The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial

Objective: Evaluation of selective decontamination of the digestive tract (SDD) on late mortality in ventilated trauma patients in an intensive care unit (ICU). Methods: A multicenter, randomized controlled trial was undertaken in 401 trauma patients with Hospital Trauma Index-Injury Severity Score of 16 or higher. Patients were randomized to control (n = 200) or SDD (n = 201), using polymyxin E, tobramycin, and amphotericin B in throat and gut throughout ICU treatment combined with cefotaxime for 4 days. Primary endpoint was late mortality excluding early death from hemorrhage or craniocerebral injury. Secondary endpoints were infection and organ dysfunction. Results: Mortality was 20.9% with SDD and 22.0% in controls. Overall late mortality was 15.3% (57/372) as 29 patients died from cerebral injury, 16 SDD and 13 control. The odds ratio (95% confidence intervals) of late mortality for SDD relative to control was 0.75 (0.40-1.37), corresponding to estimates of 13.4% SDD and 17.2% control. The overall infection rate was reduced in the test group (48.8% vs. 61.0%). SDD reduced lower airway infections (30.9% vs. 50.0%) and bloodstream infections due to aerobic Gram-negative bacilli (2.5% vs. 7.5%). No difference in organ dysfunction was found. Concluson: This study demonstrates that SDD significantly reduces infection in multiple trauma, although this RCT in 401 patients was underpowered to detect a mortality benefit.

Characteristics of Acute Kidney Injury in Patients Infected with the 2009 Influenza A (H1N1) Virus

Background and objectives: There have been few studies investigating acute kidney injury (AKI) in patients infected with the 2009 pandemic influenza A (H1N1) virus. Therefore, the objective of this study was to identify the factors associated with AKI in H1N1-infected patients. Design, setting, participants, & measurements: This was a study of 47 consecutive critically ill adult patients with reverse transcriptase-PCR-confirmed H1N1 infection in Brazil. Outcome measures were AKI (as defined by the Risk, Injury, Failure, Loss, and End-stage renal failure [RIFLE] criteria) and in-hospital death. Results: AKI was identified in 25 (53%) of the 47 H1N1-infected patients. AKI was associated with vasopressor use, mechanical ventilation, high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and severe acidosis as well as with higher levels of C-reactive protein and lactic dehydrogenase upon intensive care unit (ICU) admission. A nephrology consultation was requested for 16 patients (64%), and 8 (50%) required dialysis. At ICU admission, 7 (15%) of the 25 AKI patients had not yet progressed to AKI. However, by 72 hours after ICU admission, no difference in RIFLE score was found between AKI survivors and nonsurvivors. Of the 47 patients, 9 (19%) died, all with AKI. Mortality was associated with mechanical ventilation, vasopressor use, dialysis, high APACHE II score, high bilirubin levels, and a low RIFLE score at ICU admission. Conclusions: Among critically ill H1N1-infected patients, the incidence of AKI is high. In such patients, AKI is mainly attributable to shock. Clin J Am Soc Nephrol 5: 1916-1921, 2010. doi: 10.2215/CJN.00840110

Metabolic acidosis in patients with severe sepsis and septic shock: A longitudinal quantitative study

Objective: To describe the composition of metabolic acidosis in patients with severe sepsis and septic shock at intensive care unit admission and throughout the first 5 days of intensive care unit stay. Design: Prospective, observational study. Setting: Twelve-bed intensive care unit. Patients: Sixty patients with either severe sepsis or septic shock. Interventions: None. Measurements and Main Results: Data were collected until 5 days after intensive care unit admission. We studied the contribution of inorganic ion difference, lactate, albumin, phosphate, and strong ion gap to metabolic acidosis. At admission, standard base excess was -6.69 +/- 4.19 mEq/L in survivors vs. -11.63 +/- 4.87 mEq/L in nonsurvivors (p < .05); inorganic ion difference (mainly resulting from hyperchloremia) was responsible for a decrease in standard base excess by 5.64 +/- 4.96 mEq/L in survivors vs. 8.94 +/- 7.06 mEq/L in nonsurvivors (p < .05); strong ion gap was responsible for a decrease in standard base excess by 4.07 +/- 3.57 mEq/L in survivors vs. 4.92 +/- 5.55 mEq/L in nonsurvivors with a nonsignificant probability value; and lactate was responsible for a decrease in standard base excess to 1.34 +/- 2.07 mEq/L in survivors vs. 1.61 +/- 2.25 mEq/L in nonsurvivors with a nonsignificant probability value. Albumin had an important alkalinizing effect in both groups; phosphate had a minimal acid-base effect. Acidosis in survivors was corrected during the study period as a result of a decrease in lactate and strong ion gap levels, whereas nonsurvivors did not correct their metabolic acidosis. In addition to Acute Physiology and Chronic Health Evaluation 11 score and serum creatinine level, inorganic ion difference acidosis magnitude at intensive care unit admission was independently associated with a worse outcome. Conclusions: Patients with severe sepsis and septic shock exhibit a complex metabolic acidosis at intensive care unit admission, caused predominantly by hyperchloremic acidosis, which was more pronounced in nonsurvivors. Acidosis resolution in survivors was attributable to a decrease in strong ion gap and lactate levels. (Crit Care Med 2009; 37:2733-2739)

Clustering Lab value working with medical data

Data mining is a relatively new field of research that its objective is to acquire knowledge from large amounts of data. In medical and health care areas, due to regulations and due to the availability of computers, a large amount of data is becoming available [27]. On the one hand, practitioners are expected to use all this data in their work but, at the same time, such a large amount of data cannot be processed by humans in a short time to make diagnosis, prognosis and treatment schedules. A major objective of this thesis is to evaluate data mining tools in medical and health care applications to develop a tool that can help make rather accurate decisions. In this thesis, the goal is finding a pattern among patients who got pneumonia by clustering of lab data values which have been recorded every day. By this pattern we can generalize it to the patients who did not have been diagnosed by this disease whose lab values shows the same trend as pneumonia patients does. There are 10 tables which have been extracted from a big data base of a hospital in Jena for my work .In ICU (intensive care unit), COPRA system which is a patient management system has been used. All the tables and data stored in German Language database.

Facilitation of learning in specialist nursing training in the PICU : the supervisors´ concerns in the learning situation

With the aim to unfold nurses’ concerns of the supervision of the student in the clinical caring situation of the vulnerable child, clinical nurses situated supervision of postgraduate nursing students in the Pediatric Intensive Care Unit (PICU) are explored. A qualitative approach, interpretive phenomenology, with participant observations and narrative interviews, was used. Two qualitative variations of patterns of meaning for the nurses’ clinical facilitation were disclosed in this study. Learning by doing theme supports the students learning by doing through performing skills and embracing routines. The reflecting theme supports thinking and awareness of the situation. As the supervisor often serves as a role model for the student this might have an immediate impact on how the student applies nursing care in the beginning of his or her career. If the clinical supervisor narrows the perspective and hinders room for learning the student will bring less knowledge from the clinical education than expected, which might result in reduced nursing quality.

Ten Australian ICU nurses` perceptions of organisational restructuring

The Australian healthcare system underwent radical reform in the 1990s as economic rationalist policies were embraced. As a result, there was significant organisational restructuring within hospitals. Traditional indicators, such as nursing absenteeism and attrition, increase during times of organisational change. Despite this, nurses' views of healthcare reform are under-represented in the literature and little is known about the impact of organisational restructuring on perceived performance. This study investigated the perceived impact of organisational restructuring on a group of intensive care unit (ICU) nurses' workplace performance. It employed a qualitative approach to collect data from a purposive sample of clinical nurses. The primary method of data collection was semi-structured interviews. Content analysis generated three categories of data. Participants identified constant pressure, inadequate communication and organisational components of restructuring within the hospital as issues that had a significant impact on their workplace performance. They perceived organisational restructuring was poorly communicated, and this resulted in an environment of constant pressure. Organisational components of restructuring included the subcategories of specialised service provision and an alternative administrative structure that had both positive and negative ramifications for performance.
To date, there has been little investigation of nurses' perceptions of organisational restructure or the impact this type of change has in the clinical domain. Participants in this study believed reorganisation was detrimental to quality care delivery in intensive care, as a result of fiscal constraint, inadequate communication and pressure that influenced their workplace performance.

The role of nurses in preventing adverse events related to respiratory dysfunction: literature review

Aims. This paper reports a literature review examining the relationship between specific clinical indicators of respiratory dysfunction and adverse events, and exploring the role of nurses in preventing adverse events related to respiratory dysfunction.

Background. Adverse events in hospital are associated with poor patient outcomes such as increased mortality and permanent disability. Many of these adverse events are preventable and are preceded by a period during which the patient exhibits clearly abnormal physiological signs. The role of nurses in preserving physiological safety by early recognition and correction of physiological abnormality is a key factor in preventing adverse events.

Methods. A search of the Medline and CINAHL databases was conducted using the following terms: predictors of poor outcome, adverse events, mortality, cardiac arrest, emergency, oxygen, supplemental oxygen, oxygen therapy, oxygen saturation, oxygen delivery, assessment, patient assessment, physical assessment, dyspnoea, hypoxia, hypoxaemia, respiratory assessment, respiratory dysfunction, shortness of breath and pulse oximetry. The papers reviewed were research papers that demonstrated a relationship between adverse events and various clinical indicators of respiratory dysfunction.

Results. Respiratory dysfunction is a known clinical antecedent of adverse events such as cardiac arrest, need for medical emergency team activation and unplanned intensive care unit admission. The presence of respiratory dysfunction prior to an adverse event is associated with increased mortality. The specific clinical indicators involved are alterations in respiratory rate, and the presence of dyspnoea, hypoxaemia and acidosis.

Conclusions. The way in which nurses assess, document and use clinical indicators of respiratory dysfunction is influential in identifying patients at risk of an adverse event and preventing adverse events related to respiratory dysfunction. If such adverse events are to be prevented, nurses must not only be able to recognise and interpret signs of respiratory dysfunction, but must also take responsibility for initiating and evaluating interventions aimed at correcting respiratory dysfunction.

Evaluation of nasopharyngeal oxygen, nasal prongs and facemask oxygen therapy devices in adult patients: a randomised crossover trial

Nasopharyngeal oxygen (NPO) therapy may overcome some of the difficulties associated with nasal prongs and facemask oxygen delivery devices. In response to a lack of published studies of NPO therapy in adults, we conducted a prospective randomised crossover trial to compare the effectiveness of NPO, nasal prongs (NP) and facemasks (FM) when used in an adult population (n=37) from the intensive care unit and general hospital wards. We measured oxygen saturation (Sp[O.sub.2]) using pulse oximetry, oxygen flow (litres per minute), respiration rate (per minute) and comfort using a horizontal visual analogue scale. All three devices were effective in maintaining a Sp[O.sub.2] of [greater than or equal to]95% (NP 97.0[+ or -]1.9, NPO 97.7[+ or -]1.7, FM 98.8[+ or -]1.3%). NPO therapy consumed less oxygen than NP and FM therapy (NP 2.6[+ or -]1.0, NPO 2.2[+ or -]0.9, FM 6.1[+ or -]0.4 l/min, P <0.001). There was no significant difference in patients' respiratory rates (NP 19.9[+ or -]3.2, NPO 19.9[+ or -]3.0, FM 19.8[+ or -]3.1 per minute, P=0.491). In terms of comfort, patients rated NP higher than NPO and FM using a horizontal visual analogue scale (100 mm=most comfortable) (NP 65.5[+ or -]14.3, NPO 62.8[+ or -]19.4, FM 49.4[+ or -]21.4 mm, P <0.001). We conclude that for adult patients, nasal prongs and nasopharyngeal oxygen therapy consume less oxygen and provide greater comfort than facemasks while still maintaining Sp[O.sub.2] [greater than or equal to]95%.

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

Skin temperature as a noninvasive marker of haemodynamic and perfusion status in adult cardiac surgical patients : an observational study

Objective
Foot temperature has long been advocated as a reliable noninvasive measure of cardiac output despite equivocal evidence. The aim of this pilot study was to investigate the relationship between noninvasively measured skin temperature and the more invasive core-peripheral temperature gradients (CPTGs), against cardiac output, systemic vascular resistance, serum lactate, and base deficit.

Research methodology
The study was of a prospective, observational and correlational design. Seventy-six measurements were recorded on 10 adults postcardiac surgery. Haemodynamic assessments were made via bolus thermodilution. Skin temperature was measured objectively via adhesive probes, and subjectively using a three-point scale.

Setting
The study was conducted within a tertiary level intensive care unit.

Results
Cardiac output was a significant predictor for objectively measured skin temperature and CPTG (p = .001 and p = .004, respectively). Subjective assessment of skin temperature was significantly related to cardiac output, systemic vascular resistance, and serum lactate (p < .001, respectively).

Conclusions
These results support the utilisation of skin temperature as a noninvasive marker of cardiac output and perfusion. The use of CPTG was shown to be unnecessary, given the parallels in results with the less invasive skin temperature parameters. A larger study is however required to validate these findings.

Tracheostomy decannulation failure rate following critical illness : a prospective descriptive study

Background : Tracheostomy is a well established and practical approach to airway management for patients requiring extended periods of mechanical ventilation or airway protection. Little evidence is available to guide the process of weaning and optimal timing of tracheostomy tube removal. Thus, decannulation decisions are based on clinical judgement. The aim of this study was to describe decannulation practice and failure rates in patients with tracheostomy following critical illness.

Methods : A prospective descriptive study was conducted of consecutive patients who received a tracheostomy at a tertiary metropolitan public hospital intensive care unit (ICU) between March 2002 and December 2006. Data were analysed using descriptive and inferential tests.

Results : Of the 823 decannulation decisions, there were 40 episodes of failed decannulation, a failure rate of 4.8%. These 40 episodes occurred in 35 patients: 31 patients failed once, 3 patients failed twice and 1 patient failed three times. There was no associated mortality. Simple stoma recannulation was required in 25 episodes, with none of these patients readmitted to ICU. Translaryngeal intubation and readmission to ICU took place for the remaining 15 episodes. The primary reason for decannulation failure was sputum retention. Twenty-four patients (60%) failed decannulation within 24 h, with 14 of these occurring within 4 h.

Conclusions : Clinical assessments coupled with professional judgement to decide the optimal time to remove tracheostomy tubes in patients following critical illness resulted in a failure rate comparable with published data. Although reintubation and readmission to ICU was required in just over one third of failed decannulation episodes, there was no associated mortality or other significant adverse events. Our data suggest nurses need to exercise high levels of clinical vigilance during the first 24 h following decannulation, particularly the first 4 h to detect early signs of respiratory compromise to avoid adverse outcomes.

Oxygen delivery to patients after cardiac surgery : a medical record audit

OBJECTIVE: To describe how intensive care nurses manage the administration of supplemental oxygen to patients during the first 24 hours after cardiac surgery.
METHODS: A retrospective audit was conducted of the medical records of 245 adult patients who underwent cardiac surgery between 1 January 2005 and 31 May 2008 in an Australian metropolitan hospital. Physiological data (oxygen saturation measured by pulse oximetry and respiratory rate) and intensive care unit management data (oxygen delivery device, oxygen flow rate and duration of mechanical ventilation) were collected at hourly intervals over the first 24 hours of ICU care.
RESULTS: Of the 245 patients whose records were audited, 185 were male; mean age was 70 years (SD, 10), and mean APACHE II score was 17.5 (SD, 5.14). Almost half the patients (122, 49.8%) were extubated within 8 hours of ICU admission. The most common oxygen delivery device used immediately after extubation was the simple face mask (214 patients, 87%). Following extubation, patients received supplemental oxygen via, on average, two different delivery devices (range, 1-3), and had the delivery device changed an average of 1.38 times (range, 0-6) during the 24 hours studied. Twenty-two patients (9%) received non-invasive ventilation or high-flow oxygen therapy, and 16 (7%) experienced one or more episode of hypoxaemia during mechanical ventilation. A total of 148 patients (60%) experienced one or more episodes of low oxygenation or abnormal respiratory rate during the first 24 hours of ICU care despite receiving supplemental oxygen.
CONCLUSION: These findings suggest that the ICU environment does not protect cardiac surgical patients from suboptimal oxygen delivery, and highlights the need for strategies to prompt the early initiation of interventions aimed at optimising blood oxygen levels in cardiac surgical patients in the ICU.

Patients and nurses' perspective on oxygen therapy : a qualitative study

Aim. This paper is a report of a study to describe patients' and nurses' perspectives on oxygen therapy.
Background. Failure to correct significant hypoxaemia may result in cardiac arrest, need for mechanical ventilation or death. Nurses frequently make clinical decisions about the selection and management of low-flow oxygen therapy devices. Better understanding of patients' and nurses' experiences of oxygen therapy could inform clinical decisions about oxygen administration using low-flow devices.
Methods. Face-to-face interviews with a convenience sample of 37 adult patients (17 cardio-thoracic: 20 medical surgical) and 25 intensive care unit nurses were conducted from February 2007 to September 2007. Interviews were audio-taped, transcribed verbatim and then analysed using a thematic analysis approach.
Findings. The patients identified three key factors that underpinned their compliance with oxygen therapy: (i) device comfort; (ii) ability to maintain activities of daily living; and (iii) therapeutic effect. The nurses identified factors, such as: (i) therapeutic effect, (ii) issues associated with compliance, (iii) strategies to optimize compliance, (iv) familiarity with device, (v) triggers for changing oxygen therapy devices, as being key to the effective management of oxygen therapy.
Conclusion. Differences between the patients' and nurses' perspective of oxygen therapy illustrate the variety of factors that impact on effective oxygen administration. Further research should seek to provide a further in-depth understanding of the current oxygen administration practices of nurses and the patient factors that enhance or hinder effectiveness of oxygen therapy. Detailed information about nurse and patient factors that influence oxygen therapy will inform a sound evidence base for nurses' oxygen administration decisions.

The role of religiosity as a coping resource for relatives of critically ill patients in Greece

Critical care hospitalisation is emotionally overwhelming for the relatives of patients. Research has shown that religiosity is an effective coping resource for people with health related problems and has been correlated with better health outcomes. However the processes by which religiosity is utilized and its ejfocts on relatives of critically ill patients have not been adequately explored. This article presents relatives' experiences and processes of religiosity; it is part of a wider grounded theory study on the experiences of critically ill patients'relatives in Greece. T wenty-jive relatives of patients in the intensive care units of three public general district hospitals in Athens, Greece, participated in 19 interviews. Religiosity was found tv be the main source of hope, strength and courage for relatives and was expressed with church/monastery attendance, belief in God, praying. and performing religious rituals. Health care professionals should pay attention and understand these aspects of coping.

Skeletal morbidity among survivors of critical illness

Objectives: To describe the incident fracture rate in survivors of critical illness and to compare fracture risk with populationmatched control subjects.

Design: Retrospective longitudinal case– cohort study.

Setting: A tertiary adult intensive care unit in Australia. Patients: All patients ventilated admitted to intensive care and requiring mechanical ventilation for >48 hrs between January 1998 and December 2005.

Interventions: None.

Measurements and Main Results: New fractures were identified in the study population for the postintensive care unit period (intensive care unit discharge to January 2008). The incident fracture rate and age-adjusted fracture risk of the female intensive care unit population were compared with the general population adult females derived from the Geelong Osteoporosis Study. Over the 8-yr period, a total of 739 patients (258 women, 481 men) were identified. After a median follow-up of 3.7 yrs (interquartile range, 2.0–5.9 yrs) for women and 4.0 yrs (interquartile range, 2.1–6.1 yrs) for men, incident fracture rates (95% confidence interval) per 100 patient years were 3.84 (2.58 –5.09) for females 2.41 (1.73–3.09) for males. Compared with an age-matched random population-based sample of women, elderly women were at increased risk for sustaining an osteoporosisrelated fracture after critical illness (hazard ratio, 1.65; 95% confidence interval, 1.08 –2.52; p .02).

Conclusions: The increase in fracture risk observed in postintensive care unit older females suggests an association between critical illness and subsequent skeletal morbidity. The explanation for this association is not explored in this study and includes the effects of pre-existing patient factors and/or direct effects of critical illness. Prospective research evaluating risk factors, the relationship between critical illness and bone turnover, the extent and duration of bone loss, and the associated morbidity in this population is warranted.