Practice of Intubation of the Critically Ill at Mayo Clinic

2017 ◽  
Vol 34 (3) ◽  
pp. 204-211 ◽  
Author(s):  
Nathan J. Smischney ◽  
Mohamed O. Seisa ◽  
Katherine J. Heise ◽  
Kyle D. Busack ◽  
Theodore O. Loftsgard ◽  
...  
Keyword(s):  
Critically Ill ◽  
Difficult Intubation ◽  
Airway Device ◽  
Surgical Intensive Care Unit ◽  
Complication Rates ◽  
Common Complication ◽  
Surgical Intensive Care ◽  
First Pass ◽  
The Mean ◽  
Final Cohort

Objective: To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic’s campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. Patients and Methods: Critically ill adult (≥18 years) patients admitted to a medical–surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. Results: The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). Conclusion: We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.

Argatroban Dosage in Critically Ill Patients with HIT.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1779-1779 ◽  
Author(s):  
Sarkis B. Baghdasarian ◽  
Inder Singh ◽  
Michael A. Militello ◽  
John R. Bartholomew ◽  
Susan M. Begelman
Keyword(s):  
Liver Disease ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Thrombin Inhibitor ◽  
Surgical Intensive Care Unit ◽  
Moderate Hepatic Impairment ◽  
Surgical Intensive Care ◽  
Hepatic Congestion ◽  
Organ System Failure ◽  
The Mean

Abstract Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin therapy that can result in significant morbidity and mortality. Immediate discontinuation of heparin followed by the administration of a direct thrombin inhibitor (DTI) is the standard of care. There are two DTIs approved by the FDA for this indication, argatroban and lepirudin. Argatroban is metabolized in the liver by hydroxylation and aromatization and requires dosage adjustment in patients with moderate hepatic impairment defined as a Child-Pugh score >6. The normal recommended starting dose of 2 mcg/kg/min is reduced to 0.5 mcg/kg/min in these patients. Objective : Our clinical observation was that the recommended starting doses of argatroban in the ICU resulted in elevated activated partial thromboplastin time (aPTT) values that persisted for a prolonged time. This may result in a higher bleeding risk and delay life-saving invasive procedures especially in the absence of an antidote. Therefore, our objective is to show that critically ill patients without significant liver disease require a lower dosage of argatroban than recommended in the manufacturer’s prescribing information and to identify factors that may affect this recommendation. Materials and Method : Retrospective chart review of patients admitted to a medical or surgical intensive care unit (ICU), diagnosed with HIT who received argatroban for more than 24 hours. SPSS version 11.5 was used for data analysis. Results : 65 patients (37 men) were analyzed. The mean age was 65.8 years. 43% had abnormal liver function tests (LFT’s) defined as ALT>50 or bilirubin >1.5 (100% of the patients had a normal baseline INR), 24.6% had acute renal failure (ARF) and 36.9% were septic. 40% had one organ system failure (OSF), 40% had two and 20% three. The diagnosis of ARF, sepsis and the number of OSF was based on the ICU physician’s documentation and the patient’s active problem list. Excluding 3 patients with a history of liver disease (1) or acute liver decompensation (2), the mean argatroban dose for our ICU patients was 0.91 mcg/kg/min. Patients with ARF (n=16/65) required a significantly lower dose (0.65 mcg/kg/min, p=0.044), as did patients with sepsis (0.70 mcg/kg/min, p=0.03, n=24/65). Even in patients with normal LFT’s, dosage requirements were lower ranging from 1.2 mcg/kg/min with one OSF to 0.52 mcg/kg/min with three OSF (p=0.009). Discussion : Factors other than pre-existing liver disease appear to affect the dosage of argatroban in critically ill patients with HIT. Our mean dose to achieve a therapeutic aPTT was 0.91 mcg/kg/min with even lower doses in patients with ARF, sepsis or more than one OSF. This may be explained by the influence of ARF, sepsis, or OSF on argatroban metabolism by the liver that is not necessarily reflected in ALT, bilirubin, or even INR measurements. This metabolic effect may be due to passive hepatic congestion, accumulation of certain metabolites or interaction with the multiple medications used in these patients. Consideration should be given to initiate argatroban at a lower dosage in the critically ill patient.

Predicting the risk of pressure ulcers in critically ill patients

1999 ◽  
Vol 8 (4) ◽  
pp. 262-269 ◽  
Author(s):  
EV Carlson ◽  
MG Kemp ◽  
S Shott
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Pressure Ulcers ◽  
Sensory Perception ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Braden Scale ◽  
The Mean

BACKGROUND: Critically ill patients are at high risk for pressure ulcers. OBJECTIVES: To determine the contributions of the Braden subscales in predicting pressure ulcers in critically ill patients and to investigate how often the Braden scale should be completed to assess the risk for pressure ulcers in critically ill patients. METHOD: The Braden scale was used to assess repeatedly 136 adult patients without pressure ulcers in a medical intensive care unit, a surgical intensive care unit, and a noninvasive respiratory care unit, and the patients' skin was inspected routinely for pressure ulcers. RESULTS: A total of 36 pressure ulcers, most commonly on the sacrum or coccyx and the heels (15 stage 1, 20 stage 2, 1 stage 3), developed in 17 patients (12%). In 14 (82%) of the 17, the ulcers developed within 72 hours of admission to the intensive care unit. The risk for pressure ulcers increased as the mean sensory perception (P = .01) and the mean total Braden (P = .046) scores decreased. The mean sensory perception scores obtained at 12 and 36 hours after admission also had a significant relationship to the risk for pressure ulcers (P = .03). CONCLUSIONS: Patients in intensive care units have an increased risk for pressure ulcers. Although waiting until 12 hours after a patient's admission to the intensive care unit to obtain the initial Braden rating may be reasonable (with the second rating obtained 36 hours after admission), additional research is needed before this practice can be recommended.

Implementing Volume-Based Feeding to Optimize Delivery of Enteral Nutrition

2021 ◽  
Vol 41 (2) ◽  
pp. 16-26
Author(s):  
Angela Bonomo ◽  
Diane Lynn Blume ◽  
Katie Davis ◽  
Hee Jun Kim
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Quality Improvement ◽  
Enteral Nutrition ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Educational Approach ◽  
Lecture Demonstration

Background At least 80% of ordered enteral nutrition should be delivered to improve outcomes in critical care patients. However, these patients typically receive 60% to 70% of ordered enteral nutrition volume. In a practice review within a 28-bed medical-surgical adult intensive care unit, patients received a median of 67.5% of ordered enteral nutrition with standard rate-based feeding. Volume-based feeding is recommended to deliver adequate enteral nutrition to critically ill patients. Objective To use a quality improvement project to increase the volume of enteral nutrition delivered in the medical-surgical intensive care unit. Methods Percentages of target volume achieved were monitored in 73 patients. Comparisons between the rate-based and volume-based feeding groups used nonparametric quality of medians test or the χ2 test. A customized volume-based feeding protocol and order set were created according to published protocols and then implemented. Standardized education included lecture, demonstration, written material, and active personal involvement, followed by a scenario-based test to apply learning. Results Immediately after implementation of this practice change, delivered enteral nutrition volume increased, resulting in a median delivery of 99.8% of ordered volume (P = .003). Delivery of a mean of 98% ordered volume was sustained over the 15 months following implementation. Conclusions Implementation of volume-based feeding optimized enteral nutrition delivery to critically ill patients in this medical-surgical intensive care unit. This success can be attributed to a comprehensive, individualized, and proactive process design and educational approach. The process can be adapted to quality improvement initiatives with other patient populations and units.

scholarly journals Chlorhexidine Gluconate Bathing Program to Reduce Health Care–Associated Infections in Both Critically Ill and Non–Critically Ill Patients

2021 ◽  
Vol 41 (5) ◽  
pp. e1-e8
Author(s):  
Leigh Chapman ◽  
Lisa Hargett ◽  
Theresa Anderson ◽  
Jacqueline Galluzzo ◽  
Paul Zimand
Keyword(s):  
Health Care ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Chlorhexidine Gluconate ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Telemetry Unit ◽  
Health Care Associated Infections ◽  
The Impact

Background Critical care nurses take care of patients with complicated, comorbid, and compromised conditions. These patients are at risk for health care–associated infections, which affect patients’ lives and health care systems in various ways. Objective To gauge the impact of routinely bathing patients with 4% chlorhexidine gluconate solution on the incidence of health care–associated infections in a medical-surgical intensive care unit and a postoperative telemetry unit; to outline the framework for a hospital-wide presurgical chlorhexidine gluconate bathing program and share the results. Methods A standard bathing protocol using a 4% chlorhexidine gluconate solution was developed. The protocol included time studies, training, monitoring, and surveillance of health care–associated infections. Results Consistent patient bathing with 4% chlorhexidine gluconate was associated with a 52% reduction in health care–associated infections in a medical-surgical intensive care unit. The same program in a postoperative telemetry unit yielded a 45% reduction in health care–associated infections. Conclusion A comprehensive daily 4% chlorhexidine gluconate bathing program can be implemented with standardized protocols and detailed instructions and can significantly reduce the incidence of health care–associated infections in intensive care unit and non–intensive care unit hospital settings.

Protein C Concentrations Correlate with Organ Dysfunction and Predict Outcome Independent of the Presence of Sepsis

2007 ◽  
Vol 107 (1) ◽  
pp. 15-23 ◽  
Author(s):  
Frank Brunkhorst ◽  
Yasser Sakr ◽  
Stefan Hagel ◽  
Konrad Reinhart
Keyword(s):  
Critically Ill ◽  
Organ Dysfunction ◽  
Protein C ◽  
Multivariable Analysis ◽  
Risk Groups ◽  
University Hospital ◽  
Surgical Intensive Care Unit ◽  
Icu Mortality ◽  
Surgical Intensive Care ◽  
Time Courses

Abstract Background: Characterizing the evolution of protein C concentrations in critically ill patients may help in identifying high risk groups and potential therapeutic targets. The authors investigated the time courses of protein C concentrations and their relation to the presence of sepsis, organ dysfunction/failure, and outcome. Methods: This observational cohort study, in a university hospital surgical intensive care unit (ICU), included 312 consecutive patients with an estimated ICU length of stay more than 48 h. Plasma protein C concentrations and parameters of organ dysfunction were measured daily until discharge or death. Results: Protein C concentrations were below the lower limit of normal in 50.6% of patients (n = 158) on admission and decreased to a nadir within 3–4 days after admission before almost normalizing by 2 weeks thereafter, irrespective of the presence of sepsis, sex, source and type of admission, and type of surgery. The minimum protein C concentration was lower in patients with severe sepsis/septic shock (n = 54) than in those with sepsis (n = 63) and those who never had sepsis (n = 195), and was negatively correlated to the maximum Sequential Organ Failure Assessment score (R2 = 0.345, P < 0.001). Protein C levels were lower in nonsurvivors (n = 46; 14.7%) than in survivors, especially in the first 4 days after admission. In a multivariable analysis with ICU mortality as the dependent variable, a minimum protein C concentration less than 45% was an independent risk factor for ICU death. Conclusions: In critically ill surgical patients, protein C concentrations were generally low, associated with organ dysfunction/failure, and independently associated with a higher risk of ICU mortality.

Survey of Physiotherapy Practice in Ontario Cardiac Surgery Intensive Care Units

2021 ◽  
pp. e20200069
Author(s):  
Anastasia N.L. Newman ◽  
Michelle E. Kho ◽  
Jocelyn E. Harris ◽  
Alison Fox-Robichaud ◽  
Patricia Solomon
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Critically Ill ◽  
Outcome Measures ◽  
Median Number ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Physiotherapy Practice

Purpose: This article describes current physiotherapy practice for critically ill adult patients requiring prolonged stays in critical care (> 3 d) after complicated cardiac surgery in Ontario. Method: We distributed an electronic, self-administered 52-item survey to 35 critical care physiotherapists who treat adult cardiac surgery patients at 11 cardiac surgical sites. Pilot testing and clinical sensibility testing were conducted beforehand. Participants were sent four email reminders. Results: The response rate was 80% (28/35). The median (inter-quartile range) reported number of cardiac surgeries performed per week was 30 (10), with a median number of 14.5 (4) cardiac surgery beds per site. Typical reported caseloads ranged from 6 to 10 patients per day pe therapist, and 93% reported that they had initiated physiotherapy with patients once they were clinically stable in the intensive care unit. Of 28 treatments, range of motion exercises (27; 96.4%), airway clearance techniques (26; 92.9%), and sitting at the edge of the bed (25; 89.3%) were the most common. Intra-aortic balloon pump and extracorporeal membrane oxygenation appeared to limit physiotherapy practice. Use of outcome measures was limited. Conclusions: Physiotherapists provide a variety of interventions with critically ill cardiac surgery patients. Further evaluation of the limited use of outcome measures in the cardiac surgical intensive care unit is warranted.

Prognosis of Critically Ill Patients With Cancer and Acute Renal Dysfunction

2006 ◽  
Vol 24 (24) ◽  
pp. 4003-4010 ◽  
Author(s):  
Márcio Soares ◽  
Jorge I.F. Salluh ◽  
Marilia S. Carvalho ◽  
Michael Darmon ◽  
José R. Rocco ◽  
...  
Keyword(s):  
Renal Dysfunction ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Cox Model ◽  
Mortality Rates ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Acute Renal Dysfunction ◽  
Patients With Cancer ◽  
Organ Failures

Purpose To evaluate the outcomes of critically ill patients with cancer and acute renal dysfunction. Patients and Methods Prospective cohort study conducted at a 10-bed oncologic medical-surgical intensive care unit (ICU) over a 56-month period. Results Of 975 patients, 309 (32%) had renal dysfunction and were studied. Their mean age was 60.9 ± 15.9 years; 233 patients (75%) had solid tumors and 76 (25%) had hematologic malignancies. During the ICU stay, 98 patients (32%) received dialysis. Renal dysfunction was multifactorial in 56% of the patients, and the main associated factors were shock/ischemia (72%) and sepsis (63%). Overall hospital and 6-month mortality rates were 64% and 73%, respectively. Among patients who required dialysis, mortality rates were lower in patients who received dialysis on the first day of ICU in comparison with those who required it thereafter. In a multivariable Cox model, age more than 60 years, uncontrolled cancer, impaired performance status, and more than two associated organ failures were associated with increased 6-month mortality. Renal function was completely re-established in 82% and partially re-established in 12%, and only 6% of survivors required chronic dialysis. Conclusion Acute renal dysfunction is frequent in critically ill patients with cancer. Although mortality rates are high, selected patients can benefit from ICU care and advanced organ support. When evaluating prognosis and the appropriateness of dialysis in these patients, older age, functional capacity, cancer status and the severity of associated organ failures are important variables to take into consideration.

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