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。     

Futility and inappropriate care in pediatric intensive care: a cross-sectional survey

BACKGROUND: Over recent years, there have been increasing concerns regarding an increase in the number of futile and inappropriate admissions to pediatric intensive care units (PICUs) in the United Kingdom (UK). METHODS: A prospective cross-sectional survey was carried out using a data collection form distributed by mail to the directors of all PICUs in the UK. Respondents were asked to give details of all patients on their unit on a specific day including age, reason for admission and any preexisting medical conditions. An assessment was made by respondents of whether the care being provided in each case was, in their opinion, appropriate, futile or inappropriate according to standard definitions. RESULTS: We received responses from 21 units (68%) who reported the details of 111 patients. Care was felt to be appropriate in 88 of these cases (79%), futile in nine cases (8%) and inappropriate in 14 cases (13%). Futile cases were most commonly admitted with respiratory failure and all had preexisting medical conditions, most commonly developmental delay. Where care was felt to be inappropriate, respiratory failure was again the most common reason for admission and all had a preexisting medical condition, most commonly cardiovascular disease. CONCLUSIONS: The care being provided in 21% of the PICU cases, described in this study, was felt to be either futile or inappropriate by the directors of those units. There is an urgent need to, accurately, establish the resource consumption associated with these patients and to establish a standard approach to futility and inappropriate care in PICU in the UK.     

Current treatment practices of venous thromboembolism in children admitted to pediatric intensive care units

Objective: To describe current treatment practices of VTE in patients admitted to a pediatric intensive care unit (PICU) and compare these practices to published guidelines. Background: While the incidence of VTE is increasing, current treatment practices of VTE in patients admitted to PICUs are not known. Methods: This multicenter, prospective, observational study enrolled patients with confirmed VTE admitted to 11 PICUs over a rolling 6‐month study period. Treatment data were collected and analyzed. Results: Sixty‐six VTEs occurred in 6653 patients. Empiric treatment for VTE was initiated in 30% prior to VTE confirmation, and children with cyanotic heart disease were 15.7 times more like to receive empiric therapy. Overall, 78% received systemic anticoagulation, 8% treated with only catheter‐based interventions, and 13% of VTE were not treated. Seven patients (11%) underwent systemic fibrinolysis; more commonly in neonates (23%) vs children (5%). Surgical and interventional procedures were performed on 4 patients. The American College of Chest Physicians recommendations were incompletely followed. Only 28% of the 32 cases treated with low molecular weight heparin titrated dosing to a goal anti‐FXa level 0.5–1. Five of the 15 cases treated with unfractionated heparin titrated dosing to aPTT 60–90, and one case did not use goal‐directed therapy. Conclusions: Confirmed VTEs in patients admitted to PICUs are most frequently treated with systemic anticoagulation; however, more intensive treatments such as systemic thrombolysis and surgical or interventional procedures are not uncommon in this critically ill population. Current practices deviate from the published antithrombotic guidelines developed for the general pediatric population.     

Current United Kingdom sedation practice in pediatric intensive care

BACKGROUND: The aim of this study was to investigate the current practice of sedation, analgesia, and neuromuscular blockade in critically ill children on pediatric intensive care units (PICUs) in the UK and identify areas that merit further study. METHODS: Data were gathered in a prospective observational study of 338 critically ill children in 20 UK PICUs. RESULTS: There is considerable variation in clinical practice. A total of 24 different sedative and analgesic agents were used during the study. The most commonly used sedative and analgesic agents were midazolam and morphine. Four different neuromuscular blockers (NMBs) were used, most commonly vecuronium. There were differences in treatment between cardiac and noncardiac children, but there were a greater number of infants and neonates in the cardiac group. NMBs were used in 30% of mechanically ventilated patients. Withdrawal symptoms were reported in 13% of ventilated patients, relatively early in their stay; weaning sedative agents ('tapering') was apparently of no benefit. The use of clonidine in this setting was noted. Physical restraints were used in 7.4%. Propofol was used but in only 2.6% of patients, all over the age of 4 years, and not exceeding 2 mgxkg(-1)xh(-1). No side effects attributable to 'propofol syndrome' were noted. CONCLUSIONS: There is considerable heterogeneity of sedation techniques. NMBs are used in a large portion of this population. Withdrawal symptoms were associated with higher doses of sedation and greater lengths of stay and were not ameliorated by withdrawing sedation gradually ('tapering').     

Changes in health-related quality of life after discharge from an intensive care unit: a systematic review

Quality of life after critical illness is becoming increasingly important as survival improves. Various measures have been used to study the quality of life of patients discharged from intensive care. We systematically reviewed validated measures of quality of life and their results. We searched PubMed, CENTRAL, CINAHL, Web of Science and Open Grey for studies of quality of life, measured after discharge from intensive care. We categorised studied populations as: general; restricted to level-3 care or critical care beyond 5 days; and septic patients. We included quality of life measured at any time after hospital discharge. We identified 48 studies. Thirty-one studies used the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and 19 used the EuroQol-5D (EQ-5D); eight used both and nine used alternative validated measures. Follow-up rates ranged from 26–100%. Quality of life after critical care was worse than for age- and sex-matched populations. Quality of life improved for one year after hospital discharge. The aspects of life that improved most were physical function, physical role, vitality and social function. However, these domains were also the least likely to recover to population norms as they were more profoundly affected by critical illness.     

The development of pediatric anesthesiology and critical care medicine at the Cincinnati Children's Hospital: an interview with Dr. Theodore Striker

Dr. Theodore W. ‘Ted’ Striker (1936–), Professor of Anesthesiology and Pediatrics at the University of Cincinnati, has played a pioneering role in the development of pediatric anesthesiology in the United States. As a model educator, clinician, and administrator, he shaped the careers of hundreds of physicians‐in‐training and imbued them with his core values of honesty, integrity, and responsibility.     

Criteria for intensive care unit admission and severity of illness

Intensive care is a specialist area of the hospital with concentration of resources and expertise to look after critically unwell patients. No set criteria exist for admission to intensive care, although patients usually have severe illness associated with physiological dysfunction and actual or impending organ failure. There are multiple scoring systems designed to assess severity of illness, all with significant limitations. The National Early Warning Score 2 (NEWS-2) is a commonly used ‘track and trigger’ system designed to detect and respond to the unwell or deteriorating patient. NEWS-2 is marker of physiological disturbance and high scores correlate with intensive care admission and mortality. Looking at the elective and emergency surgical population, patients at high risk of complications should be admitted to intensive care postoperatively. Increasing age, comorbidities, poor exercise tolerance and major surgical intervention are associated with adverse outcomes. Admission to intensive care often requires difficult time-critical decisions to be made with limited information. Intensive care admission can be the difference between life and death, but there are both physical and psychological harm associated with invasive organ support. The four pillars of medical ethics – autonomy, beneficence, non-maleficence and justice – can be used to guide these decisions.     

Criteria for intensive care unit admission and severity of illness

This article explores the provision and organisation of critical care services in the UK and examines the issues surrounding admission to, discharge from and the withholding of critical care.     

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.     

Confusion assessment method for the intensive care unit (CAM-ICU): translation, retranslation and validation into Swedish intensive care settings

BACKGROUND: Becoming critical ill or severely injured leads to a process of worry, anxiety and pain. Patients in intensive care sometimes have strange and frightening experiences and may show symptoms of acute confusion or delirium. CAM-ICU, the confusion assessment method for the intensive care unit, was based on the DSM IV, the Diagnostic and Statistic Manual of Mental Disorders IV, and today, healthcare professionals and researchers are increasingly accepting this concept of diagnosing ICU delirium. In Sweden, there is no commonly used, single instrument or method to test the development of ICU delirium. The aim of this study was to translate, retranslate and validate CAM-ICU for use in Swedish ICU settings. METHODS: The translation of the instrument was done according to the guidelines suggested by The Translation and Cultural Adaptation group which includes preparation, forward translation/reconciliation, back translation, back translation review, harmonization, cognitive debriefing and validation. In the validation process, the applicability of the Swedish version of the instruments was tested in a Swedish intensive care unit. RESULTS: Fourteen adult patients were included in the study, 40 paired tests were carried out, and 80 CAM-ICU instruments were completed. The participating patients were given CAM-ICU ratings using independent paired evaluations by two nurses, specialized in intensive care, at least twice during the patients' stay in the ICU. Interrater reliability was calculated using kappa statistics. In the 40 paired observations, interrater reliability was 'very good' (kappa statistics > 0.81). In our material, we recognized a delirium rate of 48%, which is in accordance with previous studies. CONCLUSION: The translation of the instrument CAM-ICU showed good correlation with the original version and could therefore be applicable in a Swedish ICU setting. In the 40 paired observations, interrater reliability was very good. Although there are limitations in using CAM-ICU, previous studies reveal a need for a homogeneous screening instrument making it possible to detect and determine ICU delirium; and from this basis are able to implement and make the necessary decisions required in medical and nursing care practice preventing ICU delirium.     

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.     

虚拟现实技术缓解儿科重症监护室患儿分离性焦虑的效果研究

目的 探讨缓解儿科重症监护室患儿分离性焦虑的有效方法。方法 将入住儿科重症监护室的100例患儿随机分为对照组和观察组各50例。对照组在常规心理干预的基础上应用iPad分散注意力,观察组在常规心理干预基础上应用虚拟现实技术干预。比较两组干预前后各时间段的分离性焦虑评分、心率和血压变化。结果 观察组各时间段分离性焦虑评分显著低于对照组,干预后心率显著低于对照组(均P<0.05),两组干预前后血压比较,差异无统计学意义(均P>0.05)。结论 虚拟现实技术可使儿科重症监护室患儿快速达到身心放松状态,缓解分离性焦虑,安全性好。     

The Assessment of Risk in Cardiothoracic Intensive Care (ARCtIC): prediction of hospital mortality after admission to cardiothoracic critical care

The models used to predict outcome after adult general critical care may not be applicable to cardiothoracic critical care. Therefore, we analysed data from the Case Mix Programme to identify variables associated with hospital mortality after admission to cardiothoracic critical care units and to develop a risk‐prediction model. We derived predictive models for hospital mortality from variables measured in 17,002 patients within 24 h of admission to five cardiothoracic critical care units. The final model included 10 variables: creatinine; white blood count; mean arterial blood pressure; functional dependency; platelet count; arterial pH; age; Glasgow Coma Score; arterial lactate; and route of admission. We included additional interaction terms between creatinine, lactate, platelet count and cardiac surgery as the admitting diagnosis. We validated this model against 10,238 other admissions, for which the c index (95% CI) was 0.904 (0.89–0.92) and the Brier score was 0.055, while the slope and intercept of the calibration plot were 0.961 and ?0.183, respectively. The discrimination and calibration of our model suggest that it might be used to predict hospital mortality after admission to cardiothoracic critical care units.     

The proportion of intensive care unit admissions related to alcohol use: a prospective cohort study

BACKGROUND: Alcohol abuse is a risk factor for serious illnesses, and a history of chronic alcohol abuse adversely affects the outcome of critically ill patients. It is not known what proportion of intensive care unit (ICU) admissions is related to alcohol use. Therefore, we investigated the proportion of emergency admissions related to alcohol. METHODS: A prospective cohort study was conducted in a university hospital ICU. All adult patients (n = 893) who underwent emergency admission to our ICU during a period of 1 year were studied. RESULTS: The admitting physician determined whether there was a relationship between alcohol use and admission. ICU and hospital mortality and ICU length of stay (LOS) were recorded. The Therapeutic Intervention Scoring System (TISS) was used for ICU resource use estimation. There was a relationship between alcohol use and admission in 24% (215/893) of admissions and, in 156/893 admissions (17.5%), this seemed to be definite. ICU LOS was 1.2 days (0.7; 2.3) (median; interquartile range) for alcohol-related and 1.8 days (0.9; 3.6) for other admissions (P < 0.001). Patients with alcohol-related admissions consumed 17.8% of ICU patient-days and 18.7% of all accumulated TISS scores. ICU (8.8 vs. 10.5%, P = 0.603) and hospital (19.1 vs. 20.2%, P = 0.769) mortalities were no different between alcohol-related and other admissions. CONCLUSION: ICU admission is very often related to long-term chronic and/or occasional alcohol use.     

Renal medicine in the intensive care unit: a narrative review

Kidney disease, both acute and chronic, is commonly encountered on the intensive care unit. Due to the role the kidneys play in whole body homeostasis, it follows that their dysfunction has wide-ranging implications and can affect prescribing and therapeutic management. This narrative review discusses the pathophysiology of acute kidney injury and chronic kidney disease, and how this relates to critically unwell patients. We cover several aspects of the management of renal dysfunction on the critical care unit, exploring some of the recurrent themes within the literature, including type and timing of kidney replacement therapy, management of acute kidney injury, as well as discussing how novel biomarkers for acute kidney injury may help to identify patients suffering from acute kidney injury as well as risk stratifying these patients. We discuss how early involvement of specialist nephrology services can improve outcomes in patients with kidney disease as well as offer valuable diagnostic and specialist management advice, particularly for patients with established end stage kidney disease and patients who are already known to nephrology services. We also explore some of the ongoing research questions that need to be answered within this arena.     

The development of a specialty: an interview with Dr. Mark C. Rogers,a pioneering pediatric intensivist

Dr. Mark C. Rogers (1942–), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long‐term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.     

End-of-life decisions in pediatric intensive care. Recommendations of the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care (SARNePI)

End-of-life decisions represent one of the most complex and challenging issues in pediatric intensive care. These recommendations aim to offer Italian pediatric intensive care unit (PICU) teams a framework for the end-of-life decision-making process. The paper proposes a process based on the principle that the use of a diagnostic or therapeutic tool must comply with a 'criterion of proportionality'. Appropriately informed parents, as natural interpreters and advocates of the best interests of their child, can contribute in assessing the burdensomeness of the treatment and determining its proportionality. The decision to limit, withdraw or withhold life-sustaining treatments considered disproportionate represents a clinically and ethically correct choice. This decision should be made (a) collectively by PICU team and the other caregivers, (b) with the explicit involvement of parents, and (c) noting in the patient's clinical record the decisions taken and the reasons behind them. The withdrawing or withholding of life support can never entail the abandonment of the patient nor the withdrawal of any therapy aimed at treating any form of suffering. No action aimed at deliberately hastening the death of the patient is ever acceptable. These recommendations advocate a decision as far as possible shared by patient (whenever feasible), parents and caregivers. Ensuring that all involved are kept fully informed and that there is open and timely communication between them is the key to achieving this. It is the physician in charge of the patient's care and the head of the unit who bear the main responsibility for the final decision.     

Pain Assessment in INTensive care (PAINT): an observational study of physician‐documented pain assessment in 45 intensive care units in the United Kingdom

Pain is a common and distressing symptom experienced by intensive care patients. Assessing pain in this environment is challenging, and published guidelines have been inconsistently implemented. The Pain Assessment in INTensive care (PAINT) study aimed to evaluate the frequency and type of physician pain assessments with respect to published guidelines. This observational service evaluation considered all pain and analgesia‐related entries in patients’ records over a 24‐h period, in 45 adult intensive care units (ICUs) in London and the South‐East of England. Data were collected from 750 patients, reflecting the practice of 362 physicians. Nearly two‐thirds of patients (n = 475, 64.5%, 95%CI 60.9–67.8%) received no physician‐documented pain assessment during the 24‐h study period. Just under one‐third (n = 215, 28.6%, 95%CI 25.5–32.0%) received no nursing‐documented pain assessment, and over one‐fifth (n = 159, 21.2%, 95%CI 19.2–23.4)% received neither a doctor nor a nursing pain assessment. Two of the 45 ICUs used validated behavioural pain assessment tools. The likelihood of receiving a physician pain assessment was affected by the following factors: the number of nursing assessments performed; whether the patient was admitted as a surgical patient; the presence of tracheal tube or tracheostomy; and the length of stay in ICU. Physician‐documented pain assessments in the majority of participating ICUs were infrequent and did not utilise recommended behavioural pain assessment tools. Further research to identify factors influencing physician pain assessment behaviour in ICU, such as human factors or cultural attitudes, is urgently needed.