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Saturday, 8 March 2008

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Friday, 7 March 2008

Clinical review: Critical care transport and austere critical care

05 March 2008, 00:00:00 David H Rice, George Kotti and William Beninati

The development of modern intensive care units (ICU) has allowed the survival of patients with advanced illness and injury, although at a cost of substantial infrastructure. Natural disasters and military operations are two common situations that can create critically ill patients in an environment that is austere, or has been rendered austere. It is impractical to replicate the resources of a full ICU in this setting. This has driven the development of two related strategies. Portable ICU capability can be rapidly established in the area of need. This provides relatively advanced capability but limited capacity and sustainability. The other strategy is to rapidly evacuate critically ill and injured patients following their initial stabilization. This permits medical personnel in the austere location to focus resources on a much larger number of less critical patients. It also permits the most vulnerable patients to receive care in an advanced center. The optimal strategy has not been determined, but a combination of these two approaches has been used un recent disasters and military operations and is promising.

Sedation breaks: are they good for the critically ill patient? A review

Authors: Pinder, Sally1; Christensen, Martin
Source: Nursing in Critical Care, Volume 13, Number 2, March and April 2008 , pp. 64-70(7)

Tradition has led us to believe that a heavily sedated patient is a comfortable, settled, compliant patient for whom sedation will improve outcome. The current move witnessed in clinical practice today of limiting sedation has led health care in recent years to question the benefit and necessity of routine, continuous sedation for all patients requiring mechanical ventilation. However, as a result there has been a rise in the amount of agitation being reported as being experienced by patients with the daily withdrawal of sedation.

Prevalence rate of delirium at two hospitals in Western Australia

Article not specific to ICU

Authors: Speed, Gaye; Wynaden, Dianne; McGowan, Sunita; Hare, Malcolm; Landsborough, Ian
Source: Australian Journal of Advanced Nursing, Volume 25, Number 1, September 2007 , pp. 38-43(6)
Publisher: Australian Nursing Federation

To estimate the prevalence of delirium in patients on 15 medical and surgical wards at two hospitals in Western Australia.

Following a review of the literature on delirium a standardised data collection tool was developed and four prevalence audits were conducted over a four week period at the target hospitals. The nurse coordinator on each ward was asked to identify any patient who was experiencing a delirium or who was confused. These patient's records were then examined for documentation that confirmed the presence of delirium or confusion.

Tuesday, 4 March 2008

National Knowledge Week for Chronic Obstructive Pulmonary Disease 2008

3 March 2008 - National Knowledge Week for Chronic Obstructive Pulmonary Disease 2008

Published by the Respiratory Specialist Library and prepared by members of the COPD National Service Framework External Reference Group. Includes results of comprehensive literature search of the evidence base.Published by the Respiratory Specialist Library and prepared by members of the COPD National Service Framework External Reference Group. Includes results of comprehensive literature search of the evidence base.

Medication errors caused by junior doctors

BMJ 2008;336:456 (1 March),
(published 7 February 2008)

Association with depression and burn-out remains uncertain

The effects of medical errors on patient morbidity and mortality have been highlighted in the United Kingdom and the United States.1 2Preventable medication errors account for 10-20% of adverse events in patients admitted to hospital.1

In the UK, up to 1.5% of hospital prescriptions may contain a medication error, and a quarter of these could result in potentially serious effects.3 The situation is similar in Australia and the US—medication errors occur in about 1-2% of patients admitted to hospital, resulting in around 7000 deaths a year in the US alone.2 4

Advocacy at end-of-life research design: an ethnographic study of an ICU.

Sorensen R, Iedema R.
Centre for Health Services Management, Faculty of Nursing, Midwifery & Health, University of Technology, 11A The Terraces, Broadway, Sydney, NSW 2006, Australia. roslyn.sorensen@uts.edu.au

BACKGROUND: Clinicians worldwide are being called upon to reconcile accountability for patient outcomes with the resources they consume. In the case of intensive care, contradictory pressures can arise in decisions about continuing treatment where benefit is diminishing. As concern grows about the cost effectiveness of treatment at end-of-life, nursing expertise and advocacy become significant factors in decision making.

OBJECTIVES: To explore the potential for a nursing advocacy role within a specific regime of nursing practice: end-of-life care; specifically to examine the concept of nursing advocacy from the literature, to consider its application in the workplace and to assess the capacity for nurses to advocate for people who die in institutions such as intensive care units.

DESIGN: Open-ended interviews with nurse managers and educators (4), palliative care specialists (2), chaplain (1), medical managers (2), intensives (7); focus groups with nurses (4 focus groups and 29 participants); patient case studies (13); observation of family conferences (6 conferences and 15 participants); observation of ward rounds (3 ward rounds and 11 participants). Total number of participants: 84.

SETTING: A large ICU in a principal referral and teaching hospital in Sydney, Australia.

PARTICIPANTS: Clinical staff within, and clinical and non-clinical caregivers external to the unit. METHOD: Qualitative, ethnographic study.

RESULTS: Spurious economic imperatives, primacy given to medical intervention, conflict between medical and nursing clinicians about patient management and absence of nursing operational autonomy and organizational authority, impede the opportunity for nurses to define and enact an advocacy role.

CONCLUSIONS: If nurses are to be effective patient advocates at end-of-life, they will need to develop clear criteria within which nursing assessments of patient status can be framed, the specialized skills to manage the non-medical needs of dying people and the organizational and political skills to negotiate changing clinical practice and workplace relations.

Publication Types: Research Support, Non-U.S. Gov'tPMID: 16979173 [PubMed - indexed for MEDLINE]

Monday, 3 March 2008

Coronary Heart Disease National Service Framework and National Infarct Angioplasty Project (NIAP) interim report

Coronary Heart Disease National Service Framework and National Infarct Angioplasty Project (NIAP) interim report

This national service framework progress report is published to mark the seventh anniversary of the National Service Framework for Coronary Heart Disease and the nearing completion of the capital programme. In addition, an NIAP interim report has been published covering findings based on the first year of data from seven pilots. NIAP is a feasibility study looking at how far primary angioplasty can be rolled out as the main treatment for heart attack in place of clot-busting drugs.

(DH Publications) (DH press release)

Critical Care Medicine

March 2008, Volume 36, Issue 3

Feature Articles
Anatomical and functional intrapulmonary shunt in acute respiratory distress syndrome
Massimo Cressoni, MD; Pietro Caironi, MD; Federico Polli, MD; Eleonora Carlesso, MSc; Davide Chiumello, MD; et al

The Stability and Workload Index for Transfer score predicts unplanned intensive care unit patient readmission: Initial development and validation
Ognjen Gajic, MD; Michael Malinchoc, PhD; et al

Serum thrombomodulin level relates to the clinical course of disseminated intravascular coagulation, multiorgan dysfunction syndrome, and mortality in patients with sepsis
Shu-Min Lin, MD; Yu-Min Wang, MD; Horng-Chyuan Lin, MD; et al
Temporal changes in management and outcome of septic shock in patients with malignancies in the intensive care unit
Frédéric Pène, MD; Stéphanie Percheron, MD; Virginie Lemiale, MD; et al

Continuing Medical Education Article
Sleep and recovery from critical illness and injury: A review of theory, current practice, and future directions
Randall S. Friese, MD

Economic evaluation of propofol and lorazepam for critically ill patients undergoing mechanical ventilation
Christopher E. Cox, MD, MPH; Shelby D. Reed, PhD; Joseph A. Govert, MD; et al
Continuing Medical Education Questions
Continuing Medical Education Questions

Clinical Investigations
Immunoglobulin G treatment of postcardiac surgery patients with score-identified severe systemic inflammatory response syndrome—The ESSICS study
for the Early Supplemental Severe SIRS Treatment With IVIG in Score-Identified High-Risk Patients After Cardiac Surgery (ESSICS) Study Group

Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States
Marya D. Zilberberg, MD; Rose S. Luippold, MS; Sandra Sulsky, PhD; et al

Community meetings for emergency research community consultation
Jenice N. Longfield, MD, MPH, COL (Ret), MC, USA; et al
Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia
for the Canadian Critical Care Trials Group

Effects of human atrial natriuretic peptide on renal function in patients undergoing abdominal aortic aneurysm repair
Chieko Mitaka, MD; Toshifumi Kudo, MD; Masatoshi Jibiki, MD; et al
Contribution of various metabolites to the “unmeasured” anions in critically ill patients with metabolic acidosis
Miriam Moviat, MD; Anniek M. Terpstra, BSc; Wim Ruitenbeek, PhD; et al
Elevated cardiac troponin is an independent risk factor for short- and long-term mortality in medical intensive care unit patients
Luciano Babuin, MD, PhD; Vlad C. Vasile, MD, PhD; Jose A. Rio Perez, MD; et al
Isolated and reversible impairment of ventricular relaxation in patients with septic shock
Bélaïd Bouhemad, MD; Armelle Nicolas-Robin, MD; Charlotte Arbelot, MD; et al

Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department
Reto Etter, MD; Roger Ludwig, MD; Friedrich Lersch, MD; et al

A double-blind placebo-controlled study to evaluate the safety and efficacy of L-2-oxothiazolidine-4-carboxylic acid in the treatment of patients with acute respiratory distress syndrome
Peter E. Morris, MD; Peter Papadakos, MD; James A. Russell, MD; et al

Noninvasive ventilation for acute respiratory failure near the end of life
Tasnim Sinuff, MD, PhD; Deborah J. Cook, MD, MSc; Sean P. Keenan, MD, MSc; et al

Equimolar doses of mannitol and hypertonic saline in the treatment of increased intracranial pressure
Gilles Francony, MD; Bertrand Fauvage, MD; Dominique Falcon, MD; et al

Short- and long-term follow-up of intensive care unit patients after sedation with isoflurane and midazolam—A pilot study
Peter V. Sackey, MD, PhD; Claes-Roland Martling, MD, PhD; et al

Outcomes of patients considered for, but not admitted to, the intensive care unit
Thomas E. Vanhecke, MD; Mihirkumar Gandhi, MD; Peter A. McCullough, MD, MPH, FACC, FACP, FAHA, FCCP; et al

Laboratory Investigations
Noisy pressure support ventilation: A pilot study on a new assisted ventilation mode in experimental lung injury
Marcelo Gama de Abreu, MD, MSc, PhD, DEAA; Peter M. Spieth, MD; et al

Review Articles
Educational interventions for prevention of healthcare-associated infection: A systematic review
Nasia Safdar, MD, MS; Cybéle Abad, MD

Procalcitonin assay in systemic inflammation, infection, and sepsis: Clinical utility and limitations
Kenneth L. Becker, MD, PhD; Richard Snider, PhD; Eric S. Nylen, MD

Special Articles
Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American Academy of Critical Care Medicine
Robert D. Truog, MD, MA; Margaret L. Campbell, PhD, RN, FAAN; et al

Sepsis: Time to reconsider the concept
Jean Carlet, MD; Jonathan Cohen, MD; Thierry Calandra, MD, PhD; Steven M. Opal, MD; et al
Brief Reports

Autonomic dysfunction predicts both 1- and 2-month mortality in middle-aged patients with multiple organ dysfunction syndrome
Hendrik Schmidt, MD; Dirk Hoyer, PhD; Ralf Hennen; Konstantin Heinroth; et al

Intensive care unit readmission: The issue is safety not frequency
Jack E. Zimmerman, MD, FCCM

Reevaluating prognosis: Cancer, septic shock, and changing outcomes
Karl W. Thomas, MD

To sleep in an intensive care unit, perchance to heal
Jonathan E. Kass, MD

Importance of systems-based practice in achieving pharmacoeconomic benefits
Philip D. Lumb, MB BS, FCCM

Toward ethical best practices in community consultation for research conducted with waiver of informed consent
Laurence B. McCullough, PhD

How can earlier antibiotic efficacy be provided for ventilator-associated pneumonia without promoting bacterial resistance? Is initial monotherapy or a combination of antibiotics the right answer?
Laurent Papazian, MD

Sepsis-induced left ventricular diastolic dysfunction: Little time to relax
Rubin I. Cohen, MD, FCCM

Finally, a tool for triage?
Carolyn Bekes, MD

Our failure to report failure
James M. O’Brien, Jr, MD, MSc; Scott K. Aberegg, MD, MPH

Noninvasive ventilation for patients near the end of life: What do we know and what do we need to know?
William J. Ehlenbach, MD; J Randall Curtis, MD, MPH

Mannitol and hypertonic saline: Going head to head
Roger Härtl, MD; Matteus Froelich, MD

Memories of the intensive care unit
Peter J. Papadakos, MD, FCCM

When mechanical ventilation mimics nature
Theodoros Vassilakopoulos, MD; Spyros Zakynthinos, MD

Leptin and ghrelin: Through thick and thin
Albertus Beishuizen, MD, PhD; Armand R. J. Girbes, MD, PhD; A B. Johan Groeneveld, MD, PhD, FCCP, FCCM

Resuscitation end points in severe sepsis: Central venous pressure, mean arterial pressure, mixed venous oxygen saturation, and … intra-abdominal pressure
Michael L. Cheatham, MD, FACS, FCCM

Gene expression profiling in acute respiratory distress syndrome: Pathways to future interventions
Richard G. Wunderink, MD

Antithrombotic therapies for cardiac arrest: Have we missed the mark?
Karl B. Kern, MD, FSCAI; Robert A. Berg, MD, FCCM; Mathias Zuercher, MD; Michael Loedl, BS

Measuring preload—One size doesn’t necessarily fit all
Margaret M. Parker, MD, FCCM

Measures of parasympathetic function and risk stratification in critical care
Phyllis K. Stein, PhD

Letter to the Editor
Volume therapy and innate immune response during systemic inflammation or sepsis
Mirrin J. Dorresteijn, MD; Hans G. van der Hoeven, MD, PhD; Peter Pickkers, MD, PhD

Volume therapy and innate immune response during systemic inflammation or sepsis
Emanuel P. Rivers, MD, MPH, IOM

Critical Care Medicine
© 2008 Lippincott Williams & Wilkins, Inc.

Ventilation for Life : Keeping post - ICU patients out of the ICU

Author(s): Laher , D . S .
ISSUE: 2008 ; VOL 32 ; PART 2

Journal Title:Access
AARC Times ( Formerly : AAR Times ) AARC Times ( Formerly : AAR Times )

Page: 18-25
ISSN: Print: 0893-8520
BL Shelfmark: 0537.535500
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ICU management of severe acute respiratory syndrome.

Intensive Care Med. 2003 Jun;29(6):870-5. Epub 2003 May 9.
Related Articles,
Comment in: Intensive Care Med. 2003 Jun;29(6):861-2. Lapinsky SE, Hawryluck L.
Mount Sinai Hospital, Interdepartmental Division of Critical Care, University of Toronto, 600 University Ave, M5G 1X5, Toronto, Canada. Stephen.lapinsky@utoronto.ca

BACKGROUND: Severe acute respiratory syndrome (SARS) is a contagious viral illness first recognized in late 2002. It has now been documented in 26 countries worldwide, with significant outbreaks in China, Hong Kong, Singapore, and Toronto. Research into identifying the etiological agent, evaluating modes of disease transmission, and treatment options is currently ongoing.

DISCUSSION: The disease can produce a severe bilateral pneumonia, with progressive hypoxemia. Up to 20% of patients require mechanical ventilatory support, with a fatal outcome occurring in about 5% of cases.

CONCLUSIONS: We review the current knowledge about this disease, with particular emphasis on ICU management and infection control precautions to prevent disease transmission.PMID: 12739014 [PubMed - indexed for MEDLINE]


Principles of Critical Care, 3rd Ed.
Part IV. Pulmonary Disorders >EquipmentSections: Pharmacologic Preparation and Use, Muscle Relaxants and Airway Management in the Intensive Care Unit.
Topics Discussed: airway maintenance; endotracheal intubation; muscle relaxants.

Excerpt: "In spite of the vast array of available equipment, most tracheal intubation can be accomplished using a very small subset of the equipment and a very simple checklist (Table 35-5) A cart that is fully stocked with all of the equipment required to manage a difficult airway should be available to airway managers, but need not be brought to the bedside of every patient in crisis.
6) The goals of pharmacologic preparation of the patient include creating conditions that allow safe intubation, providing relief from the discomfort and hemodynamic consequences associated with airway manipulation and tracheal intubation, and decreasing the hormonal and neurologic consequences of the procedure. The spectrum of pharmacologic preparation ranges from topical to intravenous general anesthesia. In the hands of experienced operators, most airway manipulations can be accomplished with topical anesthesia alone. Intravenous general anesthesia is indicated in the setting of elevated ICP and favorable airway anatomy (Table 35-6). There are many institutions where an intravenous general anesthetic is routinely administered for tracheal intubation, but..."


Coping with relatives during end-of-life decisions

European Journal of Anaesthesiology (2008), 25:164-166 Cambridge University Press
Copyright © European Society of Anaesthesiology 2008

Nursing Session
S. Baldinazzoa1 c1
a1 Azienda ULSS 6, via Rodolfi, 37-36100 Vicenza, Italy
Article author query
baldinazzo s [PubMed] [Google Scholar]

Nurses have become independent over the last few decades in Italy, thanks to a series of legislative changes. When dealing with organ donation, the nurses usually face unexpected and complex situations from both a technical and interpersonal point of view. When the death of a loved one has to be communicated to the family, the coordinator nurse, along with the doctor, talks with the relatives to help them decide whether or not to donate organs. It is fundamental that the death of the patient is communicated by the doctor in charge of the case and this has to be done before the question of donation is raised. The idea of donation is suggested when we believe the family has understood that their beloved is dead. We try to adapt our communication style to the background of the family. Experience has shown us that these situations are emotionally complex and tiring for both the family members and health workers. Sometimes the stress level amongst health workers is so high that psychological support is needed after the interview. If the family decides to donate, the restitution phase is very important. A meeting is organized for a month after the event to inform the relatives of the success of donation.

Does ICP monitoring make a difference in neurocritical care?


O. L. Cremera1 c1

a1 University Medical Center, Department of Intensive Care, Utrecht, The Netherlands

Article author query Cremer OL [PubMed] [Google Scholar]

Raised intracranial pressure and low cerebral perfusion pressure are associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these variables. However, there are no randomized controlled trials that have demonstrated the effectiveness of intracranial pressure-guided care in severely head-injured patients. Observational studies of such therapy have yielded inconsistent results, ranging from decreased mortality to no effect or increased morbidity or mortality. A recent cohort study supports the notion that the possible benefits of intracranial pressure monitoring after traumatic brain injury are small – if present – and would exceed a number needed for the treatment of 16. Furthermore, intracranial pressure monitoring and aggressive management of intracranial pressure and cerebral perfusion pressure have been associated with increased lengths of stay in the neurocritical care unit, conceivable costs and possibly an increased rate of complications. Against this background, there is sufficient clinical equipoise to warrant an adequately powered randomized controlled trial to compare intracranial pressure-guided care with supportive critical care without intracranial pressure monitoring in patients with severe traumatic brain injury. However, the realization of such a trial is likely to be problematic for a number of reasons, not least of which the firmly held biases of many clinicians.

Therapeutic approaches to reduce systemic inflammation in septic-associated neurologic complications

M. L. Wratten

European Journal of Anaesthesiology, Volume 25, Supplement S42, February 2008, pp 1-7
doi: 10.1017/S0265021507003444, Published online by Cambridge University Press
21 Feb 2008


End-of-life decision-making in the United States

R. D. Truog
European Journal of Anaesthesiology, Volume 25, Supplement S42,
February 2008, pp 43-50
doi: 10.1017/S0265021507003419,
Published online by Cambridge University Press 21 Feb 2008


Acute respiratory infections and winter pressures on hospital admissions in England and Wales 1990 - 2005

Author(s): Alex J . Elliot
ISSUE: 2008 ; VOL 30 ; PART 1

Journal Title:Access
Journal of Public Health Medicine ( Formerly : Community Medicine . Bristol ) ( Now : Journal of Public Health ) Journal of Public Health Medicine ( Formerly : Community Medicine . Bristol ) ( Now : Journal of Public Health )

Page: 91 - 98
ISSN: Print: 0957-4832
E-Version: 1464-3782
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Community-Acquired MRSA

Bridget M. Kuehn
JAMA. 2008;299(8):890.


Ventilator - Associated Pneumonia as a Quality Indicator for Patient Safety ?

Author(s): Uckay , I . ; Ahmed , Q . A . ; Sax , H . ; Pittet , D .
ISSUE: 2008 ; VOL 46 ; PART 4
Journal Title:Access
Clinical Infectious Diseases From Free Medical Journals . com (/1997 - /Embargo: 1 year)

From Proquest NHS (12/2004 - 07/2006)
Page: 557-563
ISSN: Print: 1058-4838
E-Version: 1537-6591
BL Shelfmark: 3286.293860
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