The yield of lumbar puncture to exclude nosocomial meningitis as aetiology for mental status changes in the medical intensive care unit

We aimed to evaluate the diagnostic value of lumbar puncture in excluding nosocomial meningitis as the cause of mental status changes in medical intensive care unit patients. We retrospectively reviewed the records of all patients admitted to the medical intensive care unit at our institution over a four-year period who had a lumbar puncture performed during their stay. Patients with central nervous system devices were excluded. During the study period 63 lumbar punctures were performed, 31 to exclude nosocomial meningitis. Of these 31 patients, 25 (80.6%) received antimicrobials during hospitalization before performance of lumbar puncture. In one patient with human immunodeficiency virus (HIV) infection, Gram stain demonstrated yeast; in the remainder, Gram stain was negative. Cultures were negative for pathogenic bacteria in all 30 of these patients (overall yield: 0%, 95% CI: 0-10.0%). Five patients (16.1%) had a cerebrospinal fluid leucocytosis (>10 leukocytes/mm3); of these, all had received prior antibiotics, two had positive cryptococcal antigen results, and three had central nervous system infection suspected clinically without an evident alternative diagnosis. In no non-HIV subject did lumbar puncture alter management. Lumbar puncture performed in the medical intensive care unit to exclude nosocomial meningitis as the cause of mental status changes has a low yield and rarely changes management. These findings should not be generalized to patients who have sustained head trauma, have undergone neurosurgical procedures, or may be immunosuppressed.     

The routine use of diagnostic laparoscopy in the intensive care unit

Background: Delay in the diagnosis of intraabdominal pathology is a major contributor to the morbidity and mortality of intensive care unit (ICU) patients. Laparoscopy is a valuable diagnostic tool that can be used safely and efficiently in the evaluation of intraabdominal processes that may be difficult to diagnose with conventional methods. Our goal was to show that laparoscopy performed at the bedside in the ICU could be used as a routine diagnostic tool in the evaluation of critically ill patients, just as computed tomography (CT), ultrasonography (US), and radiography are. Methods: We present 11 patients who underwent 12 bedside examinations in the ICU of a community teaching hospital. Several different surgeons with varying degrees of laparoscopic experience performed these procedures over a 1-year period. Results: Four patients had previously undergone recent abdominal operations. Nontherapeutic laparotomy was avoided in six patients because of diagnostic laparoscopy. One patient also underwent a therapeutic maneuver at the time of diagnostic laparoscopy. None of the patients required general anesthesia, although local anesthetics and sedation with midazolam or propofol were used. One patient underwent the procedure without endotracheal intubation. There were no complications or mortalities directly related to the procedure. Conclusion: We conclude that bedside laparoscopy in the ICU under local anesthesia is a diagnostic and potentially therapeutic tool that can be used safely in the work-up of potential abdominal pathology in critically ill patients. apd: 14 May 2001     

Bedside diagnostic laparoscopy and peritoneal lavage in the intensive care unit

Background: Early diagnosis and treatment of intra-abdominal pathology in critically ill intensive care unit (ICU) patients remains a clinical challenge. The objective of this study is to assess the feasibility of portable, bedside diagnostic laparoscopy (DL) in the ICU for patients suspected of intra-abdominal pathology, and to contrast its accuracy with diagnostic peritoneal lavage (DPL). Methods: All adult ICU patients for whom a general surgery consultation was requested were eligible. Patients with a recent laparotomy or obvious peritonitis were excluded. All procedures were performed in the ICU. Results: Over a consecutive 16-month period, 12 patients underwent DPL/DL. Ages ranged from 28 to 88 (mean, 72) years. Causative findings were disclosed by DL in five patients, (42%) including intestinal ischemia in two. Perforated diverticulitis, thickened terminal ileum, and nonpurulent peritonitis were found in one patient each. All patients with findings by DL had a positive DPL (WBC > 200 cells/mm³), and one negative laparoscopy was positive by lavage. The average length of time to perform DPL was 14 min, and to complete DL 19 min. One patient underwent laparotomy based on DPL/DL and survived along with three others with negative DPL/DL. Eight patients died (67%), four from their surgically untreated intra-abdominal pathology. One patient sustained a procedure-related complication of bradycardia and high ventilatory airway pressures. Peak airway pressures increased an average of 8 mmHg and were significantly higher (p < 0.001) than pre-DL pressures without any significant change in end-tidal CO₂ or pCO₂. There were no statistically significant hemodynamic changes based on mean arterial pressure (MAP), central venous pressure (CVP), or pulmonary artery diastolic pressure (PADP). Conclusions: Bedside laparoscopy can be performed rapidly and safely in the ICU. In predicting the need for laparotomy, DL was more accurate than DPL. Received: 18 July 1995/Accepted: 19 December 1995     

End-of-life care in the intensive care unit

The transition from active, invasive interventions to comfort care for critical care patients is often fraught with misunderstandings, conflict and moral distress. The most common issues that arise are ethical dilemmas around the equivalence of withholding and withdrawing life-sustaining treatment; the doctrine of double effect; the balance between paternalism and shared decision-making; legal challenges around best-interest decisions for patients that lack capacity; conflict resolution; and practical issues during the limitation of treatment. The aim of this article is to address commonly posed questions on these aspects of end-of-life care in the intensive care unit, using best available evidence, and provide practical guidance to critical care clinicians in the UK. With the help of case vignettes, we clarify the disassociation of withdrawing and/or withholding treatment from euthanasia; offer practical suggestions for the use of sedation and analgesia around the end of life, dissipating concerns about hastening death; and advocate for the inclusion of family in decision-making, when the patient does not have capacity. We propose a step-escalation approach in cases of family conflict and advocate for incorporation of communication skills during medical and nursing training.     

End-of-life care in the intensive care unit

End-of-life care in the intensive care unit (ICU) is an oxymoron. Intensive care units appeared in the 1980s only admitting patients for ‘intensive care’. Nowadays the ICU has become one of the few places in the hospital that can provide comfort care to the dying patient. For many doctors on ICU it remains a difficult and problematic area. Yet it is conceptually simple. The difficulty for the doctor is making the decision, for the patient and family, coming to terms with it. This article will focus on how this decision should be made and then on the care that should be provided for the patient. Many of the considerations in decision making are in the General Medical Council guidelines, Treatment and Care Towards the End of Life and this is essential reading before embarking of the process.     

Anaesthesia for procedures in the intensive care unit

Taking in charge severely ill patients in the intensive care environment to manage complex procedures is a performance requiring highly specific knowledge. Close collaboration between anaesthetists and intensive care specialists is likely to improve the safety and quality of medical care. Three forms of anaesthetic care should be considered in clinical practice: sedation and analgesia; monitored anaesthetic care; and general anaesthesia or conduction block anaesthesia. Even in the field of sedation and analgesia, the anaesthesiologist can offer expertise on new anaesthetic techniques like: the most recent concepts of balanced anaesthesia in terms of pharmacokinetics and dynamics, favouring the use of short-acting agents and of sedative-opioid combinations. New modes of administration and monitoring intravenous anaesthesia have been developed, with potential application in the intensive care unit. These include the use of target-controlled administration of intravenous drugs, and of electroencephalographic signals to monitor the level of sedation.     

Sepsis in the intensive care unit

Sepsis remains a major cause of mortality in intensive care. The past 10 years has seen a more uniform, worldwide approach to the management of sepsis, severe sepsis and septic shock. This has resulted in improved survival. It is important to recognize the early symptoms and signs of sepsis; the confused, hypoxic, hypotensive patient with pyrexia, tachycardia, tachypnoea and leucocytosis. Examination must include finding a source for infection and early drainage or debridement. Next take appropriate cultures, and give fluids and broad-spectrum antibiotics. If the picture does not improve over the next 6 hours step-up the treatment to include urine output, blood gases for base excess, lactate, haemoglobin, and glucose. These will guide the management of vasopressors, insulin, fluids, transfusion and bicarbonate. If the hypotension persists (septic shock) the patient should be moved to intensive care. Steroids should be added and additional inotropes. This should be instituted with 24 hours of the start of sepsis. Further advanced care may include mechanical ventilation which requires special consideration. Prevention by screening, stopping cross-infection and appropriate use of antibiotics remains the first priority.     

Education in the intensive care unit

Intensive care medicine is a newly formed specialty. Intensive care is characterized by a multidisciplinary activity focused on patients whose vital organs are compromised or who are at risk of multiorgan failure. Education in the intensive care unit is a complex activity where the educational and pedagogical process interacts with research, continuous improvement, professionalism, and bioethics. This model provides leadership and excellence in care with high standards of quality, security, solidarity and humanism.     

Gastroenterology in the intensive care unit

Hospitalized patients often have poor nutrition, and the metabolic demands of critical illness may exacerbate this. Gastrointestinal (GI) tract dysfunction may be as a result of surgery or contributed to by critical illness itself. This article describes the evidence behind feeding strategies, stress ulceration and the management of upper GI bleeding, selective gut decontamination.     

Sedation in the intensive care unit

Analgesics and sedatives are commonly prescribed in the ICU environment for patient comfort, however, recent studies have shown that these medications can themselves lead to adverse patient outcomes. Interventions that facilitate a total dose reduction in analgesic and sedative medications e.g. the use of nurse controlled protocol guided sedation, the combination of spontaneous awakening and breathing trials, and the use of short acting medications, are associated with improved outcomes such as decreased time of mechanical ventilation and ICU length of stay. This purpose of this review is to provide an overview of the pharmacology of commonly prescribed analgesics and sedatives, and to discuss the evidence regarding best prescribing practices of these medications, to facilitate early liberation from mechanical ventilation and to promote animation in critically ill patients.     

Jaundice in the intensive care unit

Hyperbilirubinemia, or jaundice, is common in the ICU, with incidence up to 40% among critically ill patients. Unfortunately, it is poorly understood in the critically ill, and too often presents a diagnostic dilemma to the ICU physician. Causes of jaundice in the ICU are multiple; the etiology in any given patient, multifactorial. Acute jaundice can be a harbinger or marker of sepsis, multisystem organ failure (MSOF), or a reflection of transient hypotension (shock liver), right-sided heart failure, the metabolic breakdown of red blood cells, or pharmacologic toxicity. Acute ICU jaundice is best divided into obstructive and nonobstructive. This stratification directs subsequent management and therapeutic decisions.     

Echocardiography in the intensive care unit

As ultrasound technology improves and ultrasound availability increases, echocardiography utilization is growing within intensive care units. Although not replacing the often-needed comprehensive echocardiographic evaluation, limited bedside echocardiography promises to provide intensivists with enhanced diagnostic ability and improved hemodynamic understanding of individual patients. Routine and emergency echocardiography within the intensive care unit focuses on identifying and optimizing medically treatable conditions in a timely manner. Methods for such goal-directed assessments are presented.