Are written advance directives helpful to guide end-of-life therapy in the intensive care unit? A retrospective matched-cohort study

Purpose

The purpose of the study was to determine whether treatment preferences in patients' advance directives (ADs) are associated with life-supporting treatments received during end-of-life care in the intensive care unit (ICU).

Material and methods

This is a retrospective cohort study, including patients who died in 4 ICUs of a university hospital in Germany. Patients with ADs were matched with 2 patients each without ADs using propensity scores.

Results

Sixty-four (13%) of 477 patients had ADs, written a median of 109 weeks before admission. Five categories of applicability conditions were identified, most of them difficult to interpret in the ICU (eg, “advanced brain impairment” or “imminent death”). Advance directives contained a number of treatment refusals. Specifically, 63 of 64 refused “life-sustaining measures.” Compared to patients without ADs, patients with ADs were less likely to receive cardiopulmonary resuscitation (9% vs 23%, P = .029) and more likely to have do-not-resuscitate orders (77% vs 56%, P = .007). Therapy-limiting decisions and ICU length of stay did not differ between those with or without ADs.

Conclusions

Patients with ADs are less likely to receive cardiopulmonary resuscitation but otherwise receive similar life-sustaining treatments compared to matched patients without ADs. More research is needed to explore reasons for potential noncompliance with patient preferences.     

Eye care for the critically ill

Purpose: To evaluate the effectiveness and efficiency of an algorithm in the prevention of ocular surface disease in sedated and unconscious patients in the intensive care unit (ICU).¶Methods: The eyes of all sedated and unconscious patients admitted to an ICU between September and December 1998 were managed according to an eye care algorithm. The applications of the preventive measures were assessed by a single observer twice weekly. The lid position, the presence and degree of keratopathy, sedation score, and the treatment received were documented at every assessment.¶Results: Thirty-four patients were recruited for management according to the eye care algorithm over a period ranging from 1 to 28 days. Four patients were excluded because of failure by staff to adhere to the protocol. In 18 patients no active treatment was required. Out of six patients who had conjunctival exposure and were given ocular lubricants, four maintained clear corneas. No corneal or conjunctival staining was noted in two of the four patients whose lids required closure with Micropore tape for corneal exposure. Use of lid taping and lubricants prevented corneal abrasion in two patients who were prone ventilated. The prevalence of ocular surface abnormalities was 8.7 % where the algorithm was properly followed (23 patients).¶Conclusion: The proposed eye care algorithm appears to be effective in preventing ocular surface abnormalities in the sedated and unconscious patients in the ICU, and efficient in that it may reduce the workload required for critically ill patients.     

Assessing the quality of interdisciplinary rounds in the intensive care unit

Purpose

Interdisciplinary rounds (IDRs) in the intensive care unit (ICU) are increasingly recommended to support quality improvement, but uncertainty exists about assessing the quality of IDRs. We developed, tested, and applied an instrument to assess the quality of IDRs in ICUs.

Materials and Methods

Delphi rounds were done to analyze videotaped patient presentations and elaborated together with previous literature search. The IDR Assessment Scale was developed, statistically tested, and applied to 98 videotaped patient presentations during 22 IDRs in 3 ICUs for adults in 2 hospitals in Groningen, The Netherlands.

Results

The IDR Assessment Scale had 19 quality indicators, subdivided in 2 domains: “patient plan of care” and “process.” Indicators were “essential” or “supportive.” The interrater reliability of 9 videotaped patient presentations among at least 3 raters was satisfactory (κ = 0.85). The overall item score correlations between 3 raters were excellent (r = 0.80-0.94). Internal consistency in 98 videotaped patient presentations was acceptable (α = .78). Application to IDRs demonstrated that indicators could be unambiguously rated.

Conclusions

The quality of IDRs in the ICU can be reliably assessed for patient plan of care and process with the IDR Assessment Scale.     

Does high-dose vasopressor therapy in medical intensive care patients indicate what we already suspect?

Purpose

This study was conducted to determine the association between vasopressor requirement and outcome in medical intensive care patients in an environment where treatment is not withdrawn.

Materials and Methods

This was an observational study of patients in the medical intensive care unit (ICU) over a period of 18 months to determine the correlation between vasopressor requirement and mortality. Outcome was determined for all medical ICU patients, for patients receiving “low dose” (< 40 μg/min) vasopressors (noradrenaline and/or adrenaline) or “high dose” (≥ 40 μg/min) vasopressors. Receiver operator characteristic curves were constructed for ICU and hospital mortality and high-dose vasopressor use. High-dose vasopressor use as an independent predictor for ICU and hospital mortality was also determined by multiple logistic regression analysis.

Results

Patients receiving high-dose noradrenaline at any time during their ICU admission had an 84.3% mortality in ICU and 90% in hospital. The receiver operator characteristic curves for high-dose vasopressors had an area under the curve of 0.799 for ICU mortality and 0.779 for hospital mortality. High-dose vasopressor was an independent predictor of ICU mortality, with an odds ratio of 5.1 (confidence interval, 2.02-12.9; P = .001), and of hospital mortality, with an odds ratio of 3.82 (confidence interval 1.28-11.37; P = .016).

Conclusions

The requirement for high-dose vasopressor therapy at any time during ICU admission was associated with a very high mortality rate in the ICU and the hospital.     

Improving verbal communication in critical care medicine

Human errors are the most common reason for planes to crash, and of all human errors, suboptimal communication is the number 1 issue. Mounting evidence suggests the same for errors during short-term medical care. Strong verbal communication skills are key whether for establishing a shared mental model, coordinating tasks, centralizing the flow of information, or stabilizing emotions. However, in contrast to aerospace, most medical curricula rarely address communication norms during impending crises. Therefore, this article offers practical strategies borrowed from aviation and applied to critical care medicine. These crisis communication strategies include “flying by voice,” the need to combat “mitigating language,” the uses of “graded assertiveness” and “5-step advocacy,” and the potential role of Situation, Background, Assessment, and Recommendation communication. We also outline the “step-back method,” the concept of communication “below ten thousand feet,” the impetus behind “closed-loop communication,” and the closely related “repeat-back method.” The goal is for critical care practitioners to develop a “verbal dexterity” to match their procedural dexterity and factual expertise.     

Outcome of hypotensive ward patients who re-deteriorate after initial stabilization by the Medical Emergency Team

Purpose

We evaluated the outcome of hypotensive ward patients who re-deteriorated after initial stabilization by the Medical Emergency Team (MET) in our hospital, due to limited data in this regard.

Methods

One thousand one hundred seventy-nine MET calls in 32184 ward patients from January 2009 to August 2011 were evaluated. Four hundred ten hypotensive patients met study criteria and were divided into: (1)“Immediate Transfers (IT), n = 136”:admitted by MET to intensive care unit (ICU) immediately; (2)“Re-deteriorated Transfers (RDT) n = 72”:initially stabilized and signed off by MET, but later re-deteriorated within 48-hours and admitted to ICU; (3)“Ward Patients (WP) n = 202”: remained stable on ward after treatment.

Results

The RDT and IT had similar APACHE II scores (20.2 ± 5.1 vs. 19.8 ± 4.8; P= .57], but RDT showed hemodynamic stabilization with initial MET resuscitation. Patients who re-deteriorated were younger, took longer for eventual ICU transfer, had higher initial lactic acid and delayed normalization as compared to IT (P < .04). The re-deterioration predominantly occurred within 8-hours of MET evaluation. RDT had higher 28-day mortality than IT and WP; 42% vs. 27% vs. 7% respectively (P < .03). RDT also had a higher rate of endotracheal intubation and worse ICU mortality (P < .01).

Conclusion

Hypotensive ward patients who re-deteriorate after initial stabilization have higher mortality. METs should consider implementing at least an 8-hour follow-up in patients who are deemed stable to remain on the wards after hypotensive episodes.     

重症监护室护士眼部护理知识掌握与实践状况分析

目的调查重症监护室（ICU）护士眼部护理知识掌握情况及其眼部护理实践状况。方法自行设计ICU患者眼部护理知识调查表和ICU患者眼部护理实践调查表对上海市3所三级甲等医院145名相关ICU护士进行问卷调查。结果按百分制计算，ICU护士眼部护理知识的总得分为65．66±5.0，引发眼部并发症的危险因素得分为91.5±9．5，眼部护理不当可能导致的并发症的认知为37．0±5.2；知识的掌握与其在ICU工作年限呈正相关。在护理实践方面，分别有80．7％和88.3％的护士表示能做到评估和清洁眼部，100％的护士表示对眼睑闭合不全采用了必要的干预。结论应对相关专业人员进行重症患者眼部护理知识的教育以有效防治ICU患者眼部并发症。     

Ocular examination techniques for the emergency department

The purpose of this article is to provide a guide to assist the Emergency Physician in examining the eye. The evaluation of a patient with eye problems consists of a history, visual acuity, pupil examination, external examination, extra ocular movements, visual fields, and color vision. The patient is then examined at the slit lamp. After the slit lamp examination, the fundus and optic nerve is examined with a direct ophthalmoscope and intraocular pressure is measured. Special tests such as a plain film study and computed tomography (CT) scan may be obtained when indicated and, finally, referral to an ophthalmologist can be made for a dilated fundus examination, ultrasound studies of the eye and orbit, and surgical treatment.     

The effect of health insurance disparities on the health care system

UNINSURED PATIENTS put a strain on the health care system that ultimately results in increased health care costs for everyone.THE CHALLENGES faced by the Harris County Hospital District in Houston, TX, as a result of an increasing number of uninsured and underinsured patients include overcrowding in its health care facilities, decreased reimbursement from government programs, and patients who postpone seeking medical treatment until their situation is emergent and whose care is therefore more expensive.STRATEGIES FOR ADDRESSING these problems may include instituting an “everybody pays” program, improving access to care for the uninsured, and reducing or eliminating unnecessary services. AORN J 86 (November 2007) 745-756.     

From SOLER to SURETY for effective non-verbal communication

Background

This paper critiques the model for non-verbal communication referred to as SOLER (which stands for: “Sit squarely”; “Open posture”; “Lean towards the other”; “Eye contact; “Relax”). It has been approximately thirty years since Egan (1975) introduced his acronym SOLER as an aid for teaching and learning about non-verbal communication.

Aim

There is evidence that the SOLER framework has been widely used in nurse education with little published critical appraisal. A new acronym that might be appropriate for non-verbal communication skills training and education is proposed and this is SURETY (which stands for “Sit at an angle”; “Uncross legs and arms”; “Relax”; “Eye contact”; “Touch”; “Your intuition”).

The new model

The proposed model advances the SOLER model by including the use of touch and the importance of individual intuition is emphasised. The model encourages student nurse educators to also think about therapeutic space when they teach skills of non-verbal communication.     

Orbital Compartment Syndrome and Irreversible Blindness Related to Orbital Varix Thrombosis: A Case Report

BackgroundOrbital compartment syndrome (OCS) is an ocular emergency that can severely threaten the visual potential. The most common etiologies include facial trauma-related orbital wall fractures and postoperative bleeding within the orbit. Nontraumatic cases were also reported sporadically, although they are rare. The orbital volume limits the compliance to expand when space-occupying lesions develop. Both direct compression of the optic nerve and depleted perfusion from elevated intraorbital pressure subsequently lead to ischemic optic neuropathy and vision loss.Case ReportA 74-year-old man experienced headache, bulging left eye, dull pain, vision loss, nausea, and vomiting within 1 day. Computed tomography and magnetic resonance imaging revealed a heterogeneous mass extending from the orbital apex and connected with the ophthalmic vein. Lateral canthotomy and cantholysis were performed at bedside for emergent orbital decompression. The proptosis and pain relieved after surgery, but visual loss remained irreversible. Surgical exploration was conducted and pathology proved the diagnosis of varix of the ophthalmic vein with thrombosis.Why Should an Emergency Physician Be Aware of This?Clinicians should be aware of the presentation of OCS and perform timely orbital decompression, which could reverse visual impairment. These patients might also benefit from immediate consultants with ophthalmologists and radiologists.     

Confirmation of correct tracheal tube placement in newborn infants

Tracheal intubation remains a common procedure during neonatal intensive care. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes. The current gold standard test to confirm tube position is a chest radiograph, however this is often delayed until after ventilation has commenced. Hence, point of care methods to confirm correct tube placement have been developed. The aim of this article is to review the available literature on tube placement in newborn infants. We reviewed books, resuscitation manuals and articles from 1830 to the present with the search terms “Infant, Newborn”, “Endotracheal intubation”, “Resuscitation”, “Clinical signs”, “Radiography”, “Respiratory Function Tests”, “Laryngoscopy”, “Ultrasonography”, and “Bronchoscopy”. Various techniques have been studied to help clinicians assess tube placement. However, despite 85 years of clinical practice, the search for higher success rates and quicker intubation continues. Currently, chest radiography remains the gold standard test to confirm tube position. However, rigorous evaluation of new techniques is required to ensure the safety of newborn infants.     

The effects of ICU admission and discharge times on mortality in Finland

Objective Hospital mortality increases if acutely ill patients are admitted to hospitals on weekends as compared with weekdays. Night discharges may increase mortality in intensive care unit (ICU) patients but the effect of ICU admission time on mortality is not known. We studied the effects of ICU admission and discharge times on mortality and the time of death in critically ill patients.Design Cohort study using a national ICU database.Setting Eighteen ICUs in university and central hospitals in Finland.Patients Consecutive series of all 23,134 emergency admissions in January 1998–June 2001.Interventions None.Measurements and main results We defined weekend (as opposed to weekday) from 1600 hours Friday to 2400 hours Sunday and out-of-office hours (as opposed to office hours) from 1600 hours to 0800 hours. Mortality was adjusted for disease severity, intensity of care, and whether restrictions for future care were set. ICU-mortality was 10.9% and hospital mortality 20.7%. Adjusted ICU-mortality was higher for weekend as compared with weekday admissions [odds ratio (OR 1.20) 95% CI 1.01–1.43], but similar for out-of-office and office hour admissions (OR 0.98, 0.85–1.13). Adjusted risk of ICU death was higher during out-of-office hours as compared with office hours (OR 6.89, 5.96–7.96). The time of discharge from ICU to wards was not associated with further hospital mortality.Conclusions Weekend ICU admissions are associated with increased mortality, and patients in the ICU are at increased risk of dying in evenings and during nighttime. Our findings may have important implications for organization of ICU services.     

Posterior ischemic optic neuropathy associated with migraine

Posterior ischemic optic neuropathy (PION) is an uncommon form of optic nerve ischemia that results from damage to the intraorbital, intracanalicular, or intracranial optic nerve. It has been reported perioperatively, in association with systemic vasculitis, and in the nonsurgical setting with no identifiable cause. Review of the literature reveals only 2 patients with PION associated with migraine in a single report. We report a patient who developed PION in the setting of a migraine headache without any other identifiable risk factors.     

内镜下视神经管减压术治疗外伤性视神经病变手术前后球后血流的改变及分析

目的观察分析外伤性视神经病变(TON)患者在内镜下视神经管减压术(ETOCD)治疗前后眼动脉(OA)和视网膜中央动脉(CRA)的血流的改变,探索ETOCD手术的作用机制和TON的病理生理机制。方法收集连续75例临床确诊为单眼TON并接受ETOCD手术治疗的患者。观察ETOCD治疗前后OA和CRA的收缩期血流峰值速度(PSV)、舒张末期血流速度(EDV)、阻力指数(RI)及术前术后患眼最佳矫正视力(BCVA)的变化。运用Logistic回归分析观察可能影响ETOCD视力预后的因素。结果 (1)PSV的改变:OA术前患眼较健眼降低(P0.05),术后患眼较术前升高(P0.05);CRA术前患眼较健眼降低(P0.05),术后患眼较术前升高(P0.05)。EDV值:OA术后患眼较术前升高(P0.05);CRA术前患眼较健眼降低(P0.05)。RI值:CRA术前患眼较健眼降低(P0.05);(2)手术治疗后视力均较术前提高(P0.05);(3)OA术后高PSV值是视力改善的保护因素(OR^^=1.055,P0.05);患眼CRA术前高PSV值是视力改善的保护因素(OR^^=1.257,P0.05)。结论 ETOCD是治疗TON安全、有效的治疗方法,TON患者患眼OA和CRA的血流速度较正常眼下降,ETOCD术后患眼血流速度较术前改善,这对患者视力预后可能具有保护性作用。     

Incidence and predictors of new-onset atrial fibrillation in noncardiac intensive care unit patients

Background

Atrial fibrillation (AF) is thought to be a relatively common arrhythmia in the setting of noncardiac intensive care unit (ICU). However, data concerning AF deriving from such populations are scarce. In addition, it is unclear which of the wide spectrum of AF predictors are relevant to the ICU setting.

Objectives

The aim of our study was to evaluate the incidence of new-onset AF and investigate the factors that contribute to its occurrence in ICU patients.

Methods

We prospectively studied all patients admitted to our ICU during a 1-year period. Patients admitted for brief postoperative monitoring and patients with chronic or intermittent AF and AF present upon admission were excluded. A number of conditions incriminated as AF risk factors or “triggers” from demographics, medical history, present disease, and cardiac echocardiography as well as circumstances of AF onset were recorded.

Results

The study population consisted of 133 patients (90 males). Atrial fibrillation was observed in 15% of them. Age older than 65 years (P = .001), arterial hypertension (P = .03), systemic inflammatory response syndrome (P < .001), sepsis (P = .001), left atrial dilatation (P = .01), and diastolic dysfunction (P = .04) were significantly associated with the occurrence of AF. By multivariate analysis, it was demonstrated that only older than 65 years (odds ratio, 7.0; 95% confidence interval, 2.0-24.6; P = .003) and sepsis (odds ratio, 6.5; 95% confidence interval, 2.0-21.1; P = .002) independently predict new-onset AF. Patients manifesting AF were frequently hypovolemic (30%) and had electrolyte disorders (40%) as well as elevated and rising serum C-reactive protein (70%).

Conclusion

A significant fraction of ICU patients manifest AF. The predictors of interest for the ICU patients might be considerably different than those of the general population and other subgroups with systemic inflammation possibly having a pivotal role.     

Supraglottic airway devices during neonatal resuscitation: An historical perspective,systematic review and meta-analysis of available clinical trials

Introduction

Various supraglottic airway devices are routinely used to maintain airway patency in children and adults. However, oropharyngeal airways or laryngeal masks (LM) are not routinely used during neonatal resuscitation.

Methods

The aim of this article was to review the available literature about the use of supraglottic airway devices during neonatal resuscitation. We reviewed books, resuscitation manuals and articles from 1830 to the present using the search terms “Infant”, “Newborn”, “Delivery Room”, “Resuscitation”, “Airway management”, “Positive Pressure Respiration”, “Oropharyngeal Airway” and “Laryngeal Mask”.

Results

No study was identified using oropharyngeal airways during neonatal resuscitation. Four trials including 509 infants compared positive pressure ventilation with a LM, bag and mask or an endotracheal tube. Infants in the LM group were intubated less frequently compared to infants in the bag and mask ventilation group 4/275 vs. 28/234 (OR 0.13, 95% CI 0.05–0.34). Infants resuscitated with the LM had significantly less unsuccessful resuscitations 4/275 vs. 31/234 (OR 0.10, 95% CI 0.03–0.28). Two trials including 34 preterm infants compared surfactant administration via LM vs. endotracheal tube. LM surfactant administration was safe and no adverse events were reported.

Conclusion

The efficacy and safety of oropharyngeal airways during neonatal resuscitation remain unclear and randomized trials are required. The current evidence suggests that resuscitation with a LM is a feasible and safe alternative to mask ventilation in infants >34 weeks gestation and birth weight >2000 g. However, further randomized control trials are needed to evaluate short- and long-term outcomes following use of laryngeal masks. In addition, surfactant administration via LM should be used only within clinical trials.     

Early impact of medical emergency team implementation in a country with limited medical resources: a before-and-after study

Purpose

The purpose of the study was to determine whether earlier clinical intervention by a medical emergency team (MET) can improve patient outcomes in an Asian country.

Methods

A nonrandomized study was performed during two 6-month periods before and after the introduction of a MET.

Results

The rates of cardiac arrests and “potentially preventable” cardiac arrests were lower after MET introduction, but the differences did not reach statistical significance. There was a statistically significant decrease in the incidence of cardiac arrests in the first 3 months of the academic year (2.3 vs 1.2 per 1000 admissions, P = .012). Introduction of MET reduced the time interval from physiologic derangement meeting MET activation criteria to intensive care unit (ICU) admission (“derangement-to-ICU interval”) (10.8 vs 6.3 hours, P < .001). Multivariate analysis revealed that the mortality of unplanned ICU admissions was independently associated with simplified acute physiology score 3 and “derangement-to-ICU interval.”

Conclusions

Introduction of a MET reduced the number of cardiac arrests in the general ward during the first 3 months of the academic year. Introduction of MET also decreased the “derangement-to-ICU interval,” which was an independent predictor of survival in patients with unplanned ICU admissions. Therefore, MET introduction may lead to improved outcomes for hospitalized patients in a country with limited medical resources.