End-of-life care in the intensive care unit

End-of-life care in the intensive care unit (ICU) is an oxymoron. Intensive care units appeared in the 1980s only admitting patients for ‘intensive care’. Nowadays the ICU has become one of the few places in the hospital that can provide comfort care to the dying patient. For many doctors on ICU it remains a difficult and problematic area. Yet it is conceptually simple. The difficulty for the doctor is making the decision, for the patient and family, coming to terms with it. This article will focus on how this decision should be made and then on the care that should be provided for the patient. Many of the considerations in decision making are in the General Medical Council guidelines, Treatment and Care Towards the End of Life and this is essential reading before embarking of the process.     

Fever in liver transplant recipients in the intensive care unit

Whether febrile illnesses in the intensive care unit (ICU) have unique spectrum, etiologies, and outcome has not been determined in liver transplant recipients. We studied 78 consecutive febrile patients over a 4-yr period; 49% (38/78) were in the ICU and 51% (40/78) were in the non-ICU setting. Of febrile patients in the ICU, 87% (33/38) had infection and 13% had non-infectious etiology for fever. Seventy-nine percent (26/33) of the infections associated with fever in the ICU were bacterial, 9% (3/33) were viral, and 9% (3/33) were fungal in etiology. Pneumonia (30%), catheter-related bacteremia (15%), and biliary tree (9%) were the predominant sources of infections associated with fever in the ICU. Bacteremia was documented in 45% of the patients with fever in the ICU. Fifty-three percent (20/38) of the febrile episodes in the ICU occurred during the initial post-transplant stay, and 47% (18/ 38) during a subsequent readmission. Pneumonia accounted for 41% of all febrile infections during the first 7 d of ICU stay, but only 14% of those after 7 d. Febrile patients in the ICU had higher APACHE II scores (p = 0.001), higher APS scores (p = 0.0001), higher bilirubin (p = 0.001), lower cholesterol (p = 0.019), higher prothrombin time (p = 0.001), were more tachycardiac (p = 0.002), and were more likely to have abnormal blood pressure (p = 0.001) than those in the non-ICU setting. Twenty-three percent of all infections in the ICU were unaccompanied by fever and 9% were accompanied by hypothermia. Mortality at 14 d (24 versus 0%, p = 0.001) and at 30 d (34 versus 5%, p = 0.001) was significantly higher in febrile patients in the ICU, as compared to the patients in the non-ICU setting. These data have implications for diagnostic evaluation and management of critically ill febrile liver transplant recipients.     

The first intensive care unit in the world: Copenhagen 1953

After an extensive survey of the medical literature we present compelling evidence that the first intensive care unit was established at Kommunehospitalet in Copenhagen in December 1953. The pioneer was the Danish anaesthetist Bjørn Ibsen. The many factors that interacted favourably in Copenhagen to promote the idea of intensive care therapy, half a century ago, are also described.     

Stress in UK intensive care unit doctors

Background. Doctors have long been considered at risk of occupationalstress. Methods. A postal survey of all members of the Intensive CareSociety using validated instruments. Results. Eight-five per cent of members returned questionnairesand 70% were eligible for the study. Twenty-nine per cent weresuffering General Health Questionnaire-12 (GHQ-12) identifieddistress and 12% Symptom Checklist-Depression (SCL-D) defineddepression. There were no significant age or sex differencesbetween staff suffering distress or depression and those whodid not. Dissatisfaction with career correlated highly withboth distress and depression (P<0.01). Twenty doctors (3%)were bothered by suicidal thoughts. The most stressful aspectsof work were bed allocation, being over-stretched, effect ofhours of work and stress on personal/family life, and compromisingstandards when resources are short. Logistic regression revealedmental health problems were predicted by five stressors: ‘lackof recognition of one’s own contribution by others’;‘too much responsibility at times’; ‘effectof stress on personal/family life’; ‘keeping upto date with knowledge’; and ‘making the right decisionalone’. Conclusions. Nearly one in three ICU doctors appeared distressed(GHQ), and one in 10 depressed (SCL-D); this is no greater thanthat reported in other specialities. Perceived stressors revealsome key areas of concern for the employer and the specialty. Br J Anaesth 2002; 89: 873–81     

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目的 了解外科重症监护病房（SICU）中医院获得性感染（nosocomial infection,NI)的流行病学规律。指导临床防治。方法 对SICU1996年1月至2000年12月间181例NI情况进行回顾性分析。结果 平均感染率9.81%,常见感染部位是呼吸道（36.96%)、胸腹腔（25.47%)和血行感染（9.32%),各部位主要病原菌种类具有统计学差异,呼吸道、胸腹腔和胆道以细菌为主,泌尿道和消化道以真菌为主,混合感染52.25%。常见病原菌是肠球菌、耐甲氧西林的葡萄球菌、铜绿假单胞菌、大肠埃希杆菌、白色念珠菌和热带念珠菌。结论 SICU内NI主要病原菌因感染部位而不同,菌种复杂,耐药菌株多,应建立相应的监控制度,掌握病原菌变化规律,现有效地预防和治疗ICU内获得性感染。     

ICU患者安宁疗护筛查工具的研制与信效度检验

目的 研制ICU患者安宁疗护筛查工具并检验信效度,为ICU医护人员提供便捷、有效的安宁疗护对象筛查工具。 方法 通过文献分析、专家函询构建ICU患者安宁疗护筛查工具;回顾性分析206例ICU患者的相关资料,检验该筛查工具信效度,并确定安宁疗护触发值。 结果 ICU患者安宁疗护筛查工具包含3个一级条目、17个二级条目。内容效度指数为0.919,评定者间信度为0.979。2种结局（转出或死亡）患者筛查得分比较,差异有统计学意义（P＜0.05）;触发值为8.5分,ROC曲线下面积为0.992［95%CI（0.983,1.000）,P＜0.05］,灵敏度为0.936,特异度为0.969,阳性预测值为0.917,阴性预测值为0.981。 结论 ICU患者安宁疗护筛查工具的信效度良好,可作为ICU安宁疗护对象的筛查工具。     

Discharge criteria from intensive care unit in brain injured patients

Summary Objective. We investigated the value of information on clinical features and intensity of treatment activity in the Intensive Care Unit (ICU) in predicting the need for further interventions after a patient is discharged from the Intensive Care Unit. Our aim was to assess if this could aid in making decisions about transfer to an Immediate Care Unit (sub-ICU).Methods. We studied 39 patients with acute brain damage (traumatic or vascular causes). They ranged in age from 15 to 75 years and none had an associated spinal cord injury. The SAPS II, Glasgow Coma Scale (GCS), length of stay in ICU, duration of hospital stay and daily NEMS scores were recorded for each patient. We recorded the activities performed after transfer to an sICU, including complications that required active life-saving treatment. The role of each factor was assessed by using the odds ratio (OR), and with linear logistic regression.Findings. 8 of the 39 patients developed a complication in the Sub-ICU. A linear logistic regression analysis demonstrated that the principal features having significant predictive value were:a) age, with an increase in risk of over 10 times for patients that were older than 50 (p=0.011);b) SAPS II scores 50 points, with 24 times an increase in risk (p=0.002); andc) a GCS score 5 points, with an increase in risk of almost 7 times (p=0.024).Interpretation. Complications in Sub-ICU are less likely in patients younger than 50 and who have SAPS II and GCS scores within predetermined limits. These indices can help in making decisions about discharge of a patient from ICU to Sub-ICU.     

神经外科重症监护患者非计划性拔管的特征分析

目的了解神经外科重症监护患者非计划性拔管的现状,分析其特征及影响因素,为进一步研究提供参考。方法应用自行设计的调查表前瞻性观察神经外科重症监护患者置管和拔管的情况,并对结果进行统计学分析。结果观察患者119例,置管337例次,总置管时间1 872.5d,非计划性拔管18例次,16例次为胃管、尿管等低危导管;13例次为自行拔管,其中10例次为有约束自行拔管。结论神经外科重症监护患者发生非计划性拔管的可能性高,约束并不能避免其发生,应从多方面控制,加强细节管理和重点患者的防护。     

智能药柜在老年监护室基数药品管理中的应用

目的探讨自动化药品管理系统(智能药柜)应用于老年监护室基数药物管理的效果。方法应用智能药柜对病区基数药物进行管理,采用历史对照方法,将应用智能药柜前(15例)后(18例)患者的取药相关指标(每日取药次数,单次取药时间,补药次数,盘点高危药物次数及盘点普通药物次数)进行比较。结果应用智能药柜后每日取药次数较应用前明显增加,单次取药时间、每日补药次数、盘点高危药物次数及盘点普通药物次数均较应用前减少。结论在监护室使用智能药柜能加强安全用药,对患者个性化及时用药,同时能减少护士工作量。     

神经外科ICU过渡护理标准化流程的制定及实施

目的提高神经外科ICU患者转出效率及安全性。方法将神经外科ICU患者1 176例按时间段分为对照组580例、观察组596例;患者由神经外科ICU转出至普通病房过渡护理期间,对照组采用常规交接方式,观察组制订和实施标准化流程实施交接。结果观察组转运期间患者病情变化、物品遗漏发生率及交接时间显著少/短于对照组(均P0.01),患者/家属满意度显著高于对照组(P0.01)。结论制定并实施标准化流程,有利于提高神经外科ICU患者转出工作效率和保障患者安全。     

Outcome evaluation in a surgical intensive care unit in Barbados

The performance of the Acute Physiology and Chronic Health Evaluation II scoring system was prospectively assessed in the surgical intensive care unit at the Queen Elizabeth Hospital, Barbados. A total of 309 patients admitted consecutively during a 2-year period (1999-2001) were evaluated. Demographic data, diagnosis, Acute Physiology and Chronic Health Evaluation II score, duration of stay and hospital outcome were recorded. The predicted mortality for every patient and the costs incurred were also calculated. The overall observed mortality rate was 15.9% while the mean predicted mortality rate for our case-mix was 16.4%, which is comparable to results from developed countries. The cost incurred per patient was much lower at $13,636 (Barbados), compared to the patients' cost in North America ($60,000 Barbados).     

Chediak-Higashi syndrome in the intensive care unit

Chediak-Higashi Syndrome is a rare autosomal recessive disease characterized by recurrent infections, giant cytoplasmic granules and oculocutaneous albinism. We describe the clinical and laboratory findings of a patient with Chediak-Higashi syndrome who was diagnosed and treated in the intensive care unit because of bleeding tendency after surgery.     

大型NICU建立微护理专业团队的实践

目的探讨改善大型新生儿重症监护病房(NICU)住院患儿结局的有效管理方法。方法自2014开始将责任护士负责式护理模式改为以护理小组为单位、专岗执行转运、呼吸治疗,组建以专科护士为主导的微护理专业团队解决各专科护理难点问题的护理工作模式。结果截至2019年,NICU共组建新生儿肠内外营养、血管通路、皮肤(伤口造口)、呼吸道管理、感染预防控制、极低出生体重儿(VLBWI)精细化护理、护理教育7个微护理专业团队;患儿呼吸机相关性肺炎发生率,VLBWI医院感染发生率、死亡率,PICC导管相关血流感染率逐年下降(均P0.01);VLBWI母乳喂养率,患儿家长满意度得分逐年上升(均P0.01)。结论大型NICU在改进工作模式的同时建立微护理专业团队并投入实践中,有利于改善患儿结局,提高家长满意度。     

Clinical features and outcome of chronic dialysis patients admitted to an intensive care unit.

BACKGROUND: Information about chronic dialysis (CD) patients admitted to intensive care units (ICU) is scant. This study sought to determine the epidemiology and outcome of CD patients in an ICU setting and to test the performance of the Simplified Acute Physiology Score (SAPS II) to predict hospital mortality in this population. METHODS: All consecutive CD patients admitted to an adult, 10 bed medical/surgical ICU at a university hospital between January 1996 and December 1999 were included in this prospective observational study. Demographics, characteristics of the underlying renal disease, admission diagnosis, the number of organ system failures (OSFs) excluding renal failure and SAPS II, both calculated 24 h after admission, the duration of mechanical ventilation, ICU survival and survival status at hospital discharge and 6 months after discharge were recorded. RESULTS: A total of 92 CD patients, 16 on peritoneal dialysis and 76 on haemodialysis, were included. The main reason for ICU admission was sepsis and the mean ICU length of stay 6.2+/-9.9 days. ICU mortality was 26/92 (28.3%) and was associated in multivariate analysis with SAPS II (P<0.001), duration of mechanical ventilation (P<0.01) and abnormal values of serum phosphorus (high or low; P<0.05). Hospital mortality was 35/92 (38.0%) and was accurately predicted by SAPS II [receiver operating characteristics curve: 0.86+/-0.04; goodness-of-fit test: C = 6.86, 5 degrees of freedom (df), P = 0.23 and H = 4.78, 5 df, P = 0.44]. The 6 month survival rate was 48/92 (52.2%). CONCLUSIONS: CD patients admitted to the ICU are a subgroup of patients with high mortality and SAPS II can be used to assess their probability of hospital mortality. The severity of the acute illness responsible for ICU admission and an abnormal value of serum phosphorus are determinants for ICU mortality.     

Interdisciplinary communication in the intensive care unit

BACKGROUND: Patient safety research has shown poor communication among intensivecare unit (ICU) nurses and doctors to be a common causal factorunderlying critical incidents in intensive care. This studyexamines whether ICU doctors and nurses have a shared perceptionof interdisciplinary communication in the UK ICU. METHODS: Cross-sectional survey of ICU nurses and doctors in four UKhospitals using a previously established measure of ICU interdisciplinarycollaboration. RESULTS: A sample of 48 doctors and 136 nurses (47% response rate) fromfour ICUs responded to the survey. Nurses and doctors were foundto have differing perceptions of interdisciplinary communication,with nurses reporting lower levels of communication opennessbetween nurses and doctors. Compared with senior doctors, traineedoctors also reported lower levels of communication opennessbetween doctors. A regression path analysis revealed that communicationopenness among ICU team members predicted the degree to whichindividuals reported understanding their patient care goals(^adjR² = 0.17). It also showed that perceptions of the qualityof unit leadership predicted open communication. CONCLUSIONS: Members of ICU teams have divergent perceptions of their communicationwith one another. Communication openness among team membersis also associated with the degree to which they understandpatient care goals. It is necessary to create an atmospherewhere team members feel they can communicate openly withoutfear of reprisal or embarrassment.     

Airway management in the intensive care unit

Airway management practices in the intensive care unit (ICU) are still evolving, evidenced by an increasing proliferation of guidelines and algorithms in recent years. Specific considerations relate to the out-of-theatre environment and the physiological state in this patient population. Airway management in ICU is ultimately a multifaceted process spanning team training, simulation, preassessment, preparation, positioning of the patient, equipment decisions, guidelines/algorithm adherence and most recently the consideration of the coronavirus disease (COVID-19) pandemic. The use of video laryngoscopy has increased, as have the practices of apnoeic oxygenation and the use of checklists. Emergency front-of-neck access (FONA) should be taught to all staff and standardized equipment made available. This article highlights the factors a multidisciplinary team must navigate when approaching airway management in the ICU.     

Criteria for intensive care unit admission and the assessment of illness severity

Critical care expansion in the UK has increased in recent years, reflecting increased demand, yet bed occupancy remains high and there are significant difficulties in matching supply and demand. Expansion of ICU services outside the walls of critical care has involved the development of complex multidisciplinary outreach services who exist to support ward teams in caring for individuals who are critically unwell or have recently been stepped down from higher levels of care; there is increased evidence of their effectiveness in reducing mortality and preventing unexpected deterioration. Discharge of patients from critical care is also an area of controversy with conflicting evidence of increased mortality rates for those discharged prematurely or out-of-hours. Careful planning is involved with appropriate post-ICU care is critical to avoiding poor outcomes. ICU scoring systems allow comparison of outcomes between individual units and facilitate research but are unhelpful in predicting outcome for individual patients. Deciding which patients not to admit to ICU are frequently the most difficult decisions facing critical care staff. Many patients previously considered inappropriate for organ support may now be admitted pre-determined limits of treatment or to facilitate complex palliative care needs.     

新生儿重症监护病房高频接触物体表面细菌污染情况研究

目的了解新生儿重症监护病房(NICU)手高频接触物体表面细菌污染情况,为加强医院环境感染控制提供依据。方法选择NICU 10类手高频接触物体表面进行采样和细菌培养。结果共收集手高频接触物体表面样本1 088份,细菌污染样本135份,阳性率为12.41%。10类物体表面均有细菌污染,其中计算机键盘和PDA污染率最高。共培养出细菌菌株155株,以凝固酶阴性葡萄球菌为主。结论 NICU手高频接触物体表面细菌污染普遍,应加强病房内环境物体表面清洁消毒工作,降低细菌在物体表面定植,为新生儿提供清洁而安全的诊疗环境。