Evaluation and Management of the Polytraumatized Patient in Various Centers
Total Page:16
File Type:pdf, Size:1020Kb
Load more
Recommended publications
-
The Gastrointestinal Tract and Ventilator-Associated Pneumonia
The Gastrointestinal Tract and Ventilator-Associated Pneumonia Richard H Kallet MSc RRT FAARC and Thomas E Quinn MD Introduction The Role of Gastric pH on the Incidence of VAP Enteral Feeding and Nosocomial Pneumonia Gastric Residual Volumes Gastric Versus Post-Pyloric Feeding Acidification of Enteral Feedings Selective Decontamination of the Digestive Tract Microbiologic Ecology of the GI Tract Rationale for SDD Technique Clinical Evidence: Efficacy of SDD SDD and the Incidence of VAP SDD and Mortality SDD in Specific Sub-Groups SDD and ICU Length of Stay, Hospital Costs, and Antibiotic Usage/Costs Unresolved Aspects of SDD Therapy Uncertainties Regarding the Gastropulmonary Hypothesis Uncertainties Regarding Colonization Resistance SDD and Selection for Drug-Resistant Microorganisms Summary and Recommendations The gastrointestinal tract is believed to play an important role in ventilator-associated pneumonia (VAP), because during critical illness the stomach often is colonized with enteric Gram-negative bacteria. These are the same bacteria that frequently are isolated from the sputum of patients with VAP. Interventions such as selective decontamination of the digestive tract (SDD), use of sucralfate for stress ulcer prophylaxis, and enteral feeding strategies that preserve gastric pH, or lessen the likelihood of pulmonary aspiration, are used to decrease the incidence of VAP. A review of both meta-analyses and large randomized controlled trials providing Level I evidence on these topics has led to the following conclusions. First, SDD substantially decreases the incidence of VAP and may have a modest positive effect on mortality. However, there is strong contravening evidence that SDD promotes infections by Gram-positive bacteria. In the context of an emerging public health crisis from the steady rise in drug-resistant Gram-positive bacteria, we cannot endorse the general use of SDD to prevent VAP. -
Severe Sepsis and Septic Shock Antibiotic Guide
Stanford Health Issue Date: 05/2017 Stanford Antimicrobial Safety and Sustainability Program Severe Sepsis and Septic Shock Antibiotic Guide Table 1: Antibiotic selection options for healthcare associated and/or immunocompromised patients • Healthcare associated: intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days, residence in a nursing home or other long-term care facility, hospitalization in an acute care hospital for two or more days within the prior 90 days, attendance at a hospital or hemodialysis clinic within the prior 30 days • Immunocompromised: Receiving chemotherapy, known systemic cancer not in remission, ANC <500, severe cell-mediated immune deficiency Table 2: Antibiotic selection options for community acquired, immunocompetent patients Table 3: Antibiotic selection options for patients with simple sepsis, community acquired, immunocompetent patients requiring hospitalization. Risk Factors for Select Organisms P. aeruginosa MRSA Invasive Candidiasis VRE (and other resistant GNR) Community acquired: • Known colonization with MDROs • Central venous catheter • Liver transplant • Prior IV antibiotics within 90 day • Recent MRSA infection • Broad-spectrum antibiotics • Known colonization • Known colonization with MDROs • Known MRSA colonization • + 1 of the following risk factors: • Prolonged broad antibacterial • Skin & Skin Structure and/or IV access site: ♦ Parenteral nutrition therapy Hospital acquired: ♦ Purulence ♦ Dialysis • Prolonged profound • Prior IV antibiotics within 90 days ♦ Abscess -
From Mechanical Ventilation to Intensive Care Medicine: a Challenge &For Bosnia and Herzegovina
FROM MECHANICAL VENTILATION TO INTENSIVE CARE MEDICINE: A CHALLENGE &FOR BOSNIA AND HERZEGOVINA Guillaume Thiéry1,2,3*, Pedja Kovačević2,4, Slavenka Štraus5, Jadranka Vidović2, Amer Iglica1, Emir Festić6, Ognjen Gajić7 ¹ Medical Intensive Care Unit, Clinical Centre University of Sarajevo, Bolnička , Sarajevo, Bosnia and Herzegovina ² Medical Intensive Care Unit, Clinical Center Banja Luka, Banja Luka, Bosnia and Hercegovina ³ Medical Intensive Care Unit, St Louis Hospital, University Denis Diderot, avenue Claude Vellefaux, Paris, France ⁴ Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Hercegovina 5 Heart Center, Clinical Centre University of Sarajevo, Bolnička , Sarajevo, Bosnia and Herzegovina 6 Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA 7 Division of Pulmonary and Critical Care, Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Mayo Clinic, Rochester, MN, United States * Corresponding author Abstract Intensive care medicine is a relatively new specialty, which was created in the ’s, after invent of mechanical ventilation, which allowed caring for critically ill patients who otherwise would have died. First created for treating mechanically ventilated patients, ICUs extended their scope and care to all patients with life threatening conditions. Over the years, intensive care medicine developed further and became a truly multidisciplinary speciality, encompassing patients from various fi elds of medicine and involving special- ists from a range of base specialties, with additional (subspecialty) training in intensive care medicine. In Bosnia and Herzegovina, the founding of the society of intensive care medicine in , the introduction of non invasive ventilation in , and opening of a multidisciplinary ICUs in Banja Luka and Sarajevo heralded a new age of intensive care medicine. -
Septic Shock V9.0 Patient Flow Map
Septic Shock v9.0 Patient Flow Map Approval & Citation Summary of Version Changes Explanation of Evidence Ratings Patient presents to the ED with fever and/or concern for infection and ED sepsis score ≥ 6 ! BPA fires Use the ED Suspected Septic Shock RN and Well-appearing patients should be placed pathway for all ill on the appropriate ED CSW pathway for Provider appearing patients their underlying condition (e.g. ED No including HemOnc/BMT, Huddle: HemOnc BMT Suspected Infection, ED Central Line Infection Is the patient ill Suspected Central Line Infection, ED and Neonates appearing? Neonatal Fever) Yes ED Septic Shock Pathway • Use ED Suspected Septic Shock Plan • Antibiotics and blood cultures for specific populations included Inpatient Admit Criteria Does NOT meet Inpatient Admit Minute criteria • Resolution of hypotension and no • Admit to ICU ongoing signs of sepsis after ≤ 40 ml / 60 Huddle: YES NO • Follow ICU Septic Shock Pathway kg NS bolus Does patient meet • Use PICU/CICU Septic Shock Admit • First dose antibiotics administered Inpatient admit Plan • RISK to follow criteria? • Antibiotics, blood cultures for specific populations included in sub plans Previously healthy > 30 days RISK RN to follow all • Admit to General Medicine patients admitted with • Follow Admit from ED Septic Shock concern for sepsis Pathway • Use Inpatient Septic Shock Plan ! Concern for evolving sepsis Previously healthy < 30 days Any • Admit to General Medicine admitted • Call RRT or Code Blue • Follow Neonatal Fever Pathway patient with • Follow Inpatient -
Weaning and Discontinuing Ventilatory Support (2002)
Special Articles Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support A Collective Task Force Facilitated by the American College of Chest Physicians, the American Association for Respiratory Care, and the American College of Critical Care Medicine Introduction Pathophysiology of Ventilator Dependence Criteria to Assess Ventilator Dependence Managing the Patient Who Has Failed a Spontaneous Breathing Test Role of Tracheotomy in Ventilator-Dependent Patients The Role of Long-Term Facilities [Respir Care 2002;47(1):69–90] Introduction quickly as possible. Although this process often is termed “ventilator weaning” (implying a gradual process), we pre- The discontinuation or withdrawal process from me- fer the more encompassing term “discontinuation.” chanical ventilation is an important clinical issue.1,2 Pa- tients are generally intubated and placed on mechanical SEE THE RELATED EDITORIAL ON PAGE 29 ventilators when their own ventilatory and/or gas exchange capabilities are outstripped by the demands placed on them Unnecessary delays in this discontinuation process in- from a variety of diseases. Mechanical ventilation also is crease the complication rate from mechanical ventilation required when the respiratory drive is incapable of initi- (eg, pneumonia, airway trauma) as well as the cost. Ag- ating ventilatory activity, either because of disease pro- gressiveness in removing the ventilator, however, must be cesses or drugs. As the conditions that warranted placing balanced against the possibility that premature discontin- the patient on the ventilator stabilize and begin to resolve, uation may occur. Premature discontinuation carries its attention should be placed on removing the ventilator as own set of problems, including difficulty in reestablishing artificial airways and compromised gas exchange. -
Infection in Patients Under Artificial Ventilation
ISSN: 1981-8963 DOI: 10.5205/reuol.3188-26334-1-LE.0704201307 Batista JF, Santos IBC, Leite KNS et al. Infection In patients under artificial… ORIGINAL ARTICLE INFECTION IN PATIENTS UNDER ARTIFICIAL VENTILATION: UNDERSTANDING AND PREVENTIVE MEASURES ADOPTED BY NURSING STUDENTS INFECÇÃO EM PACIENTES SOB VENTILAÇÃO ARTIFICIAL: COMPREENSÃO E MEDIDAS PREVENTIVAS ADOTADAS POR ESTUDANTES DE ENFERMAGEM INFECCIÓN EN LOS PACIENTES POR VENTILACIÓN ARTIFICIAL: COMPRENSIÓN Y MEDIDAS PREVENTIVAS ADOPTADAS POR ESTUDIANTES DE ENFERMERÍA Joyce Ferreira Batista1, Iolanda Beserra da Costa Santos2, Kamila Nethielly Souza Leite3, Ana Aline Lacet Zaccara4, Smalyanna Sgren da Costa Andrade5, Sergio Ribeiro dos Santos6 ABSTRACT Objective: to investigate the understanding of nursing students about the prevention of infection in patients under artificial ventilation in the Intensive Care Unit (ICU). Method: an exploratory field study with a quantitative approach. 30 students participated. It was used a questionnaire to collect the data that were then processed and analyzed manually, from statistical software, with results shown in tables and figures. The research project was approved by the Ethics Committee in Research, with CAEE 0539.0.126.000-10. Results: 67% did not attend patients suffering from hospital infections. It was mentioned as preventive measures: 28 (24%), the education of the healthcare team, 10 (23%) cited the use of aseptic techniques, 9 (20.0%) say they do not know what actions should be taken. Conclusion: the study showed that the majority of the students cited as preventive measures the continuous education in service and the use of aseptic techniques. Descriptors: Nursing Students; Infection; Intensive Care Units. RESUMO Objetivo: investigar a compreensão de estudantes de enfermagem sobre a prevenção de infecção em pacientes sob ventilação artificial na Unidade de Terapia Intensiva (UTI). -
Shock and Hemodynamic Monitoring
Shock and Hemodynamic Monitoring Matthew Bank, MD, FACS Assistant Professor Hofstra North Shore‐LIJ School of Medicine Director, Surgical Intensive Care Unit North Shore University Hospital I do not have any financial conflicts of interest to disclose for this presentation Shock • Multiple different strategies for classifying shock, but all forms of shock result in impaired oxygen delivery secondary to either one or both: – reduced cardiac output (cardiogenic, septic) OR – loss of effective intravascular volume (hypovolemic, neurogenic, anaphylactic, septic). Septic Shock –Gram Negative • Gram negative septic shock: —Very studied well studied in animal models —Lipopolysaccharide (LPS) in bacterial cell wall binds to LPS binding protein. —LPS‐LBP complex then binds to cell surface CD14 receptors on monocytes and macrophages. —The LPS‐LBP‐CD14 complex then activates cells via Toll‐like receptor‐4 (TLR4). —TLR4 then “activates” cells which produce a cytokine “cascade” of proinflamatory mediators. Septic Shock –Gram Negative • Tumor Necrosis Factor (TNF) – First cytokine produced in response to gram negative sepsis – Principal mediator for acute response to gram negative bacteria – Major source of TNF is from activated macrophages – High levels of TNF predict mortality and can cause apoptosis. Septic Shock –Gram Negative • Interleukin‐1 (IL‐1) – Levels of IL‐1 increase soon after TNF production in gram negative sepsis (second cytokine to be elevated) – IL‐1 produced by macrophages, neutrophils and endothelial cells – IL‐1 increases levels of next proinflammatory cytokines in cascade, IL‐2 and IL‐12. – IL‐1 does NOT cause apoptosis Septic Shock –Gram Negative • Interleukin‐10 – Anti‐inflammatory cytokine – Inhibits production of IL‐12 – Inhibits T‐cell activation Septic Shock –Gram Positive • Gram positive sepsis – Gram positive cell wall components are also known to be involved in septic response – Peptidoglycans – Teichoic Acid – Likely act in a similar manner as LPS, but less potent on a weight bases. -
Pneumonia in the Context of Severe Sepsis: a Significant Diagnostic Problem
-1 plasma D-dimer level was low (282 mg?L ). Chest radiography affected by antiphospholipid antibodies syndrome and showed multiple ill-defined increased densities in both lower avoided diagnostic surgery. lung fields. High-resolution computed tomography was then In conclusion, we believe that the indications for use of performed and showed ill-defined, wedge-shaped increased endobronchial ultrasound are manifold and are certainly densities with patent airways in the posterior subpleural greater than those so far recognised. This procedure should regions of both lower lobes. The computed tomography therefore be implemented and further developed in interven- differential diagnosis was organising pneumonia, bronchop- tional pneumology. neumonia, Churg–Strauss syndrome, Wegener granulomato- sis, pulmonary haemorrhage, or vasculitis of various causes. Transbronchial lung biopsy was performed in the right lower G.L. Casoni, C. Gurioli, M. Romagnoli and V. Poletti lobe. Microscopic examination showed alveolar haemorrhage Thoracic Dept, G.B. Morgagni Hospital, Forlı´, Italy. without evidence of vasculitis, eosinophilic infiltration or organising pneumonia. Serum circulating antiphospholipid STATEMENT OF INTEREST antibodies were eventually found. Therefore, pulmonary None declared. angiography was performed and an intra-arterial low density was found in the right main pulmonary artery. This finding SUPPLEMENTARY MATERIAL was believed to be compatible with pulmonary thrombo- This article has supplementary material accessible from embolism; however, it didn’t exclude a possible right www.erj.ersjournals.com pulmonary artery sarcoma. In this case, the only procedure that would rule out the presence of a right pulmonary artery sarcoma (without delays in diagnosis) with any reasonable REFERENCES certainty was surgery. 1 Herth F, Becker HD, LoCicero J 3rd, Ernst A., Endobronchial We decided to perform rigid bronchoscopy under general ultrasound in therapeutic bronchoscopy. -
Evidence on Measures for the Prevention of Ventilator-Associated Pneumonia
Eur Respir J 2007; 30: 1193–1207 DOI: 10.1183/09031936.00048507 CopyrightßERS Journals Ltd 2007 REVIEW Evidence on measures for the prevention of ventilator-associated pneumonia L. Lorente*, S. Blot# and J. Rello",+ AFFILIATIONS ABSTRACT: Ventilator-associated pneumonia (VAP) continues to be an important cause of *Intensive Care Unit, Hospital morbidity and mortality in ventilated patients. Universitario de Canarias, La Laguna, Evidence-based guidelines have been issued since 2001 by the European Task Force on Tenerife, "Intensive Care Dept, Joan XXIII ventilator-associated pneumonia, the Centers for Disease Control and Prevention, the Canadian University Hospital, and Critical Care Society, and also by the American Thoracic Society and Infectious Diseases Society +University Rovira i Virgili Medical of America, which have produced a joint set of recommendations. School, Pere Virgili Health Institut, The present review article is based on a comparison of these guidelines, together with an Tarragona, Spain. #Critical Care Dept, Ghent University update of further publications in the literature. The 100,000 Lives campaign, endorsed by leading Hospital, Ghent, Belgium. US agencies and societies, states that all ventilated patients should receive a ventilator bundle to reduce the incidence of VAP. CORRESPONDENCE The present review article is useful for identifying evidence-based processes that can be L. Lorente Intensive Care Unit modified to improve patients’ safety. Hospital Universitario de Canarias C/ Ofra s/n KEYWORDS: Ventilator-associated pneumonia La Laguna Tenerife 38320 entilator-associated pneumonia (VAP) tracheal suctioning system’’, ‘‘open tracheal Spain Fax: 34 22662245 suctioning system’’, ‘‘change of closed tracheal continues to be an important cause of E-mail: [email protected] V morbidity and mortality in critically ill suctioning system’’, ‘‘sterilization’’, ‘‘disinfec- patients [1–3]. -
What Is Sepsis?
What is sepsis? Sepsis is a serious medical condition resulting from an infection. As part of the body’s inflammatory response to fight infection, chemicals are released into the bloodstream. These chemicals can cause blood vessels to leak and clot, meaning organs like the kidneys, lung, and heart will not get enough oxygen. The blood clots can also decrease blood flow to the legs and arms leading to gangrene. There are three stages of sepsis: sepsis, severe sepsis, and ultimately septic shock. In the United States, there are more than one million cases with more than 258,000 deaths per year. More people die from sepsis each year than the combined deaths from prostate cancer, breast cancer, and HIV. More than 50 percent of people who develop the most severe form—septic shock—die. Septic shock is a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection. Who is at risk? Anyone can get sepsis, but the elderly, infants, and people with weakened immune systems or chronic illnesses are most at risk. People in healthcare settings after surgery or with invasive central intravenous lines and urinary catheters are also at risk. Any type of infection can lead to sepsis, but sepsis is most often associated with pneumonia, abdominal infections, or kidney infections. What are signs and symptoms of sepsis? The initial symptoms of the first stage of sepsis are: A temperature greater than 101°F or less than 96.8°F A rapid heart rate faster than 90 beats per minute A rapid respiratory rate faster than 20 breaths per minute A change in mental status Additional symptoms may include: • Shivering, paleness, or shortness of breath • Confusion or difficulty waking up • Extreme pain (described as “worst pain ever”) Two or more of the symptoms suggest that someone is becoming septic and needs immediate medical attention. -
Posttraumatic Stress Disorder (PTSD)
Child and Adolescent Psychiatry and Mental Health BioMed Central Research Open Access Posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment compared to children who survived a major fire disaster Madelon B Bronner*1, Hendrika Knoester2, Albert P Bos2, Bob F Last1,3 and Martha A Grootenhuis1 Address: 1Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands, 2Department of Paediatric Intensive Care, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands and 3Department of Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands Email: Madelon B Bronner* - [email protected]; Hendrika Knoester - [email protected]; Albert P Bos - [email protected]; Bob F Last - [email protected]; Martha A Grootenhuis - [email protected] * Corresponding author Published: 20 May 2008 Received: 23 January 2008 Accepted: 20 May 2008 Child and Adolescent Psychiatry and Mental Health 2008, 2:9 doi:10.1186/1753-2000-2-9 This article is available from: http://www.capmh.com/content/2/1/9 © 2008 Bronner et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The goals were to determine the presence of posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment, to identify risk factors for PTSD, and to compare this data with data from a major fire disaster in the Netherlands. -
Guidelines for Preventing Health-Care-Associated Pneumonia, 2003
GUIDELINES FOR PREVENTING HEALTH-CARE-ASSOCIATED PNEUMONIA, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee Accessible version: https://www.cdc.gov/infectioncontrol/guidelines/pneumonia/index.html Prepared By: Ofelia C. Tablan, M.D.1 Larry J. Anderson, M.D.2 Richard Besser, M.D.3 Carolyn Bridges, M.D.2 Rana Hajjeh, M.D.3 1Division of Healthcare Quality Promotion, National Center for Infectious Diseases , CDC 2Division of Viral and Rickettsial Diseases, NCID, CDC 3Division of Bacterial and Mycotic Diseases, NCID, CDC The material in this report originated in the National Center for Infectious Diseases, James M. Hughes, M.D., Director, Division of Healthcare Quality Promotion, Denise M. Cardo, M.D., Director, and the Division of Bacterial and Mycotic Diseases, Mitchell L. Cohen, M.D., Director. HEALTHCARE INFECTION CONTROL PRACTICES ADVISORY COMMITTEE Chair: Robert A. Weinstein, M.D., Cook County Hospital, Chicago, Illinois Co-Chair: Jane D. Siegel, M.D., University of Texas Southwestern Medical Center, Dallas, Texas Executive Secretary: Michele L. Pearson, M.D., CDC, Atlanta, Georgia Members: Raymond Y.W. Chinn, M.D., Sharp Memorial Hospital, San Diego, California; Alfred DeMaria, Jr., M.D., Massachusetts Department of Public Health, Jamaica Plains, Massachusetts; Elaine L. Larson, R.N., Ph.D., Columbia University School of Nursing, New York, New York; James T. Lee, M.D.,Ph.D., Veterans Affairs Medical Center, University of Minnesota, St. Paul, Minnesota; Ramon E. Moncada, M.D.,Coronado Physician’s Medical Center Coronado, California; William A. Rutala, Ph.D.; University of North Carolina School of Medicine, Chapel Hill, North Carolina; William E.