The use of nonphysician providers in adult intensive care units

In the United States there are not currently enough critical care-trained practitioners to provide care to all critically ill patients. With calls for "high-intensity" staffing and 24-hour coverage of our intensive care units, the board-certified intensivists we do have are being stretched ever more thin. Nonphysician providers (physician assistants and nurse practitioners) are being used with increasing frequency in critical care settings to provide care to critically ill patients. In this review, we explore the impact of introducing nonphysician providers into the adult intensive care unit.     

危重患者医院获得性肺炎与输血的关系及机制探讨

ICU内患者普遍存在贫血情况,宽松、不合理的输血治疗不但不能纠正患者缺氧状态,反而增加院内肺部感染的风险,恶化病情,加重医疗负担。这个过程主要是通过输血相关性免疫调节介导。在临床实践中,对危重患者进行个体化治疗,避免过度、过量输血,以预防感染并发症的发生。     

Intracranial pressure monitoring and treatment: a contemporary view

ICP monitoring and recording provide another important parameter in the intensive care management of many critically ill patients and have been shown to augment the clinical neurologic examination, particularly in comatose patients suffering from severe head trauma, toxic and metabolic encephalopathies, massive cerebral infarctions, and many other central nervous system insults. Once considered an experimental tool restricted exclusively to sophisticated specialty neurosurgical and neuroanesthesia intensive care units, this straightforward and rapidly evolving technology is readily available and relatively easy to apply as a bedside intensive care procedure for selected patients. Many indications of particular interest to emergency physicians are indicated. The precise role of ICP monitoring in the prehospital management of patients has not been established. At this time, the conventional treatments for presumed ICP elevations, as outlined, are the mainstays of prehospital care. ICP monitoring may have a role in more extended or lengthy interinstitutional transfers of some critically ill patients.     

Hemolysis, elevated liver enzymes, and low platelet count syndrome: nursing care of the critically ill obstetric patient

Although patients with severe preeclampsia and eclampsia are infrequently admitted to critical care areas, it is important that the critical care nurse be aware of the HELLP syndrome. The case presentations demonstrated hemolysis, liver dysfunction, and abnormal platelet consumption. Knowledge of the clinical and laboratory findings will assist in nursing assessment and intervention for these critically ill obstetric patients.     

Management of head trauma

Traumatic brain injury (TBI) is a major cause of disability and death in most Western nations and consumes an estimated $100 billion annually in the United States alone. In the last 2 decades, the management of TBI has evolved dramatically, as a result of a more thorough understanding of the physiologic events leading to secondary neuronal injury as well as advances in the care of critically ill patients. However, it is likely that many patients with TBI are not treated according to current treatment principles. This article presents an overview of the current management of patients with TBI.     

Pharmacologic issues in the critically ill

The pharmacotherapy of critically ill patients poses numerous challenges to the ICU team. Polypharmacy and alterations in drug disposition are common in the ICU; critically ill patients have limited physiologic reserve to deal with adverse drug events. Careful prescribing, based upon sound pharmacologic principles, decreases the potential for preventable adverse events and maximizes the opportunity for successful therapy. A systematic approach to reporting, analysis, and prevention of errors is a further step in our ultimate goal to provide optimal care for the vulnerable patients whom we support in our ICUs.     

Hematologic failure

Hematologic factors, in particular platelets and the coagulation system, play an important role in the pathogenesis of organ failure in the intensive care unit. Failure of these hematologic systems is common in intensive care patients and may range from isolated thrombocytopenia or prolonged global clotting tests to complex defects, such as disseminated intravascular coagulation. There are many causes for a deranged coagulation in critically ill patients, and each of these underlying disorders may require specific therapeutic management. Hence, a proper differential diagnosis and initiation of adequate (supportive) treatment strategies are crucial to reduce morbidity and mortality in critically ill patients with coagulation abnormalities.     

Prediction of outcome from critical illness. A comparison of clinical judgment with a prediction rule

Quantitative methods to enhance clinical judgment would be of tremendous benefit to physicians caring for the critically ill. The ability of physicians to predict outcome is a logical standard on which to base the prospective evaluation of a prediction rule intended for this clinical use. The APACHE (acute physiology and chronic health evaluation)-II score was compared with critical care physicians' prediction of outcome for a group of patients in a medical intensive care unit. Physicians were significantly better in predicting outcome in the critically ill. However, the APACHE-II score was still a good predictor of outcome in the intensive care unit and, according to analysis using Bayes' theorem, might still be a useful test to support physicians' judgment, especially in patients with a predicted mortality risk of less than 30%.     

Preventing venous thromboembolism in critically ill patients

Critically ill patients in the medical-surgical intensive care unit are at high risk of both venous thromboembolism (VTE) and bleeding. Although thromboprophylaxis is of proven effectiveness in other settings, relatively little data exist to inform "best practice" for the prevention of VTE for these patients. This narrative review article presents the rate, clinical consequences, and optimal strategies to prevent VTE in critically ill patients, focusing primarily on medical-surgical intensive care unit (ICU) patients, but also addressing other specific subgroups of critically ill patients. Despite the large number of medical-surgical ICU patients, their moderately high risk of VTE, and the morbidity and mortality likely to be associated with the development of VTE, relatively little methodologically rigorous data are available to guide practice. Large, well-designed randomized trials, powered to detect differences in clinically relevant end points, are required to advance the care of this highly vulnerable patient population.     

The type II iodothyronine deiodinase is up-regulated in skeletal muscle during prolonged critical illness

CONTEXT: Critical illness is associated with the low T(3) syndrome. It remains unclear whether altered type II deiodinase activity (D2) in skeletal muscle contributes to this syndrome. OBJECTIVE: Our objective was to study D2 expression and activity in skeletal muscle of acute and prolonged critically ill patients. DESIGN AND SETTING: We conducted a clinical observational study in acute and prolonged critical illness with comparison with healthy controls at a university hospital surgical intensive care unit. PATIENTS: Subjects included 63 prolonged critically ill patients who died in the intensive care unit, 21 acutely ill patients, and 38 controls matched for age, gender, and body mass index. RESULTS: Elevated expression of the D2 gene and D2 activity in skeletal muscle of prolonged, but not acute, critically ill patients were observed in the face of low circulating thyroid hormone levels. CONCLUSIONS: Reduced D2 activity does not appear to play a role in the pathogenesis of the low T(3) syndrome of critical illness.     

Intensivmedizinisches Management hämatologischer und onkologischer Patienten

Management of critically ill cancer patients warrants stringent admission criteria and clear concepts concerning duration and limits of intensive care. Recent developments in mechanical ventilation and sepsis therapy can easily be used to improve the outcome of critically ill cancer patients. The incidence and overall prognosis of cancer is constantly growing and, thus, the number of critically ill cancer patients is increasing. Furthermore, novel oncology drugs—in particular immune modulators—produce unexpected and substantial side effects. Therefore, the development of an interdisciplinary algorithm by oncologists and intensivists remains an important and dynamic challenge.     

Cortisol response to critical illness: effect of intensive insulin therapy

CONTEXT: Both excessive and insufficient activation of the hypothalamic-pituitary-adrenal axis in response to critical illness is associated with increased mortality. OBJECTIVE: The objective of the study was to study the effect of intensive insulin therapy, recently shown to reduce mortality and morbidity of critically ill patients, on the cortisol response to critical illness. DESIGN: This was a preplanned subanalysis of a large randomized, controlled study measuring serum total cortisol, cortisol-binding globulin, and albumin and calculating free cortisol levels. SETTING: The study was conducted at a university hospital surgical intensive care unit. PATIENTS: Four hundred fifty-one critically ill patients dependent on intensive care for more than 5 d and 45 control subjects matched for gender, age, height, and weight participated in this study. INTERVENTION: The intervention was strict blood glucose control to normoglycemia with insulin. RESULTS: Total and calculated free cortisol levels were equally elevated upon admission in both patient groups and thereafter were lower in intensive insulin-treated patients. Lower cortisol levels statistically related to the outcome benefit of intensive insulin therapy. Cortisol-binding globulin levels and structure were affected by critical illness but not insulin therapy, and neither were albumin levels. Administration of hydrocortisone in so-called replacement dose resulted in severalfold higher total and free cortisol levels, indicating that reevaluation of the doses used is warranted. CONCLUSIONS: Lower serum cortisol levels in critically ill patients receiving intensive insulin therapy statistically related to improved outcome with this intervention. The lower cortisol levels were not related to altered cortisol-binding capacity.     

The Critical Care Obesity Paradox and Implications for Nutrition Support

Obesity is a leading cause of preventable death worldwide. The prevalence of obesity has been increasing and is associated with an increased risk for other co-morbidities. In the critical care setting, nearly one third of patients are obese. Obese critically ill patients pose significant physical and on-physical challenges to providers, including optimization of nutrition therapy. Intuitively, obese patients would have worse critical care-related outcome. On the contrary, emerging data suggests that critically ill obese patients have improved outcomes, and this phenomenon has been coined “the obesity paradox.” The purposes of this review will be to outline the historical views and pathophysiology of obesity and epidemiology of obesity, describe the challenges associated with obesity in the intensive care unit setting, review critical care outcomes in the obese, define the obesity-critical care paradox, and identify the challenges and role of nutrition support in the critically ill obese patient.     

血清降钙素原检测对院内深部真菌感染诊断价值的探讨

目的 :探讨血清降钙素原 (PCT)检测诊断危重病患者院内深部真菌感染 (IMI)的价值。方法 :回顾性分析重症监护病房内 5 6例临床资料 ,并与健康组 15例对照。结果 :IMI组较健康对照组血清PCT水平明显升高 (P <0 .0 1)。不同感染部位 ,以血液真菌感染者PCT水平最高 (P <0 .0 1)。但PCT不能鉴别不同真菌菌株。结论 :PCT可作为危重病患者院内IMI有价值的诊断指标。     

Approaches to antifungal therapy in the intensive care unit

The risk of fungal infection is increasing in intensive care unit patients and the spectrum of pathogens is changing. A number of new antifungal agents are becoming available, but their use in critically ill patients has not been assessed in randomized controlled trials. Furthermore, distinguishing colonization from infection is problematic in intensive care unit patients. Clinicians who are involved in the management of intensive care unit patients must remain vigilant and devise a risk-based antifungal strategy that is based on local experience and susceptibility patterns.     

The Role of Insulin Therapy in Critically I11 Patients

Protracted critically ill patients have a seriously deranged metabolism, characterized by severe hyperglycemia, a disturbed serum lipid profile, and protein hypercatabolism. The severity of stress-induced hyperglycemia and insulin resistance in critically ill patients reflect the risk of death. A large, prospective, randomized, controlled study showed that maintaining normoglycemia with intensive insulin therapy reduces morbidity and mortality of surgical intensive care patients. These results were recently confirmed by two studies: one randomized controlled study of surgical intensive care patients and a prospective observational study of a heterogeneous patient population admitted to a mixed medical/surgical intensive care unit. The clinical benefits of intensive insulin therapy appear to be related both to prevention of glucose toxicity and to other direct insulin actions that are independent of glycemic control. Prevention of the toxic effects of high circulating glucose levels protected the ultrastructure and function of hepatocyte mitochondria. Benefits of the non-glycemic effects of insulin included partial correction of the deranged serum lipid profile and possibly counteraction of the catabolic state. In addition to its metabolic effects, intensive insulin therapy also prevented excessive inflammation and improved immune function.     

Differences in air ambulance patient mix demonstrated by physiologic scoring

Severity of illness or injury should be the primary justification for aeromedical transport. To determine whether differences in patient severity were detectable in air transport programs, helicopter-transported patients were examined by three established physiologic scores: the Trauma Score, the Acute Physiology and Chronic Health Evaluation Score, and the Rapid Acute Physiology Score. These scores were obtained prospectively on 1,868 consecutive patient transfer requests from six air medical services for periods ranging from two to six months. A patient meeting strict physiologic criteria was considered critically ill. Overall, 42.6% of the patients (range, 34.8% to 53.3%) were considered critically ill. Patients transported from inpatient hospital units and patients with cardiac disease were less likely to be critically ill than those transported emergently from scenes of accident or from emergency departments. There were also significant differences between programs with regard to the percentage of critically ill patients transported. This study suggests that physiologic scoring may be useful in comparing air ambulance programs and that a majority of patients transported by these services may not be critically ill.     

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.     

Empfehlungen zum hämodynamischen Monitoring in der internistischen Intensivmedizin

Hemodynamic monitoring of critically ill cardiovascular patients consists of basic monitoring and extended monitoring measures. Basic monitoring should be used in all patients and consists of electrocardiography, body temperature, transcutaneous oxygen saturation, non-invasive blood pressure, measurement of urine production and clinical assessment. Multiple modalities of extended monitoring measures are available that can supplement basic monitoring, especially when the patient does not respond to the applied treatment. They are useful for experienced physicians in selected cases but when used in an undifferentiated way most modalities induce harm rather than benefits; therefore, extended monitoring has to be individually tailored to each patient. This article gives recommendations for the use of the various modalities available. The use of bedside echocardiography is a central tool in diagnostics and surveillance of critically ill cardiovascular patients and can be used to guide fluid management and hemodynamic support. Thus, training and expertise in cardiovascular intensive care and echocardiographic imaging are indispensable prerequisites for the treatment of critically ill patients. This underscores the important role of trained personnel in cardiovascular intensive care.