Patients' experiences of cardiology procedures using minimal conscous sedation

Aim: The study's purpose was to describe patients' experiences of minimal conscious sedation during diagnostic and interventional cardiology procedures.

Methods: Over a 6-week period, 119 consecutive patients (10% of annual throughput) from a major metropolitan hospital in Melbourne, Australia, were interviewed using a modified version of the American Pain Society Patient Outcome Questionnaire. Patients identified pain severity using a 10-point visual analogue scale and rated their overall comfort on a 6-point Likert scale ranging from very comfortable to very uncomfortable.

Results: Patients were aged 67.6 years (standard deviation 11.1), 70.8% were male, and the mean body mass index was 27.7 (standard deviation 4.8). Patients underwent diagnostic coronary angiography (67.5%), percutaneous coronary interventions (13.3%), or combined procedures (19.2%). Most patients (65%) were comfortable in the context of low-dose conscious sedation. Slight discomfort was reported by 26% of patients; 9% reported feeling uncomfortable primarily as a result of a combination of musculoskeletal pain, angina, and vasovagal symptoms experienced during the procedure. There was significant correlation (rho = .25, P = .01) between procedure length and patients' report of overall comfort, suggesting longer procedures were less comfortable for patients.

Conclusions: The minimal sedation protocol was effective for the majority of patients; however, 9% of patients experienced significant discomfort related to preexisting conditions, highlighting the need for individual patient assessment before, during, and after the procedure.

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

Objective: To compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients. Design: Randomized, controlled trial. Setting: General intensive care unit (24 beds) in an Australian metropolitan teaching hospital. Patients: Adult, mechanically ventilated patients (n = 312). Interventions: Patients were randomly assigned to receive sedation directed by formal guidelines (protocol group, n = 153) or usual local clinical practice (control, n = 159). Measurements and Main Results: The median (95% confidence interval) duration of ventilation was 79 hrs (56-93 hrs) for patients in the protocol group compared with 58 hrs (44-78 hrs) for patients who received control care (p = .20). Lengths of stay (median [range]) in the intensive care unit (94 [2-1106] hrs vs. 88 (14-962) hrs, p = .58) and hospital (13 [1-113] days vs. 13 (1-365) days, p = .97) were similar, as were the proportions of subjects receiving a tracheostomy (17% vs. 15%, p = .64) or undergoing unplanned self-extubation (1.3% vs. 0.6%, p = .61). Death in the intensive care unit occurred in 32 (21%) patients in the protocol group and 32 (20%) control subjects (p = .89), with a similar overall proportion of deaths in hospital (25% vs. 22%, p = .51). A Cox proportional hazards model, after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic category, and doses of commonly used drugs, estimated that protocol sedation management was associated with a 22% decrease (95% confidence interval 40% decrease to 2% increase, p = .07) in the occurrence of successful weaning from mechanical ventilation. Conclusions: This randomized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay, in either the intensive care unit or the hospital, with the use of protocol-directed sedation compared with usual local management. Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies. (C) 2008 Lippincott Williams & Wilkins, Inc.

A critical review of daily sedation interruption in the intensive care unit

Background. Daily sedation interruption (DSI) has been proposed as a method of improving sedation management of critically ill patients by reducing the adverse effects of continuous sedation infusions.

Aim. To critique the research regarding daily sedation interruption, to inform education, research and practice in this area of intensive care practice.

Design. Literature review.

Method. Medline, CINAHL and Web of Science were searched for relevant key terms. Eight research-based studies, published in the English language between 1995–December 2006 and three conference abstracts were retrieved.

Results. Of the eight articles and three conference abstracts reviewed, five originated from one intensive care unit (ICU) in the USA. The research indicates that DSI reduces ventilation time, length of stay in ICU, complications of critical illness, incidence of post-traumatic stress disorder and is reportedly used by 15–62% of ICU clinicians in Australia, Europe, USA and Canada.

Conclusions. DSI improves patients' physiological and psychological outcomes when compared with routine sedation management. However, research relating to these findings has methodological limitations, such as the use of homogenous samples, single-centre trials and retrospective design, thus limiting their generalisability.

Relevance to clinical practice. DSI may provide clinicians with a simple, cost-effective method of reducing some adverse effects of sedation on ICU patients. However, the evidence supporting DSI is limited and cannot be generalised to heterogeneous ICU populations internationally. More robust research is required to assess the potential impact of DSI on the physical and mental health of ICU survivors.

Assessing the reliability of the sedation-agitation scale between nurses and doctors in a New Zealand ICU

The aim of the study was to determine whether nurses and doctors rate “real world” intensive care unit (ICU) patients similarly using the Sedation–Agitation Scale (SAS) in a generalist ICU context outside USA

Does an evidence-based sedation protocol improve practice and patient outcomes in critical care?

Learning Objective 1: compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care.

Learning Objective 2: explain the contrasting international research findings on sedation protocol implementation.
Minimization of sedation in critical care patients has recently received widespread support. Professional organizations internationally have published sedation management guidelines for critically ill patients to improve the use of research in practice, decrease practice variability and shorten mechanical ventilation duration. Innovations in practice have included the introduction of decision making protocols, daily sedation interruptions and new drugs and monitoring technologies. The aim of this study was to compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care setting.

A randomized, controlled trial design was used to study 312 mechanically ventilated adult patients in a general critical care unit at an Australian metropolitan teaching hospital. Patients were randomly assigned to receive protocol directed sedation management developed from evidence based guidelines (n=153) or usual clinical practice (n=159).

The median (95% CI) duration of ventilation was 58 hrs (44–78 hrs) for patients in the non-protocol group and 79 hrs (56–93) for those patients in the protocol group (p=0.20). Results were not significant for length of stay in critical care or hospital, the frequency of tracheostomies, and unplanned extubations. A Cox proportional hazards model estimated that protocol directed sedation management was associated with a 22% decrease (95% CI: 40% decrease to 2% increase, p=0.07) in the occurrence of successful weaning from mechanical ventilation.

Few randomized controlled trials have evaluated the effectiveness of protocol-directed sedation outside of North America. This study highlights the lack of transferability between different settings and different models of care. Qualified, high intensity nursing in the Australian critical care setting facilitates rapid, responsive decisions for sedation management and an increased success rate for weaning from mechanical ventilation.

Effect of environmental flows on deep, anoxic pools

A series of field surveys were carried out on two permanent pools of the upper Glenelg River in SW Victoria, Australia. One was representative of the wider and deeper pools while the other was representative of the more-narrow and shallower pools. Both pools showed a typical seasonal cycle of warm, brackish, oxygen-poor, summer conditions and cool, oxygen-rich, low-salinity, winter conditions. The summer salinity increases were larger than expected, suggesting possible saline groundwater inflow from unidentified springs. Both pools contained anoxic water in their deeper sections but this was permanent only in the deeper pool. A simple model of the flushing rate of such anoxic pools subject to flows, such as environmental flow releases, was developed, based on an energy balance between the potential energy required to lift the anoxic layer and the kinetic energy derived from the river flow. The results were tested against and in agreement with the field measurements. The model also suggests that the anoxic layers are resilient to all but the largest environmental flows.

Deep identity, shallow time : sustaining a future in Victorian fishing communities

Like commercial fishers everywhere, it seems, those living in coastal communities of Victoria perceive themselves to be under threat from recreational fishers, environmentalists, imposed management regimes, and modernisation and globalisation of the industry. In responding to these threats they appeal to conventional props of tradition--to continuity in genealogical time, affiliation with place and specialised knowledge and practice. This seems paradoxical, given that most established fishers in Victoria are first or second generation members of an industry that, through its 150-year history, has been characterised by innovation and mobility. That paradox, we argue, is more apparent than real. Fisher identity is grounded primarily in engagement with an environment that is not familiar to outsiders. The paradox arises because fishers, like others who seek to sustain a future in the face of threat from outsiders, reshape strongly felt identity as tradition.

A late Changhsingian (latest Permian) deep-water brachiopod fauna from Guizhou, South China

A deep-water brachiopod fauna (20 species in 19 genera) is described from the Late Permian Shaiwa Group of Ziyun, Guizhou, South China. New species include Pygmochonetes? shaiwaensis and Martinia ziyunensis. This fauna is associated with deep-water assemblages of pelagic radiolarians, foraminifers, bivalves and ammonoids. The brachiopod faunal correlations and age constraints of the associated fossil groups suggest that the Shaiwa fauna is late Changhsingian (latest Permian) in age. The Shaiwa fauna superficially resembles the coeval deep-water assemblage from Guangxi, South China; both are characterized by a mixture of deep-water brachiopods and shallow-water elements.

Deep drawing behaviour of ultrafine grained copper : modelling and experiment

Ultrafine grained materials produced by severe plastic deformation methods possess attractive mechanical properties such as high strength compared with traditional coarse grained counterparts and reasonable ductility. Between existing severe plastic deformation methods the Equal Channel Angular Pressing is the most promising for future industrial applications and can produce a variety of ultrafine grained microstructures in materials depending on route, temperature and number of passes during processing. Driven by a rising trend of miniaturisation of parts these materials are promising candidates for microforming processes. Considering that bi-axial deformation of sheet (foil) is the major operation in microforming, the investigation of the influence of the number of ECAP passes on the bi-axial ductility in micro deep drawing test has been examined by experiments and FE simulation in this study. The experiments have showed that high force was required for drawing of the samples processed by ECAP compare to coarse grained materials. The limit drawing ratio of ultrafine grained samples was in the range of 1.9–2.0 with ECAP pass number changing from 1 to 16, while a higher value of 2.2 was obtained for coarse grained copper. However, the notable decrease in tensile ductility with increase in strength was not as pronounced for bi-axial ductility. The FE simulation using standard isotropic hardening model and von Mises yielding criterion confirmed these findings.