Treatment Of Intensive Care Patients Research Articles

Long-term consequences after intensive therapy

Many intensive care patients are affected by serious persistent or new physical, cognitive, psychological, and social consequences after discharge (post-ICU syndrome). This has an impact on the rest of life as well as the prognosis. To reduce or avoid these complications and structured treatment after discharge must be essential goals of intensive care medicine. Prevention of PICS is of central importance. The knowledge that many elements of the symptoms are triggered or intensified by therapeutic treatments as part of intensive therapy offers the opportunity to modify. Therapy must be designed to reduce potential sequelae, with the avoidance of overtreatment, such as sedation. These understanding must lead to critically questioning who is admitted to an intensive care unit and for whom a realistic therapy goal in terms of functionality, quality of life and life expectancy can be achieved. Ultimately, the treatment of intensive care patients must not end when they are discharged from the intensive care unit or hospital. Patients at risk for the very different facets of a PICS must be identified and linked to appropriate care institutions. This requires the establishment of post-ICU facilities, such as consultation hours in clinics or outpatient clinics.

Atrial fibrillation on the intensive care unit : The special prognostic importance of the first manifestation

Atrial fibrillation (AF) is the most common arrhythmia in the intensive care unit (ICU) and is associated with increased mortality. The AF is classified into five different forms, initially diagnosed AF, paroxysmal AF, persistent AF, long-standing persistent AF and permanent AF. Studies could confirm that the first manifestation of AF (new onset AF) is of particular importance in intensive care patients. The mortality and costs are much higher than for patients with chronic AF. This important clinical difference of the AF pattern should be taken into consideration in the treatment of intensive care patients. The treatment of comorbidities is essential in the treatment concept on the ICU. In patients with an increased risk of thromboembolic complications, therapeutic anticoagulation is indicated, although the greatly increased risk of bleeding during intensive care treatment should be considered in individual cases. In cases of hemodynamic instability electrical cardioversion should immediately be carried out. Otherwise, pharmacological cardioversion can also be carried out. Apart from a few exceptions, amiodarone is the antiarrhythmic drug of choice for rhythm control due to the contraindications for other drugs.

Collaboration between nurses and doctors in the decision-making process when considering ending the life-prolonging treatment of intensive care patients.

The aim of the study was to explore intensive care nurses' collaboration with doctors' when considering ending the life-prolonging treatment of patients in the intensive care unit. A qualitative method with an explorative descriptive design was employed. Data were collected through semi-structured interviews with four intensive care nurses and four doctors working in three intensive care units at two university hospitals and one local hospital. The data were analysed using systematic text condensation. This study was reported according to the consolidated criteria for reporting qualitative research checklist. Two categories were identified in the data analysis: listening to each other during the decision-making process and continuity and having time to facilitate regular discussions of prognosis and treatment plans.

Postextubation dysphagia in intensive care patients : Current findings and clinical recommendations

Aconsiderable number of critically ill and mechanically ventilated intensive care patients show pronounced dysphagia after extubation. Many studies have shown that postextubation dysphagia (PED) leads to asignificant decline of outcome. The awareness, timely diagnostic procedures and integration of suitable treatment methods in intensive care units are therefore of great importance. Current basic findings on PED, diagnostic possibilities, therapeutic methods as well as the development of concrete recommendations for clinical practice. Aselective literature search was performed in PubMed, Medline and Cochrane using keywords. In the literature the incidence PED is reported very heterogeneous but is probably at least 10% in intensive care patients after mechanical ventilation. The duration of intubation plays acritical role here. Amultifactorial interaction of several factors is assumed to be the cause, whereby the impairment of laryngeal structures is of particular relevance. A PED leads to longer hospital stays, higher mortality, more reintubation and ahigher number of patients with tube feeding. With respect to diagnostics, screening by trained nurses, clinical swallowing examinations and, in particular, the use of instrumental examinations by flexible endoscopic evaluation of swallowing (FEES) are recommended. The treatment should include adaptive measures in the sense of an adapted diet but also functional exercises. Innovative approaches, such as electrical stimulation are also conceivable. The aim is primarily to avoid penetration and aspiration in order to counteract respiratory complications. In many intensive care units the clinical picture of PED is still neglected despite clear evidence. Asimple algorithm in the treatment of intensive care patients can contribute to early detection and initiation of further steps. These should be integrated into clinical treatment standards.

Noise Reduction on the ICU

Noise pollution in the intensive care unit is not only an omnipresent but also a considerable problem, both for patients and healthcare staff. There are a number of significant sources of noise that are at least partially responsible for the frequent and serious sleep disorders of intensive care unit patients. This has a negative impact on the recovery of intensive care patients and favours the occurrence of delirium, which can be associated with increased overall mortality. This article provides a summary of the current evidence on the occurrence of noise-associated consequences and possible options for reducing noise exposure in the intensive care unit and offers perspectives for improving treatment of intensive care patients.

Results of Favipiravir Combined Treatment in Intensive Care Patients with COVID-19

Results of Favipiravir Combined Treatment in Intensive Care Patients with COVID-19

Training Need Assessment Among Health Care Providers in Public Health Facilities of Benishangul Regional State, North West Ethiopia, 2018

<i>Background:</i> Continuing education is crucial for quality improvement in health care. The needs assessment of CE helps to ensure effectiveness. However, such an assessment necessitates certain techniques that are unfamiliar to health care communities in developing countries. This study identifies the needs of providing training to health care providers in Benishangul Gumuz regional sate. <i>Objective:</i> The aim of this survey is to assess training needs among health care providers in Benishangul Gumuz regional state health facility, North West Ethiopia, 2018 <i>Methods:</i> An institution based cross-sectional study was conducted from Jun first to July 30, 2018 in public health facilities of Benishangul Gumuz regional state. This study was designed as a questionnaire survey to investigate the demographics, training needs, and preferred approaches to improve performance of the target population. The study population included the health care providers of public health care facilities in Benishangul Gumuz regional sate. We used the World Health Organization– adopted Hennessy Hicks Training Needs Analysis Questionnaire, a self-reported close-ended structured questionnaire with a core set of 30 items. <i>Results:</i> In total, 450 questionnaires were distributed; the response rate was 86%, and most respondents were nurses. Neonatal care, Gender based violence, Emergency care, Maternal care, Public health promotion /Disease prevention/, TB /Leprosy, Malaria, ART, Treatment of intensive care patients (ICU) and Leadership and system thinking was found to be the most required training needs among health care providers in the public health facilities of Benishangul Gumuz regional state <i>Conclusions:</i> Providing training according to needs is vital, particularly in developing countries like Ethiopia where resources are extremely limited. The assessment result offers perspective on how to conduct needs assessment and serve as a reference for the region. Planning to provide training to health care providers particularly on Neonatal care, Gender based violence and Emergency care take a priority for the region.

Impact of lung volume changes on perfusion estimates derived by Electrical Impedance Tomography

Abstract Electrical Impedance Tomography (EIT), an imaging technique which operates non-invasively and without radiation exposure, provides information about ventilation- and cardiac-synchronous (pulsatile) changes in the lung. It is well known, that perfusion within the thorax is influenced by lung volume or intrathoracic pressure. In this observational study, it shall be investigated if this phenomenon can be monitored by EIT. Therefore, the impact of the amount of air within the lung on the pulsatile EIT signal was evaluated by carrying out EIT measurements with a spontaneously breathing lung healthy subject holding the breath at three different inspiratory and three various expiratory volume levels during normal tidal breathing. For EIT data analysis, a region of interest was defined by including lung tissue and excluding the heart region. The EIT data revealed, that the shape and the amplitude of the pulsatile EIT signal (evaluated per heartbeat) during the phases of breath holding were dependent on the enclosed lung volume. For lung volumes &gt; 4 L, the amplitude of the pulsatile EIT signal increased with rising inspiratory level and the shape remained almost unchanged. For lung volumes &lt; 4 L, a change in shape was visible but the amplitude remained more or less the same with decreasing expiratory level. Since the results of this observational study show that the pulsatile EIT signal is influenced by the lung volume, it might be used in future to draw conclusions of cardiacpulmonary interactions or intrathoracic pressure states, benefitting the treatment of intensive care patients.

Precision nutrition for intensive care patients

Nutritional treatment of intensive care patients may require an accurate, effective and personalized approach in the future. Using nutritional risk assessment to guide nutritional treatment, factors including timing, energy expenditure and goal, pathway and dosage should be considered. Through testing the individual nutritional molecular markers, the benefits and risks can be evaluated. So nutritional therapy can enhance the nutritional and metabolic status of intensive care patients, and improve clinical outcomes.

Practice of hemodynamic monitoring and management in German, Austrian, and Swiss intensive care units: the multicenter cross-sectional ICU-CardioMan Study.

Background Hemodynamic instability is frequent and outcome-relevant in critical illness. The understanding of complex hemodynamic disturbances and their monitoring and management plays an important role in treatment of intensive care patients. An increasing number of treatment recommendations and guidelines in intensive care medicine emphasize hemodynamic goals, which go beyond the measurement of blood pressures. Yet, it is not known to which extent the infrastructural prerequisites for extended hemodynamic monitoring are given in intensive care units (ICUs) and how hemodynamic management is performed in clinical practice. Further, it is still unclear which factors trigger the use of extended hemodynamic monitoring.MethodsIn this multicenter, 1-day (November 7, 2013, and the preceding 24 h) cross-sectional study, we retrieved data on patient monitoring from ICUs in Germany, Austria, and Switzerland by means of a web-based case report form. One hundred and sixty-one intensive care units contributed detailed information on availability of hemodynamic monitoring. In addition, detailed information on hemodynamic monitoring of 1789 patients that were treated on due date was collected, and independent factors triggering the use of extended hemodynamic monitoring were identified by multivariate analysis.ResultsBesides basic monitoring with electrocardiography (ECG), pulse oximetry, and blood pressure monitoring, the majority of patients received invasive arterial (77.9 %) and central venous catheterization (55.2 %). All over, additional extended hemodynamic monitoring for assessment of cardiac output was only performed in 12.3 % of patients, while echocardiographic examination was used in only 1.9 %. The strongest independent predictors for the use of extended hemodynamic monitoring of any kind were mechanical ventilation, the need for catecholamine therapy, and treatment backed by protocols. In 71.6 % of patients in whom extended hemodynamic monitoring was added during the study period, this extension led to changes in treatment.ConclusionsExtended hemodynamic monitoring, which goes beyond the measurement of blood pressures, to date plays a minor role in the surveillance of critically ill patients in German, Austrian, and Swiss ICUs. This includes also consensus-based recommended diagnostic and monitoring applications, such as echocardiography and cardiac output monitoring. Mechanical ventilation, the use of catecholamines, and treatment backed by protocol could be identified as factors independently associated with higher use of extended hemodynamic monitoring.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0148-2) contains supplementary material, which is available to authorized users.

Preliminary Report on Efficacy of Acupuncture versus meToclopramide for Management of Post-Operative Gastroparesis (EAT POSTOP Trial)

Introduction: Gastroparesis is common in intensive care patients and may increase the incidence of malnutrition and nosocomial pneumonia, leading to poorer patient outcomes. Current pharmacotherapy has shown only modest efficacy. Acupuncture without pharmacotherapy has been shown to improve gastroparesis in animal studies and in recent clinical trials. However, no trials studying the efficacy of acupuncture as an adjunctive therapy for surgical intensive care patients have been done. This study aims to evaluate the effectiveness of adding electro-acupuncture therapy to pharmacotherapy in the management of gastroparesis in these patients. Methods: For this prospective block randomised controlled trial, we aim to recruit 200 adult surgical intensive care patients who require gastric enteral nutrition, and mechanical-assisted ventilation, and who have gastroparesis (gastric residual volumes more than 120 mL twice four hours apart). Patients will receive either metoclopramide 20 mg intravenously thrice daily (Group M) or electro-acupuncture comprising four sessions of 30-minute electro-acupuncture at specific sites over 48 hours in addition to intravenous metoclopramide 20 mg thrice daily (Group A). Gastroparesis resolution is defined as 24-hour cumulative gastric residual volumes less than 200 mL. Patients are followed-up for 48 hours from the commencement of therapy. Results: Three patients have been recruited in a four-month period thus far. Two are in Group A and one in Group M. All have met the study definition of gastroparesis resolution. The incidence of gastroparesis in this period among longer stayers in the unit (n = 92) is 8.7%. Conclusions: The trial is on-going. Reasons for the low incidence of gastroparesis are discussed. The study of the use of acupuncture in the treatment of intensive care patients with gastroparesis is worthwhile due to its excellent side-effect profile and if successful, will be a tool to improve nutritional support.

Levetiracetam compared to valproic acid: Plasma concentration levels, adverse effects and interactions in aneurysmal subarachnoid hemorrhage

Objective Both valproic acid and levetiracetam are anti-epileptic drugs, often used either alone or in combination. The present study compares valproate (VPA) with levetiracetam (LEV) as an intravenous (i.v.) anticonvulsant treatment in intensive care patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) with a high risk of seizures. Patients and methods A prospective, single-center patient registry of 35 intensive care unit (ICU) patients with onset seizure and/or high risk of seizures underwent an anticonvulsive, first-line single treatment regimen either with VPA or LEV. Plasma concentrations (pc), interactions between drugs in the ICU context, adverse effects and seizure occurrences were observed and recorded. Results A significant decrease in the pc in patients treated with LEV was observed after changing from intravenous (160 ± 51 μmol/l) to enteral liquid application (113 ± 58 μmol/l), corresponding to a 70.3% bioavailability for enteral liquid applications. The pc in VPA patients decreased significantly, from (491 ± 138 μmol/l) to (141 ± 50 μmol/l), after adding meropenem to the therapy ( p < 0.05). Three epileptic seizures occurred during anticonvulsive therapy in the LEV group, and two in the VPA group, including one non-convulsive status epilepticus (NCSE). Conclusion Though this finding needs further verification, the enteral liquid application of levetiracetam seems to be associated with lower bioavailability than the common oral application of levetiracetam. The use of the antibiotic drug meropenem together with valproic acid leads to lower pc levels in patients treated with of valproic acid. For clinical practice, this indicates the need to monitor the levels of valproic acid in combination with meropenem.

Using nonlinear model predictive control to find optimal therapeutic strategies to modulate inflammation

Modulation of the inflammatory response has become a key focal point in the treatment of critically ill patients. Much of the computational work in this emerging field has been carried out with the goal of unraveling the primary drivers, interconnections, and dynamics of systemic inflammation. To translate these theoretical efforts into clinical approaches, the proper biological targets and specific manipulations must be identified. In this work, we pursue this goal by implementing a nonlinear model predictive control (NMPC) algorithm in the context of a reduced computational model of the acute inflammatory response to severe infection. In our simulations, NMPC successfully identifies patient-specific therapeutic strategies, based on simulated observations of clinically accessible inflammatory mediators, which outperform standardized therapies, even when the latter are derived using a general optimization routine. These results imply that a combination of computational modeling and NMPC may be of practical use in suggesting novel immuno-modulatory strategies for the treatment of intensive care patients.

Blood glucose monitoring and nursing of intensive care patients with intensive insulin therapy

Objective To investigate the practical effects of intensive insulin therapy in intensive care patients. Methods A retrospective study was performed, 51 intensive care patients received intensive insulin therapy as observation group;and 51 intensive care patients received routine insulin therapy as control group. nosocomial infection rate, hypoglycemia rate and mortality were compared between the two groups. Results Intensive insulin therapy reduces the incidence of nosocomial infection and hospital mortality (P ＜ 0. 05). Conclusions Intensive insulin therapy plays an important role in the treatment of intensive care patients. Key words: Intensive care; Intensive insulin therapy; Blood glucose monitoring; Nursing

Using nonlinear model predictive control to find optimal therapeutic strategies to modulate inflammation

Modulation of the inflammatory response has become a key focal point in the treatment of critically ill patients. Much of the computational work in this emerging field has been carried out with the goal of unraveling the primary drivers, interconnections, and dynamics of systemic inflammation. To translate these theoretical efforts into clinical approaches, the proper biological targets and specific manipulations must be identified. In this work, we pursue this goal by implementing a nonlinear model predictive control (NMPC) algorithm in the context of a reduced computational model of the acute inflammatory response to severe infection. In our simulations, NMPC successfully identifies patient-specific therapeutic strategies, based on simulated observations of clinically accessible inflammatory mediators, which outperform standardized therapies, even when the latter are derived using a general optimization routine. These results imply that a combination of computational modeling and NMPC may be of practical use in suggesting novel immuno-modulatory strategies for the treatment of intensive care patients.

Does growth hormone allow more efficient nitrogen sparing in postoperative patients requiring parenteral nutrition? A double-blind, placebo-controlled randomised trial

Growth hormone (GH) has a strong anabolic effect and is thought to be useful in improving the efficacy of parenteral nutrition (PN) to preserve muscle mass (MM) in the postoperative setting. Unfortunately, the negative clinical outcome of GH treatment in intensive care patients limits its use in this setting, but demands answers to the mechanism behind the action of this therapy. In a double-blind randomised controlled study consecutive patients after major abdominal surgery were divided into four groups of either 1/2-PN (0.13 g N/kg/day and 52% of calories as lipid) or full-strength PN (Full-PN) (0.3 g N/kg/day and 65% of calories as lipid) receiving daily injections of either GH (8-16 IU) or placebo for a period of 14 days postoperative. Outcome measures included MM derived from measures of total body potassium (40K counting) and total body nitrogen (TBN) (in vivo neutron capture technique); Fat mass from skin folds; serum insulin like growth factor-I (IGF-I) and its binding proteins (IGFBP). From 43 major upper GI surgical patients randomised 35 completed the study (one patient died from sepsis in the half-strength PN (1/2-PN)+GH group). 1/2-PN (n=11) lost TBN (P=0.001), MM (P=0.005) but not fat. Full-PN (n=9) maintained TBN, MM (P=0.056) and fat. 1/2-PN+GH (n=8) maintained TBN and fat but lost MM (P=0.038). Full-PN+GH (n=7) maintained TBN and MM but lost fat (P=0.018). Two-way ANOVA indicated that PN input (P=0.031) and not GH had a significant effect on MM. GH caused a significant rise in IGF-I levels (290+/-67 and 454+/-71 microg/l for 1/2-PN+GH and Full-PN+GH, respectively) and restored serum IGFBP3 and the acid labile subunit to normal, by the postoperative day 9. After major gastrointestinal surgery, GH causes a marked hepatic IGF-I response and nitrogen retention but its effect on body composition was more significant with a high PN input. Further, Full-PN alone was sufficient to prevent nitrogen loss and preserved MM and addition of GH does not provide further metabolic advantage.

Strategies for the Treatment of Acute Renal Failure in Intensive Care Units: The Aspect of Dosing

Despite all the medical progress, the mortality rate in intensive care units for patients with acute renal failure (ARF) remains high, among specific patient populations, up to 88% [Letourneau I, Dorval M, Belanger R, Legare M, Fortier L, Leblanc M. Acute renal failure in bone marrow transplant patients admitted to the intensive care unit. Nephron Apr 2002; 90(4), 408–12.]. Recent trial results indicate that patient survival may be improved by adequate renal replacement therapy. In particular, the dose of intermittent and continuous renal replacement therapies has proved to be a significant factor affecting patient survival. Daily intermittent hemodialysis, e.g., is superior to alternate‐day intermittent hemodialysis, and with continuous therapies, survival is related to the filtration rate. Further relevant factors include early initiation of renal replacement therapy, choice of biocompatible membranes and the application of bicarbonate‐buffered replacement solutions for defined patient groups. The advantages offered by continuous techniques could be demonstrated for individual patient groups; in meta‐analyses, advantages were shown for the total population of patients with ARF. Other than for patients with chronic renal failure (NKF—DOQI. Clinical practice guidelines for hemodialysis adequacy. Am J Kid Dis 1997; Vol. 30, 515–566.), there are no current clinical guidelines for a standard treatment of intensive care patients with ARF. Therefore, such a treatment standard still needs to be determined.

Economic Implications of Optimal Diagnosis and Treatment of Sepsis – Work in Progress: Marginal Penalties, Antibiotic Alterations, and Outcome Hypotheses

Our goals: (a) to design value strategies for optimal diagnosis and treatment of sepsis; (b) to assess theoretical marginal penalties of inadequate antimicrobial treatment of intensive care patients with infections (case study); and (c) to analyse physician antibiotic alterations in patients with blood cultureproven bloodstream infections. Marginal penalties, which reflect extra procedures and excess costs arising from uninformed treatment decisions, were transformed to subject group‐distributed opportunity costs. Value analysis revealed substantial marginal penalties associated with adverse factors, such as increased ICU length of stay, procedures (catheterisation, mechanical ventilation, tracheostomy) and ultimately, higher mortality, in critically ill patients. Investigation of 66 septicaemica patients (International Classification of Disease [ICD‐9] code 038 and related derivatives) hospitalised over 17 months revealed that physicians altered antibiotics extensively during three time intervals: TI1—collection of blood for culture to qualitative positive blood culture notification, TI2—notification to final MIC result, and TI3—final MIC result to 72 hours afterward. Empirical antibiotic alterations during TI1 may have adversely affected survival. Alterations peaked after blood collection and after notification of qualitative positive blood culture results. Based on patterns of alterations and 28‐day mortality, we hypothesize that nucleic acid testing, if used to identify organisms and rule in bloodstream infections early (4–6 h) following admission, will help facilitate diagnosis, focus antibiotic therapy, and avert dysfunctional sepsis cascades. Reduced “alteration debt” and marginal penalties should offset the costs of nucleic acid testing. The potential for enhanced survival and improved outcomes warrants clinical trials of rapid nucleic acid testing to decrease indiscriminate antibiotic alterations, evaluate proposed value strategies, and test outcome hypotheses.

Durée du traitement antibiotique en réanimation : données actuelles

Duration of antibiotic treatment in intensive care patients: current data. Objective: To review the current data on the duration of an antibiotic treatment. Methods: Analysing of recent and older articles on criteria of discontinuation of an antibiotic treatment in intensive care patients. Synthesis: In intensive care patients the initiation of an antibiotic therapy is mor or less codified, in spite of numerous existing problems. The duration of its maintenance, although based on scientific data depends mainly on a multitude of variables. The first step is to assess the therapeutic efficiency in considering the regression of clinical manifestations, the normalization of the acute phase reactants, the sterility of bacteriological samples and the absence of relapse at therapy discontinuation. An assessment after 48 hours is essential, in order to decide the maintenance or the modification of therapy. Finally the indication of bitherapy is considered. The theoretical duration of antibiotic therapy is determined in taking into account the involved microbial agent(s), the centre of infection, the bacterial inoculum, the patient, the presence of foreign material, and the administered antibiotic.

Pharmaco-économie du traitement des infections sévères en réanimation

Pharmacoeconomics of the treatment of intensive care patients with severe infections. Pharmacoeconomics play an increasing role in rational decision-making for public health and therapeutic strategies. Relevant concepts such as benefit, efficacy, efficiency and utility have to be clearly defined. Fractionating the hospital costs implies to separate direct (medical and non-medical), indirect and intangible costs, fixed and variable costs. The costs of side-effects, biological tests, administration of the drug and therapeutic failures have to be taken into account. From the medical point of view, the main pharmacoeconomic criterium is the cost/efficacy ratio, not the acquisition costs of the drug. Examples of the translation of these concepts to antibiotherapy in the intensive care unit are given, with analysis according to the principles of evidence-based medicine.