摘要:

ObjectiveThe primary goal of this study was to address the documented deficiencies in end-of-life care (EOLC) in intensive care unit settings by identifying key EOLC domains and related quality indicators for use in the intensive care unit through a consensus process. A second goal was to propose specific clinician and organizational behaviors and interventions that might be used to improve these EOLC quality indicators.ParticipantsParticipants were the 36 members of the Robert Wood Johnson Foundation (RWJF) Critical Care End-of-Life Peer Workgroup and 15 nurse-physician teams from 15 intensive care units affiliated with the work group members. Fourteen adult medical, surgical, and mixed intensive care units from 13 states and the District of Columbia in the United States and one mixed intensive care unit in Canada were represented.MethodsAn in-depth literature review was conducted to identify articles that assessed the domains of quality of EOLC in the intensive care unit and general health care. Consensus regarding the key EOLC domains in the intensive care unit and quality performance indicators within each domain was established based on the review of the literature and an iterative process involving the authors and members of the RWJF Critical Care End-of-Life Peer Workgroup. Specific clinician and organizational behaviors and interventions to address the proposed EOLC quality indicators within the domains were identified through a collaborative process with the nurse-physician teams in 15 intensive care units.Measurements and Main ResultsSeven EOLC domains were identified for use in the intensive care unit: a) patient- and family-centered decision making; b) communication; c) continuity of care; d) emotional and practical support; e) symptom management and comfort care; f) spiritual support; and g) emotional and organizational support for intensive care unit clinicians. Fifty-three EOLC quality indicators within the seven domains were proposed. More than 100 examples of clinician and organizational behaviors and interventions that could address the EOLC quality indicators in the intensive care unit setting were identified.ConclusionsThese EOLC domains and the associated quality indicators, developed through a consensus process, provide clinicians and researchers with a framework for understanding quality of EOLC in the intensive care unit. Once validated, these indicators might be used to improve the quality of EOLC by serving as the components of an internal or external audit evaluating EOLC continuous quality improvement efforts in intensive care unit settings.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveNuclear factor (NF)-&kgr;B is a transcriptional factor required for the gene expression of many inflammatory mediators. This study was designed to investigate the biological effects of parthenolide, a specific inhibitor of NF-&kgr;B activation, in experimental sepsis and multiple organ failure.DesignProspective, randomized laboratory investigation that used an established model of cecal ligation and puncture to induce polymicrobial sepsis in rats.SettingUniversity hospital laboratory.SubjectsMale Sprague Dawley rats underwent cecal ligation and puncture followed by the administration of saline solution.InterventionsA group of rats received parthenolide (1 mg/kg) intraperitoneally. Mean arterial blood pressure was monitored for 18 hrs, and survival rate was monitored for 4 days. In a separate experiment, rats were killed at 1, 3, 6, and 18 hrs after cecal ligation and puncture.Measurements and Main ResultsIn vehicle-treated animals, cecal ligation and puncture resulted in polymicrobial sepsis and was associated with 20% mortality rate, marked hypotension, and lung injury. Immunohistochemistry showed positive staining for nitrotyrosine and poly(adenosine diphosphate [ADP]-ribose) polymerase-1 (PARP-1) in thoracic aortas. There was a significant increase in plasma concentrations of tumor necrosis factor-&agr;, interleukin-6, and interleukin-10. Elevated levels of myeloperoxidase activity in lung, colon, and liver were indicative of infiltration of neutrophils. These inflammatory events were associated with activation of NF-&kgr;B in the lung in a time-dependent fashion.In vivotreatment with parthenolide improved the hemodynamic profile and survival; reduced neutrophil infiltration in lung, colon, and liver; and reduced plasma concentrations of cytokines. Treatment with parthenolide also abolished formation of nitrotyrosine and expression of PARP-1 in thoracic aortas. These beneficial effects of parthenolide were associated with reduction of NF-&kgr;B activity in the lung.ConclusionsOur data suggest that pharmacologic inhibition of NF-&kgr;B may represent a potential therapeutic approach in sepsis.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess hearing impairment in adults admitted to a university surgical intensive care unit in order to identify patients at risk for impaired receptive communication.DesignProspective, clinical, observational study within the continuing quality improvement program.SettingTen-bed adult surgical intensive care unit at a university hospital.PatientsPatients were 442 adult patients admitted to the surgical intensive care unit for trauma, a critical illness, or postoperative monitoring.InterventionsAs part of a continuing quality improvement protocol, adults admitted to the surgical intensive care unit were screened for hearing loss. Screening included otoscopy, tympanometry, and distortion product otoacoustic emissions as near the time of admission as was possible. Testing was available only on weekdays.Measurements and Main ResultsAudiologic testing was performed on day 1.7 ± 3.0 and took 9.3 mins (range, 5–17 min). The women studied (n = 177, 56.2 ± 18.2 yrs) were significantly older than the men (n = 265, 51.2 ± 17.8 yrs,p< .0001). We found that 71.4% of patients had normal otoscopy. Only 42.5% of patients passed tympanometry. True failures accounted for 37.3% of patients and technical failures for 20.2%. Distortion product otoacoustic emission (DPOAE) testing was performed on 97.4% of ears. Only 36.2% of patients passed; 58.4% of ears failed, suggesting clinically significant auditory impairment. DPOAE results correlated with age. The pass rate was approximately 60% for patients <40 yrs of age but declined steadily by decade to <7% in patients >80 yrs. The mean age of passed DPOAE (44.2 ± 16.2 yrs) was significantly younger than patients who failed DPOAE (60.0 ± 16.6 yrs,p< .0001).ConclusionsAdult patients admitted to the surgical intensive care unit for trauma, postoperative monitoring, or critical illness are at significant risk of impaired auditory reception. Almost two thirds of patients studied failed the screening protocol. Risk of failure increases with age and male gender. Screening with otoscopy, tympanometry, and DPOAE is an efficient and sensitive way to identify patients at risk for impaired auditory acuity.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo study the incidence and severity of multiple organ dysfunction in severe falciparum malaria.DesignProspective, observational study.SettingIntensive care unit of a tertiary care university hospital.PatientsThree hundred one consecutive patients with severe falciparum malaria admitted during the 30-month study period.InterventionsDaily assessment of clinical and biochemical variables required for calculating the Sequential Organ Failure Assessment (SOFA) score.Measurements and Main ResultsCentral nervous system failure was present in 121 patients (53 deaths). Renal failure occurred in 91 patients (48 deaths), and 33 required dialysis. Severe thrombocytopenia occurred in 114 patients (seven required platelet transfusion), and 19 patients had thrombocytopenia and disseminated intravascular coagulation; all required component therapy; 229 patients received blood transfusion for severe hemolytic anemia. Hepatic failure occurred in 77 patients (38 deaths). Respiratory failure developed in 79 patients and carried the worst outcome (70 deaths). It occurred later in the course of the illness (mean, 3.1 days;p< .001) compared with cerebral, renal, and coagulation failure (mean, 1.3–2.3 days). Regardless of the organ system involved, only 11 of 172 patients with one or no organ failure died (6.8%), whereas mortality rate increased to 48.8% in 129 patients with multiple organ failure. Other abnormalities associated with poor outcome included seizures in 54 patients (56% mortality rate), metabolic acidosis in 167 (40% mortality rate), hypoglycemia in 88 (39% mortality rate), and hemoglobinuria in 190 (33% mortality rate). Sixty patients had quinine toxicity requiring dosage reduction. Bacterial sepsis occurred in 39 patients (35 deaths) and accounted for 85% of deaths occurring after day 7. Twenty-three pregnant women had no significant difference in outcomes. Overall mortality rate was 24.6% (301 patients, 74 deaths).ConclusionsMalaria is an important cause of multiple organ failure in India. Mortality rate is 6.4% when one or fewer organs fail but increases to 48.8% with failure of two or more organs. However, outcomes are better than for similar degrees of organ failure in sepsis.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveSemirecumbent head-of-bed positioning in mechanically ventilated patients decreases the risk of developing ventilator-associated pneumonia (VAP). The purpose of this study was to determine whether the addition of a standardized order followed by the initiation of a provider education program would increase the frequency with which our patients were maintained in the semirecumbent position.DesignProspective, pre-, and postintervention observational study.SettingA tertiary care, U.S. Army teaching hospital.PatientsMechanically ventilated medical and surgical intensive care unit patients.InterventionsThe first intervention involved the addition of an order for semirecumbent head-of-bed positioning to our intensive care unit order sets. This was followed 2 months later with a second intervention, which was a nurse and physician education program emphasizing semirecumbent positioning.Measurements and Main ResultsData regarding head-of-bed positioning were collected on 100 patient observations at baseline and at 1 and 2 months after each of our interventions. The mean angle of head of bed increased from 24 ± 9 degrees at baseline to 35 ± 9 degrees (p< .05) 2 months after the addition of the standard order. The percentage of observations with head of bed >45 degrees increased from 3% to 16% 2 months after the standardized order (p< .05). Two months after our provider education program, the mean angle of the head of bed was 34 ± 11 degrees and the percentage of patients with head of bed >45 degrees was 29% (p= NS compared with values after the first intervention). Data collected 6 months after completion of our education programs showed that these improvements were maintained.ConclusionsStandardizing the process of care via the addition of an order specifying head-of-bed position significantly increased the number of patients who were placed in the semirecumbent position. In an era of cost-conscious medicine, interventions that utilize protocols and education programs should be emphasized.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveIn the multinational PROWESS trial, drotrecogin alfa (activated) significantly reduced mortality rate in patients with severe sepsis compared with placebo. The use of large multiple-center trials can potentially complicate interpretation of results in severe sepsis populations because of variability in medical attitudes and practices and the frequency of confounding events such as protocol violations. The objective of this study was to perform a blinded, critical, integrated review of data from the 1,690 severe sepsis patients from 164 medical centers enrolled in the PROWESS trial using a Clinical Evaluation Committee.DesignBlinded, critical, integrated review of data.SettingParticipating sites.PatientsThe 1,690 severe sepsis patients from 164 medical centers enrolled in the PROWESS trial.InterventionsWe performed analyses of the optimal cohort, defined as patients who had full compliance with the protocol, had evidence of an infection, and received adequate anti-infective therapy. We also performed other analyses, including significant underlying disorders, life support measures, and causes of death.Measurements and Main ResultsThe optimal cohort of 81.4% of the intention-to-treat population [drotrecogin alfa (activated), n = 695; placebo, n = 680] had similar baseline severity of illness between the two groups, a similar pharmacodynamic effect, and a relative risk of death estimate consistent with that observed in the overall PROWESS trial (0.83, 95% confidence interval 0.69–0.99 vs. 0.806, 95% confidence interval 0.69–0.94). A beneficial effect of drotrecogin alfa (activated) similarly was observed in patients with significant underlying disorders (0.73, 95% confidence interval 0.57–0.93) who were more severely ill and had a higher percentage of patients forgoing life-sustaining therapy. In contrast with the original investigator determinations, a benefit associated with drotrecogin alfa (activated) treatment in urinary tract infection adjudicated by the Clinical Evaluation Committee was observed.ConclusionsThe survival benefit associated with drotrecogin alfa (activated) use was consistent with the results of the overall trial regardless of whether patients met criteria of the optimal cohort or had a significant underlying disorder.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess the effectiveness of routine intensive care unit surveillance compared with frequent 12-lead electrocardiogram monitoring for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia in vascular surgery patients.DesignProspective cohort trial.SettingIntensive care unit.ParticipantsWe studied 149 patients undergoing elective infrainguinal or aortic vascular surgery who were admitted to the intensive care unit postoperatively.InterventionsPatients were simultaneously monitored with a 10-electrode/12-lead electrocardiogram obtained every 2 mins (criterion standard) and routine intensive care unit surveillance that included standard monitoring (five-electrode/two-lead electrocardiogram with ST segment trends and routine 12-lead electrocardiogram) and clinical assessment for detecting myocardial ischemia. The results of the criterion standard were not available to the caregivers.Measurements and Main ResultsWe measured the ability of routine intensive care unit surveillance to detect the first 20 mins of electrocardiogram evidence suggestive of myocardial ischemia, defined as ST segment depression or elevation of ≥1 mm in two consecutive leads, during the first postoperative day. Seventeen patients (11%) had electrocardiogram evidence suggestive of prolonged myocardial ischemia, the majority of which occurred in leads V2–V4. The sensitivity of routine intensive care unit surveillance for detecting the first episode of electrocardiogram evidence suggestive of prolonged myocardial ischemia in a patient was 12% (95% confidence interval, 7–17%), and the specificity was 98% (95% confidence interval, 95–100%) with a positive predictive value of 40% (95% confidence interval, 32–48%), a negative predictive value of 90% (95% confidence interval, 85–94%), a positive likelihood ratio of 6, and a negative likelihood ratio of 1. The sensitivity of routine intensive care unit surveillance for detecting all episodes was 3% (95% confidence interval, 2–3%) and the specificity 99% (95% confidence interval, 99–100%) per 20-min monitoring interval, with a positive predictive value of 17% (95% confidence interval, 16–18%), negative predictive value of 95% (95% confidence interval, 95–96%), positive likelihood ratio of 3, and negative likelihood ratio of 1.ConclusionsRoutine intensive care unit surveillance has low sensitivity for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia compared with frequent 12-lead electrocardiograms. Because detecting electrocardiogram evidence suggestive of prolonged postoperative myocardial ischemia is important, physicians should consider alternative strategies to detect myocardial ischemia.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that low concentrations of distal airspace water-soluble antioxidants are associated with acute lung injury.DesignProspective, cohort study.SettingMedical intensive care unit of two tertiary care hospitals.SubjectsSubjects were 29 patients with acute lung injury and 23 normal, healthy, volunteers.InterventionsNone.Measurements and Main ResultsPulmonary edema fluid from subjects with acute lung injury was aspirated immediately after intubation. Compared with the bronchoalveolar lavage from normal subjects (corrected for dilution using urea concentrations), undiluted edema fluid from acute lung injury subjects had significantly lower concentrations of the antioxidants urate (757 ± 232 &mgr;M vs. 328 ± 75 &mgr;M), glutathione (138 ± 25 &mgr;M vs. 7 ± 4 &mgr;M), and ascorbate (85 ± 21 &mgr;M vs. 27 ± 10 &mgr;M).ConclusionsAcute lung injury is associated with decreased concentrations of water-soluble antioxidants in the distal airspaces. In acute lung injury, the distal airspace antioxidants ascorbate, urate, and glutathione may play a role in attenuating lung injury.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo estimate long-term mortality and medical care charges among patients with severe sepsis.DesignRetrospective cohort study.SettingLarge, integrated, geographically diverse, U.S. health-insurance claims database covering three million lives annually.PatientsAll persons with bacterial or fungal infections and acute organ dysfunction (severe sepsis) who were hospitalized between January 1, 1991, and August 31, 2000.InterventionsNone.Measurements and Main ResultsAll patients were followed from the date of hospitalization with severe sepsis (index admission) to August 31, 2000, disenrollment from the health plan, or death, whichever occurred first. Measures of interest included mortality and medical care charges and were estimated for the index admission, the 90- and 180-day periods following the index admission, and annually thereafter (up to 5 yrs), using techniques of survival analysis. A total of 16,019 patients were identified who met study entrance criteria. Most patients (81.2%) were ≥65 yrs of age; 53.4% were men. Mortality was 21.2% for the index admission, 51.4% at 1 yr, and 74.2% at 5 yrs. Mean cumulative total medical care charges were $44,600 for the index admission, $78,500 at 1 yr, and $118,800 at 5 yrs. Hospitalization accounted for the largest component of total medical care charges.ConclusionsMortality and economic costs are high in patients with severe sepsis, during the period of acute illness as well as subsequently.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether near infrared spectroscopic measurement of tissue pH and Po2has sufficient accuracy to assess variation in tissue perfusion resulting from changes in blood pressure and metabolic demand during cardiopulmonary bypass.DesignProspective clinical study.SettingAcademic medical center.SubjectsEighteen elective cardiac surgical patients.InterventionCardiac surgery under cardiopulmonary bypass.Measurements and Main ResultsA near infrared spectroscopic fiber optic probe was placed over the hypothenar eminence. Reference Po2and pH sensors were inserted in the abductor digiti minimi (V). Data were collected every 30 secs during surgery and for 6 hrs following cardiopulmonary bypass. Calibration equations developed from one third of the data were used with the remaining data to investigate sensitivity of the near infrared spectroscopic measurement to physiologic changes resulting from cardiopulmonary bypass. Near infrared spectroscopic and reference pH and Po2measurements were compared for each subject using standard error of prediction. Near infrared spectroscopic pH and Po2at baseline were compared with values during cardiopulmonary bypass just before rewarming commenced (hypotensive, hypothermic), after rewarming (hypotensive, normothermic) just before discontinuation of cardiopulmonary bypass, and at 6 hrs following cardiopulmonary bypass (normotensive, normothermic) using mixed-model analysis of variance. Near infrared spectroscopic pH and Po2were well correlated with the invasive measurement of pH (R2= .84) and Po2(R2= .66) with an average standard error of prediction of 0.022 ± 0.008 pH units and 6 ± 3 mm Hg, respectively. The average difference between the invasive and near infrared spectroscopic measurement was near zero for both the pH and Po2measurements. Near infrared spectroscopic Po2significantly decreased 50% on initiation of cardiopulmonary bypass and remained depressed throughout the bypass and monitored intensive care period. Near infrared spectroscopic pH decreased significantly during cardiopulmonary bypass, decreased significantly during rewarming, and remained depressed 6 hrs after cardiopulmonary bypass. Diabetic patients responded differently than nondiabetic subjects to cardiopulmonary bypass, with lower muscle pH values (p= .02).ConclusionsNear infrared spectroscopic-measured muscle pH and Po2are sensitive to changes in tissue perfusion during cardiopulmonary bypass.

ISSN:0090-3493    

出版商:OVID    

年代:2003

数据来源: OVID