Visiting critically ill adults: strategies for practice.

Visitation and proximity needs are consistently rated as very important by families of critically ill patients. This article reviews the literature on the proximity needs of families, presents nursing interventions to meet them, and suggests a plan for future research in this area.     

Sedation assessment in critically ill adults.

OBJECTIVE: To review methods for assessing sedation in critically ill adults, discuss their impact on patient outcomes, and provide recommendations for implementing these methods into clinical practice in the intensive care unit (ICU). DATA SOURCES: A computerized search of MEDLINE from 1980 through June 2000 and a manual search of abstracts presented at recent critical care meetings were performed. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools that have been used to titrate therapy in adult, critically ill patients were identified. Special emphasis was placed on sedation assessment instruments that have been prospectively validated. Objective methods that have been used to assess sedation therapy were also identified. DATA SYNTHESIS: Twenty-three adult sedation assessment instruments were identified. Few scales have been prospectively evaluated for validity (n = 6) or reliability (n = 7). Other methods of sedation assessment were identified (e.g., bispectral index monitor); however, most of these methods have only been studied in small subsets of critically ill patients. CONCLUSIONS: Incorporation of sedation assessment into ICU clinical practice may improve patient care. These sedation assessment instruments must be further evaluated to determine their impact on quality of care and ICU length of stay.     

Transport of critically ill adults

Interhospital transport can be hazardous because of rapid changes in a patient's physiologic status and the use of monitoring systems. A retrospective study evaluated the first 204 critically ill adult patients transported from community hospitals to Stanford Medical Center by a special transport team. To relate the risk of transport to severity of illness, a retrospective scoring system was devised. Sixty-one percent (n = 125) of the patients were at high risk for transport. The patients were stabilized at the referring hospital, and invasive monitoring was used as mandated by the patient's condition. The average transport distance was 133 km, and the average duration of transport was 4.38 h. One hundred and five patients (51.5%) were transported by air, and the remaining patients were transported by surface ambulance. All patients survived the transport, and 71.6% were eventually discharged from the hospital. Hospital mortality correlated with the risk-scoring system (p less than .01) and increased five-fold as severity of illness increased. This study demonstrates that, with appropriate hemodynamic stabilization and monitoring, severely ill patients can be transported safely.     

Evaluation of a sedation protocol for intubated critically ill children.

The aim of this study was to conduct an evaluation of a sedation protocol that transfers some decision-making authority for analgesia and sedation, within clearly defined parameters, to nurses in a pediatric intensive care unit (PICU). The sedation protocol used in this study was appropriate for any age group. The clinical course of 10 patients admitted to the PICU during a 5-month interval who were on the sedation protocol during their stay was examined using retrospective chart review. Time intervals when patients were on the protocol were compared with clinically comparable time intervals, in terms of acuity, when the same patient received conventional management. Data were collected on the number of days a child was ventilated, the number of days in the PICU, the number of days hospitalized and severity of illness. Additionally, data were collected on the amounts of sedation and analgesia required and the incidence of under-sedation. Physician and nurse satisfaction with the sedation protocol was examined using a self-report survey. The findings of this study indicate that the delegation of decision-making authority for analgesia and sedation to PICU nurses can provide effective and timely management of patient comfort, without an increase in morbidity, in a manner that is more satisfying for physicians and nurses.     

Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program.

BACKGROUND: Despite multiple reminders, education sessions, and multidisciplinary team involvement, adherence to an evidence-based mechanical ventilation weaning protocol had been less than 1% in a general systems intensive care unit since implementation. OBJECTIVE: To assess the effectiveness of using an implementation program, the Model for Accelerating Improvement, to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit. METHODS: A prospective comparative design, before and after implementation of the Model for Accelerating Improvement, was used with a consecutive sample of 129 patients and 112 multidisciplinary team members. Clinical outcomes were rate of unsuccessful extubations, rate of ventilator-associated pneumonia, and duration of mechanical ventilation; practice outcomes were staff's understanding of the mechanical ventilation weaning protocol, perceptions of the practice safety climate, and adherence to the weaning protocol. RESULTS: After the intervention, the rate of unsuccessful extubations decreased, and staff's understanding of and adherence to the weaning protocol increased significantly. The rate of ventilator-associated pneumonia, duration of mechanical ventilation, and staff's perceptions of the practice safety climate did not change significantly. CONCLUSION: Implementing the Model for Accelerating Improvement improved understanding of and adherence to protocol-directed weaning and reduced the rate of unsuccessful extubations.     

Physical antipyresis in critically ill adults

Nurses use a variety of methods to cool critically ill patients, even though there are no guidelines for the treatment of temperature elevation in this population. In order to determine whether physical methods of antipyresis, such as the application of cooling blankets, are appropriate for use in the ICU, and if so which methods are best, the authors conducted a literature review. Their findings raise concerns about whether external cooling methods should be used at all in the absence of hyperthermia or cerebral damage. In addition, the authors give an overview of the causes and effects of temperature elevation, focusing mostly on fever.A literature review examines external cooling methods for use in the ICU. The findings raise some doubts.     

Benzodiazepine-associated delirium in critically ill adults

Purpose

The association between benzodiazepine use and delirium risk in the ICU remains unclear. Prior investigations have failed to account for disease severity prior to delirium onset, competing events that may preclude delirium detection, other important delirium risk factors, and an adequate number of patients receiving continuous midazolam. The aim of this study was to address these limitations and evaluate the association between benzodiazepine exposure and ICU delirium occurrence.

Methods

In a cohort of consecutive critically ill adults, daily mental status was classified as either awake without delirium, delirium, or coma. In a first-order Markov model, multinomial logistic regression analysis was used, which considered five possible outcomes the next day (i.e., awake without delirium, delirium, coma, ICU discharge, and death) and 16 delirium-related covariables, to quantify the association between benzodiazepine use and delirium occurrence the following day.

Results

Among 1112 patients, 9867 daily transitions occurred. Benzodiazepine administration in an awake patient without delirium was associated with increased risk of delirium the next day [OR 1.04 (per 5 mg of midazolam equivalent administered) 95 % CI 1.02–1.05). When the method of benzodiazepine administration was incorporated in the model, the odds of transitioning to delirium was higher with benzodiazepines given continuously (OR 1.04, 95 % CI 1.03–1.06) compared to benzodiazepines given intermittently (OR 0.97, 95 % CI 0.88–1.05).

Conclusions

After addressing potential methodological limitations of prior studies, we confirm that benzodiazepine administration increases the risk for delirium in critically ill adults but this association seems to be limited to continuous infusion use only.

     

A new dosing protocol reduces dexmedetomidine-associated hypotension in critically ill surgical patients

Background

Although no ideal sedative exists, dexmedetomidine is unique because it produces sedation and analgesia without decreasing the respiratory drive. Hemodynamic responses to dexmedetomidine are variable and dependent on the patient population. Our initial experience was associated with an unacceptable incidence of hypotension and bradycardia. We evaluated occurrence of hypotension and bradycardia in critically ill surgical patients receiving dexmedetomidine before and after implementation of a dosing protocol.

Methods

This is a retrospective chart review of all admissions to a university medical center–based, 44-bed surgical intensive care unit pre and post protocol implementation.

Results

Forty-four patients received dexmedetomidine including 19 historic controls and 25 dosed via protocol. Both groups had comparable demographics and initial and maximum dosages of dexmedetomidine. Use of the dosing protocol resulted in fewer dosage changes (mean ± standard deviation, 4.8 ± 3.8 compared to 7.8 ± 3.9; P = .014) and fewer episodes of hypotension (16% vs 68.4%; P = .0006) but did not influence bradycardic episodes (20% vs 15.5%; P > .99).

Conclusion

We found that use of a protocol that increases the time interval between dosage adjustments may reduce dexmedetomidine-associated hypotension.     

Unresponsive thrombotic thrombocytopenic purpura in critically ill adults

Introduction

The prognosis of thrombotic thrombocytopenic purpura (TTP) has considerably improved since the introduction of plasma exchange (PEX) therapy. However, unresponsive thrombotic thrombocytopenic purpura (Un-TTP) still carries high morbidity and mortality rates, indicating a need for early specific treatments.

Patients and Methods

In a retrospective study including consecutive adults with TTP admitted between January 1997 and January 2011 in a teaching hospital intensive care unit (ICU), our objective here is to identify early clinical and laboratory features predicting Un-TTP. Patients who responded to plasma exchange and steroids (N = 49) were compared with patients with unresponsive TTP defined as requirement for other treatments, protracted course, or death (N = 37, 43 %).

Results

Hospital mortality was 24.3 % in the Un-TTP group. Variables associated with Un-TTP on univariate logistic regression were older age, cardiac involvement, neurological involvement, higher anti-a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS13) immunoglobulin G (IgG) titer, lower platelet counts starting on day 2, higher Sequential Organ Failure Assessment (SOFA) scores starting on day 3, need for higher plasma volumes to obtain remission, and greater use of adjuvant treatments and life-sustaining interventions. Multivariate logistic regression identified four factors independently associated with Un-TTP: age over 60 years [odds ratio (OR) 7.90; 95 % confidence interval (95 % CI) 1.06–78.34], cardiac (OR 5.17; 95 % CI 1.63–16.39) or neurological (OR 8.04; 95 % CI 1.27–51.03) manifestations at diagnosis, and day 2 platelet count less than 15 G/l (OR 3.88; 95 % CI 1.30–11.62).

Conclusion

Therapeutic intensification starting on day 3 or even earlier in patients with the independent risk factors for unresponsive TTP identified in our study deserves evaluation in a multicenter prospective study.     

Cardiac variability in critically ill adults: influence of sepsis.

OBJECTIVE: To evaluate, in critically ill adults, factors associated with impaired sympathovagal balance. DESIGN: One-month inception cohort study. SETTING: Twenty-six-bed medical intensive care unit of a teaching hospital. PATIENTS: Critically ill adults with an expected duration of intensive care unit stay of > or =48 hrs were enrolled. Patients with permanent arrhythmia or cardiac pacing were not included. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Sympathovagal balance was assessed on the day after intensive care unit admission by the low-frequency/high-frequency ratio obtained from spectral components of heart rate signal: overall variability, low frequency, and high frequency. RESULTS: Forty-one patients, 13 with sepsis and 28 without sepsis, were assessed. Predictors of low-frequency/high-frequency ratio with the automatic interaction detection method were sepsis and age. Binary logit analysis adjusted for age showed that sepsis remained a strong and independent factor of a low-frequency/high-frequency ratio of <1.50, with an odds ratio of 3.63 (95% confidence interval, 1.47-9.01, p =.005). Use of mechanical ventilation, catecholamines, or sedation did not add any information. The use of the low-frequency/high-frequency ratio in diagnosing sepsis may be supported by a likelihood ratio for low frequency/high frequency <1 at 6.47. CONCLUSIONS: This work suggests that impaired cardiac variability and notably sympathovagal balance (i.e., a low-frequency/high-frequency ratio <1.0) may be a diagnostic test for sepsis.     

Management of delirium in critically ill older adults

Delirium in older adults in critical care is associated with poor outcomes, including longer stays, higher costs, increased mortality, greater use of continuous sedation and physical restraints, increased unintended removal of catheters and self-extubation, functional decline, new institutionalization, and new onset of cognitive impairment. Diagnosing delirium is complicated because many critically ill older adults cannot communicate their needs effectively. Manifestations include reduced ability to focus attention, disorientation, memory impairment, and perceptual disturbances. Nurses often have primary responsibility for detecting and treating delirium, which can be extraordinarily complicated because patients are often voiceless, extremely ill, and require high levels of sedatives to facilitate mechanical ventilation. An aggressive, appropriate, and compassionate management strategy may reduce the suffering and adverse outcomes associated with delirium and improve relationships between nurses, patients, and patients' family members.     

Food and drug interactions in critically ill adults

What happens when two needed therapies collide in the critically ill patient? This article explores the negative interaction of food and drugs that can occur along with important nursing implications. Also included is a discussion on the development of a food-drug interaction program, a multifaceted and comprehensive approach to monitoring, evaluating, reporting, and reducing the occurrence of food-drug interactions.     

Evaluation of dexmedetomidine withdrawal in critically ill adults

BackgroundDexmedetomidine (DEX) withdrawal syndrome has been reported in the pediatric population, but literature describing DEX withdrawal in critically ill adults is limited. The purpose of this study was to determine the incidence of DEX withdrawal in adult patients and to identify factors associated with DEX withdrawal syndrome.MethodsA retrospective chart review was performed in the adult intensive care units of two tertiary medical centers. Eligible patients were at least 18 years of age and received DEX for 24 h or more. Patients were excluded if they presented with a primary neurologic diagnosis, had a history of substance abuse, or received any other α2-agonists 24 h before discontinuation of DEX. The primary outcome was the percentage of patients who developed withdrawal as defined by the presence of two or more symptoms (tachycardia, hypertension, vomiting, agitation) within the 24 h following DEX discontinuation.ResultsOf the 165 patients included, 50 patients experienced withdrawal (30.3%), lasting a median of two days. The incidence of withdrawal was higher in surgical (40%) compared to medical (28%) or cardiac (32%) patients (p = 0.004). Median duration of infusion was 52.5 h (interquartile range [IQR], 37.8 to 102.8) in the withdrawal group and 52 h (IQR, 41 to 87) in the non-withdrawal group (p = 0.887). Median DEX dose was 0.56 μg/kg/h (IQR, 0.39 to 0.83) in the withdrawal group and 0.48 μg/kg/h (0.36 to 0.65) in the non-withdrawal group (p = 0.12). Weaning did not reduce the incidence of withdrawal as compared to abrupt discontinuation (p = 0.68). The withdrawal group was more likely to have concomitantly discontinued opioids (54% vs 12.2%) and benzodiazepines (36% vs 0%) at the time of DEX discontinuation compared to the non-withdrawal group (p = 0.004).ConclusionDevelopment of DEX-associated withdrawal occurred in approximately 30% of adult patients, comparable to rates reported in pediatric literature. There appeared to be no correlation between dose, exposure, and weaning in the occurrence of withdrawal, but concomitant discontinuation of opioids or benzodiazepines as well as ICU admission type could highlight cases requiring closer monitoring.     

Moving our critically ill patients: mobility barriers and benefits

Diagnosis and resuscitation for critically ill patients have improved in the last 25 years, and survival has also increased. With improvements in mortality, the field of critical care has seen increased opportunities to improve posthospital quality of life for survivors of critical illness. This article focuses particularly on how mobilization may improve quality of life for patients.     

Development of clinical guidelines for prone positioning in critically ill adults

Literature reveals evidence that prone positioning can improve the oxygenation of critically ill patients suffering from acute lung injury or acute respiratory distress syndrome. Multicentre evidence, however, does not support the claim that it improves patients' outcome. The implementation of multiprofessional guidelines by which to direct the manoeuvre will facilitate the safe and effective management of patients in the prone position. They will thus heighten multiprofessional awareness of the technique and promote its proactive use at such time so as to achieve maximum clinical benefit.     

Reliability of point-of-care testing for glucose measurement in critically ill adults

BACKGROUND: Glycemic control is increasingly being recognized as a priority in the treatment of critically ill patients. Titration and monitoring of insulin infusions involve frequent blood glucose measurement to achieve target glucose ranges and prevent adverse events related to hypoglycemia. Therefore, it is imperative that bedside glucose testing methods be safe and accurate. OBJECTIVE: To determine the accuracy and clinical impact of three common methods of bedside point-of-care testing for glucose measurements in critically ill patients receiving insulin infusions. DESIGN: Prospective observational study. SETTING: A 21-bed mixed medical/surgical intensive care unit of a tertiary care teaching hospital. PATIENTS: Thirty consecutive critically ill patients who were vasopressor-dependent (n = 10), had significant peripheral edema (n = 10), or were admitted following major surgery (n = 10). MEASUREMENTS: Findings from three different methods of glucose measurement were compared with central laboratory measurements: (1) glucose meter analysis of capillary blood (fingerstick); (2) glucose meter analysis of arterial blood; and (3) blood gas/chemistry analysis of arterial blood. Patients were enrolled for a maximum of 3 days and had a maximum of nine sets of measurements determined during this time. RESULTS: Clinical agreement with the central laboratory was significantly better with arterial blood analysis (69.9% and 76.5% for glucose meter and blood gas/chemistry analysis, respectively) than with capillary blood analysis (56.8%; p = .039 and .001, respectively). During hypoglycemia, clinical agreement was only 26.3% with capillary blood analysis and 55.6% and 64.9% for glucose meter and blood gas/chemistry analysis of arterial blood (p = .010 and <.001, respectively). Glucose meter analysis of both arterial and capillary blood tended to provide higher glucose values, whereas blood gas/chemistry analysis of arterial blood tended to yield lower glucose values. CONCLUSIONS: The magnitude of the differences in the glucose values offered by the four different methods of glucose measurement led to frequent clinical disagreements regarding insulin dose titration in the context of an insulin infusion protocol for aggressive glucose control.