Multidisciplinary Intensive Care Research Articles

Frequency of Maternal Morbidity and Mortality in Women with Primary Postpartum Hemorrhage

Postpartum haemorrhage is a leading cause of severe maternal morbidity and mortality in both developed and developing countries. We aimed to determine the frequency of maternal morbidity and mortality in women with primary postpartum hemorrhage. This descriptive case study was conducted at Department of Obstetrics & Gynecology, Allied Hospital, Faisalabad, from 15th September 2018 to 14th March 2019. A total of 241 women with PPH, having the age of 18-40 years, and gestational age of 37- 41 weeks were recruited. Patients were evaluated for the presence of sepsis, disseminated intravascular coagulation, acute renal failure, anaemia, and acute respiratory distress syndrome. In this study mean age was detected as 28.96 ± 4.11 years. Majority of the patients 146 (60.58%) were between 18 to 30 years of age. Mean gestational age was 38.87 ± 1.32 weeks. Mean parity was 3.10 ± 0.85 and mean BMI was 28.54 ± 2.54 kg/m2. Sepsis was found in 25 patients (10.37%), disseminated intravascular coagulation in 16 (6.64%), acute renal failure in 21 (8.71%), anaemia in 201 patients (83.40%), acute respiratory distress syndrome in 13 (5.39%) and mortality in 44 (18.26%) patients. This study indicates that frequency of maternal morbidity and mortality in women with primary postpartum hemorrhage is quite high. This necessitates early identification of high-risk pregnancies and provision of urgent, skilled and multidisciplinary intensive care.

Ketoacidosis Secondary to Dento-Alveolar Infection in a Diabetic Pediatric Patient

Diabetic ketoacidosis (DKA) is a common complication of type I and occasionally type II diabetes mellitus. Patients with DKA require intensive multidisciplinary care involving dental surgeons and endocrine physicians in a hospital setting. The association between diabetes mellitus and oral infections is very common and infection is a well-recognized trigger of DKA. Yet very few cases of DKA secondary to dental infections have been reported in the literature. We, herein, report an interesting case of a pediatric patient presenting with ketoacidosis secondary to acute cervical adenophlegmon of dental origin.

Prognostic value of the pSOFA and PELOD 2 scales in assessing the risk of death in neonatal intensive care units

Objective. To assess the discriminatory ability of the PELOD 2 and pSOFA scales in the conditions of multidisciplinary neonatal intensive care unit. Material and methods . It is a prospective, observational, single-center study. The end points are to assess the severity of the condition on the PELOD 2 and pSOFA scales; 28-day survival. The study includes 121 patients. Results. While studying the discriminating power of the scales we have found that all scales have good model quality. At the same time, the pSOFA evaluation system has a statistically more significant (p<0.05) area under the ROC curve (0.903±0.09). Our analysis has not found significant differences in the characteristics of surrogate endpoints between the compared scales in the conditions of comparable points of separation of death risks (p<0.05). Conclusion. The high discrimination ability of the pSOFA scale allows us to recommend it for clinical use in neonatal intensive care units.

Acute fatty liver during pregnancy and gestational diabetes insipidus: a case report

Acute fatty liver during pregnancy (AFLP) is an emergency and potentially fatal condition occurring during the peripartum period. It is characterized by fatty microvascular infiltration of hepatocytes and has an incidence rate of approximately one in 7,000 to one in 20,000 pregnancies. It may induce profound liver failure and can be accompanied by renal failure, polydipsia/polyuria, disseminated intravascular coagulation, hypoglycemia, and encephalopathy. Emergency delivery at the appropriate time is crucial to control the development of AFLP. Gestational diabetes insipidus (GDI) is another rare disorder characterized by polyuria, polydipsia, and dehydration. It has an incidence rate of 2-4 cases/100,000 pregnancies and develops during the third trimester. Here the authors present the case of a patient with AFLP and transient GDI complicated with non-reassuring fetal status. The conditions were resolved after delivery and multidisciplinary intensive care.

Acute Hepatic Failure

Acute liver failure (ALF) is a rare but highly morbid condition that is optimally managed by a multidisciplinary team of surgeons, hepatologists, and intensivists at a tertiary care center that specializes in liver disorders. ALF is caused by four primary mechanisms, including viral infections (most commonly Hepatitis A and B); toxicity from acetaminophen overdose or other substances; postoperative hepatic failure ; and miscellaneous causes such as autoimmune hepatitis, genetic disorders, or idiopathic etiologies. Unlike chronic liver failure in which the body develops compensatory, protective mechanisms, ALF may be associated with severe multisystem organ involvement, including respiratory distress syndrome, renal failure, and cerebral edema. Fulminant hepatic failure represents a rapidly progressive form of ALF that portends worse prognosis. Prompt diagnosis and management of multisystem organ dysfunction in an intensive care setting is paramount to survival. However, a subset of patients will fail to improve with medical management alone. Early identification of these individuals for emergent transplant listing has been shown to improve outcomes. Multiple predictive models for ALF survival have been developed, which are based on weighted evaluation of clinical and laboratory parameters. These models may be used to facilitate treatment, predict prognosis, and guide transplant listing. In this chapter, we provide an in-depth review these concepts, focusing on the classification, epidemiology, diagnosis, and management of ALF. This review contains 5 tables and 69 references. Key Words: acute liver failure, acute respiratory distress syndrome, coagulopathy, cerebral edema, fulminant hepatic failure, hepatic necrosis, liver transplantation, metabolic disarray, multidisciplinary intensive care, prognostication

Acute Hepatic Failure

Acute liver failure (ALF) is a rare but highly morbid condition that is optimally managed by a multidisciplinary team of surgeons, hepatologists, and intensivists at a tertiary care center that specializes in liver disorders. ALF is caused by four primary mechanisms, including viral infections (most commonly Hepatitis A and B); toxicity from acetaminophen overdose or other substances; postoperative hepatic failure ; and miscellaneous causes such as autoimmune hepatitis, genetic disorders, or idiopathic etiologies. Unlike chronic liver failure in which the body develops compensatory, protective mechanisms, ALF may be associated with severe multisystem organ involvement, including respiratory distress syndrome, renal failure, and cerebral edema. Fulminant hepatic failure represents a rapidly progressive form of ALF that portends worse prognosis. Prompt diagnosis and management of multisystem organ dysfunction in an intensive care setting is paramount to survival. However, a subset of patients will fail to improve with medical management alone. Early identification of these individuals for emergent transplant listing has been shown to improve outcomes. Multiple predictive models for ALF survival have been developed, which are based on weighted evaluation of clinical and laboratory parameters. These models may be used to facilitate treatment, predict prognosis, and guide transplant listing. In this chapter, we provide an in-depth review these concepts, focusing on the classification, epidemiology, diagnosis, and management of ALF. This review contains 5 tables and 69 references. Key Words: acute liver failure, acute respiratory distress syndrome, coagulopathy, cerebral edema, fulminant hepatic failure, hepatic necrosis, liver transplantation, metabolic disarray, multidisciplinary intensive care, prognostication

Acute Hepatic Failure

Acute liver failure (ALF) is a rare but highly morbid condition that is optimally managed by a multidisciplinary team of surgeons, hepatologists, and intensivists at a tertiary care center that specializes in liver disorders. ALF is caused by four primary mechanisms, including viral infections (most commonly Hepatitis A and B); toxicity from acetaminophen overdose or other substances; postoperative hepatic failure ; and miscellaneous causes such as autoimmune hepatitis, genetic disorders, or idiopathic etiologies. Unlike chronic liver failure in which the body develops compensatory, protective mechanisms, ALF may be associated with severe multisystem organ involvement, including respiratory distress syndrome, renal failure, and cerebral edema. Fulminant hepatic failure represents a rapidly progressive form of ALF that portends worse prognosis. Prompt diagnosis and management of multisystem organ dysfunction in an intensive care setting is paramount to survival. However, a subset of patients will fail to improve with medical management alone. Early identification of these individuals for emergent transplant listing has been shown to improve outcomes. Multiple predictive models for ALF survival have been developed, which are based on weighted evaluation of clinical and laboratory parameters. These models may be used to facilitate treatment, predict prognosis, and guide transplant listing. In this chapter, we provide an in-depth review these concepts, focusing on the classification, epidemiology, diagnosis, and management of ALF. This review contains 5 tables and 69 references. Key Words: acute liver failure, acute respiratory distress syndrome, coagulopathy, cerebral edema, fulminant hepatic failure, hepatic necrosis, liver transplantation, metabolic disarray, multidisciplinary intensive care, prognostication

Successful Multimodality Life-saving Management of Placenta Percreta with Hemoperitoneum in Shock

ABSTRACT Introduction Placenta percreta is rare but may present with life-threatening emergencies. Case Report We present a near-miss case with a placenta percreta presenting with hemoperitoneum and shock and describe how multidisciplinary multimodality management was used to save the lady in a tertiary care center of a low-resource setting. Peripartum hysterectomy with bilateral internal iliac ligation could not completely control the oozing. The general condition of the patient was poor with acidosis, coagulopathy, and hypothermia. Pelvic packing followed by embolization was done along with intensive care to treat metabolic derangements. It helped salvage the patient who later underwent a relaparotomy for pack removal. Conclusion and clinical significance: Role of individualized multimodality multidisciplinary management and intensive care is emphasized. How to cite this article Chopra S, Siwatch S, Jain K, Aggarwal N, Gorsi U, Kumar N. Successful Multimodality Life-saving Management of Placenta Percreta with Hemoperitoneum in Shock. J Postgrad Med Edu Res 2016;50(4):201-203.

Recent advances in multidisciplinary critical care.

The intensive care unit is a work environment where superior dedication is crucial for optimizing patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the numerous research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovation in the field. This article broadly summarizes new developments in multidisciplinary intensive care. It provides elementary information about advanced insights in the field via brief descriptions of selected articles grouped by specific topics. Issues considered include care for heart patients, mechanical ventilation, delirium, nutrition, pressure ulcers, early mobility, infection prevention, transplantation and organ donation, care for caregivers, and family matters.

Analysis of the social network development of a virtual community for Australian intensive care professionals.

Social media platforms can create virtual communities, enabling healthcare professionals to network with a broad range of colleagues and facilitate knowledge exchange. In 2003, an Australian state health department established an intensive care mailing list to address the professional isolation experienced by senior intensive care nurses. This article describes the social network created within this virtual community by examining how the membership profile evolved from 2003 to 2009. A retrospective descriptive design was used. The data source was a deidentified member database. Since 2003, 1340 healthcare professionals subscribed to the virtual community with 78% of these (n = 1042) still members at the end of 2009. The membership profile has evolved from a single-state nurse-specific network to an Australia-wide multidisciplinary and multiorganizational intensive care network. The uptake and retention of membership by intensive care clinicians indicated that they appeared to value involvement in this virtual community. For healthcare organizations, a virtual community may be a communications option for minimizing professional and organizational barriers and promoting knowledge flow. Further research is, however, required to demonstrate a link between these broader social networks, enabling the exchange of knowledge and improved patient outcomes.

Intensive multidisciplinary care programme for frail patients

Rationale and Objectives: Patients with chronic diseases re-admitted for acute events are associated with a high use of hospital resources and represent a challenge for healthcare systems. In such cases, follow-up interventions at discharge can be effective. The widespread adoption of follow-up procedures not involving telemonitoring may greatly decrease re-admissions rates without the costs associated with telemedicine. To assess the impact of a structured follow-up programme on patient-perceived healthcare quality, treatment adherence, re-admissions and Emergency Department attendances.Methods: This was a before and after study of 242 patients at risk of re-admission for chronic obstructive pulmonary disease (COPD) or heart failure (HF), recruited between 1st July 2009 and 30th June 2010 at Donostia Tertiary University Hospital (Gipuzkoa, Spain). The follow-up ended on 30th December 2010. The intervention involved identifying independent re-admitted patients, providing personalised information and a direct number to call in the event of clinical worsening, assigning specialists and liaison nurses, structured follow-up by telephone and appointments and contact with general practitioners. Patient perceived quality of care estimated was analyzed using a focus group technique. To assess the number of re-admissions and the Emergency Department attendances we estimated the relative risk reduction as a percentage and corresponding 95% confidence intervals.Results: In terms of perceived quality of care, the most valued elements were related to having an assigned doctor/nurse and easy access in the event of worsening. Overall, 97.9% of patients reported full adherence to treatment (95% CI: 95.4-98.83).Hospital bed days and Emergency Department attendances decreased by 60.7% (95% CI: 58.7-62.7) and 77% (95% CI: 73.2-80.3), respectively.Conclusions: The intensive multidisciplinary care programme can reduce Emergency Department attendances and improve perceived quality of care in patients with HF and COPD.

A pilot investigation of feeding problems in children with esophageal atresia

While many long-term complications of esophageal atresia (EA) have been well investigated, little is known about feeding difficulties in children after surgical correction of EA and its impact on caregivers. This study investigates the feeding behaviors of children with EA through a validated feeding questionnaire. The Montreal Children's Hospital Feeding Scale (MCH-FS) was filled out by the primary caregiver during patient follow-up visits in the multidisciplinary EA clinic. Demographic information, EA subtype, associated anomalies and outcomes were recorded. Results were compared between groups and to a normative sample. Thirty caregivers have completed the MCH-FS; 26 patients had type C atresia (86.7%). In comparison to controls, 17.5% of EA cases are one standard deviation above the mean feeding difficulty score, while 6.7% (n = 2) cases are greater than two standard deviations above normative values. Typical EA patients (type C who were not born <30 weeks) had mean MCH-FS scores in the subclinical range, whereas one extremely premature child and the patients with non-type C EA (n = 4) all had scores in the severe range. Feeding difficulties of patients with typical EA appear mild. Likely explanations include the use of early protocolized care and intensive multidisciplinary care in follow up. Nonetheless, patients with complicated EA (non-type C) and their caregivers tend to experience significant feeding difficulties. Early targeted care may be required for this patient subset, and additional cases will be investigated to confirm these preliminary findings and explore further risk factors of feeding problem in this cohort.

Insights and Advances in Multidisciplinary Critical Care: A Review of Recent Research

The intensive care unit is a work environment where superior dedication is pivotal to optimize patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the abundance of research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovations in the field. This article broadly summarizes new developments in multidisciplinary intensive care, providing elementary information about advanced insights in the field by briefly describing selected articles bundled in specific topics. Issues considered include cardiovascular care, monitoring, mechanical ventilation, infection and sepsis, nutrition, education, patient safety, pain assessment and control, delirium, mental health, ethics, and outcomes research.

Anticoagulation strategies in venovenous hemodialysis in critically ill patients: a five-year evaluation in a surgical intensive care unit.

Renal failure is a common complication among critically ill patients. Timing, dosage, and mode of renal replacement (RRT) are under debate, but also anticoagulation strategies and vascular access interfere with dialysis success. We present a retrospective, five-year evaluation of patients requiring RRT on a multidisciplinary 50-bed surgical intensive care unit of a university hospital with special regard to anticoagulation strategies and vascular access. Anticoagulation was preferably performed with unfractionated heparin or regional citrate application (RAC). Bleeding and suspected HIT-II were most common causes for RAC. In CVVHD mode filter life span was significantly longer under RAC compared to heparin or other anticoagulation strategies (P = 0.001). Femoral vascular access was associated with reduced filter life span (P = 0.012), especially under heparin anticoagulation (P = 0.015). Patients on RAC had higher rates of metabolic alkalosis (P = 0.001), required more transfusions (P = 0.045), and showed higher illness severity measured by SOFA scores (P = 0.001). RRT with unfractionated heparin represented the most common anticoagulation strategy in this study population. However, patients with bleeding risk and severe organ dysfunction were more likely placed on RAC. Citrate provided longer filter life spans regardless of vascular access site. Attention has to be paid to metabolic disturbances.

Role of pharmacist in multidisciplinary pediatric intensive care rounds: a retrospective descriptive study

Multidisciplinary rounding practices in the ICU have now become the standard of care in most institutions. Few objective data are available, however, on the value each individual member of the team brings to the patient care. In our institution, pediatric pharmacists have been an integral part of the PICU rounds since 2002, although their role has evolved over the course of years. This study was undertaken with the primary aim of identifying the impact of pharmacist involvement in PICU rounds, with respect to changes in therapy.

A Pilot Study Exploring the Role of Physical Therapists and Transition in Care of Pediatric Patients with Cystic Fibrosis to the Adult Setting

Cystic fibrosis (CF) is a disease that requires intensive multidisciplinary care, including care by physical therapists (PTs). People with CF are now living well into adulthood, necessitating a transfer of care from the pediatric setting to an adult one. Physical therapists play a large role in the care of the person with CF; however, there is little known about the PT role in transition of care. To explore transition issues for people with CF from the perspective of PTs. An 18-question online survey was sent to PTs via an electronic CF listserv. Questions were derived from an analysis of transition literature in CF and other chronic childhood conditions. Physical therapists who reported treating people with CF gave their opinions on issues impacting transition from their perspective as well as their perception of patient and parent concerns. Descriptive statistics were used for data analysis. A total of 26 PTs completed the survey. A majority, 61.5%, reported that there was a transition program at their facility, with 42.3% involving physical therapy. Common themes for patients and parents included feeling uncertain about: knowledge of the adult physician, acquiring pulmonary infections in the adult setting, and pace of the adult clinic. Physical therapists were concerned about adherence with airway clearance and exercise following transfer to the adult clinic. The role of PT in transition programs is quite varied. Physical therapists should address common concerns of their patients and families to improve the transition process and possibly impact adherence to the PT plan of care.

The risk of central line-associated bloodstream infections with different types of central vascular catheters in a multidisciplinary neonatal and pediatric intensive care unit

Objective. Central line-associated bloodstream infections (CLABSIs) are a significant cause of morbidity in critically ill neonates and children. The objective of this study was to compare CLABSI rate associated with different types of central vascular catheters (CVCs) in a multidisciplinary neonatal and pediatric intensive care unit (ICU).Methods. A prospective cohort study was conducted in a multidisciplinary neonatal and pediatric ICU. All patients, admitted between January 1st 2011 and February 29th 2012, requiring a CVC were included and monitored for CLABSI (defined by CDC/NHSN criteria). CLABSI rates were calculated for each type of CVC as CLABSI episodes/1000 catheter-days. CLABSI rates were compared between patients with single and multiple CVCs.Results. Of the 557 patients admitted, 362 (65%) required insertion of a CVC (4259 patient-days, 3225 catheter-days, CVC uti-lization ratio 0.76). There were 14 episodes of CLABSI. CLABSI rate was lowest for umbilical catheters (0/1000 catheter-days), followed by short-term noncuffed and nontunneled CVCs (3.1/1000 catheter-days) and peripherally inserted CVCs (8.8/1000 catheter-days). Higher rates were observed with long-term cuffed and tunneled CVCs (15.9/1000 catheter days) and noncu-ffed, nontunneled CVCs for temporary renal replacement therapy (RRT) (20.0/1000 catheter days). CLABSI rate expressed per 1000 catheter-days was 3.0 and 19.7 for patients with single or multiple CVCs at the same time, respectively. Conclusion. The use of noncuffed, nontunneled CVCs for temporary RRT and the presence of multiple CVCs at the same time are associated with a significant increase in the rate and risk of developing CLABSI in a multidisciplinary neonatal and pediatric ICU population.

Thromboelastometry in neonates and infants undergoing cardiac surgery

Introduction. Rotational thromboelastometry (ROTEM) in monitoring coagulation in children undergoing cardiac surgery has been studied with promising results. Since the data about ROTEM in infants and neonates undergoing cardiac surgery are scarce, the aim of our study was to asses ROTEM abnormalities in this patient group.Methods. Infants and neonates undergoing cardiac surgery on cardiopulmonary bypass were included in this prospective, observational study conducted in a level III multidisciplinary neonatal and pediatric intensive care unit (ICU) between May 2011 and January 2012. ROTEM analysis, together with determination of platelet count, international normalized ratio of prothrombin time (INR), activated partial thromboplastin time (PTT), and fibrinogen concentration, was done in all neonates and infants before surgery (t1), after admission to ICU (t2) and 24 hours after surgery (t3).Results. Twenty infants and neonates were operated on during the time of the study. ROTEM abnormalities seen after sur-gery (t2) were: thrombocytopenia 14, hypofibrinogenemia 1, mixed hypofibrinogenemia and coagulation factor deficiency 1, and mixed thrombocytopenia with mild hyperfibrinolysis 1. Three patients were found to have normal ROTEM results. The median values of all except one of the ROTEM tests, as well as platelet count, INR, PTT, and fibrinogen concentration, showed significant prolongation or deterioration after admission to ICU and these deteriorations persisted in several para-meters for 24 hours.Conclusions. In our neonates and infants, cardiac surgery on cardiopulmonary bypass predominantly affects platelets, although most of the ROTEM parameters deteriorated after admission to ICU.

Erratum to: Multidisciplinary intensive care in extensive necrotizing fasciitis

The online version of the original article can be found underdoi:10.1007/s15010-012-0346-2.G.-W. Tu M.-J. Ju Z.-G. Xue Z. Luo (&)Department of Anesthesiology and Surgical Intensive Care Unit,Zhongshan Hospital, Fudan University, 180 Fenglin Rd,200032 Shanghai, Chinae-mail: luo.zhe@zs-hospital.sh.cnJ. O. HwabejireDivision of Trauma, Emergency Surgery and Surgical CriticalCare, Department of Surgery, Massachusetts General Hospital,Harvard Medical School, Boston, MA, USAY.-F. YangDepartment of Urology, Zhongshan Hospital,Fudan University, Shanghai, ChinaG.-J. Zhang C. Jiang (&)Department of Orthopedics, Zhongshan Hospital,Fudan University, Shanghai, Chinae-mail: jcyh01@sina.comJ.-W. XuDepartment of Plastic and Reconstructive Surgery,Zhongshan Hospital, Fudan University, Shanghai, China

Measuring the quality of therapeutic apheresis care in the pediatric intensive care unit

Our goal was to measure the quality of care provided in the Pediatric Intensive Care Unit (PICU) during Therapeutic Apheresis (TA). We described the care as a step by step process. We designed a flow chart to carefully document each step of the process. We then defined each step with a unique clinical indictor (CI) that represented the exact task we felt provided quality care. These CIs were studied and modified for 1 year. We measured our performance in this process by the number of times we accomplished the CI vs. the total number of CIs that were to be performed. The degree of compliance, with these clinical indicators, was analyzed and used as a metric for quality by calculating how close the process is running exactly as planned or "in control." The Apheresis Process was in control (compliance) for 47% of the indicators, as measured in the aggregate for the first observational year. We then applied the theory of Total Quality Management (TQM) through our Design, Measure, Analyze, Improve, and Control (DMAIC) model. We were able to improve the process and bring it into control by increasing the compliance to > 99.74%, in the aggregate, for the third and fourth quarter of the second year. We have implemented TQM to increase compliance, thus control, of a highly complex and multidisciplinary Pediatric Intensive Care therapy. We have shown a reproducible and scalable measure of quality for a complex clinical process in the PICU, without additional capital expenditure.