Intensive Care Management Of Patients Research Articles

Early detection of bacteremia pathogens with rapid molecular diagnostic tests and evaluation of effect on intensive care patient management

İntroductionThe BioFire FilmArray Blood Culture Identification panel (BCID2), a rapid molecular blood culture identification test based on multiplex nested polymerase chain reaction. The aim of this study was to evaluate clinical outcomes between the period before (pre-BCID2 group) and after (post-BCID2 group) the introduction of the BCID2 panel into our routine practice. MethodsThe primary endpoint was time to optimal antibiotherapy, and the secondary endpoints were duration of hospital and intensive care unit stay, 7-day, 14-day and 28-day mortality rates after bacteremia. ResultsThe median time from empirical antibiotherapy to optimal antimicrobial therapy was 4560 (IQR;3060-7140) minutes in the pre-BCID2 group and 1715 (IQR;1362- 2776.25) minutes (in the post-BCID2 group (p<0.05). ConclusionAdding the BCID2 panel may improve antibiotic management in critically ill bacteremia patients

Machine learning-derived blood culture classification with both predictive and prognostic values in the intensive care unit: A retrospective cohort study

ObjectivesDiagnosis and management of intensive care unit (ICU)-acquired bloodstream infections are often based on positive blood culture results. This retrospective cohort study aimed to develop a classification model using data-driven characterisation to optimise the management of intensive care patients with blood cultures. Setting, methodology/designAn unsupervised clustering model was developed based on the clinical characteristics of patients with blood cultures in the Medical Information Mart for Intensive Care (MIMIC)-IV database (n = 2451). It was tested using the data from the MIMIC-III database (n = 2047). Main outcome measuresThe prognosis, blood culture outcomes, antimicrobial interventions, and trajectories of infection indicators were compared between clusters. ResultsFour clusters were identified using machine learning-based k-means clustering based on data obtained 48 h before the first blood culture sampling. Cluster γ was associated with the highest 28-day mortality rate, followed by clusters α, δ, and β. Cluster γ had a higher fungal isolation rate than cluster β (P < 0.05). Cluster δ was associated with a higher isolation rate of Gram-negative organisms and fungi (P < 0.05). Patients in clusters γ and δ underwent more femoral site vein catheter placements than those in cluster β (P < 0.001, all). Patients with a duration of antibiotics treatment of 4, 6, and 7 days in clusters α, δ, and γ, respectively, had the lowest 28-day mortality rate. ConclusionsMachine learning identified four clusters of intensive care patients with blood cultures, which yielded different prognoses, blood culture outcomes, and optimal duration of antibiotic treatment. Such data-driven blood culture classifications suggest further investigation should be undertaken to optimise treatment and improve care. Implications for clinical practiceIntensive care unit-acquired bloodstream infections are heterogeneous. Meaningful classifications associated with outcomes should be described. Using machine learning and cluster analysis could help in understanding heterogeneity. Data-driven blood culture classification could identify distinct physiological states and prognoses before deciding on blood culture sampling, optimise treatment, and improve care.

Management of the acute on chronic liver failure in the intensive care unit.

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

THU-399 - Impact of plasma exchange and evolution of intensive care management in patients with acute liver failure in a liver transplant center over the past decade

THU-399 - Impact of plasma exchange and evolution of intensive care management in patients with acute liver failure in a liver transplant center over the past decade

Postoperative care after left ventricular assist device implantation: considerations for the cardiac surgical intensivist.

Heart failure is a leading cause of morbidity and mortality, the incidence of which is predicted to continue to increase as the population ages. Left ventricular assist devices (LVADs) in particular have emerged as important therapies for the support of patients with advanced heart failure needing short- or long-term mechanical circulatory support. With over 5000 implantations per year, LVADs are the most commonly used durable devices worldwide. In this article, we provide an overview of the intensive care management of patients with LVADs during the early post-implantation period.

Dexmedetomidine attenuates pneumocyte apoptosis and inflammation induced by aortic ischemia-reperfusion injury

ABSTRACT Objective Despite significant improvements in interventional vascular aneurysm repair procedures and intensive care patient management, there has been no significant decrease in mortality due to ruptured abdominal aortic aneurysm. Oxidative stress is known to play a key role in secondary organ damage due to infrarenal aortic clamping. The aim of this study was to examine the potential protective effect of the alpha-2 adrenergic receptor agonist dexmedetomidine (DMT) on aortic occlusion-induced lung injury. Methods Thirty Sprague Dawley rats were allocated into control, ischemia-reperfusion (IR), and IR+DMT groups randomly. Vascular clamps were attached to the abdominal aorta in the IR and IR+DMT groups. Two-hour reperfusion was established 1 h after ischemia. The IR+DMT group received a single intraperitoneal 100 µg dose of DMT 30 min before infrarenal abdominal aortic clamping. Results IR due to aortic occlusion led to apoptosis, widespread inflammation, alveolar septal wall thickening due to bleeding and vascular congestion were observed in both types I and II pneumocytes. Malondialdehyde levels increased while glutathione decreased. However, DMT was found to lower apoptotic pneumocytes, alveolar-septal thickness, hemorrhage, vascular congestion, and malondialdehyde levels, while glutathione levels in lung tissue increased. Conclusions This study is the first to address the effects of DMT on the lung in a ruptured abdominal aortic aneurysm model. Our findings suggest that the alpha-2 adrenergic receptor agonist DMT reduces oxidative stress and apoptosis, thus protecting against aortic occlusion-induced pulmonary injury.

Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management.

Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder.The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor.In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.

Immunosuppressive drugs and associated complications in abdominal organ transplantation.

Intensive care management of patients who have undergone organ transplantation of liver, small bowel, pancreas, and/or kidney requires a basic knowledge of immunosuppression principles and the management of immunosuppressive medications. This review highlights the core principles of immunosuppression management in abdominal organ transplantation with a focus on complications arising from immunosuppressive drugs, both in the immediate postoperative period and in long-term usage. The general principles of management of immunosuppression in the abdominal organ transplant population have remained largely unchanged. Improvements in drug monitoring coupled with improvements in knowledge of pathways involved in allograft rejection have further refined immunosuppressive therapy. Infectious and central nervous system complications remain prevalent and are common complications of immunosuppressive drug therapy. For the intensive care professional who cares for abdominal organ transplant recipients, a foundational knowledge of the core principles of immunosuppression management is essential. In addition, an understanding of the common immunosuppressive drug regimens and the complications associated with these regimens is required for optimal management, risk assessment, and outcomes.

The effect of back massage on physiological parameters, dyspnoea, and anxiety in patients with chronic obstructive pulmonary disease in the intensive care unit: A randomised clinical trial

ObjectiveThis study aimed to examine the effect of back massage on physiological parameters, dyspnoea and anxiety in patients with chronic obstructive pulmonary disease receiving noninvasive mechanical ventilation in the intensive care unit. Design and methodsThis study was a randomised controlled trial. Patients in the intervention group received back massage (15 minutes) between 16.00 and 20.00 every day for four days in the intensive care unit. The control group received no intervention. The data was collected using a personal information form, Baseline Dyspnoea Index, State-Trait Anxiety Inventory and Physiological Parameters Chart. ResultsWe found no statistically significant change between systolic-diastolic blood pressures, heart rates and respiratory rate, oxygen saturation and dyspnoea level of the intervention and control groups (p > .05), while there was a significant reduction in the anxiety scores of patients in the intervention group (p < .05). ConclusionThis study found that back massage applied in patients with chronic obstructive pulmonary disease receiving noninvasive mechanical ventilation was effective in decreasing anxiety. Back massage is a low-cost intervention with benefits for patients, and it may be a useful intervention in the anxiety management of intensive care patients.

Intensive care management of patients with COVID-19.

The COVID-19 pandemic originated in China in December 2019 and has since then, swept across the world. The last Influenza pandemic of 1918 happened before the advent of modern medicine. We have come a long way since then. But the pandemic has still caught us unprepared in many quarters. The review focuses on the management of critically ill COVID-19 patients and the various challenges faced by intensivists.

Renal replacement therapy for acute kidney injury in intensive care.

Acute kidney injury is a common occurrence on the intensive care unit and is associated with incremental risk of death and chronic kidney disease. Renal replacement therapy has become an essential tool in the intensive care management of patients with severe acute kidney injury and its use is rising. A basic understanding of renal replacement therapy is essential for all doctors treating acutely unwell patients. This article provides a brief overview of the principles and important considerations for the provision of renal replacement therapy for critically ill patients with acute kidney injury.

A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury.

Intracranial pressure (ICP) monitoring is a cornerstone of the intensive care management of patients with severe acute brain injuries, including traumatic brain injury. While elevations in ICP are common, data regarding the measurement and treatment of these ICP elevations are conflicting. There is increasing recognition that changes in the balance between supply and demand of brain tissue are critically important and therefore the measurement of multiple modalities is required. Approaches are not standard, and therefore this article provides a description of a bedside, single burr hole approach to multimodality monitoring that allows the passage of probes designed to measure not only ICP but brain tissue oxygen, blood flow, and intracranial electroencephalography. Patient selection criteria, operative procedures, and practical considerations for securing probes during critical care are described. This method is readily performed, safe, secure, and flexible for the adoption of a variety of multimodality monitoring approaches aimed at detecting or preventing secondary brain injuries.

Noise Pollution in the Pediatric Intensive Care Unit and its Effect on Sedation

Noise exposure is an important factor in the management of intensive care patients. There are many different causes of noise in the ICU such as equipment, monitors, staff, family plus other additional sources. Patients in the ICU are exposed to these noise sources for 24 hours a day with no respite. The noise levels can vary significantly during the day as well as significantly between patient bed-spaces. There are detrimental effects from excessive noise exposure; some of this is related to the risk of damage to a person's hearing.

Intensive Care Management of Patients with Cirrhosis.

Cirrhosis is a major worldwide health problem which results in a high level of morbidity and mortality. Patients with cirrhosis who require intensive care support have high mortality rates of near 50%. The goal of this review is to address the management of common complications of cirrhosis in the ICU. Recent epidemiological studies have shown an increase in hospitalizations due to advanced liver disease with an associated increase in intensive care utilization. Given an increasing burden on the healthcare system, it is imperative that we strive to improve our management cirrhotic patients in the intensive care unit. Large studies evaluating the management of patients in the intensive care setting are lacking. To date, most recommendations are based on extrapolation of data from studies in cirrhosis outside of the ICU or by applying general critical care principles which may or may not be appropriate for the critically ill cirrhotic patient. Future research is required to answer important management questions.

Evaluation of the intensive care management of patients with spinal cord trauma

Spine traumas and the resulting spinal cord injuries are among the most important health problems with their physical and psychosocial impacts due to significant mortality and morbidity. Our objective in this study was to evaluate the issues that should be taken into consideration during the intensive care treatment management of patients monitored for spinal cord trauma. Patient files were examined for obtaining the demographic and clinical properties of 68 patients followed up with spine trauma diagnosis at the Intensive Care Unit during the dates of June 2011- 2016. Age, gender, cause of trauma, trauma localization, trauma injury accompanying the spine trauma, deep vein thrombosis development, infection development, ASIA (American Spinal Injury Association) score, duration of intensive care stays, and properties were examined. An evaluation was made in our study according to ASIA scoring as a result of which it was determined that there are 4 ASIA A patients (5.88%) hospitalized or discharged, 5 ASIA B patients (7.35%), 14 ASIA C patients (20.58%), 24 ASIA D patients (35.29%) and 5 ASIA score E (neurologically intact) (7.35%) patients, while mortality rate was determined as 16 patients (23.52%). It was determined as a result of the evaluation carried out with regard to post-trauma intensive care unit length of stays that the average length of stay was 21.3 days with the shortest length of stay as 1 day and the longest as 96 days. Care attributes should be familiar for this patient group that requires a multidisciplinary approach and serious rehabilitation and a sufficient level of knowledge should be reached by all those involved in the follow-up procedure.

Critical care management of the patient with cirrhosis awaiting liver transplant in the intensive care unit.

Patients with cirrhosis who are awaiting liver transplantation (LT) are at high risk for developing critical illnesses. Current liver allocation policies that dictate a "sickest first" approach coupled with a mismatch between need and availability of organs result in longer wait times, and thus, patients are becoming increasingly ill while awaiting organ transplantation. Even patients with well-compensated cirrhosis may suffer acute deterioration; the syndrome of acute-on-chronic liver failure (ACLF) results in multisystem organ dysfunction and a marked increase in associated short-term morbidity and mortality. For patients on transplant waiting lists, the development of multisystem organ failure may eliminate candidacy for transplant by virtue of being "too sick" to safely undergo transplantation surgery. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (eg, infection and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo LT. Management of the critically ill ACLF patient awaiting transplantation is best accomplished by multidisciplinary teams with expertise in critical care and transplant medicine. Such teams are well suited to address the needs of this unique patient population and to identify patients who may be too ill to proceed to transplantation surgery. The focus of this review is to identify the common complications of ACLF and to describe our approach management in critically ill patients awaiting LT in our centers. Liver Transplantation 23 1465-1476 2017 AASLD.

Neurosurgical and Intensive Care Management of Traumatic Brain Injury.

Optimal management of patients with traumatic brain injury (TBI) remains a challenge, despite significant improvements in pathophysiologic understanding and treatment strategies in recent decades. Because primary brain injury sustained at the time of trauma is irreversible, the TBI management mainly aims for early detection and treatment of secondary brain injury such as space-occupying intracerebral hematomas and brain edema. Prevention of secondary brain injury requires a high standard of care and understanding of both medical and surgical treatment modalities. This review focuses on practical recommendations for neurosurgical and intensive care management in patients with severe TBI.

Anaesthetic management of cytoreductive surgery followed by hyperthermic intrathoracic chemotherapy perfusion

BackgroundMacroscopic cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is a new multimodal approach for selected patients with primary and secondary pleural tumors, which may provide the patient with better local tumor control and increased overall survival rate.MethodsWe present a single-center study including 20 patients undergoing cytoreductive surgery and HITHOC between September 2008 and April 2013 at the University Medical Center Regensburg, Germany. Objective of the study was to describe the perioperative, anaesthetic management with special respect to pain and complication management.ResultsAnaesthesia during this procedure is characterized by increased intrathoracic airway and central venous pressure, hemodynamic alterations and the risk of systemic hypo- and hyperthermia. Securing an adequate intravascular volume is one of the primary goals to prevent decreased cardiac output as well as pulmonary edema. Transfusion of packed red blood cells (PRBC) was necessary in seven of 20 (35%) patients. Only two patients (10%) showed an impairment of coagulation in postoperative laboratory analysis. Perioperative forced diuresis is recommended to prevent postoperative renal insufficiency. Supplementary thoracic epidural analgesia in 13 patients (65%) showed a significant reduction of post-operative pain compared with peroral administration of opioid and non-opioid analgesics.ConclusionThis article summarizes important experiences of the anaesthesiological and intensive care management in patients undergoing HITHOC.

Bronchoscopy-guided decannulation of tracheostomy in patients with brain injury

Progress in intensive care management of patients with severe brain injury due to trauma or vascular lesion significantly improved the mortality and increased the number of patients with tracheostomy who undergo treatment in rehabilitation departments. The aim of the authors was to describe the safe tracheostomy decannulation method of patients with brain injury during rehabilitation. A prospective, descriptive study performed at the rehabilitation departments of the National Institute for Medical Rehabilitation in Budapest, Hungary. From January 1 until December 31, 2013, thirty examinations with flexible bronchoscope for tracheostomy decannulation were performed in 20 patients. The patients were admitted to the rehabilitation wards with various brain injuries: 6 patients suffered from trauma, 5 had ischemic stroke, 3 patients had brain stem haemorrhage, 2 patients cerebellar and one patient bifrontal haemorrhage. One patient had menangioma, and one had multiple organ failure and anoxic brain injury caused by pneumonia. The average age of patients was 44 years (range, 18-80 years). During the procedure successful decannulation was performed in 13 patients. Decannulation occurred 62 days after tracheostomy on average. Safe patient care requires that various medical departments keep pace with the development of different specialities. To ensure early rehabilitation of patients with severe brain injury having tracheostomy, safe treatment and, if possible, decannulation should be performed. This procedure requires the involvement of a physician with bronchoscopy skills as well as the development of local protocols.

Management of Severe Hypercapnia Post Cardiac Arrest with Extracorporeal Carbon Dioxide Removal

Normocapnia is recommended in intensive care management of patients after out-of-hospital cardiac arrest. While normocapnia is usually achievable, it may be therapeutically challenging, particularly in patients with airflow obstruction. Conventional mechanical ventilation may not be adequate to provide optimal ventilation in such patients. One of the recent advances in critical care management of hypercapnia is the advent of newer, low-flow extracorporeal carbon dioxide clearance devices. These are simpler and less invasive than conventional extracorporeal devices. We report the first case of using a novel, extracorporeal carbon dioxide removal device in Australia on a patient with out-of-hospital cardiac arrest where mechanical ventilation failed to achieve normocapnia.