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Critical Care and Shock, Volume 11

Volume 11

  • November 2008, Volume 11, No. 4
    • November 2008
    • Hypertensive Emergencies: Time for Guidelines
    • Rhino-Orbital-Cerebral Mucormycosis in a Critically Ill Patient:

      Rhinocerebral mucormycosis is recognized as a potentially aggressive and commonly fatal fungal infection. Mucormycosis is a rare opportunistic necrotizing infection within the class Zygomycetes and the order mucorales. Mucormycosis is commonly seen in patients with diabetes, hemochromatosis, burns, leukemia, lymphoma, HIV and other immunocompromised status. Clinical course of the infection typically begins with the symptoms of sinusitis or rhinitis with mucosal ulceration or necrosis. The infection disseminates to the orbit and cerebrum by direct extension as in our patient, or it may spread by vessels such as those of cavernous sinus. Imaging and early surgical debribement is essential in management of these patients.

    • Airway Pressure Release Ventilation (APRV) for the Treatment of Severe Life-Threatening ARDS in a Morbidly Obese Patient:

      Airway pressure release ventilation (APRV) is a novel mode of positive pressure ventilation that has a number of advantages over low-tidal volume, assist-control ventilation in patients with the acute respiratory distress syndrome (ARDS). APRV may have particular utility in morbidly obese patients with respiratory failure. We report a case of a morbidly obese patient who developed aspiration pneumonitis and severe life threatening ARDS who was successfully managed with APRV.

    • North American Survey of Vasopressor and Inotrope Use in Severe Sepsis and Septic Shock:

      Objective: The primary objective of this study was to characterize how vasopressor and inotropic agents are prescribed and administered in the hemodynamic management of sepsis. Secondary objectives were 1) to evaluate adherence with published guidelines to identify areas of deviation and 2) to describe pharmacists’ perceived incidence of adverse drug reactions (ADRs) of vasopressors and inotropes.
      Design and setting: Web-based survey.
      Patients and participants: Critical care pharmacists.
      Interventions: An email invitation was sent to critical care pharmacists asking them to complete a web-based survey. The survey opened September 29, 2004 and closed March 4, 2005.
      Measurements and results: Of 1065 pharmacists, 235 (22.1%) responded to the survey. Median hospital and ICU size were 451 and 20 beds, respectively. Primary types of ICUs included general (42.1%), medical (28.5%), surgical/trauma (18.3%), cardiac (9.8%), and other (1.3%). Independent of pulmonary artery catheter (PAC) use, the most common initial vasopressor choice in surgical/trauma ICUs was norepinephrine. In the other ICUs, the most common first-line agent was norepinephrine if a PAC was present and dopamine if a PAC was not present. The most common dosage regimen of vasopressin was a continuous infusion of 0.04 units/min (49.8%). The most commonly used inotrope was dobutamine. Respondents reported using inotropes either sometimes (48.1%) or rarely (34.0%), with therapy continuing 24–48 (54.5%) or 48–72 (26.0%) hours. Commonly associated agents with specifi c adverse effects included dopamine with tachycardia and norepinephrine with digital ischemia. Much variability was shown in drug concentrations and various dosages of vasopressors and inotropes between institutions.
      Conclusions: Despite published guidelines, vasopressor and inotrope use in hemodynamic management of patients with sepsis and septic shock displayed much variability. Perceived incidence of ADRs for these agents also demonstrated inconsistency among respondents. National organizations need to develop recommendations for standardization of concentrations of continuous infusion medications in the ICU.

    • In-hospital Mortality among Unplanned Admissions to a Medical Intensive Care Unit:

      Objective: Despite advances in medicine, adverse clinical events, especially cardio-respiratory arrests, still occur in hospitalized patients. Unplanned Intensive Care Unit (ICU) admissions are frequently a result of this failure to recognize or appropriately treat the ‘pre-arrest’ period, when signs of physiologic deterioration are often evident. Although survival rates to hospital discharge for cardiac arrests are universally poor, the patterns of clinical deterioration and outcome of unplanned medical ICU admissions is not well studied. We aim to evaluate whether unplanned medical ICU admissions are associated with higher inhospital mortality.
      Design: Prospective observational, 3-month data collection and analysis of case records and charts. In particular, intubation rates and reasons for unplanned admissions were analyzed.
      Setting: 18-bed medical Intensive Care Unit in Changi General Hospital, a regional 790-bed hospital in Singapore.
      Patients and participants: All medical and cardiac admissions to the Medical ICU from the general wards from October 2007 to January 2008. Direct admissions from the emergency department were excluded.
      Measurements and results: A total of 423 admissions of which 37 (8.7%) were unplanned and 386 (91.3%) were planned. Data was analyzed using SPSS 12.0.1, and Pearson Chi-square for comparison. P value <0.05 considered to be statistically signifi cant. There was a statistically signifi cant difference in hospital mortality between planned (54 deaths, 14%) and unplanned admissions (25 deaths, 67.6%), (p <0.001). All but 1 patient in the unplanned group required intubation. Desaturation was the commonest reason for unplanned admissions, followed closely by sudden cardiorespiratory collapse and hypotension.
      Conclusions: The high mortality rate among unplanned medical ICU admissions is a cause for concern. Implementing a system of early critical illness detection and specialist intervention may help reduce such mortality as well as provide more defi nitive planned palliative decisions.

    • National Survey of Acute Hypertension Management:

      Background: National practice guidelines do not exist for the treatment of acute hypertension (AH) in the critically ill adult. An initial step towards guideline development is to document current prescribing patterns of intravenous (IV) antihypertensives for AH, which serves as the purpose of this survey.
      Methods: An e-mail to participate in this Web-based survey was sent to 5574 critical care physician and pharmacist members of the Society of Critical Care Medicine and the American College of Clinical Pharmacy. The survey, which requested responses concerning antihypertensive management in the respondents’ intensive care unit (ICU), opened March 12, 2007 and closed May 11, 2007.
      Results: Three hundred ninety three (7.1%) responses were returned; 25 were excluded. The most common practice setting (44.6%) was a mixed-population ICU. One hundred three (28.3%) respondents reported that a guideline exists in their institution for the treatment of hypertensive emergency (HE) in acute hemorrhagic stroke (AHS), while only 30 (8.2%) had guidelines for the non-stroke (NS) patient. Among physician respondents, mean systolic blood pressures (SBP) used to initiate IV antihypertensives were 180.9 (range 105-220) mmHg and 167.2 (range 100-220) mmHg in NS and AHS patients, respectively. In the NS patient, intermittent IV labetalol was the drug of choice among physicians (21.3%) and pharmacists (26.5%), while nicardipine was the drug of choice for the AHS patient (34.7%, 36.2% respectively). The second line agent of choice for the NS patient was sodium nitroprusside among physicians (19.8%) and continuous infusion labetalol for pharmacists (19.8%). For the AHS patient, the second line agent of choice was nicardipine among physicians (21.8%) and pharmacists (27.6%). One hundred thirty one (36%) respondents reported that they have seen a patient with symptomatic cyanide and/
      or thiocyanate toxicity.
      Conclusions: Because most institutions do not have HE guidelines, our data described herein provides the rationale for developing a national guideline.

  • August 2008, Volume 11, No. 3
  • May 2008, Volume 11, No. 2
    • Resuscitation in Puerto Rico: Where are the Survivors?:

      Resuscitation from death is not an every day event; however, it is no longer a rarity. Cardiopulmonary resuscitation (CPR) has, therefore, become a common tool in our management of these critically ill patients.
      Despite an improved understanding and management of cardiac arrest, and the widespread application of do not resuscitate (DNR) orders in an attempt to prevent the inappropriate use of CPR, the success rate following in-hospital cardiac arrest has remained unchanged
      over the last three decades, with return of spontaneous circulation (ROSC) in about 30% with approximately 15% of patients being discharged neurologically intact [1-5].

    • Angioedema Associated to Ophthalmic Beta-Blockers
    • The Science behind Weaning from Mechanical Ventilation:

      Weaning from mechanical ventilation is defi ned as the transition from the ventilatory dependence of the patient to a spontaneous breathing status. Recognizing when a patient is ready to be weaned from mechanical ventilation is greatly infl uences the outcome, and may prevent compromising a patient. Weaning indices were developed to help the physician predict the outcome of weaning trials, a common concern in the intensive care unit (ICU) setting. Many physiological mechanisms explain the reason why many patients fail weaning trial, mostly related to a noncompliant respiratory function
      and cardiovascular instability. The primary goal is to reduce failed attempts, and to adopt successful weaning protocols, in order to overcome problems that may arise in the critically ill patients. The ratio of respiratory rate to tidal volume (f/Vt), among other indices, and weaning trials like pressure support ventilation (PSV) or spontaneous breathing with the use of T tube are explained.

    • Predictors of Survival in Resuscitation:

      Objective: Study the survival-to-hospital discharge rate for veterans who underwent Advanced Cardiac Life Support (ACLS) and reach a better understanding of the variables that infl uence their
      survival after cardiac arrest. To aid in developing strategies directed towards decreasing the risks related to the event.
      Design: A retrospective record review of advanced resuscitative attempts during the period of January 1st to December 31st, 2006.
      Setting: VA Caribbean Health Care System, San Juan.
      Patients: Veterans admitted during the study period who suffered cardiac arrest.
      Measurements: Patient’s age, sex, diagnosis, initial rhythm, location, time of event and duration of the resuscitation efforts (downtime), were collected.
      Main results: There were 128 arrests documented during the study period: 122 (95%) were inhospital events and 6 involved patients brought to the emergency department during the course of resuscitation. The mean age was 72 years and 98% were males; most events occurred at general medical/surgical wards (61%). Events were mostly of cardiac origin (82.78%), with asystole (AS) and pulseless electrical activity (PEA) being the most common initial rhythms (61%). The most frequent pre-arrest diagnoses were sepsis, communityacquired pneumonia, renal failure and malignancy.
      Survival-to-hospital discharge was 7.38%; most survivors suffered primarily respiratory arrests while at the general wards. Arrest events were evenly distributed throughout the 24-hour day, and the average downtime in survivors was lower than in non-survivors (12 vs. 22.35 mins respectively, p=0.03).
      Conclusions: We found a substantially lower survival rate for in-hospital cardiac arrests than has been previously reported. Possible explanations for this phenomenon include the high incidence
      of arrhythmias associated with poor outcome (AS, PEA), the frequency of unwitnessed events occurring in general wards, patient’s age and underlying diagnoses. Measures for the timely
      identifi cation of admitted patients who are at risk for poor resuscitative outcomes with these characteristics should be instituted.

    • Semi-recumbent Position in ICU:

      Purpose: Positioning mechanically ventilated patients in an adequate semi-recumbent position is a low cost and apparently easy applied measure to prevent new VAP. We performed an unannounced
      audit to compare the actual backrest angle with the target backrest angle of 30-45 degrees, assess whether compliance was better in patients whose bed had a built-in bedside protractor, and document
      diffi culties reported when failing to achieve the target backrest angle.
      Methods: From 1/3/2007 to 30/6/2007, unannounced ad hoc inspections were made on patients receiving mechanical ventilation in the intensive care unit. During inspections, the angle of elevation of bed was formally measured by a manual technique using a hand-held protractor. The nurse at bed-side was also asked to estimate the angle of elevation of bed without referring to the built-in protractor and interviewed with a structured questionnaire.
      Results: From 1/3/2007 to 30/6/2007, inspections were made on 295 occasions. The median angle of backrest elevation was 25 degrees (interquartile range [IQR]: 20 to 30 degrees). The median angle of elevation estimated by the nurse at the bed-side was 30 (IQR: 20 to 30 degrees), (p <0.001). Semi-recumbent positions meeting the 30 degree minimum target angle were observed on only 120 (41%) occasions. Reasons provided for failing to achieve the target angle included incorrect estimation of the backrest angle and interference of the semi-recumbent position with nursing procedures and nursing inconvenience.
      Conclusions: This audit showed that the minimum target semi-recumbent position of 30 degrees was achieved only 40% of the time in an academic intensive care unit. Nurses at bedside consistently
      overestimated the angle of elevation of bed, and the presence of a built-in bedside protractor was not associated with a greater compliance with the target backrest elevation angle. Strictly enforced protocols, education programs for nurses and doctors
      and regular audit may improve compliance with backrest elevation targets.

    • Case Reports: Aeromonas Hydrophila Severe Gastroenteritis in Diabetic, Elderly Patients:

      Introduction: Aeromonas hydrophila gastroenteritis is rare in humans and common amongst fish, reptiles and amphibians. In humans, infections caused by Aeromonas species usually occur with increased frequency during warmer months. The organism is frequently isolated from meat products and its transmission is by feco-oral route.
      Clinical picture: We report 2 cases of Aeromonas hydrophila gastroenteritis in elderly, diabetic patients. Both patients had severe diarrhea and stool cultures grew Aeromonas hydrophila.
      Treatment and outcome: Both responded to intravenous ceftriaxone and were discharged well.
      Clinical implication: It is self limiting in immunocompetent hosts. In elderly, immunocompromised or pediatric patients, it can cause bacteremia and high mortality if not treated early.

  • February 2008, Volume 11, No. 1
    • Persistent Left Superior Vena Cava: Incidental Discovery in Adult:

      A middle age Caucasian gentleman presented to the Emergency Department with fever, chills and hypotension. Chest X-ray revealed consolidation in right lower lobe consistent with pneumonia. A chest radiograph after central line placement revealed a venous anomaly. CT scan with contrast revealed persistent left superior vena cava and absent right superior vena cava.

    • The Significance of Brain Natriuretic Peptide Levels in the Critically Ill:

      Brain natriuretic peptide levels (BNP) have been best studied in the heart failure (HF) literature and has been increasingly used in the critical care population as an estimate of cardiac function. BNP
      is secreted by cardiomyocytes in response to an increase in transmural ventricular pressure. The measurement of BNP is well known in the cardiac literature. Studies in the critical care population have looked at measuring BNP in different subsets of patients with sepsis, pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), pulmonary hypertension (PH) and non-cardiogenic pulmonary edema (CPE). BNP has been used to differentiate HF syndrome from other causes of respiratory failure both in the acute and chronic settings. The measurement of BNP in the critical care population is fraught with difficulties only one of which is the significant effect of renal failure on our ability to interpret BNP levels effectively. This review summarizes the current literature on the utility and significance of measuring BNP in the critical care population.

    • Multicentre Study About Nurses’ Attitude to Delirium Patients:

      Objective: The main goal of this research is to know
      a nurse’s attitude to patients that may suffer delirium
      during the hospitalization time. A second goal
      is to analyze whether relative’s visit time is a factor
      to be considered.
      Design: Multicentre prospective and observational
      study.
      Methodology: This study was performed in several
      hospitals that belong to the public sanitary health
      system of the Principado de Asturias (SESPA) and
      one hospital that belongs to Servicio Andaluz de
      Salud (SAS). The target populations are general
      hospitalization nurses, nurses specialized in
      intensive care, and relatives of patients admitted
      in intensive care units (ICU). As a tool we used a
      Likert questionnaire for validation of attitudes.
      This questionnaire included 20 questions about
      different situations that the nurses and relatives
      maintain in patients with delirium.
      Results: 215 questionnaires were sent to the target
      population including 87.91% nurses and 12.09%
      patient’s relatives. Cabueñes Hospital (SESPA) returned the highest number of questionnaires
      (46.51%). Intensive care nurses returned the
      highest number of questionnaires (73.02%). We
      considered different assistant levels for ICU, that
      in mostly corresponded to levels III and IV. The
      analysis of the variables studied using a multiple
      regression linear model revealed that the answers
      to 9 out of 20 possible items were signifi cantly
      different. Finally, the differences were highest in 3
      of those 9 items.
      Conclusions: Nurses don’t fi nd to the patients with
      delirium, of more interest than other types of patients,
      although they are highly concerned by their health
      before and after the delirium. Nurses are partially
      but not completely aware that delirium is a very
      serious illness. Nurses are not confi dent regarding
      whether the patient’s relatives could calm down
      the patient and help him to overcome the disease.
      Given the heterogeneity of the answers there are no
      defi nitive conclusions regarding whether a change
      of the visit hours might be important in the recovery
      of patients with delirium.

    • Long-Term Outcome of Long Stay ICU and HDU Patients in a New Zealand Hospital:

      Objective: The objective of the study is to determine
      factors that infl uence the outcome of long stay patients
      in a general intensive care unit (ICU) and/
      or high-dependency unit (HDU) in a New Zealand
      teaching hospital.
      Setting: 10-bed general ICU and 4-bed surgical
      HDU in a 400-bed hospital.
      Study type: Population based retrospective cohort
      study.
      Methods: All patients with prolonged stay in a high
      resource area (>7 days in the ICU or >14 days in either
      the ICU or HDU) between 2000 and 2003 were
      reviewed. Demographic data, co-morbidities, diagnoses,
      clinical events, hospital and 1-year mortality
      data were obtained using available databases and
      patient records. Multiple logistic regression analysis
      was performed to identify which variables are associated
      with death among patients with a prolonged stay in a high-resource unit (ICU/HDU).
      Results: 207 patients were included in the study.
      Twenty eight percent died before hospital discharge
      and 40% died within one year of their admission.
      Univariate analysis showed that increasing age,
      APACHE II score, admission post cardiac arrest,
      inpatient cardiac arrest, development of sepsis and
      requirement for renal support therapy were all risk
      factors for increased mortality. However, when adjusted
      for age, gender and APACHE II score the
      only risk factor strongly associated with death was
      having a cardiac arrest in the ICU.
      Conclusions: Prolonged ICU and/or HDU stay is associated
      with a high mortality rate particularly in
      patients with advancing age and increasing severity
      of illness. In this study, only cardiac arrest after a
      prolonged stay in the ICU and/or HDU is a strong
      predictor of death independent of the age and the
      APACHE II score.

    • Long-Term Outcome from Intensive Care. A One Year Follow-Up of Acute Admissions at Hawke’s Bay Hospital:

      Background: This study aimed to collect information
      about long-term survival and independence of
      patients requiring acute hospital admissions and
      care in Intensive Care Unit (ICU) and High Dependency
      Unit (HDU) in a non tertiary setting.
      Setting: An 11-bed multidisciplinary co-located
      ICU and HDU, a JFICM level 2 unit, providing all
      intensive care services for a non-tertiary (secondary)
      New Zealand District Health Board Hospital.
      Method: All acute adult admissions presenting to
      ICU/HDU between 1 Jan 2001 and 31 Dec 2001
      were studied. Admission demographic and physiological
      data was collected. From a review of the
      hospital records, NZ death registry, and the ICU
      database of published obituary notices, dates of
      death were identifi ed. After the fi rst anniversary
      of their initial ICU admission, discharged patients
      in whom death had not been confi rmed, were contacted.
      Patients surviving ICU were surveyed to
      determine their independence. The age and gender
      adjusted annual survival for the general population
      was compared to observed survival following ICU/
      HDU admission. Main Results: Adult acute admissions comprised
      586 (68.5%) of the total of 855 ICU/HDU admissions
      in 2001 (86 paediatric [<15 years] and 169 elective
      admissions excluded). Acute adult admissions (M
      49.9%; F 50.1%) had a median age of 58 years, an
      ICU survival of 86.3%, and a hospital survival of
      82.7%. Long-term outcome was established in 94%
      of admissions. One year post admission 73.2% were
      confi rmed as alive. Increased age decreased survivorship,
      with only 35.3% of the >85 years old group
      surviving one year. After ICU admission, one year
      survival was lower than that of the general population.
      Age-group matched survival was from 93% to
      32% for males and 60.2% to 90.4% for females of
      the general population survival rate. 94.4% of survivors
      were independent.
      Conclusions: Following acute admission, ICU patients
      have a lower level of survivorship than the
      general population, but the vast majority of the
      73.2% patients that survive one year remain independent.
      Generally the quality of life at one year is
      acceptable to survivors.

    • Consumption of Raw Oysters and Vibrio Vulnificus Sepsis:

      We present the case and images of a 52 yearold Hispanic gentleman with a history of hepatitis C and chronic liver disease that developed Vibrio vulnifi cus sepsis secondary to eating raw oysters.
      His course was complicated by necrotizing fasciitis in the upper extremities and renal failure.