risk factor for stress ulcer bleeding. Patients were randomized to receive either active esomeprazole 40 mg, as a 30-min intravenous (IV) infusion twice daily, and an IV placebo cimetidine infusion or active cimetidine 50 mg/h, as a continuous infusion following an initial bolus of 300 mg, and placebo esomeprazole injections, given up to 14 days. Patients were blinded using this double-dummy technique. Of 274 patients, 2.7% with esomeprazole and 4.6% with cimetidine had significant upper GI bleeding (bright red blood in the gastric tube not clearing after lavage or persistent Gastroccult-positive "coffee grounds" material). Non-inferiority of esomeprazole to cimetidine was demonstrated. The safety profiles of both drugs were similar and as expected in critically ill patients. Esomeprazole is effective in preventing upper GI bleeding in critically ill Chinese patients, as demonstrated by the non-inferiority analysis using cimetidine as an active control. ClinicalTrials.gov identifier NCT02157376.

  7. Changes in circulating blood volume after infusion of hydroxyethyl starch 6% in critically ill patients

    DEFF Research Database (Denmark)

    Christensen, P; Andersson, J; Rasmussen, S E

    2001-01-01

    The cardiovascular response to a volume challenge with hydroxyethyl starch (HES) (200/0.5) 6% depends on the relation between the volume of HES 6% infused and the expansion of the blood volume in critically ill patients. However, only relatively limited data exist on the plasma expanding effect...... of infusion of HES 6% in critically ill patients. The purpose of the study was to evaluate the variation in the expansion of the circulating blood volume (CBV) in critically ill patients after infusion of 500 ml of colloid (HES (200/0.5) 6%) using the carbon monoxide method....

  8. Bleeding prevalence and transfusion requirement in patients with thrombocytopenia in the emergency department.

    Science.gov (United States)

    Turvani, Fabrizio; Pigozzi, Luca; Barutta, Letizia; Pivetta, Emanuele; Pizzolato, Elisa; Morello, Fulvio; Battista, Stefania; Moiraghi, Corrado; Montrucchio, Giuseppe; Lupia, Enrico

    2014-10-01

    Thrombocytopenia is the most common coagulation disorder in critically ill patients. No studies have investigated the epidemiology and clinical impact of this condition in emergency department (ED) patients. We aimed to investigate epidemiological features, incidence of bleeding, and diagnostic and therapeutic requirements of patients with thrombocytopenia admitted to the ED. We performed a retrospective observational study enrolling all patients admitted to the medical-surgical ED of the "Città della Salute e della Scienza di Torino" Hospital with a platelet count <150×10(9) PLTs/L, during four non-consecutive months. There were no exclusion criteria. The study included 1218 patients. The percentage of patients with severe (<50×10(9) PLTs/L) or very severe (<20×10(9) PLTs/L) thrombocytopenia was about 12%. Thrombocytopenia associated with liver cirrhosis was the most represented etiology. On the contrary, the most frequent cause in patients with newly recognized low platelet count was disseminated intravascular coagulation/sepsis. The incidence of bleeding and hypovolemia, as well as the need of transfusional support and mechanical, surgical or endoscopic hemostasis progressively increased with the severity of thrombocytopenia. Our results suggest that the detection of a platelet count lower than 50×10(9) PLTs/L may help to identify patients with higher bleeding risk in the ED setting. Additional studies are required to evaluate whether, in this setting, thrombocytopenia may represent an independent risk factor for bleeding episodes and increased mortality.

  9. Time to look beyond one-year mortality in critically ill hematological patients?

    Science.gov (United States)

    Moors, Ine; Benoit, Dominique D

    2014-02-11

    The spectacular improvement in long-term prognosis of patients with hematological malignancies since the 1980s, coupled with the subsequent improvement over the past decade in short- and mid-term survival in cases of critical illness, resulted in an increasing referral of such patients to the ICU. A remaining question, however, is how these patients perform in the long term with regard to survival and quality of life. Here we discuss the present multicenter study on survival beyond 1 year in critically ill patients with hematological malignancies. We conclude with suggestions on how we can further improve the long-term outcome of these patients.

  10. Determination of Waste Isolation Pilot Plant (WIPP) management and institutional requirements documents for contact-handled (CH) critical systems

    International Nuclear Information System (INIS)

    1990-01-01

    This document lists the critical requirements documents applicable to the receipt of contact-handled waste at the Waste Isolation Pilot Plant. It also describes the processes used to determine the applicability of each document. This analysis is based on the applicable documents that were in effect in the February 1988 time frame. 2 refs

  11. Dietary Guidelines for Breast Cancer Patients: A Critical Review.

    Science.gov (United States)

    Limon-Miro, Ana Teresa; Lopez-Teros, Veronica; Astiazaran-Garcia, Humberto

    2017-07-01

    Current dietary guidelines for breast cancer patients (BCPs) fail to address adequate dietary intakes of macro- and micronutrients that may improve patients' nutritional status. This review includes information from the PubMed and Biomed Central databases over the last 15 y concerning dietary guidelines for BCPs and the potential impact of a personalized, nutrient-specific diet on patients' nutritional status during and after antineoplastic treatment. Results indicated that BCPs should receive a nutritional assessment immediately after diagnosis. In addition, they should be encouraged to pursue and maintain a healthy body weight [body mass index (BMI; in kg/m 2 ) 20-24.9], preserving their lean mass and avoiding an increase in fat mass. Therefore, after nutritional status diagnosis, a conservative energy restriction of 500-1000 kcal/d could be considered in the dietary intervention when appropriate. Based on the reviewed information, we propose a personalized nutrition intervention for BCPs during and after antineoplastic treatment. Specifications in the nutritional therapy should be based on the patients' nutritional status, dietary habits, schedule, activities, and cultural preferences. BCPs' daily energy intake should be distributed as follows: vegetables (∼75 g/serving) should be encouraged. Garlic and cruciferous vegetables must also be part of the nutrition therapy. Adequate dietary intakes of food-based macro- and micronutrients rich in β-carotene and vitamins A, E, and C can both prevent deterioration in BCPs' nutritional status and improve their overall health and prognosis. © 2017 American Society for Nutrition.

  12. Functional adrenal insufficiency among critically ill patients with ...

    African Journals Online (AJOL)

    Hyponatremia, hypoglycemia, hyperkalemia, postural hypotension and the use of ketoconazole were not associated with FAI in this study. Conclusion: The diagnosis of FAI should be considered in severely ill patients with stage IV HIV disease using rifampicin or those found to have unexplained eosinophilia. Further studies ...

  13. Vital Signs Monitoring and Interpretation for Critically Ill Patients

    DEFF Research Database (Denmark)

    Vilic, Adnan

    . An introduced queue-based multiple linear regression (qMLR) model achieved best results with a root mean square error (RMSE) of RMSE = 3.11 on a Scandinavian Stroke Scale (SSS) where degree of disability ranged from 0 - 46. Worse outcomes were observed in patients who had pulse > 80 and a negative correlation...

  14. Diphenylcyclopropenone in patients with alopecia areata. A critically appraised topic

    NARCIS (Netherlands)

    Kuin, R. A.; Spuls, P. I.; Limpens, J.; van Zuuren, E. J.

    2015-01-01

    To assess the efficacy and safety of topical diphenylcyclopropenone (DPCP) in patients with alopecia areata. Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors. The quality of evidence was rated with Grading of Recommendations

  15. Brain computer tomography in critically ill patients - a prospective cohort study

    NARCIS (Netherlands)

    Purmer, Ilse M.; van Iperen, Erik P.; Beenen, Ludo F. M.; Kuiper, Michael J.; Binnekade, Jan M.; Vandertop, Peter W.; Schultz, Marcus J.; Horn, Janneke

    2012-01-01

    Background: Brain computer tomography (brain CT) is an important imaging tool in patients with intracranial disorders. In ICU patients, a brain CT implies an intrahospital transport which has inherent risks. The proceeds and consequences of a brain CT in a critically ill patient should outweigh

  16. Required Critical Conversations Between Medical Examiners/Coroners and Forensic Nurses.

    Science.gov (United States)

    Infanti Mraz, Megan A

    2016-01-01

    Forensic teams work with the deceased and their families on a daily basis. The forensic team fulfills an important role during the death process and serves as a medium between the medical community and investigative community. The medical examiner, or coroner, depending on jurisdiction, plays a critical role in the death investigation, whose assessments and findings are a key element in care for the deceased in relation to the investigation. Communication regarding care for the deceased is critical to the completion of the investigation. Nine key discussion points are addressed as a means to launch communications between the forensic team and the medical examiner/coroner's office.

  17. [Incidence of dependence-related lesions in a population of critical patients].

    Science.gov (United States)

    Roca-Biosca, Alba; Rubio-Rico, Lourdes; de Molina-Fernández, María Inmaculada; Tuset-Garijo, Gemma; Colodrero-Díaz, Encarnación; García-Fernández, Francisco Pedro

    2016-01-01

    To determine the incidence of various types of dependence-related lesions (DRL) on a population of critically ill patients. Descriptive, longitudinal and prospective study in an Intensive Care Unit from January 2014 to January 2015. Adult patients who did not present DRL at the moment of admission were included. Those with brain death and/or stay at the unit for more than two days were excluded. Patients were studied till they developed DRL, were exitus, discharged or stayed for more than 14 days. Each patient was evaluated daily till DRL did develop or was excluded from the study. If DRL did develop it was photographed and related data were recorded. The comparison between quantitative variables of normal distribution was done with the t de Student. The Mann-Whitney U was used to compare the other variables. Qualitative variables were compared through Pearson's chi square. In both cases p≤.05 was considered significant. 295 patients were included, 27.45% of them developed DRL. The density of incidence was 41 DRL/1,000 days at risk. 50.62% of DRL were categorized as PU. 17.28% were moisture injuries, 13.58% were due to friction and the rest were combined injuries. The risk according to EMINA and Braden scale was significantly different in the group of patients with lesions compared to the group without them. Not all injuries were caused by pressure. Specific prevention strategies based on different causal mechanisms are required. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

  18. The Untapped Potential of Patient and Family Engagement in the Organization of Critical Care.

    Science.gov (United States)

    Haines, Kimberley J; Kelly, Phillipa; Fitzgerald, Peter; Skinner, Elizabeth H; Iwashyna, Theodore J

    2017-05-01

    There is growing interest in patient and family participation in critical care-not just as part of the bedside, but as part of educational and management organization and infrastructure. This offers tremendous opportunities for change but carries risk to patients, families, and the institution. The objective is to provide a concise definitive review of patient and family organizational participation in critical care as a high-risk population and other vulnerable groups. A pragmatic, codesigned model for critical care is offered as a suggested approach for clinicians, researchers, and policy-makers. To inform this review, a systematic search of Ovid Medline, PubMed, and Embase was undertaken in April 2016 using the MeSH terms: patient participation and critical care. A second search was undertaken in PubMed using the terms: patient participation and organizational models to search for other examples of engagement in vulnerable populations. We explicitly did not seek to include discussions of bedside patient-family engagement or shared decision-making. Two reviewers screened citations independently. Included studies either actively partnered with patients and families or described a model of engagement in critical care and other vulnerable populations. Data or description of how patient and family engagement occurred and/or description of model were extracted into a standardized form. There was limited evidence of patient and family engagement in critical care although key recommendations can be drawn from included studies. Patient and family engagement is occurring in other vulnerable populations although there are few described models and none which address issues of risk. A model of patient and family engagement in critical care does not exist, and we propose a pragmatic, codesigned model that takes into account issues of psychologic safety in this population. Significant opportunity exists to document processes of engagement that reflect a changing paradigm of

  19. Gastric residual volume in critically ill patients: a dead marker or still alive?

    Science.gov (United States)

    Elke, Gunnar; Felbinger, Thomas W; Heyland, Daren K

    2015-02-01

    Early enteral nutrition (EN) is consistently recommended as first-line nutrition therapy in critically ill patients since it favorably alters outcome, providing both nutrition and nonnutrition benefits. However, critically ill patients receiving mechanical ventilation are at risk for regurgitation, pulmonary aspiration, and eventually ventilator-associated pneumonia (VAP). EN may increase these risks when gastrointestinal (GI) dysfunction is present. Gastric residual volume (GRV) is considered a surrogate parameter of GI dysfunction during the progression of enteral feeding in the early phase of critical illness and beyond. By monitoring GRV, clinicians may detect patients with delayed gastric emptying earlier and intervene with strategies that minimize or prevent VAP as one of the major risks of EN. The value of periodic GRV measurements with regard to risk reduction of VAP incidence has frequently been questioned in the past years. Increasing the GRV threshold before interrupting gastric feeding results in marginal increases in EN delivery. More recently, a large randomized clinical trial revealed that abandoning GRV monitoring did not negatively affect clinical outcomes (including VAP) in mechanically ventilated patients. The results have revived the discussion on the role of GRV monitoring in critically ill, mechanically ventilated patients receiving early EN. This review summarizes the most recent clinical evidence on the use of GRV monitoring in critically ill patients. Based on the clinical evidence, it discusses the pros and cons and further addresses whether GRV is a dead marker or still alive for the nutrition management of critically ill patients. © 2014 American Society for Parenteral and Enteral Nutrition.

  20. Initial evaluation and management of the critical burn patient.

    Science.gov (United States)

    Vivó, C; Galeiras, R; del Caz, Ma D P

    2016-01-01

    The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns. Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized. The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control. All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage. Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound. Copyright © 2015 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

  1. Evaluation and handling of constipation in critical patients.

    Science.gov (United States)

    Pérez-Sánchez, J; Fernández-Boronat, J; Martínez-Méndez, E; Marín-Cagigas, M L; Mota-Puerto, D; Pérez-Román, M C; Martínez-Estalella, G

    To evaluate the effectiveness of nursing care against constipation and to identify, analyze and evaluate causes and consequences. Observational, descriptive and prospective study in polyvalent ICU tertiary hospital (2013-2015). >18 years, stay >7 days, connected to respiratory support, with nasogastric tube and enteral or mixed nutrition. Patients with gastrointestinal pathology, encephalopathic and jejunostomy/ileostomy were excluded. The studied variables (age, sex, weight, height, pathology, medical treatment, nutrition and volume type, depositional characteristics, quantity and frequency, corrective measures and complications) were collected by ad hoc grill. It is authorized by the CEIC. 139 patients with a mean age of 62 years and average stay of 11 days were analyzed; 63% suffered from constipation. Opiates and antacid were the drugs administered most frequently (99%), even though patients who took muscle relaxants, iron supplements and/or calcium and anti-hypertensive were the ones who suffered most from constipation (77%; 75%; 70%) The fiber free diet was the most widely used (60% constipated), followed by dietary fiber (51% constipated), and the combination of both (85% constipated). 56% used laxatives as a corrective measure, Magnesium Hydroxide being the most widely used; 54% began the first day. Gastric retention was the most relevant complication (49%). Constipation is a real multifactorial problem. We recommend: • Intensified surveillance in patients with drugs that promote constipation. • Use high-fiber diets from the outset. • Apply laxatives and prokinetics early and in combination. We need to create a protocol for prophylaxis and management of constipation. Copyright © 2017 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

  2. Kinetic therapy improves oxygenation in critically ill pediatric patients.

    Science.gov (United States)

    Schultz, Theresa Ryan; Lin, Richard; Francis, Barbara A; Hales, Roberta L; Colborn, Shawn; Napoli, Linda A; Helfaer, Mark A

    2005-07-01

    To compare changes in oxygenation after manual turning and percussion (standard therapy) and after automated rotation and percussion (kinetic therapy). Randomized crossover trial. General and cardiac pediatric intensive care units. Intubated and mechanically ventilated pediatric patients who had an arterial catheter and no contraindications to using a PediDyne bed. Patients were placed on a PediDyne bed (Kinetic Concepts) and received 18 hrs blocks of standard and kinetic therapy in an order determined by randomization. Arterial blood gases were measured every 2 hrs during each phase of therapy. Oxygenation index and arterial-alveolar oxygen tension difference [P(A-a)O(2)] were calculated. Indexes calculated at baseline and after each 18-hr phase of therapy were analyzed. Fifty patients were enrolled. Data from 15 patients were either not collected or not used due to reasons that included violation of protocol and inability to tolerate the therapies in the study. Indexes of oxygenation were not normally distributed and were compared using Wilcoxon signed rank testing. Both therapies led to improvements in oxygenation, but only those from kinetic therapy achieved statistical significance. In patients receiving kinetic therapy first, median oxygenation index decreased from 7.4 to 6.19 (p = .015). The median P(A-a)O(2) decreased from 165.2 to 126.4 (p = .023). There were continued improvements in oxygenation after the subsequent period of standard therapy, with the median oxygenation index decreasing to 5.52 and median P(A-a)O(2) decreasing to 116.0, but these changes were not significant (p = .365 and .121, respectively). When standard therapy was first, the median oxygenation index decreased from 8.83 to 8.71 and the median P(a-a)o(2) decreased from 195.4 to 186.6. Neither change was significant. Median oxygenation index after the subsequent period of kinetic therapy was significantly lower (7.91, p = .044) and median P(A-a)O(2) trended lower (143.4, p = .077

  3. The Reasons Requirement in International Investment Arbitration: Critical Case Studies (book review)

    DEFF Research Database (Denmark)

    Tang, Yi Shin

    2008-01-01

    3. In the article, the Researcher reviews the work of Professors Guillermo A. Alvarez and W. Michael Reisman from Yale Law School, regarding the mechanisms of international investment arbitration and their importance for developing countries. The article provides a critical perspective on the aut...

  4. A Retrospective study of Pressure ulcers in critically ill patients in a ...

    African Journals Online (AJOL)

    A Retrospective study of Pressure ulcers in critically ill patients in a ... reduced tissue perfusion, neurologic deficits, faecal or urinary incontinence. This study determined the prevalence and risk factors for the development of pressure ulcer in ...

  5. Micafungin versus anidulafungin in critically ill patients with invasive candidiasis: A retrospective study

    NARCIS (Netherlands)

    P.J. van der Geest (Patrick); N.G.M. Hunfeld (Nicola); S.E. Ladage (Sophie E.); A.B.J. Groeneveld (Johan)

    2016-01-01

    markdownabstract_Background:_ In critically ill patients the incidence of invasive fungal infections caused by Candida spp. has increased remarkably. Echinocandins are recommended as initial treatment for invasive fungal infections. The safety and efficacy of micafungin compared to caspofungin is

  6. Effect of a Probiotic Preparation (VSL#3 on Cardiovascular Risk Parameters in Critically-Ill Patients

    Directory of Open Access Journals (Sweden)

    Sarvin Sanaie

    2013-07-01

    Conclusion: Administration of probiotics in critically ill patients reduced the levels of TG and hs-CRP and increased HDL-C levels. However, no significant change was detected in levels of total cholesterol or LDL-C.

  7. Hypophosphatemia and duration of respiratory failure and mortality in critically ill patients

    DEFF Research Database (Denmark)

    Federspiel, C K; Itenov, T S; Thormar, K

    2018-01-01

    BACKGROUND: Hypophosphatemia has been associated with prolonged duration of respiratory failure and increased mortality in critically ill patients, but there is very limited evidence supporting the negative effects of low phosphate. We examined the association between hypophosphatemia at ICU...

  8. Diaphragm Muscle Fiber Weakness and Ubiquitin-Proteasome Activation in Critically Ill Patients

    NARCIS (Netherlands)

    Hooijman, P.E.; Beishuizen, A.; Witt, C.C.; de Waard, M.C.; Girbes, A.R.J.; Spoelstra-de Man, A.M.E.; Niessen, H.W.; Manders, E.; van Hees, H.W.H.; van den Brom, C.E.; Silderhuis, V.; Lawlor, M.W.; Labeit, S.; Stienen, G.J.M.; Hartemink, K.J.; Paul, M.A.; Heunks, L.M.A.; Ottenheijm, C.A.C.

    2015-01-01

    RATIONALE: The clinical significance of diaphragm weakness in critically ill patients is evident: it prolongs ventilator dependency, and increases morbidity and duration of hospital stay. To date, the nature of diaphragm weakness and its underlying pathophysiologic mechanisms are poorly understood.

  9. The relation of near-infrared spectroscopy with changes in peripheral circulation in critically ill patients

    NARCIS (Netherlands)

    Lima, Alexandre; van Bommel, Jasper; Sikorska, Karolina; van Genderen, Michel; Klijn, Eva; Lesaffre, Emmanuel; Ince, Can; Bakker, Jan

    2011-01-01

    We conducted this observational study to investigate tissue oxygen saturation during a vascular occlusion test in relationship with the condition of peripheral circulation and outcome in critically ill patients. Prospective observational study. Multidisciplinary intensive care unit in a university

  10. THREAT helps to identify epistaxis patients requiring blood transfusions

    Science.gov (United States)

    2013-01-01

    Objective To analyze the characteristics of patients who needed a blood transfusion due to epistaxis-caused anemia and to define potential risk factors. Design Retrospective cohort study. Setting A total cohort of 591 epistaxis patients, prospectively included between March 2007 and April 2008 at the ENT department of the University Hospital of Zurich, was evaluated concerning the need for blood transfusions. Methods The clinical charts and medical histories of these patients were evaluated. Main outcome measures Common parameters that increase the risk for severe anemia due to epistaxis. Results Twenty-two patients required blood transfusions due to their medical condition. 22.7% suffered from traumatic nosebleeds. Another 27.3% had a known medical condition with an increased bleeding tendency. These proportions were significantly higher than in the group of patients without need of blood transfusion. The odds ratio for receiving a blood transfusion was 14.0 in patients with hematologic disorders, 4.3 in traumatic epistaxis and 7.7 in posterior bleeders. The transfusion-dependent epistaxis patients suffered significantly more often from severe posterior nosebleeds with the need for a surgical therapeutic approach. Conclusions Patients with severe nosebleeds either from the posterior part of the nose or with known hematologic disorders or traumatic epistaxis should be closely monitored by blood parameter analyses to evaluate the indication for hemotransfusion. The acronym THREAT (Trauma, Hematologic disorder, and REAr origin of bleeding → Transfusion) helps to remember and identify the factors associated with an increased risk of receiving blood transfusion. PMID:23663751

  11. Management of critically ill surgical patients Case reports.

    Science.gov (United States)

    Mangiante, Gerardo; Padoan, Roberto; Mengardo, Valentina; Bencivenga, Maria; de Manzoni, Giovanni

    2016-01-01

    The acute abdomen (AA) still remains a challenging situation for surgeons. New pathological conditions have been imposed to our attention in this field in recent years. The definition of abdominal compartmental syndrome (ACS) in surgical practice and the introduction of new biological matrices, with the concepts of tension-free (TS) repair of incisional hernias, prompted us to set up new therapeutic strategies for the treatment of patients with AA. Thus we reviewed the cases of AA that we observed in recent years in which we performed a laparostomy in order to prevent or to treat an ACS. They are all cases of acute abdomen (AA), but from different origin, including chronic diseases, as in the course of inflammatory bowel disease (IBD), and acute pancreatitis. In all the cases, the open abdominal cavity was covered with a polyethylene sheet. The edges of the wound were sutured to the plastic sheet, and a traction exerted by a device that causes a negative pressure was added. This method was adopted in several cases without randomization, and resulted in excellent patient's outcomes. Abdominal compartmental syndrome, Acute abdomen, Laparostomy.

  12. Early Prediction of Sepsis Incidence in Critically Ill Patients Using Specific Genetic Polymorphisms.

    Science.gov (United States)

    David, Vlad Laurentiu; Ercisli, Muhammed Furkan; Rogobete, Alexandru Florin; Boia, Eugen S; Horhat, Razvan; Nitu, Razvan; Diaconu, Mircea M; Pirtea, Laurentiu; Ciuca, Ioana; Horhat, Delia; Horhat, Florin George; Licker, Monica; Popovici, Sonia Elena; Tanasescu, Sonia; Tataru, Calin

    2017-06-01

    Several diagnostic methods for the evaluation and monitoring were used to find out the pro-inflammatory status, as well as incidence of sepsis in critically ill patients. One such recent method is based on investigating the genetic polymorphisms and determining the molecular and genetic links between them, as well as other sepsis-associated pathophysiologies. Identification of genetic polymorphisms in critical patients with sepsis can become a revolutionary method for evaluating and monitoring these patients. Similarly, the complications, as well as the high costs associated with the management of patients with sepsis, can be significantly reduced by early initiation of intensive care.

  13. Optimum dietary protein requirement in nondiabetic maintenance hemodialysis patients.

    Science.gov (United States)

    Ohkawa, Sakae; Kaizu, Yukiko; Odamaki, Mari; Ikegaya, Naoki; Hibi, Ikuo; Miyaji, Kunihiko; Kumagai, Hiromichi

    2004-03-01

    There is controversy about whether the dietary protein requirement of 1.2 g/kg/d for hemodialysis (HD) patients, in the nutritional guidelines recommended by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI), is reasonable. A cross-sectional study was conducted in 129 stable HD patients without diabetes (84 men, 45 women) to investigate the association between the protein equivalent of nitrogen appearance normalized by ideal body weight (nPNAibw), an index of protein intake, and skeletal muscle mass or other metabolic consequences. Patients were divided into 5 groups according to nPNAibw index. Midthigh muscle area (TMA), midthigh subcutaneous fat area (TSFA), abdominal muscle area (AMA), abdominal subcutaneous fat area (ASFA), and visceral fat area (AVFA) were measured using computed tomography, and various nutritional parameters were compared among these groups. TMA and AMA values increased with increasing dietary protein intake from less than 0.7 g/kg/d to 0.9-1.1 g/kg/d and showed a plateau at greater than 0.9 to 1.1 g/kg/d of dietary protein intake. Conversely, fat mass, including TSFA, ASFA, and AVFA, and serum potassium concentration increased with graded protein intake, and no plateau was formed. Patients with nPNAibw greater than 1.3 g/kg/d satisfied the criterion of visceral obesity. Although serum prealbumin levels showed a trend similar to that of muscle mass, there was no significant difference in serum albumin levels among the study groups. Optimal dietary protein requirement for patients undergoing maintenance HD in a stable condition appears to be less than the level recommended by the NKF-KDOQI nutritional guidelines.

  14. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients.

    Science.gov (United States)

    Gosselink, R; Bott, J; Johnson, M; Dean, E; Nava, S; Norrenberg, M; Schönhofer, B; Stiller, K; van de Leur, H; Vincent, J L

    2008-07-01

    The Task Force reviewed and discussed the available literature on the effectiveness of physiotherapy for acute and chronic critically ill adult patients. Evidence from randomized controlled trials or meta-analyses was limited and most of the recommendations were level C (evidence from uncontrolled or nonrandomized trials, or from observational studies) and D (expert opinion). However, the following evidence-based targets for physiotherapy were identified: deconditioning, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. Discrepancies and lack of data on the efficacy of physiotherapy in clinical trials support the need to identify guidelines for physiotherapy assessments, in particular to identify patient characteristics that enable treatments to be prescribed and modified on an individual basis. There is a need to standardize pathways for clinical decision-making and education, to define the professional profile of physiotherapists, and increase the awareness of the benefits of prevention and treatment of immobility and deconditioning for critically ill adult patients.

  15. A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care

    DEFF Research Database (Denmark)

    Langhorn, Leanne; Sorensen, Jens C; Pedersen, Preben U

    2010-01-01

    A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care......A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care...

  16. Comparison of 2 intravenous insulin protocols: Glycemia variability in critically ill patients.

    Science.gov (United States)

    Gómez-Garrido, Marta; Rodilla-Fiz, Ana M; Girón-Lacasa, María; Rodríguez-Rubio, Laura; Martínez-Blázquez, Anselmo; Martínez-López, Fernando; Pardo-Ibáñez, María Dolores; Núñez-Marín, Juan M

    2017-05-01

    Glycemic variability is an independent predictor of mortality in critically ill patients. The objective of this study was to compare two intravenous insulin protocols in critically ill patients regarding the glycemic variability. This was a retrospective observational study performed by reviewing clinical records of patients from a Critical Care Unit for 4 consecutive months. First, a simpler Scale-Based Intravenous Insulin Protocol (SBIIP) was reviewed and later it was compared for the same months of the following year with a Sliding Scale-Based Intravenous Insulin Protocol (SSBIIP). All adult patients admitted to the unit during the referred months were included. Patients in whom the protocol was not adequately followed were excluded. A total of 557 patients were reviewed, of whom they had needed intravenous insulin 73 in the first group and 52 in the second group. Four and two patients were excluded in each group respectively. Glycemic variability for both day 1 (DS1) and total stay (DST) was lower in SSBIIP patients compared to SBIIP patients: SD1 34.88 vs 18.16 and SDT 36.45 vs 23.65 (P<.001). A glycemic management protocol in critically ill patients based on sliding scales decreases glycemic variability. Copyright © 2017 SEEN. Publicado por Elsevier España, S.L.U. All rights reserved.

  17. Fungal Peritonitis: Underestimated Disease in Critically Ill Patients with Liver Cirrhosis and Spontaneous Peritonitis.

    Science.gov (United States)

    Lahmer, Tobias; Brandl, Andreas; Rasch, Sebastian; Schmid, Roland M; Huber, Wolfgang

    2016-01-01

    Spontaneous peritonitis, especially spontaneous fungal peritonitis (SFP), is an important and potentially fatal complication in patients with endstage liver disaese. We evaluated potential risk factors, microbiological findings, and outcome of patients with SFP compared to spontaneous bacterial peritonitis (SBP) in critically ill patients. Retrospective analyses of critically ill patients with suspected spontaneous peritonitis. Out of 205 patients, 20 (10%) had SFP, 28 (14%) had SBP, 48 (24%) had peritonitis without microbiological findings (SP) and 109 (52%) had no-peritonitis (NP). APACHE II and SOFA score were significantly higher in patients with SFP (26; 22-28; pperitonitis could be significantly more often found in patients with SFP (65%; pperitonitis was significantly more often in patients with SFP (85%; pperitonitis.

  18. Review of Nuclear Criticality Safety Requirements Implementation for Hanford Tank Farms Facility

    International Nuclear Information System (INIS)

    DEFIGH PRICE, C.

    2000-01-01

    In November 1999, the Deputy Secretary of the Department of Energy directed a series of actions to strengthen the Department's ongoing nuclear criticality safety programs. A Review Plan describing lines of inquiry for assessing contractor programs was included. The Office of River Protection completed their assessment of the Tank Farm Contractor program in May 2000. This document supports that assessment by providing a compliance statement for each line of inquiry

  19. Pharmacy intervention on antimicrobial management of critically ill patients

    Directory of Open Access Journals (Sweden)

    Ijo I

    2011-06-01

    Full Text Available Frequent, suboptimal use of antimicrobial drugs has resulted in the emergence of microbial resistance, compromised clinical outcomes and increased costs, particularly in the intensive care unit (ICU. Mounting on these challenges is the paucity of new antimicrobial agents.Objectives: The study aims to determine the impact of prospective pharmacy-driven antimicrobial stewardship in the ICU on clinical and potential financial outcomes. The primary objectives were to determine the mean length of stay (LOS and mortality rate in the ICU resulting from prospective pharmacy interventions on antimicrobial therapy. The secondary objective was to calculate the difference in total drug acquisition costs resulting from pharmacy infectious diseases (ID-related interventions.Methods: In collaboration with an infectious disease physician, the ICU pharmacy team provided prospective audit with feedback to physicians on antimicrobial therapies of 70 patients over a 4-month period in a 31-bed ICU. In comparison with published data, LOS and mortality of pharmacy-monitored ICU patients were recorded. Daily cost savings on antimicrobial drugs and charges for medication therapy management (MTM services were added to calculate potential total cost savings. Pharmacy interventions focused on streamlining, dose optimization, intravenous-to-oral conversion, antimicrobial discontinuation, new recommendation and drug information consult. Antimicrobial education was featured in oral presentations and electronic newsletters for pharmacists and clinicians.Results: The mean LOS in the ICU was 6 days, which was lower than the published reports of LOS ranging from 11 to 36 days. The morality rate of 14% was comparable to the reported range of 6 to 20% in published literature. The total drug cost difference was a negative financial outcome or loss of USD192 associated with ID-related interventions.Conclusion: In collaboration with the infectious disease physician, prospective

  20. Questioning the Role of Requirements Engineering in the Causes of Safety-Critical Software Failures

    Science.gov (United States)

    Johnson, C. W.; Holloway, C. M.

    2006-01-01

    Many software failures stem from inadequate requirements engineering. This view has been supported both by detailed accident investigations and by a number of empirical studies; however, such investigations can be misleading. It is often difficult to distinguish between failures in requirements engineering and problems elsewhere in the software development lifecycle. Further pitfalls arise from the assumption that inadequate requirements engineering is a cause of all software related accidents for which the system fails to meet its requirements. This paper identifies some of the problems that have arisen from an undue focus on the role of requirements engineering in the causes of major accidents. The intention is to provoke further debate within the emerging field of forensic software engineering.

  1. Acute kidney injury in critically burned patients resuscitated with a protocol that includes low doses of Hydroxyethyl Starch.

    Science.gov (United States)

    Sánchez-Sánchez, M; Garcia-de-Lorenzo, A; Cachafeiro, L; Herrero, E; Asensio, M J; Agrifoglio, A; Flores, E; Estebanez, B; Extremera, P; Iglesias, C; Martinez, J R

    2016-09-30

    Acute kidney injury (AKI) is an important complication in burn patients. Recently, it has been recommended that hydroxyethyl starch (HES) be avoided in burn patients because it increases the incidence of AKI. Our purpose was to study incidence of AKI in critically ill burn patients resuscitated with Ringer's solution and supplements of HES. We conducted an observational study of 165 patients admitted to the critical care burn unit (with 30 ± 15% TBSA burned). The main outcome measures were incidence of AKI, contributions of colloids and crystalloids, various severity scores, comorbidities, complications and mortality. According to the RIFLE criteria, 10 (6.1%) patients presented with Risk, 11 (6.7%) presented with Injury and 11 (6.7%) presented with Failure. According to the AKIN criteria, 9.7% presented stage I, 3% stage II and 10.3% stage III. Replacement therapy (RRT) was performed in 15 patients (9.1%), but in 6 of them RRT was employed in the final stages of multi-organ failure. The incidence of AKI in severe burn patients is high according to the RIFLE or AKIN criteria and these patients experience more complications and higher mortality. Our study suggests that the use of HES in low doses in the burn resuscitation phase does not cause more AKI than resuscitation without HES, but further evaluation is required. Further studies should be conducted.

  2. Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

    Science.gov (United States)

    Kuo, Calvin C; Robb, William J

    2013-06-01

    The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

  3. Patient-centered care requires a patient-oriented workflow model.

    Science.gov (United States)

    Ozkaynak, Mustafa; Brennan, Patricia Flatley; Hanauer, David A; Johnson, Sharon; Aarts, Jos; Zheng, Kai; Haque, Saira N

    2013-06-01

    Effective design of health information technology (HIT) for patient-centered care requires consideration of workflow from the patient's perspective, termed 'patient-oriented workflow.' This approach organizes the building blocks of work around the patients who are moving through the care system. Patient-oriented workflow complements the more familiar clinician-oriented workflow approaches, and offers several advantages, including the ability to capture simultaneous, cooperative work, which is essential in care delivery. Patient-oriented workflow models can also provide an understanding of healthcare work taking place in various formal and informal health settings in an integrated manner. We present two cases demonstrating the potential value of patient-oriented workflow models. Significant theoretical, methodological, and practical challenges must be met to ensure adoption of patient-oriented workflow models. Patient-oriented workflow models define meaningful system boundaries and can lead to HIT implementations that are more consistent with cooperative work and its emergent features.

  4. Pressure ulcer dressings in critical patients: a cost analysis

    Directory of Open Access Journals (Sweden)

    Dinara Raquel Araújo Silva

    Full Text Available Abstract OBJECTIVE To assess the direct cost of dressings in pressure ulcer treatment. METHOD This was a descriptive observational study conducted at an intensive care unit in the Northeast region of Brazil, between November and December 2015. Data were gathered using the Pressure Ulcer Scale for Healing and a form to characterize and assess costs. Values in Brazilian reais (BRL were converted into U.S. dollars at the exchange rate of USD 0.26/BRL. Univariate and bivariate analyses were conducted. RESULTS The sample consisted of 15 patients with at least stage 2 ulcers. There was a significant reduction in costs with dressing materials between the initial and final assessments (p=0.002, with a mean of USD 11.9 (±7.4. The most common topical treatments used were essential fatty acids and papain. CONCLUSION Cost reduction was proportional to the stage of pressure ulcer. The role of nurses in creating evidence-based care plans is crucial to improve care management.

  5. Blood leptin levels and erythropoietin requirement in Iranian hemodialysis patients

    Directory of Open Access Journals (Sweden)

    Rahimi A

    2008-12-01

    Full Text Available "nBackground: Anemia is a common complication accompanied by high morbidity and mortality in hemodialysis patients. Considering the fact that the reduction of erythropoietin (EPO synthesis is the main cause of uremic anemia, receiving recombinant human erythropoietin (rHuEPO can improve the condition in these patients. Some of these hemodialysis patients, however, have acceptable hemoglobin levels without any need to EPO. Higher BMI, higher albumin and leptin plasma levels and longer durations of hemodialysis are possible factors contributing to the reduced need for rHuEPO in these patients. The present study is designed to asses the relationship between the plasma levels of leptin and the reduced EPO need. "nMethods: Fifty eligible hemodialysis patients with hemoglobin levels higher than 11 mg/dl were enrolled in the cross-sectional study. The information on age, sex, hemodialysis duration and the cause of renal dysfunction were extracted from the files. The baseline plasma levels of Leptin and albumin were measured. The patients BMI and the weekly need for rHuEPO were also calculated. "nResults: There was no correlation between the weekly need for rHuEPO and sex, BMI, the cause of renal dysfunction and the plasma levels of albumin and leptin; it, however, was related with age and the duration of dialysis. While age negatively influences the weekly need, the duration of dialysis has a positive effect on the need. "nConclusion: The plasma levels of leptin are not directly correlated with the required amounts of rHuEPO, indicating that leptin is not an effective factor in erythropoiesis. Conversely, older age and shorter hemodialysis durations are accompanied by reduced need for rHuEPO.

  6. What does respect for the patient's autonomy require?

    Science.gov (United States)

    Cheng, Kam-Yuen

    2013-11-01

    Personal autonomy presupposes the notion of rationality. What is not so clear is whether, and how, a compromise of rationality to various degrees will diminish a person's autonomy. In bioethical literature, three major types of threat to the rationality of a patient's medical decision are identified: insufficient information, irrational beliefs/desires, and influence of different framing effects. To overcome the first problem, it is suggested that patients be provided with information about their diseases and treatment choices according to the objective standard. I shall explain how this should be finessed. Regarding the negative impact of irrational beliefs/desires, some philosophers have argued that holding irrational beliefs can still be an expression of autonomy. I reject this argument because the degree of autonomy of a decision depends on the degree of rationality of the beliefs or desires on which the decision is based. Hence, to promote patient autonomy, we need to eliminate irrational beliefs by the provision of evidence and good arguments. Finally, I argue that the way to smooth out the framing effects is to present the same information in different perspectives: it is too often assumed that medical information can always be given in a complete and unadorned manner. This article concludes with a cautionary note that the protection of patient autonomy requires much more time and effort than the current practice usually allows. © 2012 John Wiley & Sons Ltd.

  7. An Evaluation of Ciprofloxacin Pharmacokinetics in Critically Ill Patients undergoing Continuous Veno-venous Haemodiafiltration

    LENUS (Irish Health Repository)

    Spooner, Almath M

    2011-08-04

    Abstract Background The study aimed to investigate the pharmacokinetics of intravenous ciprofloxacin and the adequacy of 400 mg every 12 hours in critically ill Intensive Care Unit (ICU) patients on continuous veno-venous haemodiafiltration (CVVHDF) with particular reference to the effect of achieved flow rates on drug clearance. Methods This was an open prospective study conducted in the intensive care unit and research unit of a university teaching hospital. The study population was seven critically ill patients with sepsis requiring CVVHDF. Blood and ultrafiltrate samples were collected and assayed for ciprofloxacin by High Performance Liquid Chromatography (HPLC) to calculate the model independent pharmacokinetic parameters; total body clearance (TBC), half-life (t1\\/2) and volume of distribution (Vd). CVVHDF was performed at prescribed dialysate rates of 1 or 2 L\\/hr and ultrafiltration rate of 2 L\\/hr. The blood flow rate was 200 ml\\/min, achieved using a Gambro blood pump and Hospal AN69HF haemofilter. Results Seventeen profiles were obtained. CVVHDF resulted in a median ciprofloxacin t1\\/2 of 13.8 (range 5.15-39.4) hr, median TBC of 9.90 (range 3.10-13.2) L\\/hr, a median Vdss of 125 (range 79.5-554) L, a CVVHDF clearance of 2.47+\\/-0.29 L\\/hr and a clearance of creatinine (Clcr) of 2.66+\\/-0.25 L\\/hr. Thus CVVHDF, at an average flow rate of ~3.5 L\\/hr, was responsible for removing 26% of ciprofloxacin cleared. At the dose rate of 400 mg every 12 hr, the median estimated Cpmax\\/MIC and AUC0-24\\/MIC ratios were 10.3 and 161 respectively (for a MIC of 0.5 mg\\/L) and exceed the proposed criteria of >10 for Cpmax\\/MIC and > 100 for AUC0-24\\/MIC. There was a suggestion towards increased ciprofloxacin clearance by CVVHDF with increasing effluent flow rate. Conclusions Given the growing microbial resistance to ciprofloxacin our results suggest that a dose rate of 400 mg every 12 hr, may be necessary to achieve the desired pharmacokinetic

  8. Clinical emergency treatment of 68 critical patients with severe organophosphorus poisoning and prognosis analysis after rescue.

    Science.gov (United States)

    Dong, Hui; Weng, Yi-Bing; Zhen, Gen-Shen; Li, Feng-Jie; Jin, Ai-Chun; Liu, Jie

    2017-06-01

    This study reports the clinical emergency treatment of 68 critical patients with severe organophosphorus poisoning, and analyzes the prognosis after rescue.The general data of 68 patients with severe organophosphorus poisoning treated in our hospital were retrospectively analyzed. These patients were divided into 2 groups: treatment group, and control group. Patients in the control group received routine emergency treatment, while patients in the treatment group additionally received hemoperfusion plus hemodialysis on the basis of routine emergency treatment. The curative effects in these 2 groups and the prognosis after rescue were compared.Compared with the control group, atropinization time, recovery time of cholinesterase activity, recovery time of consciousness, extubation time, and length of hospital stay were shorter (P poisoning rebound rate was significantly lower (P treatment group.Hemoperfusion and hemodialysis on the basis of routine emergency treatment for critical patients with organophosphorus poisoning can improve rescue outcomes and improve the prognosis of patients, which should be popularized.

  9. Defining System Requirements: a critical assessment of the Niam conceptual design procedure

    Directory of Open Access Journals (Sweden)

    Peta Darke

    1995-05-01

    Full Text Available Requirements definition is a fundamental activity within information systems development. Social and organisational issues are at the centre of many of the problems experienced during the development and implementation of information systems, and these need to be explored during requirements definition. The NIAM Conceptual Schema Design Procedure (CSDP is a method for identifying and describing information requirements using fact types. This paper discusses some limitations of the information requirements definition step of the CSDP which result from its lack of focus on the socio-organisational dimension of information systems development. Four different approaches to exploring the socio-organisational contexts of systems are discussed. It is proposed that one of these, viewpoint development, be incorporated into the NIAM CSDP to provide a means of exploring and understanding a system's socio organisational context and to ensure that contextual information is a major input to the requirements definition process. This results in an enhanced design procedure. Future and current research areas are identified.

  10. Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units.

    Science.gov (United States)

    Mosleh, S; Alja'afreh, M; Lee, A J

    2015-12-01

    The aim of the study was to assess the validity of family members/friends as proxies by comparing perceptions of satisfaction with care and decision making between critically ill patients and their family/friends. A comparative, descriptive cross-sectional study. Seven Critical Care Units across four public and military hospitals in the centre and southern regions of Jordan. A modified version of the Family Satisfaction-ICU (FS-ICU) questionnaire was distributed to Critical Care Unit (CCU) patients before hospital discharge. In addition, up to two family members/close friends were also asked to complete the questionnaire. A total of 213 patients (response rate 72%) and 246 family members/friends (response rate 79%) completed and returned the questionnaire. Although the majority of family members/friends and patients were satisfied with overall care, patients were generally significantly less satisfied (mean (SD) care subscale 75.6 (17.8) and 70.9 (17.3), respectively, (p=0.005). When individual items were examined, significant differences in nursing care (family/friends 80.1 (20.7) versus patient 75.9 (22.2), p=0.038) and inclusion in decision making (family/friends 53.9 (33.2) versus patient 62.0 (34.2), p=0.010) were found. The study showed a degree of congruence between patients and their family members/friends in relation to their satisfaction with the CCU experience. Thus, views of family/friends may serve as a proxy in assessing care and decision making processes of critically ill patients. Appropriate training of the critical care team and provision of strategies to address the concerns of patients' families are needed to improve overall patient satisfaction. Copyright © 2015 Elsevier Ltd. All rights reserved.

  11. Mortality after major amputation in elderly patients with critical limb ischemia

    NARCIS (Netherlands)

    S. Klaphake (Sanne); de Leur, K. (Kevin); P.G.H. Mulder (Paul); G.H. Ho (Gwan); H.G.W. de Groot (Hans); E.J. Veen (Eelco J.); H.J.M. Verhagen (Hence); L. van der Laan (Lyckle)

    2017-01-01

    markdownabstractBackground: Owing to the aging population, the number of elderly patients with critical limb ischemia (CLI) has increased. The consequence of amputation is immense. However, at the moment, information about the mortality after amputation in the elderly vascular patients is unknown.

  12. Innovative solutions--the art of improvisation: patient and family preferences for visitation in critical care.

    Science.gov (United States)

    Heitman, Linda; McClard, Catherine

    2009-01-01

    Critical care nurses identified that, although a liberal visitation policy was followed, patients and families occasionally expressed preferences for verbal communication, rather than have the visitor physically present in the unit. Previously tested communication devices interfered with operating equipment resulting in poor reception. The purpose of this project was to find an effective method for patients to verbally communicate with visitors.

  13. A RATIONAL BASIS FOR THE MEASUREMENT OF FREE PHENYTOIN CONCENTRATION IN CRITICALLY ILL TRAUMA PATIENTS

    NARCIS (Netherlands)

    ZIELMANN, S; MIELCK, F; KAHL, R; KAZMAIER, S; SYDOW, M; KOLK, J; BURCHARDI, H

    Phenytoin binding to serum proteins and factors influencing protein binding were investigated in 38 critically ill trauma patients. In 24% of these patients, the free fraction of phenytoin was less-than-or-equal-to 10%, whereas in 76%, the free phenytoin fraction was increased >10%-up to 24%.

  14. Pressure ulcer dressings in critical patients: a cost analysis.

    Science.gov (United States)

    Silva, Dinara Raquel Araújo; Bezerra, Sandra Marina Gonçalves; Costa, Jéssica Pereira; Luz, Maria Helena Barros Araújo; Lopes, Vanessa Caminha Aguiar; Nogueira, Lidya Tolstenko

    2017-06-12

    To assess the direct cost of dressings in pressure ulcer treatment. This was a descriptive observational study conducted at an intensive care unit in the Northeast region of Brazil, between November and December 2015. Data were gathered using the Pressure Ulcer Scale for Healing and a form to characterize and assess costs. Values in Brazilian reais (BRL) were converted into U.S. dollars at the exchange rate of USD 0.26/BRL. Univariate and bivariate analyses were conducted. The sample consisted of 15 patients with at least stage 2 ulcers. There was a significant reduction in costs with dressing materials between the initial and final assessments (p=0.002), with a mean of USD 11.9 (±7.4). The most common topical treatments used were essential fatty acids and papain. Cost reduction was proportional to the stage of pressure ulcer. The role of nurses in creating evidence-based care plans is crucial to improve care management. Avaliar o custo direto com curativos no tratamento de lesões por pressão. Estudo observacional descritivo, realizado em Unidade de Terapia Intensiva do nordeste do Brasil, de novembro a dezembro de 2015. Foi aplicada a Pressure Ulcer Scale for Healing e formulário para caracterização e avaliação de custos. Os valores da moeda brasileira (R$) foram convertidos para a moeda norte-americana (US$) à taxa de US$0,26/R$. Foram realizadas análises univariadas e bivariadas. Compuseram a amostra 15 pacientes com lesões, no mínimo, estágio 2. Houve redução significativa dos custos com materiais de curativos entre as avaliações inicial e final (p=0,002), com média de US$11,9 (±7,4). As terapias tópicas mais frequentes foram ácidos graxos essenciais e papaína. Verificou-se redução de custos proporcional aos estágios das lesões. Enfatiza-se o papel do enfermeiro na elaboração de planos de cuidados baseados em evidências para melhor gerenciamento do cuidado. Evaluar el costo directo de curativos para el tratamiento de lesiones por

  15. Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management.

    Science.gov (United States)

    Chiu, Ada W; Contreras, Sofia; Mehta, Sangeeta; Korman, Jennifer; Perreault, Marc M; Williamson, David R; Burry, Lisa D

    2017-12-01

    To (1) provide an overview of the epidemiology, clinical presentation, and risk factors of iatrogenic opioid withdrawal in critically ill patients and (2) conduct a literature review of assessment and management of iatrogenic opioid withdrawal in critically ill patients. We searched MEDLINE (1946-June 2017), EMBASE (1974-June 2017), and CINAHL (1982-June 2017) with the terms opioid withdrawal, opioid, opiate, critical care, critically ill, assessment tool, scale, taper, weaning, and management. Reference list of identified literature was searched for additional references as well as www.clinicaltrials.gov . We restricted articles to those in English and dealing with humans. We identified 2 validated pediatric critically ill opioid withdrawal assessment tools: (1) Withdrawal Assessment Tool-Version 1 (WAT-1) and (2) Sophia Observation Withdrawal Symptoms Scale (SOS). Neither tool differentiated between opioid and benzodiazepine withdrawal. WAT-1 was evaluated in critically ill adults but not found to be valid. No other adult tool was identified. For management, we identified 5 randomized controlled trials, 2 prospective studies, and 2 systematic reviews. Most studies were small and only 2 studies utilized a validated assessment tool. Enteral methadone, α-2 agonists, and protocolized weaning were studied. We identified 2 validated assessment tools for pediatric intensive care unit patients; no valid tool for adults. Management strategies tested in small trials included methadone, α-2 agonists, and protocolized sedation/weaning. We challenge researchers to create validated tools assessing specifically for opioid withdrawal in critically ill children and adults to direct management.

  16. Clinical outcome of critically ill, not fully recompensated, patients undergoing MitraClip therapy

    DEFF Research Database (Denmark)

    Rudolph, Volker; Huntgeburth, Michael; von Bardeleben, Ralph Stephan

    2014-01-01

    AIMS: As periprocedural risk is low, MitraClip implantation is often performed in critically ill, not fully recompensated patients, who are in NYHA functional class IV at the time of the procedure, to accelerate convalescence. We herein sought to evaluate the procedural and 30-day outcome.......3%. CONCLUSION: MitraClip therapy is feasible and safe even in critically ill, not fully recompensated patients and leads to symptomatic improvement in over two-thirds of these patients; however, it is associated with an elevated 30-day mortality....

  17. Long-Term Impact of Acute, Critical Illness and Admission to an Intensive Care Unit. Perspectives of Patients and Partners

    DEFF Research Database (Denmark)

    Ågård, Anne Sophie

    2013-01-01

    of the critical illness trajectory. Recovery after critical illness and admission to an ICU entailed a dynamic, reciprocal process requiring substantial efforts from both parties as individuals and as a couple. The findings contribute to the existing body of knowledge about recovery after discharge from an ICU...... and rehabilitation pro-fessionals in hospitals and community-based services to consider the best content, timing, and organization of supportive measures aimed at assisting spouses in their support of recovering patients. To broaden the overall insight into the recovery of the heterogeneous population of ICU......ENGLISH SUMMARY The focus of the study was to describe post-ICU recovery as seen from the perspective of ICU survivors and their spouses in a Danish setting. The aims were to describe the trajectories of the participating patients and spouses and generate theoretical accounts of their main concerns...

  18. Critical water requirements for food, methodology and policy consequences for food security

    NARCIS (Netherlands)

    Gerbens-Leenes, P.W.; Nonhebel, S.

    2004-01-01

    Food security and increasing water scarcity have a dominant place on the food policy agenda. Food security requires sufficient water of adequate quality because water is a prerequisite for plant growth. Nowadays, agriculture accounts for 70% of the worldwide human fresh water use. The expected

  19. Seeing beyond monitors-Critical care nurses' multiple skills in patient observation: Descriptive qualitative study.

    Science.gov (United States)

    Alastalo, Mika; Salminen, Leena; Lakanmaa, Riitta-Liisa; Leino-Kilpi, Helena

    2017-10-01

    The aim of this study was to provide a comprehensive description of multiple skills in patient observation in critical care nursing. Data from semi-structured interviews were analysed using thematic analysis. Experienced critical care nurses (n=20) from three intensive care units in two university hospitals in Finland. Patient observation skills consist of: information gaining skills, information processing skills, decision-making skills and co-operation skills. The first three skills are integrated in the patient observation process, in which gaining information is a prerequisite for processing information that precedes making decisions. Co-operation has a special role as it occurs throughout the process. This study provided a comprehensive description of patient observation skills related to the three-phased patient observation process. The findings contribute to clarifying this part of the competence. The description of patient observation skills may be applied in both clinical practice and education as it may serve as a framework for orientation, ensuring clinical skills and designing learning environments. Based on this study, patient observation skills can be recommended to be included in critical care nursing education, orientation and as a part of critical care nurses' competence evaluation. Copyright © 2017 Elsevier Ltd. All rights reserved.

  20. Assessing Critical Thinking Outcomes of Dental Hygiene Students Utilizing Virtual Patient Simulation: A Mixed Methods Study.

    Science.gov (United States)

    Allaire, Joanna L

    2015-09-01

    Dental hygiene educators must determine which educational practices best promote critical thinking, a quality necessary to translate knowledge into sound clinical decision making. The aim of this small pilot study was to determine whether virtual patient simulation had an effect on the critical thinking of dental hygiene students. A pretest-posttest design using the Health Science Reasoning Test was used to evaluate the critical thinking skills of senior dental hygiene students at The University of Texas School of Dentistry at Houston Dental Hygiene Program before and after their experience with computer-based patient simulation cases. Additional survey questions sought to identify the students' perceptions of whether the experience had helped develop their critical thinking skills and improved their ability to provide competent patient care. A convenience sample of 31 senior dental hygiene students completed both the pretest and posttest (81.5% of total students in that class); 30 senior dental hygiene students completed the survey on perceptions of the simulation (78.9% response rate). Although the results did not show a significant increase in mean scores, the students reported feeling that the use of virtual patients was an effective teaching method to promote critical thinking, problem-solving, and confidence in the clinical realm. The results of this pilot study may have implications to support the use of virtual patient simulations in dental hygiene education. Future research could include a larger controlled study to validate findings from this study.

  1. The Patient-Centered Medical Home Neighbor: A Critical Concept for a Redesigned Healthcare Delivery System

    Science.gov (United States)

    2011-01-25

    Sharing Knowledge: Achieving Breakthrough Performance 2010 Military Health System Conference The Patient -Centered Medical Home Neighbor: A Critical...DATE 25 JAN 2011 2. REPORT TYPE 3. DATES COVERED 00-00-2011 to 00-00-2011 4. TITLE AND SUBTITLE The Patient -Centered Medical Home Neighbor: A...Conference What is the Patient -Centered Medical Home?  …a vision of health care as it should be  …a framework for organizing systems of care at both the

  2. Long term psychological effects of a no sedation protocol in critically ill Patients

    DEFF Research Database (Denmark)

    Stroem, Thomas; Stylsvig, Mette; Toft, Palle

    2011-01-01

    interviewed (13 from each group). No difference was found with respect to quality of life (SF-36). Both mental and physical components were non-significant. Becks depression index was low in both groups (1 patient in intervention group vs. 3 patients in the control group were depressed, P=0.32). Evaluated...... applied to critically ill patients undergoing mechanical ventilation does not increase the risk of long term psychological sequelae after intensive care compared to standard treatment with sedation....

  3. Modelling elderly cardiac patients decision making using Cognitive Work Analysis: identifying requirements for patient decision aids.

    Science.gov (United States)

    Dhukaram, Anandhi Vivekanandan; Baber, Chris

    2015-06-01

    Patients make various healthcare decisions on a daily basis. Such day-to-day decision making can have significant consequences on their own health, treatment, care, and costs. While decision aids (DAs) provide effective support in enhancing patient's decision making, to date there have been few studies examining patient's decision making process or exploring how the understanding of such decision processes can aid in extracting requirements for the design of DAs. This paper applies Cognitive Work Analysis (CWA) to analyse patient's decision making in order to inform requirements for supporting self-care decision making. This study uses focus groups to elicit information from elderly cardiovascular disease (CVD) patients concerning a range of decision situations they face on a daily basis. Specifically, the focus groups addressed issues related to the decision making of CVD in terms of medication compliance, pain, diet and exercise. The results of these focus groups are used to develop high level views using CWA. CWA framework decomposes the complex decision making problem to inform three approaches to DA design: one design based on high level requirements; one based on a normative model of decision-making for patients; and the third based on a range of heuristics that patients seem to use. CWA helps in extracting and synthesising decision making from different perspectives: decision processes, work organisation, patient competencies and strategies used in decision making. As decision making can be influenced by human behaviour like skills, rules and knowledge, it is argued that patients require support to different types of decision making. This paper also provides insights for designers in using CWA framework for the design of effective DAs to support patients in self-management. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  4. The effect of human patient simulation on critical thinking and its predictors in prelicensure nursing students.

    Science.gov (United States)

    Shinnick, Mary Ann; Woo, Mary A

    2013-09-01

    Human patient simulation (HPS) is becoming a popular teaching method in nursing education globally and is believed to enhance both knowledge and critical thinking. While there is evidence that HPS improves knowledge, there is no objective nursing data to support HPS impact on critical thinking. Therefore, we studied knowledge and critical thinking before and after HPS in prelicensure nursing students and attempted to identify the predictors of higher critical thinking scores. Using a one-group, quasi-experimental, pre-test post-test design, 154 prelicensure nursing students (age 25.7± 6.7; gender=87.7% female) from 3 schools were studied at the same point in their curriculum using a high-fidelity simulation. Pre- and post-HPS assessments of knowledge, critical thinking, and self-efficacy were done as well as assessments for demographics and learning style. There was a mean improvement in knowledge scores of 6.5 points (Pcritical thinking scores. A logistic regression with 10 covariates revealed three variables to be predictors of higher critical thinking scores: greater "age" (P=0.01), baseline "knowledge" (P=0.04) and a low self-efficacy score ("not at all confident") in "baseline self-efficacy in managing a patient's fluid levels" (P=.05). This study reveals that gains in knowledge with HPS do not equate to changes in critical thinking. It does expose the variables of older age, higher baseline knowledge and low self-efficacy in "managing a patient's fluid levels" as being predictive of higher critical thinking ability. Further study is warranted to determine the effect of repeated or sequential simulations (dosing) and timing after the HPS experience on critical thinking gains. Copyright © 2012 Elsevier Ltd. All rights reserved.

  5. Dropping The Bomb? On Critical and Cinematic Reactions to Michael Ondaatje's The English Patient

    OpenAIRE

    Pesch, Josef

    2018-01-01

    This paper analyses Anthony Minghella's film adaptation of Michael Ondaatje’s The English Patient. It aims at establishing patterns of transformation and strategies of adaptation. Not only the nostalgie romanticisation, but also the de-politicisation of the novel is critically scrutinized. As dropping all reference to the atomic bomb from the film is the most blatant example of deviation from the novel, critical and political background is provided which may explain this act of self-censorshi...

  6. Are patient specific meshes required for EIT head imaging?

    Science.gov (United States)

    Jehl, Markus; Aristovich, Kirill; Faulkner, Mayo; Holder, David

    2016-06-01

    Head imaging with electrical impedance tomography (EIT) is usually done with time-differential measurements, to reduce time-invariant modelling errors. Previous research suggested that more accurate head models improved image quality, but no thorough analysis has been done on the required accuracy. We propose a novel pipeline for creation of precise head meshes from magnetic resonance imaging and computed tomography scans, which was applied to four different heads. Voltages were simulated on all four heads for perturbations of different magnitude, haemorrhage and ischaemia, in five different positions and for three levels of instrumentation noise. Statistical analysis showed that reconstructions on the correct mesh were on average 25% better than on the other meshes. However, the stroke detection rates were not improved. We conclude that a generic head mesh is sufficient for monitoring patients for secondary strokes following head trauma.

  7. Hormonal Signaling Cascade during an Early-Adult Critical Period Required for Courtship Memory Retention in Drosophila.

    Science.gov (United States)

    Lee, Sang Soo; Ding, Yike; Karapetians, Natalie; Rivera-Perez, Crisalejandra; Noriega, Fernando Gabriel; Adams, Michael E

    2017-09-25

    Formation and expression of memories are critical for context-dependent decision making. In Drosophila, a courting male rejected by a mated female subsequently courts less avidly when paired with a virgin female, a behavioral modification attributed to "courtship memory." Here we show the critical role of hormonal state for maintenance of courtship memory. Ecdysis-triggering hormone (ETH) is essential for courtship memory through regulation of juvenile hormone (JH) levels in adult males. Reduction of JH levels via silencing of ETH signaling genes impairs short-term courtship memory, a phenotype rescuable by the JH analog methoprene. JH-deficit-induced memory impairment involves rapid decay rather than failure of memory acquisition. A critical period governs memory performance during the first 3 days of adulthood. Using sex-peptide-expressing "pseudo-mated" trainers, we find that robust courtship memory elicited in the absence of aversive chemical mating cues also is dependent on ETH-JH signaling. Finally, we find that JH acts through dopaminergic neurons and conclude that an ETH-JH-dopamine signaling cascade is required during a critical period for promotion of social-context-dependent memory. Copyright © 2017 Elsevier Ltd. All rights reserved.

  8. Critical lysine residues of Klf4 required for protein stabilization and degradation

    Energy Technology Data Exchange (ETDEWEB)

    Lim, Key-Hwan; Kim, So-Ra; Ramakrishna, Suresh; Baek, Kwang-Hyun, E-mail: baek@cha.ac.kr

    2014-01-24

    Highlights: • Klf4 undergoes the 26S proteasomal degradation by ubiquitination on its multiple lysine residues. • Essential Klf4 ubiquitination sites are accumulated between 190–263 amino acids. • A mutation of lysine at 232 on Klf4 elongates protein turnover. • Klf4 mutants dramatically suppress p53 expression both under normal and UV irradiated conditions. - Abstract: The transcription factor, Krüppel-like factor 4 (Klf4) plays a crucial role in generating induced pluripotent stem cells (iPSCs). As the ubiquitination and degradation of the Klf4 protein have been suggested to play an important role in its function, the identification of specific lysine sites that are responsible for protein degradation is of prime interest to improve protein stability and function. However, the molecular mechanism regulating proteasomal degradation of the Klf4 is poorly understood. In this study, both the analysis of Klf4 ubiquitination sites using several Klf4 deletion fragments and bioinformatics predictions showed that the lysine sites which are signaling for Klf4 protein degradation lie in its N-terminal domain (aa 1–296). The results also showed that Lys32, 52, 232, and 252 of Klf4 are responsible for the proteolysis of the Klf4 protein. These results suggest that Klf4 undergoes proteasomal degradation and that these lysine residues are critical for Klf4 ubiquitination.

  9. [The optimal blood glucose target in critically ill patient: comparison of two intensive insulin therapy protocols].

    Science.gov (United States)

    Raurell Torredà, Marta; del Llano Serrano, César; Almirall Solsona, Dolors; Catalan Ibars, Rosa María; Nicolás Arfelis, José María

    2014-03-04

    Recent studies in critically ill patients receiving insulin intravenous therapy (IIT) have shown an increased incidence of severe hypoglycemia, while intermittent subcutaneous insulin «sliding scales» (conventional insulin therapy [CIT]) is associated with hyperglycemia. The objective of this study is to assess whether glycemic control range IIT can affect glucose levels and their variability and to compare it with CIT. Prospective comparative cohort study in intensive care unit, with 2 study periods: Period 1, IIT with glycemic target range 110-140 mg/dL, and Period 2, IIT of 140-180 mg/dL. In both periods CIT glycemic target was 110-180 mg/dL. We assessed severe hypoglycemia ( 216 mg/L) and the variability of blood glucose. We studied 221 patients with 12.825 blood glucose determinations. Twenty-six and 17% of patients required IIT for glycemic control in Period 1 and 2, respectively. Hypoglycemia was associated with a discontinuous nutritional intake, glycemic target 110-140 mg/dL and low body mass index (BMI) (P = .002). Hyperglycemia was exclusively associated with a history of diabetes mellitus (OR 2.6 [95% CI 1.6 to 4.5]). Glycemic variability was associated with a discontinuous nutritional intake, low BMI, CIT insulinization, diabetes mellitus, elderly and high APACHE II (P < .001). The use of IIT is useful to reduce the variability of blood glucose. Although the 140-180 mg/dL range would be more secure as to presenting greater variability and hyperglycemia, the 110-140 mg/dL range is most suitable. Copyright © 2012 Elsevier España, S.L. All rights reserved.

  10. Criticality safety requirements for transporting EBR-II fuel bottles stored at INTEC

    International Nuclear Information System (INIS)

    Lell, R. M.; Pope, C. L.

    2000-01-01

    Two carrier/shipping cask options are being developed to transport bottles of EBR-II fuel elements stored at INTEC. Some fuel bottles are intact, but some have developed leaks. Reactivity control requirements to maintain subcriticality during the hypothetical transport accident have been examined for both transport options for intact and leaking bottles. Poison rods, poison sleeves, and dummy filler bottles were considered; several possible poison materials and several possible dummy filler materials were studied. The minimum number of poison rods or dummy filler bottles has been determined for each carrier for transport of intact and leaking bottles

  11. Procalcitonin increase in early identification of critically ill patients at high risk of mortality

    DEFF Research Database (Denmark)

    Jensen, Jens Ulrik; Heslet, L; Jensen, TH

    2006-01-01

    OBJECTIVE: To investigate day-by-day changes in procalcitonin and maximum obtained levels as predictors of mortality in critically ill patients. DESIGN: Prospective observational cohort study. SETTING:: Multidisciplinary intensive care unit at Rigshospitalet, Copenhagen University Hospital......, a tertiary reference hospital in Denmark. PATIENTS: Four hundred seventy-two patients with diverse comorbidity and age admitted to this intensive care unit. INTERVENTIONS: Equal in all patient groups: antimicrobial treatment adjusted according to the procalcitonin level. MEASUREMENTS AND MAIN RESULTS: Daily...... in the intensive care unit and in a 30-day follow-up period. A total of 3,642 procalcitonin measurements were evaluated in 472 critically ill patients. We found that a high maximum procalcitonin level and a procalcitonin increase for 1 day were independent predictors of 90-day all-cause mortality...

  12. Critical evaluation of the JDO API for the persistence and portability requirements of complex biological databases

    Directory of Open Access Journals (Sweden)

    Schwieger Michael

    2005-01-01

    Full Text Available Abstract Background Complex biological database systems have become key computational tools used daily by scientists and researchers. Many of these systems must be capable of executing on multiple different hardware and software configurations and are also often made available to users via the Internet. We have used the Java Data Object (JDO persistence technology to develop the database layer of such a system known as the SigPath information management system. SigPath is an example of a complex biological database that needs to store various types of information connected by many relationships. Results Using this system as an example, we perform a critical evaluation of current JDO technology; discuss the suitability of the JDO standard to achieve portability, scalability and performance. We show that JDO supports portability of the SigPath system from a relational database backend to an object database backend and achieves acceptable scalability. To answer the performance question, we have created the SigPath JDO application benchmark that we distribute under the Gnu General Public License. This benchmark can be used as an example of using JDO technology to create a complex biological database and makes it possible for vendors and users of the technology to evaluate the performance of other JDO implementations for similar applications. Conclusions The SigPath JDO benchmark and our discussion of JDO technology in the context of biological databases will be useful to bioinformaticians who design new complex biological databases and aim to create systems that can be ported easily to a variety of database backends.

  13. Iron metabolism in critically ill patients developing anemia of inflammation: a case control study.

    Science.gov (United States)

    Boshuizen, Margit; Binnekade, Jan M; Nota, Benjamin; van de Groep, Kirsten; Cremer, Olaf L; Tuinman, Pieter R; Horn, Janneke; Schultz, Marcus J; van Bruggen, Robin; Juffermans, Nicole P

    2018-05-02

    Anemia occurring as a result of inflammatory processes (anemia of inflammation, AI) has a high prevalence in critically ill patients. Knowledge on changes in iron metabolism during the course of AI is limited, hampering the development of strategies to counteract AI. This case control study aimed to investigate iron metabolism during the development of AI in critically ill patients. Iron metabolism in 30 patients who developed AI during ICU stay was compared with 30 septic patients with a high Hb and 30 non-septic patients with a high Hb. Patients were matched on age and sex. Longitudinally collected plasma samples were analyzed for levels of parameters of iron metabolism. A linear mixed model was used to assess the predictive values of the parameters. In patients with AI, levels of iron, transferrin and transferrin saturation showed an early decrease compared to controls with a high Hb, already prior to the development of anemia. Ferritin, hepcidin and IL-6 levels were increased in AI compared to controls. During AI development, erythroferrone decreased. Differences in iron metabolism between groups were not influenced by APACHE IV score. The results show that in critically ill patients with AI, iron metabolism is already altered prior to the development of anemia. Levels of iron regulators in AI differ from septic controls with a high Hb, irrespective of disease severity. AI is characterized by high levels of hepcidin, ferritin and IL-6 and low levels of iron, transferrin and erythroferrone.

  14. An integrative psychotherapist's account of his focus when treating self-critical patients.

    Science.gov (United States)

    Shahar, Golan

    2013-09-01

    This article presents the factors on which I focus as an integrative psychotherapist when treating self-critical patients. I first describe my personal version of psychotherapy integration. Drawing principally from Wachtel's cyclical psychodynamic model, I also incorporate existential and neurocognitive elements highlighting patients' future-oriented thinking and goal-directed action. I then relate this integrative model to the vexing clinical problem of self-criticism. Finally, I outline three types of interventions I attempt to implement in each session: (1) Multiple-Selves Analysis (MSA); (2) Behavioral Activation (BA), conceptualized integratively; and (3) use of therapist's presence. 2013 APA, all rights reserved

  15. European legislation impedes critical care research and fails to protect patients' rights

    DEFF Research Database (Denmark)

    Berg, Ronan M G; Møller, Kirsten; Rossel, Peter Johannes Hancke

    2011-01-01

    in which a waiver of consent is deemed necessary, the Ethical Review Board should ensure that non-therapeutic risks are minimal, that the research is specifically designed to benefit critically ill patients, and that it cannot be conducted under circumstances where an informed consent can be obtained....... If the European Directive is changed accordingly, this permits clinical trials in critical care settings, while adequate protection from risky non-therapeutic procedures is ensured and exploitation of the patient as an easily accessible research subject is prevented....

  16. Identification and Analysis of Critical Gaps in Nuclear Fuel Cycle Codes Required by the SINEMA Program

    International Nuclear Information System (INIS)

    Miron, Adrian; Valentine, Joshua; Christenson, John; Hawwari, Majd; Bhatt, Santosh; Dunzik-Gougar, Mary Lou; Lineberry, Michael

    2009-01-01

    The current state of the art in nuclear fuel cycle (NFC) modeling is an eclectic mixture of codes with various levels of applicability, flexibility, and availability. In support of the advanced fuel cycle systems analyses, especially those by the Advanced Fuel Cycle Initiative (AFCI), University of Cincinnati in collaboration with Idaho State University carried out a detailed review of the existing codes describing various aspects of the nuclear fuel cycle and identified the research and development needs required for a comprehensive model of the global nuclear energy infrastructure and the associated nuclear fuel cycles. Relevant information obtained on the NFC codes was compiled into a relational database that allows easy access to various codes' properties. Additionally, the research analyzed the gaps in the NFC computer codes with respect to their potential integration into programs that perform comprehensive NFC analysis.

  17. Identification and Analysis of Critical Gaps in Nuclear Fuel Cycle Codes Required by the SINEMA Program

    Energy Technology Data Exchange (ETDEWEB)

    Adrian Miron; Joshua Valentine; John Christenson; Majd Hawwari; Santosh Bhatt; Mary Lou Dunzik-Gougar: Michael Lineberry

    2009-10-01

    The current state of the art in nuclear fuel cycle (NFC) modeling is an eclectic mixture of codes with various levels of applicability, flexibility, and availability. In support of the advanced fuel cycle systems analyses, especially those by the Advanced Fuel Cycle Initiative (AFCI), Unviery of Cincinnati in collaboration with Idaho State University carried out a detailed review of the existing codes describing various aspects of the nuclear fuel cycle and identified the research and development needs required for a comprehensive model of the global nuclear energy infrastructure and the associated nuclear fuel cycles. Relevant information obtained on the NFC codes was compiled into a relational database that allows easy access to various codes' properties. Additionally, the research analyzed the gaps in the NFC computer codes with respect to their potential integration into programs that perform comprehensive NFC analysis.

  18. EFFECTIVENESS OF PROSTAGLANDIN E1 IN THE PAIN MANAGEMENT OF PATIENTS WITH CRITICAL LIMB ISCHAEMIA- A PROSPECTIVE OBSERVATIONAL STUDY

    Directory of Open Access Journals (Sweden)

    John Sajan Kurien

    2017-08-01

    Full Text Available BACKGROUND Critical Limb Ischaemia (CLI was defined for the first time in 1982 by P. R. F. Bell as a manifestation of peripheral artery disease, which describes patient with typical chronic ischaemic rest pain or ischaemic skin ulcers or gangrene.1 This term of CLI should only be used in patients with chronic ischaemic disease defined as presence of recurring rest pain that persists for more than two weeks requiring regular analgesics and with ulceration or gangrene of the foot or toes. These criteria correspond to stage 3 and 4 of Fontaine’s classification of POVD. Observational studies have shown that one year after diagnosis of CLI, 25% of patients experience a major amputation, 25% had died and only 50% survived without requiring a major amputation, though some have rest pain, ulcer or gangrene persisting. The primary goals in treating CLI are to relieve claudication pain and rest pain, to heal the ulcer, to prevent amputation of limbs, to improve quality of life and to prolong survival. The aim of the study is to study the improvement of claudication pain, rest pain and improvement of the level of amputation in patients with diffuse peripheral arterial disease (CLI after administration of PGE1. MATERIALS AND METHODS From June 2013 to November 2014, a total of 45 patients having advanced CLI (Fontaine’s grade III and IV not suitable for angioplasty and stenting or bypass procedures received different courses of PGE1. 20 patients (44.44% received 6 full courses of PGE1,3 patients (6.66% received 5 courses, 5 patients (11.11% received 4 courses, 4 patients (8.8% received 3 courses, 4 patients (8.8% received 2 courses and 9 patients (20% received one course. PGE1 was administered through intravenous infusion (alprostadil 100mcg over 10 hours a day for 5 days in one month (1course. The reduction in claudication and rest pain, improvement in level of amputation and complications were assessed. RESULTS In all cases, there was reduction in pain

  19. The Effect of Learning Styles, Critical Thinking Disposition, and Critical Thinking on Clinical Judgment in Senior Baccalaureate Nursing Students during Human Patient Simulation

    Science.gov (United States)

    McCormick, Kiyan

    2014-01-01

    Simulated learning experiences using high-fidelity human patient simulators (HPS) are increasingly being integrated into baccalaureate nursing programs. Thus, the purpose of this study was to examine relationships among learning style, critical thinking disposition, critical thinking, and clinical judgment during high-fidelity human patient…

  20. Clinical review: optimizing enteral nutrition for critically ill patients - a simple data-driven formula

    Science.gov (United States)

    2011-01-01

    In modern critical care, the paradigm of 'therapeutic nutrition' is replacing traditional 'supportive nutrition'. Standard enteral formulas meet basic macro- and micronutrient needs; therapeutic enteral formulas meet these basic needs and also contain specific pharmaconutrients that may attenuate hyperinflammatory responses, enhance the immune responses to infection, or improve gastrointestinal tolerance. Choosing the right enteral feeding formula may positively affect a patient's outcome; targeted use of therapeutic formulas can reduce the incidence of infectious complications, shorten lengths of stay in the ICU and in the hospital, and lower risk for mortality. In this paper, we review principles of how to feed (enteral, parenteral, or both) and when to feed (early versus delayed start) patients who are critically ill. We discuss what to feed these patients in the context of specific pharmaconutrients in specialized feeding formulations, that is, arginine, glutamine, antioxidants, certain ω-3 and ω-6 fatty acids, hydrolyzed proteins, and medium-chain triglycerides. We summarize current expert guidelines for nutrition in patients with critical illness, and we present specific clinical evidence on the use of enteral formulas supplemented with anti-inflammatory or immune-modulating nutrients, and gastrointestinal tolerance-promoting nutritional formulas. Finally, we introduce an algorithm to help bedside clinicians make data-driven feeding decisions for patients with critical illness. PMID:22136305

  1. The process of death imminence awareness by family members of patients in adult critical care.

    Science.gov (United States)

    Baumhover, Nancy C

    2015-01-01

    A focus on cost-effective quality end-of-life care remains a high priority in adult critical care given an aging population, high prevalence of death, and aggressive technologies used to extend or sustain life in this setting. A Glaserian grounded theory design was used to conduct this retrospective study to yield a substantive middle-range theory. The data source was semistructured interviews with 14 family members of decedents who died 6 to 60 months prior to the study. The purpose of this study was to generate a theory on how family members of patients in adult critical care come to realize that their loved one is dying. The Process of Death Imminence Awareness by Family Members of Patients in Adult Critical Care middle-range theory contained 6 phases: (1) patient's near-death awareness, (2) dying right in front of me, (3) turning points in the patient's condition, (4) no longer the person I once knew, (5) doing right by them, and (6) time to let go. Patient's near-death awareness preceded all other phases, if communicated by the decedent with their family. Then, family members iteratively moved through all the other key phases in the process until a time to let go became evident. This substantive middle-range theory will guide nursing education, practice, and research aimed at providing quality and cost-effective end-of-life care in adult critical care.

  2. The role of infection models and PK/PD modelling for optimising care of critically ill patients with severe infections

    NARCIS (Netherlands)

    Tangden, T.; Martin, V.; Felton, T.W.; Nielsen, E.I.; Marchand, S.; Bruggemann, R.J.M.; Bulitta, J.B.; Bassetti, M.; Theuretzbacher, U.; Tsuji, B.T.; Wareham, D.W.; Friberg, L.E.; Waele, J.J. De; Tam, V.H.; Roberts, J.A.

    2017-01-01

    Critically ill patients with severe infections are at high risk of suboptimal antimicrobial dosing. The pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobials in these patients differ significantly from the patient groups from whose data the conventional dosing regimens were developed.

  3. Comparison of mortality prediction models and validation of SAPS II in critically ill burns patients.

    Science.gov (United States)

    Pantet, O; Faouzi, M; Brusselaers, N; Vernay, A; Berger, M M

    2016-06-30

    Specific burn outcome prediction scores such as the Abbreviated Burn Severity Index (ABSI), Ryan, Belgian Outcome of Burn Injury (BOBI) and revised Baux scores have been extensively studied. Validation studies of the critical care score SAPS II (Simplified Acute Physiology Score) have included burns patients but not addressed them as a cohort. The study aimed at comparing their performance in a Swiss burns intensive care unit (ICU) and to observe whether they were affected by a standardized definition of inhalation injury. We conducted a retrospective cohort study, including all consecutive ICU burn admissions (n=492) between 1996 and 2013: 5 epochs were defined by protocol changes. As required for SAPS II calculation, stays burned (TBSA) and inhalation injury (systematic standardized diagnosis since 2006). Study epochs were compared (χ2 test, ANOVA). Score performance was assessed by receiver operating characteristic curve analysis. SAPS II performed well (AUC 0.89), particularly in burns burns <40% TBSA. Ryan and BOBI scores were least accurate, as they heavily weight inhalation injury.

  4. Variability of linezolid concentrations after standard dosing in critically ill patients: a prospective observational study

    Science.gov (United States)

    2014-01-01

    Introduction Severe infections in intensive care patients show high morbidity and mortality rates. Linezolid is an antimicrobial drug frequently used in critically ill patients. Recent data indicates that there might be high variability of linezolid serum concentrations in intensive care patients receiving standard doses. This study was aimed to evaluate whether standard dosing of linezolid leads to therapeutic serum concentrations in critically ill patients. Methods In this prospective observational study, 30 critically ill adult patients with suspected infections received standard dosing of 600 mg linezolid intravenously twice a day. Over 4 days, multiple serum samples were obtained from each patient, in order to determine the linezolid concentrations by liquid chromatography tandem mass spectrometry. Results A high variability of serum linezolid concentrations was observed (range of area under the linezolid concentration time curve over 24 hours (AUC24) 50.1 to 453.9 mg/L, median 143.3 mg*h/L; range of trough concentrations (Cmin) linezolid concentrations over 24 hours and at single time points (defined according to the literature as AUC24  400 mg*h/L and Cmin > 10 mg/L) were observed for 7 of the patients. Conclusions A high variability of linezolid serum concentrations with a substantial percentage of potentially subtherapeutic levels was observed in intensive care patients. The findings suggest that therapeutic drug monitoring of linezolid might be helpful for adequate dosing of linezolid in critically ill patients. Trial registration Clinicaltrials.gov NCT01793012. Registered 24 January 2013. PMID:25011656

  5. IEEE 802.15.4 Frame Aggregation Enhancement to Provide High Performance in Life-Critical Patient Monitoring Systems.

    Science.gov (United States)

    Akbar, Muhammad Sajjad; Yu, Hongnian; Cang, Shuang

    2017-01-28

    In wireless body area sensor networks (WBASNs), Quality of Service (QoS) provision for patient monitoring systems in terms of time-critical deadlines, high throughput and energy efficiency is a challenging task. The periodic data from these systems generates a large number of small packets in a short time period which needs an efficient channel access mechanism. The IEEE 802.15.4 standard is recommended for low power devices and widely used for many wireless sensor networks applications. It provides a hybrid channel access mechanism at the Media Access Control (MAC) layer which plays a key role in overall successful transmission in WBASNs. There are many WBASN's MAC protocols that use this hybrid channel access mechanism in variety of sensor applications. However, these protocols are less efficient for patient monitoring systems where life critical data requires limited delay, high throughput and energy efficient communication simultaneously. To address these issues, this paper proposes a frame aggregation scheme by using the aggregated-MAC protocol data unit (A-MPDU) which works with the IEEE 802.15.4 MAC layer. To implement the scheme accurately, we develop a traffic patterns analysis mechanism to understand the requirements of the sensor nodes in patient monitoring systems, then model the channel access to find the performance gap on the basis of obtained requirements, finally propose the design based on the needs of patient monitoring systems. The mechanism is initially verified using numerical modelling and then simulation is conducted using NS2.29, Castalia 3.2 and OMNeT++. The proposed scheme provides the optimal performance considering the required QoS.

  6. Feasibility and safety of virtual-reality-based early neurocognitive stimulation in critically ill patients.

    Science.gov (United States)

    Turon, Marc; Fernandez-Gonzalo, Sol; Jodar, Mercè; Gomà, Gemma; Montanya, Jaume; Hernando, David; Bailón, Raquel; de Haro, Candelaria; Gomez-Simon, Victor; Lopez-Aguilar, Josefina; Magrans, Rudys; Martinez-Perez, Melcior; Oliva, Joan Carles; Blanch, Lluís

    2017-12-01

    Growing evidence suggests that critical illness often results in significant long-term neurocognitive impairments in one-third of survivors. Although these neurocognitive impairments are long-lasting and devastating for survivors, rehabilitation rarely occurs during or after critical illness. Our aim is to describe an early neurocognitive stimulation intervention based on virtual reality for patients who are critically ill and to present the results of a proof-of-concept study testing the feasibility, safety, and suitability of this intervention. Twenty critically ill adult patients undergoing or having undergone mechanical ventilation for ≥24 h received daily 20-min neurocognitive stimulation sessions when awake and alert during their ICU stay. The difficulty of the exercises included in the sessions progressively increased over successive sessions. Physiological data were recorded before, during, and after each session. Safety was assessed through heart rate, peripheral oxygen saturation, and respiratory rate. Heart rate variability analysis, an indirect measure of autonomic activity sensitive to cognitive demands, was used to assess the efficacy of the exercises in stimulating attention and working memory. Patients successfully completed the sessions on most days. No sessions were stopped early for safety concerns, and no adverse events occurred. Heart rate variability analysis showed that the exercises stimulated attention and working memory. Critically ill patients considered the sessions enjoyable and relaxing without being overly fatiguing. The results in this proof-of-concept study suggest that a virtual-reality-based neurocognitive intervention is feasible, safe, and tolerable, stimulating cognitive functions and satisfying critically ill patients. Future studies will evaluate the impact of interventions on neurocognitive outcomes. Trial registration Clinical trials.gov identifier: NCT02078206.

  7. Structural empowerment and patient safety culture among registered nurses working in adult critical care units.

    Science.gov (United States)

    Armellino, Donna; Quinn Griffin, Mary T; Fitzpatrick, Joyce J

    2010-10-01

    The aim of the present study was to examine the relationship between structural empowerment and patient safety culture among staff level Registered Nurses (RNs) within adult critical care units (ACCU). There is literature to support the value of RNs' structurally empowered work environments and emerging literature towards patient safety culture; the link between empowerment and patient safety culture is being discovered. A sample of 257 RNs, working within adult critical care of a tertiary hospital in the United States, was surveyed. Instruments included a background data sheet, the Conditions of Workplace Effectiveness and the Hospital Survey on Patient Safety Culture. Structural empowerment and patient safety culture were significantly correlated. As structural empowerment increased so did the RNs' perception of patient safety culture. To foster patient safety culture, nurse leaders should consider providing structurally empowering work environments for RNs. This study contributes to the body of knowledge linking structural empowerment and patient safety culture. Results link structurally empowered RNs and increased patient safety culture, essential elements in delivering efficient, competent, quality care. They inform nursing management of key factors in the nurses' environment that promote safe patient care environments. © 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd.

  8. Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage.

    Science.gov (United States)

    Kumble, Sowmya; Zink, Elizabeth K; Burch, Mackenzie; Deluzio, Sandra; Stevens, Robert D; Bahouth, Mona N

    2017-08-01

    Recent trials have challenged the notion that very early mobility benefits patients with acute stroke. It is unclear how cerebral autoregulatory impairments, prevalent in this population, could be affected by mobilization. The safety of mobilizing patients who have external ventricular drainage (EVD) devices for cerebrospinal fluid diversion and intracranial pressure (ICP) monitoring is another concern due to risk of device dislodgment and potential elevation in ICP. We report hemodynamic and ICP responses during progressive, device-assisted mobility interventions performed in a critically ill patient with intracerebral hemorrhage (ICH) requiring two EVDs. A 55-year-old man was admitted to the Neuroscience Critical Care Unit with an acute thalamic ICH and complex intraventricular hemorrhage requiring placement of two EVDs. Progressive mobilization was achieved using mobility technology devices. Range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using a tilt table. Physiological parameters were recorded before and after the interventions. All mobility interventions were completed without any adverse event or clinically detectable change in the patient's neurological state. Physiological parameters including hemodynamic variables and ICP remained within prescribed goals throughout. Progressive, device-assisted early mobilization was feasible and safe in this critically ill patient with hemorrhagic stroke when titrated by an interdisciplinary team of skilled healthcare professionals. Studies are needed to gain insight into the hemodynamic and neurophysiological responses associated with early mobility in acute stroke to identify subsets of patients who are most likely to benefit from this intervention.

  9. Management of emergency caesarean section in a patient with decompensated critical aortic stenosis

    Directory of Open Access Journals (Sweden)

    Andrew C Leatherbarrow

    2018-01-01

    Full Text Available Increasing numbers of congenital heart disease patients are now surviving to child bearing age. This complex patient cohort present a great challenge to the obstetric anaesthetist and multidisciplinary teams. This report describes a rare case of a patient undergoing emergency caesarean section at 31 weeks gestation due to decompensated critical congenital aortic stenosis. The physiological effects of pregnancy in patients with aortic stenosis are discussed along with principles of managing anaesthesia for caesarean section in the presence of this cardiac lesion.

  10. One Year Survival and Quality of Life in Patients Successfully Discharged From Neuro Critical Care Unit

    Directory of Open Access Journals (Sweden)

    Maryam Poursadeghfard

    2017-09-01

    Discussion: is lower in NICU survivors compared with general population; however, if patients' selection and out of hospital care are done appropriately and continuously, more patients can live independently or even come back to their work. Indeed, it is important to identify patients who benefit more from NICU during decision making for ICU admission. As a result, more efficient rehabilitation could be achieved in the future. However, our conclusions are only related to our ward and do not apply to the total population of critical neurology patients.

  11. The effect of a natural food based tube feeding in minimizing diarrhea in critically ill neurological patients.

    Science.gov (United States)

    Schmidt, Simone B; Kulig, Willibald; Winter, Ralph; Vasold, Antje S; Knoll, Anette E; Rollnik, Jens D

    2018-01-09

    Diarrhea has negative consequences for patients, health care staff and health care costs when neurological patients are fed enterally over long periods. We examined the effect of tube feeding with natural foods in reducing the number of fluid stool evacuations and diarrhea in critically ill neurological patients. A multicenter, prospective, open-label and randomized controlled trial (RCT) was conducted at facilities in Germany specializing in early rehabilitation after neurological damage. Patients of the INTERVENTION group were fed by tube using a commercially available product based on real foods such as milk, meat, carrots, whereas CONTROL patients received a standard tube-feed made of powdered raw materials. All received enteral nutrition over a maximum of 30 days. The number of defecations and the consistency of each stool according to the Bristol Stool Chart (BSC) were monitored. In addition, daily calories, liquids and antibiotic-use were recorded. 118 Patients who had suffered ischemic stroke, intracerebral hemorrhage, traumatic brain injury or hypoxic brain damage and requiring enteral nutrition were enrolled; 59 were randomized to receive the intervention and 59 control feed. There were no significant differences in clinical screening data, age, sex, observation period or days under enteral nutrition between the groups. Patients in both groups received equivalent amount of calories and fluids. In both groups antibiotics were frequently prescribed (69.5% in the INTERVENTION group and 75.7% in the CONTROL group) for 10-11 days on average. In comparison to the CONTROL group, patients in the INTERVENTION group had a significant reduction of the number of watery stool evacuations (type 7 BSC) (minus 61%, IRR = 0.39, p natural based food was effective in reducing the number of watery defecations and diarrhea in long term tube-fed critically ill neurological patients, compared to those fed with standard tube feeding. Copyright © 2018 The Authors. Published

  12. Factors influencing patient compliance with therapeutic regimens in chronic heart failure: A critical incident technique analysis.

    Science.gov (United States)

    Strömberg, A; Broström, A; Dahlström, U; Fridlund, B

    1999-01-01

    The aim of this study was to identify factors influencing compliance with prescribed treatment in patients with chronic heart failure. A qualitative design with a critical incident technique was used. Incidents were collected through interviews with 25 patients with heart failure strategically selected from a primary health care clinic, a medical ward, and a specialist clinic. Two hundred sixty critical incidents were identified in the interviews and 2 main areas emerged in the analysis: inward factors and outward factors. The inward factors described how compliance was influenced by the personality of the patient, the disease, and the treatment. The outward factors described how compliance was influenced by social activities, social relationships, and health care professionals. By identifying the inward and outward factors influencing patients with chronic heart failure, health care professionals can assess whether intervention is needed to increase compliance.

  13. Elizabethkingia meningosepticum: an emerging nosocomial pathogen in a critical patient with septicaemia

    Directory of Open Access Journals (Sweden)

    Vittorio Panetta

    2017-03-01

    Full Text Available We describe a case of sepsis due to the non-fermenter Gram-negative bacillus Elizabethkingia meningosepticum in a patient (M, 23 y.o. hospitalized at the Intensive Care and Critical Care Medicine suffering of a severe neurological disease and acute surgical abdomen, caused by suppurative peritonitis secondary to PEG removal. Two sets of blood cultures were collected at the time of persistent fever. The culture on chocolate and blood agar showed the presence of colonies with characteristic grey-shiny appearance and 1-2 mm in diameter. No growth was instead evident on Mac-Conkey agar. The Gram stain was performed, but the final identification of the isolate as E. meningosepticum was obtained by Vitek2 System, on the basis of growth characteristics, biochemical reaction results, and the peculiar antibiotic susceptibility profile. The identification was also confirmed by Vitek MS MALDI-TOF mass spectrometry instrument (bioMérieux, Marcy-l’Étoile, France. Results of susceptibility testing highlighted the resistance to most antibiotics useful against Gram-negative bacteria and a paradoxical susceptibility to those targeting mainly Gram-positives. The vancomycin and ciprofloxacin combined therapy improved the patient’s conditions, with a complete resolution of the E. meningosepticum bacteraemia. Unfortunately, due to the onset of important clinical and surgical complications, the patient died as a result of a septic shock caused by a MDR Acinetobacter baummannii. The present work underline the importance of correct species identification in the case of E. meningosepticum, a rare bacterium whose unique antimicrobial susceptibility pattern, require an ad hoc therapeutic approach.

  14. Prediction model of critical weight loss in cancer patients during particle therapy.

    Science.gov (United States)

    Zhang, Zhihong; Zhu, Yu; Zhang, Lijuan; Wang, Ziying; Wan, Hongwei

    2018-01-01

    The objective of this study is to investigate the predictors of critical weight loss in cancer patients receiving particle therapy, and build a prediction model based on its predictive factors. Patients receiving particle therapy were enroled between June 2015 and June 2016. Body weight was measured at the start and end of particle therapy. Association between critical weight loss (defined as >5%) during particle therapy and patients' demographic, clinical characteristic, pre-therapeutic nutrition risk screening (NRS 2002) and BMI were evaluated by logistic regression and decision tree analysis. Finally, 375 cancer patients receiving particle therapy were included. Mean weight loss was 0.55 kg, and 11.5% of patients experienced critical weight loss during particle therapy. The main predictors of critical weight loss during particle therapy were head and neck tumour location, total radiation dose ≥70 Gy on the primary tumour, and without post-surgery, as indicated by both logistic regression and decision tree analysis. Prediction model that includes tumour locations, total radiation dose and post-surgery had a good predictive ability, with the area under receiver operating characteristic curve 0.79 (95% CI: 0.71-0.88) and 0.78 (95% CI: 0.69-0.86) for decision tree and logistic regression model, respectively. Cancer patients with head and neck tumour location, total radiation dose ≥70 Gy and without post-surgery were at higher risk of critical weight loss during particle therapy, and early intensive nutrition counselling or intervention should be target at this population. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  15. Validity and reliability of The Johns Hopkins Adapted Cognitive Exam for critically ill patients.

    Science.gov (United States)

    Lewin, John J; LeDroux, Shannon N; Shermock, Kenneth M; Thompson, Carol B; Goodwin, Haley E; Mirski, Erin A; Gill, Randeep S; Mirski, Marek A

    2012-01-01

    To validate The Johns Hopkins Adapted Cognitive Exam designed to assess and quantify cognition in critically ill patients. Prospective cohort study. Neurosciences, surgical, and medical intensive care units at The Johns Hopkins Hospital. One hundred six adult critically ill patients. One expert neurologic assessment and four measurements of the Adapted Cognitive Exam (all patients). Four measurements of the Folstein Mini-Mental State Examination in nonintubated patients only. Adapted Cognitive Exam and Mini-Mental State Examination were performed by 76 different raters. One hundred six patients were assessed, 46 intubated and 60 nonintubated, resulting in 424 Adapted Cognitive Exam and 240 Mini-Mental State Examination measurements. Criterion validity was assessed by comparing Adapted Cognitive Exam with a neurointensivist's assessment of cognitive status (ρ = 0.83, p validity was assessed by comparing Adapted Cognitive Exam with Mini-Mental State Examination in nonintubated patients (ρ = 0.81, p validity was assessed by surveying raters who used both the Adapted Cognitive Exam and Mini-Mental State Examination and indicated the Adapted Cognitive Exam was an accurate reflection of the patient's cognitive status, more sensitive a marker of cognition than the Mini-Mental State Examination, and easy to use. The Adapted Cognitive Exam demonstrated excellent interrater reliability (intraclass correlation coefficient = 0.997; 95% confidence interval 0.997-0.998) and interitem reliability of each of the five subscales of the Adapted Cognitive Exam and Mini-Mental State Examination (Cronbach's α: range for Adapted Cognitive Exam = 0.83-0.88; range for Mini-Mental State Examination = 0.72-0.81). The Adapted Cognitive Exam is the first valid and reliable examination for the assessment and quantification of cognition in critically ill patients. It provides a useful, objective tool that can be used by any member of the interdisciplinary critical care team to support

  16. 42 CFR 3.210 - Required disclosure of patient safety work product to the Secretary.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 1 2010-10-01 2010-10-01 false Required disclosure of patient safety work product... HUMAN SERVICES GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.210 Required disclosure of patient...

  17. Accuracy of bedside glucose measurement from three glucometers in critically ill patients.

    NARCIS (Netherlands)

    Hoedemaekers, C.W.E.; Klein Gunnewiek, J.M.T.; Prinsen, M.A.; Willems, J.L.; Hoeven, J.G. van der

    2008-01-01

    OBJECTIVE: Implementation of strict glucose control in most intensive care units has resulted in increased use of point-of-care glucose devices in the intensive care unit. The aim of this study was to determine the reliability of point-of-care testing glucose meters among critically ill patients

  18. Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients.

    Science.gov (United States)

    Johnson-Obaseki, Stephanie; Veljkovic, Andrea; Javidnia, Hedyeh

    2016-11-01

    In the setting of critical care, the most common indications for tracheostomy include: prolonged intubation, to facilitate weaning from mechanical ventilation, and for pulmonary toileting. In this setting, tracheostomy can be performed either via open surgical or percutaneous technique. Advantages for percutaneous dilatational tracheostomy (PDT) include: simplicity, smaller incision, less tissue trauma, lower incidence of wound infection, lower incidence of peristomal bleeding, decreased morbidity from patient transfer, and cost-effectiveness. Despite many studies comparing surgical tracheostomy (ST) versus PDT, there remains no consensus on which of these techniques minimizes complications in critically ill patients. To provide an updated meta-analysis to answer the following question: Is there a difference in complication rates between ST and PDT in the setting of critically ill patients? Our secondary outcome of interest was to examine the difference in procedure time in the ST versus PDT groups. We conducted a literature search using the following databases: Ovid MEDLINE, Embase, Google Scholar, and Cochrane Database of Systematic Reviews. Studies from 1985 until October 2014 published in French or English languages in peer-reviewed journals were included. With regard to rates of mortality, intraoperative hemorrhage, and postoperative hemorrhage, there was no statistically significant difference between the two techniques. Evaluation of infections rates and operative time, however, revealed a statistically significant difference, favoring PDT over ST. In critically ill patients, PDT appears to be a safe and efficient alternative to open ST. NA Laryngoscope, 126:2459-2467, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

  19. Efficacy and pharmacokinetics of intravenous paracetamol in the critically ill patient

    NARCIS (Netherlands)

    Samson, A.D.; Hunfeld, N.G.; Touw, D.J.; Melief, P.H.

    2009-01-01

    Introduction: Paracetamol (PCM) is a drug with analgesic and antipyretic properties. Despite its frequent use, little is known about its efficacy and pharmacokinetics (PK) when intravenously administered in the critically ill patient. A previous study suggests that therapeutic concentrations are not

  20. Use of Intravenous Fat Emulsions in Adult Critically Ill Patients: Does ...

    African Journals Online (AJOL)

    2017-08-09

    Aug 9, 2017 ... estimated to range from 20% to 60%, with approximately ... This literature review focuses on the administration of different lipid emulsions, ... including the ideal method of assessing energy and protein ... published guidelines for lipid intake in critically ill patients ..... In adults, fat accumulation more often ...

  1. Pharmacokinetic properties of micafungin in critically ill patients diagnosed with invasive candidiasis

    NARCIS (Netherlands)

    Boonstra, J M; van der Elst, K C; Veringa, A; Jongedijk, E M; Brüggemann, R J; Koster, R A; Kampinga, G A; Kosterink, J G; van der Werf, T S; Zijlstra, J G; Touw, D J; Alffenaar, J W C

    2017-01-01

    Background: The estimated attributable mortality rate for invasive candidiasis (IC) in the Intensive Care Unit (ICU) setting varies from 30-40%. Physiological changes in critically ill patients may affect the distribution and elimination of micafungin and therefore dosing adjustments might be

  2. Glutaminemia prognostic significance in critical surgical patients - An analysis of plasma aminogram profile.

    Science.gov (United States)

    Costa, Beatriz Pinto; Martins, Paulo; Verissimo, Carla; Simões, Marta; Tomé, Marisa; Grazina, Manuela; Pimentel, Jorge; Sousa, Francisco Castro

    2017-07-28

    Glutamine depletion is common in the critically-ill patients. Glutaminemia lower than 420 μmol/l has been considered as an independent predictive factor of mortality, but the indications for exogenous glutamine supplementation remain controversial. This study intends to determine the glutaminemia profile in critical surgical patients and to investigate its correlation with the severity indexes and the prognosis. A prospective study of 28 adult critical surgical patients was performed. Plasma amino acid concentrations were quantified, by ion exchange chromatography, at the moment of admission and at the first and third days, and compared with those of 11 reference healthy individuals. Severity indexes and parameters of prognosis were registered. In critical surgical patients, mean glutaminemia at admission was lower than that of control individuals (385.1 ± 123.1 versus515 ± 57.9 μmol/l, p = 0.002) and decreased until the third day (p = 0.042). Prevalence of severe hypoglutaminemia (definition of the indications for glutamine supplementation.

  3. Quality of interhospital transport of critically ill patients: a prospective audit

    NARCIS (Netherlands)

    Ligtenberg, JJM; Arnold, LG; Stienstra, Y; van der Werf, TS; Tulleken, JE; Zijlstra, JG; Meertens, John H. J. M.

    Introduction The aim of transferring a critically ill patient to the intensive care unit (ICU) of a tertiary referral centre is to improve prognosis. The transport itself must be as safe as possible and should not pose additional risks. We performed a prospective audit of the quality of

  4. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: A retrospective study.

    Science.gov (United States)

    Olthof, Laura E; Koekkoek, W A C Kristine; van Setten, Coralien; Kars, Johannes C N; van Blokland, Dick; van Zanten, Arthur R H

    2017-08-10

    Refeeding syndrome comprises metabolic disturbances that occur after the reintroduction of feeding after prolonged fasting. Standard care consists of correcting fluid and electrolytes imbalances. Energy intake during refeeding syndrome is heavily debated. This study addresses the effect of caloric intake on outcome during the management of refeeding syndrome. A retrospective study among critically ill invasive mechanically ventilated patients admitted for >7 days to a medical-surgical ICU. Refeeding syndrome was diagnosed by the occurrence of new onset hypophosphatemia (refeeding syndrome were compared and subgroup analysis on energy intake within the refeeding population was performed for the duration of survival. Of 337 enrolled patients, 124 (36.8%) developed refeeding syndrome and 213 patients (63.2%) maintained normal serum phosphate levels. Between the two groups, no statistical significant differences in clinical outcomes were observed. Within the refeeding syndrome group, a reduced 6-month mortality risk for low caloric intake (Refeeding syndrome is common among prolonged mechanically ventilated critically ill patients, however not predictable by baseline characteristics. Among patients that develop refeeding syndrome low caloric intake was associated with a reduction in 6-month mortality risk. This effect was not seen in patients without refeeding syndrome. Findings support caloric restriction in refeeding syndrome during critical illness. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

  5. Prospective implementation of an algorithm for bedside intravascular ultrasound-guided filter placement in critically ill patients.

    Science.gov (United States)

    Killingsworth, Christopher D; Taylor, Steven M; Patterson, Mark A; Weinberg, Jordan A; McGwin, Gerald; Melton, Sherry M; Reiff, Donald A; Kerby, Jeffrey D; Rue, Loring W; Jordan, William D; Passman, Marc A

    2010-05-01

    Although contrast venography is the standard imaging method for inferior vena cava (IVC) filter insertion, intravascular ultrasound (IVUS) imaging is a safe and effective option that allows for bedside filter placement and is especially advantageous for immobilized critically ill patients by limiting resource use, risk of transportation, and cost. This study reviewed the effectiveness of a prospectively implemented algorithm for IVUS-guided IVC filter placement in this high-risk population. Current evidence-based guidelines were used to create a clinical decision algorithm for IVUS-guided IVC filter placement in critically ill patients. After a defined lead-in phase to allow dissemination of techniques, the algorithm was prospectively implemented on January 1, 2008. Data were collected for 1 year using accepted reporting standards and a quality assurance review performed based on intent-to-treat at 6, 12, and 18 months. As defined in the prospectively implemented algorithm, 109 patients met criteria for IVUS-directed bedside IVC filter placement. Technical feasibility was 98.1%. Only 2 patients had inadequate IVUS visualization for bedside filter placement and required subsequent placement in the endovascular suite. Technical success, defined as proper deployment in an infrarenal position, was achieved in 104 of the remaining 107 patients (97.2%). The filter was permanent in 21 (19.6%) and retrievable in 86 (80.3%). The single-puncture technique was used in 101 (94.4%), with additional dual access required in 6 (5.6%). Periprocedural complications were rare but included malpositioning requiring retrieval and repositioning in three patients, filter tilt >/=15 degrees in two, and arteriovenous fistula in one. The 30-day mortality rate for the bedside group was 5.5%, with no filter-related deaths. Successful placement of IVC filters using IVUS-guided imaging at the bedside in critically ill patients can be established through an evidence-based prospectively

  6. Impact on mortality of prompt admission to critical care for deteriorating ward patients: an instrumental variable analysis using critical care bed strain.

    Science.gov (United States)

    Harris, Steve; Singer, Mervyn; Sanderson, Colin; Grieve, Richard; Harrison, David; Rowan, Kathryn

    2018-05-07

    To estimate the effect of prompt admission to critical care on mortality for deteriorating ward patients. We performed a prospective cohort study of consecutive ward patients assessed for critical care. Prompt admissions (within 4 h of assessment) were compared to a 'watchful waiting' cohort. We used critical care strain (bed occupancy) as a natural randomisation event that would predict prompt transfer to critical care. Strain was classified as low, medium or high (2+, 1 or 0 empty beds). This instrumental variable (IV) analysis was repeated for the subgroup of referrals with a recommendation for critical care once assessed. Risk-adjusted 90-day survival models were also constructed. A total of 12,380 patients from 48 hospitals were available for analysis. There were 2411 (19%) prompt admissions (median delay 1 h, IQR 1-2) and 9969 (81%) controls; 1990 (20%) controls were admitted later (median delay 11 h, IQR 6-26). Prompt admissions were less frequent (p care. In the risk-adjust survival model, 90-day mortality was similar. After allowing for unobserved prognostic differences between the groups, we find that prompt admission to critical care leads to lower 90-day mortality for patients assessed and recommended to critical care.

  7. Measuring the quality of patient-centered care: why patient-reported measures are critical to reliable assessment

    Directory of Open Access Journals (Sweden)

    Tzelepis F

    2015-06-01

    the Lung Information Needs Questionnaire and the EORTC QLQ-INFO25. In relation to physical comfort, only patients can report the severity of physical symptoms and whether medications provide adequate relief. Patient-reported measures that investigate physical comfort include the Pain Care Quality Survey and the Brief Pain Inventory. Using patient-reported measures to regularly measure patient-centered care is critical to identifying areas of health care where improvements are needed.Keywords: patient-centered care, quality of care, quality assessment, patient-reported measures

  8. Patients' experiences and actions when describing pain after surgery--a critical incident technique analysis.

    Science.gov (United States)

    Eriksson, Kerstin; Wikström, Lotta; Fridlund, Bengt; Årestedt, Kristofer; Broström, Anders

    2016-04-01

    Postoperative pain assessment remains a significant problem in clinical care despite patients wanting to describe their pain and be treated as unique individuals. Deeper knowledge about variations in patients' experiences and actions could help healthcare professionals to improve pain management and could increase patients' participation in pain assessments. The aim of this study was, through an examination of critical incidents, to describe patients' experiences and actions when needing to describe pain after surgery. An explorative design involving the critical incident technique was used. Patients from one university and three county hospitals in both urban and rural areas were included. To ensure variation of patients a strategic sampling was made according to age, gender, education and surgery. A total of 25 patients who had undergone orthopaedic or general surgery was asked to participate in an interview, of whom three declined. Pain experiences were described according to two main areas: "Patients' resources when in need of pain assessment" and "Ward resources for performing pain assessments". Patients were affected by their expectations and tolerance for pain. Ability to describe pain could be limited by a fear of coming into conflict with healthcare professionals or being perceived as whining. Furthermore, attitudes from healthcare professionals and their lack of adherence to procedures affected patients' ability to describe pain. Two main areas regarding actions emerged: "Patients used active strategies when needing to describe pain" and "Patients used passive strategies when needing to describe pain". Patients informed healthcare professionals about their pain and asked questions in order to make decisions about their pain situation. Selfcare was performed by distraction and avoiding pain or treating pain by themselves, while others were passive and endured pain or refrained from contact with healthcare professionals due to healthcare professionals

  9. A critical ethnography of doctor-patient interaction in southern Iran.

    Science.gov (United States)

    Sadati, Ahmad Kalateh; Iman, Mohammad Taghi; Lankarani, Kamran Bagheri; Derakhshan, Soghra

    2016-01-01

    Doctor-patient interaction is a subject with ethical ramifications, besides being an important issue in medical sociology. The main goal of this critical study is to explore the interactional experience of hospital admitted patients. For this reason, the study, carried out in an educational hospital in southern Iran, entailed 156 recorded clinical consultations, 920 hours of participant observation, and six focus groups consisting of patients and their families. The research method used is Critical Ethnography, which was introduced by PF Carspecken. The results showed that negative interactional experience was common among the participants. Six related themes were: doctors' inattentiveness; weak interaction; violation of patients' privacy; unjustified pain; long waiting period and ambiguity; and faceless physicians. According to the participants' observations, poor interaction with doctors has led to these negative experiences. The findings showed that doctors were inconsiderate about patients' concerns and due to this, patients were dissatisfied. Theoretically, this form of fragmented collaboration has deep roots in the framework of modern medicine, but in the context of this study, the intensity of the fragmentation between doctors and patients was observed to be intolerable. To solve this problem, models of patient-centredness and narrative medicine are recommended. In addition, the health system should monitor and evaluate the observance of ethics by physicians.

  10. Effect of regional citrate anticoagulation on critical patients with continuous renal replacement therapy

    Directory of Open Access Journals (Sweden)

    Li-Li You

    2016-12-01

    Full Text Available Objective: To investigate the efficacy and safety of regional citrate anticoagulation (RCA in continuous renal replacement therapy (CRRT for critical patients. Methods: A total of 83 critical patients need CRRT in the intensive care units of our hospital from July 2012 to June 2016 were recruited in the study, and the patients were divided into two groups randomly, the patients in observation group received the RCA treatment, and the patients in control group received traditional low molecular heparin anticoagulation. The difference of safety indicators, biochemical indicators, extracorporeal circulation blood coagulation condition and complications in patients were determined between two groups. Results: Compared with control group, the patients in observation group had an elevated level of iCa2+, the level of chloride ion reduced, the use time of filter increased, the bleeding cases reduced, the concentrations of urea nitrogen, creatinine TNF-α , IL-1β, IL-8 and NO were all significantly downregulated, the data have a significant difference (P < 0.05. Conclusions: RCA is a safe and effective method for CRRT in patients with a high risk of bleeding.

  11. Community-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus in critically-ill patients: systematic review

    Directory of Open Access Journals (Sweden)

    Nuria Carballo

    2017-03-01

    Full Text Available Introduction: Community-acquired pneumonia (CAP is associated with high morbidity and mortality rates. Despite methicillin-resistant Staphylococcus aureus (MRSA having often been associated with nosocomial pneumonia, the condition of some MRSA CAP patients is severe enough to warrant their being admitted to ICU. Objective: The purpose of this study is to conduct a systematic review of the literature on antibiotic treatment of MRSA CAP in critically-ill patients. Material and methods: An online search was conducted for locating articles on MRSA CAP in critically ill patients. Relevant publications were identified in PUBMED, the BestPractice database, UpToDate database and the Cochrane Library for articles published in English within the December 2001 - April 2016 time frame. Results: A total of 70 articles were found to have been published, 13 (18.8% having been included and 57 (81.4% excluded. Cohort studies were predominant, having totaled 16 in number (20.7% as compared to one sole cross-sectional study (3.5%. Conclusions: The experience in the treatment of MRSA CAP in patients requiring admission to ICU is quite limited. Vancomycin or linezolid seem to be the treatments of choice for MRSA CAP, although there not be any specific recommendation in this regard. It may be useful to use alternative routes, such as administration via aerosolized antibiotics, continuous infusion or in association with other antibiotics.

  12. Nutritional status plays a crucial role in the mortality of critically ill patients with acute renal failure.

    Science.gov (United States)

    Zhang, Haiyan; Zhang, Xiaodong; Dong, Lei

    2018-02-01

    We aimed to clarify associations between nutritional status and mortality in patients with acute renal failure. De-identified data were obtained from the Medical Information Mart for Intensive Care III database comprising more than 40,000 critical care patients treated at Beth Israel Deaconess Medical Centerbetween 2001 and 2012. Weight loss and body mass index criteria were used to define malnutrition. Data of 193 critically ill patients with acute renal failure were analyzed, including demographics, nutrition intervention, laboratory results, and disease severity. Main outcomes were in-hospital and 1-year mortality. The 1-year mortality was significantly higher in those with malnutrition than in those without malnutrition (50.0% vs 29.3%, p=0.010), but differences in in-hospital survival were not significant (p=0.255). Significant differences in mortality were found between those with malnutrition and without starting at the 52nd day after intensive care unit (ICU) discharge (p=0.036). No significant differences were found between men and women with malnutrition in in-hospital mortality (p=0.949) and 1-year mortality (p=0.051). Male patients requiring intervention with blood products/colloid supplements had greater risk of 1-year mortality, but without statistical significance. Nutritional status is a predictive factor for mortality among critically ill patients with acute renal failure, particularly 1-year mortality after ICU discharge. © American Federation for Medical Research (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  13. Percutaneous cholecystostomy in critically ill patients with acute cholecystitis: Complications and late outcome

    International Nuclear Information System (INIS)

    Atar, E.; Bachar, G.N.; Berlin, S.; Neiman, C.; Bleich-Belenky, E.; Litvin, S.; Knihznik, M.; Belenky, A.; Ram, E.

    2014-01-01

    Aim: To evaluate the outcome of percutaneous cholecystostomy in critically ill patients with acute cholecystitis. Materials and methods: The study group included critically ill patients who underwent percutaneous cholecystostomy for acute cholecystitis at a tertiary medical centre in 2007–2011. Data on complications, morbidities, surgical outcome, and imaging findings were collected from the medical files and radiology information system. Results: There were 48 women (59.3%) and 33 men (40.7%), with a median age of 82 years (range 47–99 years). Seventy-one (88%) had calculous cholecystitis and 10 (12%), acalculous cholecystitis. The drain was successfully inserted in all cases with no immediate major procedural complications. Fifteen patients (18.5%) died in-hospital within 30 days, mainly (93%) due to septic shock (14/15), another 20 patients (24.7%) died during the study period of unrelated co-morbidities. Of the remaining 46 patients, 36 (78.2%) had surgical cholecystectomies. In patients with acalculous cholecystitis, the drain was removed after cessation of symptoms. Transcystic cholangiography identified five patients with additional stones in the common bile duct. They were managed by pushing the stones into the duodenum via the cystostomy access, sparing them the need for surgical exploration. Conclusions: Early percutaneous gallbladder drainage is safe and effective in critically ill patients in the acute phase of cholecystitis, with a high technical success rate. Surgical results in survivors are better than reported in patients treated surgically without drainage. Bile duct stones can be eliminated without creating an additional access

  14. Program Director Perceptions of Surgical Resident Training and Patient Care under Flexible Duty Hour Requirements.

    Science.gov (United States)

    Saadat, Lily V; Dahlke, Allison R; Rajaram, Ravi; Kreutzer, Lindsey; Love, Remi; Odell, David D; Bilimoria, Karl Y; Yang, Anthony D

    2016-06-01

    The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial was a national, cluster-randomized, pragmatic, noninferiority trial of 117 general surgery programs, comparing standard ACGME resident duty hour requirements ("Standard Policy") to flexible, less-restrictive policies ("Flexible Policy"). Participating program directors (PDs) were surveyed to assess their perceptions of patient care, resident education, and resident well-being during the study period. A survey was sent to all PDs of the general surgery residency programs participating in the FIRST trial (N = 117 [100% response rate]) in June and July 2015. The survey compared PDs' perceptions of the duty hour requirements in their arm of the FIRST trial during the study period from July 1, 2014 to June 30, 2015. One hundred percent of PDs in the Flexible Policy arm indicated that residents used their additional flexibility in duty hours to complete operations they started or to stabilize a critically ill patient. Compared with the Standard Policy arm, PDs in the Flexible Policy arm perceived a more positive effect of duty hours on the safety of patient care (68.9% vs 0%; p care (98.3% vs 0%; p care (71.8%), continuity of care (94.0%), quality of resident education (83.8%), and resident well-being (55.6%) would be improved with a hypothetical permanent adoption of more flexible duty hours. Program directors involved in the FIRST trial perceived improvements in patient safety, continuity of care, and multiple aspects of resident education and well-being with flexible duty hours. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  15. Surrogate decision makers' perspectives on preventable breakdowns in care among critically ill patients: A qualitative study.

    Science.gov (United States)

    Fisher, Kimberly A; Ahmad, Sumera; Jackson, Madeline; Mazor, Kathleen M

    2016-10-01

    To describe surrogate decision makers' (SDMs) perspectives on preventable breakdowns in care among critically ill patients. We screened 70 SDMs of critically ill patients for those who identified a preventable breakdown in care, defined as an event where the SDM believes something "went wrong", that could have been prevented, and resulted in harm. In-depth interviews were conducted with SDMs who identified an eligible event. 32 of 70 participants (46%) identified at least one preventable breakdown in care, with a total of 75 discrete events. Types of breakdowns involved medical care (n=52), communication (n=59), and both (n=40). Four additional breakdowns were related to problems with SDM bedside access to the patient. Adverse consequences of breakdowns included physical harm, need for additional medical care, emotional distress, pain, suffering, loss of trust, life disruption, impaired decision making, and financial expense. 28 of 32 SDMs raised their concerns with clinicians, yet only 25% were satisfactorily addressed. SDMs of critically ill patients frequently identify preventable breakdowns in care which result in harm. An in-depth understanding of the types of events SDMs find problematic and the associated harms is an important step towards improving the safety and patient-centeredness of healthcare. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  16. Blood glucose response to rescue dextrose in hypoglycemic, critically ill patients receiving an insulin infusion.

    Science.gov (United States)

    Murthy, Manasa S; Duby, Jeremiah J; Parker, Patricia L; Durbin-Johnson, Blythe P; Roach, Denise M; Louie, Erin L

    2015-08-01

    There is inadequate guidance for clinicians on selection of the optimal dextrose 50% (D50W) dose for hypoglycemia correction in critically ill patients. The purpose of this study was to determine the blood glucose (BG) response to D50W in critically ill patients. A retrospective analysis was conducted of critically ill patients who received D50W for hypoglycemia (BG 150 mg/dL), resulting in a 6.8% rate of overcorrection; 49% of hypoglycemic episodes (230/470) corrected to a BG >100 mg/dL. A multivariable GEE analysis showed a significantly higher BG response in participants with diabetes (0.002) but a lower response in those with recurrent hypoglycemia (P = 0.049). The response to D50W increased with increasinginsulin infusion rate (P = 0.022). Burn patients experienced a significantly larger BG response compared with cardiac, medical, neurosurgical, or surgical patients. The observed median effect of D50W on BG was approximately 4 mg/dL per gram of D50W administered. Application of these data may aid in rescue protocol development that may reduce glucose variability associated with hypoglycemic episodes and the correction. © The Author(s) 2015.

  17. Using Six Sigma methodology to reduce patient transfer times from floor to critical-care beds.

    Science.gov (United States)

    Silich, Stephan J; Wetz, Robert V; Riebling, Nancy; Coleman, Christine; Khoueiry, Georges; Abi Rafeh, Nidal; Bagon, Emma; Szerszen, Anita

    2012-01-01

    In response to concerns regarding delays in transferring critically ill patients to intensive care units (ICU), a quality improvement project, using the Six Sigma process, was undertaken to correct issues leading to transfer delay. To test the efficacy of a Six Sigma intervention to reduce transfer time and establish a patient transfer process that would effectively enhance communication between hospital caregivers and improve the continuum of care for patients. The project was conducted at a 714-bed tertiary care hospital in Staten Island, New York. A Six Sigma multidisciplinary team was assembled to assess areas that needed improvement, manage the intervention, and analyze the results. The Six Sigma process identified eight key steps in the transfer of patients from general medical floors to critical care areas. Preintervention data and a root-cause analysis helped to establish the goal transfer-time limits of 3 h for any individual transfer and 90 min for the average of all transfers. The Six Sigma approach is a problem-solving methodology that resulted in almost a 60% reduction in patient transfer time from a general medical floor to a critical care area. The Six Sigma process is a feasible method for implementing healthcare related quality of care projects, especially those that are complex. © 2011 National Association for Healthcare Quality.

  18. (1, 3)-β-D-glucan assay for diagnosing invasive fungal infections in critically ill patients with hematological malignancies.

    Science.gov (United States)

    Azoulay, Elie; Guigue, Nicolas; Darmon, Michael; Mokart, Djamel; Lemiale, Virginie; Kouatchet, Achille; Mayaux, Julien; Vincent, François; Nyunga, Martine; Bruneel, Fabrice; Rabbat, Antoine; Bretagne, Stéphane; Lebert, Christine; Meert, Anne-Pascale; Benoit, Dominique; Pene, Frédéric

    2016-04-19

    Invasive fungal infections (IFIs) are life-threatening complications of hematological malignancies that must be diagnosed early to allow effective treatment. Few data are available on the performance of serum (1-3)-β-D-glucan (BG) assays for diagnosing IFI in patients with hematological malignancies admitted to the intensive care unit (ICU). In this study, 737 consecutive patients with hematological malignancies admitted to 17 ICUs routinely underwent a BG assay at ICU admission. IFIs were diagnosed using standard criteria applied by three independent specialists. Among the 737 patients, 439 (60%) required mechanical ventilation and 273 (37%) died before hospital discharge. Factors known to alter BG concentrations were identified in most patients. IFIs were documented in 78 (10.6%) patients (invasive pulmonary aspergillosis, n = 54; Pneumocystis jirovecii pneumonia, n = 13; candidemia, n = 13; and fusarium infections, n = 3). BG concentrations (pg/mL) were higher in patients with than without IFI (144 (77-510) vs. 50 (30-125), 80 pg/mL were IFI, admission SOFA score, autologous bone-marrow or hematopoietic stem-cell transplantation, and microbiologically documented bacterial infection. In conclusion, in unselected critically ill hematology patients with factors known to affect serum BG, this biomarker showed only moderate diagnostic performance and rarely detected IFI. However, the negative predictive value was high. Studies are needed to assess whether a negative BG test indicates that antifungal de-escalation is safe.

  19. Sequential compression biomechanical device in patients with critical limb ischemia and nonreconstructible peripheral vascular disease.

    LENUS (Irish Health Repository)

    Sultan, Sherif

    2011-08-01

    Critical limb ischemia (CLI) patients who are unsuitable for intervention face the dire prospect of primary amputation. Sequential compression biomechanical device (SCBD) therapy provides a limb salvage option for these patients. This study assessed the outcome of SCBD in severe CLI patients who otherwise would face an amputation. Primary end points were limb salvage and 30-day mortality. Secondary end points were hemodynamic outcomes (increase in popliteal artery flow and toe pressure), ulcer healing, quality-adjusted time without symptoms of disease or toxicity of treatment (Q-TwiST), and cost-effectiveness.

  20. Adopting a critical intercultural communication approach to understanding health professionals' encounter with ethnic minority patients

    DEFF Research Database (Denmark)

    Jæger, Kirsten

    2012-01-01

    professionals and their approach to ethnic minority patients influence the accessibility of healthcare and availability of health prevention resources of ethnic minorities. When adapting healthcare practice to minority patients, healthcare professionals draw on insights from intercultural communication...... and anthropology. However, within these disciplines such concepts as culture, interculturality, and ethnicity are subjected to contestation due to co-existing, but competing paradigms. This paper demonstrates how healthcare discourses on ethnic minority patients reflect shifting intercultural communication...... paradigms and advocates the adoption of a critical intercultural communication approach in relation to ethnicity-based health inequality....

  1. Effects of levosimendan for low cardiac output syndrome in critically ill patients

    DEFF Research Database (Denmark)

    Koster, Geert; Wetterslev, Jørn; Gluud, Christian

    2015-01-01

    PURPOSE: To assess the benefits and harms of levosimendan for low cardiac output syndrome in critically ill patients. METHODS: We conducted a systematic review with meta-analyses and trial sequential analyses (TSA) of randomised clinical trials comparing levosimendan with any type of control. Two...... in the systematic review and 49 trials (6,688 patients) in the meta-analysis. One trial had low risk of bias and nine trials (2,490 patients) were considered lower risk of bias. Trials compared levosimendan with placebo, control interventions, and other inotropes. Pooling all trials including heterogenous...

  2. Understanding Response Rates to Surveys About Family Members' Psychological Symptoms After Patients' Critical Illness.

    Science.gov (United States)

    Long, Ann C; Downey, Lois; Engelberg, Ruth A; Nielsen, Elizabeth; Ciechanowski, Paul; Curtis, J Randall

    2017-07-01

    Achieving adequate response rates from family members of critically ill patients can be challenging, especially when assessing psychological symptoms. To identify factors associated with completion of surveys about psychological symptoms among family members of critically ill patients. Using data from a randomized trial of an intervention to improve communication between clinicians and families of critically ill patients, we examined patient-level and family-level predictors of the return of usable surveys at baseline, three months, and six months (n = 181, 171, and 155, respectively). Family-level predictors included baseline symptoms of psychological distress, decisional independence preference, and attachment style. We hypothesized that family with fewer symptoms of psychological distress, a preference for less decisional independence, and secure attachment style would be more likely to return questionnaires. We identified several predictors of the return of usable questionnaires. Better self-assessed family member health status was associated with a higher likelihood and stronger agreement with a support-seeking attachment style with a lower likelihood, of obtaining usable baseline surveys. At three months, family-level predictors of return of usable surveys included having usable baseline surveys, status as the patient's legal next of kin, and stronger agreement with a secure attachment style. The only predictor of receipt of surveys at six months was the presence of usable surveys at three months. We identified several predictors of the receipt of surveys assessing psychological symptoms in family of critically ill patients, including family member health status and attachment style. Using these characteristics to inform follow-up mailings and reminders may enhance response rates. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

  3. Adrenal insufficiency in critical patients: New ethiopathogenic concepts and therapeutic implications.

    Science.gov (United States)

    Mateos Moreno, Laura; Palacios García, Nuria; Estrada García, Francisco Javier

    2017-12-01

    Recently, there have been advances in understanding of the changes that occur in the hypothalamic-pituitary-adrenal axis during the different stages of critical disease. Such advances have led to a paradigm change, so that the aforementioned adaptations are no longer considered the result of adrenal axis activation, but a consequence of decreased cortisol metabolism illness. Knowledge of this new pathophysiological bases should lead to reconsider the diagnosis and treatment of adrenal insufficiency in critically ill patients, a condition poorly understood to date. Copyright © 2017 SEEN y SED. Publicado por Elsevier España, S.L.U. All rights reserved.

  4. Activated protein synthesis and suppressed protein breakdown signaling in skeletal muscle of critically ill patients

    DEFF Research Database (Denmark)

    Jespersen, Jakob G; Nedergaard, Anders; Reitelseder, Søren

    2011-01-01

    Skeletal muscle mass is controlled by myostatin and Akt-dependent signaling on mammalian target of rapamycin (mTOR), glycogen synthase kinase 3β (GSK3β) and forkhead box O (FoxO) pathways, but it is unknown how these pathways are regulated in critically ill human muscle. To describe factors invol...... involved in muscle mass regulation, we investigated the phosphorylation and expression of key factors in these protein synthesis and breakdown signaling pathways in thigh skeletal muscle of critically ill intensive care unit (ICU) patients compared with healthy controls....

  5. Activated protein synthesis and suppressed protein breakdown signaling in skeletal muscle of critically ill patients

    DEFF Research Database (Denmark)

    Jespersen, Jakob G; Nedergaard, Anders; Reitelseder, Søren

    2011-01-01

    Skeletal muscle mass is controlled by myostatin and Akt-dependent signaling on mammalian target of rapamycin (mTOR), glycogen synthase kinase 3ß (GSK3ß) and forkhead box O (FoxO) pathways, but it is unknown how these pathways are regulated in critically ill human muscle. To describe factors invol...... involved in muscle mass regulation, we investigated the phosphorylation and expression of key factors in these protein synthesis and breakdown signaling pathways in thigh skeletal muscle of critically ill intensive care unit (ICU) patients compared with healthy controls....

  6. SU-F-BRD-14: Dose Weighted Linear Energy Transfer Analysis of Critical Structures in Proton Therapy of Pediatric Brain Tumor Patients

    Energy Technology Data Exchange (ETDEWEB)

    Pirlepesov, F.; Shin, J.; Moskvin, V. P.; Gray, J.; Hua, C.; Gajjar, A.; Krasin, M. J.; Merchant, T. E.; Farr, J. B. [St. Jude Children’s Research Hospital, Memphis, TN (United States); Li, Z. [University of Florida Proton Therapy Institute, Jacksonville, FL (United States)

    2015-06-15

    Purpose: Dose weighted Linear Energy Transfer (LETd) analysis of critical structures may be useful in understanding the side effects of the proton therapy. The objective is to analyze the differences between LETd and dose distributions in brain tumor patients receiving double scattering proton therapy, to quantify LETd variation in critical organs, and to identify beam arrangements contributing to high LETd in critical organs. Methods: Monte Carlo simulations of 9 pediatric brain tumor patients were performed. The treatment plans were reconstructed with the TOPAS Monte Carlo code to calculate LETd and dose. The beam data were reconstructed proximal to the aperture of the double scattering nozzle. The dose and LETd to target and critical organs including brain stem, optic chiasm, lens, optic nerve, pituitary gland, and hypothalamus were computed for each beam. Results: Greater variability in LETd compared to dose was observed in the brainstem for patients with a variety of tumor types including 5 patients with tumors located in the posterior fossa. Approximately 20%–44% brainstem volume received LETd of 5kev/µm or greater from beams within gantry angles 180°±30° for 5 patients treated with a 3 beam arrangement. Critical organs received higher LETd when located in the vicinity of the beam distal edge. Conclusion: This study presents a novel strategy in the evaluation of the proton treatment impact on critical organs. While the dose to critical organs is confined below the required limits, the LETd may have significant variation. Critical organs in the vicinity of beam distal edge receive higher LETd and depended on beam arrangement, e.g. in posterior fossa tumor treatment, brainstem receive higher LETd from posterior-anterior beams. This study shows importance of the LETd analysis of the radiation impact on the critical organs in proton therapy and may be used to explain clinical imaging observations after therapy.

  7. Factors affecting experiences of intensive care patients in Turkey: patient outcomes in critical care setting.

    Science.gov (United States)

    Demir, Yurdanur; Korhan, Esra Akin; Eser, Ismet; Khorshid, Leyla

    2013-07-01

    To determine the factors affecting a patient's intensive care experience. The descriptive study was conducted at an intensive care unit in the Aegean Region of Turkey, and comprised 158 patients who spent at least 48 hours at the unit between June and November 2009. A questionnaire form and the Intensive Care Experience Scale were used as data collection tools. SPSS 11.5 was used for statistical analysis of the data. Of the total, 86 (54.4%) patients related to the surgical unit, while 72 (45.5%) spent time at the intensive care unit. Most of the subjects (n=113; 71.5%) reported that they constantly experienced pain during hospitalisation. Patients receiving mechanical ventilation support and patients reporting no pain had significantly higher scores on the intensive care experience scale. Patients who reported pain remembered their experiences less than those having no pain. Interventions are needed to make the experiences of patients in intensive care more positive.

  8. Dual agency in critical care nursing: Balancing responsibilities towards colleagues and patients.

    Science.gov (United States)

    Trapani, Josef; Scholes, Julie; Cassar, Maria

    2016-10-01

    To explore critical care nurses' decisions to seek help from doctors. Despite their well-documented role in improving critically ill patients' outcomes, research indicates that nurses rarely take decisions about patients' treatment modalities on their own and constantly need to seek advice or authorization for their clinical decisions, even for protocol-guided actions. However, research around the factors related to, and the actual process of, such referrals is limited. A grounded theory study, underpinned by a symbolic interactionist perspective. Data collection took place in a general intensive care unit between 2010 - 2012 and involved: 20 hours of non-participant and 50 hours of participant observation; ten informal and ten formal interviews; and two focus groups with ten nurses, selected by purposive and theoretical sampling. Data analysis was guided by the dimensional analysis approach to generating grounded theory. Nurses' decisions to seek help from doctors involve weighing up several occasionally conflicting motivators. A central consideration is that of balancing their moral obligation to safeguard patients' interests with their duty to respect doctors' authority. Subsequently, nurses end up in a position of dual agency as they need to concurrently act as an agent to medical practitioners and patients. Nurses' dual agency relationship with patients and doctors may deter their moral obligation of keeping patients' interest as their utmost concern. Nurse leaders and educators should, therefore, enhance nurses' assertiveness, courage and skills to place patients' interest at the forefront of all their actions and interactions. © 2016 John Wiley & Sons Ltd.

  9. Delirium and Catatonia in Critically Ill Patients: The Delirium and Catatonia Prospective Cohort Investigation.

    Science.gov (United States)

    Wilson, Jo E; Carlson, Richard; Duggan, Maria C; Pandharipande, Pratik; Girard, Timothy D; Wang, Li; Thompson, Jennifer L; Chandrasekhar, Rameela; Francis, Andrew; Nicolson, Stephen E; Dittus, Robert S; Heckers, Stephan; Ely, E Wesley

    2017-11-01

    Catatonia, a condition characterized by motor, behavioral, and emotional changes, can occur during critical illness and appear as clinically similar to delirium, yet its management differs from delirium. Traditional criteria for medical catatonia preclude its diagnosis in delirium. Our objective in this investigation was to understand the overlap and relationship between delirium and catatonia in ICU patients and determine diagnostic thresholds for catatonia. Convenience cohort, nested within two ongoing randomized trials. Single academic medical center in Nashville, TN. We enrolled 136 critically ill patients on mechanical ventilation and/or vasopressors, randomized to two usual care sedation regimens. Patients were assessed for delirium and catatonia by independent and masked personnel using Confusion Assessment Method for the ICU and the Bush Francis Catatonia Rating Scale mapped to Diagnostic Statistical Manual 5 criterion A for catatonia. Of 136 patients, 58 patients (43%) had only delirium, four (3%) had only catatonia, 42 (31%) had both, and 32 (24%) had neither. In a logistic regression model, more catatonia signs were associated with greater odds of having delirium. For example, patient assessments with greater than or equal to three Diagnostic Statistical Manual 5 symptoms (75th percentile) had, on average, 27.8 times the odds (interquartile range, 12.7-60.6) of having delirium compared with patient assessments with zero Diagnostic Statistical Manual 5 criteria (25th percentile) present (p delirium, these data prompt reconsideration of Diagnostic Statistical Manual 5 criteria for "Catatonic Disorder Due to Another Medical Condition" that preclude diagnosing catatonia in the presence of delirium.

  10. Acute myocardial infarctation in patients with critical ischemia underwent lower limb revascularization

    Directory of Open Access Journals (Sweden)

    Esdras Marques Lins

    2013-12-01

    Full Text Available BACKGROUND: Atherosclerosis is the main cause of peripheral artery occlusive disease (PAOD of the lower limbs. Patients with PAOD often also have obstructive atherosclerosis in other arterial sites, mainly the coronary arteries. This means that patients who undergo infrainguinal bypass to treat critical ischemia have a higher risk of AMI. There are, however, few reports in the literature that have assessed this risk properly. OBJECTIVE: The aim of this study was to determine the incidence of acute myocardial infarction in patients who underwent infrainguinal bypass to treat critical ischemia of the lower limbs caused by PAOD. MATERIAL AND METHODS: A total of 64 patients who underwent 82 infrainguinal bypass operations, from February 2011 to July 2012 were studied. All patients had electrocardiograms and troponin I blood assays during the postoperative period (within 72 hours. RESULTS: There were abnormal ECG findings and elevated blood troponin I levels suggestive of AMI in five (6% of the 82 operations performed. All five had conventional surgery. The incidence of AMI as a proportion of the 52 conventional surgery cases was 9.6%. Two patients died. CONCLUSION: There was a 6% AMI incidence among patients who underwent infrainguinal bypass due to PAOD. Considering only cases operated using conventional surgery, the incidence of AMI was 9.6%.

  11. Dealing with aggressive methadone patients in community pharmacy: a critical incident study.

    Science.gov (United States)

    Irwin, Amy; Laing, Christianne; Mearns, Kathryn

    2012-01-01

    Community pharmacists are an important link between methadone patients and the health service in the United Kingdom. However, many pharmacists feel ill prepared to deal with methadone patients, with aggressive behavior a particular concern. To assess the perceived impact of methadone patient aggression on pharmacy practice. Sixteen registered pharmacists with a minimum of 3 years' work experience were recruited from within 3 Scottish health boards. Critical incident interviews were conducted to assess pharmacist behavior during an interaction with an aggressive methadone patient. Factors considered by pharmacists to have a negative impact on an interaction with an aggressive methadone patient included intoxication of the patient, the presence of a new or an inexperienced pharmacist, and a restricted time frame for dispensing methadone. Positive factors when dealing with aggressive patients were authoritative behavior by the pharmacist, a separate dispensing area for methadone patients, or a solid counter and a positive relationship between pharmacist and patient. Aggression from methadone patients is a risk when dispensing methadone. However, action can be taken by the pharmacist to minimize the impact of that aggression on pharmacy practice. The provision of further training and support, particularly to inexperienced pharmacists, could further reduce the negative impact of patient aggression. The present study indicates that such training could be based on nontechnical skills to strengthen current leadership and teamwork behaviors. Copyright © 2012 Elsevier Inc. All rights reserved.

  12. The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

    NARCIS (Netherlands)

    Azoulay, E.; Schellongowski, P.; Darmon, M.; Bauer, P.R.; Benoit, D.; Depuydt, P.; Divatia, J.V.; Lemiale, V.; Vliet, M. van; Meert, A.P.; Mokart, D.; Pastores, S.M.; Perner, A.; Pene, F.; Pickkers, P.; Puxty, K.A.; Vincent, F.; Salluh, J.; Soubani, A.O.; Antonelli, M.; Staudinger, T.; Bergwelt-Baildon, M. von; Soares, M.

    2017-01-01

    Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-code

  13. The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

    DEFF Research Database (Denmark)

    Azoulay, Elie; Schellongowski, Peter; Darmon, Michael

    2017-01-01

    Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-co...

  14. Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients.

    Science.gov (United States)

    Corl, Keith A; George, Naomi R; Romanoff, Justin; Levinson, Andrew T; Chheng, Darin B; Merchant, Roland C; Levy, Mitchell M; Napoli, Anthony M

    2017-10-01

    Measurement of inferior vena cava collapsibility (cIVC) by point-of-care ultrasound (POCUS) has been proposed as a viable, non-invasive means of assessing fluid responsiveness. We aimed to determine the ability of cIVC to identify patients who will respond to additional intravenous fluid (IVF) administration among spontaneously breathing critically-ill patients. Prospective observational trial of spontaneously breathing critically-ill patients. cIVC was obtained 3cm caudal from the right atrium and IVC junction using POCUS. Fluid responsiveness was defined as a≥10% increase in cardiac index following a 500ml IVF bolus; measured using bioreactance (NICOM™, Cheetah Medical). cIVC was compared with fluid responsiveness and a cIVC optimal value was identified. Of the 124 participants, 49% were fluid responders. cIVC was able to detect fluid responsiveness: AUC=0.84 [0.76, 0.91]. The optimum cutoff point for cIVC was identified as 25% (LR+ 4.56 [2.72, 7.66], LR- 0.16 [0.08, 0.31]). A cIVC of 25% produced a lower misclassification rate (16.1%) for determining fluid responsiveness than the previous suggested cutoff values of 40% (34.7%). IVC collapsibility, as measured by POCUS, performs well in distinguishing fluid responders from non-responders, and may be used to guide IVF resuscitation among spontaneously breathing critically-ill patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  15. Endocrine emergencies in critically ill patients: Challenges in diagnosis and management

    Directory of Open Access Journals (Sweden)

    Sukhminder Jit Singh Bajwa

    2012-01-01

    Full Text Available Endocrine emergencies pose unique challenges for the attending intensivist while managing critically ill patients. Besides taking care of primary disease state, one has to divert an equal attention to the possible associated endocrinopathies also. One of the common reasons for inability to timely diagnose an endocrinal failure in critically ill patients being the dominance of other severe systemic diseases and their clinical presentation. The timely diagnosis and administration of therapeutic interventions for these endocrine disorders can improve the outcome in critically ill patients. The timely diagnosis and administration of timely therapeutics in common endocrine disorders like severe thyroid disease, acute adrenal insufficiency and diabetic ketoacidosis significantly influence the outcome and prognosis. Careful evaluation of clinical history and a high degree of suspicion are the corner stone to diagnose such problems. Aggressive management of the patient is equally important as the complications are devastating and can prove highly fatal. The present article is an attempt to review some of the common endocrine emergencies in intensive care unit and the challenges associated with their diagnosis and management.

  16. INTRA-ABDOMINAL HYPERTENSION AS A RISK FACTOR FOR ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS

    Directory of Open Access Journals (Sweden)

    Sreelatha

    2016-05-01

    Full Text Available BACKGROUND AND AIMS Increased intra-abdominal pressure (IAP, also referred to as intra-abdominal hypertension (IAH, affects organ function in critically ill patients. The prevalence of IAH is between 32% - 65% in intensive care units. Normal IAP is ≈ 5–7 mmHg. According to WSACS definition, IAH = IAP ≥12 mmHg and is divided into 4 grades. They are Grade I (12-15 mmHg, Grade II (16-20 mmHg, Grade III (21-25 mmHg, Grade IV (>25 mmHg. Transvesical measurement of IAP currently is the most popular technique. Several systems with or without the need for electronic equipment are available that allow IAP measurement. The aim is to study the incidence of IAH in critically ill patients, to assess the risk factors for development of IAH, to study the role of IAH as a risk factor for Acute Kidney Injury (AKI, to assess the role of IAH as a risk factor for increased (Intensive Care Unit ICU mortality. SUBJECTS AND METHODS This is a prospective observational study. Study period was six months. The study included 52 patients admitted to Medical ICU in Government Medical College, Kozhikode, Kerala. RESULTS AND CONCLUSION There was a very high incidence of intra-abdominal hypertension in critically ill patients. IAH was significantly associated with risk factors like sepsis, mechanical ventilation, pancreatitis, capillary leak, ascites, cumulative fluid balance and cirrhosis. IAH is an independent risk factor for development of acute kidney injury. IAH is an independent predictor of mortality in critically ill patients.

  17. Activated protein synthesis and suppressed protein breakdown signaling in skeletal muscle of critically ill patients.

    Directory of Open Access Journals (Sweden)

    Jakob G Jespersen

    Full Text Available BACKGROUND: Skeletal muscle mass is controlled by myostatin and Akt-dependent signaling on mammalian target of rapamycin (mTOR, glycogen synthase kinase 3β (GSK3β and forkhead box O (FoxO pathways, but it is unknown how these pathways are regulated in critically ill human muscle. To describe factors involved in muscle mass regulation, we investigated the phosphorylation and expression of key factors in these protein synthesis and breakdown signaling pathways in thigh skeletal muscle of critically ill intensive care unit (ICU patients compared with healthy controls. METHODOLOGY/PRINCIPAL FINDINGS: ICU patients were systemically inflamed, moderately hyperglycemic, received insulin therapy, and showed a tendency to lower plasma branched chain amino acids compared with controls. Using Western blotting we measured Akt, GSK3β, mTOR, ribosomal protein S6 kinase (S6k, eukaryotic translation initiation factor 4E binding protein 1 (4E-BP1, and muscle ring finger protein 1 (MuRF1; and by RT-PCR we determined mRNA expression of, among others, insulin-like growth factor 1 (IGF-1, FoxO 1, 3 and 4, atrogin1, MuRF1, interleukin-6 (IL-6, tumor necrosis factor α (TNF-α and myostatin. Unexpectedly, in critically ill ICU patients Akt-mTOR-S6k signaling was substantially higher compared with controls. FoxO1 mRNA was higher in patients, whereas FoxO3, atrogin1 and myostatin mRNAs and MuRF1 protein were lower compared with controls. A moderate correlation (r2=0.36, p<0.05 between insulin infusion dose and phosphorylated Akt was demonstrated. CONCLUSIONS/SIGNIFICANCE: We present for the first time muscle protein turnover signaling in critically ill ICU patients, and we show signaling pathway activity towards a stimulation of muscle protein synthesis and a somewhat inhibited proteolysis.

  18. Enhanced Vascular Endothelial Growth Factor Gene Expression in Ischaemic Skin of Critical Limb Ischaemia Patients

    Directory of Open Access Journals (Sweden)

    Silvia Bleda

    2012-01-01

    Full Text Available Objectives. To perform a quantitative analysis of the vascular endothelial growth factor (VEGF gene transcription in the skin of ischemic legs and provide information for VEGF in the pathogenesis in critical limb ischemia (CLI. Methods. Skin biopsies were obtained from 40 patients with CLI. Control samples came from 44 patients with chronic venous disease. VEGF gene expression was analysed using quantitative polymerase chain reaction. Results. Patients with CLI had higher skin VEGF expression than control group (RQ: 1.3 ± 0.1 versus 1, P=0.04. Conclusions. We found an association between ischemic skin and an elevated VEGF expression in legs from patients with CLI. These data support that the mechanism for VEGF upregulation in hypoxia conditions is intact and acts appropriately in the ischaemic limbs from patients with CLI.

  19. Scalable Predictive Analysis in Critically Ill Patients Using a Visual Open Data Analysis Platform.

    Directory of Open Access Journals (Sweden)

    Sven Van Poucke

    Full Text Available With the accumulation of large amounts of health related data, predictive analytics could stimulate the transformation of reactive medicine towards Predictive, Preventive and Personalized (PPPM Medicine, ultimately affecting both cost and quality of care. However, high-dimensionality and high-complexity of the data involved, prevents data-driven methods from easy translation into clinically relevant models. Additionally, the application of cutting edge predictive methods and data manipulation require substantial programming skills, limiting its direct exploitation by medical domain experts. This leaves a gap between potential and actual data usage. In this study, the authors address this problem by focusing on open, visual environments, suited to be applied by the medical community. Moreover, we review code free applications of big data technologies. As a showcase, a framework was developed for the meaningful use of data from critical care patients by integrating the MIMIC-II database in a data mining environment (RapidMiner supporting scalable predictive analytics using visual tools (RapidMiner's Radoop extension. Guided by the CRoss-Industry Standard Process for Data Mining (CRISP-DM, the ETL process (Extract, Transform, Load was initiated by retrieving data from the MIMIC-II tables of interest. As use case, correlation of platelet count and ICU survival was quantitatively assessed. Using visual tools for ETL on Hadoop and predictive modeling in RapidMiner, we developed robust processes for automatic building, parameter optimization and evaluation of various predictive models, under different feature selection schemes. Because these processes can be easily adopted in other projects, this environment is attractive for scalable predictive analytics in health research.

  20. Scalable Predictive Analysis in Critically Ill Patients Using a Visual Open Data Analysis Platform.

    Science.gov (United States)

    Van Poucke, Sven; Zhang, Zhongheng; Schmitz, Martin; Vukicevic, Milan; Laenen, Margot Vander; Celi, Leo Anthony; De Deyne, Cathy

    2016-01-01

    With the accumulation of large amounts of health related data, predictive analytics could stimulate the transformation of reactive medicine towards Predictive, Preventive and Personalized (PPPM) Medicine, ultimately affecting both cost and quality of care. However, high-dimensionality and high-complexity of the data involved, prevents data-driven methods from easy translation into clinically relevant models. Additionally, the application of cutting edge predictive methods and data manipulation require substantial programming skills, limiting its direct exploitation by medical domain experts. This leaves a gap between potential and actual data usage. In this study, the authors address this problem by focusing on open, visual environments, suited to be applied by the medical community. Moreover, we review code free applications of big data technologies. As a showcase, a framework was developed for the meaningful use of data from critical care patients by integrating the MIMIC-II database in a data mining environment (RapidMiner) supporting scalable predictive analytics using visual tools (RapidMiner's Radoop extension). Guided by the CRoss-Industry Standard Process for Data Mining (CRISP-DM), the ETL process (Extract, Transform, Load) was initiated by retrieving data from the MIMIC-II tables of interest. As use case, correlation of platelet count and ICU survival was quantitatively assessed. Using visual tools for ETL on Hadoop and predictive modeling in RapidMiner, we developed robust processes for automatic building, parameter optimization and evaluation of various predictive models, under different feature selection schemes. Because these processes can be easily adopted in other projects, this environment is attractive for scalable predictive analytics in health research.

  1. Long-term sequelae of severe acute kidney injury in the critically ill patient without comorbidity: a retrospective cohort study.

    Directory of Open Access Journals (Sweden)

    Gijs Fortrie

    Full Text Available Acute kidney injury (AKI necessitating renal replacement therapy (RRT is associated with high mortality and increased risk for end stage renal disease. However, it is unknown if this applies to patients with a preliminary unremarkable medical history. The purpose of this study was to describe overall and renal survival in critically ill patients with AKI necessitating RRT stratified by the presence of comorbidity.A retrospective cohort study was performed, between 1994 and 2010, including all adult critically ill patients with AKI necessitating RRT, stratified by the presence of comorbidity. Logistic regression, survival curve and cox proportional hazards analyses were used to evaluate overall and renal survival. Standardized mortality rate (SMR analysis was performed to compare long-term survival to the predicted survival in the Dutch population.Of the 1067 patients included only 96(9.0% had no comorbidity. Hospital mortality was 56.6% versus 43.8% in patients with and without comorbidity, respectively. In those who survived hospitalization 10-year survival was 45.0% and 86.0%, respectively. Adjusted for age, sex and year of treatment, absence of comorbidity was not associated with hospital mortality (OR=0.74, 95%-CI=0.47-1.15, while absence of comorbidity was associated with better long-term survival (adjusted HR=0.28, 95%-CI = 0.14-0.58. Compared to the Dutch population, patients without comorbidity had a similar mortality risk (SMR=1.6, 95%-CI=0.7-3.2, while this was increased in patients with comorbidity (SMR=4.8, 95%-CI=4.1-5.5. Regarding chronic dialysis dependency, 10-year renal survival rates were 76.0% and 92.9% in patients with and without comorbidity, respectively. Absence of comorbidity was associated with better renal survival (adjusted HR=0.24, 95%-CI=0.07-0.76.While hospital mortality remains excessively high, the absence of comorbidity in critically ill patients with RRT-requiring AKI is associated with a relative good long

  2. Critical evaluation of safety and radiological protection requirements adopted for the transport of uranium and thorium ores and concentrates

    International Nuclear Information System (INIS)

    Mezrahi, Arnaldo; Crispim, Verginia R.

    2009-01-01

    This work evaluates in a critical way the safety and radiological protection recommendations established by the International Atomic Energy Agency - IAEA and adopted national and internationally, for the transport of uranium and thorium ores and concentrates, known according the transport regulations, as being of the Low Specific Activity Material Type-I, LSA-I, basing on more realistic scenarios than the presently existent, aiming at the determination of maximum exposure levels of radiation as well as the maximal contents of those materials in packages and conveyance. A general overview taking into account the scenarios foreseen by the regulations of the IAEA pointed out for a need of a better justification of the requirements edited by the Agency or should be used to support a request of revision of those regulations, national and internationally adopted, in the pertinent aspects to the transport of uranium and thorium ores and concentrates. (author)

  3. Warfarin Dosing Algorithms Underpredict Dose Requirements in Patients Requiring ≥7 mg Daily: A Systematic Review and Meta-analysis.

    Science.gov (United States)

    Saffian, S M; Duffull, S B; Wright, Dfb

    2017-08-01

    There is preliminary evidence to suggest that some published warfarin dosing algorithms produce biased maintenance dose predictions in patients who require higher than average doses. We conducted a meta-analysis of warfarin dosing algorithms to determine if there exists a systematic under- or overprediction of dose requirements for patients requiring ≥7 mg/day across published algorithms. Medline and Embase databases were searched up to September 2015. We quantified the proportion of over- and underpredicted doses in patients whose observed maintenance dose was ≥7 mg/day. The meta-analysis included 47 evaluations of 22 different warfarin dosing algorithms from 16 studies. The meta-analysis included data from 1,492 patients who required warfarin doses of ≥7 mg/day. All 22 algorithms were found to underpredict warfarin dosing requirements in patients who required ≥7 mg/day by an average of 2.3 mg/day with a pooled estimate of underpredicted doses of 92.3% (95% confidence interval 90.3-94.1, I 2 = 24%). © 2017 American Society for Clinical Pharmacology and Therapeutics.

  4. Patient outcomes after critical illness: a systematic review of qualitative studies following hospital discharge.

    Science.gov (United States)

    Hashem, Mohamed D; Nallagangula, Aparna; Nalamalapu, Swaroopa; Nunna, Krishidhar; Nausran, Utkarsh; Robinson, Karen A; Dinglas, Victor D; Needham, Dale M; Eakin, Michelle N

    2016-10-26

    There is growing interest in patient outcomes following critical illness, with an increasing number and different types of studies conducted, and a need for synthesis of existing findings to help inform the field. For this purpose we conducted a systematic review of qualitative studies evaluating patient outcomes after hospital discharge for survivors of critical illness. We searched the PubMed, EMBASE, CINAHL, PsycINFO, and CENTRAL databases from inception to June 2015. Studies were eligible for inclusion if the study population was >50 % adults discharged from the ICU, with qualitative evaluation of patient outcomes. Studies were excluded if they focused on specific ICU patient populations or specialty ICUs. Citations were screened in duplicate, and two reviewers extracted data sequentially for each eligible article. Themes related to patient outcome domains were coded and categorized based on the main domains of the Patient Reported Outcomes Measurement Information System (PROMIS) framework. A total of 2735 citations were screened, and 22 full-text articles were eligible, with year of publication ranging from 1995 to 2015. All of the qualitative themes were extracted from eligible studies and then categorized using PROMIS descriptors: satisfaction with life (16 studies), including positive outlook, acceptance, gratitude, independence, boredom, loneliness, and wishing they had not lived; mental health (15 articles), including symptoms of post-traumatic stress disorder, anxiety, depression, and irritability/anger; physical health (14 articles), including mobility, activities of daily living, fatigue, appetite, sensory changes, muscle weakness, and sleep disturbances; social health (seven articles), including changes in friends/family relationships; and ability to participate in social roles and activities (six articles), including hobbies and disability. ICU survivors may experience positive emotions and life satisfaction; however, a wide range of mental

  5. Brain computer tomography in critically ill patients - a prospective cohort study

    International Nuclear Information System (INIS)

    Purmer, Ilse M; Iperen, Erik P van; Beenen, Ludo F M; Kuiper, Michael J; Binnekade, Jan M; Vandertop, Peter W; Schultz, Marcus J; Horn, Janneke

    2012-01-01

    Brain computer tomography (brain CT) is an important imaging tool in patients with intracranial disorders. In ICU patients, a brain CT implies an intrahospital transport which has inherent risks. The proceeds and consequences of a brain CT in a critically ill patient should outweigh these risks. The aim of this study was to critically evaluate the diagnostic and therapeutic yield of brain CT in ICU patients. In a prospective observational study data were collected during one year on the reasons to request a brain CT, expected abnormalities, abnormalities found by the radiologist and consequences for treatment. An “expected abnormality” was any finding that had been predicted by the physician requesting the brain CT. A brain CT was “diagnostically positive”, if the abnormality found was new or if an already known abnormality was increased. It was “diagnostically negative” if an already known abnormality was unchanged or if an expected abnormality was not found. The treatment consequences of the brain CT, were registered as “treatment as planned”, “treatment changed, not as planned”, “treatment unchanged”. Data of 225 brain CT in 175 patients were analyzed. In 115 (51%) brain CT the abnormalities found were new or increased known abnormalities. 115 (51%) brain CT were found to be diagnostically positive. In the medical group 29 (39%) of brain CT were positive, in the surgical group 86 (57%), p 0.01. After a positive brain CT, in which the expected abnormalities were found, treatment was changed as planned in 33%, and in 19% treatment was changed otherwise than planned. The results of this study show that the diagnostic and therapeutic yield of brain CT in critically ill patients is moderate. The development of guidelines regarding the decision rules for performing a brain CT in ICU patients is needed

  6. Predictors of Inadequate Linezolid Concentrations after Standard Dosing in Critically Ill Patients.

    Science.gov (United States)

    Taubert, Max; Zoller, Michael; Maier, Barbara; Frechen, Sebastian; Scharf, Christina; Holdt, Lesca-Miriam; Frey, Lorenz; Vogeser, Michael; Fuhr, Uwe; Zander, Johannes

    2016-09-01

    Adequate linezolid blood concentrations have been shown to be associated with an improved clinical outcome. Our goal was to assess new predictors of inadequate linezolid concentrations often observed in critically ill patients. Fifty-two critically ill patients with severe infections receiving standard dosing of linezolid participated in this prospective observational study. Serum samples (median, 32 per patient) were taken on four consecutive days, and total linezolid concentrations were quantified. Covariates influencing linezolid pharmacokinetics were identified by multivariate analysis and a population pharmacokinetic model. Target attainment (area under the concentration-time curve over 12 h [AUC12]/MIC ratio of >50; MIC = 2 mg/liter) was calculated for both the study patients and a simulated independent patient group (n = 67,000). Target attainment was observed for only 36% of the population on both days 1 and 4. Independent covariates related to significant decreases of linezolid concentrations included higher weight, creatinine clearance rates, and fibrinogen and antithrombin concentrations, lower concentrations of lactate, and the presence of acute respiratory distress syndrome (ARDS). Linezolid clearance was increased in ARDS patients (by 82%) and in patients with elevated fibrinogen or decreased lactate concentrations. In simulated patients, most covariates, including fibrinogen and lactate concentrations and weight, showed quantitatively minor effects on target attainment (difference of ≤9% between the first and fourth quartiles of the respective parameters). In contrast, the presence of ARDS had the strongest influence, with only ≤6% of simulated patients reaching this target. In conclusion, the presence of ARDS was identified as a new and strong predictor of insufficient linezolid concentrations, which might cause treatment failure. Insufficient concentrations might also be a major problem in patients with combined alterations of other covariate

  7. Quality indicators for enteral and parenteral nutrition therapy: application in critically ill patients "at nutritional risk".

    Science.gov (United States)

    Oliveira Filho, Ronaldo Sousa; Ribeiro, Lia Mara Kauchi; Caruso, Lucia; Lima, Patricia Azevedo; Damasceno, Náglia Raquel Teixeira; García Soriano, Francisco

    2016-09-20

    Quality Indicators for Nutritional Therapy (QINT) allow a practical assessment of nutritional therapy (NT) quality. To apply and monitor QINT for critically ill patients at nutritional risk. Cross sectional study including critically ill patients > 18 years old, at nutritional risk, on exclusive enteral (ENT) or parenteral nutritional therapy (PNT) for > 72 hours. After three consecutive years, 9 QINT were applied and monitored. Statistical analysis was performed with SPSS version 17.0. A total of 145 patients were included, 93 patients were receiving ENT, among then 65% were male and the mean age was 55.7 years (± 17.4); 52 patients were receiving PNT, 67% were male and the mean age was 58.1 years (± 17.4). All patients (ENT and PNT) were nutritionally screened at admission and their energy and protein needs were individually estimated. Only ENT was early initiated, more than 70% of the prescribed ENT volume was infused and there was a reduced withdrawal of enteral feeding tube. The frequency of diarrhea episodes and digestive fasting were not adequate in ENT patients. The proper supply of energy was contemplated only for PNT patients and there was an expressive rate of oral intake recovery in ENT patients. After three years of research, the percentage of QINT adequacy varied between 55%-77% for ENT and 60%-80% for PNT. The results were only made possible by the efforts of a multidisciplinary team and the continuous re-evaluation of the procedures in order to maintain the nutritional assistance for patients at nutritional risk.

  8. Prospective analysis of skin findings in surgical critically Ill patients intensive care unit

    Directory of Open Access Journals (Sweden)

    Suzan Demir Pektas

    2017-01-01

    Full Text Available Background: Intensive Care Units (ICUs are places where critically ill patients are managed. Aim: We aimed to investigate skin disorders that developed in critically ill surgical patients during their stay in the ICU. Methods: The prevalence of dermatological disorders and factors affecting their clinical features was prospectively analyzed in surgical ICU patients. We recorded age, sex, type of ICU, comorbidities, skin disorders, time to consultation, duration of ICU stay, and mortality rate. Results: Our study included 605 patients (mean age of 60.1 ± 20.2 years; 56.4% males. Seventy-three (12.1% patients were consulted with the Dermatology Department, among which 28.8% had infectious dermatological lesions, 26% dermatoses, and 45.2% drug reactions. The most common infectious dermatological disorder was wound infection (55.6%, the most common drug reaction was maculopapular drug eruption (75.8%, and the most common dermatosis was frictional blisters (47.4%. Multiple comorbidities, hypertension, diabetes mellitus, coronary artery disease, Parkinson disease, and stroke increased dermatological disorders (P < 0.05. The consulted patients had a median ICU stay of 7 days (range 2–53 days; consultation was significantly more common when it exceeded 10 days (74% vs. 26%, P < 0.05. The consulted patients died more commonly (P < 0.05. Infectious dermatological disorders and dermatoses were more common in patients older and younger than 50 years, respectively (P < 0.05. Dermatoses were more common among women (P < 0.05. The median time to consultation was 6 (2–30 days; it was longest for dermatological infections and shortest for dermatoses (P < 0.05. Infectious dermatological disorders were significantly more common among the deceased patients (P < 0.05. Conclusion: Multiple factors including multiple comorbidities, duration of ICU stay, time to consultation, and mortality increase dermatological disorders among surgical ICU patients.

  9. Which pediatric blunt trauma patients do not require pelvic imaging?

    Science.gov (United States)

    Haasz, Maya; Simone, Laura A; Wales, Paul W; Stimec, Jennifer; Stephens, Derek; Beno, Suzanne; Schuh, Suzanne

    2015-11-01

    This study aimed to develop a tool in identifying traumatized children at low risk of pelvic fracture and to determine the sensitivity of this low-risk model for pelvic fractures. We hypothesized that the proportion of children without predictors with pelvic fracture is less than 1%. This is a retrospective trauma registry analysis of previously healthy children 1 year to 17 years old presenting to the pediatric emergency department with blunt trauma. Postulated predictors of pelvic fracture on radiograph or computed tomography included pain/abnormal examination result of the pelvis/hip, femur deformity, hematuria, abdominal pain/tenderness, Glasgow Coma Scale (GCS) score of 13 or lower, and hemodynamic instability. We used multivariable logistic regression to identify independent predictors of fracture. Of 1,121 eligible patients (mean [SD] age, 8.5 [4.6] years), 87 (7.8%) had pelvic fracture. Independent predictors included pain/abnormal examination result of the pelvis/hip (odds ratio [OR], 16.7; 95% confidence interval [CI], 9.6-29.1), hematuria (OR, 6.6; 95% CI, 3.0-14.6), femoral deformity (OR, 5.9; 95% CI, 3.1-11.3), GCS score of 13 or lower (OR, 2.4; 95% CI, 1.3-4.3), and hemodynamic instability (OR, 3.4; 95% CI, 1.7-6.9). One of 590 children (0.2%; 95% CI, 0-0.5%) without predictors had pelvic fractures versus 86 (16.2%) of 531 in those with one or more predictors (OR, 119; 95% CI, 16.6-833). One of 87 children with pelvic fractures had no predictors (1.1%; 95% CI, 0-3%). When assuming a 100% radiography rate, this tool saves 53% pelvic radiographs. Children with multiple blunt trauma without pain/abnormal examination result of the pelvis/hip, femur deformity, hematuria, abdominal pain/tenderness, GCS score of 13 or lower, or hemodynamic instability constitute a low-risk population for pelvic fracture, with less than 0.5% risk rate. This population does not require routine pelvic imaging. Therapeutic study, level IV.

  10. Interprofessional collaborative patient-centred care: a critical exploration of two related discourses.

    Science.gov (United States)

    Fox, Ann; Reeves, Scott

    2015-03-01

    There has been sustained international interest from health care policy makers, practitioners, and researchers in developing interprofessional approaches to delivering patient-centred care. In this paper, we offer a critical exploration of a selection of professional discourses related to these practice paradigms, including interprofessional collaboration, patient-centred care, and the combination of the two. We argue that for some groups of patients, inequalities between different health and social care professions and between professionals and patients challenge the successful realization of the positive aims associated with these discourses. Specifically, we argue that interprofessional and professional-patient hierarchies raise a number of key questions about the nature of professions, their relationships with one another as well as their relationship with patients. We explore how the focus on interprofessional collaboration and patient-centred care have the potential to reinforce a patient compliance model by shifting responsibility to patients to do the "right thing" and by extending the reach of medical power across other groups of professionals. Our goal is to stimulate debate that leads to enhanced practice opportunities for health professionals and improved care for patients.

  11. Wound healing of critical limb ischemia with tissue loss in patients on hemodialysis.

    Science.gov (United States)

    Honda, Yohsuke; Hirano, Keisuke; Yamawaki, Masahiro; Mori, Shinsuke; Shirai, Shigemitsu; Makino, Kenji; Tokuda, Takahiro; Takama, Takuro; Tsutumi, Masakazu; Sakamoto, Yasunari; Takimura, Hideyuki; Kobayashi, Norihiro; Araki, Motoharu; Ito, Yoshiaki

    2017-06-01

    We assessed wound healing in patients on hemodialysis (HD) with critical limb ischemia (CLI). This study enrolled 267 patients (including 120 patients on HD and 147 patients not on HD) who underwent endovascular therapy (EVT) for CLI. The primary endpoint was wound-healing rate at two years. Secondary endpoints were time to wound healing, wound recurrence rate, and limb salvage at two years. The percentage of male and young patients was higher in the HD patients ( p healing rate was significantly lower in HD patients (79.5% vs. 92.4%, p healing was significantly longer in HD patients (median 132 days vs. 82 days, p = 0.005). Wound recurrence was observed more frequently in HD patients (25.0% vs. 10.2%, p = 0.007). Limb salvage (72.8% vs. 86.4%, p = 0.002) was significantly lower in HD patients. In a cox proportional hazard model, HD was an independent predictor of wound healing (risk ratio (RR), 0.46; 95% confidence interval (CI), 0.33-0.62; p healing, and wound recurrence.

  12. Microbiological analysis of bile and its impact in critically ill patients with secondary sclerosing cholangitis.

    Science.gov (United States)

    Voigtländer, Torsten; Leuchs, Ensieh; Vonberg, Ralf-Peter; Solbach, Philipp; Manns, Michael P; Suerbaum, Sebastian; Lankisch, Tim O

    2015-05-01

    Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an emerging disease entity with unfavourable outcome. Our aim was to analyze the microbial spectrum in bile of patients with SSC-CIP and to evaluate the potential impact on the empiric antibiotic treatment in these patients. 169 patients (72 patients with SSC-CIP and 97 patients with primary sclerosing cholangitis (PSC)) were included in a prospective observational study between 2010 and 2013. Bile was obtained during endoscopic retrograde cholangiography (ERC) and microbiologically analyzed. Patients with SSC displayed a significantly different microbiological profile in bile. Enterococcus faecium, Pseudomonas aeruginosa and non-albicans species of Candida were more frequent in SSC compared to patients with PSC (p bile (p = 0.001). The antimicrobial therapy was adjusted in 64% of patients due to resistance or presence of microorganisms not covered by the initial therapy regimen. Patients with SSC-CIP have a distinct microbial profile in bile. Difficult to treat organisms are frequent and an ERC with bile fluid collection for microbiological analysis should be considered in case of insufficient antimicrobial treatment. Copyright © 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

  13. Correlation between the severity of critically ill patients and clinical predictors of bronchial aspiration

    Science.gov (United States)

    de Medeiros, Gisele Chagas; Sassi, Fernanda Chiarion; Zambom, Lucas Santos; de Andrade, Claudia Regina Furquim

    2016-01-01

    Objective: To determine whether the severity of non-neurological critically ill patients correlates with clinical predictors of bronchial aspiration. Methods: We evaluated adults undergoing prolonged orotracheal intubation (> 48 h) and bedside swallowing assessment within the first 48 h after extubation. We collected data regarding the risk of bronchial aspiration performed by a speech-language pathologist, whereas data regarding the functional level of swallowing were collected with the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) scale and those regarding health status were collected with the Sequential Organ Failure Assessment (SOFA). Results: The study sample comprised 150 patients. For statistical analyses, the patients were grouped by ASHA NOMS score: ASHA1 (levels 1 and 2), ASHA2 (levels 3 to 5); and ASHA3 (levels 6 and 7). In comparison with the other patients, those in the ASHA3 group were significantly younger, remained intubated for fewer days, and less severe overall clinical health status (SOFA score). The clinical predictors of bronchial aspiration that best characterized the groups were abnormal cervical auscultation findings and cough after swallowing. None of the patients in the ASHA 3 group presented with either of those signs. Conclusions: Critically ill patients 55 years of age or older who undergo prolonged orotracheal intubation (≥ 6 days), have a SOFA score ≥ 5, have a Glasgow Coma Scale score ≤ 14, and present with abnormal cervical auscultation findings or cough after swallowing should be prioritized for a full speech pathology assessment. PMID:27167432

  14. Flucytosine Pharmacokinetics in a Critically Ill Patient Receiving Continuous Renal Replacement Therapy.

    Science.gov (United States)

    Kunka, Megan E; Cady, Elizabeth A; Woo, Heejung C; Thompson Bastin, Melissa L

    2015-01-01

    Purpose. A case report evaluating flucytosine dosing in a critically ill patient receiving continuous renal replacement therapy. Summary. This case report outlines an 81-year-old male who was receiving continuous venovenous hemofiltration (CVVH) for acute renal failure and was being treated with flucytosine for the treatment of disseminated Cryptococcus neoformans infection. Due to patient specific factors, flucytosine was empirically dose adjusted approximately 50% lower than intermittent hemodialysis (iHD) recommendations and approximately 33% lower than CRRT recommendations. Peak and trough levels were obtained, which were supratherapeutic, and pharmacokinetic parameters were calculated. The patient experienced thrombocytopenia, likely due to elevated flucytosine levels, and flucytosine was ultimately discontinued. Conclusion. Despite conservative flucytosine dosing for a patient receiving CVVH, peak and trough serum flucytosine levels were supratherapeutic (120 μg/mL at 2 hours and 81 μg/mL at 11.5 hours), which increased drug-related adverse effects. The results indicate that this conservative dosing regimen utilizing the patient's actual body weight was too aggressive. This case report provides insight into flucytosine dosing in CVVH, a topic that has not been investigated previously. Further pharmacokinetic studies of flucytosine dosing in critically ill patients receiving CVVH are needed in order to optimize pharmacokinetic and pharmacodynamic parameters while avoiding toxic flucytosine exposure.

  15. Restructuring patient flow logistics around patient care needs: implications and practicalities from three critical cases.

    Science.gov (United States)

    Villa, Stefano; Barbieri, Marta; Lega, Federico

    2009-06-01

    To make hospitals more patient-centered it is necessary to intervene on patient flow logistics. The study analyzes three innovative redesign projects implemented at three Italian hospitals. The three hospitals have reorganized patient flow logistics around patient care needs using, as proxies, the expected length of stay and the level of nursing assistance. In order to do this, they have extensively revised their logistical configuration changing: (1) the organization of wards, (2) the hospital's physical lay-out, (3) the capacity planning system, and (4) the organizational roles supporting the patient flow management. The study describes the changes implemented as well as the results achieved and draws some general lessons that provide useful hints for those other hospitals involved in such type of redesign projects. The paper ends by discussing some policy implications. In fact, the results achieved in the three cases investigated provide interesting material for further discussion on clinical, operational, and economic issues.

  16. Acute kidney injury in critically burned patients resuscitated with a protocol that includes low doses of Hydroxyethyl Starch

    OpenAIRE

    Sánchez-Sánchez, M.; Garcia-de-Lorenzo, A.; Cachafeiro, L.; Herrero, E.; Asensio, MJ.; Agrifoglio, A.; Flores, E.; Estebanez, B.; Extremera, P.; Iglesias, C.; Martinez, J.R..

    2016-01-01

    Acute kidney injury (AKI) is an important complication in burn patients. Recently, it has been recommended that hydroxyethyl starch (HES) be avoided in burn patients because it increases the incidence of AKI. Our purpose was to study incidence of AKI in critically ill burn patients resuscitated with Ringer’s solution and supplements of HES. We conducted an observational study of 165 patients admitted to the critical care burn unit (with 30 ± 15% TBSA burned). The main outcome measures were in...

  17. Initiation of nutritional support is delayed in critically ill obese patients: a multicenter cohort study.

    Science.gov (United States)

    Borel, Anne-Laure; Schwebel, Carole; Planquette, Benjamin; Vésin, Aurélien; Garrouste-Orgeas, Maité; Adrie, Christophe; Clec'h, Christophe; Azoulay, Elie; Souweine, Bertrand; Allaouchiche, Bernard; Goldgran-Toledano, Dany; Jamali, Samir; Darmon, Michael; Timsit, Jean-François

    2014-09-01

    A high catabolic rate characterizes the acute phase of critical illness. Guidelines recommend an early nutritional support, regardless of the previous nutritional status. We aimed to assess whether the nutritional status of patients, which was defined by the body mass index (BMI) at admission in an intensive care unit (ICU), affected the time of nutritional support initiation. We conducted a cohort study that reported a retrospective analysis of a multicenter ICU database (OUTCOMEREA) by using data prospectively entered from January 1997 to October 2012. Patients who needed orotracheal intubation within the first 72 h and >3 d were included. Data from 3257 ICU stays were analyzed. The delay before feeding was different according to BMI groups (P = 0.035). The delay was longer in obese patients [BMI (in kg/m²) ≥30; n = 663] than in other patients with either low weight (BMI nutritional status and a delay in nutrition initiation was independent of potential confounding factors such as age, sex, and diabetes or other chronic diseases. In comparison with normal weight, the adjusted RR (95% CI) associated with a delayed nutrition initiation was 0.92 (0.86, 0.98) for patients with low weight, 1.00 (0.94, 1.05) for overweight patients, and 1.06 (1.00, 1.12) for obese patients (P = 0.004). The initiation of nutritional support was delayed in obese ICU patients. Randomized controlled trials that address consequences of early compared with delayed beginnings of nutritional support in critically ill obese patients are needed. © 2014 American Society for Nutrition.

  18. Advantages and Disadvantages of the Patient-Centered Medical Home: A Critical Analysis and Lessons Learned.

    Science.gov (United States)

    Budgen, Jacqueline; Cantiello, John

    This article provides a detailed examination of the pros and cons associated with patient-centered medical homes (PCMHs). Opinions and findings from those who have studied PCMHs and those who have been directly involved with this type of health care model are outlined. Key lessons from providers are detailed, and critical success factors are highlighted. This synthesized analysis serves to lend evidence to health care managers and providers who are considering implementation of the PCMH model.

  19. Early ICU Standardized Rehabilitation Therapy for the Critically Injured Burn Patient

    Science.gov (United States)

    2016-10-01

    care hospitalization in elderly patients with chronic critical illness. Med Care 2013;51(1):4–10 18 Cox CE, Martinu T, Sathy SJ, et al. Expectations...sixth vital sign”. J Geriatr Phys Ther 2009;32(2):46–49 125 Troosters T, Gosselink R, Decramer M. Six minute walking distance in healthy elderly subjects...of a return to a pre-hospital level of reduced muscle function in pa- tients with underlying neuromyopathies or sarcopenia ? Answering these questions

  20. Low plasma leptin level at admission predicts delirium in critically ill patients: A prospective cohort study.

    Science.gov (United States)

    Li, Guicheng; Lei, Xiaobao; Ai, Chenmu; Li, Tao; Chen, Zhongqing

    2017-07-01

    The pathophysiology of delirium remains poorly understood. Low leptin level has been associated with features leading to delirium such as dysregulated immune functions and loss of neuroprotective effects. The purpose of the present study was to investigate the relationship between plasma leptin level at intensive care unit (ICU) entry and subsequent occurrence of delirium in critically ill patients. This single-center prospective cohort study in China allocated 336 critically ill patients admitted to ICU between 05/2015 and 05/2016 into a delirium group (n=102) and non-delirium group (n=234) based on whether delirium occurred during their stay at the ICU. Patients were examined at least twice daily and delirium was diagnosed using the Confusion Assessment Method for the ICU (CAM-ICU). Blood samples were obtained after ICU entry. Plasma leptin concentrations were measured by ELISA. Delirium occurred in 30.4% (102/336) of patients. Patients who developed delirium showed significantly lower leptin level at ICU entry than those who did not (6.1±3.2 vs. 9.2±5.9ng/mL; Pdelirium (OR, 0.865; 95%CI, 0.802-0.934; Pdelirium included increasing age (OR, 1.050; 95%CI, 1.020-1.080; P=0.001) and Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score (OR, 1.148; 95%CI, 1.092-1.208; Pdelirium had a prolonged duration of ICU stay and higher mortality. Low plasma leptin level at ICU entry was associated with the occurrence of delirium in critically ill patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  1. Sequential compression biomechanical device versus primary amputation in patients with critical limb ischemia.

    LENUS (Irish Health Repository)

    Tawfick, Wael A

    2013-10-01

    Introduction: Patients with critical limb ischemia (CLI), who are unsuitable for intervention, face the consequence of primary amputation. Sequential compression biomechanical device (SCBD) therapy provides a limb salvage option for these patients. Objectives: To assess the outcome of SCBD in patients with severe CLI who are unsuitable for revascularization. Primary end points were limb salvage and 30-day mortality. Methods: From 2005 to 2012, 189 patients with severe CLI were not suitable for revascularization. In all, 171 joined the SCBD program. We match controlled 75 primary amputations. Results: All patients were Rutherford category 4 or higher. Sustained clinical improvement was 68% at 1 year. Mean toe pressure increased from 19.9 to 35.42 mm Hg, P < .0001. Mean popliteal flow increased from 35.44 to 55.91 cm\\/sec, P < .0001. The 30-day mortality was 0.6%. Limb salvage was 94% at 5 years. Freedom from major adverse clinical events was 62.5%. All-cause survival was 69%. Median cost of managing a primary amputation patient is €29 815 compared to €3985 for SCBD. We treated 171 patients with artassist at a cost of €681 965. However, primary amputation for 75 patients cost €2 236 125. Conclusion: The SCBD therapy is a cost-effective and clinically effective solution in patients with CLI having no option of revascularization. It provides adequate limb salvage while providing relief of rest pain without any intervention.

  2. The Effects of Homocysteine Level in the Critically Ill Patient. A Review

    Directory of Open Access Journals (Sweden)

    Bedreag Ovidiu Horea

    2016-09-01

    Full Text Available Increased levels of homocysteine (HCYS represent a risk factor for a series of physiopathological conditions: mental retardation, cardiovascular and neurodegenerative diseases, Parkinson's and Alzheimer's disease, depression, osteoporosis, endothelial dysfunction and inhibition of cell proliferation. This paper aims to present the pathophysiological implications of HCYS and the correlation of hyperhomocysteinemia (H-HCYS with critical condition in the intensive care unit (ICU. Hypovitaminosis B and folate deficiency is directly involved in the inhibition of HCYS metabolism and the accumulation of HCYS in the plasma and tissues. Critically ill patients are more prone to H-HCYS due to hypermetabolism and accelerated synthesis produced by reactive oxygen species (ROS. In conclusion it can be affirmed that the determination and monitoring of HCYS plasma levels may be of interest in optimizing the therapy for critically ill patients. Moreover, by controlling HCYS levels, and implicitly the essential cofactors that intervene in the specific biochemical pathways, such as vitamin B6, vitamin B12 and folic acid can provide a diversified and personalized treatment for each patient.

  3. Critical Outcomes in Longitudinal Observational Studies and Registries in Patients with Rheumatoid Arthritis

    DEFF Research Database (Denmark)

    Zamora, Natalia V; Christensen, Robin; Goel, Niti

    2017-01-01

    OBJECTIVE: Outcomes important to patients are those that are relevant to their well-being, including quality of life, morbid endpoints, and death. These outcomes often occur over the longterm and can be identified in prospective longitudinal observational studies (PLOS). There are no standards...... for which outcome domains should be considered. Our overarching goal is to identify critical longterm outcome domains for patients with rheumatic diseases, and to develop a conceptual framework to measure and classify them within the scope of OMERACT Filter 2.0. METHODS: The steps of this initiative...

  4. Clinical review: Ethics and end-of-life care for critically ill patients in China

    OpenAIRE

    Li, Li Bin

    2013-01-01

    Critical care medicine in China has made great advances in recent decades. This has led to an unavoidable issue: end-of-life ethics. With advances in medical technology and therapeutics allowing the seemingly limitless maintenance of life, the exact time of death of an individual patient is often determined by the decision to limit life support. How to care for patients at the end of life is not only a medical problem but also a social, ethical, and legal issue. A lot of factors, besides cult...

  5. [Echinocandins: searching for differences. The example of their use in patients requiring continuous renal replacement therapy].

    Science.gov (United States)

    de la Llama-Celis, Natalia; Huarte-Lacunza, Rafael; Gómez-Baraza, Cristina; Cañamares-Orbis, Iciar; Sebastián-Aldeanueva, Manuel; Arrieta-Navarro, Raquel

    2012-12-01

    The echinocandins have a growing role in the treatment of fungal infections because of their novel mechanism of action. This is reflected in recently published management guidelines, but available in vitro data, animal studies, and clinical studies do not clearly differentiate the three agents in class. Comparative clinical efficacy among agents within the class, pharmacokinetic profiles in special populations, pharmacoeconomics justifications, and place in therapy have been largely unanswered. They share many common properties but marketing strategies of drug manufacturers are engaged in product differentiation. Although exist similarities in the pharmacokinetic (PK) profiles of the echinocandins, limited data have been published regarding their pharmacokinetics in continuous renal replacement therapy (CRRT) patients. The pharmacokinetics of drug removal in critically ill patients receiving CRRT is very complex, with multiple variables affecting clearance. This review outlines the basic principles that determine whether a dose adjustment is required. Two studies with data on PK parameters of micafungin and anidulafungin in CRRT patients have been published and are compared following that basic principles in the review.

  6. Acute psychological trauma in the critically ill: Patient and family perspectives.

    Science.gov (United States)

    Dziadzko, Volha; Dziadzko, Mikhail A; Johnson, Margaret M; Gajic, Ognjen; Karnatovskaia, Lioudmila V

    2017-07-01

    Post-intensive care syndrome (PICS), which encompasses profound psychological morbidity, affects many survivors of critical illness. We hypothesize that acute psychological stress during the intensive care unit (ICU) confinement likely contributes to PICS. In order to develop strategies that mitigate PICS associated psychological morbidity, it is paramount to first characterize acute ICU psychological stress and begin to understand its causative and protective factors. A structured interview study was administered to adult critical illness survivors who received ≥48h of mechanical ventilation in medical and surgical ICUs of a tertiary care center, and their families. Fifty patients and 44 family members were interviewed following ICU discharge. Patients reported a high level of psychological distress. The families' perception of patient's stress level correlated with the patient's self-estimated stress level both in daily life (rho=0.59; ptherapy/walking (14%) were perceived to be important mitigating factors. Clinicians' actions that were perceived to be very constructive included reassurance (54%), explanations (32%) and physical touch (8%). Fear, hallucinations, and the inability to communicate, are identified as central contributors to psychological stress during an ICU stay; the presence of family, and physician's attention are categorized as important mitigating factors. Patients and families identified several practical recommendations which may help assuage the psychological burden of the ICU stay. Copyright © 2017 Elsevier Inc. All rights reserved.

  7. [Is the critical patient competent for decision taking? Psychological and psychopathological reasons of cognitive impairment].

    Science.gov (United States)

    Bernat-Adell, M D; Ballester-Arnal, R; Abizanda-Campos, R

    2012-01-01

    Emotional factors may lead to cognitive impairment that can adversely affect the capacity of patients to reason, and thereby, limit their participation in decision taking. To analyze critical patient aptitude for decision taking, and to identify variables that may influence competence. An observational descriptive study was carried out. Intensive care unit. Participants were 29 critically ill patients. Social, demographic and psychological variables were analyzed. Functional capacities and psychological reactions during stay in the ICU were assessed. The patients are of the firm opinion that they should have the last word in the taking of decisions; they prefer bad news to be given by the physician; and feel that the presence of a psychologist would make the process easier. Failure on the part of the professional to answer their questions is perceived as the greatest stress factor. Increased depression results in lesser cognitive capacity, and for patients with impaired cognitive capacity, participation in the decision taking process constitutes a burden. The variables anxiety and depression are significantly related to decision taking capacity. Copyright © 2011 Elsevier España, S.L. and SEMICYUC. All rights reserved.

  8. Patient outcomes for the chronically critically ill: special care unit versus intensive care unit.

    Science.gov (United States)

    Rudy, E B; Daly, B J; Douglas, S; Montenegro, H D; Song, R; Dyer, M A

    1995-01-01

    The purpose of this study was to compare the effects of a low-technology environment of care and a nurse case management case delivery system (special care unit, SCU) with the traditional high-technology environment (ICU) and primary nursing care delivery system on the patient outcomes of length of stay, mortality, readmission, complications, satisfaction, and cost. A sample of 220 chronically critically ill patients were randomly assigned to either the SCU (n = 145) or the ICU (n = 75). Few significant differences were found between the two groups in length of stay, mortality, or complications. However, the findings showed significant cost savings in the SCU group in the charges accrued during the study period and in the charges and costs to produce a survivor. The average total cost of delivering care was $5,000 less per patient in the SCU than in the traditional ICU. In addition, the cost to produce a survivor was $19,000 less in the SCU. Results from this 4-year clinical trial demonstrate that nurse case managers in a SCU setting can produce patient outcomes equal to or better than those in the traditional ICU care environment for long-term critically ill patients.

  9. Flucytosine Pharmacokinetics in a Critically Ill Patient Receiving Continuous Renal Replacement Therapy

    Directory of Open Access Journals (Sweden)

    Megan E. Kunka

    2015-01-01

    Full Text Available Purpose. A case report evaluating flucytosine dosing in a critically ill patient receiving continuous renal replacement therapy. Summary. This case report outlines an 81-year-old male who was receiving continuous venovenous hemofiltration (CVVH for acute renal failure and was being treated with flucytosine for the treatment of disseminated Cryptococcus neoformans infection. Due to patient specific factors, flucytosine was empirically dose adjusted approximately 50% lower than intermittent hemodialysis (iHD recommendations and approximately 33% lower than CRRT recommendations. Peak and trough levels were obtained, which were supratherapeutic, and pharmacokinetic parameters were calculated. The patient experienced thrombocytopenia, likely due to elevated flucytosine levels, and flucytosine was ultimately discontinued. Conclusion. Despite conservative flucytosine dosing for a patient receiving CVVH, peak and trough serum flucytosine levels were supratherapeutic (120 μg/mL at 2 hours and 81 μg/mL at 11.5 hours, which increased drug-related adverse effects. The results indicate that this conservative dosing regimen utilizing the patient’s actual body weight was too aggressive. This case report provides insight into flucytosine dosing in CVVH, a topic that has not been investigated previously. Further pharmacokinetic studies of flucytosine dosing in critically ill patients receiving CVVH are needed in order to optimize pharmacokinetic and pharmacodynamic parameters while avoiding toxic flucytosine exposure.

  10. Extracorporeal circulatory systems in the interhospital transfer of critically ill patients: experience of a single institution

    International Nuclear Information System (INIS)

    Haneya, Assad; Philipp, Alois; Foltan, Maik; Camboni, Daniele; Rupprecht, Leopold; Puehler, Thomas; Hirt, Stephan; Hilker, Michael; Kobuch, Reinhard; Schmid, Christof; Arlt, Matthias; Mueller, Thomas

    2009-01-01

    Critically ill patients with acute circulatory failure cannot be moved to other institutions unless stabilized by mechanical support systems. Extracorporeal heart and lung assist systems are increasingly used as a bridge to end-organ recovery or transplantation, and as an ultimate rescue tool in cardiopulmonary resuscitation. From July 2001 to April 2008, we had 38 requests for extracorporeal support for interhospital transfer carried out by the air medical service. Respiratory failure was present in 29 patients, who were provided with pumpless extracorporeal lung assist (PECLA) or veno-venous extracorporeal membrane oxygenation (ECMO). Cardiac failure dominated in 9 patients, who underwent implantation of extracorporeal life support (ECLS). Underlying diseases were acute respiratory distress syndrome in 15 patients, pneumonia in 7, prior lung transplant status in 4, cardiogenic shock in 7, and septic shock in 4. All assist systems were connected via peripheral vessels by the Seldinger technique. Transport was uneventful in all cases with no technical failures. On arrival at the specialized care hospital, two patients had leg ischemia and underwent relocation of the arterial cannula. After a mean (SD) support of 5.1 (3.0) days for PECLA, 3.5 (2.9) days for ECLS, and 7.3 (5.8) days for ECMO, 60%, 66%, and 66% of patients, respectively, could be successfully weaned from the systems. Discharge rates were 45% for PECLA, 44% for ECLS, and 56% for ECMO. Our experience proves that minimized extracorporeal assist devices allow safe assistance of patients with isolated or combined heart and lung failure in need of interhospital transfer. Critically ill patients get a chance to reach a center of maximum medical care. (author)

  11. Caring for patients of Islamic denomination: Critical care nurses' experiences in Saudi Arabia.

    Science.gov (United States)

    Halligan, Phil

    2006-12-01

    To describe the critical care nurses' experiences in caring for patients of Muslim denomination in Saudi Arabia. Caring is known to be the essence of nursing but many health-care settings have become more culturally diverse. Caring has been examined mainly in the context of Western cultures. Muslims form one of the largest ethnic minority communities in Britain but to date, empirical studies relating to caring from an Islamic perspective is not well documented. Research conducted within the home of Islam would provide essential truths about the reality of caring for Muslim patients. Phenomenological descriptive. Methods. Six critical care nurses were interviewed from a hospital in Saudi Arabia. The narratives were analysed using Colaizzi's framework. The meaning of the nurses' experiences emerged as three themes: family and kinship ties, cultural and religious influences and nurse-patient relationship. The results indicated the importance of the role of the family and religion in providing care. In the process of caring, the participants felt stressed and frustrated and they all experienced emotional labour. Communicating with the patients and the families was a constant battle and this acted as a further stressor in meeting the needs of their patients. The concept of the family and the importance and meaning of religion and culture were central in the provision of caring. The beliefs and practices of patients who follow Islam, as perceived by expatriate nurses, may have an effect on the patient's health care in ways that are not apparent to many health-care professionals and policy makers internationally. Readers should be prompted to reflect on their clinical practice and to understand the impact of religious and cultural differences in their encounters with patients of Islam denomination. Policy and all actions, decisions and judgments should be culturally derived.

  12. Preventable Complications Driving Rising Costs in Management of Patients with Critical Limb Ischemia.

    Science.gov (United States)

    Dua, Anahita; Desai, Sapan S; Patel, Bhavin; Seabrook, Gary R; Brown, Kellie R; Lewis, Brian; Rossi, Peter J; Malinowski, Michael; Lee, Cheong J

    2016-05-01

    This study aimed to identify factors that drive increasing health-care costs associated with the management of critical limb ischemia in elective inpatients. Patients with a primary diagnosis code of critical limb ischemia (CLI) were identified from the 2001-2011 Nationwide Inpatient Sample. Demographics, CLI management, comorbidities, complications (bleeding, surgical site infection [SSI]), length of stay, and median in-hospital costs were reviewed. Statistical analysis was completed using Students' t-test and Mann-Kendall trend analysis. Costs are reported in 2011 US dollars corrected using the consumer price index. From 2001 to 2011, there were a total of 451,823 patients who underwent open elective revascularization as inpatients for CLI. Costs to treat CLI increased by 63% ($12,560 in 2001 to $20,517 in 2011, P cost of care. From 2001 to 2011, the number of patient comorbidities (7.56-12.40) and percentage of endovascular cases (13.4% to 27.4%) increased, accounting for a 6% annual increase in total cost despite decreased median length of stay (6 to 5 days). Patients who developed SSI had total costs 83% greater than patients without SSIs ($30,949 vs. $16,939; P costs 41% greater than nonbleeding patients ($23,779 vs. $16,821, P cost of CLI treatment is increasing and driven by rising endovascular use, SSI, and bleeding in the in-patient population. Further efforts to reduce complications in this patient population may contribute to a reduction in health care-associated costs of treating CLI. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Myasthenic crisis patients who require intensive care unit management.

    Science.gov (United States)

    Sakaguchi, Hideya; Yamashita, Satoshi; Hirano, Teruyuki; Nakajima, Makoto; Kimura, En; Maeda, Yasushi; Uchino, Makoto

    2012-09-01

    The purpose of this report was to investigate predictive factors that necessitate intensive care in myasthenic crisis (MC). We retrospectively reviewed MC patients at our institution and compared ICU and ward management groups. Higher MG-ADL scale scores, non-ocular initial symptoms, infection-triggered findings, and higher MGFA classification were observed more frequently in the ICU group. In patients with these prognostic factors, better outcomes may be obtained with early institution of intensive care. Copyright © 2012 Wiley Periodicals, Inc.

  14. Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model.

    Science.gov (United States)

    Best, Kaitlin M; Boullata, Joseph I; Curley, Martha A Q

    2015-02-01

    Analgesia and sedation are common therapies in pediatric critical care, and rapid titration of these medications is associated with iatrogenic withdrawal syndrome. We performed a systematic review of the literature to identify all common and salient risk factors associated with iatrogenic withdrawal syndrome and build a conceptual model of iatrogenic withdrawal syndrome risk in critically ill pediatric patients. Multiple databases, including PubMed/Medline, EMBASE, CINAHL, and the Cochrane Central Registry of Clinical Trials, were searched using relevant terms from January 1, 1980, to August 1, 2014. Articles were included if they were published in English and discussed iatrogenic withdrawal syndrome following either opioid or benzodiazepine therapy in children in acute or intensive care settings. Articles were excluded if subjects were neonates born to opioid- or benzodiazepine-dependent mothers, children diagnosed as substance abusers, or subjects with cancer-related pain; if data about opioid or benzodiazepine treatment were not specified; or if primary data were not reported. In total, 1,395 articles were evaluated, 33 of which met the inclusion criteria. To facilitate analysis, all opioid and/or benzodiazepine doses were converted to morphine or midazolam equivalents, respectively. A table of evidence was developed for qualitative analysis of common themes, providing a framework for the construction of a conceptual model. The strongest risk factors associated with iatrogenic withdrawal syndrome include duration of therapy and cumulative dose. Additionally, evidence exists linking patient, process, and system factors in the development of iatrogenic withdrawal syndrome. Most articles were prospective observational or interventional studies. Given the state of existing evidence, well-designed prospective studies are required to better characterize iatrogenic withdrawal syndrome in critically ill pediatric patients. This review provides data to support the

  15. Safety management of the patient with tracheostomy from a critical care unit.

    Directory of Open Access Journals (Sweden)

    Marleny CASASOLA-GIRÓN

    2018-03-01

    Full Text Available Introduction and objective: A patient with a tracheostomy has a high morbidity and mortality when comes to a general ward from the critical care unit. This situation has led us to develop a quality and safety program, to improve care and reduce the number of incidents that could endanger his life. Method: Adapting to our environment the recommendations of literature, the program is composed of four elements: standardized information, training of the staff involved, patient follow up and general scheme. Results: The elaborate documentation, offers the way of assessing a patient with tracheostomy, and carry out its assistance. Through interactive workshops, this information is transmitted to the staff responsible for these patients. The periodic inspection by an Otolaryngologist (ENT, an ENT nurse and an intensive care physician, allows to register the clinical situation and possible complications, applying specific protocols of decannulation and swallowing. Finally, we add a set of general rules, to decrease variability. Discussion: The multidisciplinary care in the patient with a tracheostomy is a complex intervention where the lack of previous data, the important number of neurocritical ill patients, the multiplicity of general wards that can accommodate these patients and its clinical diversity, make difficult proper monitoring. Conclusions: We are confident that this project can reach its goals, improving the quality and safety of patient carrier of a tracheal cannula.

  16. Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients.

    Science.gov (United States)

    Weijs, Peter J M; Looijaard, Wilhelmus G P M; Dekker, Ingeborg M; Stapel, Sandra N; Girbes, Armand R; Oudemans-van Straaten, H M; Beishuizen, Albertus

    2014-01-13

    Higher body mass index (BMI) is associated with lower mortality in mechanically ventilated critically ill patients. However, it is yet unclear which body component is responsible for this relationship. This retrospective analysis in 240 mechanically ventilated critically ill patients included adult patients in whom a computed tomography (CT) scan of the abdomen was made on clinical indication between 1 day before and 4 days after admission to the intensive care unit. CT scans were analyzed at the L3 level for skeletal muscle area, expressed as square centimeters. Cutoff values were defined by receiver operating characteristic (ROC) curve analysis: 110 cm2 for females and 170 cm2 for males. Backward stepwise regression analysis was used to evaluate low-muscle area in relation to hospital mortality, with low-muscle area, sex, BMI, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and diagnosis category as independent variables. This study included 240 patients, 94 female and 146 male patients. Mean age was 57 years; mean BMI, 25.6 kg/m2. Muscle area for females was significantly lower than that for males (102 ± 23 cm2 versus 158 ± 33 cm2; P muscle area was observed in 63% of patients for both females and males. Mortality was 29%, significantly higher in females than in males (37% versus 23%; P = 0.028). Low-muscle area was associated with higher mortality compared with normal-muscle area in females (47.5% versus 20%; P = 0.008) and in males (32.3% versus 7.5%; P muscle area, sex, and APACHE II score, whereas BMI and admission diagnosis were not. Odds ratio for low-muscle area was 4.3 (95% confidence interval, 2.0 to 9.0, P muscle mass appeared as primary predictor, not sex. Low skeletal muscle area, as assessed by CT scan during the early stage of critical illness, is a risk factor for mortality in mechanically ventilated critically ill patients, independent of sex and APACHE II score. Further analysis suggests muscle mass as primary predictor, not

  17. Sonographic and Clinical Features of Upper Extremity Deep Venous Thrombosis in Critical Care Patients

    Directory of Open Access Journals (Sweden)

    Michael Blaivas

    2012-01-01

    Full Text Available Background-Aim. Upper extremity deep vein thrombosis (UEDVT is an increasingly recognized problem in the critically ill. We sought to identify the prevalence of and risk factors for UEDVT, and to characterize sonographically detected thrombi in the critical care setting. Patients and Methods. Three hundred and twenty patients receiving a subclavian or internal jugular central venous catheter (CVC were included. When an UEDVT was detected, therapeutic anticoagulation was started. Additionally, a standardized ultrasound scan was performed to detect the extent of the thrombus. Images were interpreted offline by two independent readers. Results. Thirty-six (11.25% patients had UEDVT and a complete scan was performed. One (2.7% of these patients died, and 2 had pulmonary embolism (5.5%. Risk factors associated with UEDVT were presence of CVC [(odds ratio (OR 2.716, P=0.007], malignancy (OR 1.483, P=0.036, total parenteral nutrition (OR 1.399, P=0.035, hypercoagulable state (OR 1.284, P=0.045, and obesity (OR 1.191, P=0.049. Eight thrombi were chronic, and 28 were acute. We describe a new sonographic sign which characterized acute thrombosis: a double hyperechoic line at the interface between the thrombus and the venous wall; but its clinical significance remains to be defined. Conclusion. Presence of CVC was a strong predictor for the development of UEDVT in a cohort of critical care patients; however, the rate of subsequent PE and related mortality was low.

  18. Endogenous glutamine production in critically ill patients: the effect of exogenous glutamine supplementation.

    Science.gov (United States)

    Mori, Maiko; Rooyackers, Olav; Smedberg, Marie; Tjäder, Inga; Norberg, Ake; Wernerman, Jan

    2014-04-14

    Glutamine rate of appearance (Ra) may be used as an estimate of endogenous glutamine production. Recently a technique employing a bolus injection of isotopically labeled glutamine was introduced, with the potential to allow for multiple assessments of the glutamine Ra over time in critically ill patients, who may not be as metabolically stable as healthy individuals. Here the technique was used to evaluate the endogenous glutamine production in critically ill patients in the fed state with and without exogenous glutamine supplementation intravenously. Mechanically ventilated patients (n = 11) in the intensive care unit (ICU) were studied on two consecutive days during continuous parenteral feeding. To allow the patients to be used as their own controls, they were randomized for the reference measurement during basal feeding without supplementation, before or after the supplementation period. Glutamine Ra was determined by a bolus injection of 13C-glutamine followed by a period of frequent sampling to establish the decay-curve for the glutamine tracer. Exogenous glutamine supplementation was given by intravenous infusion of a glutamine containing dipeptide, L-alanyl-L-glutamine, 0.28 g/kg during 20 hours. A 14% increase of endogenous glutamine Ra was seen at the end of the intravenous supplementation period as compared to the basal measurements (P = 0.009). The bolus injection technique to measure glutamine Ra to estimate the endogenous production of glutamine in critically ill patients was demonstrated to be useful for repetitive measurements. The hypothesized attenuation of endogenous glutamine production during L-alanyl-L-glutamine infusion given as a part of full nutrition was not seen.

  19. Four hour creatinine clearance is better than plasma creatinine for monitoring renal function in critically ill patients

    Science.gov (United States)

    2012-01-01

    Introduction Acute kidney injury (AKI) diagnosis is based on an increase in plasma creatinine, which is a slowly changing surrogate of decreased glomerular filtration rate. We investigated whether serial creatinine clearance, a direct measure of the glomerular filtration rate, provided more timely and accurate information on renal function than serial plasma creatinine in critically ill patients. Methods Serial plasma creatinine and 4-hour creatinine clearance were measured 12-hourly for 24 hours and then daily in 484 patients. AKI was defined either as > 50% increase in plasma creatinine from baseline, or > 33.3% decrease in creatinine clearance. The diagnostic and predictive performance of the two AKI definitions were compared. Results Creatinine clearance decrease diagnosed AKI in 24% of those not diagnosed by plasma creatinine increase on entry. These patients entered the ICU sooner after insult than those diagnosed with AKI by plasma creatinine elevation (P = 0.0041). Mortality and dialysis requirement increased with the change in creatinine clearance-acute kidney injury severity class (P = 0.0021). Amongst patients with plasma creatinine creatinine clearance improved the prediction of AKI considerably (Net Reclassification Improvement 83%, Integrated Discrimination Improvement 0.29). On-entry, creatinine clearance associated with AKI severity and duration (P 33.3% decrease in creatinine clearance over the first 12 hours was associated with a 2.0-fold increased relative risk of dialysis or death. Conclusions Repeated 4-hour creatinine clearance measurements in critically ill patients allow earlier detection of AKI, as well as progression and recovery compared to plasma creatinine. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN012606000032550. PMID:22713519

  20. MCDA swing weighting and discrete choice experiments for elicitation of patient benefit-risk preferences: a critical assessment.

    Science.gov (United States)

    Tervonen, Tommi; Gelhorn, Heather; Sri Bhashyam, Sumitra; Poon, Jiat-Ling; Gries, Katharine S; Rentz, Anne; Marsh, Kevin

    2017-12-01

    Multiple criteria decision analysis swing weighting (SW) and discrete choice experiments (DCE) are appropriate methods for capturing patient preferences on treatment benefit-risk trade-offs. This paper presents a qualitative comparison of the 2 methods. We review and critically assess similarities and differences of SW and DCE based on 6 aspects: comprehension by study participants, cognitive biases, sample representativeness, ability to capture heterogeneity in preferences, reliability and validity, and robustness of the results. The SW choice task can be more difficult, but the workshop context in which SW is conducted may provide more support to patients who are unfamiliar with the end points being evaluated or who have cognitive impairments. Both methods are similarly prone to a number of biases associated with preference elicitation, and DCE is prone to simplifying heuristics, which limits its application with large number of attributes. The low cost per patient of the DCE means that it can be better at achieving a representative sample, though SW does not require such large sample sizes due to exact nature of the collected preference data. This also means that internal validity is automatically enforced with SW, while the internal validity of DCE results needs to be assessed manually. Choice between the 2 methods depends on characteristics of the benefit-risk assessment, especially on how difficult the trade-offs are for the patients to make and how many patients are available. Although there exist some empirical studies on many of the evaluation aspects, critical evidence gaps remain. Copyright © 2017 John Wiley & Sons, Ltd.

  1. Comparison of the Safety Critical Software V and V Requirements for the Research Reactor Instrumentation and Control System

    Energy Technology Data Exchange (ETDEWEB)

    Joo, Sungmoon; Suh, Yong-Suk; Park, Cheol [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

    2016-10-15

    This study was motivated by a research reactor project where the owner of the project and the equipment vendors are from two different standards frameworks. This paper reviews two major standards frameworks - NRC-IEEE and IAEA-IEC - and the software classification schemes as a background, then discuss the V and V issue. The purpose of this paper is by no means to solve the cross-standards-framework qualification issue, but, rather, is to remind the stakeholders of research reactor projects. V and V are also essential for the approval from regulatory bodies. As standards define or recommend consolidated engineering practices, methods, or criteria, V and V activities for software qualification are not exceptional. Within a standards framework, usually, the processes for the qualification of safety-critical software are well-established such that the safety is maximized while minimizing the compromises in software quality, safety, and reliability. When, however, multiple standards frameworks are involved in a research reactor project, it is difficult for equipment vendors to implement appropriate V and V activities as there is no unified view on this cross-standards-framework qualification issue yet. There are two major standards frameworks for safety-critical software development in nuclear industry. Unfortunately different safety classifications for software and thus different requirements for qualification are in place. What makes things worse is that (i) there are ambiguities in the standards and rooms for each stakeholders’ interpretation, and (ii) there is no one-to-one mapping between the associated V and V methods and activities. These may put the stakeholders of research reactor projects in trouble.

  2. Comparison of the Safety Critical Software V and V Requirements for the Research Reactor Instrumentation and Control System

    International Nuclear Information System (INIS)

    Joo, Sungmoon; Suh, Yong-Suk; Park, Cheol

    2016-01-01

    This study was motivated by a research reactor project where the owner of the project and the equipment vendors are from two different standards frameworks. This paper reviews two major standards frameworks - NRC-IEEE and IAEA-IEC - and the software classification schemes as a background, then discuss the V and V issue. The purpose of this paper is by no means to solve the cross-standards-framework qualification issue, but, rather, is to remind the stakeholders of research reactor projects. V and V are also essential for the approval from regulatory bodies. As standards define or recommend consolidated engineering practices, methods, or criteria, V and V activities for software qualification are not exceptional. Within a standards framework, usually, the processes for the qualification of safety-critical software are well-established such that the safety is maximized while minimizing the compromises in software quality, safety, and reliability. When, however, multiple standards frameworks are involved in a research reactor project, it is difficult for equipment vendors to implement appropriate V and V activities as there is no unified view on this cross-standards-framework qualification issue yet. There are two major standards frameworks for safety-critical software development in nuclear industry. Unfortunately different safety classifications for software and thus different requirements for qualification are in place. What makes things worse is that (i) there are ambiguities in the standards and rooms for each stakeholders’ interpretation, and (ii) there is no one-to-one mapping between the associated V and V methods and activities. These may put the stakeholders of research reactor projects in trouble

  3. Does this adult patient with suspected bacteremia require blood cultures?

    Science.gov (United States)

    Coburn, Bryan; Morris, Andrew M; Tomlinson, George; Detsky, Allan S

    2012-08-01

    Clinicians order blood cultures liberally among patients in whom bacteremia is suspected, though a small proportion of blood cultures yield true-positive results. Ordering blood cultures inappropriately may be both wasteful and harmful. To review the accuracy of easily obtained clinical and laboratory findings to inform the decision to obtain blood cultures in suspected bacteremia. A MEDLINE and EMBASE search (inception to April 2012) yielded 35 studies that met inclusion criteria for evaluating the accuracy of clinical variables for bacteremia in adult immunocompetent patients, representing 4566 bacteremia and 25,946 negative blood culture episodes. Data were extracted to determine the prevalence and likelihood ratios (LRs) of findings for bacteremia. The pretest probability of bacteremia varies depending on the clinical context, from low (eg, cellulitis: 2%) to high (eg, septic shock: 69%). Elevated temperatures alone do not accurately predict bacteremia (for ≥38°C [>100.3°F], LR, 1.9 [95% CI, 1.4-2.4]; for ≥38.5°C [>101.2°F], LR, 1.4 [95% CI, 1.1-2.0]), nor does isolated leukocytosis (LR, cultures should not be ordered for adult patients with isolated fever or leukocytosis without considering the pretest probability. SIRS and the decision rule may be helpful in identifying patients who do not need blood cultures. These conclusions do not apply to immunocompromised patients or when endocarditis is suspected.

  4. Effect of vitamin D on stress-induced hyperglycaemia and insulin resistance in critically ill patients.

    Science.gov (United States)

    Alizadeh, N; Khalili, H; Mohammadi, M; Abdollahi, A; Ala, S

    2016-05-01

    Effects of vitamin D supplementation on the glycaemic indices and insulin resistance in diabetic and non-diabetic patients were studied. In this study, effects of vitamin D supplementation on stress-induced hyperglycaemia and insulin resistance were evaluated in non-diabetic surgical critically ill patients. Adult surgical patients with stress-induced hyperglycaemia within the first 24 h of admission to the ICU were recruited. The patients randomly assigned to receive either vitamin D or placebo. Patients in the vitamin D group received a single dose of 600,000 IU vitamin D3 as intramuscular injection at time of recruitment. Besides demographic and clinical characteristics of the patients, plasma glucose, insulin, 25(OH) D and adiponectin levels were measured at the time of ICU admission and day 7. Homoeostasis model assessment for insulin resistance (HOMA-IR) and homestasis model assessment adiponectin (HOMA-AD) ratio were considered at the times of assessment. Comparing with the baseline, plasma 25(OH) D level significantly increased in the subjects who received vitamin D (p = 0.04). Improvement in fasting plasma glucose levels was detected in day 7 of the study compared with the baseline status in both groups. HOMA-IR showed a decrement pattern in vitamin D group (p = 0.09). Fasting plasma adiponectin levels increased significantly in the vitamin D group (p = 0.007), but not in the placebo group (p = 0.38). Finally, changes in HOMA-AD ratio were not significant in the both groups. Vitamin D supplementation showed positive effect on plasma adiponectin level, as a biomarker of insulin sensitivity in surgical critically ill patients with stress-induced hyperglycaemia. However, effects of vitamin D supplementation on HOMA-IR and HOMA-AD as indicators of insulin resistance were not significant. © 2016 John Wiley & Sons Ltd.

  5. Feasibility of a multiple-choice mini mental state examination for chronically critically ill patients.

    Science.gov (United States)

    Miguélez, Marta; Merlani, Paolo; Gigon, Fabienne; Verdon, Mélanie; Annoni, Jean-Marie; Ricou, Bara

    2014-08-01

    Following treatment in an ICU, up to 70% of chronically critically ill patients present neurocognitive impairment that can have negative effects on their quality of life, daily activities, and return to work. The Mini Mental State Examination is a simple, widely used tool for neurocognitive assessment. Although of interest when evaluating ICU patients, the current version is restricted to patients who are able to speak. This study aimed to evaluate the feasibility of a visual, multiple-choice Mini Mental State Examination for ICU patients who are unable to speak. The multiple-choice Mini Mental State Examination and the standard Mini Mental State Examination were compared across three different speaking populations. The interrater and intrarater reliabilities of the multiple-choice Mini Mental State Examination were tested on both intubated and tracheostomized ICU patients. Mixed 36-bed ICU and neuropsychology department in a university hospital. Twenty-six healthy volunteers, 20 neurological patients, 46 ICU patients able to speak, and 30 intubated or tracheostomized ICU patients. None. Multiple-choice Mini Mental State Examination results correlated satisfactorily with standard Mini Mental State Examination results in all three speaking groups: healthy volunteers: intraclass correlation coefficient = 0.43 (95% CI, -0.18 to 0.62); neurology patients: 0.90 (95% CI, 0.82-0.95); and ICU patients able to speak: 0.86 (95% CI, 0.70-0.92). The interrater and intrarater reliabilities were good (0.95 [0.87-0.98] and 0.94 [0.31-0.99], respectively). In all populations, a Bland-Altman analysis showed systematically higher scores using the multiple-choice Mini Mental State Examination. Administration of the multiple-choice Mini Mental State Examination to ICU patients was straightforward and produced exploitable results comparable to those of the standard Mini Mental State Examination. It should be of interest for the assessment and monitoring of the neurocognitive

  6. Antibiotic dosing in critically ill patients receiving CRRT: underdosing is overprevalent.

    Science.gov (United States)

    Lewis, Susan J; Mueller, Bruce A

    2014-01-01

    Published CRRT drug dosing algorithms and other dosing guidelines appear to result in underdosed antibiotics, leading to failure to attain pharmacodynamic targets. High mortality rates persist with inadequate antibiotic therapy as the most important risk factor for death. Reasons for unintended antibiotic underdosing in patients receiving CRRT are many. Underdosing may result from lack of the recognition that better hepatic function in AKI patients yields higher nonrenal antibiotic clearance compared to ESRD patients. Other factors include the variability in body size and fluid composition of patients, the serious consequence of delayed achievement of antibiotic pharmacodynamic targets in septic patients, potential subtherapeutic antibiotic concentrations at the infection site, and the influence of RRT intensity on antibiotic concentrations. Too often, clinicians weigh the benefits of overcautious antibiotic dosing to avoid antibiotic toxicity too heavily against the benefits of rapid attainment of therapeutic antibiotic concentrations in critically ill patients receiving CRRT. We urge clinicians to prescribe antibiotics aggressively for these vulnerable patients. © 2014 Wiley Periodicals, Inc.

  7. The association of plasma gamma-aminobutyric acid concentration with postoperative delirium in critically ill patients.

    Science.gov (United States)

    Yoshitaka, Shiho; Egi, Moritoki; Kanazawa, Tomoyuki; Toda, Yuichiro; Morita, Kiyoshi

    2014-12-01

    Delirium is a common complication in postoperative, critically ill patients. The mechanism of postoperative delirium is not well understood but many studies have shown significant associations between benzodiazepine use, alcohol withdrawal and cirrhosis, and an increased risk of delirium. We aimed to investigate a possible link with alterations of gamma-aminobutyric acid (GABA) activity. A prospective observational investigation of 40 patients > 20 years old who had undergone elective surgery with general anaesthesia and were expected to need postoperative intensive care for more than 48 hours. We assessed postoperative delirium using the confusion assessment method in the intensive care unit at 1 hour after the operation and on postoperative Day (POD) 1 and POD 2. We collected blood samples for measurement of plasma GABA concentrations before the operation and on POD 1 and 2. Postoperative delirium and perioperative plasma GABA concentrations in patients with and without delirium. Postoperative delirium occurred in 13 of the patients. Patients with delirium had significantly higher Acute Physiology and Chronic Health Evaluation II scores than patients without delirium. The mean plasma GABA concentration on POD 2 was significantly lower in patients with delirium than in those without delirium. After adjustment of relevant variables, plasma GABA concentration on POD 2 was independently associated with postoperative delirium. Plasma GABA level on POD 2 has a significant independent association with postoperative delirium.

  8. Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients.

    Science.gov (United States)

    Peris, Adriano; Bonizzoli, Manuela; Iozzelli, Dario; Migliaccio, Maria Luisa; Zagli, Giovanni; Bacchereti, Alberto; Debolini, Marta; Vannini, Elisetta; Solaro, Massimo; Balzi, Ilaria; Bendoni, Elisa; Bacchi, Ilaria; Trevisan, Monica; Giovannini, Valtere; Belloni, Laura

    2011-01-01

    Critically ill patients who require intensive care unit (ICU) treatment may experience psychological distress with increasing development of psychological disorders and related morbidity. Our aim was to determine whether intra-ICU clinical psychologist interventions decrease the prevalence of anxiety, depression and posttraumatic stress disorder (PTSD) after 12 months from ICU discharge. Our observational study included critical patients admitted before clinical psychologist intervention (control group) and patients who were involved in a clinical psychologist program (intervention group). The Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale-Revised questionnaires were used to assess the level of posttraumatic stress, anxiety and depression symptoms. The control and intervention groups showed similar demographic and clinical characteristics. Patients in the intervention group showed lower rates of anxiety (8.9% vs. 17.4%) and depression (6.5% vs. 12.8%) than the control group on the basis of HADS scores, even if the differences were not statistically significant. High risk for PTSD was significantly lower in patients receiving early clinical psychologist support than in the control group (21.1% vs. 57%; P < 0.0001). The percentage of patients who needed psychiatric medications at 12 months was significantly higher in the control group than in the patient group (41.7% vs. 8.1%; P < 0.0001). Our results suggest that that early intra-ICU clinical psychologist intervention may help critically ill trauma patients recover from this stressful experience.

  9. Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients.

    Science.gov (United States)

    Mathews, Kusum S; Durst, Matthew S; Vargas-Torres, Carmen; Olson, Ashley D; Mazumdar, Madhu; Richardson, Lynne D

    2018-05-01

    ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality. A retrospective cohort study. Single academic tertiary care hospital. Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period. None. Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase). ICU admission decisions for

  10. Clinical course teaching in transport of critically ill patients: Small group methods

    Directory of Open Access Journals (Sweden)

    Mohammad Taghi Beigmohammadi

    2016-10-01

    Full Text Available Critically ill patient transfer is potentially risky and may be lead to morbidity and mortality. Physicians' skill is very important for safe transport. We want to evaluate the effect of clinical course teaching on the promotion of physicians' abilities in the transport of critically ill patients. In an interventional study, 320 interns, male and female, were taught about patient transfer in two groups include in one day clinical course as the small group system (n=160 and other group the lecture base learning (n=160. In the clinical course, each participant under observation of an anesthesiologist in the operation room and ICU was acquainted with mask ventilation, intubation and learned to work with a defibrillator, infusion pump, portable ventilator and pulse oximeter. In lecture group, the anesthesiologist explained the topics by video and dummy. At the end of education course, the interns’ abilities were evaluated based on checklist method and scored by the project colleague in all educational items. Three hundred twenty interns, 122 males, and 198 females; were enrolled, two groups. The clinical course training caused improvements in the interns’ knowledge and abilities in intubation and use of the defibrillator and portable ventilator vs.lecture group significantly (P<0.005. The males were better than females in laryngoscopy, but the progress of the females was significantly better than males (P=0.003. The rate of adverse events was reduced significantly after clinical course teaching (P=0.041 Clinical course teaching could promote interns' clinical competencies in the transport of critically ill patients.

  11. Neuromuscular electrical stimulation for preventing skeletal-muscle weakness and wasting in critically ill patients

    DEFF Research Database (Denmark)

    Maffiuletti, Nicola A.; Roig, Marc; Karatzanos, Eleftherios

    2013-01-01

    ill patients, in comparison with usual care. Methods: We searched PubMed, CENTRAL, CINAHL, Web of Science, and PEDro to identify randomized controlled trials exploring the effect of NMES in critically ill patients, which had a well-defined NMES protocol, provided outcomes related to skeletal......-muscle strength and/or mass, and for which full text was available. Two independent reviewers extracted data on muscle-related outcomes (strength and mass), and participant and intervention characteristics, and assessed the methodological quality of the studies. Owing to the lack of means and standard deviations...... yielded 8 eligible studies involving 172 patients. The methodological quality of the studies was moderate to high. Five studies reported an increase in strength or better preservation of strength with NMES, with one study having a large effect size. Two studies found better preservation of muscle mass...

  12. Bypassing non-adherence via PEG in a critically ill HIV-1-infected patient.

    Science.gov (United States)

    Leipe, J; Hueber, A J; Rech, J; Harrer, T

    2008-08-01

    This case study describes a 44-year-old, chronically non-adherent, HIV-infected male with relapsing, life threatening toxoplasmic encephalitis (TE) and other recurring opportunistic infections. Non-adherence resulted in critical illness, suppressed CD4 lymphocyte count and elevated viral load. In order to bypass the patient's complete psychological aversion to taking medication, and after exhausting various psychological interventions, a percutaneous endoscopic gastronomy (PEG) tube was inserted for delivery of indispensable medication. During the 15-month follow-up the patient was adherent, exhibiting a consistently undetectable viral load, high CD4 count and a remission of the opportunistic infections. This is an interesting case study demonstrating life-saving and long-term benefit of PEG in an exceptional setting, which has implications for future research and treatment of non-adherent HIV-infected patients.

  13. Expression of NK cell and monocyte receptors in critically ill patients - potential biomarkers of sepsis

    DEFF Research Database (Denmark)

    Kjaergaard, A G; Nielsen, Jeppe Sylvest; Tønnesen, Else

    2015-01-01

    UNLABELLED: Sepsis is characterized by activation of both the innate and adaptive immune systems as a response to infection. During sepsis, the expression of surface receptors expressed on immune competent cells, such as NKG2D and NKp30 on NK cells and TLR4 and CD14 on monocytes, is partly...... regulated by pro- and anti-inflammatory mediators. In this observational study, we aimed to explore whether the expression of these receptors could be used as diagnostic and/or prognostic biomarkers in sepsis. Patients with severe sepsis or septic shock (n = 21) were compared with critically ill non...... were higher in the septic patients compared with the non-septic patients (P sepsis...

  14. A critical analysis of national policies, systems, and structures of patient empowerment in England and Greece.

    Science.gov (United States)

    Boudioni, Markella; McLaren, Susan; Lister, Graham

    2017-01-01

    Comparison of patient empowerment (PE) policies in European countries can provide evidence for improvement and reform across different health systems. It may also influence patient and public involvement, patient experience, preference, and adherence. The objective of this study was to compare PE within national policies, systems, and structures in England and Greece for achieving integrated people-centered health services. We performed a critical search and review of policy and legislation papers in English and Greek languages. This included 1) general health policy and systems papers, 2) PE, patient and/or public involvement or patients' rights policy and legislation (1990-2015), and 3) comparative or discussion papers for England and/or Greece. A total of 102 papers on PE policies, systems, and structures were identified initially; 80 papers were included, in which 46 were policy, legislative, and discussion papers about England, 21 were policy, legislation, and discussion papers about Greece, and 13 were comparative or discussion papers including both the countries. In England, National Health Service policies emphasized patient-centered services, involvement, and empowerment, with recent focus on patients' rights; while in Greece, they emphasized patients' rights and quality of services, with recent mentions on empowerment. The health ombudsman is a very important organization across countries; however, it may be more powerful in Greece, because of the nonexistence of local mediating bodies. Micro-structures at trusts/hospitals are comparable, but legislation gives more power to the local structures in Greece. PE policies and systems have been developed and expressed differently in these countries. However, PE similarities, comparable dimensions and mechanisms, were identified. For both the countries, comparative research and these findings could be beneficial in building connections and relationships, contributing to wider European and international

  15. Temporal Trends in the Use of Parenteral Nutrition in Critically Ill Patients

    Science.gov (United States)

    Kahn, Jeremy M.; Wunsch, Hannah

    2014-01-01

    Background: Clinical practice guidelines recommend enteral over parenteral nutrition in critical illness and do not recommend early initiation. Few data are available on parenteral nutrition use or timing of initiation in the ICU or how this use may have changed over time. Methods: We used the Project IMPACT database to evaluate temporal trends in parenteral nutrition use (total and partial parenteral nutrition and lipid supplementation) and timing of initiation in adult ICU admissions from 2001 to 2008. We used χ2 tests and analysis of variance to examine characteristics of patients receiving parenteral nutrition and multilevel multivariate logistic regression models to assess parenteral nutrition use over time, in all patients and in specific subgroups. Results: Of 337,442 patients, 20,913 (6.2%) received parenteral nutrition. Adjusting for patient characteristics, the use of parenteral nutrition decreased modestly over time (adjusted probability, 7.2% in 2001-2002 vs 5.5% in 2007-2008, P nutrition use increased simultaneously (adjusted probability, 11.5% in 2001-2002 vs 15.3% in 2007-2008, P parenteral nutrition declined most rapidly in emergent surgical patients, patients with moderate illness severity, patients in the surgical ICU, and patients admitted to an academic facility (P ≤ .01 for all interactions with year). When used, parenteral nutrition was initiated a median of 2 days (interquartile range, 1-3), after ICU admission and > 90% of patients had parenteral nutrition initiated within 7 days; timing of initiation of parenteral nutrition did not change from 2001 to 2008. Conclusions: Use of parenteral nutrition in US ICUs declined from 2001 through 2008 in all patients and in all examined subgroups, with the majority of parenteral nutrition initiated within the first 7 days in ICU; enteral nutrition use coincidently increased over the same time period. PMID:24233390

  16. Mesenteric panniculitis patients requiring emergency surgery: report of three cases.

    Science.gov (United States)

    Duman, Mustafa; Koçak, Osman; Fazli, Olgaç; Koçak, Cengiz; Atici, Ali Emre; Duman, Uğur

    2012-04-01

    Mesenteric panniculitis is a rare, benign disease characterized by a chronic non-specific inflammatory process of mesenteric fat tissue with unknown etiology. The small bowel mesentery is affected mostly. This process rarely involves the large intestine mesentery. Mesenteric panniculitis includes symptoms as abdominal pain, nausea and vomiting, diarrhea, constipation, and fever. In our cases, we had difficulty in the preoperative diagnosis as the clinical changes imitated an obstruction or ischemia of the small bowel. All the cases required emergency abdominal surgery and partial jejunal resection. The aim of this article was to present three cases of mesenteric panniculitis of the small bowel mesentery requiring emergency surgery together with a short review of the literature.

  17. [Experts consensus on the management of the right heart function in critically ill patients].

    Science.gov (United States)

    Wang, X T; Liu, D W; Zhang, H M; Long, Y; Guan, X D; Qiu, H B; Yu, K J; Yan, J; Zhao, H; Tang, Y Q; Ding, X; Ma, X C; Du, W; Kang, Y; Tang, B; Ai, Y H; He, H W; Chen, D C; Chen, H; Chai, W Z; Zhou, X; Cui, N; Wang, H; Rui, X; Hu, Z J; Li, J G; Xu, Y; Yang, Y; Ouyan, B; Lin, H Y; Li, Y M; Wan, X Y; Yang, R L; Qin, Y Z; Chao, Y G; Xie, Z Y; Sun, R H; He, Z Y; Wang, D F; Huang, Q Q; Jiang, D P; Cao, X Y; Yu, R G; Wang, X; Chen, X K; Wu, J F; Zhang, L N; Yin, M G; Liu, L X; Li, S W; Chen, Z J; Luo, Z

    2017-12-01

    To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle. (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of

  18. [Establishment of comprehensive prediction model of acute gastrointestinal injury classification of critically ill patients].

    Science.gov (United States)

    Wang, Yan; Wang, Jianrong; Liu, Weiwei; Zhang, Guangliang

    2018-03-25

    To develop the comprehensive prediction model of acute gastrointestinal injury (AGI) grades of critically ill patients. From April 2015 to November 2015, the binary channel gastrointestinal sounds (GIS) monitor system which has been developed and verified by the research group was used to gather and analyze the GIS of 60 consecutive critically ill patients who were admitted in Critical Care Medicine of Chinese PLA General Hospital. Also, the AGI grades (Grande I(-IIII(, the higher the level, the heavier the gastrointestinal dysfunction) were evaluated. Meanwhile, the clinical data and physiological and biochemical indexes of included patients were collected and recorded daily, including illness severity score (APACHE II( score, consisting of the acute physiology score, age grade and chronic health evaluation), sequential organ failure assessment (SOFA score, including respiration, coagulation, liver, cardioascular, central nervous system and kidney) and Glasgow coma scale (GCS); body mass index, blood lactate and glucose, and treatment details (including mechanical ventilation, sedatives, vasoactive drugs, enteral nutrition, etc.) Then principal component analysis was performed on the significantly correlated GIS (five indexes of gastrointestinal sounds were found to be negatively correlated with AGI grades, which included the number, percentage of time, mean power, maximum power and maximum time of GIS wave from the channel located at the stomach) and clinical factors after standardization. The top 5 post-normalized main components were selected for back-propagation (BP) neural network training, to establish comprehensive AGI grades models of critically ill patients based on the neural network model. The 60 patients aged 19 to 98 (mean 54.6) years and included 42 males (70.0%). There were 22 cases of multiple fractures, 15 cases of severe infection, 7 cases of cervical vertebral fracture, 7 cases of aortic repair, 5 cases of post-toxicosis and 4 cases of cerebral

  19. Identification of critical regions in human SAMHD1 required for nuclear localization and Vpx-mediated degradation.

    Science.gov (United States)

    Guo, Haoran; Wei, Wei; Wei, Zhenhong; Liu, Xianjun; Evans, Sean L; Yang, Weiming; Wang, Hong; Guo, Ying; Zhao, Ke; Zhou, Jian-Ying; Yu, Xiao-Fang

    2013-01-01

    The sterile alpha motif (SAM) and HD domain-containing protein-1 (SAMHD1) inhibits the infection of resting CD4+ T cells and myeloid cells by human and related simian immunodeficiency viruses (HIV and SIV). Vpx inactivates SAMHD1 by promoting its proteasome-dependent degradation through an interaction with CRL4 (DCAF1) E3 ubiquitin ligase and the C-terminal region of SAMHD1. However, the determinants in SAMHD1 that are required for Vpx-mediated degradation have not been well characterized. SAMHD1 contains a classical nuclear localization signal (NLS), and NLS point mutants are cytoplasmic and resistant to Vpx-mediated degradation. Here, we demonstrate that NLS-mutant SAMHD1 K11A can be rescued by wild-type SAMHD1, restoring its nuclear localization; consequently, SAMHD1 K11A became sensitive to Vpx-mediated degradation in the presence of wild-type SAMHD1. Surprisingly, deletion of N-terminal regions of SAMHD1, including the classical NLS, generated mutant SAMHD1 proteins that were again sensitive to Vpx-mediated degradation. Unlike SAMHD1 K11A, these deletion mutants could be detected in the nucleus. Interestingly, NLS-defective SAMHD1 could still bind to karyopherin-β1 and other nuclear proteins. We also determined that the linker region between the SAM and HD domain and the HD domain itself is important for Vpx-mediated degradation but not Vpx interaction. Thus, SAMHD1 contains an additional nuclear targeting mechanism in addition to the classical NLS. Our data indicate that multiple regions in SAMHD1 are critical for Vpx-mediated nuclear degradation and that association with Vpx is not sufficient for Vpx-mediated degradation of SAMHD1. Since the linker region and HD domain may be involved in SAMHD1 multimerization, our results suggest that SAMHD1 multimerization may be required for Vpx-mediation degradation.

  20. Cumulative radiation dose caused by radiologic studies in critically ill trauma patients.

    Science.gov (United States)

    Kim, Patrick K; Gracias, Vicente H; Maidment, Andrew D A; O'Shea, Michael; Reilly, Patrick M; Schwab, C William

    2004-09-01

    Critically ill trauma patients undergo many radiologic studies, but the cumulative radiation dose is unknown. The purpose of this study was to estimate the cumulative effective dose (CED) of radiation resulting from radiologic studies in critically ill trauma patients. The study group was composed of trauma patients at an urban Level I trauma center with surgical intensive care unit length of stay (LOS) greater than 30 days. The radiology records were reviewed. A typical effective dose per study for each type of plain film radiograph, computed tomographic scan, fluoroscopic study, and nuclear medicine study was used to calculate CED. Forty-six patients met criteria. The mean surgical intensive care unit and hospital LOS were 42.7 +/- 14.0 and 59.5 +/- 28.5 days, respectively. The mean Injury Severity Score was 32.2 +/- 15.0. The mean number of studies per patient was 70.1 +/- 29.0 plain film radiographs, 7.8 +/- 4.1 computed tomographic scans, 2.5 +/- 2.6 fluoroscopic studies, and 0.065 +/- 0.33 nuclear medicine study. The mean CED was 106 +/- 59 mSv per patient (range, 11-289 mSv; median, 104 mSv). Among age, mechanism, Injury Severity Score, and LOS, there was no statistically significant predictor of high CED. The mean CED in the study group was 30 times higher than the average yearly radiation dose from all sources for individuals in the United States. The theoretical additional morbidity attributable to radiologic studies was 0.78%. From a radiobiologic perspective, risk-to-benefit ratios of radiologic studies are favorable, given the importance of medical information obtained. Current practice patterns regarding use of radiologic studies appear to be acceptable.

  1. Percutaneous treatment of critical lower limb ischemia in patients with obstruction of the crural arteries

    International Nuclear Information System (INIS)

    Falkowski, A.; Rutkowski, D.; Poncyliusz, W.; Sienko, J.

    2006-01-01

    This article describes the application of percutaneous transluminal angioplasty (PTA) in the treatment of crural artery obstruction in patients with critical lower limb ischemia. In 17 patients, 24 PTAs of crural artery obstructions were performed. The clinical material consisted of 9 men and 8 women, whose mean age was 72 years (range 54-85 years). 11 patients were classified in clinical stage Fontaine IV, and 6 in stage III. The obstructions were from 3 to 21 cm (mean 6 cm). In 8 cases, PTA of the femoropopliteal segment was also carried out. The risk factors and comorbidities included diabetes 10 cases (58.8%), hypertension 9 cases (56%), ischemic heart disease 8 cases (50%), hyperlipidaemia 7 cases (43.8%), cerebrovascular diseases 3 cases (18.8%), and cigarette smoking 6 cases (37.5%). Technical success was defined as restoration of the artery along its whole length to the foot. Pain relief at rest and healing of trophic lesions at 30-day follow-up were recognized as a good outcome. Technical success was achieved in 12 patients (70.6%). In 2 cases the patency was only restored in the proximal part of the artery (12.5%). In 3 cases (17.6%) the procedure failed. In one case acute occlusion of the artery occurred. In 2 cases the obstruction was not successfully passed with a guidewire. In 4 cases hematoma was found at the puncture site, without clinical consequences. In 13 patients (76.4%) clinical success was achieved. Percutaneous transluminal angioplasty is an effective and relatively safe method of treatment of patients with critical limb ischemia caused by obstruction of the crural arteries. (author)

  2. Nurses Use of Critical Care Pain Observational Tool in Patients with Low Consciousness

    Directory of Open Access Journals (Sweden)

    Ahmad-Ali Asadi-Noghabi

    2015-07-01

    Full Text Available Objectives: The diagnosis of pain in patients with low consciousness is a major challenge in the intensive care unit (ICU. Therefore, the use of behavioral tools for pain assessment could be an effective tool to manage pain in this group of patients. The aim of this study was to determine the effects on pain management by nurses using a critical care pain observational tool in patients with a decreased level of consciousness. Methods: Our research used a before and after design to evaluate the ability of nurses to manage pain in patients with low consciousness. A total of 106 ICU nurses were included in the study. The study was divided into three phases: pre-implementation, implementation, and post-implementation. The researchers first observed the nurses management of pain in their patients; this was done three times using a checklist following tracheal suctioning and position change procedures. The nurses were then taught how to apply the critical-care pain observational tool (CPOT. Post-implementation of the tool, the researchers re-evaluated trained the nurses’ pain management. Results: Performance scores after training improved with relation to the nurses diagnosis of pain, pharmacological and nonpharmacological actions, reassessment of pain, and re-relieving of any pain. However, use of the tool did not improve the recording of the patient’s pain and the relief measures used. Conclusion: Use of the CPOT can increase nurse’s sensitivity to pain in non-conscious patients and drive them to track and perform pain management.

  3. Evaluation of the i-STAT point-of-care analyzer in critically ill adult patients.

    Science.gov (United States)

    Steinfelder-Visscher, Jacoline; Teerenstra, Steven; Gunnewiek, Jacqueline M T Klein; Weerwind, Patrick W

    2008-03-01

    Point-of-care analyzers may benefit therapeutic decision making by reducing turn-around-time for samples. This is especially true when biochemical parameters exceed the clinical reference range, in which acute and effective treatment is essential. We therefore evaluated the analytical performance of the i-STAT point-of-care analyzer in two critically ill adult patient populations. During a 3-month period, 48 blood samples from patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and 42 blood samples from non-cardiac patients who needed intensive care treatment were analyzed on both the i-STAT analyzer (CPB and non-CPB mode, respectively) and our laboratory analyzers (RapidLab 865/Sysmex XE-2100 instrument). The agreement analysis for quantitative data was used to compare i-STAT to RapidLab for blood gas/electrolytes and for hematocrit with the Sysmex instrument. Point-of-care electrolytes and blood gases had constant deviation, except for pH, pO2, and hematocrit. A clear linear trend in deviation of i-STAT from RapidLab was noticed for pH during CPB (r = 0.32, p = .03) and for pO2 > 10 kPa during CPB (r = -0.59, p pO2 pO2 pO2 range (10.6 pO2 range below 25% (n = 11) using the i-STAT. The i-STAT analyzer is suitable for point-of-care testing of electrolytes and blood gases in critically ill patients, except for high pO2. However, the discrepancy in hematocrit bias shows that accuracy established in one patient population cannot be automatically extrapolated to other patient populations, thus stressing the need for separate evaluation.

  4. Omcg1 is critically required for mitosis in rapidly dividing mouse intestinal progenitors and embryonic stem cells.

    Science.gov (United States)

    Léguillier, Teddy; Vandormael-Pournin, Sandrine; Artus, Jérôme; Houlard, Martin; Picard, Christel; Bernex, Florence; Robine, Sylvie; Cohen-Tannoudji, Michel

    2012-07-15

    Recent studies have shown that factors involved in transcription-coupled mRNA processing are important for the maintenance of genome integrity. How these processes are linked and regulated in vivo remains largely unknown. In this study, we addressed in the mouse model the function of Omcg1, which has been shown to participate in co-transcriptional processes, including splicing and transcription-coupled repair. Using inducible mouse models, we found that Omcg1 is most critically required in intestinal progenitors. In absence of OMCG1, proliferating intestinal epithelial cells underwent abnormal mitosis followed by apoptotic cell death. As a consequence, the crypt proliferative compartment of the small intestine was quickly and totally abrogated leading to the rapid death of the mice. Lack of OMCG1 in embryonic stem cells led to a similar cellular phenotype, with multiple mitotic defects and rapid cell death. We showed that mutant intestinal progenitors and embryonic stem cells exhibited a reduced cell cycle arrest following irradiation, suggesting that mitotic defects may be consecutive to M phase entry with unrepaired DNA damages. These findings unravel a crucial role for pre-mRNA processing in the homeostasis of the small intestine and point to a major role of OMCG1 in the maintenance of genome integrity.

  5. Omcg1 is critically required for mitosis in rapidly dividing mouse intestinal progenitors and embryonic stem cells

    Directory of Open Access Journals (Sweden)

    Teddy Léguillier

    2012-05-01

    Recent studies have shown that factors involved in transcription-coupled mRNA processing are important for the maintenance of genome integrity. How these processes are linked and regulated in vivo remains largely unknown. In this study, we addressed in the mouse model the function of Omcg1, which has been shown to participate in co-transcriptional processes, including splicing and transcription-coupled repair. Using inducible mouse models, we found that Omcg1 is most critically required in intestinal progenitors. In absence of OMCG1, proliferating intestinal epithelial cells underwent abnormal mitosis followed by apoptotic cell death. As a consequence, the crypt proliferative compartment of the small intestine was quickly and totally abrogated leading to the rapid death of the mice. Lack of OMCG1 in embryonic stem cells led to a similar cellular phenotype, with multiple mitotic defects and rapid cell death. We showed that mutant intestinal progenitors and embryonic stem cells exhibited a reduced cell cycle arrest following irradiation, suggesting that mitotic defects may be consecutive to M phase entry with unrepaired DNA damages. These findings unravel a crucial role for pre-mRNA processing in the homeostasis of the small intestine and point to a major role of OMCG1 in the maintenance of genome integrity.

  6. Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU.

    Science.gov (United States)

    Droogh, Joep M; Kruger, Hanneke L; Ligtenberg, Jack J M; Zijlstra, Jan G

    2012-12-01

    Transporting critically ill ICU patients by standard ambulances, with or without an accompanying physician, imposes safety risks. In 2007 the Dutch Ministry of Public Health required that all critically ill patients transferred between ICUs in different hospitals be transported by a mobile ICU (MICU). Since March 2009 a specially designed MICU and a retrieval team have served the region near University Medical Center Groningen, in the northeastern region of the Netherlands. The MICU transport program includes simulator-based crew resource management (CRM) training for the intensivists and ICU nurses, who, with the drivers, constitute the MICU crews. Training entails five pivotal aspects: (1) preparation, (2) teamwork, (3) new equipment, (4) mobility, and (5) safety. For example, the training accustoms participants to working in the narrow, moving ambulance and without benefit of additional manpower. The scenario-based team training, which takes about four hours, occurs in a training facility, with its reconstructed ICU, and then in the MICU itself. A "wireless" patient simulator that is able to mimic hemodynamic and respiratory patterns and to simulate lung and heart sounds is used. All scenarios can be adjusted to simulate medical, logistic, or technical problems. Since the start of MICU training in 2009, more than 70 training sessions, involving 100 team members, have been conducted. Quality issues identified include failure to anticipate possible problems (such as failing to ask for intubation of a respiratory-compromised patient at intake); late responses to alarms of the ventilator, perfusor pump, or monitor; and not anticipating a possible shortage of medication. Setting up and implementing simulator-based CRM training provides feasible and helpful preparation for an MICU team.

  7. Impact of outlier status on critical care patient outcomes: Does boarding medical intensive care unit patients make a difference?

    Science.gov (United States)

    Ahmad, Danish; Moeller, Katherine; Chowdhury, Jared; Patel, Vishal; Yoo, Erika J

    2018-04-01

    To evaluate the impact of outlier status, or the practice of boarding ICU patients in distant critical care units, on clinical and utilization outcomes. Retrospective observational study of all consecutive admissions to the MICU service between April 1, 2014-January 3, 2016, at an urban university hospital. Of 1931 patients, 117 were outliers (6.1%) for the entire duration of their ICU stay. In adjusted analyses, there was no association between outlier status and hospital (OR 1.21, 95% CI 0.72-2.05, p=0.47) or ICU mortality (OR 1.20, 95% CI 0.64-2.25, p=0.57). Outliers had shorter hospital and ICU lengths of stay (LOS) in addition to fewer ventilator days. Crossover patients who had variable outlier exposure also had no increase in hospital (OR 1.61; 95% CI 0.80-3.23; p=0.18) or ICU mortality (OR 1.05; 95% CI 0.43-2.54; p=0.92) after risk-adjustment. Boarding of MICU patients in distant units during times of bed nonavailability does not negatively influence patient mortality or LOS. Increased hospital and ventilator utilization observed among non-outliers in the home unit may be attributable, at least in part, to differences in patient characteristics. Prospective investigation into the practice of ICU boarding will provide further confirmation of its safety. Copyright © 2017 Elsevier Inc. All rights reserved.

  8. [Respiratory infections caused by Aspergillus spp. in critically ill patients admitted to the intensive care units].

    Science.gov (United States)

    Álvarez Lerma, F; Olaechea Astigarraga, P; Palomar Martínez, M; Rodríguez Carvajal, M; Machado Casas, J F; Jiménez Quintana, M M; Esteve Urbano, F; Ballesteros Herráez, J C; Zavala Zegarra, E

    2015-04-01

    The presence of respiratory fungal infection in the critically ill patient is associated with high morbidity and mortality. To assess the incidence of respiratory infection caused by Aspergillus spp. independently of the origin of infection in patients admitted to Spanish ICUs, as well as to describe the rates, characteristics, outcomes and prognostic factors in patients with this type of infection. An observational, retrospective, open-label and multicenter study was carried out in a cohort of patients with respiratory infection caused by Aspergillus spp. admitted to Spanish ICUs between 2006 and 2012 (months of April, May and June), and included in the ENVIN-HELICS registry (108,244 patients and 825,797 days of ICU stay). Variables independently related to in-hospital mortality were identified by multiple logistic regression analysis. A total of 267 patients from 79 of the 198 participating ICUs were included (2.46 cases per 1000 ICU patients and 3.23 episodes per 10,000 days of ICU stay). From a clinical point of view, infections were classified as ventilator-associated pneumonia in 93 cases (34.8%), pneumonia unrelated to mechanical ventilation in 120 cases (44.9%), and tracheobronchitis in 54 cases (20.2%). The study population included older patients (mean 64.8±17.1 years), with a high severity level (APACHE II score 22.03±7.7), clinical diseases (64.8%) and prolonged hospital stay before the identification of Aspergillus spp. (median 11 days), transferred to the ICU mainly from hospital wards (58.1%) and with high ICU (57.3%) and hospital (59.6%) mortality rates, exhibiting important differences depending on the type of infection involved. Independent mortality risk factors were previous admission to a hospital ward (OR=7.08, 95%CI: 3.18-15.76), a history of immunosuppression (OR=2.52, 95%CI: 1.24-5.13) and severe sepsis or septic shock (OR=8.91, 95%CI: 4.24-18.76). Respiratory infections caused by Aspergillus spp. in critically ill patients admitted to

  9. Current status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review

    Directory of Open Access Journals (Sweden)

    P Priyanka Niranjane

    2014-01-01

    Full Text Available Rehabilitation of cleft lip and palate (CLP patients is a challenge for all the concerned members of the cleft team, and various treatment modalities have been attempted to obtain aesthetic results. Presurgical infant orthopaedics (PSIO was introduced to reshape alveolar and nasal segments prior to surgical repair of cleft lip. However, literature reports lot of controversy regarding the use of PSIO in patients with CLP. Evaluation of long-term results of PSIO can provide scientific evidence on the efficacy and usefulness of PSIO in CLP patients. The aim was to assess the scientific evidence on the efficiency of PSIO appliances in patients with CLP and to critically analyse the current status of PSIO. A PubMed search was performed using the terms PSIO, presurgical nasoalveolar moulding and its long-term results and related articles were selected for the review. The documented studies report no beneficial effect of PSIO on maxillary arch dimensions, facial aesthetics and in the subsequent development of dentition and occlusion in CLP patients. Nasal moulding seems to be more beneficial and effective in unilateral cleft lip and palate patients with better long-term results.

  10. Secondary Sclerosing Cholangitis in Critically Ill Patients: Clinical Presentation, Cholangiographic Features, Natural History, and Outcome: A Series of 16 Cases.

    Science.gov (United States)

    Leonhardt, Silke; Veltzke-Schlieker, Wilfried; Adler, Andreas; Schott, Eckart; Eurich, Dennis; Faber, Wladimir; Neuhaus, Peter; Seehofer, Daniel

    2015-12-01

    Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an important differential diagnosis in patients presenting with cholestasis and PSC-like cholangiographic changes in endoscopic retrograde cholangiography (ERC). As a relatively newly described entity, SSC-CIP is still underdiagnosed, and the diagnosis is often delayed. The present study aims to improve the early detection of SSC-CIP and the identification of its complications.A total of 2633 records of patients who underwent or were listed for orthotopic liver transplantation at the University Hospital Charité, Berlin, were analyzed retrospectively. The clinical presentation and outcome (mean follow-up 62.7 months) of the 16 identified SSC-CIP cases were reviewed.Cholestasis was the first sign of SSC-CIP. GGT was the predominant enzyme of cholestasis. Hypercholesterolemia occurred in at least 75% of the patients. SSC-CIP provoked a profound weight loss (mean 18 kg) in 94% of our patients. SSC-CIP was diagnosed by ERC in all patients. The 3 different cholangiographic features detected correspond roughly to the following stages: (I) evidence of biliary casts, (II) progressive destruction of intrahepatic bile ducts, and (III) picture of pruned tree. Biliary cast formation is a hallmark of SSC-CIP and was seen in 87% of our cases. In 75% of the patients, the clinical course was complicated by cholangiosepsis, cholangitic liver abscesses, acalculous cholecystitis, or gallbladder perforation. SSC-CIP was associated with worse prognosis; transplant-free survival was ∼40 months (mean).Because of its high rate of serious complications and unfavorable prognosis, it is imperative to diagnose SSC-CIP early and to differentiate SSC-CIP from other types of sclerosing cholangitis. Specific characteristics enable identification of SSC-CIP. Early cooperation with a transplant center and special attention to biliary complications are required after diagnosis of SSC-CIP.

  11. Factors precipitating the risk of aspiration in hospitalized patients: findings from a multicentre critical incident technique study.

    Science.gov (United States)

    Palese, Alvisa; Lesa, Lucia; Stroppolo, Giulia; Lupieri, Giulia; Tardivo, Stefano; Brusaferro, Silvio

    2017-04-01

    To elucidate factors, other than those clinical, precipitating the risk of aspiration in hospitalized patients. The Critical Incident Technique was adopted for this study in 2015. Three departments located in two academic hospitals in the northeast of Italy, equipped with 800 and 1500 beds, respectively. A purposeful sample of 12 registered nurses (RN), all of whom (i) had reported one or more episodes of aspiration during the longitudinal survey, (ii) had worked ≥3 years in the department, and (iii) were willing to participate, were included. Antecedent factors involved in episodes of aspiration as experienced by RNs were collected through an open-ended interview, and qualitatively analysed. In addition to clinical factors, other factors interacting with each other may precipitate the risk of aspiration episodes during hospitalization: at the nursing care level (misclassifying patients, transferring tasks to other healthcare professionals and standardizing processes to remove potential threats); at the family level (misclassifying patients, dealing with the cultural relevance of eating) and at the environmental level (positioning the patient, managing time pressures, distracting patient while eating, dealing with food consistency and irritating oral medication). At the hospital level, an adequate nursing workforce and models of care delivery, as well as time for initial and continuing patient and family assessment are required. At the unit level, patient-centred models of care aimed at reducing care standardization are also recommended; in addition, nursing, family and environmental factors should be recorded in the incident reports documenting episodes of aspiration. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

  12. [Is plasma selenium correlated to transthyretin levels in critically ill patients?

    Science.gov (United States)

    Freitas, Renata G B O N; Nogueira, Roberto Jose Negrão; Cozzolino, Silvia Maria Franciscato; Vasques, Ana Carolina Junqueira; Ferreira, Matthew Thomas; Hessel, Gabriel

    2017-06-05

    Selenium is an essential trace element, but critically ill patients using total parenteral nutrition (PN) do not receive selenium because this mineral is not commonly offered. Threfore, the eval uation of plasma selenium levels is very important for treating or preventing this deficiency. Recent studies have shown that transthyretin may reflect the selenium intake and could be considered a biomarker. However, this issue is still little explored in the literature. This study aims to investigate the correlation of transthyretin with the plasma selenium of critically ill patients receiving PN. This was a prospective cohort study with 44 patients using PN without selenium. Blood samples were carried out in 3 stages: initial, 7th and 14th day of PN. In order to evaluate the clinical condition and the inflammatory process, albumin, C-reactive protein (CRP), transthyretin, creatinine and HDL cholesterol levels were observed. To assess the selenium status, plasma selenium and glutathione peroxidase (GPx) in whole blood were measured. Descriptive analyses were performed and the ANOVA, Mann-Whitney and Spearman's coefficient tests were conducted; we assumed a significance level of 5%. A positive correlation of selenium with the GPx levels (r = 0.46; p = 0.03) was identified. During two weeks, there was a positive correlation of transthyretin with plasma selenium (r = 0.71; p = 0.05) regardless of the CRP values. Transthyretin may have reflected plasma selenium, mainly because the correlation was verified after the acute phase.

  13. Identification of risk factors for enteral feeding intolerance screening in critically ill patients

    Science.gov (United States)

    Xu, Lei; Wang, Ting; Chen, Ting; Yang, Wen-Qun; Liang, Ze-Ping; Zhu, Jing-Ci

    2017-01-01

    Objectives: To identify risk factors for enteral feeding intolerance screening in critically ill patients, thereby, provide some reference for healthcare staff to assess the risk of feeding intolerance, and lay the foundation for future scale development. Methods: This study used a mixed methodology, including a literature review, semi-structured interviews, the Delphi technique, and the analytic hierarchy process. We used the literature review and semi-structured interviews (n=22) to draft a preliminarily item pool for feeding intolerance, Delphi technique (n=30) to screen and determine the items, and the analytic hierarchy process to calculate the weight of each item. The study was conducted between June 2014 and September 2015 in Daping Hospital, Third Military Medical University, Chongqing, China. Results: Twenty-three risk factors were selected for the scale, including 5 dimensions. We assigned a weight to each item according to their impact on the feeding intolerance, with a higher score indicating a greater impact. The weight of each dimension was decreasing as follows: patient conditions, weight score equals 42; general conditions, weight score equals 23; gastrointestinal functions, weight score equals 15; biochemical indexes, weight score equals 14; and treatment measures, weight score equals 6. Conclusion: Developed list of risk factors based on literature review, survey among health care professionals and expert consensus should provide a basis for future studies assessing the risk of feeding intolerance in critically ill patients. PMID:28762434

  14. Quality indicators on the use of antimicrobials in critically ill patients.

    Science.gov (United States)

    Vera, P; Palomar, M; Álvarez-Lerma, F

    2014-12-01

    Quality indicators have been applied to many areas of health care in recent years, including intensive care. However, they have not been specifically developed and validated for antimicrobial use in critically ill patients. Antimicrobials play a key role in intensive care units not only in the prognosis of each individual patient, but also in the development of resistance and changes in the flora in this setting. Evaluating the use of these agents is complex in the intensive care unit, however, because the indications vary greatly and antimicrobial treatment is often changed during admission. We designed and developed specific quality indicators regarding the use of antimicrobials in critically ill patients admitted to the intensive care unit. These indicators are proposed as a tool for application in intensive care units to detect problems in the use of antimicrobials. Future trials are needed, however, to validate these indicators in a large population over time. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

  15. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

    Science.gov (United States)

    Arora, V; Johnson, J; Lovinger, D; Humphrey, H J; Meltzer, D O

    2005-12-01

    The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or "sign-out". This study aims to describe how communication failures during this process can lead to patient harm. In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers. Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (kappa 0.78-1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems. Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

  16. Linezolid extracorporeal removal during haemodialysis with high cut-off membrane in critically ill patients.

    Science.gov (United States)

    Villa, Gianluca; Cassetta, Maria Iris; Tofani, Lorenzo; Valente, Serafina; Chelazzi, Cosimo; Falsini, Silvia; De Gaudio, Angelo Raffaele; Novelli, Andrea; Ronco, Claudio; Adembri, Chiara

    2015-10-01

    Continuous venovenous haemodialysis with high cut-off membrane (HCO-CVVHD) is often used in critically ill septic patients with acute kidney injury (AKI) to sustain renal function and to remove circulating inflammatory mediators. The aim of this study was to analyse the extracorporeal removal of linezolid and related alterations in pharmacokinetic/pharmacodynamic (PK/PD) parameters during HCO-CVVHD. Three critically ill septic patients with AKI, treated with linezolid and HCO-CVVHD, were prospectively observed. To calculate the extracorporeal clearance of linezolid and the PK parameters, effluent, pre-filter and post-filter samples were contemporaneously collected before linezolid infusion, just after 1-h infusion (maximum serum concentration; C(max)), at 3 h and 6 h after dosing, and before the next dose (trough serum concentration; C(min)). Linezolid C(max) and C(min) (pre-filter) ranged from 10.4-23.5 mg/L and from 2.9-10.3 mg/L. The dialysate saturation coefficient was 0.66-0.85 and the extracorporeal clearance with a diffusive dose of 35 m L/kg/h ranged from 2.1-2.5 L/h. Total linezolid clearance was between 1.7 L/h and 6.3 L/h. The total area under the plasma concentration-time curve (AUC0-∞) ranged from 95.1 mgh/L to 352.9 mgh/L, in accordance with the different clinical conditions. AUCfree/MIC ratios were always linezolid total clearance, the clinical features of critically ill septic patients appear to be mainly responsible for the high variability of linezolid serum concentrations. Copyright © 2015. Published by Elsevier B.V.

  17. Supplemental parenteral nutrition in critically ill patients: a study protocol for a phase II randomised controlled trial.

    Science.gov (United States)

    Ridley, Emma J; Davies, Andrew R; Parke, Rachael; Bailey, Michael; McArthur, Colin; Gillanders, Lyn; Cooper, David J; McGuinness, Shay

    2015-12-24

    Nutrition is one of the fundamentals of care provided to critically ill adults. The volume of enteral nutrition received, however, is often much less than prescribed due to multiple functional and process issues. To deliver the prescribed volume and correct the energy deficit associated with enteral nutrition alone, parenteral nutrition can be used in combination (termed "supplemental parenteral nutrition"), but benefits of this method have not been firmly established. A multi-centre, randomised, clinical trial is currently underway to determine if prescribed energy requirements can be provided to critically ill patients by using a supplemental parenteral nutrition strategy in the critically ill. This prospective, multi-centre, randomised, stratified, parallel-group, controlled, phase II trial aims to determine whether a supplemental parenteral nutrition strategy will reliably and safely increase energy intake when compared to usual care. The study will be conducted for 100 critically ill adults with at least one organ system failure and evidence of insufficient enteral intake from six intensive care units in Australia and New Zealand. Enrolled patients will be allocated to either a supplemental parenteral nutrition strategy for 7 days post randomisation or to usual care with enteral nutrition. The primary outcome will be the average energy amount delivered from nutrition therapy over the first 7 days of the study period. Secondary outcomes include protein delivery for 7 days post randomisation; total energy and protein delivery, antibiotic use and organ failure rates (up to 28 days); duration of ventilation, length of intensive care unit and hospital stay. At both intensive care unit and hospital discharge strength and health-related quality of life assessments will be undertaken. Study participants will be followed up for health-related quality of life, resource utilisation and survival at 90 and 180 days post randomisation (unless death occurs first). This trial

  18. Two unique patients with novel microdeletions in 4p16.3 that exclude the WHS critical regions: implications for critical region designation.

    Science.gov (United States)

    South, Sarah T; Bleyl, Steven B; Carey, John C

    2007-09-15

    Wolf-Hirschhorn syndrome (WHS) is characterized by growth delay, developmental delay, hypotonia, seizures, feeding difficulties, and characteristic facial features. Deletion of either of two critical regions (WHSCR and WHSCR-2) within chromosome band 4p16.3 has been proposed as necessary for the minimal clinical manifestations of WHS and controversy remains regarding their designation. We describe two patients with novel terminal microdeletions in 4p16.3 who lack the characteristic facial features but do show some of the more nonspecific manifestations of WHS. The first patient had a ring chromosome 4 with an intact 4q subtelomere and a terminal 4p microdeletion of approximately 1.27-1.46 Mb. This deletion was distal to both proposed critical regions. The second patient had a normal karyotype with a terminal 4p microdeletion of approximately 1.78 Mb. This deletion was distal to WHSCR and the breakpoint was near or within the known distal boundary for WHSCR-2. Both patients showed significant postnatal growth delay, mild developmental delays and feeding difficulties. Their facial features were not typical for WHS. The phenotype of the first patient may have been influenced by the presence of a ring chromosome. Seizures were absent in the first patient whereas the second patient had a complex seizure disorder. Characterization of these patients supports the hypothesis that a gene in WHSCR-2, LETM1, plays a direct role in seizure development, and demonstrates that components of the WHS phenotype can be seen with deletions distal to the known boundaries of the two proposed critical regions. These patients also emphasize the difficulty of mapping clinical manifestations common to many aneusomy syndromes. (c) 2007 Wiley-Liss, Inc.

  19. Utility of Volume Assessment Using Bioelectrical Impedance Analysis in Critically Ill Patients Receiving Continuous Renal Replacement Therapy: A Prospective Observational Study

    Directory of Open Access Journals (Sweden)

    Ki Hyun Park

    2017-08-01

    Full Text Available Background Fluid overload prior to continuous renal replacement therapy (CRRT is an important prognostic factor. Thus, precise evaluation of fluid status is necessary to treat such patients. In this study, we investigated whether fluid assessment using bioelectrical impedance analysis (BIA can predict outcomes in critically ill patients requiring CRRT. Methods A prospective observational study was performed in patients who were admitted to the intensive care unit and who required CRRT. BIA was conducted before CRRT; then, the ratio of extracellular water to total body water (ECW/TBW was derived to estimate volume status. Results A total of 31 patients treated with CRRT were included. There were 18 men (58.1%, and the median age was 67 years (interquartile range, 51 to 78 years. Fourteen patients (45.2% died within 28 days after CRRT initiation. Patients were divided into 16 with ECW/TBW ≥0.41 and 15 with ECW/TBW <0.41. Survival rate within 28 days was different between the two groups (P = 0.044. Cox regression analysis revealed a relationship between ECW/TBW ≥0.41 and 28-day mortality, but it was not statistically significant (hazard ratio, 3.0; 95% confidence interval, 0.9 to 9.8; P = 0.061. Lastly, the area under the curve of ECW/TBW for 28-day mortality was analyzed. The area under the curve of ECW/TBW was 0.73 (95% confidence interval, 0.54 to 0.92, and this was significant (P = 0.037. Conclusions Fluid status can be assessed using BIA in critically ill patients requiring CRRT, and BIA can predict mortality. Further large trials are needed to confirm the usefulness of BIA in critically ill patients.

  20. Simulation-based multidisciplinary team training decreases time to critical operations for trauma patients.

    Science.gov (United States)

    Murphy, Margaret; Curtis, Kate; Lam, Mary K; Palmer, Cameron S; Hsu, Jeremy; McCloughen, Andrea

    2018-05-01

    Simulation has been promoted as a platform for training trauma teams. However, it is not clear if this training has an impact on health service delivery and patient outcomes. This study evaluates the association between implementation of a simulation based multidisciplinary trauma team training program at a metropolitan trauma centre and subsequent patient outcomes. This was a retrospective review of trauma registry data collected at an 850-bed Level 1 Adult Trauma Centre in Sydney, Australia. Two concurrent four-year periods, before and after implementation of a simulation based multidisciplinary trauma team training program were compared for differences in time to critical operations, Emergency Department (ED) length of stay (LOS) and patient mortality. There were 2389 major trauma patients admitted to the hospital during the study, 1116 in the four years preceding trauma team training (the PREgroup) and 1273 in the subsequent 4 years (the POST group). There were no differences between the groups with respect to gender, body region injured, incidence of polytrauma, and pattern of arrival to ED. The POST group was older (median age 54 versus 43 years, p team training was associated with a reduction in time to critical operation while overall ED length of stay increased. Simulation is promoted as a platform for training teams; but the complexity of trauma care challenges efforts to demonstrate direct links between multidisciplinary team training and improved outcomes. There remain considerable gaps in knowledge as to how team training impacts health service delivery and patient outcomes. Retrospective comparative therapeutic/care management study, Level III evidence. Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.

  1. Interpretation of chest radiographs in both cancer and other critical care patients with acute respiratory distress syndrome

    Directory of Open Access Journals (Sweden)

    Sema Yilmaz

    2013-04-01

    Full Text Available Acute respiratory distress syndrome is a clinical, pathophysiological and radiographic pattern that has signs of pulmonary edema occur without elevated pulmonary venous pressures. Clinical presentation and progression of acute respiratory distress syndrome are followed by frequently ordered portable chest X-ray in critically ill patients. We evaluated chest radiographs of ten cancer and other six critical care pediatric patients. The parenchymal imaging of lung in patients with cancer was reported the same as that of other critically ill children despite underlying pathophysiological variations in our investigation. [Cukurova Med J 2013; 38(2.000: 270-273

  2. Superficial Temporal Artery Pseudoaneurysm: A Conservative Approach in a Critically Ill Patient

    International Nuclear Information System (INIS)

    Grasso, Rosario Francesco; Quattrocchi, Carlo Cosimo; Crucitti, Pierfilippo; Carboni, Giampiero; Coppola, Roberto; Zobel, Bruno Beomonte

    2007-01-01

    A 71-year-old man affected by cardio- and cerebrovascular disease experienced an accidental fall and trauma to the fronto-temporal area of the head. A few weeks later a growing mass appeared on his scalp. A diagnosis of superficial temporal artery pseudoaneurysm was made following CT and color Doppler ultrasound. His clinical condition favoured a conservative approach by ultrasound-guided compression and subsequent surgical resection. A conservative approach should be considered the treatment of choice in critically ill patients affected by superficial temporal artery pseudoaneurysm

  3. [The association between early blood glucose fluctuation and prognosis in critically ill patients].

    Science.gov (United States)

    Tang, Jian; Gu, Qin

    2012-01-01

    To investigate the association between early blood glucose level fluctuation and prognosis of critically ill patients. A retrospective study involving 95 critically ill patients in intensive care unit (ICU) was conducted. According to the 28-day outcome after admission to ICU, the patients were divided into nonsurvivors (43 cases) and survivors (52 cases), and the blood glucose level in them was monitored in the first 72 hours. Blood glucose concentration at admission (BGadm), mean blood glucose level (MBG), hyperglycemia index (HGI), glycemic lability index (GLI), incidence of hypoglycemia and total dosage of intravenous insulin for each patient were compared. The index as an independent risk factor of mortality was determined by multivariate logistic regression analysis and the predictor value by comparing the area under the receiver operating characteristic curve (ROC curve, AUC) of each index. The BGadm (mmol/L), MBG (mmol/L), HGI and the incidence of hypoglycemia showed no significant differences between nonsurvivors and survivors [BGadm: 9.87 ± 4.48 vs. 9.26 ± 3.07, MBG: 8.59 ± 1.23 vs. 8.47 ± 1.01, HGI(6.0): 2.45 ± 0.94 vs. 1.68 ± 1.05, HGI(8.3): 0.84 ± 0.70 vs. 0.68 ± 0.51, the incidence of hypoglycemia: 9.30% vs. 5.77%, all P > 0.05], but acute physiology and chronic health evaluation II (APACHE II ) score, GLI and the total dosage of intravenous insulin (U) were significantly higher in nonsurvivors than survivors [APACHE II score: 23 ± 6 vs. 19 ± 6, GLI: 56.96 (65.43) vs. 23.87 (41.62), the total dosage of intravenous insulin: 65.5 (130.5) vs. 12.5 (90.0), all P curve was plotted, the AUC of APACHE II score and GLI was respectively 0.69 and 0.71, and there was no significant difference (P > 0.05). Early fluctuation of blood glucose is a significant independent risk factor of mortality in critically ill patients. Control the early fluctuation of blood glucose concentration might improve the patients' outcome.

  4. Criticism and Depression among the Caregivers of At-Risk Mental State and First-Episode Psychosis Patients.

    Directory of Open Access Journals (Sweden)

    Yumiko Hamaie

    Full Text Available Expressed emotion (EE, especially criticism, is an important predictor of outcomes for the patient for a wide range of mental health problems. To understand complex links between EE and various relevant variables in early phase psychosis, this study examined criticism, distress of caregivers, other patients', and caregivers' variables, and links between criticism and these variables in those with at-risk mental state (ARMS for psychosis and first-episode psychosis (FEP. The participants were 56 patients (mean age 18.8 ± 4.2 years with ARMS and their caregivers (49.4 ± 5.8 years and 43 patients (21.7 ± 5.2 years with FEP and their caregivers (49.3 ± 7.4 years. We investigated criticisms made by caregivers using the Japanese version of the Family Attitude Scale and caregiver depressive symptoms via the self-report Beck Depression Inventory. We also assessed psychiatric symptoms and functioning of the patients. Approximately one-third of caregivers of patients with ARMS or FEP had depressive symptoms, predominately with mild-to-moderate symptom levels, whereas only a small portion exhibited high criticism. The level of criticism and depression were comparable between ARMS and FEP caregivers. The link between criticism, caregivers' depression, and patients' symptoms were observed in FEP but not in ARMS caregivers. These findings imply that the interaction between criticism and caregivers' and patients' mental states may develop during or after the onset of established psychosis and interventions for the caregivers should be tailored to the patient's specific stage of illness. Interventions for FEP caregivers should target their emotional distress and include education about patient's general symptoms.

  5. Which patients need critical care intervention after total joint arthroplasty? : a prospective study of factors associated with the need for intensive care following surgery.

    Science.gov (United States)

    Courtney, P M; Melnic, C M; Gutsche, J; Hume, E L; Lee, G-C

    2015-11-01

    Older patients with multiple medical co-morbidities are increasingly being offered and undergoing total joint arthroplasty (TJA). These patients are more likely to require intensive care support, following surgery. We prospectively evaluated the need for intensive care admission and intervention in a consecutive series of 738 patients undergoing elective hip and knee arthroplasty procedures. The mean age was 60.6 years (18 to 91; 440 women, 298 men. Risk factors, correlating with the need for critical care intervention, according to published guidelines, were analysed to identify high-risk patients who would benefit from post-operative critical care monitoring. A total of 50 patients (6.7%) in our series required critical care level interventions during their hospital stay. Six independent multivariate clinical predictors were identified (p 1000 mL (OR 17.36, 95% CI 5.36 to 56.19), chronic obstructive pulmonary disease (13.90, 95% CI 4.78 to 40.36), intra-operative use of vasopressors (OR 8.10, 95% CI 3.23 to 20.27), revision hip arthroplasty (OR 2.71, 95% CI 1.04 to 7.04) and body mass index > 35 kg/m(2) (OR 2.70, 95% CI 123 to 5.94). The model was then validated against an independent, previously published data set of 1594 consecutive patients. The use of this risk stratification model can be helpful in predicting which high-risk patients would benefit from a higher level of monitoring and care after elective TJA and aid hospitals in allocating precious critical care resources. ©2015 The British Editorial Society of Bone & Joint Surgery.

  6. Setting the vision: applied patient-reported outcomes and smart, connected digital healthcare systems to improve patient-centered outcomes prediction in critical illness.

    Science.gov (United States)

    Wysham, Nicholas G; Abernethy, Amy P; Cox, Christopher E

    2014-10-01

    Prediction models in critical illness are generally limited to short-term mortality and uncommonly include patient-centered outcomes. Current outcome prediction tools are also insensitive to individual context or evolution in healthcare practice, potentially limiting their value over time. Improved prognostication of patient-centered outcomes in critical illness could enhance decision-making quality in the ICU. Patient-reported outcomes have emerged as precise methodological measures of patient-centered variables and have been successfully employed using diverse platforms and technologies, enhancing the value of research in critical illness survivorship and in direct patient care. The learning health system is an emerging ideal characterized by integration of multiple data sources into a smart and interconnected health information technology infrastructure with the goal of rapidly optimizing patient care. We propose a vision of a smart, interconnected learning health system with integrated electronic patient-reported outcomes to optimize patient-centered care, including critical care outcome prediction. A learning health system infrastructure integrating electronic patient-reported outcomes may aid in the management of critical illness-associated conditions and yield tools to improve prognostication of patient-centered outcomes in critical illness.

  7. Nutrition Therapy in Critically Ill Patients Following Cardiac Surgery: Defining and Improving Practice.

    Science.gov (United States)

    Rahman, Adam; Agarwala, Ravi; Martin, Claudio; Nagpal, Dave; Teitelbaum, Michael; Heyland, Daren K

    2017-09-01

    Malnutrition is a predictor of poor outcome following cardiac surgery. We define nutrition therapy after cardiac surgery to identify opportunities for improvement. International prospective studies in 2007-2009, 2011, and 2013 were combined. Sites provided institutional and patient characteristics from intensive care unit (ICU) admission to ICU discharge for a maximum of 12 days. Patients had valvular, coronary artery bypass graft (CABG) surgery, or combined procedures and were mechanically ventilated and staying in the ICU for ≥3 days. There were 787 patients from 144 ICUs. In total, 120 patients (15.2%) had valvular surgery, 145 patients (18.4%) had CABG, and 522 patients (66.3%) underwent a combined procedure. Overall, 60.1% of patients received artificial nutrition support. For these patients, 78% received enteral nutrition (EN) alone, 17% received a combination of EN and parenteral nutrition (PN), and 5% received PN alone. The remaining 314 patients (40%) received no nutrition. The mean (SD) time from ICU admission to EN initiation was 2.3 (1.8) days. The adequacy of calories was 32.4% ± 31.9% from EN and PN and 25.5% ± 27.9% for patients receiving only EN. In EN patients, 57% received promotility agents and 20% received small bowel feeding. There was no significant relationship between increased energy or protein provision and 60-day mortality. Postoperative cardiac surgery patients who stay in the ICU for 3 or more days are at high risk for inadequate nutrition therapy. Further studies are required to determine if targeted nutrition therapy may alter clinical outcomes.

  8. Critical threshold levels of DNA methyltransferase 1 are required to maintain DNA methylation across the genome in human cancer cells.

    Science.gov (United States)

    Cai, Yi; Tsai, Hsing-Chen; Yen, Ray-Whay Chiu; Zhang, Yang W; Kong, Xiangqian; Wang, Wei; Xia, Limin; Baylin, Stephen B

    2017-04-01

    Reversing DNA methylation abnormalities and associated gene silencing, through inhibiting DNA methyltransferases (DNMTs) is an important potential cancer therapy paradigm. Maximizing this potential requires defining precisely how these enzymes maintain genome-wide, cancer-specific DNA methylation. To date, there is incomplete understanding of precisely how the three DNMTs, 1, 3A, and 3B, interact for maintaining DNA methylation abnormalities in cancer. By combining genetic and shRNA depletion strategies, we define not only a dominant role for DNA methyltransferase 1 (DNMT1) but also distinct roles of 3A and 3B in genome-wide DNA methylation maintenance. Lowering DNMT1 below a threshold level is required for maximal loss of DNA methylation at all genomic regions, including gene body and enhancer regions, and for maximally reversing abnormal promoter DNA hypermethylation and associated gene silencing to reexpress key genes. It is difficult to reach this threshold with patient-tolerable doses of current DNMT inhibitors (DNMTIs). We show that new approaches, like decreasing the DNMT targeting protein, UHRF1, can augment the DNA demethylation capacities of existing DNA methylation inhibitors for fully realizing their therapeutic potential. © 2017 Cai et al.; Published by Cold Spring Harbor Laboratory Press.

  9. Patient safety climate strength: a concept that requires more attention

    Science.gov (United States)

    Ginsburg, Liane; Gilin Oore, Debra

    2016-01-01

    Background When patient safety climate (PSC) surveys are used in healthcare, reporting typically focuses on PSC level (mean or per cent positive scores). This paper explores how an additional focus on PSC strength can enhance the utility of PSC survey data. Setting and participants 442 care providers from 24 emergency departments (EDs) across Canada. Methods We use anonymised data from the Can-PSCS PSC instrument collected in 2011 as part of the Qmentum accreditation programme. We examine differences in climate strength across EDs using the Rwg(j) and intraclass correlation coefficients measures of inter-rater agreement. Results Across the six survey dimensions, median Rwg(j) was sufficiently high to support shared climate perceptions (0.64–0.83), but varied widely across the 24 ED units. We provide an illustrative example showing vastly different climate strength (Rwg(j) range=0.17–0.86) for units with an equivalent level of PSC (eg, climate mean score=3). Conclusions Most PSC survey results focus solely on climate level. To facilitate improvement in PSC, we advocate a simple, holistic safety climate profile including three metrics: climate level (using mean or per cent positive climate scores), climate strength (using the Rwg(j), or SD as a proxy) and the shape of the distribution (using histograms to see the distribution of scores within units). In PSC research, we advocate paying attention to climate strength as an important variable in its own right. Focusing on PSC level and strength can further understanding of the extent to which PSC is a key variable in the domain of patient safety. PMID:26453636

  10. Childhood Maltreatment, Depressive Symptoms, and Body Dissatisfaction in Patients with Binge Eating Disorder: The Mediating Role of Self-Criticism

    Science.gov (United States)

    Dunkley, David M.; Masheb, Robin M.; Grilo, Carlos M.

    2010-01-01

    Objective We examined the mediating role of self-criticism in the relation between childhood maltreatment and both depressive symptoms and body dissatisfaction in patients with binge eating disorder (BED). Method Participants were 170 BED patients who completed measures of childhood maltreatment, self-criticism, self-esteem, depressive symptoms, and body dissatisfaction. Results Specific forms of childhood maltreatment (emotional abuse, sexual abuse) were significantly associated with body dissatisfaction. Path analyses demonstrated that self-criticism fully mediated the relation between emotional abuse and both depressive symptoms and body dissatisfaction. Specificity for the mediating role of self-criticism was demonstrated in comparison to other potential mediators (low self-esteem) and alternative competing mediation models. Conclusion These results highlight self-criticism as a potential mechanism through which certain forms of childhood maltreatment may be associated with depressive symptoms and body dissatisfaction in BED patients. PMID:20119938

  11. Effect of early vs. late tracheostomy on clinical outcomes in critically ill pediatric patients.

    Science.gov (United States)

    Lee, J-H; Koo, C-H; Lee, S-Y; Kim, E-H; Song, I-K; Kim, H-S; Kim, C-S; Kim, J-T

    2016-10-01

    Few studies investigated the optimal timing for tracheostomy and its influence on the clinical outcomes in critically ill pediatric patients. This study evaluated the differences in clinical outcomes between early and late tracheostomy in pediatric intensive care unit (ICU) patients. We assessed 111 pediatric patients. Patients who underwent a tracheostomy within 14 days of mechanical ventilation (MV) were assigned to the early tracheostomy group, whereas those who underwent tracheostomy after 14 days of MV were included in the late tracheostomy group. Clinical outcomes, including mortality, duration of MV, length of ICU and hospital stays, and incidence of ventilator-associated pneumonia (VAP) were compared between the groups. Of the 111 pediatric patients, 61 and 50 were included in the early and late tracheostomy groups, respectively. Total MV duration and the length of ICU and hospital stay were significantly longer in the late tracheostomy group than in the early tracheostomy group (all P tracheostomy was 2.6 and 3.8 in the early and late tracheostomy groups, respectively. There were no significant differences in mortality rate between the groups. No severe complications were associated with tracheostomy itself. Tracheostomy performed within 14 days after the initiation of MV was associated with reduced duration of MV and length of ICU and hospital stay. Although there was no effect on mortality rate, children may benefit from early tracheostomy without severe complications. © 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

  12. Restrictive versus liberal transfusion strategies for older mechanically ventilated critically ill patients: a randomized pilot trial.

    Science.gov (United States)

    Walsh, Timothy S; Boyd, Julia A; Watson, Douglas; Hope, David; Lewis, Steff; Krishan, Ashma; Forbes, John F; Ramsay, Pamela; Pearse, Rupert; Wallis, Charles; Cairns, Christopher; Cole, Stephen; Wyncoll, Duncan

    2013-10-01

    To compare hemoglobin concentration (Hb), RBC use, and patient outcomes when restrictive or liberal blood transfusion strategies are used to treat anemic (Hb≤90 g/L) critically ill patients of age≥55 years requiring≥4 days of mechanical ventilation in ICU. Parallel-group randomized multicenter pilot trial. Six ICUs in the United Kingdom participated between August 2009 and December 2010. One hundred patients (51 restrictive and 49 liberal groups). Patients were randomized to a restrictive (Hb trigger, 70 g/L; target, 71-90 g/L) or liberal (90 g/L; target, 91-110 g/L) transfusion strategy for 14 days or the remainder of ICU stay, whichever was longest. Baseline comorbidity rates and illness severity were high, notably for ischemic heart disease (32%). The Hb difference among groups was 13.8 g/L (95% CI, 11.5-16.0 g/L); pdisease, Acute Physiology and Chronic Health Evaluation II score, and total non-neurologic Sequential Organ Failure Assessment score at baseline (hazard ratio, 0.54 [95% CI, 0.28-1.03]; p=0.061). A large trial of transfusion strategies in older mechanically ventilated patients is feasible. This pilot trial found a nonsignificant trend toward lower mortality with restrictive transfusion practice.

  13. Economic impact of Tegaderm chlorhexidine gluconate (CHG) dressing in critically ill patients.

    Science.gov (United States)

    Thokala, Praveen; Arrowsmith, Martin; Poku, Edith; Martyn-St James, Marissa; Anderson, Jeff; Foster, Steve; Elliott, Tom; Whitehouse, Tony

    2016-09-01

    To estimate the economic impact of a Tegaderm TM chlorhexidine gluconate (CHG) gel dressing compared with a standard intravenous (i.v.) dressing (defined as non-antimicrobial transparent film dressing), used for insertion site care of short-term central venous and arterial catheters (intravascular catheters) in adult critical care patients using a cost-consequence model populated with data from published sources. A decision analytical cost-consequence model was developed which assigned each patient with an indwelling intravascular catheter and a standard dressing, a baseline risk of associated dermatitis, local infection at the catheter insertion site and catheter-related bloodstream infections (CRBSI), estimated from published secondary sources. The risks of these events for patients with a Tegaderm CHG were estimated by applying the effectiveness parameters from the clinical review to the baseline risks. Costs were accrued through costs of intervention (i.e. Tegaderm CHG or standard intravenous dressing) and hospital treatment costs depended on whether the patients had local dermatitis, local infection or CRBSI. Total costs were estimated as mean values of 10,000 probabilistic sensitivity analysis (PSA) runs. Tegaderm CHG resulted in an average cost-saving of £77 per patient in an intensive care unit. Tegaderm CHG also has a 98.5% probability of being cost-saving compared to standard i.v. dressings. The analyses suggest that Tegaderm CHG is a cost-saving strategy to reduce CRBSI and the results were robust to sensitivity analyses.

  14. Evidence-based guidelines for the use of tracheostomy in critically ill patients.

    Science.gov (United States)

    Raimondi, Néstor; Vial, Macarena R; Calleja, José; Quintero, Agamenón; Cortés, Albán; Celis, Edgar; Pacheco, Clara; Ugarte, Sebastián; Añón, José M; Hernández, Gonzalo; Vidal, Erick; Chiappero, Guillermo; Ríos, Fernando; Castilleja, Fernando; Matos, Alfredo; Rodriguez, Enith; Antoniazzi, Paulo; Teles, José Mario; Dueñas, Carmelo; Sinclair, Jorge; Martínez, Lorenzo; von der Osten, Ingrid; Vergara, José; Jiménez, Edgar; Arroyo, Max; Rodríguez, Camilo; Torres, Javier; Fernandez-Bussy, Sebastián; Nates, Joseph L

    2017-04-01

    To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions. Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used. Copyright © 2016 Elsevier Inc. All rights reserved.

  15. Impact of supplementation with amino acids or their metabolites on muscle wasting in patients with critical illness or other muscle wasting illness: a systematic review.

    Science.gov (United States)

    Wandrag, L; Brett, S J; Frost, G; Hickson, M

    2015-08-01

    Muscle wasting during critical illness impairs recovery. Dietary strategies to minimise wasting include nutritional supplements, particularly essential amino acids. We reviewed the evidence on enteral supplementation with amino acids or their metabolites in the critically ill and in muscle wasting illness with similarities to critical illness, aiming to assess whether this intervention could limit muscle wasting in vulnerable patient groups. Citation databases, including MEDLINE, Web of Knowledge, EMBASE, the meta-register of controlled trials and the Cochrane Collaboration library, were searched for articles from 1950 to 2013. Search terms included 'critical illness', 'muscle wasting', 'amino acid supplementation', 'chronic obstructive pulmonary disease', 'chronic heart failure', 'sarcopenia' and 'disuse atrophy'. Reviews, observational studies, sport nutrition, intravenous supplementation and studies in children were excluded. One hundred and eighty studies were assessed for eligibility and 158 were excluded. Twenty-two studies were graded according to standardised criteria using the GRADE methodology: four in critical care populations, and 18 from other clinically relevant areas. Methodologies, interventions and outcome measures used were highly heterogeneous and meta-analysis was not appropriate. Methodology and quality of studies were too varied to draw any firm conclusion. Dietary manipulation with leucine enriched essential amino acids (EAA), β-hydroxy-β-methylbutyrate and creatine warrant further investigation in critical care; EAA has demonstrated improvements in body composition and nutritional status in other groups with muscle wasting illness. High-quality research is required in critical care before treatment recommendations can be made. © 2014 The British Dietetic Association Ltd.

  16. Update on metabolism and nutrition therapy in critically ill burn patients.

    Science.gov (United States)

    Moreira, E; Burghi, G; Manzanares, W

    Major burn injury triggers severe oxidative stress, a systemic inflammatory response, and a persistent hypermetabolic and hypercatabolic state with secondary sarcopenia, multiorgan dysfunction, sepsis and an increased mortality risk. Calorie deficit, negative protein balance and antioxidant micronutrient deficiency after thermal injury have been associated to poor clinical outcomes. In this context, personalized nutrition therapy with early enteral feeding from the start of resuscitation are indicated. Over the last four decades, different nutritional and pharmacological interventions aimed at modulating the immune and metabolic responses have been evaluated. These strategies have been shown to be able to minimize acute malnutrition, as well as modulate the immunoinflammatory response, and improve relevant clinical outcomes in this patient population. The purpose of this updating review is to summarize the most current evidence on metabolic response and nutrition therapy in critically ill burn patients. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

  17. Immune-modulating interventions in critically ill septic patients: pharmacological options

    DEFF Research Database (Denmark)

    Toft, Palle; Tønnesen, Else

    2011-01-01

    Critically ill patients with severe sepsis and septic shock are characterized by a systemic inflammatory response consisting of pro- and anti-inflammatory mediators. Owing to the high mortality of severe sepsis, great efforts have been undertaken within the last 30 years to develop an immune...... insulin therapy have been shown to improve survival in septic patients. However, in later studies, it has been difficult to reproduce these beneficial effects. There appears to be a discrepancy between the promising effects of immune-modulating interventions in animal studies and the effects seen......-modulating therapy to improve survival. Relatively few pharmacological immune-modulating interventions have demonstrated a beneficial impact on survival, while other studies have shown a detrimental effect of such interventions. Among the immune-modulating interventions tested, activated protein C and intensive...

  18. Reduction of xerostomia in head and neck cancer patients. A critical review of the literature

    International Nuclear Information System (INIS)

    Hanley, O.; Leech, M.

    2016-01-01

    Background: Radical radiotherapy given with or without concurrent chemotherapy is the main treatment modality in non-surgical patients for the management of squamous cell carcinoma in the head and neck. Xerostomia, which results from reduced salivary production is a debilitating side-effect of radiation therapy to these patients. Xerostomia may greatly impact on quality of life for head and neck cancer patients for up to 24 months post-radiation therapy. Such effects include difficulties in fundamental daily activities such as speech, mastication and swallowing. It is believed that modulated techniques provide better sparing to surrounding salivary glands. The aim of this critical review of the literature is to investigate what advantage intensity modulated radiotherapy (IMRT) can provide over 3 dimensional conformal radiation therapy (3DCRT) in reducing xerostomia in this subset of patients. Search methodology: An extensive literature search was undertaken to compare the incidence of grade 2 or worse xerostomia in HNSCC patients treated with IMRT or 3DCRT (±chemotherapy). Results: Studies reported a lower incidence of grade 2 or worse xerostomia with IMRT over patients treated with 3DCRT. The highest incidence of xerostomia was reported at 6 months following the completion of radiotherapy treatment. The incidence of xerostomia in patients declined with time, in both patients treated with IMRT and those of the 3DCRT cohort. The incidence of xerostomia was greater in the acute setting than in the late. Conclusion: An IMRT technique can consistently reduce grade 2 or worse xerostomia in head and neck cancer patients over conformal techniques. This will not compromise dose homogeneity or dose coverage. IMRT should remain the standard of care for head and neck patients. - Highlights: • IMRT technique can consistently reduce grade 2 or worse xerostomia in head and neck cancer patients over 3DCRT. • IMRT does not compromise the treatment's dose homogeneity or

  19. The performance of flash glucose monitoring in critically ill patients with diabetes.

    Science.gov (United States)

    Ancona, Paolo; Eastwood, Glenn M; Lucchetta, Luca; Ekinci, Elif I; Bellomo, Rinaldo; Mårtensson, Johan

    2017-06-01

    Frequent glucose monitoring may improve glycaemic control in critically ill patients with diabetes. We aimed to assess the accuracy of a novel subcutaneous flash glucose monitor (FreeStyle Libre [Abbott Diabetes Care]) in these patients. We applied the FreeStyle Libre sensor to the upper arm of eight patients with diabetes in the intensive care unit and obtained hourly flash glucose measurements. Duplicate recordings were obtained to assess test-retest reliability. The reference glucose level was measured in arterial or capillary blood. We determined numerical accuracy using Bland- Altman methods, the mean absolute relative difference (MARD) and whether the International Organization for Standardization (ISO) and Clinical and Laboratory Standards Institute Point of Care Testing (CLSI POCT) criteria were met. Clarke error grid (CEG) and surveillance error grid (SEG) analyses were used to determine clinical accuracy. We compared 484 duplicate flash glucose measurements and observed a Pearson correlation coefficient of 0.97 and a coefficient of repeatability of 1.6 mmol/L. We studied 185 flash readings paired with arterial glucose levels, and 89 paired with capillary glucose levels. Using the arterial glucose level as the reference, we found a mean bias of 1.4 mmol/L (limits of agreement, -1.7 to 4.5 mmol/L). The MARD was 14% (95% CI, 12%-16%) and the proportion of measurements meeting ISO and CLSI POCT criteria was 64.3% and 56.8%, respectively. The proportions of values within a low-risk zone on CEG and SEG analyses were 97.8% and 99.5%, respectively. Using capillary glucose levels as the reference, we found that numerical and clinical accuracy were lower. The subcutaneous FreeStyle Libre blood glucose measurement system showed high test-retest reliability and acceptable accuracy when compared with arterial blood glucose measurement in critically ill patients with diabetes.

  20. Private prayer as a suitable intervention for hospitalised patients: a critical review of the literature.

    Science.gov (United States)

    Hollywell, Claire; Walker, Jan

    2009-03-01

    This critical review seeks to identify if there is evidence that private (personal) prayer is capable of improving wellbeing for adult patients in hospital. The review was conducted in the belief that the spiritual needs of hospitalised patients may be enhanced by encouragement and support to engage in prayer. Systematic review. A systematic approach was used to gather evidence from published studies. In the absence of experimental research involving this type of population, evidence from qualitative and correlational studies was critically reviewed. Results. The findings indicate that private prayer, when measured by frequency, is usually associated with lower levels of depression and anxiety. Most of the studies that show positive associations between prayer and wellbeing were located in areas that have strong Christian traditions and samples reported a relatively high level of religiosity, church attendance and use of prayer. Church attenders, older people, women, those who are poor, less well educated and have chronic health problems appear to make more frequent use of prayer. Prayer appears to be a coping action that mediates between religious faith and wellbeing and can take different forms. Devotional prayers involving an intimate dialogue with a supportive God appear to be associated with improved optimism, wellbeing and function. In contrast, prayers that involve pleas for help may, in the absence of a pre-existing faith, be associated with increased distress and possibly poorer function. Future research needs to differentiate the effects of different types of prayer. Encouragement to engage in prayer should be offered only following assessment of the patient's faith and likely content and form of prayer to be used. Hospitalised patients who lack faith and whose prayers involve desperate pleas for help are likely to need additional support from competent nursing and chaplaincy staff.

  1. The Effects of Moderate- and High-Fidelity Patient Simulator Use on Critical Thinking in Associate Degree Nursing Students

    Science.gov (United States)

    Vieck, Jana

    2013-01-01

    The purpose of this study was to examine the impact of moderate- and high-fidelity patient simulator use on the critical thinking skills of associate degree nursing students. This quantitative study used a quasi-experimental design and the Health Sciences Reasoning Test (HSRT) to evaluate the critical thinking skills of third semester nursing…

  2. Critical care at extremes of temperature: effects on patients, staff and equipment.

    Science.gov (United States)

    Hindle, Elise M; Henning, J D

    2014-12-01

    Modern travel and military operations have led to a significant increase in the need to provide medical care in extreme climates. Presently, there are few data on what happens to the doctor, their drugs and equipment when exposed to these extremes. A review was undertaken to find out the effects of 'extreme heat or cold' on anaesthesia and critical care; in addition, subject matter experts were contacted directly. Both extreme heat and extreme cold can cause a marked physiological response in a critically ill patient and the doctor treating these patients may also suffer a decrement in both physical and mental functioning. Equipment can malfunction when exposed to extremes of temperature and should ideally be stored and operated in a climatically controlled environment. Many drugs have a narrow range of temperatures in which they remain useable though some have been shown to remain effective if exposed to extremes of temperature for a short period of time. All personnel embarking on an expedition to an extreme temperature zone should be of sufficient physical robustness and ideally should have a period of acclimatisation which may help mitigate against some of the physiological effects of exposure to extreme heat or extreme cold. Expedition planners should aim to provide climatic control for drugs and equipment and should have logistical plans for replenishment of drugs and medical evacuation of casualties. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  3. Methods to measure target site penetration of antibiotics in