2,833 publications from this institution
The performance of hand disinfection by staff in a 31-bed department of intensive care was monitored. During 32 hours of observation, 727 opportunities for hand disinfection were observed, and the compliance rate was 27.9%. The level of work experience was not correlated with hand disinfection compliance rates.
Models incorporating daily, time-updating LAPS2 to predict mortality among an ICU population perform as well or better than models incorporating modified admission LAPS2 alone.
SCOPUS: le.j
In 36 hemodynamically stable septic patients, we explored whether changes in gastric mucosal-arterial PCO(2) gradient (PCO(2)gap) induced by a short-term dobutamine infusion may reveal hepatosplanchnic hypoperfusion. Hepatosplanchnic blood flow (HSBF) was determined by the continuous indocyanine green infusion technique and gastric mucosal PCO(2) (Pg(CO(2))) by saline tonometry. In each patient, hemodynamic measurements, blood samples, and Pg(CO(2)) determinations were performed three times: first at baseline (DOB 0), second during a dobutamine infusion at a dose of 5 microgram/kg/min (DOB 5), and third at a dose of 10 microgram/kg/min (DOB 10). The results were analyzed by Wilcoxon's matched-pairs signed rank test and are presented as medians with ranges. The PCO(2)gap decreased preferentially in groups of patients with inadequate hepatosplanchnic perfusion, i.e., with a low fractional HSBF (HSBF/CI), defined as the ratio of the HSBF to the simultaneous cardiac index, or a high gradient between the mixed venous blood and the suprahepatic blood O(2) saturations (DSvh(O(2))). In the 11 patients with a DSvh(O(2)) above 20% at baseline, PCO(2)gap decreased from 12.1 (6.3 to 19.5) mm Hg at DOB 0 to 6.2 (2.5 to 19. 3) mm Hg at DOB 5 (p < 0.001 versus DOB 0), and to 4.2 (0.1 to 35.9) mm Hg at DOB 10 (p < 0.05 versus DOB 5), whereas in the 25 patients with a DSvh(O(2)) below 20% at baseline, PCO(2)gap did not change significantly. At no time was the PCO(2)gap correlated with HSBF/CI or DSvh(O(2)). We conclude that although the PCO(2)gap does not correlate well with global indexes of gut oxygenation, such a simple dobutamine infusion test could identify patients with inadequate hepatosplanchnic perfusion.
on Intensive Care and Emergency Medicine seal is maintained by gentle pressure on the TT keeping the cuff pressing on the vocal cords. During percutaneous tracheostomy the bougie remains in the trachea. When ventilation through the tracheostomy tube (cuff inflated) is confirmed, the TT and bougie are withdrawn. Throughout the procedure, if ventilation difficulties occur, the TT can be easily re-inserted using the bougie as a guide.
<h3>Background</h3> The majority of ICU deaths are preceded by an end-of-life decision. <h3>Aim</h3> To discuss the challenges of end-of-life care and use of ACPs in critically ill patients. <h3>Methods</h3> Review of relevant literature and personal experience. <h3>Results</h3> ACPs apply more to patients with chronic conditions (eg. advanced cancer or progressively debilitating diseases) and are rarely relevant in the ICU setting. <h3>Discussion</h3> The more acute the disease, the more difficult it is to determine how an individual would wish to be treated, as he/she is no longer in a position to make decisions. There are many different types of acute, unexpected events and many different processes, and it is not possible to cover every eventuality in one document, whatever its length. Moreover, it is often difficult to predict the likelihood of recovery in these patients. Hence, ACPs do not make sense in the acute setting. One could argue that ACPs may prevent futile therapy, but disproportionate care (a preferred term nowadays) should anyway be avoided in all cases, and there is no need for a document to confirm this. Many consider it preferable to identify a proxy, who will be able to express the patient's wishes as reliably as possible. <h3>Conclusion</h3> End-of-life decisions are complex and influenced by religious and cultural background. They must be guided by the four key ethical principles: beneficence, non-maleficence, patient autonomy, and distributive justice. ACPs are rarely relevant in the ICU. Every attempt must be made to facilitate an end-of-life with dignity and without suffering.
Sepsis remains a leading cause of death in the intensive care unit. With no specific sepsis therapies available, management currently relies on infection control and hemodynamic stabilization. Rapid diag-nosis enabling early initiation of appropri-ate therapy is essential to maximize sur-vival rates. Effective antimicrobial therapy should be started as soon as possible after diagnosis, with empirical choices based on likely pathogens, local microbiologi-cal patterns, and any recent antimicrobial therapy. At the same time, fluids and va-sopressor agents should be commenced to restore and maintain hemodynamic stability and adequate tissue perfusion. No effective immunomodulatory therapies are available, but some candidates are un-dergoing clinical trials. Better techniques for characterization of the degree of sepsis response in individual patients are needed to help target such agents more appropri-ately as some patients may benefit from immunosuppressive agents while others may require an immune stimulating in-tervention. The management of patients with septic shock is often complex and the development of sepsis teams should be encouraged so that the multiple compo-nents of treatment, e.g., insertion of intra-vascular lines, blood sampling for culture and biochemistry, positioning of required monitoring devices, fluid, antibiotic and vasoactive drug administration, etc, can be carried out simultaneously.
Severe sepsis is a common and frequently fatal condition. Evidence showing a link between the coagulation system and the inflammatory response to sepsis led to the development of drotrecogin alfa (activated) as an agent in the treatment of sepsis. This recombinant form of the natural protein, activated protein C (Xigris, Eli Lilly Co.), has been shown to significantly reduce mortality in a large randomised, controlled Phase III study involving 1690 patients. The exact mode of action of drotrecogin alfa (activated) remains uncertain, although it clearly combines anticoagulant and anti-inflammatory properties. Although associated with an increased risk of bleeding, this is usually procedure-related rather than spontaneous. Although costly, this is a drug that effectively reduces mortality rates in patients with severe sepsis.
Treatment with drotrecogin alfa activated significantly reduces mortality in patients with severe sepsis and may be associated with an increased risk of bleeding.
Recent advances in technology and better understanding of mechanisms underlying disease are beginning to enable us to better characterize critically ill patients. Instead of using nonspecific syndromic groupings, such as sepsis or acute respiratory distress syndrome, we can now classify individual patients according to various specific characteristics, such as immune status. This "personalized" medicine approach will enable us to distinguish patients who have similar clinical presentations but different cellular and molecular responses that will influence their need for and responses (both negative and positive) to specific treatments. Treatments will be able to be chosen more accurately for each patient, resulting in more rapid institution of appropriate, effective therapy. We will also increasingly be able to conduct trials in groups of patients specifically selected as being most likely to respond to the intervention in question. This has already begun with, for example, some new interventions being tested only in patients with coagulopathy or immunosuppressive patterns. Ultimately, as we embrace this era of precision medicine, we may be able to offer precision therapies specifically designed to target the molecular set-up of an individual patient, as has begun to be done in cancer therapeutics.
