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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Tag: intensive care unit (Page 1 of 2)

Which parameters of ventricular function should be evaluated in the intensive care unit?

Abstract

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern intensivist, providing the means to diagnose cardiac dysfunction, its underlying cause and suggest therapeutic interventions. Although seemingly simple, meaningful and clinically relevant evaluation of ventricular function is challenging, and standard measures frequently unhelpful. Although at present the widespread application of physiological echocardiography and advanced echocardiographic techniques within intensive care remains disappointingly limited, the huge potential for collaborative research between cardiologists and intensivists within this field is evident.

Key words: echocardiographic assessment, cardiac function, intensive care unit

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Inhalation sedation with the ‘Anaesthetic Conserving Device’ for patients in intensive care units: A literature review

Abstract

Background. The Anaesthetic Conserving Device is a modified heat and moisture exchanger that enables the application of inhalation sedation with existing ventilators in intensive care units. The following review describes the advantages of inhalation sedation using the Anaesthetic Conserving Device in comparison to standard intravenous sedation for patients in intensive care units and highlights the technical aspects of its functioning.

Methods. The literature search was limited to PubMed, Sage Journals and CINAHL databases, using the terms »anaesthetic conserving device«, »volatile anaesthetic reflection filter«, »AnaConDa« independently and in connection with the terms »sedation« and »intensive care unit«. Included are articles published up until December 2014.

Results. Use of inhalation sedation with the Anaesthetic Conserving Device enables faster transition to spontaneous breathing and a shorter awakening time than with intravenous sedation. Even short-term inhalation sedation of patients after open heart procedures has a cardioprotective effect and reduces troponin T values. Despite increased concentrations of inorganic fluoride in serum after sevoflurane exposure, no clinical studies to date have shown its nephrotoxic effect, even after long-term (48 h) sedation. The Anaesthetic Conserving Device is accurate in maintaining target values of volatile anaesthetics. However, increased dead space volume was found in several studies, exceeding the internal volume of the Anaesthetic Conserving Device.

Conclusion. Results to date show that inhalation sedation with the Anaesthetic Conserving Device may be an effective and safe alternative to existing protocols of intravenous sedation for patients requiring intensive treatment.

Key words: anaesthetic conserving device, inhalational sedation, intravenous sedation, intensive care unit

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Procalcitonin – potential, limitations and availability

Abstract

Bacterial infections and sepsis are major problems in critically ill patients. Timely diagnosis and therapy reduce morbidity and mortality. Many studies have included the investigation of various biomarkers whose elevated concentrations can indicate sepsis; among them, PCT proved to be most useful.

PCT is synthesized in the thyroid gland as a prohormone of calcitonin. In healthy individuals the PCT concentration is <0.1 ng/mL.

The advantage of the PCT is a high negative predictive value for the exclusion of sepsis, with the cut-off value of 0.5 ng/ml. A concentration between 2 and 10 ng/ml indicates strong sepsis, whereas a value ≥10 ng/ml is associated with septic shock. In addition to the diagnosis of sepsis, the measurement of PCT concentration is useful for the introduction and monitoring of antibiotic therapy, which is performed according to an algorithm based on the cut-off value for PCT.

Immunoassays are used to measure PCT concentrations in serum or plasma. It is possible to determine the concentration in whole blood by using point-of-care testing.

In pathological conditions that are not associated with sepsis, PCT is useful as a prognostic indicator of disease complications. Some studies suggest that PCT is a potential early indicator of acute coronary syndrome.

Key words: procalcitonin, bacterial infection, sepsis, intensive care unit

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Continuous infusion versus bolus injection of furosemide in pediatric patients after cardiac surgery: a meta-analysis of randomized studies

Abstract

Introduction. Acute renal failure and fluid retention are common problems in pediatric patients after cardiac surgery. Furosemide, a loop diuretic drug, is frequently administered to increase urinary output. The aim of the present study was to compare efficacy and complications of continuous infusion of furosemide vs bolus injection among pediatric patients after cardiac surgery.

Methods. A systematic review and meta-analysis was performed in compliance with The Cochrane Collaboration and the Quality of Reporting of Meta-Analysis (QUORUM) guidelines. The following inclusion criteria were employed for potentially relevant studies: a) random treatment allocation, b) comparison of furosemide bolus vs continuous infusion, c) surgical or intensive care pediatric patients. Non-parallel design randomized trials (e.g. cross-over), duplicate publications and non-human experimental studies were excluded.

Results. Up to August 2008, only three studies were found, with 92 patients randomized (50 to continuous infusion and 42 to bolus treatment). Overall analysis showed that continuous infusion and bolus administration were equally effective in achieving the predefined urinary output, and were associated with a similar amount of administered furosemide (WMD=-1.71 mg/kg/day [-5.20; +1.78], p for effect=0.34, p for heterogeneity<0.001, I2=99.0). However, in the continuous infusion group, patients had a significantly reduced urinary output (WMD=-0.48 ml/kg/day [-0.88; -0.08], p for effect=0.02, p for heterogeneity <0.70, I2=0%).

Conclusions. Existing data comparing furosemide bolus injection with a continuous infusion are insufficient to confidently assess the best way to administer furosemide to pediatric patients after cardiac surgery. Larger studies are needed before any recommendations can be made.

Key words: furosemide, cardiac surgery, meta-analysis, intensive care unit, paediatric, acute kidney failure

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Observed versus predicted hospital mortality in general wards patients assisted by a medical emergency team

Abstract

Introduction. In many countries the demand for intensive care beds exceeds their availability. The Medical Emergency Team (MET) can manage critically ill patients outside the intensive care unit (ICU). Hospital mortality rate for patients admitted to general wards and assisted by the MET was never compared to the predicted mortality for the same group of patients in an ICU setting.

Methods. Single-centre, prospective, observational study on consecutive adult patients assisted by the MET in all general wards and in the Emergency Department of a 1100-bed teaching Hospital. Patients with a ‘do-not-attempt-resuscitation’ decision were excluded.

Results. Eighty-two consecutive patients were included. Observed hospital mortality was 34.1% (28 patients), while the Simplified Acute Physiology Score II (SAPS II) predicted a mortality for the first MET visit of 17% (p=0.02). Patients transferred to an ICU, but not during the first MET evaluation (delayed ICU admission), had worse than predicted outcomes, while patients immediately transferred to an ICU showed hospital mortality similar to the predicted one. The fifty patients treated for acute respiratory failure (especially those with pneumonia – 12 patients) had the worst observed/predicted hospital mortality ratio (3.0 for acute respiratory failure, p=0.02; 8.06, p=0.03 for pneumonia patients).

Conclusions. Critically ill patients who remained in general wards or who were admitted to the ICU with some delay had markedly higher hospital mortality than the SAPS II predicted hospital mortality, even if they were assisted by the MET.

Key words: medical emergency team, rapid response system, intensive care unit; critical care

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