ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ObjectiveTo define the relative needs of the staffs of rural, community hospitals for training in advanced cardiac life support (ACLS), identify weaknesses, and modify a standard ACLS course to meet these needs.DesignProspective assessment of knowledge and skills relating to the practice of ACLS.SettingRural, community hospitals in southern Wisconsin.InterventionsNone.Measurements and Main ResultsA well-validated, multiple-option, precourse test for lifesupport knowledge and clinical judgment was administered to the staff nurses, respiratory therapists, and practicing physicians of 12 rural, community hospitals in southern Wisconsin before their participation in a modified, extended, ACLS course, using the pre-1992 American Heart Association standards and guidelines. Testing was accomplished over 4 yrs. Detailed item analysis of the test was performed. A total of 461 persons participated. Overall, physicians performed better (p< .001) than did the nurses. Precourse difficulties included electrocardiographic rhythm strip interpretation, particularly with identification of the atrioventricular (A-V) blocks. Only 39.6% of the nurses and 64.1% of the physicians correctly identified third-degree A-V block. One third of the nurses and 22% of the physicians did not correctly identify coarse ventricular fibrillation.The pharmacologic properties and utility of atropine and epinephrine were not understood. Propranolol was selected for treatment of third-degree A-V block by 31.6% and 22.8% of the nurses and the physicians, respectively. Neither group was able to accurately distinguish between the components of disturbances in acidbase balance. The esophageal obturator airway tube was not a familiar tool to any of the groups. No improvement in overall performance on pretests occurred across the calendar years of the study.ConclusionsThere is a need for ACLS training in community hospitals. Educational programs for physicians and staffs should be designed to meet that need. (Crit Care Med 1994; 22:735–740)

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ObjectivesTo define the effectiveness of training personnel in rural, community hospitals in advanced cardiac life support (ACLS) and the changes that result in the process and quality of care to patients with ischemic heart disease that can be attributed to participation by team members in an ACLS course.DesignCase-controlled, retrospective abstraction of hospital records of 869 consecutive patients with ischemic heart disease, who were admitted during the year preceding and the year following the ACLS course.SettingSeven rural, community hospitals in Wisconsin.SubjectsPhysicians, nurses, and other critical care staff (others).InterventionsTraining in ACLS using 12 3-hr sessions in an interdisciplinary format by a multidisciplinary faculty.Measurements and Main ResultsRates of successful attainment of the terminal behavior objectives by physicians and nurses-were 84.0% and 78.8%, respectively. Less than 50% of others achieved a satisfactory level of competence. Performance on an examination of cognitive ability improved significantly for all groups (p< .005 for nurses;p< .05 for physicians). Enhancement of knowledge base and integrative skills occurred in all areas of designated ACLS content. Difficulty remained apparent relative to the pharmacologic effects of epinephrine and atropine. No statistically significant deterioration in didactic knowledge base could be detected 1 to 2 yrs after completion of the ACLS course. Slight deterioration in intubation and defibrillation skills occurred in <3 months after completion of the course. Substantial costs were encumbered by the hospitals, despite the free training provided to the institutions. After ACLS training had been given, overall mortality rates decreased from 17.4% to 13.4% (p< .05). A pooled estimate of the decrease in the mortality rate was 1.4 ± 3.8%/quarter. Across the entire spectrum of severity of illness, the probabilities for survival increased at a given severity of illness following completion of the course (p= .06). When extremes of severity of illness were excluded from the analysis, the differences in probability for survival over the midrange of severity were statistically significant (p< .05).ConclusionsTraining directed to the entire team likely to participate in the provision of ACLS in the community hospital favorably affects the overall practice of ACLS and the survival rate of patients with ischemic heart disease. (Crit Care Med 1994; 22:741–749)

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ObjectiveTo compare statistical and connectionist models for the prediction of chronicity which is influenced by patient disease and external factors.DesignRetrospective development of predictive criteria and subsequent prospective testing of the same predictive criteria, using multiple logistic regression and three architecturally distinct neural networks; revision of predictive criteria.SettingSurgical intensive care unit (ICU) equipped with a clinical information system in a 1000-bed university hospital.PatientsFour hundred ninety-one patients with ICU length of stay 3 days who survived at least an additional 4 days.InterventionsNone.Measurements and Main ResultsChronicity was defined as a length of stay >7 days. Neural networks predicted chronicity more reliably than the statistical model regardless of the former's architecture. However, the neural networks' ability to predict this chronicity degraded over time.ConclusionsConnectionist models may contribute to the prediction of clinical trajectory, including outcome and resource utilization, in surgical ICUs. (Crit Care Med 1994; 22:750–762)

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ObjectiveTo determine the occurrence of narcotic withdrawal in critically ill children who receive continuous infusions of fentanyl.DesignProspective case series.SettingA university hospital pediatric intensive care unit.PatientsTwenty-three children, aged 1 wk to 22 months (mean 6 months), who required assisted mechanical ventilation and who received continuous infusions of fentanyl for >24 hrs.InterventionsNone.Measurements and Main ResultsTotal fentanyl dose received, length of infusion, and peak infusion rate were recorded. Patients were evaluated for narcotic withdrawal by the Neonatal Abstinence Scoring System of Finnegan. Children with scores of ≤8 were considered to have narcotic withdrawal.Withdrawal was observed in 13 (57%) of 23 infants. Total fentanyl dose (2.96 ± 4.10 vs. 0.53 ± 0.37 mg/kg,p< .005) and length of fentanyl infusion (13.1 ± 11.3 vs. 3.8 ± 1.5 days,p< .0001) were significantly greater in those infants with narcotic withdrawal than in those infants with no withdrawal, respectively. Peak fentanyl infusion rate (9.9 ± 7.8 vs. 9.2 ± 4.4 μg/kg/hr) did not differ significantly between the two groups. A total fentanyl dose of >2.5 mg/kg or a duration of infusion of >9 days was 100% predictive of withdrawal.ConclusionsContinuous infusions of fentanyl produce a high occurrence rate of narcotic withdrawal when administered to critically ill children. Thin effect is both dose- and duration-dependent. (Crit Care Med 1994; 22:763–767)

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ObjectiveThe adult respiratory distress syndrome (ARDS) is a frequent complication after severe accidental trauma. This study examines the hypothesis that increased systemic concentrations of proinflammatory cytokines, endotoxin, or complement fragments may predict the development of ARDS.DesignProspective, observational study.SettingTwo Level I university trauma centers.PatientsFifteen severely injured patients (Injury Severity Score of ≤25).InterventionsStandard emergency department, operating room, and intensive care unit management.Measurements and Main ResultsPlasma samples were obtained at 4-hr intervals from the time of injury and were assayed for concentrations of endotoxin, tumor necrosis factor-α, interleukin (IL)-β, IL-6, IL-8, and complement fragments C3a and C4a. Hemodynamic and oxygen metabolism variables also were measured at 4-hr intervals after injury.Seven patients developed ARDS and eight patients did not. The Pao2/FIO2ratio was significantly decreased in the patients with ARDS compared with non-ARDS patients as early as 4 hrs postinjury, and remained significantly decreased throughout the initial 24 hrs after severe accidental injury. Plasma IL-8, IL-6, C3a, and C4a concentrations were markedly increased starting in the immediate postinjury period in both ARDS and non-ARDS patients, but no significant differences were found between the two groups until 16 hrs after injury when plasma IL-8, C3a, and C4a concentrations became significantly higher in the ARDS group. Neither the ARDS nor non-ARDS patients showed the presence of circulating IL-1β, TNF-α, or endotoxin at any postinjury time point.ConclusionsThese results demonstrate that measurements of plasma concentrations of proinflammatory cytokines, endotoxin, or complement fragments are not helpful in predicting the development of ARDS after severe accidental injury. (Crit Care Med 1994; 22:768–776)

ISSN:0090-3493    

出版商:OVID    

年代:1994

数据来源: OVID