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Biomedical subjects

Curtis N Sessler

Publications and source records attributed to Curtis N Sessler.

At least 19 recordsLinked to original sources
PubMed2006

Infection control and the prevention of nosocomial infections in the intensive care unit.

Nosocomial infections continue to be significant causes of morbidity, mortality, and added costs in the health care setting. Half of all life-threatening nosocomial bloodstream infections and pneumonias occur in intensive care units (ICUs), despite ICUs representing only 15 to 20% of all hospital beds. Thus an efficient focus for prevention and control of life-threatening health care-associated infections should be in ICUs. Further, growing antibiotic resistance complicates the therapy of serious infections. Meticulous infection control practice with continued attention to hand hygiene is of paramount importance. Strict adherence to evidence-based catheter insertion and maintenance policies reduces nosocomial bloodstream infections. Evidence-based prevention strategies for ventilator-associated pneumonia, including management of respiratory equipment according to published guidelines and maintaining backrest elevation at 30 to 45 degrees, are effective. For greatest risk reduction, multifaceted programs ensuring maximal adherence with evidence-based infection control guidelines are needed.

Cross Infection↗
PubMed2006

Oral health status and development of ventilator-associated pneumonia: a descriptive study.

BACKGROUND: Ventilator-associated pneumonia is a significant cause of morbidity and mortality and may be influenced by oral health. OBJECTIVE: To describe the relationship between ventilator-associated pneumonia and oral health status, changes in oral health status during the first 7 days after intubation, and microbial colonization of the oropharynx and trachea. METHODS: A total of 66 patients were enrolled within 24 hours of intubation and were followed up for up to 7 days. Data on oral health measures and the Clinical Pulmonary Infection Score (CPIS) were collected at baseline, day 4 (n = 37), and day 7 (n = 21). A regression model was used to predict risk of pneumonia at day 4. RESULTS: Dental plaque and oral organisms increased over time. Correlations were significant for baseline and day 4 dental plaque (P < .001), baseline salivary lactoferrin and day 4 plaque (P = .01), and lower salivary volume and higher day 4 CPIS (P = .02). Potential pathogens were identified in oral cultures for 6 patients before or at the same time as the appearance of the organisms in tracheal aspirates. Correlations were significant with day 4 CPIS for score on the Acute Physiology and Chronic Health Evaluation (APACHE) II (P = .007), day 4 salivary volume (P = .02), interaction of APACHE II score and day 1 CPIS (P<.001), and interaction of day 1 CPIS and plaque (P=.01). CONCLUSIONS: Higher dental plaque scores confer greater risk for ventilator-associated pneumonia, particularly for patients with greater severity of illness. Salivary volume and lactoferrin may affect the risk.

Critical Illness↗
PubMed2005

Protocol-directed weaning: a process of continuous performance improvement.

The use of a nursing-directed and/or respiratory therapist-directed protocol in many intensive care units for weaning from mechanical ventilation is associated with a shorter duration of ventilation and length of stay in the ICU. Most protocols have two formal components: the daily screening of a set of simple observations or interventions to identify readiness to proceed, followed by a spontaneous breathing trial that tests the patient's ability to breathe independently. The daily screen is designed to identify potential barriers regarding medical stability, level of consciousness, oxygenation, ventilation, and airway patency and protection. However, one must avoid selecting criteria that are too restrictive, potentially delaying the discontinuation of ventilation.

Humans↗
PubMed2005

Sedation, analgesia, and neuromuscular blockade for high-frequency oscillatory ventilation.

OBJECTIVE: To provide a comprehensive review of the issue related to the administration of sedative, analgesic, and neuromuscular blocking agents (NMBA) to patients who are receiving ventilatory support for acute respiratory distress syndrome (ARDS) with high-frequency oscillatory ventilation. RESULTS: Sedative, analgesic, and NMBA are used with great frequency in patients with severe ARDS who are undergoing high-frequency oscillatory ventilation. In particular, the use of NMBA has been higher than for other ARDS populations. Important considerations for effective treatment include careful patient evaluation, patient-based medication selection, identification of treatment goals with periodic re-assessment, titration of medications to objective parameters such as sedation scales and peripheral nerve stimulation, use of intermittent therapy when feasible, implementation of drug interruption strategies, and discontinuation of medications at the earliest possible time. It is important to recognize that patients evolve from severe ARDS through phases of recovery to the resolution of respiratory failure and that ventilatory management, as well as sedative and related medication requirements, will vary markedly over the course of this process. CONCLUSIONS: A multidisciplinary, structured approach that is based on the considerations described should help achieve optimal results in this challenging patient population.

Analgesia↗
PubMed2005

A comprehensive review of disseminated Salmonella arizona infection with an illustrative case presentation.

Salmonella arizona is known to cause infection in reptiles and other animals. Disseminated human infection is rare, except in the setting of a deficient immune system. The following is a unique account of disseminated infection including pericardial involvement. Unusual features include nonreptile vector transmission and eastern seaboard (rather than southwestern) locale. A comprehensive literature review of disseminated S arizona infections is presented describing the types of infection, sources of exposure, underlying conditions, locale, treatments, and outcomes.

AIDS-Related Opportunistic Infections↗
PubMed2005

Actigraphy in the critically ill: correlation with activity, agitation, and sedation.

OBJECTIVES: To determine the feasibility of continuous measurement of limb movement via wrist and ankle actigraphy (an activity measure) in critically ill patients and to compare actigraphy measurements with observed activity, subjective scores on sedation-agitation scales, and heart rate and blood pressure of patients. METHODS: In a prospective, descriptive, correlational study, all activity of 20 adult patients in medical and coronary care units in a university medical center were observed for 2 hours and documented. Wrist and ankle actigraphy, heart rate, and systolic and diastolic blood pressure data were collected every minute. The Comfort Scale and the Richmond Agitation-Sedation Scale were completed at the beginning of the observation period and 1 and 2 hours later. RESULTS: Wrist actigraphy data correlated with scores on the Richmond Agitation-Sedation Scale (r = 0.58) and the Comfort Scale (r = 0.62) and with observed stimulation and activity events of patients (r = 0.45). Correlations with systolic, diastolic, and mean arterial pressures were weaker. Wrist and ankle actigraphy data were significantly correlated (r = 0.69; P < .001); however, their mean values (wrist, 418; ankle, 147) were significantly different (t = 5.77; P < .001). CONCLUSIONS: Actigraphy provides a continuous recording of patients' limb movement. Actigraphy measurements correlate well with patients' observed activity and with subjective scores on agitation and sedation scales. Actigraphy may become particularly important as a continuous measurement of activity for use in behavioral research and may enhance early recognition and management of the excessive activity that characterizes agitation.

Adult↗
PubMed2005

Effect of backrest elevation on the development of ventilator-associated pneumonia.

BACKGROUND: Ventilator-associated pneumonia is a common complication of mechanical ventilation. Backrest position and time spent supine are critical risk factors for aspiration, increasing the risk for pneumonia. Empirical evidence of the effect of backrest positions on the incidence of ventilator-associated pneumonia, especially during mechanical ventilation over time, is limited. OBJECTIVE: To describe the relationship between backrest elevation and development of ventilator-associated pneumonia. METHODS: A nonexperimental, longitudinal, descriptive design was used. The Clinical Pulmonary Infection Score was used to determine ventilator-associated pneumonia. Backrest elevation was measured continuously with a transducer system. Data were obtained from laboratory results and medical records from the start of mechanical ventilation up to 7 days. RESULTS: Sixty-six subjects were monitored (276 patient days). Mean backrest elevation for the entire study period was 21.7 degrees . Backrest elevations were less than 30 degrees 72% of the time and less than 10 degrees 39% of the time. The mean Clinical Pulmonary Infection Score increased but not significantly, and backrest elevation had no direct effect on mean scores. A model for predicting the Clinical Pulmonary Infection Score at day 4 included baseline score, percentage of time spent at less than 30 degrees on study day 1, and score on the Acute Physiology and Chronic Health Evaluation II, explaining 81% of the variability (F=7.31, P=.003). CONCLUSIONS: Subjects spent the majority of the time at backrest elevations less than 30 degrees . Only the combination of early, low backrest elevation and severity of illness affected the incidence of ventilator-associated pneumonia.

APACHE↗
PubMed2004

Management of severe sepsis and septic shock.

PURPOSE OF REVIEW: Severe sepsis and septic shock are common and deadly conditions for which the epidemiology, pathogenesis, and management continue to evolve. Recent publications (2003 and early 2004) have been systematically reviewed for important new original research and scholarly reviews, with an emphasis on clinical advances in adults. RECENT FINDINGS: Important new epidemiologic studies establish the increasing frequency (nearly 9% per year) and falling mortality rates associated with sepsis. Sepsis definitions were reviewed by a group of experts, and the principal features of the 1991 consensus conference definitions were supported, with a new framework for evaluation of sepsis proposed. New research and thoughtful reviews continue to elucidate the pathogenesis of sepsis, with emphasis on innate immunity and time-based changes in immune status, varying from hyperreactive immunity and inflammation to immune depression with enhanced risk for nosocomial infections. A comprehensive evidence-based approach to the management of severe sepsis is presented in an important document developed by representatives from many critical care and infectious disease societies. Management includes early targeted resuscitation, broad empiric antibiotic coverage and source control, effective shock evaluation and treatment, adjuvant therapy with recombinant human activated protein C and moderate-dose hydrocortisone in selected patients, and comprehensive supportive care. Recently published multicenter clinical trials for novel agents have been disappointing, particularly for a nitric oxide synthase inhibitor that effectively supported blood pressure but increased mortality. SUMMARY: The works reviewed reflect the advances in the care of patients with sepsis.

Humans↗
PubMed2003

Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).

CONTEXT: Goal-directed delivery of sedative and analgesic medications is recommended as standard care in intensive care units (ICUs) because of the impact these medications have on ventilator weaning and ICU length of stay, but few of the available sedation scales have been appropriately tested for reliability and validity. OBJECTIVE: To test the reliability and validity of the Richmond Agitation-Sedation Scale (RASS). DESIGN: Prospective cohort study. SETTING: Adult medical and coronary ICUs of a university-based medical center. PARTICIPANTS: Thirty-eight medical ICU patients enrolled for reliability testing (46% receiving mechanical ventilation) from July 21, 1999, to September 7, 1999, and an independent cohort of 275 patients receiving mechanical ventilation were enrolled for validity testing from February 1, 2000, to May 3, 2001. MAIN OUTCOME MEASURES: Interrater reliability of the RASS, Glasgow Coma Scale (GCS), and Ramsay Scale (RS); validity of the RASS correlated with reference standard ratings, assessments of content of consciousness, GCS scores, doses of sedatives and analgesics, and bispectral electroencephalography. RESULTS: In 290-paired observations by nurses, results of both the RASS and RS demonstrated excellent interrater reliability (weighted kappa, 0.91 and 0.94, respectively), which were both superior to the GCS (weighted kappa, 0.64; P<.001 for both comparisons). Criterion validity was tested in 411-paired observations in the first 96 patients of the validation cohort, in whom the RASS showed significant differences between levels of consciousness (P<.001 for all) and correctly identified fluctuations within patients over time (P<.001). In addition, 5 methods were used to test the construct validity of the RASS, including correlation with an attention screening examination (r = 0.78, P<.001), GCS scores (r = 0.91, P<.001), quantity of different psychoactive medication dosages 8 hours prior to assessment (eg, lorazepam: r = - 0.31, P<.001), successful extubation (P =.07), and bispectral electroencephalography (r = 0.63, P<.001). Face validity was demonstrated via a survey of 26 critical care nurses, which the results showed that 92% agreed or strongly agreed with the RASS scoring scheme, and 81% agreed or strongly agreed that the instrument provided a consensus for goal-directed delivery of medications. CONCLUSIONS: The RASS demonstrated excellent interrater reliability and criterion, construct, and face validity. This is the first sedation scale to be validated for its ability to detect changes in sedation status over consecutive days of ICU care, against constructs of level of consciousness and delirium, and correlated with the administered dose of sedative and analgesic medications.

Aged↗
PubMed2003

Steroids for septic shock: back from the dead? (Con).

The role of corticosteroid therapy in the management of septic shock has been debated for half a century. Results from large, well-designed, randomized clinical trials demonstrate no benefit, and perhaps harm, associated with short duration, high-dose methylprednisolone or dexamethasone administered at the onset of septic shock. Based on evidence of "relative adrenal insufficiency" and steroid-responsive adrenergic receptor desensitization in sepsis, administration of modest doses (200 to 300 mg/d) of hydrocortisone for 1 to 3 weeks has been investigated. A multicenter, placebo-controlled clinical trial demonstrated improved survival rates and faster cessation of vasopressors among patients with septic shock who have a poor response to corticotropin injection, consistent with relative adrenal insufficiency. However, concerns regarding a trend for higher mortality among corticotropin responders and the possibility that patients with true adrenal insufficiency may have been enrolled in this placebo-controlled trial, potentially skewing results, should be considered.

Adrenal Insufficiency↗
PubMed2003

Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation.

BACKGROUND: Use of protocols to reduce weaning time for patients receiving mechanical ventilation helps reduce cost and length of stay. However, implementation of this type of protocol is not easy and requires a consistent collaborative effort. OBJECTIVE: To provide a systematic approach to the weaning process by developing, implementing, and evaluating a protocol for weaning patients from mechanical ventilation in a medical respiratory intensive care unit. METHODS: The weaning protocol used was a modification of a protocol developed by Ely et al. Modifications included a more aggressive approach in proceeding to the spontaneous breathing trial, inclusion of the Richmond Agitation-Sedation Scale, and documentation of the production of secretions. RESULTS: Implementation of the protocol significantly reduced the duration of mechanical ventilation as measured by 8-hour shifts and ventilator days. Although length of stay in the intensive care unit was not significantly reduced (P = .29), a continuing downward trend occurred, from a mean of 8.6 days before the protocol was implemented to 7.9 days during the last 6 months of data collection (P = .07). CONCLUSIONS: The need to provide efficient care requires the collaboration of all disciplines involved in providing patients' care. The weaning protocol introduced in this study demonstrates the benefits of using a collaborative team to identify best practices and implement them in a practice setting.

Clinical Protocols↗
PubMed2002

The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.

Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 "combative" to -5 "unarousable") scale, the Richmond Agitation-Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; kappa = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922-0.983) (kappa = 0.64-0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93) with a visual analog scale anchored by "combative" and "unresponsive," including all patient subgroups (r = 0.84-0.98). In the second phase, after implementation of RASS in our medical ICU, inter-rater reliability between a nurse educator and 27 RASS-trained bedside nurses in 101 patient encounters was high (r = 0.964, lower 90% confidence limit = 0.950; kappa = 0.80, 95% confidence interval = 0.69, 0.90) and very good for all subgroups (r = 0.773-0.970, kappa = 0.66-0.89). Correlations between RASS and the Ramsay sedation scale (r = -0.78) and the Sedation Agitation Scale (r = 0.78) confirmed validity. Our nurses described RASS as logical, easy to administer, and readily recalled. RASS has high reliability and validity in medical and surgical, ventilated and nonventilated, and sedated and nonsedated adult ICU patients.

Adult↗