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.

 

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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Inhaled epoprostenol vs inhaled nitric oxide for refractory hypoxemia in critically ill patients. (Stockwell)

J Crit Care. 2013 May 14. pii: S0883-9441(13)00067-1. PMID: 23683572

PURPOSE: The purpose of this is to compare efficacy, safety, and cost outcomes inpatients who have received either inhaled epoprostenol (iEPO) or inhaled nitric oxide (iNO) for hypoxic respiratory failure.

MATERIALS AND METHODS: This is a retrospective, single-center analysis of adult, mechanically ventilated patients receiving iNO or iEPO for improvement in oxygenation.

RESULTS: We evaluated 105 mechanically ventilated patients who received iEPO (52patients) or iNO (53 patients) between January 2009 and October 2010. Most patientsreceived therapy for acute respiratory distress syndrome (iNO 58.5% vs iEPO 61.5%; P = .84). There was no difference in the change in the partial pressure of arterial O2/fraction of inspired O2 ratio after 1 hour of therapy (20.58 ± 91.54 vs 33.04 ± 36.19 [P = .36]) in the iNO and iEPO groups, respectively. No difference was observed in duration of therapy (P = .63), mechanical ventilation (P = .07), intensive care unit (P = .67), and hospital lengths of stay (P = .26) comparing the iNO and iEPO groups. No adverse events were attributed to either therapy. Inhaled nitric oxide was 4.5 to 17 times more expensive than iEPO depending on contract pricing.

CONCLUSIONS: We found no difference in efficacy and safety outcomes when comparing iNO and iEPO in hypoxic, critically ill patients. Inhaled epoprostenol is associated with less drug expenditure than iNO.

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A general Critical Care Ultrasonography workshop: results of a novel Web-based learning program combined with simulation-based hands-on training. (Chandler)

J Crit Care. 2013 Apr;28(2):217.e7-12. PMID: 22762931

PURPOSE: The aim of this study was to facilitate attainment of Critical Care Ultrasonography (CCUS) competence.

MATERIALS AND METHODS: We developed a Web-based learning program followed by simulation-based hands-on training in noncardiac CCUS for novice learners. We administered knowledge and skills tests before and after the workshop and conducted surveys on confidence levels using a 10-point Likert scale. Knowledge tests were conducted online, and skills tests were video-captured for evaluation.

RESULTS: Sixteen physicians participated in a 4-hour combined vascular and thoracic CCUS workshop, and 23 in a 2-hour abdominal CCUS workshop. In the combined vascular and thoracic workshop, the mean (SD) pre-workshop and post-workshop knowledge scores were 24 (4) and 33 (5), respectively, out of 43 (P < .001). The pre-workshop and post-workshop skill scores were 15 (5) and 23 (2), out of 28 (P < .001). In the abdominal workshop, the pre-workshop and post-workshop knowledge scores were 11 (3) and 18 (2), out of 20 (P < .001). The pre-workshop and post-workshop skill scores were 6 (3) and 15 (2), out of 16 (P < .001). Learners’ confidence increased significantly in both workshops (P < .001).

CONCLUSIONS: Our novel hybrid educational workshop on general CCUS significantly improved knowledge, skills, and confidence levels. Our flexibly scheduled module can be a practical option for the busy intensivist.

Copyright © 2013 Elsevier Inc. All rights reserved.

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