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PubMedDate not supplied

Capnography confirms correct feeding tube placement in intensive care unit patients.

PURPOSE: To test the accuracy and potential time savings of capnography as compared with a two-step radiographic method in placing feeding tubes in critically ill patients. METHODS: One hundred feeding tube placements were studied in our tertiary care intensive care unit. All placements utilized a two-step radiographic method, but capnography was added to the procedure. The procedure was then completed or abandoned depending on radiographic interpretation. RESULTS: Radiography showed 11 feeding tubes projecting within the tracheobronchial tree. In all 11 of these placements, the capnography unit displayed a normal capnogram. Radiography revealed 86 tube placements in the midesophageal region. In all 86 of these placements, capnography displayed a "purging warning". In three placements, radiography indicated that the tube was coiled in the oropharynx. In these cases, the capnograph displayed one "no purging/no capnogram" result, and two "purging" warnings. If using capnography alone, an average of 72.5 min would be required to complete a feeding tube placement (which includes time for requisite "pre-feed radiograph"). The two-step radiological approach took an average of 169.4 min, a difference of 96.9 min (P <0.0001) between the two methods. CONCLUSIONS: Capnography accurately identified all intratracheal feeding tube placements in this study. This study also shows that the use of capnography would significantly shorten the time needed for tube placement compared with a two-step radiologic method. Capnography should be considered for routine use when placing feeding tubes since it adds little time to the procedure and may improve patient safety.

Adult↗
PubMedDate not supplied

Taking the fear out of postanesthesia care in the intensive care unit.

This article was written for intensive care unit (ICU) nurses who find themselves having to recover surgical patients from anesthesia, whether they are critical care patients or acute care patients to be transferred to a regular nursing unit after recovery. Intensive care orientation programs may not adequately address the care of postanesthesia patients. This inadequacy manifests itself in the stress that intensive care nurses experience in caring for their patients. It may also present as a discomfort among anesthesia personnel with leaving a patient in the ICU postoperatively, and a lack of rapport between ICU nurses and anesthesia personnel. This article presents specific, practical information about nursing care of patients recovering from anesthesia, building on the existing assessment and interventional skills of the critical care nurse. It discusses the roles of the anesthesiologist, nurse anesthetist, and the postanesthesia care unit (PACU) nurse, and the types of anesthesia often seen in ICU recovery patients. It also covers preparation activities that can make the recovery process progress smoothly and offers tips and suggestions based on the author's experience related to special needs of postanesthesia patients that differ from the typical ICU patient.

Anesthesia Recovery Period↗
PubMed2004

Oral health and care in the intensive care unit: state of the science.

Oral health is influenced by oral microbial flora, which are concentrated in dental plaque. Dental plaque provides a microhabitat for organisms and an opportunity for adherence of the organisms to either the tooth surface or other microorganisms. In critically ill patients, potential pathogens can be cultured from the oral cavity. These microorganisms in the mouth can translocate and colonize the lung, resulting in ventilator-associated pneumonia. The importance of oral care in the intensive care unit has been noted in the literature, but little research is available on mechanical or pharmacological approaches to reducing oral microbial flora via oral care in critically ill adults. Most research in oral care has been directed toward patients' comfort; the microbiological and physiological effects of tooth brushing in the intensive care unit have not been reported. Although 2 studies indicated reductions in rates of ventilator-associated pneumonia in cardiac surgery patients who received chlorhexidine before intubation and postoperatively, the effects of chlorhexidine in reducing ventilator-associated pneumonia in other populations of critically ill patients or its effect when treatment with the agent initiated after intubation have not been reported. In addition, no evaluation of the effectiveness of pharmacological and mechanical interventions relative to each other or in combination has been published. Additional studies are needed to develop and test best practices for oral care in critically ill patients.

Chlorhexidine↗
PubMed1985

Consistency of care in an intensive care nursery staffed by nurse clinicians.

Variables related to both the process and outcome of newborn intensive care were studied to evaluate care consistency in a level 3 Newborn Intensive Care Unit (NICU) where neonatal nurse clinicians function in a role usually held by pediatric house officers. In routine delivery of intensive care, there were no statistically significant diurnal variations in the overall mortality, maintenance of intravenous infusions, tolerance of oral feedings, or respiratory care except a decrease in frequency of blood gas sampling during the weekday days as compared with nights. Our data suggest that a tertiary NICU in which medical coverage by neonatologists is supplemented by carefully trained and supervised neonatal nurse clinicians provides a consistent level of care that does not vary between night and day or day of the week.

Blood Gas Analysis↗
PubMed2001

Development and testing of a hierarchical method to code the reason for admission to intensive care units: the ICNARC Coding Method. Intensive Care National Audit & Research Centre.

A computer-based hierarchical method was developed to code conditions leading to admission to intensive care in the UK. The hierarchy had five tiers: surgical status, body system, anatomical site, physiological or pathological process and medical condition. The hierarchy was populated initially using the free-text descriptions of the reason for admission from 10,806 admissions recorded as part of the Intensive Care Society's UK APACHE II study. After refinement and error-checking, a prospective evaluation was undertaken on 22,059 admissions to 62 UK intensive care units. Individual units coded between 60 and 1610 (mean 356) admissions. All but 50 (0.2%) of the admissions could be coded and 38 units coded every admission. Fifty admissions (0.2%) could not be coded within 24 h of admission but were coded subsequently when more information became available. Of the admissions, 96.1% were coded at all levels of the hierarchy in the coding method. Six hundred and thirty-seven of the 741 unique conditions (85.9%) were used in one of the five reasons for admission and 564 (76.1%) in the primary reason for admission. Five conditions account for 19.4% of all primary reasons for admission. This is the first method to be developed empirically for coding the reason for intensive care admission.

Diagnosis-Related Groups↗
PubMed1999

National epidemiology of mycoses survey (NEMIS): variations in rates of bloodstream infections due to Candida species in seven surgical intensive care units and six neonatal intensive care units.

Candida species are the fourth most frequent cause of nosocomial bloodstream infections, and 25%-50% occur in critical care units. During an 18-month prospective study period, all patients admitted for > or = 72 hours to the surgical (SICUs) or neonatal intensive care units (NICUs) at each of the participant institutions were followed daily. Among 4,276 patients admitted to the seven SICUs in six centers, there were 42 nosocomial bloodstream infections due to Candida species (9.8/1,000 admissions; 0.99/1,000 patient-days). Of 2,847 babies admitted to the six NICUs, 35 acquired a nosocomial bloodstream infection due to Candida species (12.3/1,000 admissions; 0.64/1,000 patient-days). The following were the most commonly isolated Candida species causing bloodstream infections in the SICU: Candida albicans, 48%; Candida glabrata, 24%; Candida tropicalis, 19%; Candida parapsilosis, 7%; Candida species not otherwise specified, 2%. In the NICU the distribution was as follows: C. albicans, 63%; C. glabrata, 6%; C. parapsilosis, 29%; other, 3%. Of the patients, 30%-50% developed incidental stool colonization, 23% of SICU patients developed incidental urine colonization, and one-third of SICU health care workers' hands were positive for Candida species.

Candidiasis↗
PubMedDate not supplied

West Nile virus infection in the intensive care unit: a case series and literature review.

BACKGROUND: West Nile virus (WNV) is a rapidly spreading infectious disease in North America. Critical care issues related to WNV are not well described. OBJECTIVES: Three cases of severe WNV meningoencephalitis with flaccid paralysis are reported and relevant critical care issues are highlighted. METHODS: Case series and a review of the literature. RESULTS: Three patients with WNV meningoencephalitis and flaccid paralysis were admitted to the authors' academic, tertiary-care intensive care unit (ICU) in the late summer of 2002. All three patients were middle-aged or elderly and presented with a febrile illness that preceded or coincided with their neurological symptoms. Confirmation of WNV infection was problematic because each patient had at least one initial negative serum serology test. Radiological testing yielded nonspecific results. Serial electroencephalograms were consistent with severe toxic metabolic encephalopathy in all cases. All patients had a severe, diffuse axonal polyneuropathy demonstrated by nerve conduction studies and electromyography. Prolonged mechanical ventilation resulted in ICU lengths of stay of 44 to 118 days. At one point, 21% of the ICU beds were dedicated for these patients. All three patients died in hospital - two following the withdrawal of life support. One patient demonstrated resolving encephalitis and was discharged from the ICU after a 118-day ICU stay, but later died in a step-down unit. CONCLUSIONS: The management of WNV-related critical illness creates challenges in making a timely and accurate diagnosis, and predicting patient morbidity and mortality. As a consequence, end-of-life discussions with families are especially difficult. The prolonged ICU length of stay and growing incidence of this disease may challenge limited critical care resources.

Aged↗
PubMed2003

Nature of conflict in the care of pediatric intensive care patients with prolonged stay.

OBJECTIVE: To determine the frequency, types, sources, and predictors of conflict surrounding the care of pediatric intensive care unit (PICU) patients with prolonged stay. SETTING: A tertiary care, university-affiliated PICU in Boston. PARTICIPANTS: All patients admitted over an 11-month period whose stay exceeded 8 days (the 85th percentile length of stay for the PICU under study), and intensive care physicians and nurses who were responsible for their care. METHODS: We prospectively identified conflicts by interviewing the treating physicians and nurses at 2 stages during the patients' PICU stay. All conflicts detected were classified by type (team-family, intrateam, or intrafamily) and source. Using a case-control design, we then identified predictors of conflict through bivariate and multivariate analyses. RESULTS: We enrolled 110 patients based on the length-of-stay criterion. Clinicians identified 55 conflicts involving 51 patients in this group. Hence, nearly one half of all patients followed had a conflict associated with their care. Thirty-three of the conflicts (60%) were team-family, 21 (38%) were intrateam, and the remaining 1 was intrafamily. The most commonly cited sources of team-family conflict were poor communication (48%), unavailability of parents (39%), and disagreements over the care plan (39%). Medicaid insurance status was independently associated with the occurrence of conflict generally (odds ratio = 4.97) and team-family conflict specifically (odds ratio = 7.83). CONCLUSIONS: Efforts to reduce and manage conflicts that arise in the care of critically ill children should be sensitive to the distinctive features of these conflicts. Knowledge of risk factors for conflict may also help to target such interventions at the patients and families who need them most.

Case-Control Studies↗
PubMed2005

The teleo-affective limits of end-of-life care in the intensive care unit.

This paper explores the relevance of a specific kind of sensed connectedness or 'teleo-affectivity' to the organisation and enactment of end-of-life care. Referred to as heedful inter-relating, this teleo-affective connectedness has been found to occur among employees as they carry out their highly complex and dangerous work. This paper focuses on the proposals put in the literature for confronting the complexity of end-of-life care in the intensive care unit (ICU), and inquires into the positionings incurred in and around end-of-life care in one specific unit, with the aim of gauging the pertinence of heedful inter-relating to end-of-life care in ICU. The paper argues that while several commentators appear to be calling for enhanced heedful conduct in end-of-life care, ICU practices may not admit the kind of heedful inter-relating that is evident in high-reliability organisations such as nuclear aircraft carriers. We suggest it may be unwise to gauge intensive care units' complexity purely against the brief of realising cultural scripts of the dying, and that ICU in fact manifests a broader societal concern necessitating a more variegated composition: to devise multiple ways to contain the impression and impact of (the meaning) death for society (societies) generally.

Attitude of Health Personnel↗
PubMedDate not supplied

[Assessment of severity of the state and intensive care of newborns in the intensive care units].

A point-based evaluation of the severity condition was made on the bases of an analysis of clinical findings (cardiovascular, respiratory, central nervous, urinary and gastrointestinal systems) for 130 newborns who were admitted to the intensive care and resuscitation unit: 3-5 points--severe condition, 6-10 points--highly severe condition and 12-15 points--extremely severe condition. The severity assessment scale as applicable to newborns and based only on the clinical findings enables the practitioner to optimize the conducted therapy in accordance with a severity degree.

Blood Cell Count↗
PubMed1995

Comparative assessment of pediatric intensive care: a national multicenter study. Pediatric Intensive Care Assessment of Outcome (PICASSO) Study Group.

OBJECTIVE: Comparative assessment of performance of pediatric intensive care. DESIGN: Open, prospective multicenter study. SETTING: All pediatric intensive care units (n = 10; six tertiary and four nontertiary) in the Netherlands. PATIENTS: 1063 consecutive unselected admissions, < or = 18 yrs old, during a 4-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Effectiveness was defined as the ratio of observed to expected (Pediatric Risk of Mortality-score-derived) mortality. Efficiency was determined by two objective criteria: mortality risk of > 1%, or administration of at least one intensive care unit (ICU)-dependent therapy. In the total population, observed and expected mortality rates were similar. Between hospitals, crude mortality showed wide variations (mean 7.1%, range 1% to 10%). However, in each center, observed and expected mortality rates were similar (mean ratio of observed/expected mortality 0.99, range 0.8 to 1.5). In tertiary care centers, severity of illness-corrected mortality rates in high-risk patients were less than in a United States reference population. Paradoxically, in low-risk tertiary care patients, the observed mortality rate was higher than expected. The relatively high mortality rate in this group is probably the result of the large number of low-risk tertiary care patients suffering from severe, incurable chronic disease. The average number of efficient ICU days was 72%, although large fluctuations between units were found (range 22% to 95%), suggesting that in several centers efficiency rates might be improved by a better selection of high-risk patients requiring ICU-dependent therapies. CONCLUSIONS: Differences in mortality rates among pediatric ICUs were largely explained by differences in severity of illness. High efficiency rates combined with adequate effectiveness were found in several centers, indicating that admission and discharge decisions might be improved in less efficient centers.

Child, Preschool↗
PubMed2003

Life-sustaining treatment decisions in Portuguese intensive care units: a national survey of intensive care physicians.

INTRODUCTION: The objective of the present study was to evaluate the opinion of Portuguese intensive care physicians regarding 'do-not-resuscitate' (DNR) orders and decisions to withhold/withdraw treatment. METHODS: A questionnaire was sent to all physicians working on a full-time basis in all intensive care units (ICUs) registered with the Portuguese Intensive Care Society. RESULTS: A total of 266 questionnaires were sent and 175 (66%) were returned. Physicians from 79% of the ICUs participated. All participants stated that DNR orders are applied in their units, and 98.3% stated that decisions to withhold treatment and 95.4% stated that decisions to withdraw treatment are also applied. About three quarters indicated that only the medical group makes these decisions. Fewer than 15% of the responders stated that they involve nurses, 9% involve patients and fewer than 11% involve patients' relatives in end-of-life decisions. Physicians with more than 10 years of clinical experience more frequently indicated that they involve nurses in these decisions (P < 0.05), and agnostic/atheist doctors more frequently involve patients' relatives in decisions to withhold/withdraw treatment (P < 0.05). When asked about who they thought should be involved, more than 26% indicated nurses, more than 35% indicated the patient and more than 25% indicated patients' relatives. More experienced doctors more frequently felt that nurses should be involved (P < 0.05), and male doctors more frequently stated that patients' relatives should be involved in DNR orders (P < 0.05). When a decision to withdraw treatment is made, 76.8% of 151 respondents indicated that they would initiate palliative care; no respondent indicated that they would administer drugs to accelerate the expected outcome. CONCLUSION: The probability of survival from the acute episode and patients' wishes were the most important criteria influencing end-of-life decisions. These decisions are made only by the medical group in most of the responding ICUs, with little input from nursing staff, patients, or patients' relatives, although many respondents expressed a wish to involve them more in this process. Sex, experience and religious beliefs of the respondents influences the way in which these decisions are made.

Adult↗