Intensive Care Unit Team Research Articles

Improving Care Near the End of Life

A 56-year-old smoker with chronic obstructive pulmonary disease develops pneumonia and respiratory failure and is placed on mechanical ventilation. He dies 2 weeks later, after a stormy intensive care unit (ICU) course complicated by gastrointestinal bleeding and septic shock. The next morning, the ICU team questions how such a series of events occurred. Although each intervention could be justified as a response to a treatable complication, did the team truly consider the patient's overall prognosis or determine whether he really wanted such aggressive care? See also p 1591. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) intervention described in this issue ofThe Journalattempted to prevent such high-technology deaths.¹The SUPPORT investigators are to be congratulated on a rigorous, complex project. Yet, despite their best efforts in this multicenter randomized clinical trial, the intervention failed to improve any of the study outcomes.

Samuel — the boy with tonsillitis. A care study

Portsmouth is a nine-bedded mixed adult and paediatric general intensive care unit (ICU) There is great controversy about nursing children in adult ICUs but it occurs. The aim in this care study is to show how this problem was approached in one instance and how care could have been improved. Samuel was a 13-month-old boy who presented to his general practitioner (GP) with a 2-day history of feeling unwell, miserable and lethargic. The GP provisionally diagnosed epiglottis and referred him to the paediatric unit at St Mary's Hospital. The diagnosis was later changed to severe tonsillitis. His condition deteriorated over 24 h and he was referred to the intensive care unit (ICU) team, intubated and admitted to the ICU. Betty Neuman's systems model (Aggleton & Chalmers 1989) was used as a basis for Samuel's care. This incorporates the physiological, psychological, socio-cultural, developmental and spiritual aspects of an individual's needs. In Samuel's case this involved care of his family as well as himself. All names have been changed to protect the individuals involved.

Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations.

Hospitalized patients outside of the operating room frequently require emergency airway management. This study investigates complications of emergency airway management in critically ill adults, including: (1) the incidence of difficult and failed intubation; (2) the frequency of esophageal intubation; (3) the incidence of pneumothorax and pulmonary aspiration; (4) the hemodynamic consequences of emergent intubation, including death, during and immediately following intubation; and (5) the relationship, if any, between the occurrence of complications and supervision of the intubation by an attending physician. Data were collected on consecutive tracheal intubations carried out by the intensive care unit team over a 10-month period. Non-anesthesia residents were supervised by anesthesia residents, critical care attending physicians, or anesthesia attending physicians. Two hundred ninety-seven consecutive intubations were carried out in 238 adult patients. Translaryngeal tracheal intubation was accomplished in all patients. Intubation was difficult in 8% of cases (requiring more than two attempts at laryngoscopy by a physician skilled in airway management). Esophageal intubation occurred in 25 (8%) of the attempts but all were recognized before any adverse sequelae resulted. New infiltrates suggestive of pulmonary aspiration were present on chest radiography after 4% of intubations. Seven patients (3%) died during or within 30 min of the procedure. Five of the seven patients had systemic hypotension (systolic blood pressure < or = 90 mmHg), and four of the five were receiving vasopressors to support systolic blood pressure. Patients with systolic hypotension were more likely to die after intubation than were normotensive patients (P < 0.001). There was no relationship between supervision by an attending physician and the occurrence of complications. In critically ill patients, emergency tracheal intubation is associated with a significant frequency of major complications. In this study, complications were not increased when intubations were accomplished without the supervision of an attending physician as long as the intubation was carried out or supervised by an individual skilled in airway management. Mortality associated with emergent tracheal intubation is highest in patients who are hemodynamically unstable and receiving vasopressor therapy before intubation.

Patterns of prescribing and administering drugs for agitation and pain in patients in a surgical intensive care unit

To describe the variety of medications prescribed along with the doses administered and routes of administration, and to delineate the clarity of orders written and the accuracy of transcription of drugs used for sedation, anxiety, pain, and neuromuscular blockade in a surgical intensive care unit (ICU). A prospective, observational study of drug-related information collected from forms used by physicians and nurses. Three adult surgical ICUs at an academic medical center. Patients were admitted to a surgical service and co-managed by the surgical ICU team and primary surgical service. Consecutive patients admitted to all of these units from September 1992 to January 1993. None. Information on prescribing and administering sedatives, analgesics, and neuromuscular blocking drugs was obtained from data collected on 221 patients. A total of 202 (91%) patients received, on average, 1.9 +/- 1.4 study drugs (range 0 to 9) in a wide variety of combinations. There were 2,103 total doses administered from 448 drug orders. Ninety percent of study drug orders were written for administration on an "as-needed" basis; in 42% of these orders, the indication for use was not specified. On average, only 27% of the maximal allowable daily dose was administered; this number ranged from 15% for hydromorphone to 77% for chlordiazepoxide. Morphine sulfate, the most commonly prescribed drug, was ordered primarily for intravenous administration in 84% of patients. Morphine sulfate was prescribed using 19 different doses (written as a range of doses) and 13 different dosing intervals. Transcription discrepancies were observed in 17% of orders. In 2.7% of doses, the actual dose that was administered could not be determined. A wide variety of sedatives and analgesics are frequently used in surgical ICU patients. These agents are often ordered on an "as-needed" basis using a range of doses, sometimes without adequate directions about the indication for their use. Daily doses received are significantly less than their maximum allowable daily doses. Orders for these medications are sometimes transcribed and charted incorrectly. In contrast, neuromuscular blocking agents are not commonly prescribed. Future studies are needed to improve order writing of these agents, and to determine the criteria used by physicians and nurses in the selection and administration of these agents, the outcomes of therapy, and the most cost-effective regimen.

Prehospital Treatment with Dobutamine

AbstractPurpose:To assess the effectiveness of the use of dobutamine hydrochloride in out-of hospital emergency situations.Population:Patients with severe circulatory insufficiency caused by acute illness or injury encountered by the Mobile Intensive Care Unit of Copenhagen (population 467,000) during a 15-month study period.Methods:A newly developed dobutamine solution was administered by infusion pump to patients in whom normal emergency treatment failed to restore an acceptable circulatory state.Results:A total of 40 patients were treated with 4–48 μg dobutamine/kg/minute. The treatment was judged to be primary life-saving in 15 patients, the condition was improved in 16 patients, and nine patients died. Systolic blood pressures (in those who survived) rose from a mean value of 45 mmHg (range 0–80 mmHg) to 105 mmHg (range 65–180 mmHg). No tachycardia or arrhythmias were noted.Conclusion:This newly developed dobutamine solution is very useful in prehospital treatment of patients with circulatory failure and is recommend for use by mobile intensive care unit teams.

Establishing and Justifying Specialized Teams in Intensive Care Units for Nutrition, Ventilator Management, and Palliative Care

The team concept should be better appreciated and used as a tool for managing or solving problems in the ICU. If teams are designed improperly or employed inappropriately, however, they can easily fragment care and interfere with efficiency. Formally rounding with three or four teams a day is bound to lead to chaos and is impractical, but the team can be used to generate multidisciplinary protocols that reduce the need for formal face-to-face interaction. The team also can be convened when problems arise. In all three areas discussed in this article, specific teams were carefully formed in response to perceived problems in patient care. A great deal of attention was paid to determining the problems, and approaches were designed to resolve them in the most expedient manner possible. The results reported from all three types of teams are impressive. The team approach also has an unmeasured beneficial effect on staff morale. Although much of this discussion is intuitive, it must be emphasized that the types of interactions described in this article and the resulting positive outcomes happened not by accident, but by careful and conscious design. More research is needed in critical care areas to best define how to optimize the use of personnel. After all, volumes of data are generated on drugs, technologies, and other medical issues that often show little, if any, impact on outcome. The human component of the ICU is by far the most valuable and expensive commodity; we can ill afford to misapply it.

Guardian: A prototype intelligent agent for intensive-care monitoring

Effective monitoring of device-supported patients in the intensive care unit (ICU) is complex, involving interpretation of many variables, comparative evaluation of many therapy options, and control of many patient-management parameters. Even skilled clinicians make errors that limit the quality of care, harm patients, or cause life-threatening situations. A growing body of research aims to improve ICU monitoring with computer technology. Most of this research falls in two areas: (a) short-term engineering of practical solutions to narrowly defined immediate problems (e.g. smart alarm systems); or (b) basic research on fundamental issues potentially relevant to ICU monitoring (e.g. temporal reasoning). By contrast, our project aims to develop a more comprehensive ‘intelligent agent’, having a broad range of capabilities, to cooperate on the ICU team. We do not aim to produce a practical system suitable for near-term deployment in the ICU, but rather a ‘proof of concept’, an experimental system that: (a) demonstrably performs and coordinates a range of intelligent reasoning tasks of use in ICU monitoring; (b) does so reliably in a significant range of medical situations; and (c) arguably will scale up to meet the comprehensive set of practical requirements with an appropriate development effort. We have developed an experimental system called Guardian, which exhibits several of the required capabilities and utilizes an underlying architecture hypothesized to support the full range of required capabilities. In this paper, we describe the Guardian system, its architecture, and its current knowledge base. We describe its performance and summarize the results of preliminary evaluations. Finally, we discuss ongoing and planned research on Guardian.

Facing Tragic Decisions With Parents in the Neonatal Intensive Care Unit: Clinical Perspectives

Withdrawing a neonate's life supports and limiting resuscitation efforts are among the most complex, tragic, and stressful decisions faced by parents and physicians. There is an extensive body of literature discussing ethical and legal implications of such decisions.1-8 There is also a substantial body of literature on parental grieving, the risks of long-term depression and family dysfunction,9-12 and the inevitable stress on the pediatric team when dealing with critically ill infants.13-20 However, despite all that has been written, our own review has found little that addresses the clinical and psychological questions that the physician and family must face together during the several intense and intimate meetings where they actually decide to withdraw life support or limit resuscitation efforts. These questions will be most relevant for the senior members of the neonatal intensive care unit (NICU) team and should be part of the training of pediatric house officers, although the underlying principles are relevant to many of the decisions made by a pediatrician and family. For the purposes of this discussion we will assume that the appropriate legal and ethical standards are being observed in terms of the substance of the decision and will focus on the clinical process of physician-family decision making. We expect that technology will necessitate ongoing revisions of the legal/ethical guidelines but that the clinical goals of decision making will remain interpersonal, intimate, humane, respectful, and sensitive to long-term emotional concerns. The clinical context is loss. Grief replaces the family's hopes for a happy, healthy baby, their expectations of bringing a new baby into their home, and the dreams that come with raising this child.

Decision making to cease or to continue cardiopulmonary resuscitation (CPR)

CPR should be initiated in any patient who has a cardiac arrest. This might improve overall outcome but implies that CPR is started in patients without any virtual chance for long-term survival (LTS). The aim of this study is, by analysing retrospectively 2713 out-of-hospital cardiac arrests (CA), to identify indices which might be of help in the decision making to continue or to discontinue CPR. In an important number of unsuccessful CPR attempts ALS-time did not exceed 20 min. This occurred more frequently in subgroups where limited chances of LTS are expected on clinical grounds. The decision to cease CPR might have been based on other clinical and/or ethical parameters which were not recorded in the registry. This behavior results in a "self-fulfilling prophecy". A subset of patients with limited chances for LTS (0/405) can be identified: patients in electromechanical dissociation (EMD) or asystole on arrival of the mobile intensive care unit (MICU) team, without pupil reaction to light during CPR and with inefficient cardiac massage by the MICU (405/2713). Other patients in EMD or asystole without pupil reaction to light during CPR (1373/2713) but with efficient ECC should be resuscitated for more than 30 min, especially if the patient is gasping during CPR (LTS 27/1373). Patients in EMD or asystole on arrival of the MICU with pupil reaction to light during CPR (236/2713) should have an ALS-time of at least 45 min (LTS 42/236). Cardiac arrests in ventricular fibrillation (VF) (699/2713) should be resuscitated for at least 45 min, especially when gasping during CPR (LTS 119/699).

Role of the physiotherapist in the intensive care unit

Most intensive care units (ICUs) will have at least one physiotherapist attached to the team. Some ICUs will have physiotherapists who work only in these units and become closely involved with the team. In other hospitals physiotherapists visit ICUs as members of the referring specialty teams. Each method of staffing has its advantages and disadvantages. The physiotherapists always consider themselves as members of the ICU team and close co-operation with all members brings about the best results for the patients. The physiotherapy management of the patient in an ICU is concerned with the well-being of the whole patient. While the patient is in the ICU the physiotherapist will be treating the problems that are presented there but will also have a responsibility to reduce the long-term problems that could arise from a period of immobility.

Coping With Caring for Sick Newborns

Caring for critically ill newborn infants is physically, intellectually, and emotionally demanding. Care providers who learn to cope with the myriad stresses in a busy neonatal intensive care unit benefit their patients, their co-workers, and themselves. Those who adapt poorly to this taxing environment soon experience burnout, which Marshall defines as loss of motivation for creative involvement. This volume addresses the nature of the stresses inherent in caring for sick infants, as experienced by various members of the multidisciplinary health care team, and strategies for coping with these stresses. Nurses, physicians, and social workers who serve sick infants and their families have detailed practical recipes for work satisfaction and stress management, and experiences and philosophies from which these approaches are derived. This aspect of the book, by representatives of the neonatal intensive care unit team as traditionally defined, is done very well; accepted material is reviewed thoroughly and a few

Clinician Choice of Direct Laryngoscopy vs Video Laryngoscopy for Emergency Airway Management

Introduction: Emergency department (ED) and intensive care unit (ICU) teams are responsible for the care of a population which is especially vulnerable to conditions requiring immediate and decisive airway control. Our study aimed to determine if physicians performing emergency intubations will choose direct laryngoscopy or video laryngoscopy more frequently, and which intubator or intubation factors influenced the decision to choose direct versus video laryngoscopy.Methods: Emergency intubations occurring in hospital were recorded via an operator-completed survey following emergency intubations.Results: 51 cases were captured, 32 in the ICU, 16 in the ED, and 3 on regular wards. The direct laryngoscope was the first choice of device 32 times (63%) and the Glidescope videolaryngoscope 16 times (31%). A Glidescope was used to “rescue” failed direct intubations 8 times; a direct laryngoscope was used to rescue failed glidescope intubations twice. Intubators were more likely to choose the Glidescope for intubations which they predicted to be difficult. Both modalities were chosen across all levels of training and every specialty, with the exception that all emergency physicians chose direct laryngoscopy first. Conclusion: Physicians working in high acuity care environments use both direct laryngoscopy and Glidescope video laryngoscopy to intubate. The Glidescope video laryngoscope was chosen more frequently than direct laryngoscopy when intubation was predicted to be difficult, and despite this was successful in a greater number of cases (92% vs 71%) in our study. Both devices had notable failure rates, emphasizing the importance of ubiquitous training in both techniques and access to both devices.