Summary.Background: Deep vein thrombosis (DVT) is a major complication in intensive care units (ICU) but dedicated guidelines on its management are still lacking. Objectives and Methods: This study investigated the effect of a 1-year educational program for the implementation of DVT prophylaxis on the incidence of inferior limb DVT in a mixed-bed ICU that admits high-risk surgical and trauma patients, investigated during a first retrospective phase [126 patients, SAPS II score 42 (28-54)] and a following prospective phase [264 patients, SAPS II score II 41 (27-55)]. The role of baseline and time-dependent DVT risk factors in DVT occurrence was also investigated during the prospective phase. Results: The educational program on implementation of DVT prophylaxis was associated with a significant decrease in DVT incidence from 11.9% to 4.5% (P < 0.01) and in the mean length of ICU stay (P < 0.01). Combined with pharmacological prophylaxis, the use of elastic compressive stockings significantly also increased in the prospective phase (P < 0.01). The duration of mechanical ventilation, vasopressor administration and neuromuscular block were significantly different between DVT-positive and DVT-negative patients (P < 0.01). Multivariate analysis identified neuromuscular block as the strongest independent predictor for DVT incidence. Conclusion: One-year ICU-based educational programs on implementation of DVT prophylaxis were associated with a significant decrease in the incidence of DVT and also in the length of stay in ICU.
BackgroundThe use of lung ultrasound (LUS) in ICU is increasing but ultrasonographic patterns of lung are often difficult to quantify by different operators. The aim of this study was to evaluate the accuracy and quality of LUS reporting after the introduction of a standardized electronic recording sheet.MethodsIntensivists were trained for LUS following a teaching programme. From April 2008, an electronic sheet was designed and introduced in ICU database in order to uniform LUS examination reporting. A mark from 0 to 24 has been given for each exam by two senior intensivists not involved in the survey. The mark assigned was based on completeness of a precise reporting scheme, concerning the main finding of LUS. A cut off of 15 was considered sufficiency.ResultsThe study comprehended 12 months of observations and a total of 637 LUS. Initially, although some improvement in the reports completeness, still the accuracy and precision of examination reporting was below 15. The time required to reach a sufficient quality was 7 months. A linear trend in physicians progress was observed.ConclusionsThe uniformity in teaching programme and examinations reporting system permits to improve the level of completeness and accuracy of LUS reporting, helping physicians in following lung pathology evolution.
SummaryWe present the case of a healthy young male who developed acute respiratory failure as a result of infection with influenza A ⁄ H1N1 of swine-origin and in whom ventilatory support was optimised and recovery of lung function was monitored by the use of sequential chest ultrasound examinations. The potential pivotal role of bedside lung ultrasonography in H1N1-induced respiratory failure is discussed. Patients affected by the novel swine-origin influenza A ⁄ H1N1 virus can develop an acute alveolar interstitial syndrome. A recent survey of Spanish Intensive Care Units (ICUs) showed that patients requiring ICU admission had a young median age and a relatively high casemortality rate [1]. We present the case of a young healthy male who developed H1N1-induced Acute Respiratory Distress Syndrome (ARDS) and in whom management was guided by daily lung ultrasonography.A 39-year-old man was referred to the Emergency Room of a peripheral hospital with a fever (38.5°C), arthralgia and severe dyspnoea. Over the previous 4 days he had been complaining of mild fever, abdominal pain, nausea, and diarrhoea. He was a heavy cigarette smoker with no significant co-morbidities in his past medical history.At presentation in the Emergency Room the patient was disoriented. He had a systemic arterial pressure of 135 ⁄ 70 mmHg, a heart rate of 140 beats.min )1 , a respiratory rate of 35 breaths.min, and S p O 2 of 77% Arterial blood gas analysis demonstrated: pH 7.46; P a O 2 5.3 kPa with a F I O 2 0.3 (P a O 2 ⁄ F I O 2 ratio of 17.6 (140 if P a O 2 expressed in mmHg)); P a CO 2 4.6 kPa; base excess 1.5 mmol.l )1 and bicarbonate 25 mmol.l )1 . Computed tomography (CT) of the chest showed multiple, bilateral areas of increased lung density (Fig. 1). The patient was sedated, underwent tracheal intubation and his lungs were mechanically ventilated. After 2 h of mechanical ventilation with a F I O 2 of 1.0 and using high inspiratory pressure levels (plateau pressure 47 cmH 2 O, positive-end expiratory pressure (PEEP) 20 cmH 2 O), and with no response to recruitment manoeuvres, blood gas analysis showed a P a O 2 of 21 kPa (P a O 2 ⁄ F I O 2 ratio of 21 (160 if P a O 2 expressed in mmHg)). According to the local protocol for the management of patients with ARDS, the patient was subsequently transferred to our hospital which is the designated referral centre for extracorporeal membrane oxygenation. Following transfer and admission to our ICU, a pulmonary artery catheter was inserted; measurements showed a pulmonary artery wedge pressure of 14 mmHg, confirming the presence of ARDS. A protective lung
This CIRSE Standards of Practice document provides best practices for the safe administration of procedural sedation and analgesia for interventional radiology procedures in adults. The document is aimed at health professionals involved in the provision of sedation and analgesia during interventional radiology procedures. The document has been developed by a writing group consisting of physicians with internationally recognised expertise in interventional radiology, and analgesia and sedation.
Hemodynamic instability associated with acute renal replacement therapy (aRRT, HIRRT) and/or with acute kidney injury (AKI) is frequently observed in the intensive care unit; it affects patients’ renal recovery, and negatively impacts short- and long-term mortality. A thorough understanding of mechanisms underlying HIRRT and AKI-related hemodynamic instability may allow the physician in adopting adequate strategies to prevent their occurrence and reduce their negative consequences. The aim of this review is to summarize the main alterations occurring in patients with AKI and/or requiring aRRT of those homeostatic mechanisms which regulate hemodynamics and oxygen delivery. In particular, a pathophysiological approach has been used to describe the maladaptive interactions between cardiac output and systemic vascular resistance occurring in these patients and leading to hemodynamic instability. Finally, the potential positive effects of aRRT on these pathophysiological mechanisms and on restoring hemodynamic stability have been described.
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