Hepatic Artery Rupture in a Young Man with Abdominal Pain and a Testicular Mass

Background

Male patients presenting to the emergency department (ED) with abdominal pain accompanied by a testicular mass should be evaluated for the presence of hernia, epididymitis, orchitis, and testicular torsion. When a patient presents with an asymptomatic testicular nodule or mass, the emergency physician should consider testicular carcinoma, a diagnosis that typically warrants no more than prompt urologic outpatient referral.

Physiological responses during a T-piece weaning trial with a deflated tube

Rationale T-piece trials and spontaneous breathing trials through the tracheostomy tube are often used as weaning techniques. They are usually performed with the cuff inflated, which may increase the inspiratory load and/or influence the tidal volume generated by the patient. We assessed diaphragmatic effort during T-piece trials with or without cuff inflation.Settings Respiratory intensive care unitMethods We measured breathing pattern, transdiaphragmatic pressure (Pdi), the pressure-time product of the diaphragm, per minute (PTPdi/min) and per breath (PTPdi/b), and lung mechanics (lung compliance and resistance) in 13 tracheotomized patients ready for a weaning trial. V_T was recorded with respiratory inductive plethysmography (RIP-V_T) or pneumotachography PT-V_T). Patients completed two T-piece trials of 30 min each with or without the cuff inflated.Results RIP-V_T and PT-V_T values were similar with the cuff inflated, but PT-V_T significantly underestimated RIP-V_T when the cuff was deflated, and therefore the RIP-V_T was chosen as the reference method. The RIP-V_T was significantly greater and the Pdi and PTPdi/min significantly lower when the cuff was deflated than when it was inflated. The efficiency of the diaphragm, calculated by the ratio of PTPdi/b over RIP-V_T, was also improved, while no changes were observed in lung mechanics.Conclusions Diaphragmatic effort is significantly lower during a T-piece trial with a deflated cuff than when the cuff is inflated, while RIP-V_T is higher, so that the diaphragm's efficiency in generating tidal volume is also improved.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.     

Control of tracheal cuff pressure: a pilot study using a pneumatic device

OBJECTIVE: To evaluate the efficacy of a simple mechanical device to maintain constant endotracheal cuff pressure (Pcuff) during mechanical ventilation (large encased inflatable cuff connected to the endotracheal cuff and receiving constant pressure from a heavy mass attached to an articulated arm). DESIGN AND SETTING: Single-center, prospective, randomized, crossover, pilot study in a medical intensive care unit. PATIENTS AND PARTICIPANTS: Nine consecutive mechanically ventilated patients (age 62+/-20 years, SAPS II score 39+/-15). INTERVENTIONS: Control day: Pcuff monitored and adjusted with a manometer (Hi-Lo, Tyco Healthcare) according to current recommendations (twice a day and after each intervention on the tracheal tube); initial target Pcuff 22-28 cmH20. Prototype day: test device connected to the endotracheal cuff; same initial target. Continuous Pcuff recording during both days. Control and prototype days in random order. RESULTS: Pcuff values over 50 cmH20 were recorded in six patients during the control day (178+/-159min), never during the prototype day. During the control day, Pcuff was between 30 and 50 cmH20 for 29+/-25% of the time, vs 0.3+/-0.3% during the prototype day (p<0.01). Pcuff was between 15 and 30 cmH20 for 56+/-36% of the time during the control day, vs 95+/-14% during the prototype day p<0.01). During the control day, Pcuff was below 15 cmH20 for 15+/-17% of the time, vs 4.7+/-15% during the prototype day (p<0.05). CONCLUSIONS: The tested device successfully controlled Pcuff with minimal human resource consumption. Prospective studies are required to assess its clinical impact.     

Mobile Phone-assisted Basic Life Support Augmented with a Metronome

Background

Basic life support (BLS) performed by lay rescuers is poor. We developed software for mobile phones augmented with a metronome to improve BLS.

Study Objectives

To assess BLS in lay rescuers with or without software assistance.

Methods

Medically untrained volunteers were randomized to run through a cardiac arrest scenario with (“assisted BLS”) or without (“non–assisted BLS”) the aid of a BLS software program installed on a mobile phone.

Results

Sixty-four lay rescuers were enrolled in the “assisted BLS” and 77 in the “non-assisted BLS” group. The “assisted BLS” when compared to the “non-assisted BLS” group, achieved a higher overall score (19.2 ± 7.5 vs. 12.9 ± 5.7 credits; p < 0.001). Moreover, the “assisted BLS” when compared to the “non-assisted” group checked (64% vs. 27%) and protected themselves more often from environmental risks (70% vs. 39%); this group also called more often for help (56% vs. 27%), opened the upper airway (78% vs. 16%), and had more correct chest compressions rates (44% ± 38% vs. 14% ± 28%; all p < 0.001). However, the “assisted BLS” when compared to the “non-assisted BLS” group, was slower in calling the dispatch center (113.6 ± 86.4 vs. 54.1 ± 45.1 s; p < 0.001) and starting chest compressions (165.3 ± 93.3 vs. 87.1 ± 53.2 s; p < 0.001).

Conclusions

“Assisted BLS” augmented by a metronome resulted in a higher overall score and a better chest compression rate when compared to “non-assisted BLS.” However, in the “assisted BLS” group, time to call the dispatch center and to start chest compressions was longer. In both groups, lay persons did not ventilate satisfactorily during this cardiac arrest scenario.     

Acquisition of imipenem-resistant Acinetobacter baumannii in a pediatric intensive care unit: a case-control study

Objective To investigate the risk factors associated with nosocomial acquisition of imipenem-resistant Acinetobacter baumannii (IRAB) among pediatric intensive care patients.Abstract Design and setting A retrospective case control study was conducted in a pediatric intensive care unit (PICU).Patients and participants Cases were children in whom IRAB was isolated from any clinical specimen obtained at least 48 h following admission to PICU. Controls were children without IRAB matched to cases in 2:1 ratio. Twenty-six cases were matched with 52 controls according to the chronological order of admission.Measurements and results Between July 2001 and December 2003, 52 (62%) of 84 clinical A. baumannii isolates were found nonsusceptible to imipenem (MIC ≥ 8 μg/ml). Demographic variables, comorbid conditions, clinical picture at admission, invasive procedures, use of antimicrobials and other drugs were analyzed as potential risk factors. Use of carbapenems and other β-lactams, aminoglycosides, ranitidine, mechanical ventilation, central venous or urinary catheters and length of stay in PICU were among the factors significantly associated with IRAB acquisition in the univariate analysis. By multivariate analysis, however, only aminoglycoside use and length of stay in the PICU were independent risk factors.Conclusions Acquisition of IRAB by PICU patients was independently associated with aminoglycoside use and prolonged stay in the unit. Studies of evaluation of infection control policies need to be pursued.     

Burnout in a surgical ICU team

Objective Psychologically stressful situations, a physically demanding workload and a high requirement for technological skills can lead ICU caregivers to burnout. The aim of our study was to evaluate their level of burnout as well as the related factors. Design A self-administered anonymous questionnaire. Setting A 20-bed surgical ICU in a university hospital. Patients and participants Nurse assistants, nurses. Interventions None. Measurements and results Ninety-seven of 107 questionnaires (91%) were returned. Of the members of ICU nursing team, 28% showed a high level of burnout. They reported a number of concerns, and that they felt discomfort and suffering. There was a discrepancy between the factors felt to be important by them and those statistically related to the burnout. Among the reported concerns, only the lack of patients' co-operation, the organization of the service and the rapid patient turnover were independently associated with a high level of burnout. As many as 49% of the nursing team felt stressed. Conclusions Almost a third of the ICU nursing team showed a high level of burnout. The factors felt to be important may not be those related to burnout. Since the well-being of the nursing team is important for the quality of care, corrective actions against the related factors should be sought in order to alleviate the suffering. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. This article is discussed in the editorial available at: .     

The views of patients and relatives of what makes a good intensivist: a European survey

Objective This study examined the views of adult patients and relatives about desirable characteristics of specialists in intensive care medicine (ICM) to incorporate these into an international competency-based training programme, CoBaTrICE. Design Convenience sample of patients and relatives administered after discharge from 70 participating ICUs in eight European countries (1,398 evaluable responses). The structured questionnaire included 21 characteristics of medical competence categorised as ‘medical knowledge and skills’, ‘communication with patients’, and ‘communication with relatives’. It was available in the national languages of the countries involved. Questions were rated by respondents for importance using a four-point Likert scale. Responses to open questions were also invited. Results Most characteristics were highly rated, with priority given to medical knowledge and skills. Women were more likely to emphasise communication skills. There were no consistent regional differences. Free-text responses welcomed the opportunity to participate. Conclusions Patients and relatives with experience of intensive care in different European countries share similar views on the importance of knowledge, skills, decision making and communication in the training of intensive care specialists. These generic patient-centred components of training have been incorporated into the international competency-based ICM training programme, CoBaTrICE. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. On behalf of The CoBaTrICE Collaboration: Hans U. Rothen University Hospital Department of Intensive Care Medicine 3010 Berne, Switzerland e-mail: hrothen@insel.ch Tel.: +41-31-6321176 Fax: +41-31-6329644 The full list of authors is provided under “Acknowledgements”. This article is discussed in the editorial available at: .     

Attitudes Toward Making Babies … With a Deceased Partner's Cryopreserved Gametes

A multiple segment factorial vignette was used with a probability sample of 857 U.S. households to assess the effects of contextual variables on attitudes toward posthumous reproduction using the cryopreserved gametes of a deceased partner. Attitudes were affected in predictable directions by marital status, gender of the deceased individual, disposition of the deceased's parents, and the deceased's wishes. In addition, respondents who identified more closely with their chosen religion tended to perceive posthumous conception as less appropriate and those who had never had children attributed a greater degree of obligation to assist on the part of medical professionals.     

Management of ventilator-associated pneumonia in a multidisciplinary intensive care unit: does trauma make a difference?

OBJECTIVE: Antibiotic exposure and timing of pneumonia onset influence ventilator-associated pneumonia (VAP) isolates. The first goal of this investigation was to evaluate whether trauma also influences prevalence of microorganisms. DESIGN: A retrospective, single-center, observational cohort study. SETTING: Multidisciplinary teaching ICU. PATIENTS: Adult patients requiring mechanical ventilation identified as having VAP. INTERVENTIONS: Retrospective evaluation of a prospective manual database. MEASUREMENTS AND MAIN RESULTS: VAP isolates in a multidisciplinary ICU documented by quantitative respiratory cultures and recorded in a 42-month database were compared, based on the presence or absence of trauma. Causative microorganisms were classified in four groups, based on mechanical ventilation duration (> 5 days), and previous antibiotic exposure. One hundred eighty-three patients developed 196 episodes of VAP (98 trauma). Methicillin-sensitive Staphylococcus aureus (MSSA) was more frequent (34.5% vs. 11.5%, p < 0.01) in trauma, whereas methicillin-resistant Staphylococcus aureus (MRSA) was more frequent (2% vs. 11.5%, p < 0.01) in non-trauma. No significant differences were found between trauma and non-trauma patients regarding prevalence of other microorganisms. In trauma patients, MSSA episodes were equally distributed between early- and late-onset VAP (51% vs. 49%), but no MRSA episode occurred in the early-onset group. CONCLUSIONS: Trauma influences the microbiology of pneumonia and it should be considered in the initial antibiotic regimen choice. Our data demonstrate that patients with trauma had a higher prevalence of MSSA, but the overall prevalence was sufficiently high to warrant S. aureus coverage for both groups. On the other hand, since no MRSA was isolated during the first 10 days of mechanical ventilation on trauma patients, MRSA coverage in these patients becomes necessary only 10 days after admission.     

C-reactive protein concentration as a predictor of in-hospital mortality after ICU discharge: a prospective cohort study

OBJECTIVE: The objective was to assess the ability of potential clinical predictors and inflammatory markers within 24 h of intensive care unit (ICU) discharge to predict subsequent in-hospital mortality. DESIGN AND SETTING: A prospective cohort study of 603 consecutive patients who survived their first ICU admission, between 1 June and 31 December 2005, in a 22-bed multidisciplinary ICU of a university hospital. MEASUREMENTS AND RESULTS: A total of 26 in-hospital deaths after ICU discharge (4.3%) were identified. C-reactive protein (CRP) concentrations at ICU discharge were associated with subsequent in-hospital mortality in the univariate analysis (mean CRP concentrations of non-survivors=174 vs. survivors=85.6 mg/l, p=0.001). CRP concentrations remained significantly associated with post-ICU mortality (a 10-mg/l increment in CRP concentrations increased the odds ratio [OR] of death: 1.09, 95% confidence interval [CI]: 1.03-1.16); after adjusting for age, the Acute Physiology and Chronic Health Evaluation (APACHE) II predicted mortality, and the Delta Sequential Organ Failure Assessment (Delta SOFA) score. The area under the receiver operating characteristic curve of this multivariate model to discriminate between survivors and non-survivors after ICU discharge was 0.85 (95% CI: 0.73-0.96). The destination and timing of ICU discharge, and the Discharge SOFA score, white cell counts and fibrinogen concentrations at ICU discharge were not significantly associated with in-hospital mortality after ICU discharge. CONCLUSIONS: A high CRP concentration at ICU discharge was an independent predictor of in-hospital mortality after ICU discharge in our ICU.     

Contrast-enhanced multiphasic CT and MRI of primary hepatic pregnancy: a case report and literature review

Primary hepatic pregnancy is extremely rare and difficult to diagnose radiologically. We present a 32-year-old woman with primary hepatic pregnancy diagnosed by using multi-modality imaging techniques, including ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI), which highlights diagnostic challenges. These techniques can define tissue planes in detail and identify embryo implantation into the hepatic parenchyma, thereby allowing accurate preoperative diagnosis and preoperative planning by the surgical team. To the best of our knowledge, this study is the first in the English literature to report a case of primary hepatic pregnancy, in which diffusion-weighted and contrast-enhanced multiphasic MRI were utilized for diagnosis and evaluation.     

Life-threatening adverse drug reactions at admission to medical intensive care: a prospective study in a teaching hospital

Objective To assess the characteristics of life-threatening adverse drug reactions in patients admitted to medical intensive care unit and to define those that could facilitate early identification. Design A prospective 6-month observational study. Patients Of the 436 admissions to the teaching hospital medical intensive care unit, all patients aged over 15 years and who had received documented drug treatment were included (n = 405). Measurements Characteristics of patients [age, gender, underlying diseases, organ failure(s), drugs taken, Severity Acute Physiologic Score II, length of stay, outcome at discharge] were prospectively collected using a standardised questionnaire. A panel of experts assessed putative serious adverse drug reaction(s) for each drug taken and each organ failure at admission by using a standardised causality assessment method. Characteristics of patients with and without serious adverse drug reactions at admission were compared using univariate and then stepwise descending multivariate logistic regression. Results Of the 405 patients included, 111 (27.4%) presented an adverse drug reaction leading to organ failure. In 48% of cases adverse drug reactions were preventable, 23% were undiagnosed and 19% contributed to death. Age over 75 years [odds ratio (OR) 2.25; 95% confidence interval (CI) 1.15–4.38; p = 0.02], having more than three drugs (OR 6.90; 95% CI 1.44–33.00; p = 0.02) and a diagnosis of haematological malignancy (OR 6.19; 95% CI 2.07–18.53; p = 0.001) were independently associated with serious adverse drug reactions. Conclusions Preventable life-threatening adverse drug reactions were frequently involved in organ failure at admission to medical intensive care; many of them had not been identified. Financial disclosures: None Conflict of interest: None     

Factors associated with posttraumatic stress symptoms in a prospective cohort of patients after abdominal sepsis: a nomogram

OBJECTIVE: To determine to what extent patients who have survived abdominal sepsis suffer from symptoms of posttraumatic stress disorder (PTSD) and depression, and to identify potential risk factors for PTSD symptoms. DESIGN AND SETTING: PTSD and depression symptoms were measured using the Impact of Events Scale-Revised (IES-R), the Post-Traumatic Symptom Scale 10 (PTSS-10) and the Beck Depression Inventory II (BDI-II). PATIENTS AND PARTICIPANTS: A total of 135 peritonitis patients were eligible for this study, of whom 107 (80%) patients completed the questionnaire. The median APACHE-II score was 14 (range 12-16), and 89% were admitted to the ICU. MEASUREMENTS AND RESULTS: The proportion of patients with "moderate" PTSD symptom scores was 28% (95% CI 20-37), whilst 10% (95% CI 6-17) of patients had "high" PTSD symptom scores. Only 5% (95% CI 2-12) of the patients expressed severe depression symptoms. Factors associated with increased PTSD symptoms in a multivariate ordinal regression model were younger age (0.74 per 10 years older, p=0.082), length of ICU stay (OR=1.4 per doubling of duration, p=0.003) and having some (OR=4.9, p=0.06) or many (OR=55.5, p<0.001) traumatic memories of the ICU or hospital stay. CONCLUSION: As many as 38% of patients after abdominal sepsis report elevated levels of PTSD symptoms on at least one of the questionnaires. Our nomogram may assist in identifying patients at increased risk for developing symptoms of PTSD.     

A double-layer tracheal tube cuff designed to prevent leakage: a bench-top study

OBJECTIVE: We designed a new endotracheal tube (ETT) cuff that does not form the folds that cause leakage of colonized subglottic secretions upon inflation within the trachea: a standard high-volume low-pressure cuff was draped with a second, highly elastic cuff made of a low-protein guayule natural latex rubber with 0.5[Symbol: see text]ml gel between the cuffs. We compared this prototype ETT cuff with four commercially available ETTs for efficacy in the prevention of fluid leakage across the cuff. DESIGN: In vitro study. MEASUREMENTS AND RESULTS: We compared fluid leakage in our prototype cuff with that in four commercially available ETTs. Three cylindrical glass tubes 16, 20, and 22[Symbol: see text]mm in diameter were used as model tracheas, and five different intracuff pressures (20, 25, 30, 40, and 50[Symbol: see text]cmH(2)O) were tested. Each test was repeated three times with new ETTs. The guayule latex ETT cuff showed an average fluid leakage of 0.0007[Symbol: see text]+/-[Symbol: see text]0.002[Symbol: see text]ml/min which was significantly lower than that in any of the other ETTs (Microcuff 0.07[Symbol: see text]+/-[Symbol: see text]0.09, Mallinckrodt/Hi-Lo Evac 5[Symbol: see text]+/-[Symbol: see text]5, Euromedical 7[Symbol: see text]+/-[Symbol: see text]4, Sheridan/CF 41[Symbol: see text]+/-[Symbol: see text]69). CONCLUSIONS: Our prototype ETT cuff significantly reduced fluid leakage in this bench-top study. In vivo testing and evaluation is to follow.