BackgroundAcetaminophen is a common cause of acute liver failure in pediatrics. Cerebral edema is a significant complication of acute hepatic failure and is associated with increased mortality.Case presentationWe present a case of a 13 -year old girl with severe cerebral edema secondary to acetaminophen toxicity and hepatic failure. Her poor neurological status precluded her from liver transplantation and withdrawal of life sustaining treatment was recommended. However, with supportive care, she remarkably made a full recovery.ConclusionsThis case highlights the difficulties surrounding prognostication in pediatric patients with cerebral edema from acute liver failure secondary to acetaminophen toxicity.
Objective: Evidence-based guidelines recommend promoting sleep in the Intensive Care Unit (ICU), yet many patients experience poor sleep quality. We sought to engage allied health staff and patient families to determine barriers to sleep promotion, to measure sleep quality for ICU patients, and to evaluate the improvement in sleep quality after implementation of nursing morning report protocol and a doorway poster. Design: The study followed an interrupted time-series framework of quality improvement. Qualitative diagnostics included focus groups and interviews with patients, families, and allied health care workers, analyzed by qualitative descriptive analysis. Quantitative diagnostics included direct observation of nurses and patients overnight. Analysis of primary outcome data used statistical process control methodology. Patients: Patients included were >18 years old, admitted overnight to a Canadian tertiary academic ICU, with a Richards Agitation Sedation Scale (RASS) ≥−2. Interventions: Sleep quality was measured using the Richards Campbell Sleep Questionnaire (RCSQ). Two interventions were developed: sleep quality in morning nursing report, and a doorway poster. Main results: A total of 2332 patient nights across 7 consecutive months were included for analysis. Baseline sleep in the ICU was poor (mean RCSQ 53.7/100). Root cause-analysis identified the most prominent sleep barriers as nurse stigma associated with less active management of patients and lack of physician engagement. No significant improvement occurred over the sleep quality improvement initiative (mean RCSQ 59.5/100). Sleep quality was better among non-delirious patients compared with delirious patients (mean RCSQ 62.7 vs 53.3). Conclusion: The intervention of a nursing morning report protocol and sleep posters did not improve the quality of ICU patient sleep in this study. Structured interviews revealed potential sleep barriers to be addressed such as nursing stigma and inappropriate awakenings. Nursing stigma has not been previously linked to sleep quality.
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Technical proficiency Minimum performance criteria for acquisition and interpretation. All studies overseen by CCUS program director Optional: Identification of specific examinations that may be challenged (i.e., ARDMS, NBE) Minimum 250 performed and interpreted/ 6 months Core CCUS applications including CCE, thoracic, abdominal, vascular, and procedural guidance Minimum 500 performed and interpreted/ 12 months Core ? additional modalities (i.e., advanced TEE, transcranial Doppler) Quality assurance Administrative duties including quality assurance of CCUS resident rotator scans. Provide real-time assistance to residents learning CCUS Set minimum QA 250/ 6 months Weekly QA rounds Set minimum QA 500/ 6 months Weekly QA rounds Education Participation in postgraduate CCUS education Additionally, identify optimal educational materials including courses, modules, textbooks Facilitate or participate in: Bedside rounds with students/ residents National CCUS training courses Resident academic half day Ultrasound conferences Ultrasound journal club Curriculum and resource design and development Dedicated self-study Administrative Training on program administration, delivery and development of academic deliverables Facilitate: Competency-based assessments of trainee performance. Participate in CCUS program design and evaluation activities Research Research requirement in the area of CCUS flexible depending on time and long-term goals Case report publication Design of an original project or systematic review
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