Today's Intensive Care Research Articles

MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges.

Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.

Evaluation of the Relationship between Transcutaneous Carbondioxide Monitorization and End-tidal Carbondioxide and Partial Carbondioxide Monitorization

MonitorizationNon-invasive methods have replaced invasive methods in line with developments in pediatric intensive care units. (Especially methods that enable continuous monitoring) Although arterial carbon dioxide measurement is still the gold standard for the evaluation of alveolar ventilation, the need for continuous monitoring of PaCO2 and the invasive nature of this method have led to the investigation of alternative methods. To evaluate the correlation of transcutaneous CO2 (TcCO2) monitoring with PaCO2 and ETCO2 in mechanically ventilated patients in peditaric intensive care units. Single-center, prospective, observational cohort study. We enrolled 60 patients between the age of 1 month-18 years who were mechanically ventilated in pediatric intensive care unit for this single-center, prospective, observational cohort study from February 2019 through March 2019. Correlation analysis was performed for arterial PaCO2, end-tidal CO2, TcCO2 parameters. P<0.05 values were considered significant. The Bland-Altman plot was created for determining the agreement between the methods. The correlation of transcutaneous CO2 and end-tidal CO2 with arterial PaCO2 was evaluated, both parameters were found to be positively and highly correlated (r=0.864, p<0.001, r:0.962, p<0.001, respectively). The mean bias between the arterial carbondioxide mesaurement and transcutaneous measurement was 5.5, and limits of agreement (bias ±1.96 SD) ranged from -13.9 to 2.9. The mean bias between the arterial carbondioxide mesaurement and end-tidal carbondioxide measurement was 2.3, and limits of agreement (bias ±1.96 SD) ranged from -4.1 to 8.6. In 44 measurements (88%), the TcCO2 was ±7.5 mm Hg of the PaCO2. TcCO2 seems to be a good alternative for carbon dioxide measurement, as it is non-invasive and allows continuous monitoring in view of today's intensive care conditions, but arterial PaCO2 measurement is still the gold standard method. Continuous TcCO2 monitoring provides a promising alternative to repeated blood sampling in subjects requiring mechanical ventilation for critically ill children.

Energy expenditure and oxygen uptake kinetics in critically ill elderly patients.

Resting energy expenditure (REE) measurement of critically ill patients is essential for better nutrition management. Younger people increase their oxygen delivery ( ) to meet energy demands, but few reports have investigated oxygen uptake kinetics in elderly patients, which are the main target population in today's intensive care units (ICUs). In this study, we evaluated REE, , and oxygen extraction ratio (O2 Ext: oxygen consumption [ ]/ ) to clarify appropriate energy needs and consumption in elderly ICU patients. This retrospective observational study included ventilated ICU patients who were divided into elderly participants (age ≥ 65 years) and nonelderly participants (age ≤64 years). , CO2 production, and cardiac output were measured by indirect calorimetry and noninvasive hemodynamic monitoring for up to 5 days. The initial values of REE, , and O2 Ext were compared between elderly and nonelderly patients. This study included 102 patients, of whom 52% (n = 53) were elderly. The absolute deviation of measured REE per ideal body weight (IBW) was significantly higher in elderly than in nonelderly patients (9.3 ± 6.9 vs 6.3 ± 6.6 kcal/kg; P < .01). had a strong negative correlation with age (P < .01). The O2 Ext value was significantly higher in elderly than in nonelderly patients (37 ± 19% vs 29 ± 13%; P = .03). Elderly critically ill patients were characterized by higher deviations in REE, lower , and higher O2 Ext. In elderly patients, O2 Ext rather than could be increased to meet energy consumption demands.

The Utility of Teleultrasound to Guide Acute Patient Management.

Ultrasound has evolved into a core bedside tool for diagnostic and management purposes for all subsets of adult and pediatric critically-ill patients. Teleintensive care unit coverage has undergone a similar rapid expansion period throughout the United States. Round-the-clock access to ultrasound equipment is very common in today's intensive care unit, but 24/7 coverage with staff trained to acquire and interpret point-of-care ultrasound in real time is lagging behind equipment availability. Medical trainees and physician extenders require attending level supervision to ensure consistent image acquisition and accurate interpretation. Teleintensivists can extend the utility of ultrasound by supervising and guiding providers without or with only partial training in ultrasound, and also by extending direct trainee ultrasound supervision to time periods when no direct bedside attending supervisor is available, and when treatment decisions otherwise would have been made without supervision and feedback on image acquisition and interpretation. Nursing staff without ultrasound training can also be directed to perform basic ultrasound exams, which may have immediate diagnostic and/or treatment consequences, thereby overcoming access barriers in the absence of physicians or physician extenders. We discuss 4 real-life clinical scenarios in which teleintensivist supervision extended and standardized bedside ultrasound exams to guide management decisions which significantly impacted patient outcomes.

Is there opportunity for automated decision-support and closed-loop control in ICU patients receiving vasopressor infusion?

Vasopressors are administered to critically ill patients suffering from a body-wide reduction in blood circulation. In theory, if the vasopressor infusion is either too high or too low, it could be harmful to the patient. In a retrospective analysis, we investigated the degree to which today's intensive care unit (ICU) patients receive appropriate vasopressor therapy, in terms of how often the mean arterial pressure (MAP) was kept within a normative range. Using the MIMIC II database, we studied patients with minute-by-minute MAP data, sourced from the bedside monitor, who were receiving vasopressor therapy. For each record, we identified MAP samples that were out-of-range, i.e., MAP <; 60 mmHg or MAP > 100 mmHg, and grouped these into out-of-range episodes. Each out-of-range episode was categorized as either transient (<; 15 min) or sustained (≥ 15 min). Out of the 224 ICU stays, we identified 152 ICU stays (68% of ICU stays) with at least one sustained MAP out-of-range episode. In that subset, MAP was frequently out-of-range (out-of-range 18.4% of the time) due to a combination of sustained episodes of hypotension and hypertension. Compared with all ICU stays, those stays with sustained out-of-range events did not demonstrate an increased MAP variability per hour. It is possible that the out-of-range events resulted from insufficient dose-adjustment. Technologies that might continuously optimize vasopressor dosing throughout the patient's stay and thereby minimize these abnormal cardiovascular states may be worthy of further study.

Who is attending? End-of-life decision making in the intensive care unit.

Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units. The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer. Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.

Cochrane review: Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support

AbstractBackgroundChest physiotherapy (CPT) has been used in many neonatal nurseries around the world to improve airway clearance and treat lung collapse; however, the evidence to support its use has been conflicting. Despite the large number of studies there is very little evidence of sufficiently good quality on which to base current practice.ObjectivesTo assess the effects of active CPT techniques, such as percussion and vibration followed by suction compared with suction alone, on the respiratory system in infants receiving mechanical ventilation. Additionally, differences between types of active CPT techniques were assessed.Search strategyOur search included The Cochrane Library (Issue 2, 2007), MEDLINE (1966 to 2007), EMBASE (1988 to 2007), CINAHL, Science Citation Index, previous reviews including cross‐references, abstracts, conference proceedings and grey literature.Selection criteriaTrials in which ventilated newborn infants up to four weeks of age were randomly or quasi‐randomly assigned to receive active CPT or suction alone. Infants receiving CPT for the extubation period were excluded.Data collection and analysisTwo review authors independently conducted quality assessments and data extraction for included trials. We analysed data for individual trial results using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, we could not undertake meta‐analysis.Main resultsThree trials involving 106 infants were included in this review. In one trial (n = 20) CPT was no better than standard care in clearing secretions. No increase in the risk of intraventricular haemorrhage was noted. Two trials compared different types of active CPT. One trial (n = 56) showed that non‐resolved atelectasis was reduced in more neonates receiving the lung squeezing technique (LST) when compared to postural drainage, percussion and vibration (PDPV) (RR 0.25; 95% CI 0.11 to 0.57). No difference in secretion clearance or in the rate of intraventricular haemorrhage or periventricular leucomalacia was demonstrated. The other trial (n = 30) showed that the use of percussion or 'cupping' resulted in an increased incidence of hypoxaemia (RR 0.53; 95% CI 0.28 to 0.99) and increased oxygen requirements (MD ‐9.68; 95% CI ‐14.16 to ‐5.20) when compared with contact heel percussion. There was insufficient information to adequately assess important short and longer‐term outcomes, including adverse effects.Authors' conclusionsThe results of this review do not provide sufficient evidence on which to base clinical practice. There is a need for larger randomised controlled trials to address these issues.Plain Language SummaryChest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory supportThere is not enough evidence to determine whether active chest physiotherapy is of benefit to neonates on mechanical ventilation. Babies who require mechanical ventilation are at risk of lung collapse from increased secretions. Chest physiotherapy (patting or vibrating the chest) is used to improve clearance of secretions from the airway to try to prevent lung collapse. This review found no clear overall benefit or harm from chest physiotherapy. Some individual chest physiotherapy techniques were more beneficial than others in resolving atelectasis and maintaining oxygenation. These results do not support one technique over another. Due to the limited number, poor quality and age of trials in this review, there is not enough evidence to determine whether or not chest physiotherapy is beneficial or harmful in the treatment of infants being ventilated in today's intensive care units. Further good quality trials are needed to address this issue.

Patología neuromuscular en cuidados intensivos

The spectrum of neuromuscular disease encountered in today's intensive care units (ICU) has evolved over the last few decades. However, in spite of many studies on neuromuscular disorders complicating critical illness as well as its epidemiology, etiology, treatment and prognosis, several key areas remain unclear. Two main groups are found among these neuromuscular abnormalities. The first group includes primary neuromuscular disorders present on admission to the ICU in which a possible etiology can be identified. Guillain-Barré syndrome and myasthenia gravis are two of the most common diseases admitted to ours units. In the second group, weakness is acquired in the ICU in the absence of preexisting neuromuscular disease. It is believed to reflect illnesses or treatments occurring in the ICU. Critical illness polyneuropathy (CIP) is the most clearly defined neuromuscular complication in this group. However, although we have better knowledge of its clinical, diagnosis, and prognosis features, its pathophysiological substrate has not been fully elucidated. Neuromuscular junction defects and specially myopathies, that frequently coexist with CIP, are the others main causes of acquired weakness in critically ill patients. Advances in understanding of these neuromuscular disorders could have an important impact in terms of developing effective preventive and therapeutic interventions that could help to improve the poor prognosis of these patients.

Intelligent decision support systems for mechanical ventilation

An overview of different methodologies used in various intelligent decision support systems (IDSSs) for mechanical ventilation is provided. The applications of the techniques are compared in view of today's intensive care unit (ICU) requirements. Information available in the literature is utilized to provide a methodological review of different systems. Comparisons are made of different systems developed for specific ventilation modes as well as those intended for use in wider applications. The inputs and the optimized parameters of different systems are discussed and rule-based systems are compared to model-based techniques. The knowledge-based systems used for closed-loop control of weaning from mechanical ventilation are also described. Finally, in view of increasing trend towards automation of mechanical ventilation, the potential utility of intelligent advisory systems for this purpose is discussed. IDSSs for mechanical ventilation can be quite helpful to clinicians in today's ICU settings. To be useful, such systems should be designed to be effective, safe, and easy to use at patient's bedside. In particular, these systems must be capable of noise removal, artifact detection and effective validation of data. Systems that can also be adapted for closed-loop control/weaning of patients at the discretion of the clinician, may have a higher potential for use in the future.

Role of the tissue factor pathway in the pathogenesis and management of multiple organ failure.

Sepsis is caused by a dysregulated immune response to infection and, without intervention, can lead to septic shock and multiple organ failure. A leading cause of morbidity and mortality in intensive care units worldwide, severe sepsis is also associated with a considerable cost burden that places significant strain on global healthcare budgets. The development of an efficacious and cost-effective treatment strategy is therefore of vital importance to today's intensive care physicians. This paper will examine the pathophysiology of sepsis and multiple organ dysfunction before reviewing trials recently undertaken to investigate three potential anticoagulant therapies: antithrombin III, activated protein C, and tissue factor pathway inhibitor. Finally, other recent developments in the care of sepsis patients will be briefly examined.

Evaluation of Bluetooth as a replacement for cables in intensive care and surgery.

In today's intensive care and surgery, a great number of cables are attached to patients. These cables can make the care and nursing of the patient difficult. Replacing them with wireless communications technology would facilitate patient care. Bluetooth is a modern radio technology developed specifically to replace cables between different pieces of communications equipment. In this study we sought to determine whether Bluetooth is a suitable replacement for cables in intensive care and during surgery with respect to electromagnetic compatibility. The following questions were addressed: Does Bluetooth interfere with medical equipment? And does the medical equipment decrease the quality of the Bluetooth communication? A Bluetooth link, simulating a patient monitoring system, was constructed with two laptops. The prototype was then used in laboratory and clinical tests according to American standards at the Karolinska Hospital in Stockholm. The tests, which included 44 different pieces of medical equipment, indicated that Bluetooth does not cause any interference. The tests also showed that the hospital environment does not affect the Bluetooth communication negatively. Bluetooth, a new radio technology transmitting at 2.4 GHz, was tested in a clinical setting. The study showed that a single Bluetooth link was robust and electromagnetically compatible with the tested electronic medical devices.

A personal reflection: the intimacy of dying: an act of presence.

The focus of critical care education is usually on the development of knowledge and skills needed to manage care for the critically ill patient. In today's intensive care units, what is also needed is the education and development of the skills that enable nurses the ability to enter into a relationship with the patients and families that touch the spirit, and provide another dimension to healing.

Sepsis: A follow-up of cytokine production in different phases of septic patients

Sepsis and its sequelae are still a major cause of morbidity and mortality on today's intensive care units. The evidence that primary responses in sepsis are mediated by cytokines has led to various approaches to evaluate the potential of these mediators as markers of disease progression, prognosis or treatment. This study evaluated variations of plasma levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), interleukin-1 (IL-1) and nitric oxide (NO) in different phases of sepsis and compared the relation of these data with disease evaluation and outcome. No difference in interleukin production in different phases of septic patients or between septic and polytrauma group was found. The only parameter that showed correlation with disease severity was the increase in interleukin-6 in final phase of sepsis, which corresponds to septic shock. No significant difference in plasma cytokine levels was found between survival or non-survival septic or polytraumatic patients and the use of carbapenem and cephalosporin. Taken together, the data indicate that, with the exception of interleukin-6, cytokine determination does not serve as marker of infectious disease nor can it be used to predict the prognosis of sepsis.

End-of-life care in the intensive care unit: a challenge for nurses

Results from several research studies combined with increasing public tensions surrounding physician-assisted suicide have fueled a growing awareness of the inadequacies of end-of-life care. Investigators also suggest that intensive care unit nurses have a limited role in end-of-life decision making and care planning. This article explores cultural issues influencing end-of-life care in intensive care units, explores factors surrounding the limited involvement of critical care nurses in end-of-life decision making and care planning, and offers recommendations for changing nursing practice. Because improving end-of-life care will require cultural changes, an understanding of the cultural issues involved is needed. Recommendations for changing nursing practice include a model of end-of-life care that incorporates the goals of both cure and comfort care, as well as a shared decision-making process. Nurses are essential to improving end-of-life care in today's intensive care units.

Effects of Genomic Polymorphisms on the Course of Sepsis

Abstract. Sepsis and its sequelae are still a major cause of morbidity and mortality on today's intensive care units. The evidence that endogenous mediators actually mediate the individual's response to infection has led to various approaches to assess the individual's contribution to the course of the disease. The role of an individual's genetic background and predisposition for the extent of inflammatory responses is determined by variabilities of genes encoding endogenous mediators that constitute the pathways of inflammation. Primary responses in inflammation are mediated by proinflammatory cytokines such as tumor necrosis factor and interleukin 1. Conversely, anti-inflammatory mediators are released and may induce a state of immunosuppression in sepsis. Pro- and anti-inflammatory responses contribute to the outcome of patients with systemic inflammation and sepsis. Therefore, all genes encoding proteins involved in the transduction of inflammatory processes are candidate genes to determine the human genetic background that is responsible for interindividual differences in systemic inflammatory responses to injury. The genetically determined capacity of cytokine production and release, heat shock protein expression, nitric oxide synthase activity, gene polymorphisms of coagulation factors or factors of the innate immune system-like defensins, and other genes involved in inflammation may contribute to a wide range of clinical manifestations of an inflammatory disease. Genomic information may be used to identify groups of patients with a high risk of developing severe sepsis and multiple organ dysfunction, and determining which patients will benefit from antimediator strategies because of their genetic determination to high cytokine release in the inflammatory response will be the subject of future trials.

Adult respiratory distress syndrome: current concepts.

Adult Respiratory Distress Syndrome (ARDS) is a common diagnosis in today's intensive care units, representing a final common pathway of lung response to a variety of disease states. Mortality rates remain excessively high, despite comprehensive monitoring and intensive treatment. The incidence, etiology, clinical features, pathology and pathophysiology of ARDS are reviewed, with special emphasis on current research regarding potentially injurious mediators and possible etiopathogenetic mechanisms. Current therapy is summarized, and new therapeutic modalities are assessed. It is hoped that increased knowledge and awareness of the various aspects of ARDS will lead to further understanding and better clinical results in patients with this syndrome.

Dilemmas in Intensive Care Medicine: An Ethical and Legal Analysis

The high-technology medicine available in today's intensive care setting not only provides near miraculous benefits for some patients, but it also creates new and troublesome ethical and legal dilemmas for patients and practitioners. Standards for access to and discharge from the intensive care unit, "do not resuscitate" orders, determination of death, organ retrieval, advanced directives, decision-making capacity, and substantive and procedural guidelines for termination of treatment in incompetent patients are among the problems. Those issues, along with the emerging question of withholding nutrition and fluids, are discussed in this article.

Radiant Energy and Insensible Water Loss in the Premature Newborn Infant Nursed Under a Radiant Warmer

Radiant warmers are a powerful and efficient source of heat serving to warm the cold-stressed infant acutely and to provide uninterrupted maintenance of body temperature despite a multiplicity of nursing, medical, and surgical procedures required to care for the critically ill premature newborn in today's intensive care nursery. A recognized side-effect of radiant warmer beds is the now well-documented increase in insensible water loss through evaporation from an infant's skin. Particularly the very-low-birth-weight, severely premature, and critically ill neonate is subject to this increase in evaporative water loss. The clinician caring for the infant is faced with the difficult problem of fluid and electrolyte balance, which requires vigilant monitoring of all parameters of fluid homeostasis. Compounding these difficulties, other portions of the electromagnetic spectrum (for example, phototherapy) may affect an infant's fluid metabolism by mechanisms that are not well understood. The role of plastic heat shielding in reducing large insensible losses in infants nursed on radiant warmer beds is currently under intense investigation. Apparently, convective air currents and not radiant heat energy may be the cause of the observed increase in insensible water loss in the intensive care nursery. A thin plastic blanket may be effective in reducing evaporative water loss by diminishing an infant's exposure to convective air currents while being nursed on an open radiant warmer bed. A rigid plastic body hood, although effective as a radiant heat shield, is not as effective in preventing exposure to convection in the intensive care nursery and, therefore, is not as effective as the thin plastic blanket in reducing insensible water loss. Care should be exercised in determining the effect of heat shielding on all parameters of heat exchange (convection, evaporation, and radiation) before application is made to the critically ill premature infant nursed on an open radiant warmer bed.

All Is Well in Perinatal Land

Dr William A. Silverman's review of the career of Dr Martin A. Couney1 as an exhibitor of premature infants in the late nineteenth and early twentieth centuries was interesting. I found it difficult to imagine, however, how this exploitation was permitted to go on as long as it did. I am even more amazed at Dr Silverman's concluding remarks. Although I agree that there is indeed a "disturbing detachment from reality" present for parents, patients, and staff in today's intensive care nurseries, I heartily disagree that, when compared with the technical energy expended to save the child's life, no similar "effort is mounted to deal with the enormous problems which face the graduate at home and in the community."1