Clinical review: Probiotics in critical care

Patients in ICUs represent a relatively small subgroup of hospitalised patients, but they account for approximately 25% of all hospital infections. Approximately 30% of ICU patients suffer from infection as a complication of critical illness, which increases the length of ICU stay, morbidity, mortality and cost. Gram-negative bacteria are the predominant cause of ICU-related infections and with the rise in multidrug-resistant strains we should focus our attention on nonantibiotic strategies in the prevention and treatment of nosocomial infections. Probiotics have been proposed as one option in this quest; however, mechanisms of action in the critically ill population require further investigation. Some of the beneficial effects appear to be associated with improvement in gastrointestinal barrier function, restoration of normal intestinal permeability and motility, modification of the balance of intestinal microbiota and immunomodulation. However, the information we have to date on the use of probiotics in the critical care setting is difficult to interpret due to small sample sizes, differences in ICU populations, the variety of probiotic combinations studied and differences in administration techniques. In this review we shall examine the use of probiotics in the critical care setting, look at some of the proposed mechanisms of action and discuss their potential benefits and drawbacks.     

Clinical review: Critical care transport and austere critical care

The development of modern intensive care units (ICUs) has allowed the survival of patients with advanced illness and injury, although at a cost of substantial infrastructure. Natural disasters and military operations are two common situations that can create critically ill patients in an environment that is austere or has been rendered austere. This has driven the development of two related strategies to care for these casualties. Portable ICU capability can be rapidly established in the area of need, providing relatively advanced capability but limited capacity and sustainability. The other strategy is to rapidly evacuate critically ill and injured patients following their initial stabilization. This permits medical personnel in the austere location to focus resources on a larger number of less critical patients. It also permits the most vulnerable patients to receive care in an advanced center. This strategy requires careful planning to overcome the constraints of the transport environment. The optimal strategy has not been determined, but a combination of these two approaches has been used in recent disasters and military operations and is promising. The critical care delivered in an austere setting must be integrated with a long-term plan to provide follow-on care.     

Clinical review: Medication errors in critical care

Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed twice as many medications as patients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay. The aim of this article is to provide a basic review of medication errors in the ICU, identify risk factors for medication errors, and suggest strategies to prevent errors and manage their consequences.     

Meridian therapy: current research and implications for critical care

The National Institutes of Health recently recommended further research on the efficacy of acupuncture and allocated Federal funds to stimulate clinical studies. Their decision was based on a growing body of successful research outcomes in which acupuncture was used in the treatment of acute and chronic pain, nausea, circulatory functions, and mood-related behavioral disorders. Despite a burgeoning body of clinical research, the ability to generalize findings has been affected by design flaws, sample type and size, and multiple methods of acupuncture site stimulation. Complicating the communication of findings is use of the term acupuncture when other strategies are used to stimulate the point, such as electrical probes and low-intensity laser. A more appropriate term for acupuncture is meridian therapy, because it encompasses all methods used to treat an acupoint. The purpose of this article is to define meridian therapy with a focus on current clinical perspectives, to review research outcomes in areas important to the care of critically ill patients, to identify issues related to the application of meridian therapy in the clinical arena, and to elaborate practitioner preparation and licensure requirements.     

Oral measurement of temperature in orally intubated critical care patients: state-of-the-science review.

Many nurses are hesitant to use the oral site to measure body temperature when patients are orally intubated with an endotracheal tube. It is often thought that the temperature of the gases flowing through the tube and the patient's inability to form a tight seal around the tube may result in an inaccurate measurement that does not reflect body temperature. Consequently, other sites such as the rectum are used, resulting in embarrassment and increased stress for patients, increased use of resources, and inappropriate use of nursing time. An integrated review and synthesis of research on the validity of using the posterior sublingual site to measure temperature in critically ill patients intubated with an oral endotracheal tube were done to determine if a change in nursing practice is indicated for these patients. Of 10 studies that address this topic, 5 specifically investigated this nursing area. The results indicate that for critically ill patients with stable hemodynamic status, the posterior sublingual pocket is a valid site for measurement of body temperature in patients who are orally intubated with an endotracheal tube.     

Multicenter clinical research in adult critical care

OBJECTIVE: To describe the development, organization, and operation of several collaborative groups conducting investigator-initiated multicenter clinical research in adult critical care. DESIGN: To review the process by which investigator-initiated critical care clinical research groups were created using examples from Europe, Australia, the United States, and Canada. Various models of group structure and function are discussed, highlighting complementary approaches to protocol development, multicenter study management, and project funding. DATA SOURCES: Published peer review research and unpublished terms of reference documents on the structure and function of these groups. DATA SYNTHESIS: The overall goal of clinical critical care research groups engaged in multicenter studies is to improve patient outcomes through conducting large, rigorous investigations. Research programs we reviewed included the following: a) multicenter epidemiologic studies and surveys; b) technology evaluations of mechanical ventilation; c) investigations focused on three priority fields (acute lung injury, infection, and acute brain injury); d) a series of randomized trials of treatments for one syndrome (acute respiratory distress syndrome); and e) diverse methodologies addressing several clinical problems. The structure and function of these research groups differ according to their historical development, research culture, and enabling resources. Specific protocols emerge from clinical questions generated by investigators or from collectively prioritized research agendas. Project funding includes government support, peer-review grants, intensive care foundations, industry, local hospital funds, and hybrid models. Infrastructure for study management varies widely. CONCLUSIONS: Several national and international groups have engaged in investigator-initiated multicenter critical care research. The development, organization, and operational methods of these groups illustrate several collaborative models for clinical investigations in the intensive care unit. Common characteristics of these groups are a cohesive spirit, a sense of mission to achieve shared research goals, and acknowledgment that such an organization is much more than the sum of its parts.     

Clinical review: Independent lung ventilation in critical care

Independent lung ventilation (ILV) can be classified into anatomical and physiological lung separation. It requires either endobronchial blockade or double-lumen endotracheal tube intubation. Endobronchial blockade or selective double-lumen tube ventilation may necessitate temporary one lung ventilation. Anatomical lung separation isolates a diseased lung from contaminating the non-diseased lung. Physiological lung separation ventilates each lung as an independent unit. There are some clear indications for ILV as a primary intervention and as a rescue ventilator strategy in both anatomical and physiological lung separation. Potential pitfalls are related to establishing and maintaining lung isolation. Nevertheless, ILV can be used in the intensive care setting safely with a good understanding of its limitations and potential complications.     

Clinical review: mass casualty triage--pandemic influenza and critical care

Worst case scenarios for pandemic influenza planning in the US involve over 700,000 patients requiring mechanical ventilation. UK planning predicts a 231% occupancy of current level 3 (intensive care unit) bed capacity. Critical care planners need to recognise that mortality is likely to be high and the risk to healthcare workers significant. Contingency planning should, therefore, be multi-faceted, involving a robust health command structure, the facility to expand critical care provision in terms of space, equipment and staff and cohorting of affected patients in the early stages. It should also be recognised that despite this expansion of critical care, demand will exceed supply and a process for triage needs to be developed that is valid, reproducible, transparent and consistent with distributive justice. We advocate the development and validation of physiological scores for use as a triage tool, coupled with candid public discussion of the process.     

Clinical review: Bedside lung ultrasound in critical care practice

Lung ultrasound can be routinely performed at the bedside by intensive care unit physicians and may provide accurate information on lung status with diagnostic and therapeutic relevance. This article reviews the performance of bedside lung ultrasound for diagnosing pleural effusion, pneumothorax, alveolar-interstitial syndrome, lung consolidation, pulmonary abscess and lung recruitment/derecruitment in critically ill patients with acute lung injury.     

Sleep deprivation in critical care units

Sleep deprivation is a significant problem for patients in critical care units. Sleep is a complex, active process that is divided into 4 stages of non-rapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep. Noise, lights, discomfort, pain, medications, and stress all contribute to a patient's inability to sleep. Lack of knowledge about the sleep stages, nursing routines, and frequent nursing assessment and interventions also impact the critically ill patient's ability to sleep. Education about sleep deprivation needs to be integrated into critical care courses and orientation programs. Sleep deprivation should be addressed on the multidisciplinary care plan and in health team conference, and nursing care planned accordingly. Sleep medications and their effects should be evaluated for each patient, as well as identifying medications that might be preventing or disturbing sleep.     

Clinical review: International comparisons in critical care - lessons learned

ABSTRACT: Critical care medicine is a global specialty and epidemiologic research among countries provides important data on availability of critical care resources, best practices, and alternative options for delivery of care. Understanding the diversity across healthcare systems allows us to explore that rich variability and understand better the nature of delivery systems and their impact on outcomes. However, because the delivery of ICU services is complex (for example, interplay of bed availability, cultural norms and population case-mix), the diversity among countries also creates challenges when interpreting and applying data. This complexity has profound influences on reported outcomes, often obscuring true differences. Future research should emphasize determination of resource data worldwide in order to understand current practices in different countries; this will permit rational pandemic and disaster planning, allow comparisons of in-ICU processes of care, and facilitate addition of pre- and post-ICU patient data to better interpret outcomes.     

Clinical review: The Israeli experience: conventional terrorism and critical care

Valproic acid (VPA) is a broad-spectrum antiepileptic drug and is usually well tolerated, but rare serious complications may occur in some patients receiving VPA chronically, including haemorrhagic pancreatitis, bone marrow suppression, VPA-induced hepatotoxicity (VHT) and VPA-induced hyperammonaemic encephalopathy (VHE). Some data suggest that VHT and VHE may be promoted by carnitine deficiency. Acute VPA intoxication also occurs as a consequence of intentional or accidental overdose and its incidence is increasing, because of use of VPA in psychiatric disorders. Although it usually results in mild central nervous system depression, serious toxicity and even fatal cases have been reported. Several studies or isolated clinical observations have suggested the potential value of oral L-carnitine in reversing carnitine deficiency or preventing its development as well as some adverse effects due to VPA. Carnitine supplementation during VPA therapy in high-risk patients is now recommended by some scientific committees and textbooks, especially paediatricians. L-carnitine therapy could also be valuable in those patients who develop VHT or VHE. A few isolated observations also suggest that L-carnitine may be useful in patients with coma or in preventing hepatic dysfunction after acute VPA overdose. However, these issues deserve further investigation in controlled, randomized and probably multicentre trials to evaluate the clinical value and the appropriate dosage of L-carnitine in each of these conditions.     

Clinical review: the Israeli experience: conventional terrorism and critical care

Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients.