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Young D.,Adult Intensive Care Unit | Young D.,University of Oxford | Lamb S.E.,University of Oxford | Shah S.,Royal Infirmary | And 5 more authors.
New England Journal of Medicine

BACKGROUND: Patients with the acute respiratory distress syndrome (ARDS) require mechanical ventilation to maintain arterial oxygenation, but this treatment may produce secondary lung injury. High-frequency oscillatory ventilation (HFOV) may reduce this secondary damage. METHODS: In a multicenter study, we randomly assigned adults requiring mechanical ventilation for ARDS to undergo either HFOV with a Novalung R100 ventilator (Metran) or usual ventilatory care. All the patients had a ratio of the partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FIO 2) of 200 mm Hg (26.7 kPa) or less and an expected duration of ventilation of at least 2 days. The primary outcome was all-cause mortality 30 days after randomization. RESULTS: There was no significant between-group difference in the primary outcome, which occurred in 166 of 398 patients (41.7%) in the HFOV group and 163 of 397 patients (41.1%) in the conventional- ventilation group (P=0.85 by the chi-square test). After adjustment for study center, sex, score on the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the initial PaO2:FIO2 ratio, the odds ratio for survival in the conventional-ventilation group was 1.03 (95% confidence interval, 0.75 to 1.40; P=0.87 by logistic regression). CONCLUSIONS: The use of HFOV had no significant effect on 30-day mortality in patients undergoing mechanical ventilation for ARDS. (Funded by the National Institute for Health Research Health Technology Assessment Programme; OSCAR Current Controlled Trials number, ISRCTN10416500.) Copyright © 2013 Massachusetts Medical Society. All rights reserved. Source

Chow M.,Hong Kong Polytechnic University | Herold D.K.,Hong Kong Polytechnic University | Choo T.-M.,Adult Intensive Care Unit | Chan K.,Hong Kong Polytechnic University
Computers and Education

Learners need to have good reasons to engage and accept e-learning. They need to understand that unless they do, the outcomes will be less favourable. The technology acceptance model (TAM) is the most widely recognized model addressing why users accept or reject technology. This study describes the development and evaluation of a virtual environment, the online 3D world Second Life (SL), for learning rapid sequence intubation (RSI). RSI is an increasingly frequently used method of acute airway management in healthcare settings. The intention of learners to use the system was explored based on the TAM, with the computer self-efficacy construct as an external variable. Two hundred and six nursing students participated in this study. The findings suggest that the system was perceived as useful, and that the students felt confident working with computers and intended to review RSI in SL as often as needed. However, they remained neutral regarding the ease of use of the system. Strategies were suggested for boosting the students' self-confidence in using the system. Overall use of the TAM in this context was successful, indicating the robustness of the model. The limitations of the study were discussed and further areas of research on the TAM were proposed. © 2012 Elsevier Ltd. All rights reserved. Source

Messer B.,Royal Infirmary | Griffiths J.,Adult Intensive Care Unit | Baudouin S.V.,Royal Infirmary

Introduction: Chronic Obstructive Pulmonary Disease (COPD) frequently presents with an acute exacerbation (AECOPD). Debate exists as to whether these patients should be admitted to intensive care units (ICUs). An integrative review was performed to determine whether clinical variables available at the time of ICU admission are predictive of the intermediate-term mortality of patients with an AECOPD. Methods: An integrative review was structured to incorporate a five-stage review framework to facilitate data extraction, analysis and presentation. The quality of the studies contributing to the integrative review was assessed with a novel scoring system developed from previously published data and adapted to this setting. Results: The integrative review search strategy identified 28 studies assessing prognostic variables in this setting. Prognostic variables associated with intermediate-term mortality were low Glasgow Coma Scale (GCS) on admission to ICU, cardiorespiratory arrest prior to ICU admission, cardiac dysrhythmia prior to ICU admission, length of hospital stay prior to ICU admission and higher values of acute physiology scoring systems. Premorbid variables such as age, functional capacity, pulmonary function tests, prior hospital or ICU admissions, body mass index and long-term oxygen therapy were not found to be associated with intermediate-term mortality nor was the diagnosis attributed to the cause of the AECOPD. Discussion: Variables associated with intermediateterm mortality after AECOPD requiring ICU admission are those variables, which reflect underlying severity of acute illness. Premorbid and diagnostic data have not been shown to be predictive of outcome. A scoring system is proposed to assess studies of prognosis in AECOPD. ©The Author 2011. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. Source

Finney S.J.,Adult Intensive Care Unit
European Respiratory Review

Extracorporeal membrane oxygen (ECMO) has been used for many years in patients with life-threatening hypoxaemia and/or hypercarbia. While early trials demonstrated that it was associated with poor outcomes and extensive haemorrhage, the technique has evolved. It now encompasses new technologies and understanding that the lung protective mechanical ventilation it can facilitate is inextricably linked to improving outcomes for patients. The positive results from the CESAR (Conventional ventilation or ECMO for Severe Adult Respiratory failure) study and excellent outcomes in patients who suffered severe influenza A (H1N1/09) infection have established ECMO in the care of patients with severe acute respiratory distress syndrome. Controversy remains as to at what point in the clinical pathway ECMO should be employed; as a rescue therapy or more pro-actively to enable and ensure high-quality lung protective mechanical ventilation. The primary aims of this article are to discuss: 1) the types of extracorporeal support available; 2) the rationale for its use; 3) the relationship with lung protective ventilation; and 4) the current evidence for its use. © ERS 2014. Source

Morgan T.J.,Adult Intensive Care Unit
Journal of Clinical Monitoring and Computing

'Standard' or 'extracellular' base excess (SBE) is a modified calculation using one-third the normal hemoglobin concentration. It is a 'CO 2-invariant' expression of meta- bolic acid-base status integrated across interstitial, plasma and erythrocytic compartments (IPE). SBE also integrates conflicting physical chemical influences on metabolic acid-base status. Until recently attempts to quantify individual contributions to SBE, for example the plasma strong ion gap, failed to span the 'CO 2-stable' IPE dimension. The first breakthrough was from Anstey, who determined the con- centration of unmeasured charged species referenced to the IPE domain using Wooten's physical chemical version of the Van Slyke equation. In this issue Drs Wolf and DeLand present a diagnostic tool based on an IPE model which dissects a version of SBE (BEnet) into nine independent (BEind) components, all referenced to the IPE domain. The reported components are excess/deficits of free water, chlo- ride, albumin, unmeasured ions, sodium, potassium, lactate, 'Ca-Mg' (a composite divalent cation entity), and phosphate. The model also reports individualised volumes of plasma, erythrocytes and interstitial fluid. The tool is an original contribution, but there are concerns. The impact of assum- ing fixed relationships between arterial and venous acid-base and saturation values in sepsis, anaemia and in differing shock states is unclear. Clinicians are also unlikely to accept that unique, accurate IPE volume determinations can be derived from a single set of blood gas and biochemistry results. Nevertheless, volume determinations aside, the tool is likely to become a valuable addition to the diagnostic armamentarium. © 2011 Springer Science+Business Media, LLC. Source

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