Part 1. Chemical and Physical Restraints in the Management of Mechanically Ventilated Patients in the ICU: Contributing Factors

Chemical and physical restraints are frequently used in the intensive care unit (ICU) to control agitated patients and to prevent self-harm and unplanned extubations. Published work relating to the numerous issues of the care and treatment strategies for these patients remains conflicting and unclear. Literature regarding sedation and chemical restraint reveals a trend towards management with lighter sedation, use of sedation assessment tools and sedation protocols. It remains unclear which treatment is best for agitated and delirious patients, and the evidence on the effect of sedation is conflicting. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. The purpose of this paper is to provide a summary of the existing literature on the use of physical and chemical restraints in the ICU setting. In Part 1 of this two-part paper, the evidence on chemical and physical restraints is explored with specific focus on definition of terms, unplanned

Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: A patient perspective

An important goal of the care for the mechanically ventilated patient is to minimize patient discomfort and anxiety. This is partly achieved by frequent use of chemical and physical restraints. The majority of patients in intensive care will receive some form of sedation. The goal and use of sedation has changed considerably over the past few decades with literature evidencing trends toward overall lighter sedation levels and daily interruption of sedation. Conversely, the use of physical restraint for the ventilated patient in ICU differs considerably between nations and continents. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. Recent literature suggests minimal use of physical restraint in the ICU, and that reduction programmes have been initiated. However, very few papers illuminate the patient's experience of physical and chemical restraints as a treatment strategy. In Part 1 of this two-part review, the evidence on chemical and physical restraints was explored with specific focus on definitions of terms, unplanned extubation, agitation, delirium as well as the impact of nurse–patient ratios in the ICU on these issues. This paper, Part 2, examines the evidence related to chemical and physical restraints from the mechanically ventilated patient's perspective.

Development of descriptor tools for the characterization of Australian sugar mill evaporator scale

Cleaning of sugar mill evaporators is an expensive exercise. Identifying the scale components assists in determining which chemical cleaning agents would result in effective evaporator cleaning. The current methods (based on x-ray diffraction techniques, ion exchange/high performance liquid chromatography and thermogravimetry/differential thermal analysis) used for scale characterisation are difficult, time consuming and expensive, and cannot be performed in a conventional analytical laboratory or by mill staff. The present study has examined the use of simple descriptor tests for the characterisation of Australian sugar mill evaporator scales. Scale samples were obtained from seven Australian sugar mill evaporators by mechanical means. The appearance, texture and colour of the scale were noted before the samples were characterised using x-ray fluorescence and x-ray powder diffraction to determine the compounds present. A number of commercial analytical test kits were used to determine the phosphate and calcium contents of scale samples. Dissolution experiments were carried out on the scale samples with selected cleaning agents to provide relevant information about the effect the cleaning agents have on different evaporator scales. Results have shown that by simply identifying the colour and the appearance of the scale, the elemental composition and knowing from which effect the scale originates, a prediction of the scale composition can be made. These descriptors and dissolution experiments on scale samples can be used to provide factory staff with an on-site rapid process to predict the most effective chemicals for chemical cleaning of the evaporators.

Membrane filtration of clarified juice

A membrane filtration plant using suitable micro or ultra-filtration membranes has the potential to significantly increase pan stage capacity and improve sugar quality. Previous investigations by SRI and others have shown that membranes will remove polysaccharides, turbidity and colloidal impurities and result in lower viscosity syrups and molasses. However, the conclusion from those investigations was that membrane filtration was not economically viable. A comprehensive assessment of current generation membrane technology was undertaken by SRI. With the aid of two pilot plants provided by Applexion and Koch Membrane Systems, extensive trials were conducted at an Australian factory using clarified juice at 80–98°C as feed to each pilot plant. Conditions were varied during the trials to examine the effect of a range of operating parameters on the filtering characteristics of each of the membranes. These parameters included feed temperature and pressure, flow velocity, soluble solids and impurity concentrations. The data were then combined to develop models to predict the filtration rate (or flux) that could be expected for nominated operating conditions. The models demonstrated very good agreement with the data collected during the trials. The trials also identified those membranes that provided the highest flux levels per unit area of membrane surface for a nominated set of conditions. Cleaning procedures were developed that ensured the water flux level was recovered following a clean-in-place process. Bulk samples of clarified juice and membrane filtered juice from each pilot were evaporated to syrup to quantify the gain in pan stage productivity that results from the removal of high molecular weight impurities by membrane filtration. The results are in general agreement with those published by other research groups.

Fouling of tubular ceramic membranes during processing of cane sugar juice

This paper examines the fouling characteristics of four tubular ceramic membranes with pore sizes 300 kDa, 0.1 μm and 0.45 μm installed in a pilot plant at a sugar factory for processing clarified cane sugar juices. All the membranes, except the one with a pore size of 0.45 μm, generally gave reproducible results through the trials, were easy to clean and could handle operation at high volumetric concentration factors. Analysis of fouled and cleaned ceramic membranes revealed that polysaccharides, lipids and to a lesser extent, polyphenols, as well as other colloidal particles cause fouling of the membranes. Electrostatic and hydrophobic forces cause strong aggregation of the polymeric components with one another and with colloidal particles. To combat irreversible fouling of the membranes, treatment options that result in the removal of particles having a size range of 0.2–0.5 μm and in addition remove polymeric impurities, need to be identified. Chemical and microscopic evaluations of the juices and the structural characterisation of individual particles and aggregates identified options to mitigate the fouling of membranes. These include conditioning the feed prior to membrane filtration to break up the network structure formed between the polymers and particles in the feed and the use of surfactants to prevent the aggregation of polymers and particles.

Low moisture mud from solid bowl decanters

The high moisture content of mill mud (typically 75–80% for Australian factories) results in high transportation costs for the redistribution of mud onto cane farms. The high transportation cost relative to the nutrient value of the mill mud results in many milling companies subsidising the cost of this recycle to ensure a wide distribution across the cane supply area. An average mill would generate about 100 000 t of mud (at 75% moisture) in a crushing season. The development of mud processing facilities that will produce a low moisture mud that can be effectively incorporated into cane land with existing or modified spreading equipment will improve the cost efficiency of mud redistribution to farms; provide an economical fertiliser alternative to more farms in the supply area; and reduce the potential for adverse environmental impacts from farms. A research investigation assessing solid bowl decanter centrifuges to produce low moisture mud with low residual pol was undertaken and the results compared to the performance of existing rotary vacuum filters in factory trials. The decanters were operated on filter mud feed in parallel with the rotary vacuum filters to allow comparisons of performance. Samples of feed, mud product and filtrate were analysed to provide performance indicators. The decanter centrifuge could produce mud cakes with very low moistures and residual pol levels. Spreading trials in cane fields indicated that the dry cake could be spread easily by standard mud trucks and by trucks designed specifically to spread fertiliser.

Deposition of hydroxyapatite and calcium oxalate dihydrate on a heat exchanger tube

Most studies on the characterisation of deposits on heat exchangers have been based on bulk analysis, neglecting the fine structural features and the compositional profiles of layered deposits. Attempts have been made to fully characterise a fouled stainless steel tube obtained from a quintuple Roberts evaporator of a sugar factory using X-ray diffraction and scanning electron microscopy techniques. The deposit contains three layers at the bottom of the tube and two layers on the other sections and is composed of hydroxyapatite, calcium oxalate dihydrate and an amorphous material. The proportions of these phases varied along the tube height. Energy-dispersive spectroscopy and XRD analysis on the surfaces of the outermost and innermost layers showed that hydroxyapatite was the major phase attached to the tube wall, while calcium oxalate dihydrate (with pits and voids) was the major phase on the juice side. Elemental mapping of the cross-sections of the deposit revealed the presence of a mineral, Si-Mg-Al-Fe-O, which is probably a silicate mineral. Reasons for the defects in the oxalate crystal surfaces, the differences in the crystal size distribution from bottom to the top of the tube and the composite fouling process have been postulated.

Formation of thermodynamically unstable calcium oxalate dihydrate in sugar mill evaporators

Calcium oxalate (CaOX) is the most intractable scale component to remove in sugar mill evaporators by either mechanical or chemical means. The operating conditions of sugar mill evaporators should preferentially favour the formation of the thermodynamically stable calcium oxalate monohydrate (COM), yet analysis of scale deposit from different sugar factories have shown that calcium oxalate dihydrate (COD) is usually the predominant phase, and in some cases is the only hydrate formed. The effects of trans-aconitic, succinic and acetic acids, all of which are present in sugarcane juice, and ethylenediamine tetraacetic acid disodium salt (EDTA) on the growth of CaOX crystals have been examined by scanning electron microscopy (SEM), transmission electron microscopy (TEM), X-ray powder diffraction (XRD) and thermogravimetric analysis (TGA). trans-Aconitic acid, which constitutes two-thirds of the organic acid component in sugarcane juice, in the presence of sugar resulted in the formation of COD and COM in a 3:1 ratio. EDTA was the most effective acid to promote the formation of COD followed by trans-aconitic acid, then acetic acid and lastly succinic acid.

Industrial design in endoscopy : the development of a tissue and organ extractor

Throughout history, developments in medicine have aimed to improve patient quality of life, and reduce the trauma associated with surgical treatment. Surgical access to internal organs and bodily structures has been traditionally via large incisions. Endoscopic surgery presents a technique for surgical access via small (1 Omm) incisions by utilising a scope and camera for visualisation of the operative site. Endoscopy presents enormous benefits for patients in terms of lower post operative discomfort, and reduced recovery and hospitalisation time. Since the first gall bladder extraction operation was performed in France in 1987, endoscopic surgery has been embraced by the international medical community. With the adoption of the new technique, new problems never previously encountered in open surgery, were revealed. One such problem is that the removal of large tissue specimens and organs is restricted by the small incision size. Instruments have been developed to address this problem however none of the devices provide a totally satisfactory solution. They have a number of critical weaknesses: -The size of the access incision has to be enlarged, thereby compromising the entire endoscopic approach to surgery. - The physical quality of the specimen extracted is very poor and is not suitable to conduct the necessary post operative pathological examinations. -The safety of both the patient and the physician is jeopardised. The problem of tissue and organ extraction at endoscopy is investigated and addressed. In addition to background information covering endoscopic surgery, this thesis describes the entire approach to the design problem, and the steps taken before arriving at the final solution. This thesis contributes to the body of knowledge associated with the development of endoscopic surgical instruments. A new product capable of extracting large tissue specimens and organs in endoscopy is the final outcome of the research.