BACKGROUND:Noninvasive ventilation (NIV) requires a close “partnership” between a conscious patient and the patient’s caregivers. Specific perceptions of NIV stakeholders and their impact have been ...poorly described to date. The objectives of this study were to compare the perceptions of NIV by intensive care unit (ICU) physicians, nurses, patients, and their relatives and to explore factors associated with caregivers’ willingness to administer NIV and patients’ and relatives’ anxiety in relation to NIV.
METHODS:This is a prospective, multicenter questionnaire-based study.
RESULTS:Three hundred and eleven ICU physicians, 752 nurses, 396 patients, and 145 relatives from 32 ICUs answered the questionnaire. Nurses generally reported more negative feelings and more frequent regrets about providing NIV (median score, 3; interquartile range, 1 to 5 vs. 1 1 to 5; P < 0.0001) compared to ICU physicians. Sixty-four percent of ICU physicians and only 32% of nurses reported a high level of willingness to administer NIV, which was independently associated with NIV case-volume and workload. A high NIV session–related level of anxiety was observed in 37% of patients and 45% of relatives. “Dyspnea during NIV,” “long NIV session,” and “the need to have someone at the bedside” were identified as independent risk factors of high anxiety in patients.
CONCLUSIONS:Lack of willingness of caregivers to administer NIV and a high level of anxiety of patients and relatives in relation to NIV are frequent in the ICU. Most factors associated with low willingness to administer NIV by nurses or anxiety in patients and relatives may be amenable to change. Interventional studies are now warranted to evaluate how to reduce these risk factors and therefore contribute to better management of a potentially traumatic experience. (Anesthesiology 2016; 124:1347-59)
Abstract
Background
Noninvasive ventilation (NIV) requires a close “partnership” between a conscious patient and the patient’s caregivers. Specific perceptions of NIV stakeholders and their impact ...have been poorly described to date. The objectives of this study were to compare the perceptions of NIV by intensive care unit (ICU) physicians, nurses, patients, and their relatives and to explore factors associated with caregivers’ willingness to administer NIV and patients’ and relatives’ anxiety in relation to NIV.
Methods
This is a prospective, multicenter questionnaire-based study.
Results
Three hundred and eleven ICU physicians, 752 nurses, 396 patients, and 145 relatives from 32 ICUs answered the questionnaire. Nurses generally reported more negative feelings and more frequent regrets about providing NIV (median score, 3; interquartile range, 1 to 5 vs. 1 1 to 5; P < 0.0001) compared to ICU physicians. Sixty-four percent of ICU physicians and only 32% of nurses reported a high level of willingness to administer NIV, which was independently associated with NIV case-volume and workload. A high NIV session–related level of anxiety was observed in 37% of patients and 45% of relatives. “Dyspnea during NIV,” “long NIV session,” and “the need to have someone at the bedside” were identified as independent risk factors of high anxiety in patients.
Conclusions
Lack of willingness of caregivers to administer NIV and a high level of anxiety of patients and relatives in relation to NIV are frequent in the ICU. Most factors associated with low willingness to administer NIV by nurses or anxiety in patients and relatives may be amenable to change. Interventional studies are now warranted to evaluate how to reduce these risk factors and therefore contribute to better management of a potentially traumatic experience. (Anesthesiology 2016; 124:1347-59)
Tissue hypercarbia is related to hypoperfusion and microcirculatory disturbances in patients with septic shock. Transcutaneous Pco₂ devices using a heated sensor to arterialize the tissue have been ...used as an alternative method for estimation of Paco₂. This study investigates whether a cutaneous sensor attached to an ear lobe and regulated to 37°C could be used to measure cutaneous Pco₂ (Pcco₂) and evaluate microperfusion in patients with septic shock.
Fifteen stable patients in an ICU were studied as a control group. Forty-six patients with septic shock who were ventilated were enrolled as the study group. The difference of the gradients between Pcco₂ and Paco₂ (Pc-aco₂) and between Pcco₂ and end-tidal Pco₂(Pc-etco₂) were evaluated for 36 h. Variations of the Pc-aco₂ and Pc-etco₂ during fluid challenge were compared with microcirculatory skin blood flow (mBFskin) assessed by laser Doppler flowmetry.
The baseline levels for Pc-aco₂ and Pc-etco₂ were significantly higher in the patients with septic shock than in the control group (14.8 12.6 vs 6 2.7 mm Hg and 25 16.3 vs 9 3.8 mm Hg, P < .0001, respectively). During the following 36 h, the Pc-aco₂ and Pc-etco₂ for the surviving patients with septic shock decreased significantly compared with the nonsurvivors (P < .01). The evolution of macrohemodynamic parameters showed no differences between survivors and nonsurvivors. At hour 24, a Pc-aco₂ > 16 mm Hg and a Pc-etco₂ > 26 mm Hg were related to poor outcome. Pc-aco₂ and Pc-etco₂ variations during fluid challenge were inversely correlated with changes in mBFskin (r² = 0.7).
Ear lobe cutaneous Pco₂ at 37°C represents a noninvasive technique to assess tissue Pco₂ measurement. Pc-aco₂ and Pc-etco₂ were related to outcome and provide continuous information on microperfusion in patients with septic shock.
To assess whether the quality of chest compressions (CC) differs before and after a night shift. We carried out a cluster randomized study in three Emergency Departments and three ICUs in Paris, ...France. Physicians were assessed on a control day and immediately following after a night shift. The primary endpoint was the proportion of CC with a depth greater than 50 mm. We analyzed 67 participants. The proportion of CC with a depth greater than 50 mm was similar on a control day and after a night shift 52% in both groups, mean difference of 0 (95% confidence interval−17 to 17). Other indicators of CC quality were unchanged after a night shift, except for the mean depth of CC (51 vs. 48 mm, P=0.01). We report in our sample that the quality of CC after a night shift is not inferior to a control day.
1‐Aminocyclopropane‐1‐carboxylic oxidase (ACCO) is a non‐heme iron(II)‐containing enzyme involved in the biosynthesis of the phytohormone ethylene, which regulates fruit ripening and flowering in ...plants. The active conformation of ACCO, and in particular that of the C‐terminal part, remains unclear and open and closed conformations have been proposed. In this work, a combined experimental and computational study to understand the conformation and dynamics of the C‐terminal part is reported. Site‐directed spin‐labeling coupled to electron paramagnetic resonance (SDSL‐EPR) spectroscopy was used. Mutagenesis experiments were performed to generate active enzymes bearing two paramagnetic labels (nitroxide radicals) anchored on cysteine residues, one in the main core and one in the C‐terminal part. Inter‐spin distance distributions were measured by pulsed EPR spectroscopy and compared with the results of molecular dynamics simulations. The results reveal the existence of a flexibility of the C‐terminal part. This flexibility generates several conformations of the C‐terminal part of ACCO that correspond neither to the existing crystal structures nor to the modelled structures. This highly dynamic region of ACCO raises questions on its exact function during enzymatic activity.
The key is flexibility! A combined experimental and theoretical study has been performed to unravel the conformation of the C‐terminal part of the fruit‐ripening enzyme 1‐aminocyclopropane‐1‐carboxylic oxidase (ACCO; see figure). The results reveal the existence of a flexibility of the C‐terminal part that generates several conformations in this part of the ACCO enzyme.
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