Dying feet in ICU : why might extracorporeal membrane oxygenation machines cause necrotic feet?

Background Extracorporeal membrane oxygenation (ECMO) is used for severe lung and/or heart failure in intensive care units (ICU). The Prince Charles Hospital (TPCH) has one of the largest ECMO units in Australia. Its use rapidly increased during the H1N1 (“swine flu”) pandemic and an increase in pedal complications resulted. The relationship between ECMO and pedal complications has been described, particularly in children, though no strong data exists. This paper presents a case series of foot complications in patients having received ECMO treatment. Methods We present nine cases of severe foot complications resulting from patients receiving ECMO treatment at TPCH in 2009–2012. Results Case ages ranged from 16 - 58 years and three were male. Six cases had an unremarkable medical history prior to H1N1 or H1N2 infection, one had Cardiomyopathy, one had received a lung transplant, and one had multi-organ failure post-sepsis. Common medications prescribed included vasopressors, antibiotics, and sedatives. All cases showed signs of markedly impaired peripheral perfusion whilst on ECMO and seven developed increasing areas of foot necrosis. Outcomes include two bilateral below knee amputations, two multiple digital amputations, one Reflex Sympathetic Dystrophy Syndrome, three pressure injuries, and three deaths. Conclusion Necrosis of the feet appears to occur more readily in younger people requiring ECMO treatment than others in ICU. The authors are conducting further studies to investigate associations between particular infections, medical history, medications, or machine techniques and severe foot complications. Some of these early results will also be presented at this conference.

A high performance feedback active noise control system

In many active noise control (ANC) applications, an online secondary path modelling method that uses a white noise as a training signal is required. This paper proposes a new feedback ANC system. Here we modified both the FxLMS and the VSS-LMS algorithms to raised noise attenuation and modelling accuracy for the overall system. The proposed algorithm stops injection of the white noise at the optimum point and reactivate the injection during the operation, if needed, to maintain performance of the system. Preventing continuous injection of the white noise increases the performance of the proposed method significantly and makes it more desirable for practical ANC systems. Computer simulation results shown in this paper indicate effectiveness of the proposed method.

Simulating the effect of acoustic treatment types for residential balconies with road traffic noise

Development of design guides to estimate the difference in speech interference level due to road traffic noise between a reference position and balcony position or façade position is explored. A previously established and validated theoretical model incorporating direct, specular and diffuse reflection paths is used to create a database of results across a large number of scenarios. Nine balcony types with variable acoustic treatments are assessed to provide acoustic design guidance on optimised selection of balcony acoustic treatments based on location and street type. In total, the results database contains 9720 scenarios on which multivariate linear regression is conducted in order to derive an appropriate design guide equation. The best fit regression derived is a multivariable linear equation including modified exponential equations on each of nine deciding variables, (1) diffraction path difference, (2) ratio of total specular energy to direct energy, (3) distance loss between reference position and receiver position, (4) distance from source to balcony façade, (5) height of balcony floor above street, (6) balcony depth, (7) height of opposite buildings, (8) diffusion coefficient of buildings, and; (9) balcony average absorption. Overall, the regression correlation coefficient, R2, is 0.89 with 95% confidence standard error of ±3.4 dB.

An exploratory study of staff nurses' knowledge of delirium in the medical ICU: An Asian perspective

Aim The aim of this study was to establish intensive care unit nurses’ knowledge of delirium within an acute tertiary hospital within South East Asia. Background Delirium is a common, life threatening and often preventable cause of morbidity and mortality among older patients. Undetected and untreated delirium is a catalyst to increased mortality, morbidity, functional decline and results in increased requirement for nursing care, healthcare expense and hospital length of stay. However, despite effective assessment tools to identify delirium in the acute setting, there still remains an inability of ICU nurses’ to accurately identify delirium in the critically ill patient especially that of hypoactive delirium. Method A purposive sample of 53 staff nurses from a 13-bedded medical intensive care unit within an acute tertiary teaching hospital in South East Asia were asked to participate. A 40 item 5-point Likert scale questionnaire was employed to determine the participants’ knowledge of the signs and symptoms; the risk factors and negative outcomes of delirium. Results The overall positively answered mean score was 27 (67.3%) out of a possible 40 questions. Mean scores for knowledge of signs and symptoms, risk factors and negative outcomes were 9.52 (63.5%, n = 15), 11.43 (63.5%, n = 17) and 6.0 (75%, n = 8), respectively. Conclusion Whilst the results of this study are similar to others taken from a western perspective, it appeared that the ICU nurses in this study demonstrated limited knowledge of the signs and symptoms, risk factors and negative outcomes of delirium in the critically patient. The implications for practice of this are important given the outcomes of untreated delirium.

Delirium in the ICU : a review

AIM The aim of this paper was to review the current discourse in relation to intensive care unit (ICU) delirium. In particular, it will discuss the predisposing and contributory factors associated with delirium's development as well as effects of delirium on patients, staff and family members. BACKGROUND Critically ill patients are at greater risk of developing delirium and, with an ageing population and increased patient acuity permitted by medical advances, delirium is a growing problem in the ICU. However, there is a universal consensus that the definition of ICU delirium needs improvement to aid its recognition and to ensure both hypoalert-hypoactive and hyperalert-hyperactive variants are easily and readily identified. RELEVANCE TO CLINICAL PRACTICE The effects of ICU delirium have cost implications to the National Health Service in terms of prolonged ventilation and length of hospital stay. The causes of delirium can be readily classified as either predisposing or precipitating factors, which are organic in nature and commonly reversible. However, contributory factors also exist to exacerbate delirium and having an awareness of all these factors promises to aid prevention and expedite treatment. This will avoid or limit the host of adverse physiological and psychological consequences that delirium can provoke and directly enhance both patient and staff safety. CONCLUSIONS Routine screening of all patients in the ICU for the presence of delirium is crucial to its successful management. Nurses are on the front line to detect, manage and even prevent delirium.

Patient empowerment : does it still occur in the ICU?

The theoretical underpinnings of patient empowerment were developed through the work of educators and community psychologists, working primarily with the socially disadvantaged. Empowerment is seen as a philosophy based upon the belief of the inherent worth and creative potential of each individual. Therefore, the aim of this paper is to explore whether this creative potential associated with patient choice that encapsulates empowerment is applicable to the Intensive Care Unit.

Defining the expert ICU nurse

This paper explores the concept of expertise in intensive care nursing practice from the perspective of its relationship to the current driving forces in healthcare. It discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. It argues that nursing expertise which focuses on the provision of individualised, holistic care and which is based largely on intuitive decision-making cannot and should not be reduced to being articulated in positivist terms. The principles of abduction or fuzzy logic, derived from computer science, may be useful in assisting nurses to explain in terms, which others can comprehend, the value of nursing expertise.

Noise levels in a General Surgical Ward : a descriptive study

Aims and objectives.  This study was undertaken to measure and analyse levels of acoustic noise in a General Surgical Ward. Method.  Measurements were undertaken using the Norsonic 116 sound level meter (SLM) recording noise levels in the internationally agreed ‘A’ weighted scale. Noise level data and observational data as to the number of staff present were obtained and recorded at 5-min intervals over three consecutive days. Results.  Results of noise level analysis indicated that mean noise level within this clinical area was 42.28 dB with acute spikes reaching 70 dB(A). The lowest noise level attained was that of 36 dB(A) during the period midnight to 7 a.m. Non-parametric testing, using Spearman's Rho (two-tailed), found a positive relationship between the number of staff present and the level of noise recorded, indicating that the presence of hospital personnel strongly influences the level of noise within this area. Relevance to clinical practice.  Whilst the results of this may seem self-evident in many respects the problems of excessive noise production and the exposure to it for patients, hospital personnel and relatives alike continues unabated. What must be of concern is the psychophysiological effects excessive noise exposure has on individuals, for example, decreased wound healing, sleep deprivation and cardiovascular stimulation.

Acoustic, electric and virtual noise : the cultural identity of the guitar

Guitar technology underwent significant changes in the 20th century in the move from acoustic to electric instruments. In the first part of the 21st century, the guitar continues to develop through its interaction with digital technologies. Such changes in guitar technology are usually grounded in what we might call the "cultural identity" of the instrument: that is, the various ways that the guitar is used to enact, influence and challenge sociocultural and musical discourses. Often, these different uses of the guitar can be seen to reflect a conflict between the changing concepts of "noise" and "musical sound."

Residential balconies with road traffic noise : a combined source image and radiosity model

Several significant studies have been made in recent decades toward understanding road traffic noise and its effects on residential balconies. These previous studies have used a variety of techniques such as theoretical models, scale models and measurements on real balconies. The studies have considered either road traffic noise levels within the balcony space or inside an adjacent habitable room or both. Previous theoretical models have used, for example, simplified specular reflection calculations, boundary element methods (BEM), adaptations of CoRTN or the use of Sabine Theory. This paper presents an alternative theoretical model to predict the effects of road traffic noise spatially within the balcony space. The model includes a specular reflection component by calculating up to 10 orders of source images. To account for diffusion effects, a two compartment radiosity component is utilised. The first radiosity compartment is the urban street, represented as a street with building facades on either side. The second radiosity compartment is the balcony space. The model is designed to calculate the predicted road traffic noise levels within the balcony space and is capable of establishing the effect of changing street and balcony geometries. Screening attenuation algorithms are included to determine the effects of solid balcony parapets and balcony ceiling shields.

Fault detection of slow speed rolling element bearing with noise removal techniques

Rolling Element Bearings (REBs) are vital components in rotating machineries for providing rotating motion. In slow speed rotating machines, bearings are normally subjected to heavy static loads and a catastrophic failure can cause enormous disruption to production and human safety. Due to its low operating speed the impact energy generated by the rotating elements on the defective components is not sufficient to produce a detectable vibration response. This is further aggravated by the inability of general measuring instruments to detect and process the weak signals at the initiation of the defect accurately. Furthermore, the weak signals are often corrupted by background noise. This is a serious problem faced by maintenance engineers today and the inability to detect an incipient failure of the machine can significantly increases the risk of functional failure and costly downtime. This paper presents the application of noise removal techniques for enhancing the detection capability for slow speed REB condition monitoring. Blind deconvolution (BD) and adaptive line enhancer (ALE) are compared to evaluate their performance in enhancing the source signal with consequential removal of background noise. In the experimental study, incipient defects were seeded on a number of roller bearings and the signals were acquired using acoustic emission (AE) sensor. Kurtosis and modified peak ratio (mPR) were used to determine the detectability of signal corrupted by noise.

Noise is the outsider to be expelled

This was a catalogue essay for the emerging Brisbane artist Sarah Byrne's exhibition Trenchmouth at MetroArts from 31st October until 21st November 2009. The essay contextualised her practice in the history of experimental soundart and discussed her methods of practice and approach to sound from the postion of a multi-discplinary artist.The essay also discussed the way in which her practice engages with and recontextualises camp, trash, and lo-fi aspects of popular culture

Metal Skin and the cinema of noise

In traditional communication and information theory, noise is the demon Other, an unwelcome disruption in the passage of information. Noise is "anything that is added to the signal between its transmission and reception that is not intended by the source...anything that makes the intended signal harder to decode accurately". It is in Michel Serres' formulation, the "third man" in dialogue who is always assumed, and whom interlocutors continually struggle to exclude. Noise is simultaneously a condition and a by-product of the act of communication, it represents the ever present possibility of disruption, interruption, misunderstanding. In sonic or musical terms noise is cacophony, dissonance. For economists, noise is an arbitrary element, both a barrier to the pursuit of wealth and a basis for speculation. For Mick (Jeremy Sims) and his mate Kev (Ben Mendelsohn) in David Caesar's Idiot Box (1996), as for Hando (Russell Crowe) and his gang of skinheads in Geoffrey Wright's Romper Stomper (1992), or Dazey (Ben Mendelsohn) and Joe (Aden Young) in Wright's Metal Skin (1994) and all those like them starved of (useful) information and excluded from the circuit - the information poor - their only option, their only point of intervention in the loop, is to make noise, to disrupt, to discomfort, to become Serres' "third man", "the prosopopoeia of noise" (5).

Investigations on road noise level spatial variability within a specially designed acoustic balcony

An investigation into the spatial distribution of road traffic noise levels on a balcony is conducted. A balcony constructed to a special acoustic design due to its elevation above an 8 lane motorway is selected for detailed measurements. The as-constructed balcony design includes solid parapets, side walls, ceiling shields and highly absorptive material placed on the ceiling. Road traffic noise measurements are conducted spatially using a five channel acoustic analyzer, where four microphones are located at various positions within the balcony space and one microphone placed outside the parapet at a reference position. Spatial distributions in both vertical and horizontal planes are measured. A theoretical model and prediction configuration is presented that assesses the acoustic performance of the balcony under existing traffic flow conditions. The prediction model implements a combined direct path, specular reflection path and diffuse reflection path utilizing image source and radiosity techniques. Results obtained from the prediction model are presented and compared to the measurement results. The predictions are found to correlate well with measurements with some minor differences that are explained. It is determined that the prediction methodology is acceptable to assess a wider range of street and balcony configuration scenarios.