The use of echocardiography in the critical care setting.

Echocardiography has become an invaluable tool in the management of critically ill patients. Its safety and portability allow for use at the bedside to provide rapid, detailed information regarding the cardiovascular system. Echocardiography can elucidate cardiac structure and mechanical function. Recently, the power of clinical echocardiography has been augmented by the use of Doppler techniques to evaluate cardiovascular hemodynamics. An in-depth understanding of the proper use of echocardiography is a prerequisite for the intensivist.     

The use of erythropoiesis-stimulating agents in the intensive care unit

Anemia is common in critically ill patients, but treatment with red blood cell transfusions can have unwanted effects. Limiting the occurrence and severity of anemia by using erythropoietic agents (iron and/or recombinant erythropoietin), therefore, remains an attractive option during the intensive care unit stay but also after hospital discharge. Moreover, these agents may have additional beneficial properties. In this article the authors review the rationale for the administration of iron and/or erythropoietin in critically ill patients.     

PDCA在儿科重症监护室优质护理服务中的应用

目的探讨PDCA对改善儿科重症监护室(以下简称PICU)优质护理服务管理、提高护理质量的作用。方法优质护理服务中运用PDCA循环管理模式,对本科"以患者为中心,强化基础护理,全面落实护理责任制,深化护理专业内涵,提升整体护理服务水平"中各要素、指标、环节、结果等进行原因分析,制定相应护理计划、执行实施、检查效果、并对下一个行动的循环模式进行持续质量改进。结果自2010年本科运用PDCA后,患者及家属满意度提高,对本科服务、护理质量给予较高肯定,护士成就感、自信心得到提升。结论 PDCA循环对本科实施优质护理服务,提高护理质量起到非常重要的作用。     

右美托咪啶在重症监护病房中的应用

镇静镇痛是医院重症监护病房(ICU)危重患者尤其是机械通气患者的基本治疗措施,理想和适度的镇静镇痛可缩短机械通气时间、住ICU时间和住院时间[1-2].     

The use of patient diaries in an intensive care unit

Many patients experience posttraumatic stress disorder following a stay in intensive care; this can be due to a lack of recall of their stay. Retrospective patient diaries (n = 8) with follow-up have been used to try and help patients' recovery but have been found to be impersonal. Prospective diaries (n= 35) were implemented and trialled with follow-up at 2, 6 and 12 months postdischarge. Patients' and relatives' initial feedback regarding diaries is extremely positive. Benefits included better understanding of the events of the critical illness, helping with more realistic goal setting during the recovery period, improving communication within families through discussion of the diary and providing a source of comfort for the bereaved. More formal audit of these diaries is required and is currently being undertaken.     

The changing face of critical care medicine: nurse practitioners in the pediatric intensive care unit

Over the last 50 years, healthcare has undergone countless changes. Some of the important changes in recent years have been budget cuts, decreased resident work hours, and increased patient acuity. The need for additional clinical expertise at the bedside has resulted in nurse practitioners becoming an integral part of the healthcare delivery team. To date, little has been published regarding the role of the nurse practitioners in intensive care units. This article outlines how one pediatric hospital has successfully utilized nurse practitioners in the intensive care unit.     

Neuromuscular complications in the intensive care unit: critical illness polyneuromyopathy

Critical illness polyneuromyopathy, a complication of critical illness, is a primary axonal degeneration of motor and sensory fibers that leads to skeletal muscle weakness. It significantly contributes to the unexplained difficulty in weaning from mechanical ventilation and to their prolonged rehabilitation and poor quality of life after discharge. This article will discuss the diagnosis of critical illness polyneuromyopathy, identify risk factors, review several pathomechanisms that have been proposed, and discuss the implications for practice.     

The use of propofol sedation in a paediatric intensive care unit

Background: The aim of this study was to prospectively evaluate and report the experience of the use of continuous intravenous propofol sedation in a paediatric intensive care unit (PICU). Methods: All children younger than 16 years who were admitted to the PICU at a University Hospital for slightly more than a year and received propofol infusion were included prospectively and data were recorded before and within 6 h after completion of the propofol infusion. Results: A total of 174 out of 955 children (18·2%) received propofol infusion for sedation. The median age was 2 years 10 months (range: 2 months to 16 years), duration of propofol infusion 13 h (range: 1·6–179 h) and dose of propofol 2·9 mg/kg/h (range: 0·3–6·5 mg/kg/h). No one developed signs of the propofol infusion syndrome (PRIS). Neither dose >3 mg/kg/h, duration of infusion >48 h nor both were found to be related to adverse metabolic derangements or circulatory failure. Eight children increased their lactate concentration ≥1·8 mmol/L during propofol infusion. All had a favourable outcome. One child who had received propofol infusion for 10 h died, but this occurred 14 h after the infusion ceased and was without doubt attributed to a multiple organ failure not related to the propofol infusion. Conclusion: Propofol infusion was used in this population at low risk of PRIS with no metabolic or circulatory adverse effects. These findings indicate that the occurrence of adverse effects may not be directly related to dose or duration of infusion, but emphasizes the risk that sporadic factors may be involved, such as genetic mutations. Guidelines are presented.     

Multiprofessional survey of protocol use in the intensive care unit

Purpose

To date, there has been no large multicenter, multiprofessional evaluation of protocol and guideline use in the intensive care unit (ICU). The primary purpose of this study was to describe national availability, development, implementation, and assessment of protocols in ICUs. A secondary objective was to compare perceived utility by ease of use, patient safety, cost containment, and compliance of protocols between nurses, physicians, and pharmacists.

Materials and Methods

The survey was developed and tested for validity by 15 clinicians who identified additional domains of interest. An additional 15 clinicians of the 3 different professions evaluated the survey for relevancy and appropriateness of responses. Three survey experts evaluated survey construction. The survey was uploaded to a Web survey tool and pilot tested for clarity and ease of completion.

Results

The overall response rate for the survey was 18.1% (n = 614). Popular methods of education for protocol implementation included staff meetings (85.3%) and unit-specific in-services (77.7%). Protocols were most often updated when new information was available (40.8%) or every 12 months (17.9%). The most common limitation to development and implementation was limited personnel resources (24.5%) and physicians not wanting to use them (21.3%), respectively. Clinicians indicated that protocols made their job easier and improved cost containment some or most of the time. Sepsis protocols were identified as most useful in promoting patient outcomes by all 3 professions.

Conclusions

The types of protocols available appear to be those assisting with management of high-alert medications. Overcoming the perceived barriers of protocol use within ICUs requires personnel for development and physician support. A better protocol review process may be necessary to assure optimal content, desired outcomes, and consistency with Institute for Safe Medication Practices guidelines.     

Strategic use of antibiotics in the neonatal intensive care unit

Infection is one of the most common causes of infant morbidity and mortality in the neonatal intensive care unit, despite the availability of various therapeutic medical interventions, such as mechanical ventilation, that allow premature infants a better chance of survival. In fact, many of these therapeutic interventions violate the natural protective barriers for infection. Fortunately, maternal and neonatal risk factors have been identified for early- and late-onset sepsis and the prevalence of highly suspected pathogens for each type of infection influences the empiric selection of antibiotics. In many institutions, the common pathogens have developed resistance to antibiotics. In others, the predominance of pathogens has shifted. Both challenges may warrant modification of traditional antibiotic regimens. Continual monitoring of pathogen shifts within an individual neonatal intensive care unit and application of various antibiotic characteristics are key elements of strategic, safe, and effective use of antibiotics in this patient population. Development of a protocol incorporating infection control measures and guidelines for judicious use of antibiotics can minimize the threat of antibiotic resistance.