Neto A.S.,Medical Intensive Care Unit |
Neto A.S.,Hospital Israelita Albert Einstein |
Schultz M.J.,University of Amsterdam
Current Opinion in Critical Care | Year: 2014
PURPOSE OF REVIEW: There is convincing evidence for benefit from lung-protective mechanical ventilation with lower tidal volumes in patients with the acute respiratory distress syndrome (ARDS). It is uncertain whether this strategy benefits critically ill patients without ARDS as well. This manuscript systematically reviews recent preclinical studies of ventilation in animals with uninjured lungs, and clinical trials of ventilation in ICU patients without ARDS on the association between tidal volume size and pulmonary complications and outcome. RECENT FINDINGS: Successive preclinical studies almost without exception show that ventilation with lower tidal volumes reduces the injurious effects of ventilation in animals with uninjured lungs. This finding is in line with results from recent trials in ICU patients without ARDS, demonstrating that ventilation with lower tidal volumes has a strong potential to prevent development of pulmonary complications and maybe even to improve survival. However, evidence mostly comes from nonrandomized clinical trials, and concerns are expressed regarding unselected use of lower tidal volumes in the ICU, that is, in all ventilated critically ill patients, since this strategy could also increase needs for sedation and/or neuromuscular blockade, and maybe even cause respiratory muscle fatigue. These all then could in fact worsen outcome, possibly counteracting the beneficial effects of ventilation with lower tidal volumes. SUMMARY: Ventilation with lower tidal volumes protects against pulmonary complications, but well-powered randomized controlled trials are urgently needed to determine whether this ventilation strategy truly benefits all ventilated ICU patients without ARDS. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Neto A.S.,Medical Intensive Care Unit |
Neto A.S.,Hospital Israelita Albert Einstein |
Schultz M.J.,University of Amsterdam
Current Opinion in Anaesthesiology | Year: 2013
Purpose of Review: It is uncertain whether patients undergoing short-lasting mechanical ventilation for surgery benefit from lung-protective intraoperative ventilatory settings including the use of lower tidal volumes, higher levels of positive end-expiratory pressure (PEEP) and/or recruitment maneuvers. We meta-analyzed trials testing the effect of lung-protective intraoperative ventilatory settings on the incidence of postoperative pulmonary complications. Recent Findings: Eight articles (1669 patients) were included. Meta-analysis showed a decrease in lung injury development [risk ratio (RR) 0.40; 95% confidence interval (CI) 0.22-0.70; I 0%; number needed to treat (NNT) 37], pulmonary infection (RR 0.64; 95% CI 0.43-0.97; I 0%; NNT 27) and atelectasis (RR 0.67; 95% CI 0.47-0.96; I 48%; NNT 31) in patients receiving intraoperative mechanical ventilation with lower tidal volumes. Meta-analysis also showed a decrease in lung injury development (RR 0.29; 95% CI 0.14-0.60; I 0%; NNT 29), pulmonary infection (RR 0.62; 95% CI 0.40-0.96; I 15%; NNT 33) and atelectasis (RR 0.61; 95% CI 0.41-0.91; I 0%; NNT 29) in patients ventilated with higher levels of PEEP, with or without recruitment maneuvers. Summary: Lung-protective intraoperative ventilatory settings have the potential to protect against postoperative pulmonary complications. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.
News Article | October 28, 2016
The Rev. Patrick J. Conroy, chaplain of the U.S. House of Representatives, will be the featured speaker at the Wholeness of Life Gala hosted by HealthCare Chaplaincy Network (HCCN) on November 3 in New York City. The event will honor select health care and community leaders and hands-on hospital staff who exemplify outstanding compassion and commitment to their profession and/or community. HCCN asked Father Conroy to be this year’s guest speaker because of his role as a resource for the well-being of the members of the U.S. House—one that aligns with HCCN’s mission to provide optimal spiritual care to all patients and their families. Father Conroy has been serving as U.S. House Chaplain since May 2011. His wide-ranging career as a Jesuit priest, attorney, educator and musician has spanned 40 years. HCCN’s annual gala is the New York City-based nonprofit organization’s single largest source of awareness-raising and revenue-raising to advance the integration of spiritual care in health care through clinical practice, research and education, and improve quality of life for patients and their families, regardless of religion or beliefs. The gala will take place at the Mandarin Oriental New York in New York City. “The 2016 gala comes at an exciting time in health care, in which spiritual care is increasingly being recognized as a critical part of whole-person care,” said Rev. Eric J. Hall, HCCN’s president and CEO. “HealthCare Chaplaincy is committed to amplifying our resources to meet the rising demand for spiritual support inside and outside traditional hospital settings from countless people who are ill, grieving or in spiritual distress. Professional chaplaincy and other spiritual support can make a significant impact on their quality of life.” HCCN will present Community Honoree Awards to Jay Badame, president and COO of Tishman Construction, An AECOM Company, in New York, New Jersey and Pennsylvania, who has overseen the construction of some of the region’s newest landmark structures, such as the 1, 3 and 4 World Trade Center office towers; and Wendell Scanterbury, director of pastoral care at Cancer Treatment Centers of America at Eastern Regional Medical Center, Philadelphia, Pa., who provides spiritual and emotional support, education and counseling to patients and their families. It will also present Raymond R. Schroeder, president, Interim HealthCare of the Upstate South Carolina, Greenville, S.C., with its prestigious Lifetime Achievement Award. Earlier this year, HCCN granted its “Excellence in Spiritual Care Award” to Interim HealthCare Hospice, a part of Interim HealthCare of the Upstate South Carolina, distinguishing the local agency as the first hospice in the nation to receive this honor. In addition, HCCN will recognize, as Patient Care Honorees, a diverse group of employees for their efforts in improving the patient experience at major New York area hospitals. They are: Elizabeth Colman, RN, a registered nurse at Hospital for Special Surgery, New York City; Melanie J. Carrow, RN, a clinical nurse in the Department of Nursing, Outpatient Service: Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York City; Denise Knox, a dietary worker at Mount Sinai Beth Israel, New York City; Fernando G. Rivera, RN, clinical nurse manager, Medical Intensive Care Unit, Mount Sinai Hospital, New York City; Mark Collazo, director of Respiratory Care Services, Mount Sinai St. Luke’s/Mount Sinai West, New York City; and Paul Hartendorp, M.D., a colorectal surgeon, at Winthrop University Hospital, Mineola, N.Y. For more information about the Wholeness of Life Gala, visit http://www.HCCNgala.org. HealthCare Chaplaincy Network™ is a global health care nonprofit organization that offers spiritual-related information and resources, and professional chaplaincy services in hospitals, other health care settings, and online. Its mission is to advance the integration of spiritual care in health care through clinical practice, research and education in order to improve patient experience and satisfaction and help people faced with illness and grief find comfort and meaning—whoever they are, whatever they believe, wherever they are. For more information, visit http://www.healthcarechaplaincy.org, call 212-644-1111, and connect with us on twitter and Facebook.
Zolak J.S.,University of Alabama at Birmingham |
de Andrade J.A.,University of Alabama at Birmingham |
de Andrade J.A.,Medical Intensive Care Unit
Immunology and Allergy Clinics of North America | Year: 2012
Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease of unknown cause characterized by progressive scarring of the lung parenchyma and relentless loss of lung function. The diagnosis depends on close collaboration between clinicians, radiologists, and pathologists. No therapies approved by the Food and Drug Administration are available for IPF, and an analysis of completed clinical trials has demonstrated that the clinical course of IPF is largely unpredictable. Until therapies that improve survival become available, measures to preserve function and quality of life should be considered, and gastroesophageal reflux should be treated aggressively. © 2012.
Roch A.,Medical Intensive Care Unit |
Wiramus S.,Medical Intensive Care Unit |
Pauly V.,Hopital Sainte Marguerite |
Forel J.,Medical Intensive Care Unit |
And 3 more authors.
Critical Care | Year: 2011
Introduction: The aim of this study was to evaluate factors influencing short- and long-term survival in medical patients aged 80 and over following admission to an intensive care unit.Methods: All patients aged 80 years or over and admitted between 2001 and 2006 were included in this study. Survival was evaluated between the time of admission and June 2009; factors associated with mortality were determined. Health-related quality of life was evaluated using Short Form (SF)-36 in long-term survivors.Results: For the 299 patients included (mean age, 84 ± 4 y), hospital mortality was 55%. Factors independently associated with hospital mortality were a higher SAPS II score at ICU admission; the existence of a fatal disease as reflected by the McCabe score and a cardiac diagnosis at admission. In the 133 hospital survivors, median survival time was 710 days (95% CI, 499-921). Two-year mortality rates were 79% of the initial cohort and 53% of hospital survivors. The standardized ratio of mortality at 2 years after hospital discharge was 2.56 (95% CI, 2.08-3.12) when compared with age- and gender-adjusted mortality of the general population. Factors independently associated with mortality at 2 years after hospital discharge were SAPS II score at ICU admission and the McCabe score. Conversely, functional status prior to admission as assessed by Knaus or Karnofsky scores was not associated with long-term mortality. In long-term survivors, SF-36 physical function scores were poor but scores for pain, emotional well-being and social function were not much affected.Conclusions: The severity of acute disease at admission influences mortality at the hospital and following discharge in patients aged 80 or over. Although up to 50% of patients discharged from the hospital were still alive at 2 years, mortality was increased when compared with the general population. Physical function of long-term hospital survivors was greatly altered. © 2011 Roch et al.; licensee BioMed Central Ltd.
Bardou M.,CHU de Dijon |
Quenot J.-P.,Medical Intensive Care Unit |
Barkun A.,McGill University
Nature Reviews Gastroenterology and Hepatology | Year: 2015
Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease. © 2015 Macmillan Publishers Limited. All rights reserved.
Hough C.L.,University of Washington |
Hough C.L.,Medical Intensive Care Unit
Current Opinion in Critical Care | Year: 2013
PURPOSE OF REVIEW: Although it has been demonstrated that physical functional impairments are common among survivors of critical illness, few studies have proven benefits of intervention. This review will discuss assessment of physical functional impairment, recent and ongoing interventional studies, and implementation of rehabilitation beginning in the ICU, hospital ward, and after hospital discharge. RECENT FINDINGS: New studies confirm challenges around measurement of physical function both during and after critical illness, and offer potential new modalities that could inform mechanism and treatment. Longitudinal cohort studies emphasize the importance of recognition and measurement of premorbid status. Although no recent studies have proven new approaches to improving physical function in survivors of critical illness, emerging data support the safety, feasibility, and cost-effectiveness of providing physical rehabilitation early in the course of critical illness. Pilot and ongoing studies hold promise for improving physical function and quality of life for future survivors of critical illness. SUMMARY: Improving physical function for survivors of critical illness will require careful application of current knowledge, as well as rigorous investigation into causes, research methodologies, and implementation of results of future interventional studies. © 2013 Wolters Kluwer Health Lippincott Williams & Wilkins.
Goudet V.,Medical Intensive Care Unit
Trials | Year: 2013
Catheter-related infection is the third cause of infections in intensive care units (ICU), increasing the length of stay in ICU and hospital, mortality, and costs. Skin antisepsis is one of the most prevalent preventive measures. In this respect, it would appear preferable to recommend the use of alcoholic povidone iodine or chlorhexidine rather than aqueous povidone iodine. However, the data comparing chlorhexidine to povidone-iodine, both of them in alcoholic solutions, remain limited. Moreover, the benefits of enhanced cleaning prior to disinfection of skin that is not visibly soiled have yet to be confirmed in a randomized study. A prospective multicenter, 2 × 2 factorial, randomized-controlled, assessor-blind trial will be conducted in 11 intensive care units in six French hospitals. All adult patients aged over 18 years requiring the insertion of at least one peripheral arterial catheter and/or a non-tunneled central venous catheter and/or a hemodialysis catheter and/or an arterial pulmonary catheter will be randomly assigned to have all their catheters cared with one of four skin preparation strategies (2% chlorhexidine/70% isopropyl alcohol or 5% povidone iodine/69% ethanol with or without prior skin scrubbing). At catheter removal, catheter tips will be quantitatively cultured. Sets of aerobic and anaerobic blood cultures will be routinely obtained when a patient has fever, hypothermia, or other indications. In case of suspected catheter-related infection the patient's form will be reviewed by an independent adjudication committee. We plan to enroll 2,400 patients (4,800 catheters). The main objective is to demonstrate that use of 2% alcoholic chlorhexidine compared to 5% alcoholic povidone iodine in skin preparation lowers the rate of catheter-related infection. The second endpoint is to demonstrate that enhanced skin cleaning prior to disinfection of skin that is not visibly soiled does not reduce catheter colonization. Other outcomes include comparison of skin colonization at catheter insertion site, comparison of catheter colonization and catheter-related bacteremia taking place during implementation of the four strategies of skin preparation, and cutaneous tolerance, length of hospitalization, mortality, and costs. This study will help to update recommendations on the choice of an antiseptic agent to use in skin preparation prior to insertion of a vascular catheter and, by extension, of an epidural catheter and it will likewise help to update recommendations on the usefulness of skin scrubbing prior to disinfection when the skin is not visibly soiled. Clinicaltrials.gov number NCT01629550.
Yang G.-H.,Medical Intensive Care Unit
Chinese Critical Care Medicine | Year: 2011
Objective: To investigate the clinical effects and safety degree of high positive end-expiratory pressure (PEEP) combined with lung recruitment maneuver (RM) in patients with acute respiratory distress syndrome (ARDS). Methods: Thirty-eight patients in medical intensive care unit (MICU) of Affiliated Hospital of Guiyang Medical College suffering from ARDS admitted from June 2008 to May 2010 were enrolled in the study. With the envelope method they were randomized into RM group and non-RM group, with n = 19 in each group. All patients received protective ventilation: pressure support ventilation (PSV) with plateau pressure limited at 30 cm H 2O (1 cm H 2O = 0.098 kPa) or lower. PEEP was set at the minimum level with fraction of inspired oxygen (FiO 2) < 0.60 and partial pressure of arterial oxygen (PaO 2) kept between 60 and 80 mm Hg (1 mm Hg = 0.133 kPa). RM was conducted by regulating FiO 2 to 1.00, support pressure to 0, PEEP increased to 40 cm H 2O and maintained for 30 seconds before lowering, and this maneuver was repeated every 8 hours for a total of 5 days. Base status, ventilation parameters, blood gas analysis and vital signs were obtained at baseline and for the next 5 days. Oxygenation status and lung injury indexes were compared between RM group and non-RM group, the adverse effects of RM and incidence of barotrauma were recorded. Results: Circled digit one There were no significant differences of base status and ventilation parameters between RM group and non-RM group. Circled digit twoPaO 2 and oxygenation index (PaO 2/FiO 2) were both increased in RM group and non-RM group, but the values were higher in RM group [PaO 2(mmHg) 2 days: 85.8±21.3 vs. 73.5±18.7, 3 days: 88.6±22.8 vs. 74.3±19.8, 4 days: 98.8± 30.7 vs. 79.3±19.3, 5 days, 105.5±29.4 vs. 84.4±13. 8; PaO 2/FiO 2 (mm Hg) 4 days: 221.8±103.5 vs. 160.3±51.4, 5 days: 239.6±69.0 vs. 176.8±45.5, all P<0.05]. Circled digit three Hydrogen peroxide (H 2O 2) and interleukin-6 (IL-6) concentration in exhaled breath condensate (EBC) decreased in both groups but lower in RM group with significant difference [5 days H 2O 2 (μmol/L): 0.04±0.02 vs. 0.10±0.03) IL-6 (ng/L): 4.12±2.09 vs. 9.26±3.47, both P<0.05]. Circled digit four Barotrauma and arrhythmia did not occur in both groups. No significant changes in heart rate were found during RM. Central venous pressure and mean arterial pressure remained unchanged after RM. Conclusion: High level PEEP combined with RM can improve gas exchange and oxygenation, decrease ventilator associated lung injury (VALI). RM was safe and had good tolerance, no hypoxemia, barotrauma and hemodynamic instability were observed.
Neto A.S.,Medical Intensive Care Unit |
Pereira V.G.M.,Medical Intensive Care Unit |
Esposito D.C.,Medical Intensive Care Unit |
Damasceno M.C.T.,Medical Intensive Care Unit |
Schultz M.J.,University of Amsterdam
Annals of Intensive Care | Year: 2012
Background Acute respiratory distress syndrome (ARDS) is a potentially fatal disease with high mortality. Our aim was to summarize the current evidence for use of neuromuscular blocking agents (NMBA) in the early phase of ARDS. Methods Systematic review and meta-analysis of publications between 1966 and 2012. The Medline and CENTRAL databases were searched for studies on NMBA in patients with ARDS. The meta-analysis was limited to: 1) randomized controlled trials; 02) adult human patients with ARDS or acute lung injury; and 03) use of any NMBA in one arm of the study compared with another arm without NMBA. The outcomes assessed were: overall mortality, ventilatorfree days, time of mechanical ventilation, adverse events, changes in gas exchange, in ventilator settings, and in respiratory mechanics. Results Three randomized controlled trials covering 431 participants were included. Patients treated with NMBA showed less mortality (Risk ratio, 0.71 [95% CI, 0.55 - 0.90]; number needed to treat, 1 - 7), more ventilator free days at day 28 (p = 0.020), higher PaO 2 to FiO 2 ratios (p = 0.004), and less barotraumas (p = 0.030). The incidence of critical illness neuromyopathy was similar (p = 0.540). Conclusions The use of NMBA in the early phase of ARDS improves outcome. © 2012 Quintard et al; licensee Springer.