Including Intensive Care Unit Research Articles

O estresse entre enfermeiros que atuam em Unidade de Terapia Intensiva

A presença de estresse tem sido verificada em diferentes profissionais e também entre enfermeiros de UTI, pelo fato de ser grande sua proximidade com os pacientes em sofrimento e com risco de morte. Esse fato se agrava devido à necessidade de cuidados diretos e intensivos. Este estudo, seguindo uma metodologia quantitativa, objetivou caracterizar os enfermeiros que desenvolvem suas atividades em UTI e verificar a presença de estresse entre eles. Para isso, vinte e um enfermeiros de UTIs de cinco hospitais do interior do estado de São Paulo responderam a um roteiro de perguntas direcionadas a sua caracterização e ao Inventário do Estresse em Enfermeiros. Os resultados mostraram que 57,1% dos enfermeiros estudados consideraram a UTI um local estressante e 23,8% deles apresentaram um escore elevado, indicando a presença de estresse. Tal fato demonstra que o estresse, mesmo sendo discutido desde longa data, ainda acomete esses profissionais, e as instituições ainda não oferecem atenção especial aos enfermeiros no sentido de promover sua saúde integral.

Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours

This study aimed to determine the impact of providing chest physiotherapy after routine clinical assessment on the duration of mechanical ventilation, outcome and intensive care length of stay. Single-centre, single-blind, prospective, randomised, controlled trial in a university hospital general intensive care unit. 180 patients requiring mechanical ventilation for more than 48 h. Patients randomly allocated, one group receiving physiotherapy as deemed appropriate by physiotherapists after routine daily assessments and another group acting as controls were limited to receiving decubitus care and tracheal suctioning. Primary endpoints were initial time to become ventilator-free, secondary endpoints included intensive care unit (ICU) and hospital mortality and ICU length of stay. Kaplan-Meier analysis censored for death revealed a significant prolongation of median time to become ventilator-free among patients receiving physiotherapy (p=0.047). The time taken for 50% of patients (median time) to become ventilator-free was 15 and 11 days, respectively, for physiotherapy and control groups. There were no differences between groups in ICU or hospital mortality rates, or length of ICU stay. The number of patients needing re-ventilation for respiratory reasons was similar in both groups.

Delirium in the ICU

Delir ium is a disturbance of consciousness delirium. However till recently, the diagnosis of delirium characterized by acute onset, rapid fluctuations in mental in the ICU was imprecise and not standardized, leading status and impaired cognitive functioning. The patient’s to wide variations in the incidence of delirium in various ability to receive, process, store and recall information studies and difficulty in interpreting their results. Recently, is strikingly impaired. The patient may be agitated or the confusion assessment method has been refined and lethargic. It is perhaps better known by its synonyms validated for use in ICU patients, the CAM-ICU. This including intensive care unit (ICU) psychosis, acute can be performed at the bedside and takes less than confusional state, toxic encephalopathy organic brain two minutes. Changes in mental status are best determined using the Richmond Agitation-Sedation Scale (RASS). This is superior to the Glasgow Coma Delirium is unfortunately often regarded as ICU score or other sedation scores as it also includes eyepsychosis or a behavioural disturbance due to the contact, rather than eye-opening alone, in the environment in the ICU. However, the mnemonic for the assessment. Inattention is determined by responses differential diagnosis I WATCH DEATH (Infections, to the attention screening examination (ASE), in which Withdrawal, Acute metabolic encephalopathy, Trauma, the patient has to identify cards previously shown to him. central nervous system (CNS) pathology, hypoxia, Disorganized thinking is detected by answers to four deficiencies, endocrine disorders, acute vascular standard questions or inability to follow simple insufficiency, toxins and drugs, Heavy metals) is commands. testimony to the fact that delirium may be the symptom of a serious underlying life-threatening disorder. The Using the CAM-ICU, Ely et al found delirium to be article by Rudra et al in this issue of the Indian Journal present in 40% patients who appeared alert or rousable of Critical Care Medicine[3] is timely and important and in 80% of all mechanically ventilated patients.[5] because in reviewing the subject of postoperative delirium, it also draws attention to the larger problem of The diagnosis of delirium requires the presence of syndrome, etc.

INJURY-ASSOCIATED HYPOTHERMIA: AN ANALYSIS OF THE 2004 NATIONAL TRAUMA DATA BANK

Severe injury and shock are frequently associated with abnormalities in patient body temperature. Substantial increases in mortality have been associated with profound hypothermia, especially below 35 degrees C. The purpose of this study was to further characterize the impact of hypothermia in a large dataset of trauma patients. This study was a retrospective analysis of the 2004 version of the National Trauma Data Bank (NTDB), which contains approximately 1.1 million patients from over 400 trauma centers. Admission temperature was analyzed with respect to mortality, injury severity score (ISS), base deficit (BD), Glasgow Coma Score (GCS), and hospital outcomes. The NTDB contained 701,491 patients with temperatures recorded upon trauma center admission. Of these, 11,026 patients had admission temperatures <35 degrees C, and 802 had temperatures <32 degrees C. Comparison of core temperature versus mortality revealed that as temperature decreased, the mortality rate increased, reaching approximately 39% at 32 degrees C, and remained constant at lower temperatures. Surprisingly, 477 patients (59.5%) survived with temperatures <32 degrees C. Similarly, BD increased as hypothermia worsened until body temperature reached 31 degrees C, below which there was little further increase. Patients with admission temperatures less than 35 degrees C had significantly greater mortality (25.5% vs. 3.0%, P < 0.001) and BD (7.8 vs. 3.7, P < 0.001) when compared with patients with temperatures >or=35 degrees C. In survivors, average ventilator days and intensive care unit (ICU) days were 14.4 and 12.8, respectively, for patients with temperatures <35 degrees C as opposed to more normothermic patients who demonstrated an average of 9.5 ventilator days and 9.1 ICU days (P < 0.001). When grouped by individual ISS, BD level, and GCS motor score, mortality was significantly greater when admission temperature was below 35 degrees C (ISS mean difference = 11.4%, BD mean difference = 22.8%, and GCS motor mean difference = 9.85%). Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71). Admission hypothermia is associated with greater mortality, increased injury severity, more profound acidosis, and prolonged ICU/ventilator courses. However, although mortality at <32 degrees C is high, patients with temperatures this low do survive. As temperatures drop below 32 degrees C, mortality rates remain constant, which may indicate a threshold below which physiologic mechanisms are unable to correct body temperature regardless of injury severity. Although shock severity is highly indicative of outcome, hypothermia independently contributes to the substantial mortality associated with severe injury.

Nutrition for critically ill patients

Nutrition is an integral component of general care for critically ill patients, and numerous randomized trials have addressed research questions related to the optimal feeding route, formulation, dose, and timing of initiation. The mission of the free website http://www.criticalcarenutrition.com is 'to improve the practice of nutrition support in the critical care setting through knowledge translation', with specific objectives for knowledge generation, synthesis and translation. Most of the website's resources are devoted to the dissemination of a recently published multidisciplinary evidence-based clinical practice guideline (CPG) on nutritional support for mechanically ventilated critically ill adults [1]. The guideline was peer funded and developed with the participation of multiple academic, professional society, and industry stakeholders. The related website is operated by Critical Care Nutrition, a group of Canadian intensivists and dietitians with diverse backgrounds (intensive care, surgery, nutrition, clinical epidemiology). For practicing clinicians, including intensive care unit (ICU) directors and dietitians, the most useful website features are the Tools & Training Kit (designed to facilitate local CPG implementation) and the Nutrition Survey. Implementation tools include a training manual (text and flow diagrams that highlight important CPG recommendations), sample order sets for glycemic control and enteral feeding, printable summary pocket cards, and tips on organizing an implementation workshop. Nine slide presentations on various nutrition topics (e.g. 'Optimizing the Benefits and Minimizing the Risk of Enteral Nutrition' and 'Nutritional Support in Severe Acute Pancreatitis') are available as zipped PowerPoint files and can be modified for local use. Overall, the materials are comprehensive, practical, and novel. They are especially appealing given the traditional ineffective approach of relying on journal publication as the primary method of knowledge translation. However, an enthusiastic but administratively inexperienced intensivist or dietitian may find it extremely challenging to build a nutritional quality improvement program using the website tools. Additional useful information would include the following: a specific 'how-to' manual for implementing the CPG (which might include a downloadable lecture, a sample project timeline, and estimated personnel, time and monetary requirements); links to general change management resources; and evidence of usability testing of the implementation tools to match the rigor of the CPG development process. The Nutrition Survey is a quality improvement tool that an ICU can use initially to compare its nutrition practice to that in other centres and subsequently to assess the impact of a quality improvement initiative on adherence to best practices. Patient data are entered on the website either directly or after initial data entry on downloadable printable forms. Local experience with the survey has been positive, with straightforward, rapid, and reliable web data entry. The ICU must enter data on at least 10 patients in order to receive a report. Prospective participants can examine the manual data collection forms and help information, but there is no information on the length of time required for data entry, sample reports, or the number and experience of participating hospitals to date. Other useful features of the site are a list of planned and ongoing nutritional support studies initiated by the Critical Care Nutrition group and a list of upcoming conferences (although at the time of this review the three conferences listed had already taken place). Of note, one recently completed randomized trial evaluated the effectiveness of the website's implementation tools as compared with passive CPG dissemination. The website is functional, with rapid page loading and downloads, easy navigation, working links to nutrition and critical care professional organizations, and no advertisements. I saved some files to my hard drive because they would not open directly. The website does not disclose funding sources but it does not endorse or advertise specific products. There are plans to update the CPG as new evidence becomes available. Other objectives, such as developing a warehouse of randomized trials of nutritional interventions, remain to be implemented. Overall, this site provides intensivists, dietitians, and others interested in nutritional support of the critically ill with a rich set of tools to help translate evidence-based recommendations into practice.

Severe acute respiratory syndrome: correlation between clinical outcome and radiologic features.

To evaluate whether there is a correlation between the clinical outcomes and radiologic features of severe acute respiratory syndrome (SARS). The clinical, laboratory, and radiologic features of 138 patients with SARS were analyzed. Three radiologists in consensus retrospectively assessed the frontal chest radiographs obtained at presentation and during treatment (n = 2045) for the distribution (each lung was divided into upper, middle, and lower zones) and extent of lung parenchymal abnormality. Clinical end points included intensive care unit (ICU) admission and death. Thirty-six (26.1%) patients required ICU care, and eight (5.8%) died. The patients who required ICU care and/or died had more extensive consolidation on chest radiographs obtained initially (median percentage of consolidation, 3.30%, with interquartile range [IR] of 1.70%-8.78% vs 1.70% [IR, 0%-3.30%]; P < .001) and on day 7 after fever onset (median percentage of consolidation, 15.00% [IR, 6.48%-28.73%] vs 5.00% [IR, 2.50%-7.50%]; P < .001) than did surviving patients who did not require ICU care. Patients with involvement of more than one lung zone on initial and day 7 chest radiographs were more likely to require ICU care and/or die than were those with involvement of one or fewer zones (P < .001). Patients with bilateral pneumonic changes at presentation were more likely to have an adverse outcome than were those with unilateral pneumonia (P < .001). Involvement of more than one lung zone at baseline chest radiography was an independent predictor of ICU admission and/or death (odds ratio, 3.16; 95% confidence interval: 1.07, 9.32; P = .037) after adjustments for other significant factors (ie, patient age, and baseline neutrophil count and lactate dehydrogenase level). More extensive airspace disease at presentation is an independent predictor of adverse outcome in patients with SARS.

Classification for coding procedures in the intensive care unit.

There is no commonly accepted coding system for non-operative procedures in general, including intensive care unit (ICU) procedures. In order to create a classification of codes for ICU procedures, a system developed at the University Hospital of Bergen was evaluated in four Nordic countries. Classification codes were constructed using seven main groups of related procedures that were given a letter from A to G. Within each group major procedures were given a number from 00 to 99, with the possibility of up to 10 subclassifications within each procedure. A simple questionnaire regarding the use of coding general ICU procedures and some specific procedures was sent to 171 ICUs in Sweden, Finland, Denmark, and Norway. They were also asked to give their comments on the new classification coding system, which was attached. One hundred and fifty-four questionnaires were returned (response rate 90%). Some or most of the ICU procedures were registered in the ICUs (82.2%). However 38% did not use any coding system and 24% used a specific internal system. The new classification coding system was well received, and was given a mean value of 7.5 using a VAS scale from 0 to 10 (best). Most ICUs would consider using this system if introduced at a national level. Most Nordic ICUs do register some or most of the procedures performed. Such procedures are however, registered in very different ways, using several different systems, and are often home-made. The new classification system of ICU procedures was well rated.

Upper gastrointestinal bleeding in patients with hepatic cirrhosis: clinical course and mortality prediction.

We conducted this study to describe the complications and validate the accuracy of previously reported prognostic indices in predicting the mortality of cirrhotic patients hospitalized for upper GI bleeding. This prospective, observational study included 111 consecutive hospitalizations of 85 cirrhotic patients admitted for GI bleeding. Data obtained included intensive care unit (ICU) admission status, Child-Pugh score, the development of systemic inflammatory response syndrome (SIRS), organ failure, and inhospital mortality. The performances of Garden's, Gatta's, and Acute Physiology and Chronic Health Evaluation (APACHE) II prognostic systems in predicting mortality were assessed. Patients' mean age was 48.7 yr, and the median APACHE II and Child-Pugh scores were 17 and 9, respectively. Their ICU admission rate was 71%. Organ failure developed in 57%, and SIRS in 46% of the patients. Nine patients had acute respiratory distress syndrome, and three patients had hepatorenal syndrome. The inhospital mortality was 21%. The APACHE II, Garden's, and Gatta' s predicted mortality rates were 39%, 24%, and 20%, respectively, and their areas under the receiver operating characteristic curve (AUC) were 0.78, 0.70, and 0.71, respectively. The AUC for Child-Pugh score was 0.76. SIRS and organ failure develop in many patients with hepatic cirrhosis hospitalized for upper GI bleeding, and are associated with increased mortality. Although the APACHE II prognostic system overestimated the mortality of these patients, the receiver operating characteristic curves did not show significant differences between the various prognostic systems.

Upper gastrointestinal bleeding in patients with hepatic cirrhosis: clinical course and mortality prediction

OBJECTIVE: We conducted this study to describe the complications and validate the accuracy of previously reported prognostic indices in predicting the mortality of cirrhotic patients hospitalized for upper GI bleeding. METHODS: This prospective, observational study included 111 consecutive hospitalizations of 85 cirrhotic patients admitted for GI bleeding. Data obtained included intensive care unit (ICU) admission status, Child-Pugh score, the development of systemic inflammatory response syndrome (SIRS), organ failure, and inhospital mortality. The performances of Garden’s, Gatta’s, and Acute Physiology and Chronic Health Evaluation (APACHE) II prognostic systems in predicting mortality were assessed. RESULTS: Patients’ mean age was 48.7 yr, and the median APACHE II and Child-Pugh scores were 17 and 9, respectively. Their ICU admission rate was 71%. Organ failure developed in 57%, and SIRS in 46% of the patients. Nine patients had acute respiratory distress syndrome, and three patients had hepatorenal syndrome. The inhospital mortality was 21%. The APACHE II, Garden’s, and Gatta’s predicted mortality rates were 39%, 24%, and 20%, respectively, and their areas under the receiver operating characteristic curve (AUC) were 0.78, 0.70, and 0.71, respectively. The AUC for Child-Pugh score was 0.76. CONCLUSIONS: SIRS and organ failure develop in many patients with hepatic cirrhosis hospitalized for upper GI bleeding, and are associated with increased mortality. Although the APACHE II prognostic system overestimated the mortality of these patients, the receiver operating characteristic curves did not show significant differences between the various prognostic systems.

Acute Confusional States in Critically III Patients: A Review

Critical care patients become confused in the intensive care setting. Several dangers exist in acute confusional states. Confused patients jeopardize their own safety, are more likely to die than nonconfused patients and are more likely to become cognitively impaired and require institutionalization. This article reviews the literature about patients experiencing acute confusional states in the critical care setting including intensive care unit (ICU) psychosis, postcardiotomy delirium and confusion in the elderly.