Intensive Care Ward Research Articles

Фармакоэкономическая оценка интермиттирующей и продолжительной заместительной почечной терапии

Lately, in Russia, the number of patients with severe stage of acute renal failure requiring renal replacement therapy is increasing. Intermittent hemodialysis is the most common type of this therapy, however, the continuous methods of renal replacement therapy also started to be more often used in clinical practice despite of their high basic cost. The subject of this study is to investigate of pharmaco-economic results reflecting direct medical and indirect non-medical costs when using these technologies versus the maximum effective use of funds while treating patients with severe renal dysfunctions. Objective: to perform comparative clinical and economic analysis of intermittent and continuous renal replacement therapy in the intensive care wards of medical units in Russia. Methods. The study was conducted in compliance with acting Standards on Clinical Economic Studies used in Russian Federation. The study methods included evaluation of existing randomized clinical studies and trials which included data from network meta-analyses and systematic reviews of the investigated technologies. The direct medical and indirect non-medical costs were calculated and analyzed in respect of cost-effectiveness and costs-utility and budget impact analyses, utility, expressed in the number of saved quality-adjusted life years. Result: Simulation and comparative healtheconomic analysis of intermittent (IRRT) and continuous (CRRT) renal replacement therapy showed that the use continuous (CRRT) renal replacement therapy resulted in reduction of direct medical and indirect non-medical costs even within the first year. By the end of the third year savings can achieve 341,129.5 RUR per patient, and of this amount, savings in direct medical costs show 279,646.3 RUR and savings of indirect non-medical costs show 61,483.1 RUR. Budget impact analysis identified that using continuous renal replacement therapy (CRRT) allowed to save more than 230 million RUR for the whole country during 3 years per 1,740 patients with acute renal failure. Conclusion: Despite its high initial costs, the use of CRRT results in the reduction of costs and maximum efficient use of funds, and thus CRRT can be recommended for wider use in the Russian practice.

Utilization of a clinical microbiology service at a Cambodian paediatric hospital and its impact on appropriate antimicrobial prescribing.

BackgroundAntimicrobial resistance threatens human health worldwide. Antimicrobial misuse is a major driver of resistance. Promoting appropriate antimicrobial use requires an understanding of how clinical microbiology services are utilized, particularly in resource-limited settings.ObjectivesTo assess the appropriateness of antimicrobial prescribing and the factors affecting utilization of the established clinical microbiology service (CMS). The CMS comprises the microbiology laboratory, clinical microbiologists (infection doctors) and antimicrobial treatment guidelines.MethodsThis mixed-methods study was conducted at a non-governmental Cambodian paediatric hospital. Empirical and post-culture antimicrobial prescriptions were reviewed from medical records. The random sample included 10 outpatients per week in 2016 (retrospective) and 20 inpatients per week for 4 weeks in the medical, neonatal and intensive care wards (prospective). Post-culture prescriptions were assessed in patients with positive blood and cerebrospinal fluid cultures from 1 January 2014 to 31 December 2016. Focus group discussions and semi-structured interviews with clinicians explored barriers and facilitators to use of the CMS.ResultsOnly 31% of outpatients were prescribed empirical antimicrobials. Post-culture prescriptions (394/443, 89%) were more likely to be appropriate than empirical prescriptions (447/535, 84%), based on treatment guidelines, microbiology advice and antimicrobial susceptibility test results (P = 0.015). Being comprehensive, accessible and trusted enabled CMS utilization. Clinical microbiologists provided a crucial human interface between the CMS and physicians. The main barriers were a strong clinical hierarchy and occasional communication difficulties.ConclusionsAntimicrobial prescribing in this hospital was largely appropriate. A culturally appropriate human interface linking the laboratory and physicians is essential in providing effective microbiology services and ensuring appropriate antimicrobial prescribing in resource-limited settings.

Nasogastric tube checks: Is the recommended pH cut-off safe? Accuracy and intra-rater reliability of pH readings

The National Patient Safety Agency guidelines recommend that nasogastric (NG) tubes are safe to use if the aspirate pH is ≤ 5.5. However, our trust has had two “never events” in the last two years where patients have been fed into a bronchially placed tube when the aspirate pH was reported as 5. Tracheobronchial secretions have been found to have a mean pH of 7.64 and the probability of bronchial placement of an NG tube with pH ≤ 5.5 is 0% [1,2]. There is limited data on nurses’ accuracy in reading pH paper [3,4] and intra-rater reliability does not seem to have been assessed. The aim of this study was to assess accuracy and intra-rater reliability of pH paper readings by nurses. Forty nurses tested three, undisclosed, standardised solutions (pH 1.6, 4 and 7) in a random order using MerckSerono pH indicator strips. Exact and adjacent (pH within 0.5) agreement were assessed for pH 1.6 and 4, but not for pH 7 as the pH strips read up to pH 6. The process was repeated by 32 of the nurses the following day to assess intra-rater reliability. The participating nurses worked in intensive care (n=11), surgical (n=21) and medical (n=8) wards and the majority were Band 5 (n=23) and permanent staff (n=37). None of the nurses were colour blind. Fourteen said they checked pH of NG aspirates on a daily basis, 16 less frequently than daily but at least once per week and 10 nurses less than once per week. Half of the nurses said they had been formally trained in NG position checks. Overall, 144 observations were analysed to determine accuracy (solutions of pH 1.6 and 4). Nurses demonstrated substantial accuracy (kappa=0.63) with 71% exact agreement and 85% exact and adjacent agreement. However, pH was under-estimated in four readings of the pH 1.6 solution and 18 readings of the pH 4 solution. Accuracy of pH readings was significantly greater for nurses on medical wards (p=0.02) and those with previous training in NG position checks (p=0.01). A pH was assigned in all 72 observations of the pH 7 solution with a range of answers given: pH 3.5 (n=1), pH 5.5 (n=2), pH 6 (n=47) and pH >6 (n=22). Substantial intra-rater reliability was demonstrated (kappa=0.77) with 84% exact agreement and 94% exact and adjacent agreement. There were no significant factors influencing intra-rater reliability. Overall intra-rater reliability is good, however there are issues with accuracy of pH readings. As bronchial secretions have a minimum pH of 6, exact agreement is required at this level. Under-estimation, which occurred in 15% of readings (pH 1.6 and pH 4 solutions), may result in harm. Although this may be addressed by training, which improved accuracy in this study, other strategies may need to be adopted as only half of this cohort had been formally trained despite widespread teaching programmes across the trust. Further consideration should be given to the use of pH meters or lowering the pH threshold for feeding without x-ray, but this poses other issues including radiation exposure, delays in feeding whilst awaiting imaging and difficulties with x-ray interpretation.

Noninvasive ventilation in pediatric acute respiratory failure

ZusammenfassungAkutes Atemversagen kann auch im Kindesalter mit nichtinvasiver Beatmung (NIV) behandelt werden. In den letzten Jahren wurden die technischen Voraussetzungen der NIV-Beatmungsgeräte für das Kindesalter verbessert, zudem steht heutzutage eine größere Auswahl an konfektionierten nasalen und Full-face-Masken für Kinder ab dem Säuglingsalter als Interface zur Verfügung. Vor allem Kinder mit hyperkapnischem Atemversagen profitieren von der NIV. Evidenz für Vorteile der NIV besteht für die Bronchiolitis, Asthma sowie für das „Acute-on-chronic“-Atemversagen, d. h. ein Atemversagen bedingt durch eine akute Infektion bei einer zugrunde liegenden neuromuskulären Erkrankung, Zerebralparese oder einer chronischen Lungenerkrankung wie der zystischen Fibrose. Nichtinvasive Beatmung ist bei prolongiertem Weaning von invasiver Beatmung und bei Fehlbildungen des oberen Atemwegs hilfreich. Alveoläre Erkrankungen mit vorwiegend hypoxämischem Atemversagen wie ambulant erworbene Pneumonien oder das „acute respiratory distress syndrome“ (ARDS) stellen keine Indikationen für die NIV dar. Aufgrund relevanter möglicher Nebenwirkungen und der Möglichkeit der schnellen Verschlechterung des Gasaustauschs bei NIV-Versagen sollte die NIV auf der pädiatrischen Intensivstation mit der Möglichkeit zu einem raschen Wechsel auf einen invasiven Beatmungszugang stattfinden.

Fecal Carriage of Carbapenem-Resistant Enterobacteriaceae and Risk Factor Analysis in Hospitalised Patients: A Single Centre Study from India

Purpose: Carbapenem-resistant Enterobacteriaceae (CRE) have emerged and disseminated widely causing a variety of infections. In India, the carriage of CRE in hospitalised patients has not been well-studied. Therefore, we conducted the present study to observe gut carriage rate of CRE in patients admitted to our tertiary care hospital. Methods: A total of 232 faecal swabs collected from consecutive stool samples from admitted patients were inoculated on ChromID extended spectrum β-lactamase plates and members of Enterobacteriaceae family were subjected to antibiotic susceptibility as per the Clinical Laboratory Standards Institute guidelines. Polymerase chain reaction for blaVIM, blaKPC, blaIMP and blaNDM-1 genes was performed. CRE was identified if the isolates showed resistance to either imipenem or meropenem or showed the presence of resistant genes. Risk factors of patients with or without CRE colonisation were also analysed. Results: A total of 232 faecal swabs yielded 252 Enterobacteriaceae isolates, of which 49 isolates from 42 patients showed the presence of CRE (occurrence 42/232; 18.1%); 27 isolates from 22 patients carried blaNDM-1, whereas 20 isolates from 17 patients possessed blaVIM gene. No isolate was positive for blaKPC and blaIMP genes. The CRE was common in both intensive care units (38.4%) and wards (46%) which may reflect the excessive use of broad-spectrum antibiotics in both these settings. The CRE was also found to have a significantly higher antimicrobial resistance as compared to non-CRE isolates. The logistic regression analysis of significance showed the presence of any indwelling device (P = 0.049) and nasogastric tube (P = 0.043) as independent risk factors for acquiring gut colonisation. Conclusions: The study is the first from India to show high CRE carriage in patients admitted to a tertiary care centre and emphasises the need of strict antimicrobial stewardship implementation in hospitals to prevent dissemination of multidrug-resistant CRE.

Study of Life Stressors and Suicidal Intent of Suicidal Attempters with or Without Axis 1 Psychiatric Comorbidities: A Case Control Study

Background: Suicide attempts and Psychiatric illness are interrelated in a complex and bi directional way such that either of them leaves an impact on the other. People with Psychiatric morbidity are at high risk of attempting suicide. Even though extensive research works have been done in suicide, there is a paucity of studies focusing the mentally ill attempters, especially with reference to Intent and Lethality. Hence the present study designed to study the various parameters , contributing factors and Risk factors associated with suicide attempts of patient with Axis I disorders. Aim: 1.To assess the life stressors and suicidal intent in suicide attempters with Axis I psychiatric disorders. 2. To assess the life stressors and suicidal intent in suicide attempters without Axis I psychiatric disorders. 3. Compare the life stressors and suicidal intent in suicide attempters with and without axis I disorders. Material and Methods: The study subjects of this case control study were recruited from the patients referred to the department of Psychiatry from Medicine, Surgical and Intensive care wards for Psychiatric evaluation.30 patients of attempted suicide who had Axis I diagnosis as per the ICD – 10 criteria were taken as cases and 30 age and sex matched patients were taken as controls. Results: 1.The suicidal intent is high in Suicide attempters with Axis I Disorders. 2. The lethality is high in Suicidal attempters with Axis I Disorders. 3. Stress factors play a major role in Suicide attempters with Axis I disorders.

Effect of Diabetes on Severity of Illness, Length of Hospital Stay and Mortality among Patients Brought by EMS

International Journal of Medicine and Public Health,2017,7,3,156-161.DOI:10.5530/ijmedph.2017.3.32Published:Aug 2017Type:Original ArticleEffect of Diabetes on Severity of Illness, Length of Hospital Stay and Mortality among Patients Brought by Emergency Medical System (EMS)Prasad Ananta Rajhans, Priya Yogesh Kulkarni, Dhananjay Shrakrishna Kelkar, Sameer Arvind Jog, Gouri Ranade, Sonal Utpat, and Varsha Hande Prasad Ananta Rajhans1, Priya Yogesh Kulkarni*2, Dhananjay Shrakrishna Kelkar3, Sameer Arvind Jog4, Gouri Ranade5, Sonal Utpat6, Varsha Hande7 1FICCM,Chief Intensivist, Deenanath Mangeshkar Hospital and research centre, Pune, INDIA. 2Community Medicine, SMBT Medical College, Nasik, Maharashtra, INDIA. 3Medical director, Deenanath Mangeshkar Hospital and research centre, Pune, INDIA. 4Consultant Intensivist, Deenanath Mangeshkar Hospital and research centre, Pune, INDIA. 5Consultant Intensivist, Deenanath Mangeshkar Hospital and research centre, Pune, INDIA. 6Head of Emergency Department, Deenanath Mangeshkar Hospital and research centre, Pune, INDIA. 7Senior Emergency medical officer, Deenanath Mangeshkar Hospital and research centre, Pune, INDIA. Abstract:Background: In view of growing epidemic of diabetes it is important to assess how it affects various parameters of the disease especially in developing countries. Aim: To compare severity of illness, length of various hos pital stays and mortality in diabetics and non-diabetics. Material and methods: It was hospital record based study carried out at Deena Nath Mangeshkar Hospital and research centre, Pune. Patients admitted to intensive care unit from 1st January 2013 to 31st December 2014 through emergency medical services were enrolled. Socio-demographic information, chief complaints, diabetes status, co-morbidities, Glasgow coma scale at initial examination, definitive diagnosis, and length of stay in intensive care unit, wards and total hospital stay and outcome of the patient were recorded from available data. Results: Data 1951 patients were analyzed. 37.6% were females, 62.4% were males. 45.8% were diabetics, out of them 28.81% were new cases. Though, co-morbidities were significantly more among diabetics, they were significantly less to have severe condition according to Glasgow coma scale (p=0.003). Diabetics had significantly less intensive care unit stay than non-diabetics (Mean 5.98 days (±6.579) vs 7.52 (±9.293) respectively, p=0.008). Ward stay and total hospital stay did not differ. Mortality did not differ among diabetics and non-diabetics (23.8% and 23.6% respectively, p=0.947). Conclusion: Though proportion of diabetics was very high among study subjects, diabetes did not contribute to any adverse outcome or length of hospital stay. Keywords:Diabetes (DM), EMS, Length of hospital stay (LOS), Severity of DMView:PDF (265.79 KB)

ОПРЕДЕЛЕНИЕ ПОДХОДОВ К ОПЛАТЕ МЕДИЦИНСКОЙ ПОМОЩИ ПО ПРОФИЛЮ «аНЕСТЕЗИОЛОГИЯ-РЕАНИМАТОЛОГИЯ» В УСЛОВИЯХ ПЕРЕХОДА НА НОВУЮ СИСТЕМУ ФИНАНСИРОВАНИЯ ЗДРАВООХРАНЕНИЯ

A new federal model of in-patient medical care funding provides payment for treatment basing on the average costs estimated when evaluating cases of certain diseases grouped together due to their similarity and types of the provided medical care (CSG system). The lack of differentiation does not allow full reimbursement of expenses of in-patient units occurring during treatment of the severely ill in the intensive care wards. Goal: to estimate risks of financial losses of units providing medical care to the patients with high chances of a complicated course of the disease when medical care is reimbursed within the system described above (CSG system) and to propose improvement of this system. Results. The article presents the results of joint work of the experts from Organizational Economic Committee of the Association of Anesthesiologists and Intensive Care Physicians and workers of St. Petersburg Regional Fund of Mandatory Medical Insurance aimed at the improvement of the medical care funding system based on the so-called clinical statistic groups (CSG). It was suggested splitting up certain clinical statistic groups into subgroups considering the need of patients in the intensive care and its content. The coefficients reflecting the content of costs were calculated for the identified subgroups. The offered approach was piloted during the project in St. Petersburg through estimating costs for a completed case in parallel with estimation as per the existing method of reimbursement related to medical economic standards. The obtained results proved that the offered approach allowed achieving better differentiation due to re-distribution of funds from less severely ill patients who required no treatment in the intensive care departments to the more severely ill. The data were submitted to Center of Expertise and Monitoring of Medical Care Quality in order to prepare suggestions to amend guidelines on medical care reimbursement by the Russian Ministry of Health. Conclusion. The article describes specific practical outcomes – the model was developed to be introduced for reimbursement of the in-patient care as per CSG system within mandatory medical insurance.

Development of Anaesthesia-Related Mortality and Impact On Perioperative Outcome

Achievements in anaesthesiology form the basis for the tremendous development of surgical therapy. Reliable monitoring technology, which is scrutinized on a regular basis using checklists, is allowing anaesthesia at the borders of physiology. During the last decades, anaesthesia-related mortality has been decreasing considerably. Well-trained anaesthesiology staff, who considers patient- and procedure-specific risks in anaesthetic management, is of major importance. Furthermore, postoperative care in specialised units and intensive care wards is a key factor of improved patient outcome after surgery. In the future, unravelling the interactions of anaesthesia, surgical trauma and postoperative complications will further contribute to improved patient safety.

The effect of periuretral care and follow-up on bacteriuria in patients with urinary catheter: A comparison of three solutions

Objective: The aim of this study was to compare urinary colonization rates in subjects whose periurethral area was cleaned with sterile water or tap water versus povidone-iodine before and after urinary catheter insertion. Patients and Methods: The study was conducted in intensive care, surgery and medical wards of a university hospital. The study assessed a total of 207 adult patients requiring urinary catheterization for bacteriuria. They were screened for eligibility by the supervising physician. 110 patients were excluded from the study. The study sample included a total of 97 patients. The only difference among the three groups was that sterile, tap water and povidone-iodine were used to clean the periurethral area. A urine specimen was collected immediately before and 72 hours after catheter insertion. Results: The povidone-iodine group patients had a mean age of 67.9±12 years, the mean of the sterile group patients was 66.3±14 years, and the mean of the tap water group patients was 63.5±12 years. The Chi-Square test revealed no inter-group difference for age groups (P=0.483). Urinary tract infections occurred in 18% of the total sample. The percentage of infection for povidone-iodine, sterile water and tap water groups was 22.2%, 38.9%, and 38.9% respectively. Conclusion: There were no significant differences in the rate of bacteriuria or urinary tract infections in the sterile water, tap water and povidone-iodine groups. Traditionally, povidone-iodine solutions have been used to clean the periurethral area is probably not useful than water solutions.

Detection of pathogenic bacteria and drug resistance analysis on children with pulmonary infection in ICU and respiratory ward

Objective To investigate the distribution and drug resistance of bacteria infection in children with pneumonia between pediatric intensive care ward and respiratory ward , in order to guide clinical treatment. Methods From 2010 January to 2014 January, two-hundred and sixty cases of pneumonia in hospitalized pediatric intensive care ward were included in the severe group, 300 patients from respiratory ward into the common group, severe group were divided into the mechanical ventilation group(126 cases), non mechanical ventilation(134 cases), mechanical ventilation were divided into invasive ventilation group(94 cases), noninvasive ventilation group(32 cases). Conventional sputum specimens were detected, bacterial culture, identification and drug resistance of pathogenic bacteria ratio were done in each case, to compare the pathogenic bacteria and drug resistance rate of different groups. Results Both severe group and common group , gram negative bacteria were significantly higher than those of gram positive, But in the severe group, gram negative bacteria ratio was significantly higher than the common group(P<0.05), while the positive bacteria ratio was significantly lower than that of common group(P<0.05). Stenotrophomonas maltophilia, Acinetobacter and Pseudomonas aeruginosa ratio in severe group were significantly higher than that of common group(P<0.05), while the Haemophilus influenzae and Streptococcus pneumoniae in common group was significantly higher than the proportion of severe group(P<0.05). Stenotrophomonas maltophilia, Acinetobacter, Pseudomonas aeruginosa ratio in ventilation group was significantly higher than that of non ventilation group(P<0.05), and in the invasive ventilation group was significantly higher than the proportion of noninvasive ventilation group(P<0.05). Multi drug resistant bacteria detection rate in severe group was significantly higher than the common group(P<0.05). Conclusion Both pediatric intensive care ward and respiratory ward , bacterial lung infections are dominated by Gram negative bacteria, but bacteria spectrum and drug resistance have obvious difference, multi drug resistant bacteria detection rate in pediatric intensive care ward significantly higher than that of respiratory ward.Mechanical ventilation especially invasive mechanical ventilation may easily lead to drug-resistant strains. Key words: Pediatric intensive care ward; Respiratory ward; Bacteria; Drug resistance

Evaluating effectiveness of infection control efforts in hospitals using information in microbiological laboratory databases.

PurposeTo analyze the quality of infection control activities, bacteriological data relevant to infection control was evaluated through the microbiological data warehouse networking hospitals in two medical regions.MethodsData regarding bacterial test results of 19 hospitals were extracted from two microbiological laboratory information data bases. The rate of MRSA among total S. aureus was used as a general indicator of infection control activities. The occupancy rate of nasal or pharyngeal swabs among MRSA‐positive bacteriological samples was used as an indicator of attention paid for infection control in intensive care wards. The number of blood culture sets per examined patient was utilized as an indicator for life‐long vocational education on updated medical practice relevant to infectious diseases.ResultsThe rate of MRSA was significantly higher in secondary private hospitals. The occupancy rate of nasal or pharyngeal swabs was significantly higher in tertiary hospitals. The average number of blood culture set per examined patient were 1.55, 1.54 and 1.39 in tertiary, secondary public and secondary private hospitals, respectively; however, there were no statistical differences between groups.ConclusionsData bases of microbiological test results shared by hospital laboratories are useful for evaluating regional infection control activities.

David Ashbaugh reminisces

In 1964, while I was working as codirector of the University of Colorado's (Boulder, CO, USA) first intensive care unit (ICU), I saw my first case of what turned out to be acute respiratory distress syndrome. At the time, I was puzzled about a number of symptoms that I hadn't previously recognised. If the patient had been admitted in the time before intensive care wards and respirators, they would have died without the attending physician knowing why and how. This particular patient was one of the first admitted to a new ICU set up by Dr Thomas Petty and myself. We had just finished residencies in medicine and surgery, respectively, and had lobbied for and obtained the necessary funds and space. We had one primitive respirator to use on patients with respiratory failure. The patient was admitted as a surgical trauma patient to my service, with multiple fractures after an automobile accident. Despite major blood loss, he soon stabilised and had a normal chest x-ray despite a few broken ribs. Over the course of 48 h, he developed respiratory distress and was intubated and put on the respirator, which was run from the hospital wall oxygen supply on a pressure-controlled basis. Despite 100% oxygen and maximum pressure, his condition worsened and fluffy infiltrates appeared in both lungs. He proceeded to die of respiratory failure. The rapid onset fluffy infiltrates, increasing pressures that required us to ventilate the patient, and falling oxygenation puzzled me as I had not seen this in patients before. Over the following months I saw a couple of similar cases, and went to the library to see what I could find. At the time there was only one reported case of congestive atelectasis following trauma. I consulted with our pathologists and infectious disease specialists and we did find hyaline membranes and alveolar haemorrhage in our patient. Some months later I had borrowed an Engstrom respirator from our anaesthesia department. It was a volume-controlled device and superior to anything we had on our ICU. When a 12-year-old boy presented in the emergency room on a Saturday morning, I was called to come down as he was in severe respiratory distress and coughing up blood after being backed over by a pickup truck. I did an immediate tracheostomy and transferred him to the paediatric care unit. Tom Petty had recently obtained a new blood gas analyser and I learned how to operate it. I spent the morning running up and down four flights of stairs and watching the patient's arterial blood gas deteriorate as we suctioned more and more blood from his tracheotomy. He was attached to the new respirator and I noticed, off to the right hand side, a red dial labelled “end expiratory pressure”. I wondered if this might help and dialled in a moderate amount. Within minutes the bleeding slowed and then stopped and the arterial blood gas returned to normal limits. Over the next few days he was weaned from the respirator and made a complete recovery. While this was obviously a case of traumatic pulmonary contusion, it was still a case of severe respiratory distress and positive end expiratory pressure was clearly an effective treatment. Within 2 years we had collected 12 cases, which included three patients treated with positive end expiratory pressure. Getting the paper published was a struggle, and after four rejections from US-based journals, we submitted it to The Lancet, which not only accepted the paper, but published it on the basis of in-house review within 6 weeks. For the first description of ARDS see Lancet 1967; 290: 319–23 For the first description of ARDS see Lancet 1967; 290: 319–23

ПЕРВЫЙ КЛИНИЧЕСКИЙ ОПЫТ ПРИМЕНЕНИЯ КОЛОНОК ДЛЯ ЛПС-АДСОРБЦИИ «ТОКСИПАК» В ЛЕЧЕНИИ ПАЦИЕНТОВ С СЕПСИСОМ

Endotoxicosis is one of the main factors of the pathogenesis of multiple organic dysfunctions in gram-negative sepsis, induced by the accumulation of lipopolysaccharides - wall components of gram-negative bacteria. In vitro removal of them (LPS-adsorption) promotes better treatment outcomes in sepsis patients. Development and introduction of the Russian tools for LPS-adsorption becomes more crucial. Objective: to evaluate the efficiency and safety of the column of Toxipak for endotoxin removal, manufactured by POCARD Ltd. Materials and methods: 7 adult sepsis patients who had LPS-adsorption were included into the study. The changes of the following parameters were monitored in the patients: temperature, pulse, arterial pressure, respiration rate, central venous pressure, oxygen saturation, hourly rate of diuresis, oxygenation index was calculated, hematologic and biochemical blood parameters were tested as well as coagulation system rates, endotoxin level, C-reactive protein (CRP), procalcitonin, and interleukins (IL) 1, 6, 8. Criteria of the system inflammatory response and SOFA score were used for the comprehensive evaluation of clinical status. The adverse events, duration of stay in the intensive care ward and 18- and 24-day mortality were followed up during manipulations. Results: the studied column provided no negative effect on the cellular and biochemical composition, main parameters of clotting system and acid-base balance of blood. Its use resulted in the reduction of endotoxin (LPS) (by 64%), CRP (by 14%), IL-1 (by 38%) in blood, increase of oxygenation index, and renal function improvement. LPS adsorption promoted the reduction of clinical and laboratory signs of system inflammatory response, and severity of organ dysfunction (from 6.0 to 3.0 as per SOFA score) in patients with sepsis and septic shock. Conclusion: Toxipak column is safe and efficient for removal of endotoxins from blood.

Environmental noise levels in 2 intensive care units in a tertiary care centre

The World Health Organisation (WHO) has established a maximum noise level of 40 decibels (dB) for an intensive care unit. The aim of this study was to compare the noise levels in 2 different intensive care units at a tertiary care centre. Using a cross-sectional design study, an analysis was made of the maximum noise level was within the intensive coronary care unit and intensive care unit using a digital meter. A measurement was made in 4 different points of each room, with 5minute intervals, for a period of 60minutes 7:30, 14:30, and 20:30. The means of the observations were compared with descriptive statistics and Mann-Whitney U. An analysis with Kruskal-Wallis test was performed to the mean noise level. The noise observed in the intensive care unit had a mean of 64.77±3.33dB (P=.08), which was similar to that in the intensive coronary care unit, with a mean of 60.20±1.58dB (P=.129). Around 25% or more of the measurements exceeded the level recommended by the WHO by up to 20 points. Noise levels measured in intensive care wards exceed the maximum recommended level for a hospital. It is necessary to design and implement actions for greater participation of health personnel in the reduction of environmental noise.

ИНГАЛЯЦИОННАЯ СЕДАЦИЯ У ПАЦИЕНТОВ С СЕПСИС-АССОЦИИРОВАННЫМ ДЕЛИРИЕМ

Delirium in the intensive care ward is actively being discussed by anesthesiologists for a long period of time. However at present there are fairly scarce evidences on the efficiency of various techniques of prevention and management of this disorder. Goal of the research: to assess the impact of inhalation sedation on the intensity and duration of sepsis-associated delirium in the intensive care ward of the surgical hospital. Methods. The one-centered, prospective, randomized comparative study was conducted in order to assess the efficiency of inhalation sedation in the patients with sepsis-associated delirium. Propofol was used for the intravenous sedation in the control group. 187 adult patients, admitted to the intensive care ward of Vorokhobov City Clinical Hospital no. 67, were included into the study. Results. Inhalation sedation reduced the delirium duration compared to intravenous use of propofol: delirium was fully managed on the 5th day in the group where sevorane was used [4; 7], while in the group where propofol was used delirium lasted for 7 days [6; 8] (p = 0.03). The study did not detect any effect of inhalation sedation on the intensity of oxidative stress (level of oxidized peptides in the blood plasma of the patients) and degree of neuronal damage (differences between groups are not significant, p = 0.37). No differences were recorded in the value of procalcitonin and SOFA score at any stage of the study. Conclusion. The frequency of delirium in the mixed population of sepsis patients makes 27.9%. Use of inhalation sedation with sevoflurane compared to intravenous administration of propofol reduces the duration of delirium therapy from 7 to 5 days.

Elderly Trauma Patients Do Well in Non-ICU Wards

CORONADO, CA — When elderly patients are appropriately triaged, they can be selectively admitted to non–intensive care wards with acceptable outcomes, results from a single-center study showed. “Trauma centers across the United States are caring for elderly trauma patients with greater frequency,” researchers led by Marc D. Trust, MD, wrote in an abstract presented during a poster session at the annual meeting of the Western Surgical Association. “Previous literature showed improved outcomes in this population from aggressive care and invasive monitoring. This may have led to an increased utilization of intensive care resources for these patients,” they noted. Dr. Trust, a surgery resident at the University of Texas at Austin, and his associates retrospectively reviewed the medical records of 3,682 trauma patients 65 and older who were admitted from 2006 to 2015. They compared demographic data and outcomes between patients admitted to the ICU and those admitted to the surgical ward. The primary endpoint was mortality, while secondary endpoints were transfer to higher level of care and hospital length of stay. The mean age of the 3,682 patients was 76 years; 1,838 (50%) were admitted to the ICU, while the remaining 1,844 (50%) were admitted to the surgical ward. When the researchers compared patients admitted to the ICU with those admitted to the surgical ward, they observed significant differences in mortality (7% vs. 0.82%, respectively), as well as systolic blood pressure on admission (146 vs. 149 mm Hg), pulse (85 vs. 81 beats per minute), Glasgow Coma Scale (14 vs. 15), Injury Severity Score (16 vs. 8), and hospital stay (a mean of 8 vs. 4 days). In addition, fewer than 1% of patients admitted to the surgical ward required transfer to a higher level of care. Doug Brunk is with the San Diego bureau of Frontline Medical News.

The relationship between professional autonomy and moral distress among nurses working in children's units and pediatric intensive care wards

BackgroundNurses serve as the primary source of care for minor patients in intensive care units. Even though they support both patients and their relatives, these nurses may experience moral distress from their profession. While managing their daily relationships with their patients, nurses must also be able to control their actions to feel that they are from a social unit and feel their competence in association with others. ObjectiveThis study aimed to investigate the relationship between professional autonomy and moral distress among nurses working in children's units and pediatric intensive care wards. MethodsThis descriptive/comparative cross-sectional study was conducted in 2015 using 120 nurses as subjects. Subjects were selected using the census method. The research tools used to gain measurable data were the Pankratznursing questionnaire(PNQ) and Corley'sMoral distress scale (MDS). In order to analyze the collected data, descriptive statistic tests such as the relative frequency distribution, mean, standard deviation and the Pearson correlation test, T-test, ANOVA, and regression were used. The SPSSv.20 software was also used to analyze the data obtained. ResultsThe relationship between professional autonomy and moral distress revealed that there was a significant positive relationship between professional autonomy and moral distress in the intensity (r = 0.39; P < 0.001) and the iteration (r = 0.41; P < 0.001). In addition, professional autonomy predicted 18% of changes in intensity of moral distress in total(MR = 0.42, R2 = 0.18) and also professional autonomy predicted 25% of iteration in moral distress in total(MR = 0.507, R2 = 0.25). ConclusionsThe results of this study revealed that there was a direct positive relationship between professional autonomy and moral distress.

ANESTHETIC MANAGEMENT OF ENDOSCOPIC ENDONASAL SURGERIES IN PEDIATRIC ONCOLOGY

Treatment of children with tumors of the nasal cavity and the base of the skull is an urgent issue in both surgery and anesthesiology. First of all, it is related to the anatomical and physiological characteristics of children, as well as to the localisation of tumors in the anatomical zone surrounded by important anatomical structures (internal carotid arteries and their branches, cavernous sinus, orbit). Currently, such tumors are removed by the endoscopic endonasal method. Considering anesthetic support of such surgeries, the issues of upper respiratory tract protection, correction of systemic hemostasis disorders, adequate analgesia, prevention of postoperative complications (postoperative nausea and vomiting, postoperative cognitive dysfunction (delirium), delayed bleeding) are the most importrant. Adequate anesthetic support in pediatric ENT surgery is the most important factor determining the patient’s safety and psychophysiological comfort, improving the quality of treatment and hospitalization. Materials and methods . From July 2016 to March 2017 27 endoscopic endonasal surgeries were performed. The age of patients was from 39 days to 17 years, the median age was 6.6 years. Types of surgeries: 18 out of 27 (66.7%) cases — resection of the tumor, 9 out of 27 (33.3%) — biopsy. Multicomponent anesthesia was conducted according to the protocol presented. The parameters of hemodynamics, the incidence of complications in the perioperative and postoperative periods were recorded. Results . Hemodynamically stable course of anesthesia without significant fluctuations in mean arterial pressure and heart rates was noted at all the stages of surgeries. The terms of observation of patients after surgery in the intensive care ward — from 1 to 3 days, median — 1.2 days. There were no cases of delayed postoperative hemorrhage. Episodes of excitement, postoperative delirium were registered in 4 (14.8%) cases. Postoperative nausea and vomiting were observed in 3 (11.1%) cases. Conclusion . The anatomical and physiological features of pediatric patients determine the tactics of anesthesia, and only taking into account these features, it is possible to achieve patient’s safety during the perioperative and postoperative periods, to improve the quality of treatment and to shorten the periods of hospitalization.

RARELY DETECTED COMPLICATION DURING CATHETERIZATION OF INTERNAL JUGULAR VEIN — DAMAGE TO THE VAGUS NERVE

In the course of intensive therapy for central venous catheterization is a high risk of mechanical complications. The probability of damage to the nervus vagus in the catheterization internal jugular vein is very high, but the lack of vigilance of medical personnel and damage to the knowledge of the clinical picture does not allow prevent and register this type of complication. The purpose of research — the use of ultrasound in the diagnosis of the location of the n.vagus to prevent damage during puncture and catheterization IJV. In the process of intensive care at various emergencies in 100 children aged from 2 weeks to 17 years, conducted IJV ultrasound to identify anatomic relationships of the internal jugular vein, carotid artery and n.vagus . At 30 children ultrasound preceded IJV catheterization (static method) and then selecting the most safe vascular access to the IJV. Dynamic method of ultrasound guidance during IJV catheterization was performed аt 26 саses. We made a retrospective analysis of a series of stationary cards of patients in the intensive care ward with suspected damage to the vagus nerve as a result of catheterization (attempts) IJV. Results — when the preliminary ultrasound neurovascular bundle all the children had rendered the vagus nerve. Selection of the optimal, secure access to the IJV on the basis of static methods and ultrasound assisted of catheterization allowed to successfully catheterize IJV and avoided mechanical complications, including damage of the nervus vagus. Retrospective analysis of stationary cards of patients allow to think about the presence of such complications are not recorded according to medical records.