Benefit of using a “bundled” consent for intensive care unit procedures as part of an early family meeting. (Betters)

Dhillon A, Tardini F, Bittner E, Schmidt U, Allain R, Bigatello L. Benefit of using a “bundled” consent for intensive care unit procedures as part of an early family meeting. J Crit Care. 2014 Dec;29(6):919-22.

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PURPOSE: Relatives of patients in the intensive care unit (ICU) are often dissatisfied with family-physician communication. Our prospective preintervention and postintervention study tested the hypothesis that introducing this informed consent process would improve family satisfaction with the ICU process of care.

MATERIALS AND METHODS: We developed a consent form that included an introductory explanation of the main ICU interventions and a description of 8 common procedures in a surgical ICU. We administered it early in the ICU course during a scheduled family meeting. The study was a prospective preintervention and postintervention design.

RESULTS: The “Family Satisfaction in the Intensive Care Unit” (FS-ICU) score was higher in the intervention than in the control group (95.4 ± 4 vs 78.2 ± 22, P < .001). The nursing perception of satisfaction with care was also higher in the intervention group (95.8 ± 13 vs 71.9 ± 28, P < .001).

CONCLUSION: A bundled informed consent resulted in higher family satisfaction with the process of care in ICU.

 

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Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. (Dugan)

Kanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH. Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. J Crit Care. 2014 Oct;29(5):700-5.

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PURPOSE: The purpose of the study was to compare the effect of limited echocardiography (LE)-guided therapy to standard management on 28-day mortality, intravenous fluid prescription, and inotropic dosing following early resuscitation for shock.

MATERIALS AND METHODS: Two hundred twenty critically ill patients with undifferentiated shock from a quaternary intensive care unit were included in the study. The LE group consisted of 110 consecutive patients prospectively studied over a 12-month period receiving LE-guided management. The standard management group consisted of 110 consecutive patients retrospectively studied with shock immediately prior to the LE intervention.

RESULTS: In the LE group, fluid restriction was recommended in 71 (65%) patients and initiation of dobutamine in 27 (25%). Fluid prescription during the first 24 hours was significantly lower in LE patients (49 [33-74] vs 66 [42-100] mL/kg, P = .01), whereas 55% more LE patients received dobutamine (22% vs 12%, P = .01). The LE patients had improved 28-day survival (66% vs 56%, P = .04), a reduction in stage 3 acute kidney injury (20% vs 39%), and more days alive and free of renal support (28 [9.7-28] vs 25 [5-28], P = .04).

CONCLUSIONS: Limited echocardiography-guided management following early resuscitation is associated with improved survival, less fluid, and increased inotropic prescription. A prospective randomized control trial is required to verify these results.

Administration of proton pump inhibitors in critically ill medical patients is associated with increased risk of developing Clostridium difficile-associated diarrhea. (Teppa)

Buendgens L, Bruensing J, Matthes M, Dückers H, Luedde T, Trautwein C, Tacke F, Koch A. Administration of proton pump inhibitors in critically ill medical patients is associated with increased risk of developing Clostridium difficile-associated diarrhea. J Crit Care. 2014 Aug;29(4):696.e11-5.

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PURPOSE: Proton pump inhibitors (PPIs) effectively prevent gastrointestinal bleedings in critically ill patients at the intensive care unit (ICU). In non-ICU hospitalized patients, PPI administration increases the risk of infectious complications, especially Clostridium difficile-associated diarrhea (CDAD); but no such data are available for the ICU setting.

MATERIALS AND METHODS: This is a retrospective, observational, single-center analysis (1999-2010) including 3286 critically ill patients.

RESULTS: A total of 91.3% of patients received stress ulcer prophylaxis by PPI (55.6%), histamine 2 receptor antagonists (5.8%), sucralfate (10.1%), or combinations (19.8%). Only 29 (0.9%) of 3286 patients developed gastrointestinal bleedings during the course of ICU treatment, independent from the type of prophylaxis. The PPIs were not an independent risk factor for nosocomial pneumonia. One hundred and ten (3.3%) patients developed CDAD during the course of ICU treatment, which was associated with prolonged ICU stay and increased ICU mortality (odds ratio, 1.59). Similar to fluoroquinolones and cephalosporins, PPI was identified as an independent risk factor (odds ratio, 3.11) for developing CDAD at the ICU by multivariate analysis.

CONCLUSIONS: Proton pump inhibitor therapy was an independent risk factor for CDAD in medical ICU patients. Instead of routine PPI use for bleeding prophylaxis, further trials should investigate risk-adjusted algorithms, balancing benefits, and threats of PPI medication.

Pediatric upper airway obstruction: Interobserver variability is the road to perdition. (Chandler)

J Crit Care. 2013 Aug;28(4):490-7. PMID: 23337481

PURPOSE: The purposes of the study are to determine the interobserver variability in the clinical assessment of pediatric upper airway obstruction (UAO) and to explore how variability in assessment of UAO may contribute to risk factors and incidence of postextubation UAO.

MATERIALS: This is a prospective trial in 2 tertiary care pediatric intensive care units. Bedside practitioners performed simultaneous, blinded UAO assessments on 112 children after endotracheal extubation.

RESULTS: Agreement among respiratory therapists, pediatric intensive care nurses, and pediatric intensive care physicians was poor for cyanosis (κ = 0.01) and hypoxemia at rest (κ = 0.14) and fair for consciousness (κ = 0.27), air entry (κ = 0.32), hypoxemia with agitation (κ = 0.27), and pulsus paradoxus (κ = 0.23). When looking at “stridor” and “retractions,” defined using more than 2 grades of severity from the Westley Croup Score, the interrelater reliability was moderate (κ = 0.43 and κ = 0.47, respectively). This could be improved marginally by dichotomizing the presence or absence of stridor (κ = 0.54) or retractions (κ = 0.53). The overall incidence of UAO after extubation (stridor plus retractions) could range from 7% to 22%, depending on how many providers were required to agree.

CONCLUSIONS: Physical findings routinely used for UAO have poor interobserver reliability among bedside providers. This variability may contribute to inconsistent findings regarding incidence, risk factors, and therapies for postextubation UAO.

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