OBJECTIVE:The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and ...safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice.
DESIGN:Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012.
SETTING:Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center.
PATIENTS:Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions’ medical or surgical critical care service.
INTERVENTIONS:Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle.
MEASUREMENTS AND MAIN RESULTS:For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median interquartile range, 24 7–26 vs 21 0–25; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33–0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29–3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates.
CONCLUSIONS:Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.
The purpose of the study was to determine whether applying highly recommended changes in the 2005 American Heart Association (AHA) Guidelines would improve outcomes after out-of-hospital cardiac ...arrest.
In 2005, AHA recommended multiple ways to improve circulation during cardiopulmonary resuscitation (CPR).
Conglomerate quality assurance data were analyzed during prospective implementation of the 2005 AHA Guidelines in five emergency medical services (EMS) systems. All EMS personnel were trained in the key new aspects of the 2005 AHA Guidelines, including use of an impedance threshold device. The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation (ROSC), survival by initial cardiac arrest rhythm, and the cerebral performance category (CPC) score at hospital discharge.
There were 1,605 patients in the intervention group and 1,641 patients in the control group. Demographics, the rate of bystander CPR, and time from the 911 call for help to arrival of EMS personnel were similar between groups. Survival to hospital discharge was 10.1% in the control group versus 13.1% in the intervention group (P = .007). For patients with a presenting rhythm of ventricular fibrillation/ventricular tachycardia, survival to discharge was 20% in controls versus 32.3% in the intervention group (P <.001). Survival to discharge with a CPC classification of 1 or 2 was 33.3% (10/30) in the control versus 59.6% (31/52) in the intervention group (P = .038).
Compared with controls, patients with out-of-hospital cardiac arrest treated with a renewed emphasis on improved circulation during CPR had significantly higher neurologically intact hospital discharge rates.
Abstract Background As alcohol use is highly prevalent in trauma patients, we hypothesized that a significant proportion of hospitalized trauma patients would demonstrate alcohol withdrawal (AW). ...Methods The trauma registries at a joint trauma center system from 1999 to 2008 were evaluated for patients aged at least 16 years. Results Of 19,369 trauma admissions, 159 patients had AW. Blood alcohol concentration (BAC) testing was performed in 31.5% of the patients. BAC was significantly higher in AW patients versus other traumas (205.7 ± 130.1 vs 102.9 ± 121.7 mg/dL). BAC was 0 in 14.4% of AW patients. As compared with other trauma patients, patients with AW had a significantly greater age (50.2 vs 42.1 years), hospital length of stay (10 vs 3 days), intensive care unit length of stay (2 vs 0 days), need for mechanical ventilation (34% vs 12.7%), and pneumonia (12% vs 2.3%). AW patients were less frequently discharged to home (59.8% vs 69.9%). Mortality was not different. Conclusions AW was diagnosed in few patients. Of note, it occurred in patients with an initial BAC of 0. AW is associated with adverse outcomes.
Transfusion associated-graft versus host disease (TA-GVHD) is a rare complication of blood transfusion. It carries a very high mortality rate. Although the phenomenon has been well described in ...immunocompromised patients, this review focuses on the immunocompetent host. Cases of TA-GVHD continue to be reported following a variety of surgical procedures, especially cardiac procedures requiring cardiopulmonary bypass. Additional risk factors for TA-GVHD include blood component transfusion in populations with limited genetic diversity, the use of directed donations from family members, and the transfusion of fresh blood. As there is no effective treatment, the focus is on prevention.
Farm machinery is a major source of injury. The objective of this study is to characterize the incidence, injury characteristics, and outcomes of patients admitted with farm machinery injuries (FMIs) ...to an urban joint trauma system in a rural state. A retrospective 15-year review of the trauma registries of the two trauma centers that function as a single state-designated Level I joint trauma center system was conducted. There were 65 admissions for FMIs at hospital A and 41 at hospital B; this represents under 0.4% of total trauma admissions. The patients ranged in age from 2 to 87 years. At hospital A, 89% of admitted patients sustained extremity injuries, 16% sustained torso trauma, 92% required surgical intervention, and the mortality rate was 0%. At hospital B, 60% of admitted patients sustained extremity injuries, 36.6% of patients sustained torso trauma, 63% required surgical intervention, and the mortality rate was 14.6%. Tractor-related injuries were responsible for 17% of admissions at hospital A and 69% at hospital B. Of the six fatalities, five were tractor related. The data demonstrate that FMIs affect people in nearly all decades of life. FMIs at the two hospitals had differing injury characteristics and outcomes, in large part secondary to the differing frequency of tractor-related injuries. FMIs frequently required surgical intervention.
To investigate the effects of N omega-nitro-L-arginine methyl ester, an inhibitor of nitric oxide synthesis, on hemodynamics, gas exchange and oxygen transport in an ovine model of hyperdynamic ...sepsis.
Prospective, nonrandomized, controlled study, with repeated measurements.
University research laboratory.
Twenty healthy adult sheep (weighing 20 to 45 kg) were divided into two groups of 12 treated sheep and eight control sheep and studied.
Twenty awake, chronically instrumented sheep received a continuous infusion of endotoxin (10 ng/kg/min) over 48 hrs. Twenty-four hours after the start of the endotoxin infusion, 12 sheep (treatment group) received a bolus of the nitric oxide synthesis inhibitor N omega-nitro-L-arginine methyl ester (25 mg/kg), while the other eight animals (control group) received the carrier (0.9% NaCl).
Twenty-four hours after the start of the endotoxin infusion, both groups exhibited a hyperdynamic state with increased cardiac indices, decreased systemic vascular resistance indices, impaired oxygenation, and increased pulmonary shunt fractions. In both groups, oxygen delivery was significantly increased, while oxygen consumption remained virtually unchanged, resulting in a decreased oxygen extraction ratio. In the control group, the significant alterations in systemic hemodynamics, lung function and oxygen transport persisted for the remainder of the study. Administration of N omega-nitro-L-arginine methyl ester normalized cardiac index and systemic vascular resistance index, increased mean arterial blood pressure, and decreased heart rate. Although oxygen delivery significantly decreased after administration of N omega-nitro-L-arginine methyl ester, oxygen consumption did not change, resulting in a normalization of oxygen extraction ratio. Despite a significant reduction of pulmonary shunt fraction, oxygenation did not improve. Pulmonary arterial pressure and pulmonary vascular resistance index showed a peak 2 hrs after administration of the nitric oxide synthesis inhibitor and then tended to decrease. In contrast, the effects of N omega-nitro-L-arginine methyl ester on the systemic circulation persisted for the remainder of the study.
The data support the assumption that augmented nitric oxide production is a major cause of the hemodynamic alterations seen in hyperdynamic endotoxemia. Administration of the nitric oxide synthesis inhibitor N omega-nitro-L-arginine methyl ester normalized the endotoxin-induced hyperdynamic state, but did not impair oxygen consumption, indicating adequate tissue perfusion of metabolically active organs. Inhibition of nitric oxide synthesis may be a therapeutic option in the treatment of hyperdynamic septic patients when conventional therapy fails to maintain a minimum of cardiovascular performance.
The rectilinear biphasic (RLB) waveform has been shown to effectively defibrillate short-duration ventricular fibrillation (VF) at significantly lower energies than a monophasic damped sine (MDS) ...waveform. This article reports RLB waveform defibrillation effectiveness for patients presenting in VF during out-of-hospital cardiac arrest when compared with historical MDS effectiveness.
External RLB defibrillators were deployed in the Omaha Fire Department's emergency medical services (EMS) system. The RLB defibrillators delivered an escalating three-shock sequence of 120, 150, and 200 J. The results observed during the first year of full deployment were compared with the results observed during the previous year when only MDS defibrillators were deployed in the system. The MDS defibrillators delivered an escalating three-shock sequence of 200, 300, and 360 J. Defibrillation was defined as termination of VF for at least 5 seconds after a defibrillation shock.
There were 141 adult patients presenting in VF without trauma during the first year using RLB defibrillators. By comparison, there were 153 adult patients during the comparable year using MDS defibrillators. The 120-J RLB shocks had a significantly higher first-shock rate of successful VF termination (67%, 95% CI: 59%–75%) compared with the initial 200-J MDS shocks (48%, 95% CI: 40%–57%, p < 0.0025; odds ratio 2.14 1.33–3.42). The number of patients who were defibrillated to a return of spontaneous circulation with a sinus rhythm was significantly greater (25%, 95% CI: 18%–33%) when using the RLB defibrillator compared with using the MDS defibrillator (15%, 95% CI: 10%–22%, p
=
0.05; odds ratio 1.85 1.04–3.31).
The RLB defibrillator terminated the VF of patients in out-of-hospital cardiac arrest with superior rates using significantly less energy compared with historical rates for a higher-energy MDS defibrillator.
Autopsy in general surgery practice Stothert, Jr, J C; Gbaanador, G
The American journal of surgery,
12/1991, Letnik:
162, Številka:
6
Journal Article
Recenzirano
This study evaluates the impact of the autopsy on a general surgical training program from 1984 through 1988. We have retrospectively examined the charts of all patients who died during this period. ...Included in this analysis are the records of patients from the general, cardiac, pediatric, and transplant surgery departments during this 5-year period. In all, 628 patients were evaluated. The overall autopsy rate was 73%. The clinical impressions prior to death are correlated with the anatomic diagnoses found during autopsy. Significant diagnostic discrepancies (errors unrecognized and directly related to or associated with the cause of death) were determined. On a yearly basis, diagnostic discrepancies range between 23% to 39%. Gross and histologic examination of surgical patients reveals significant information concerning the cause of death. These data confirm the educational benefit of autopsy despite escalating utilization of sophisticated, noninvasive diagnostic modalities. It is our opinion that the mortality conference, with formal autopsy presentation, is a vital forum for the discussion of patient care and quality assurance issues. Autopsy remains the most specific indicator of errors in diagnosis, management, judgment, and technique in surgical practice today.
Objective. The rectilinear biphasic (RLB) waveform has been shown to effectively defibrillate short-duration ventricular fibrillation (VF) at significantly lower energies than a mono-phasic damped ...sine (MDS) waveform. This article reports RLB waveform defibrillation effectiveness for patients presenting in VF during out-of-hospital cardiac arrest when compared with historical MDS effectiveness. Methods. External RLB defibrillators were deployed in the Omaha Fire Department's emergency medical services (EMS) system. The RLB defibrillators delivered an escalating three-shock sequence of 120, 150, and 200 J. The results observed during the first year of full deployment were compared with the results observed during the previous year when only MDS defibrillators were deployed in the system. The MDS defibrillators delivered an escalating three-shock sequence of 200, 300, and 360 J. Defibrillation was defined as termination of VF for at least 5 seconds after a defibrillation shock. Results. There were 141 adult patients presenting in VF without trauma during the first year using RLB defibrillators. By comparison, there were 153 adult patients during the comparable year using MDS defibrillators. The 120-J RLB shocks had a significantly higher first-shock rate of successful VF termination (67%, 95% CI: 59%-75%) compared with the initial 200-J MDS shocks (48%, 95% CI: 40%-57%, p < 0.0025; odds ratio 2.14 1.33-3.42). The number of patients who were defibrillated to a return of spontaneous circulation with a sinus rhythm was significantly greater (25%, 95% CI: 18%-33%) when using the RLB defibrillator compared with using the MDS defibrillator (15%, 95% CI: 10%-22%, p = 0.05; odds ratio 1.85 1.04-3.31). Conclusion. The RLB defibrillator terminated the VF of patients in out-of-hospital cardiac arrest with superior rates using significantly less energy compared with historical rates for a higher-energy MDS defibrillator.
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