Search

In this article we have attempted to delineate the importance of developmental levels in a young person's response to stressors and, conversely, the effect of stressors on levels of development. In so doing, we isolated specific lines of development from their context. We neglected the important roles of rewards and punishments, permissions and prohibitions, family and community dynamics, values, stories and myths. Even in this simplified schema, we have not addressed the importance of protective and risk factors, neither of which are found in isolation; but all of these issues are the subject of articles elsewhere in this issue.

TDPs occasionally are used to standardize or control respiratory management of the critically ill. Weaning protocols are most common. Little objective evaluation of the effects of TDPs in the critically ill has been published. Most protocols have been developed to improve efficiency of respiratory care staff and reduce unnecessary treatments in non-ICU patients. The most important reason for using TDPs in the ICU is to improve consistency of care. Reduction of variation between individual therapist style improves physicians' trust in the respiratory care department. Improved consistency may allow novel ICU therapies to be evaluated objectively. In general, TDPs are not directly transportable from one area or institution to another. TDPs require local development, and all interested parties must be part of the development process for success. The process of creating TDPs provides a forum for physicians, nurses, and therapists to establish mutual respect and understanding. The analytic approach needed to create useful TDPs provides a critical evaluation of unit procedures and promotes changes in care delivery extending outside the TDP. The complexity of disease process and patient care in the ICU makes comprehensive TDPs difficult to establish; however, use of computers for decision support can overcome the limitations of paper flow charts. Even without comprehensive TDPs, the development process is important to improving and understanding care of the critically ill. The effects of TDPs on ICU patient outcome are unknown currently. Benefits are possible and improved collaboration, better respiratory care staff morale, consistency of approach to care, and critical approach to clinical decision making can be gained by attempting to develop TDPs for respiratory care delivery in the ICU.

One of the most demanding and stressful situations is management of the agitated, unintubated, critically ill patient. Sedation often must be provided without a specific diagnosis, and the need for rapid airway control must be anticipated. No predictably safe and effective techniques are proven. The experience and skill of the physician managing the patient during sedation are the predictive factors for the best outcome. Even in expert hands, airway compromise and cardiovascular decompensation often occur in these very ill patients. Many techniques for sedation have been described. Treatment of pain followed by small boluses of intravenous sedative agents is a reasonable initial approach. Benzodiazepines have a good safety record and provide good amnesia. Other agents have been used, by themselves or in combination. Haloperidol may have a therapeutic advantage in the disoriented, agitated patient. Prolonged need for significant sedative medication usually mandates a secure airway. Once this is accomplished, the requirement for a continuously present airway expert at the bedside is removed. The standard for sedating a patient without an artificial airway requires a higher level of expertise than sedating a critically ill patient with an artificial airway.

Over a 26-month period we assessed the ability of APACHE II, scored on admission to the surgical intensive care unit (SICU), to predict the in-hospital mortality of liver and kidney transplant recipients either post-operatively or after subsequent complications, and compared these results to non-transplant SICU admissions. There were 866 SICU admissions, of which 128 were liver transplant recipients, 112 were renal transplant recipients, 211 were trauma admissions and 415 were non-transplant/non-trauma admissions. In hospital mortalities among all liver transplant admissions were 0%, 10%, 38%, and 82% for APACHE II ranges of 0-10, 11-20, 21-30 and > 30, respectively, with differences between the second and third, and third and fourth ranges significant (p < or = 0.05 by chi-square analysis). These differences were also seen when examining scores following the primary transplantation alone. Mortalities in corresponding APACHE II ranges for trauma and nontransplant/nontrauma admissions were similar. APACHE II scoring was not useful for renal transplant recipient, as it consistently overpredicted mortality. We conclude that APACHE II scoring may be useful in predicting outcome in post-operative liver transplant recipients, but is not useful in stratifying risk in renal transplant recipients due to the inherently low mortality involved.

Objectives: To determine which clinical features are associated with bacteremia in a SICU. To determine if infections are identified prior to bacteremia via culturing of other body fluids. To determine if antibiotic regimens are changed after the results of the blood culture were obtained., Design: A retrospective, unit-based, case control study., Setting: A 10 bed SICU in a 552-bed, tertiary care and Level I Trauma center., Patients: All SICU patients with one or more positive blood cultures over a 2 year period (n = 24) were matched by diagnosis, procedure, and age to SICU patients with negative blood cultures (n = 48)., Measurements and Results: Bacteremic and control patients had similar APACHE II scores though death was more likely in bacteremic patients (p < 0.05) and they had higher hospital charges (p < 0.02). There was no difference in any of the clinical variables studied (minimum and maximum temperature, maximum white blood cell count, minimum mean arterial blood pressure) between the bacteremic and control groups on the days leading up to and the day of the positive blood culture. Coincident infections of lung, bladder, wound, and central venous catheters were identified in 42% of bacteremic patients. The identification of organisms found in the blood had a direct impact on the antibiotic regimen of 54% of the bacteremic patients., Conclusions: A better screen for obtaining blood cultures in this SICU was not identified. If antibiotics are begun empirically before the results of blood cultures are known, the results of other body fluid cultures can be used to guide therapy initially. However, the data obtained from positive blood cultures was often helpful in changing empirical therapy. Therefore, blood cultures remain important diagnostic tools.

Critically ill patients experience many unpleasant and frightening events while in an ICU. Appropriate concern for pain, discomfort, and anxiety is required from caregivers. The use of reassuring mannerisms, honest communication, and analgesics and sedatives, especially during therapeutic paralysis, improves patient comfort and reduces the morbidity rate. This article reviews the therapeutic options for sedation and experience with these agents in the critically ill.

Objective: To determine characteristics of patients requiring readmission to an intensive care unit (ICU)., Design: Retrospective case-control chart review., Setting: Adult patients in an 8-bed medical and 16-bed surgical ICU in a 650-bed university teaching hospital during an 18-month period., Interventions: None., Methods: Each patient readmitted to either ICU was compared to a single control patient matched for age, sex, unit, and diagnosis. A total of 117 variables were obtained from chart review. The last value for each variable before ICU discharge was used. Chi-square analysis, linear regression factor analysis, correlation, and Student's t-test were used to identify significant factors predicting the patient's return to an ICU. Descriptive statistics were used to describe various subgroups., Results: Mortality rate was 41.5% in the 82 readmitted patients (comprising 4.6% of the total ICU admissions) and only 7.3% in the controls. Mean (+/- SD) hospital length of stay was 47.8 +/- 42.0 days in the study group and 20.8 +/- 14.2 days (p < .0009) in the controls. Initial ICU length of stay was 8.3 +/- 16.1 days in the readmitted group and 4.0 +/- 5.0 days (p = .02) in the controls. Variables that predicted readmission to the ICU were: increased respiratory rate (24.2 vs. 20 breaths/min, p < .002), lower hematocrit value (31.9% vs. 34.4%, p = .01), positive fluid balance (p < .03), and positive blood cultures (six in the readmitted group, none in the controls, p = .002). More than 30% of readmissions were for a recurrence or worsening of the original problem. Fifty-four percent of the patients were readmitted with pulmonary failure. Mortality rate in both groups was related to advanced age, Acute Physiology and Chronic Health Evaluation (APACHE II) scores at ICU discharge, and increased blood urea nitrogen concentrations. Mortality rate in the control group, but not in the readmitted group, correlated with the level of consciousness, serum creatinine concentration, and use of hemodialysis., Conclusions: Readmission to an ICU carries a risk of high mortality rate and increased length of stay and may represent premature discharge in at least 30% of patients. Pulmonary failure is the immediate cause of readmission in more than half of the readmitted patients. Increased respiratory rate correlates with ICU readmission. Intermediate care areas for patients with poor pulmonary function may help to avoid readmission to an ICU, prevent death, and conserve hospital resources.

The number of anesthesiology residents pursuing critical care medicine (CCM) fellowship training has been decreasing in recent years. A significant number of training positions remain unfilled each year. Possible causes of this decline were evaluated by surveying residents regarding their attitudes toward practice and training in CCM. All 38 anesthesiology programs having accredited CCM fellowships were surveyed. Four of these and one program without CCM fellowships were used to develop the survey instrument. Four programs without CCM fellowships and 34 programs with CCM fellowships make up the survey group. Returned were 640 surveys from 37 (97%) programs accounting for over 30% of the possible residents. Resident interest in pursuing CCM training decreased as year of residency increased (P < 0.0001). Residents in programs with little patient care responsibility during intensive care unit (ICU) rotations expressed less interest in CCM training (P < 0.012). The administrative role of the anesthesiology department in the ICU also influenced resident interest (P < 0.014). Written responses to open-ended questions suggested resident concerns with the following: stress of chronic care, financial consequences of additional year of training, ICU call frequency and load, ICU role ambiguity, and shared decision-making in the ICU. A recurring question was, "Are there jobs (outside of academics) for anesthesiologist intensivists?" Most residents knew a CCM anesthesiologist they admired and knew that there were unfilled fellowship positions available. Defining the job market, improving curriculum and teaching, supporting deferment of student loans, and introducing residents and medical students to the ICU earlier may increase the interest in CCM practice among anesthesiology residents.

Temporary dual chamber atrioventricular (AV) pacing is often used to increase cardiac output (CO) after cardiac surgery. The AV interval was varied to investigate the effect on CO in 13 patients. CO was computed from the Fick principle using mixed venous oxygen saturation (SvO2), arterial oxygen saturation (SaO2), hemoglobin, and oxygen consumption (VO2). AV intervals were varied randomly from 0.025 to 0.300 seconds in 0.025-second increments. The effect on CO from increasing the AV interval was dependent on the control CO. In all patients, as the AV interval was increased from 0.025 to 0.100 seconds, CO progressively increased. In most patients, the highest (optimal) CO occurred with AV pacing and averaged 300 mL/min greater than with atrial (A) pacing alone (P < .0001). In patients with a high initial CO (> 6.0 L/min), CO peaked and averaged 0.5 L/min more than with A pacing. CO was maximal for each of these patients at a unique AV interval between 0.100 and 0.225 seconds, and at intervals greater than 0.225 seconds CO decreased (P < .01). In patients with intermediate CO (4-6 L/min) at AV intervals greater than 0.100 seconds, a plateau in CO was reached. No consistent pattern was seen in patients with low initial CO (< 4.0 L/min). Maximal CO may be achieved by optimizing the AV interval in patients following cardiac surgery. The optimal AV interval is between 0.100 and 0.225 seconds and is different for each patient. Continuous SvO2 monitoring allows rapid evaluation of CO changes and optimization of the AV pacing interval.

This study is a retrospective review of all patients who died without cardiopulmonary resuscitation (CPR) or who sustained a sudden cardiopulmonary arrest in the hospital and received CPR during a 2-yr period at a large medical center. Based on a review of Current Procedural Terminology codes, patients were classified into one of the ten disease categories: multiple medical problems, acute disease, procedure-related, congenital disease, neoplasm, metastatic neoplasm, trauma, burn, acquired immunodeficiency syndrome, and dementia. A total of 1206 patient deaths without a CPR effort were identified. CPR was administered to another 550 patients who had a sudden cardiopulmonary arrest, of which 71% survived the resuscitative attempt initially, but only 25% survived CPR until discharge from the hospital. CPR was applied less frequently than the mean in the metastatic neoplasm (P < 0.0001), trauma (P = 0.013), and dementia (P = 0.0003) groups and more frequently in the acute disease (P < 0.0001) and procedure-related (P < 0.0001) groups. Survival to discharge from the hospital was more frequent than the mean in the congenital disease group (P = 0.0004) and less frequent in the neoplasm group (P = 0.0425). The other groups had survival rates comparable to the mean. Patients 70 yr of age and older were less likely to receive CPR than those younger than 70 (P < 0.0001). However, if they did receive CPR, they were just as likely to survive to discharge from the hospital as the younger patients (P = 0.3404).(ABSTRACT TRUNCATED AT 250 WORDS)

We investigated the effects of establishing a blood gas analysis service controlled by respiratory care practitioners (RCPs) on the appropriateness of arterial blood gas (ABG) sampling. An ABG analyzer was placed outside the surgical intensive care unit (SICU) and only RCPs were permitted to process samples on it. In 1-month and 1-year follow-up audits of appropriateness of ABG analysis, the nursing staff improved from 42% appropriate to 73% appropriate in both follow-up periods. RCPs maintained a high degree of appropriateness in all periods (90%, 87%, and 91%), although the percentage of the total ABGs performed by RCPs increased. Additional benefits included a better mutual understanding of each caregiver's role and work load, more collaboration among caregiver groups, and caregiver's perception of improved patient care.

Objective: To determine factors influencing rationing decisions in a surgical ICU during a temporary nursing shortage when two to six of the unit's 16 beds were closed., Design: Blinded, concurrent data collection, retrospective chart review., Setting: Surgical ICU., Patients: All patients (n = 308) for whom a surgical ICU bed was requested were studied during a 3-month period., Measurements and Main Results: Admitting patterns did not change and no attempts were made to limit admissions to more severely ill patients during times of the greatest shortage of surgical ICU beds. Contrary to findings in previous reports, the severity of illness of patients admitted to the surgical ICU decreased as bed availability and bed census decreased. Bed allocation across surgical services was influenced by factors other than medical suitability. Of major users, cardiothoracic surgery experienced the highest percentage (59%) of all patient admissions and lowest percentage (1.6%) of all denied admissions. General surgery experienced the lowest percentage (15%) of all admissions and highest percentage (10.4%) of all denied admissions, although these patients had the highest average Acute Physiology and Chronic Health Evaluation (APACHE II) scores for all patients admitted (17.7) and for patients denied admission (15.8)., Conclusions: Surgical attending physicians rarely used other open inhouse ICU beds when surgical ICU beds were unavailable. Political power, medical provincialism, and income maximization overrode medical suitability in the provision of critical care services.

The use of sedatives and muscle relaxants is common in the ICU. Therapeutic goals should be carefully established. Monitoring of desired effects and toxic side effects is essential to avoid preventable morbidity.

Pulmonary artery catheters are frequently used and may be the cause of pulmonary artery rupture. The "feel" of balloon inflation, a clinical sign of a "wedged" catheter, was noted to vary among different manufacturers' catheters. The inflation pressures of five catheters from four manufacturers were examined in the laboratory. Peak pressures ranged from 475 +/- 10 mm Hg to 1,037 +/- 36.8 mm Hg. Plateau pressures ranged from 220 +/- 4 mm Hg to 495 +/- 2.9 mm Hg. Catheters with high inflation pressures may make detection of a wedged catheter by feel impossible and, thus, may increase the risk of a pulmonary artery rupture.

The effects of intravenous dantrolene sodium, alone and in combination with verapamil, upon atrioventricular conduction, cardiovascular function, and neuromuscular function were studied in chloralose-urethane anesthetized dogs. Hemodynamic variables (systemic arterial, central venous, and pulmonary arterial pressures and cardiac output) and His-bundle electrograms were monitored, and measurements were made during atrial pacing at 175 beats/min, as well as at the spontaneous heart rate. In one part of the study animals received dantrolene sodium incrementally at 30-min intervals to cumulative doses of 1, 2.5, 5, and 10 mg/kg. Subsequently, verapamil was administered incrementally at 30-min intervals to cumulative doses of 0.1, 0.2, 0.4, and 0.6 mg/kg. In the second part of the study, dogs received identical dosage sequences, but verapamil preceded dantrolene administration. Dantrolene caused no significant depression of atrioventricular conduction or cardiac performance but did increase systemic vascular resistance at doses above 2.5 mg/kg. Verapamil alone (greater than or equal to 0.2 mg/kg) or with dantrolene (greater than or equal to 0.1 mg/kg) increased the atrial-His-bundle conduction interval. In the presence of verapamil, dantrolene (greater than or equal to 2.5 mg/kg) decreased cardiac index and increased pulmonary artery occlusion pressure. Although 0.6 mg/kg verapamil depressed cardiac index and increased pulmonary artery occlusion pressure, this effect was observed at 0.4 mg/kg after prior treatment with dantrolene. Verapamil did not augment the dose-dependent twitch depression observed with dantrolene. Dantrolene alone had no apparent effect on atrioventricular conduction and caused little enhancement of the effects of verapamil. However, each drug appeared to enhance the myocardial depressant effects of the other.

Although the hemodynamic changes produced by small doses of nalbuphine given to patients with cardiac disease are minimal, the cardiovascular effects of large doses which have been used as supplements for general anesthesia have not been investigated. Cardiovascular variables were measured after incremental doses of nalbuphine, up to 2 or 3 mg/kg in fourteen patients with coronary artery disease with normal left ventricular function and in seven patients with mitral valve disease. No significant changes in cardiac index, stroke work index, mean arterial pressure, pulmonary diastolic or wedge pressure, heart rate, or central venous pressure occurred in the preoperative period. However, nalbuphine alone did not produce surgical anesthesia and the addition of diazepam, nitrous oxide, or halothane was required in all patients. The addition of halothane coupled with surgical stimulation significantly decreased cardiac and stroke indices, increased mean arterial and pulmonary wedge pressures, and increased systemic vascular resistance in patients with coronary artery disease. In patients with mitral valve disease, following surgical incision, there were small but significant decreases in cardiac index and left ventricular stoke work index, and increases in systemic vascular resistance. Despite its lack of deleterious hemodynamic effects, the place of nalbuphine in the armamentarium of the anesthesiologist must be limited to use as a premedicant, as an adjunct to balanced anesthesia, or for postoperative pain relief.

Hydrochloric acid (HCl) infusions for the correction of metabolic alkalosis have been used for 20 yr. In the critical care setting, HCl is usually infused through a central venous or pulmonary artery (PA) catheter. In two patients receiving HCl infusions through a PA catheter, we observed and examined solid yellow particulate material in the aspirating syringe while testing the proximal lumen for patiency. We carried out in vitro investigation infusing PA catheters with 0.1, 0.2, 0.3, and 0.4 normal HCl at 20 degrees, 38 degrees, and 42 degrees C for 24 and 48 h. Although frank catheter deterioration could not be documented, the surface and interior of those catheters infused with greater than 0.1 normal HCl changed texture, indicating a change in catheter composition. Exceeding a concentration of 0.1 normal is not recommended when HCl is infused through PA catheters.