The state of intubated ICU patients: development of a two-dimensional sedation rating scale for critically ill adults

STUDY OBJECTIVES: To develop and evaluate an observer-rated instrument, the Minnesota Sedation Assessment Tool (MSAT), which is a measure of arousability, spontaneous muscle activity, and global sedation quality of mechanically ventilated adults. DESIGN: Paired raters assessment for reliability testing and observational design for validation testing. SETTING: Medical and surgical ICUs at a university-based hospital. PARTICIPANTS: Ninety-four intubated patients in ICUs and 93 ICU staff nurses. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The MSAT had very good overall reliability between raters, with the arousal scale (kappa = 0.85) having slightly better agreement than the motor activity scale (kappa = 0.72). The instrument had good coverage, very few missing values, and very good correlation with visual analog scales. The MSAT arousal scale had moderate correlation (rho = 0.68) with the analogous scale of a previously validated sedation instrument, the Vancouver Interaction and Calmness Scale. The correlation was weaker (rho = -0.41) between the MSAT motor activity scale and the calmness subscale, probably because of their dissimilar constructs. Both MSAT scales demonstrated convergent validity, whereas predictive validity was demonstrated in both a hypothetical scenario and in actual clinical practice for the MSAT arousal scale only. A patient's spontaneous motor activity was not associated with future sedative administration, with the possible exception of a more-sedated patient subgroup. CONCLUSIONS: The MSAT combines the efficiency of a single-item response format while permitting the separate reliable measurement of distinct observable characteristics of intubated patients. The level of consciousness of intubated patients influences the future administration of sedative medications. Spontaneous motor activity is less important in determining subsequent sedative use but may be useful as a comparative measure of patients' kinesiologic state during critical illness.     

Transnasal endoscopy for enteral feeding tube placement in critically ill patients

OBJECTIVE: Early enteral feedings may improve outcomes in critically ill patients. Recently, transnasal endoscopy with an ultrathin transnasal endoscope has been shown to be of value for diagnostic endoscopy without conscious sedation. We developed a technique for the placement of postpyloric feeding tubes in critically ill patients using transnasal endoscopy. We describe our initial experience in a consecutive series of patients. METHODS: We collected data on consecutive intensive care unit patients undergoing bedside transnasal endoscopy for nasoenteric feeding tube placement using a standardized technique. Tube position was confirmed in all patients with a plain abdominal radiograph. Tube placement was deemed successful if the feeding tube traversed the pylorus. RESULTS: Transnasal endoscopy was completed in all fourteen patients, as was placement of a feeding tube. Feeding tubes were successfully placed in the jejunum or duodenum in 13 of the 14 patients (93%). Tubes remained in place from 3 to 45 days (mean 16 days). Two patients required conscious sedation during tube placement, and two ultimately required percutaneous gastrostomy. CONCLUSIONS: Transnasal endoscopy allows simple and successful postpyloric feeding tube placement at the bedside of critically ill patients. This method can facilitate early enteral feeding in intensive care units.     

Clinical assessment of central venous pressure in the critically ill

To evaluate the accuracy of central venous pressure (CVP) assessment in critically ill patients, and measure disagreement amongst clinicians, 50 consecutive intensive care unit (ICU) patients with right internal jugular catheters were examined. CVP was measured by the indwelling catheter, and was assessed by: (1) one of three ICU staff physicians, (2) one of six medical residents, and (3) one of six medical students. There was no significant difference in CVP assessment between medical students, residents, and staff physicians. Although all clinicians tended to underestimate CVP, only the residents did so significantly (p less than 0.05). Sensitivity and specificity, and agreement and correlation between the clinicians' assessment and catheter measurements were higher when ventilated patients were excluded. All clinicians agreed more often and were better at identifying low CVP. In summary, considerable disagreement and inaccuracy exists in the clinical assessment of central venous pressure in critically ill patients.     

Subjective and objective measurement of tidal volume in critically ill patients

Subjective assessment of the respiratory rate and the adequacy of tidal ventilation are the oldest and most widely practiced forms of respiratory monitoring in critically ill patients. Surprisingly, this method of assessment has itself never been evaluated in patients. The estimation of tidal volume in nine patients was performed by full-time intensive care unit (ICU) personnel and compared to the objective measurement of using a calibrated and validated respiratory inductive plethysmograph (RIP). Linear correlation analysis was performed. Poor correlation between clinical estimation by ICU personnel and actual measurement by RIP was revealed in all cases. A widespread and potentially dangerous tendency to overestimate tidal volume was noted. These data suggest that subjective assessment of tidal volume is inaccurate in critically ill patients and that the development of techniques of continuous, nonobtrusive and objective monitoring are to be encouraged.     

吞咽功能障碍的老年重症患者经鼻肠管和鼻胃管肠内营养的比较

目的 比较经鼻肠管和鼻胃管两种途径在伴有吞咽功能障碍的老年重症患者中的肠内营养（EN）支持的效果及并发症情况,以选择更安全有效的EN途径。方法 选取2012年1月至2014年11月在南京市市级机关医院重症医学科住院的伴有吞咽功能障碍的老年患者共53例进行EN,将患者随机分为留置鼻胃管组（31例）和留置鼻空肠管组（22例）。EN 2周后观察两组的营养指标情况、并发症发生率及预后,进行比较及统计分析。结果 两组患者中鼻空肠管组前白蛋白升高更显著,胃肠道并发症及吸入性肺炎发生率均显著下降,差异存在统计学意义（P＜0.05）。但机械通气率和病死率两组相比差异无统计学意义（P＞0.05）。结论 伴有吞咽功能障碍的老年重症患者应用鼻空肠管给予EN更为安全、有效。     

The assessment of acute kidney injury in critically ill patients

Acute kidney injury (AKI) is common in critically ill patients and is associated with high morbidity and mortality. The availability of several biomarkers of kidney injury offers new tools for its early recognition and management. The early identification of high-risk patients provides an opportunity to develop strategies for the prevention, early diagnosis and treatment of AKI. Despite progress in critical care medicine over the past decade, the treatment strategies for AKI in critically ill patients, such as when to start renal replacement therapy, remain controversial. A recently proposed risk prediction score for AKI, based on routinely available clinical variables, presents a new means of identifying patients at high risk of AKI.     

Arterial oxygen pressure targets in critically ill patients: Analysis of a large ICU database

BackgroundProviding supplemental oxygen is common in the management of critically ill patients, yet the optimal oxygen regimen remains unclear.ObjectivesTo explore the optimal range of PaO₂ in critically ill patients.MethodsThis is a retrospective study conducted in the Medical Information Mart for Intensive Care III (MIMIC-III) database. The patients with a least 48 h of oxygen therapy were included. Nonlinear regression was used to analyze the association between PaO₂ and mortality. We derived an optimal range of PaO₂ and evaluated the association between the proportion of PaO₂ measurements within this range and mortality.ResultsIn total, 8401 patients were included in the study. A J-shaped relationship was observed between median PaO₂ and hospital mortality. Compared with the reference group of 100–120 mmHg, patients with values of 80–100 mmHg and 120–140 mmHg had higher hospital mortality (adjusted odds ratio [aOR], 1.23; 95% CI, 1.05–1.43 and 1.29; 95%CI, 1.08–1.54, respectively). Similarly, mortality rates were significantly higher for PaO₂ <80 mmHg and ≥140 mmHg (aOR, 1.97; 95%CI, 1.58–2.45 and 1.42; 95%CI, 1.19–1.69, respectively). Patients spent a greater proportion of time within 100–120 mmHg tended to have a lower mortality rate.ConclusionAmong critically ill patients, the relationship between median PaO₂ and hospital mortality was J-shaped. The lowest rates of mortality was observed in those with PaO₂ levels within 100 to 120 mmHg.     

Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review

OBJECTIVE: The purpose of this literature review is to examine the effect of the interaction between gastrointestinal motility and feeding site on the aspiration risk in critically ill, tube-fed patients. METHODS AND RESULTS: A single answer to the question of the preferred feeding site is not likely to be found because the degree of aspiration risk varies significantly according to individual variations in gastrointestinal motility and multiple pre-existing and treatment-related risk factors. However, regardless of the feeding site, it is ultimately regurgitated gastric contents that are aspirated into the lungs. For this reason, the clinical assessment of greatest interest is the evaluation of gastric emptying, usually monitored clinically by measuring gastric residual volumes. CONCLUSION: Current recommendations for monitoring residual volumes and preventing aspiration are provided.     

Stress ulceration: a serious complication in critically ill patients

The incidence of gastrointestinal bleeding in critically ill patients appears to have declined over the past decade; however, it has not been shown that the incidence of stress ulceration has declined as well. The pathophysiology of stress ulceration is not totally understood, although various factors have been implicated: mucosal barrier breakdown, decreased mucosal blood flow, increased intraluminal acid, decreased epithelial regeneration, and lowered intramural pH. It is widely accepted that prevention is the cornerstone of management for stress ulceration. The critical care nurse must be aware of the importance of monitoring and maintaining a gastric pH greater than 3.5. Antacids, histamine receptor antagonists, sucralfate, and prostaglandins have all been shown to play a role in the treatment of stress ulcerations.     

An objective assessment of the tube spacer in patients unable to use a conventional pressurized aerosol efficiently

The tube spacer, a device designed to simplify the inhalation of terbutaline from a pressurized aerosol, was objectively assessed in a group of patients with reversible airways obstruction who were found to have some difficulty in using conventional inhalers. Terbutaline was administered to 22 patients in a dose of 250 μg via the conventional pressurized aerosol and the tube spacer. In 16 the improvements in FEV₁ were greater after the tube spacer, in four they were greater after the conventional inhaler and in two patients there was no difference. Using an open sequential plan for evaluation of paired preferences it was concluded that the tube spacer was better than the conventional inhaler in these patients.     

Acute kidney injury in critically ill cirrhotic patients: a review

Acute kidney injury (AKI) is an important marker of morbidity and mortality in critically ill cirrhotic patients. The most common causes of AKI in cirrhotic patients include prerenal or hepatorenal syndrome (HRS). Diagnosis of AKI may be delayed by the lack of clinical, biochemical, and radiological markers with proven sensitivity and specificity in cirrhotic patients. In this review, we discuss the epidemiology, pathophysiology, diagnosis, and therapies for AKI in cirrhotic patients admitted to an intensive care unit (ICU).     

The pressure to withhold or withdraw life-sustaining therapy from critically ill patients in the United States

Physicians and nurses sometimes exert pressure on the families of critically ill patients to withhold or withdraw life-sustaining therapy from them. This pressure may stem from prognostic, professional, social, and economic factors. Although the pressure to limit life support may be appropriate in some circumstances, in others it is not justified. The pressure also may damage communications and cause resentment. If communications cannot be improved, and if the pressure cannot be relieved, a due process approach to conflict resolution that involves other parties may be required.