Science topic

ICU - Science topic

An Intensive Care Unit (ICU), also known as a Critical Care Unit (CCU), Intensive Therapy Unit or Intensive Treatment Unit (ITU) is a special department of a hospital that provides intensive-care medicine. Intensive Care Units cater to patients with the most serious injuries and illnesses, most of which are life-threatening and need constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions.
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Hi everyone,
ICU nursing staffing's impact on patient (and other) outcomes is well documented in the literature. Nonetheless, methods (e.g. Nursing activities score) have been criticized during the last decade for not including several aspects of the nurse's work besides bedside duties.
Currently, which would be the most valid approach /tool to objectively estimate nursing staffing?
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Cristobal,
it depends on what you are most interested in. There are scores and ways for assessing workload in bedside nursing that accounts for physical and cognitive workload. Look at work by Heather Tubbs-Cooley. Also, make sure you are looking at the right measures. As I’m sure you know, tools to assess staffing models are not the same as nursing workload. I have partnered with nurse scientists at Emory to look at a combination of metrics, but it also depends on the question you are asking. Hope this helps. Feel free to DM me if you want to discuss further
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I am working on a model to capture data from monitors in ICU and send it to doctors if their patients were in danger
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Thank You Very much Dr/
Pierre-Henri Moury
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Hello. For our research study on determining laboratory tests which has prognostic values in COVID-19 ICU patients, we divided our data from admission, 3-5 days hospitalization, and composite endpoint. Do you have literatures that may help us address the problem wherein 2 or more values are performed in the admission. We wanted to only record one data for this. Do you have literature that says we can get its mean, or probably get the earliest or the most recent value? Thank you
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some study choose using the worst value in the first 24h of admission
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The question I am trying to solve for my graduate assignment.
I have a group of people (Doctors, nurses, and other providers in the hospital, who were trained by a team of non-specialists ( pre-group) and a group that a specialist trained ( post group) on how to treat alcohol withdrawal in the hospitalized patient effectively. Both pre and post group used the same tool (scale from 1-67—the higher the number, the more severe the withdrawal. I divide the CIWA score into a range: Mild moderate. Severe and extreme. (AWS severity) . The nurse in the hospital assesses the patient in the hospital with the CIWA score. If higher than 7, the nurse calls the doctor, and medicine is prescribe. There is a policy for this. The assumption is that the earlier you treat, the less possibility of severe withdrawal, as evidence by the lower Ciwa number, throughout the patient's hospital stay. If the patient continues to have scores higher than16, the patient is transferred to the Intensive care unit (ICU) from the non-icu floor ( Medsurg).
I would like to see if a standardized training of the alcohol withdrawal protocol at a local hospital, improve patient outcomes ( decrease worsening of AWS symptom), as evidenced from CIWA score (range); decrease ICU upgrades; decrease the length of stay (LOS) compared to a non-standardized training of the CIWA protocol? (Pre and post)
CIWA scoring. Mild ( 1-8) Moderate (10-15); Severe (16-21). (22-67) extreme. All coded in SPSS with numerical value 0,1,2, etc.
The issue: I imported the data from Excel in the statistical program IBM-SPSS using either the independent t-test, Mann-Whitney you test, or a few, which all failed the analysis.
My professor wrote me this.
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The outcome variables for CIWA scoring are ordinal, not continuous, so you’d want to use an ordinal logistic regression. The model would have a score as the dependent variable and CIWA (pre vs. post) as the independent variable. Exponentiate the slopes with 95% of their CI, and you'll have the odds ratios (and 95% CI) that reflect the fold-increased probability of going to a higher level on the ordinal scale after the CIWA training. Make sure that proportionality assumption holds for your fit model, and if it doesn’t, use multinomial logistic regression instead that considers these as categorical variables but is less powerful.
Upgrades to ICU are binomial outcomes, so they would be analyzed using standard logistic regression. Upgrade Y or N) would be the outcome, and CIWA would be the independent variable
Length of stay is an integer type value and can be analyzed with several techniques but I’d use quantile regression and report the data as medians and ranges.
Frequency (or contingency) tables where the data are strictly categorical can be analyzed using Chi^2 test or (or Fisher’s exact test if the expected frequency of a cell is less than five and it’s a 2x2 table). Still, I find these analyses not to be as helpful as regression techniques. Such tests give the same results as regression techniques. Still, they only tell you that the counts are not distributed randomly across the table, and it can be hard to explain how they differ (regression methods tell you that they differ and by which variables).
Even though means could work, I would still use medians and ranges to describe length of stay because that is an integer variable that is measured in whole numbers. If no one staying for part of a day, when you average the results you'll get things like cases differed from control by .234 days (P = 0.02) that are hard to interpret. Medians are also less affected by extreme values than means so that 1 patient that stays won't have as much influence as they would otherwise.
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Using Chi^2 test to compare different CIWA scoring level between pre and post group. You can try to compare means of CIWA scoring between pre and post group also, treating CIWA scoring as an integer type variable (1-67).
Your professor's opinions are quite correct. You can try ordinal logistic regression, logistic regression, and quantile regression to validate your three research objectives separately.
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I would also like to know how far is it possible to follow the principles of ABS using pharmacokinetic & Pharmacodynamic model in ICU ?
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Every hospital should have dedicated staff to implement and monitor antibiotic stewardship policies,
The empiric antibiotic prescriptions should be based on hospital wide written antibiotic policy
And escalation should require preauthorization.
In the absence of superspecialist ID personel, ICU doctors and nurses should follow rational Antibiotics policies to curb overuse and Antimicrobial resistance.
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I was asked to give suggestions for the equipment list for ICU up-gradation. The ICU shall be catering to predominantly medical and mostly respiratory cases. I could think up of NAVA ventilators, Esophageal pressure monitors, and stuff. Although I am not sure of the cost-benefit ratio of NAVA ventilators. Could I get some suggestions on cutting-edge tech for a majorly respiratory ICU?
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HFNC,CPAP
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I am a Neonatal Sister who is collating a file on Nutrition and Hydration for use in a Neonatal Unit that admits from 23 weeks gestation. Do you have any helpful info for me?
Thank you so much
Su Samuels
Feeding Lead Nurse
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We font have TPN in iraq unfortunatly
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We are all living in a strange era since last year due to the pandemic of COVID-19, so we are all seeking to find the truth about basic parameters of it.
As everybody knows, any research needs reliable data, so we need data.
But, despite the plethora of available online sets, the critical ones are not always presented publicly.
For example in Greece we do not have online data for next categories, all related to COVID-19:
  • daily confirmed cases by vaccination status (vaccinated-partially vaccinated-non vaccinated)
  • daily deaths by vaccination status (vaccinated-partially vaccinated-non vaccinated)
In Greece we do not have also next data online:
  • number of patients in simple hospital beds or in ICU by vaccination status (3 cases)
  • deaths of patients in simple hospital beds or in ICU by vaccination status (3 cases)
The only available set was next:
The webpage is down, but you can see its cached version by Google:
Recently a paper about inside and outside ICU mortality was published with correspondent author having next past jobs
  • 2020-02 to 2020-08 | Head of Department (Department of Database Design, Statistics and Data Management)-National Public Health Organization
  • 2019-05 to 2020-02 (Office of Scientific Advisors)-National Public Health Organization
  • 2017-01 to 2019-05 (Office of Scientific Advisors)-Hellenic Centre for Disease Control and Prevention
  • 2014-04 to 2017-01 (Department of Epidemiological Surveillance and Intervention)-Hellenic Centre for Disease Control & Prevention
(All those jobs were at the same Organization, now called "EODY", which is the Greek CDC for all of you that you do not know the Greek reality)
Now we find a paper that uses detailed data from all ICU in Greece.
  • Where is the raw data used for that?
  • Why nobody else has access to that?
  • Is it coming from a Public Organization or not?
Not to make you tired:
  1. Do you think it is ethical for a scientist to use its exclusively access to COVID-19 data set for making private scientific research?
  2. Do you agree that all data for COVID-19 that wre collected from public authorities should be open accessed by anyone online?
Thank you for your patient to read such a big test,
I am waiting for your thoughts,
Demetris
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Unfortunately for a western country that declares its pride for inventing Democracy, COVID-19 and other critical data sets are not transparent.
They are eligible to be distributed only for the "inner circle" of chosen ones...
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Considering the huge oxygen supply shortages specially during Covid 19 pandemic, breathing circuit which consumes less oxygen and meets the patient's needs for oxygen is something which we should be looking forward to. We have used circle system for decades in operation theatres and we are now becoming more and more trained in using low flow Anesthesia with the help of Co2 canister and scavenging system. This helps for environment of it room as well. Even modern ICU ventilators don't have a scavenging system and depletes a large amount of oxygen from hospital source.
This is why what occured to my mind as why not incorporate the circle system with scavenging into the ICU ventilators itself with some modifications which could suit for the ICU ventilator.
Limitations:-
1) there can be some modes of ventilating the patient in ICU ventilators in which circle system may not be useful, however with required modifications to suit a the modes it can be made.
This needs a good clinical engineer who understands the parts and physiology of how machines and breathing system of a human body works. This sure would be a great idea to work upon which could reduce the oxygen consumption significantly. This is because most ICU ventilators at minimum use 7-8 litres per minute of oxygen whereas Anesthesia ventilators with the help of closed circle breathing system , oxygen consumption can be used to a minimum of 1-2 litres per minute. This happens due to exhaled gas from the patient passing through the canister containing co2 absorber such as soda lime and the same gas is rebreathed by the patient.
In conclusion, incorporating closed circle system in the modern ICU ventilators is something to look forward to in the context of eye opening oxygen shortages happening in this COVID 19 crisis.
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Using a circle breathing circuit in critically ill patients must be carefully considered. Most operations under general anaesthesia are relatively short, lasting a few hours at most. Critically ill patients may be ventilated for days to weeks. In this context there are potential benefits of rebreathing exhaled gases. However, rebreathing of exhaled toxins such as carbon monoxide may be problematic with prolonged use of a circle circuit.
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I have been active in a European research project the VIP= Very old Intensive care Patients and since the start of the pandemic we have had a prospective study running in elderly COVID-19 patients in the ICU. We constantly have been surprised by the lack of good evidence for core issues in intensive care for the elderly, and suggested a research agenda back in 2017 (https://doi.org/10.1007/s00134-017-4718-z). Our task has first and foremost been concentrated on various outcomes and explanatory variables. We have recently also started to find peculiar trends in the treatment of the elderly Covid-19 patients. Our data suggested that they had en excess mortality during the second surge, and also that it seems that systemic steroids given to this group may result in increased mortality, on contrast to the less old COVID-19 patients. It would be good to start a discussion about this, and feel free to comment and suggest other issues related to this topic.
You can also have a look at our web-page if you are interested in contribute (https://vipstudy.org/)
Hans Flaatten
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Revered Professor Dr.Hans Flaatten,
Of course, this is mandatory for the elderly people who needs special ICU facilities during COVID 19 pandemic period because they might have inherited diseases in the body decline the immune power.
It is to considered for the aged people need to have a specialized facilities in the hospital.
Very few old people have good health might have affected due to COVID 19 but they should have to go under treatment with ICU including serious medical attention for them.
My answer may be general but it supports the medical care and treatment for aged ones should have to assist for everyone.
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For the acute resuscitation of adults with COVID-19 and shock, the current recommendations are suggesting, using buffered/balanced crystalloids over unbalanced crystalloids.
The purpose of this discussion is address the need for guidance on fluid resuscitation among severe COVID-19 patients and shock management in resource-limited settings
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Fluid management is a very complex issue.
There are many confounding factors including co-morbidities such as heart failure, liver disease and renal impairment.
It is important that management is individualised on a case by case basis.
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I have tried to install phyloseq in R 4.0.1. I checked my packages and could see it but when l try to import_mothur l get this error:
Error: package or namespace load failed for ‘phyloseq’ in inDL(x, as.logical(local), as.logical(now), ...):
ICU init failed: U_FILE_ACCESS_ERROR
In addition: Warning message:
package ‘phyloseq’ was built under R version 4.0.3
Could anyone help me with this issue.
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I recommend updating R to the the last stable version (4.1.1) and then running the following code
if (!requireNamespace("BiocManager", quietly = TRUE)) install.packages("BiocManager") BiocManager::install("phyloseq")
It should run import_mothur() without errors.
Best wishes,
Francesco
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In Germany the minister of Health wants to drop the incedence, the number of new infect Io ns per 100 thousand people, as the major indicator to take policy decisions to contain the pandemic in Germany. The president of the RKI has protested to do this.
Who is right?
I think the incedence is still an important leading indicator to judge the actual development. The attempt to replace it by the share of ICUs occupied by coronavirus patients is wrong.
First, the is a lagging indicator compared to the current incidence. Causality runs from infections toward hospitalizations not the other way round.
It is true in particular through vaccinations over time the relation between both indicators has changed, but this could be modelled using Kalman-Filtering techniques including variable coefficients.
Using such estimates to predict the future share of ICUs occupied by the corona-patients would be more efficient than just looking at the actual ICU shares.
What do you think?
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Hi Georg Erber . I think it is a very complicated issues come together. If you want to fix one , the other one will break . I think the best solution is to make optimization among these different issues.
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Patient's with chronic liver diseases who get admitted due to decompensation, have a grim path down the line. There is just worsening of scores as the time pass by & then the mortality hits them inspite of active interventions. Can we downgrade the scores in this population who get hospitalized within an ICU setting, (not undergoing any surgery) with any specific goal-directed targets that improve their survival rates?
Evidence :
The 3-month mortality for hospitalized patients not undergoing surgery was 4% for Child A, 14% for Child B, and 51% for Child C. A MELD score of 25 was associated with 30-day mortality of 50%.
Current evidence on goal-directed targets in Anaesthesia as part of Pre-operative care : Medical management undertaken to optimize cirrhotic patients undergoing surgery is usually directed toward treating active infection, optimizing central blood volume and renal status while minimizing ascites, and improving encephalopathy and coagulopathy. However, there is little evidence to support specific goal-directed targets for preoperative care.
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Given that PFT's have a diurnal variation, can this data be extrapolated or inferred akin to saying that diaphragm parameters also have diurnal variation? If so, wouldn't our choice to choose sedation drugs say in an ICU setting, would differ based on the duration of the day considering human's circadian rhythm?
Main Article : Borsboom GJ, van Pelt W, van Houwelingen HC, van Vianen BG, Schouten JP, Quanjer PH. Diurnal variation in lung function in subgroups from two Dutch populations: consequences for longitudinal analysis. Am J Respir Crit Care Med. 1999 Apr;159(4 Pt 1):1163-71. doi: 10.1164/ajrccm.159.4.9703106. PMID: 10194161.
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Yes, of course,because they are subjected - like so many other things in human physiology - to circadian cycles or the like.
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Common sense suggests that quarantine centers or ICU's where COVID patients are being treated have a high probability of transmission of virus especially to those providing assistance (doctors and nurses). My question here is there a measure to qualitatively or quantitively describe the air ( primary source of the virus spread) quality like PPM. If so how is the air quality in COVID affected areas different from COVID ICU's and how does it compare to COVID free areas. Can anyone please provide information or relevant literature on this topic.
Thanks in advance.
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Based on the data presented at the following site
we see that there are roughly two hundred quadrillion (2x10¹⁷ or two hundred million billion) virus particles in the world at any one time.
The back of the envelope estimates based on the above approximate number can easily give you the answer about the concentrations at the specific places such as medical centers.
For a more precise data please see also
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Seizures are fascinating intellectually, but they can be devastating for the person suffering from them. We have all heard stories of young people who seemingly have no genetic or other past medical history and present to the Neurological ICU in status epilepticus -- an entity known as NORSE. All our algorithms fail and we are left scrambling for effective approaches without any evidence. Often, despite our best interventions, these young healthy patients have >35% mortality rate. And those that survive rarely make it past the SNF.
We have one such patient in our Neurological ICU currently. So I wanted to ask what you guys do when the standard treatments have failed? Per the American Epilepsy Society guidelines, we initially treated her status with Ativan, Midazolam, Keppra loads, Vimpat loads, Fosphenytoin loads, Versed drips, and finally Pentobarbital coma. Currently she is on Keppra, Vimpat, Fosphenytoin, Felbamate, Epidiolex, and Fycompa. Thankfully the Pentobarbital is now off, but she continues to require continuous Versed drip.
In your experience, have you found anything effective in these situations?
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Amit Chaudhari last resort: pentobarbital and thiopental sodium. Unfortunately, majority of the physicians carry out the same management as you mentioned.
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SARS COV2 while still burning through the US, we and other nations have researched practically every topic that this Virus could have. Everything from the Spike Protein on the surface binds to our ACE2-R to the Disseminated Intravascular Coagulation, also known as (DIC). One of the research topics that caught my eyes was the Comorbidities leading to serious outcome cases and unfortunately death.
Mississippi Statistical data shows the number one cause for serious complications and is common comorbidity is Hypertension (HTN) and related cardiovascular disease (CVD), (MSDH, 2021). That said, the problem surrounding HTN and CVD is the increased expression of ACE2-R, thus leaving subjects with increased susceptibility to not only more infection but certainly increased shedding of the virus. This overexpression of ACE2-R is a popular subject in many think tanks and schools of thought.
One would surmise that other comorbidities would have similar if not worse increases in ACE2-R in SARS COV2 infection. Asthma and Chronic Obstructive Pulmonary Disease (COPD), in particular, has a risk in that the pulmonary system is compromised pre-infection which you would think would be a good predictor of severe case outcomes and death. Researchers from the Journal of Immunology and Clinical Immunology found that indeed this was not the case. Interestingly, asthma, COPD, inhaled corticosteroid treatment, and oral corticosteroid treatment were not independent risk factors for ICU admission or death, (Calmes, 2021). Please read the Journal Articles below for your enhanced SARS COV2 knowledge and education.
References:
Calmes, D., Graff, S., Maes, N., Frix, A. N., Thys, M., Bonhomme, O., Berg, J., Debruche, M., Gester, F., Henket, M., Paulus, V., Duysinx, B., Heinen, V., Dang, D. N., Paulus, A., Quaedvlieg, V., Vaillant, F., Van Cauwenberge, H., Malaise, M., Gilbert, A., … Schleich, F. (2021). Asthma and COPD Are Not Risk Factors for ICU Stay and Death in Case of SARS-CoV2 Infection. The journal of allergy and clinical immunology. In practice, 9(1), 160–169. https://doi.org/10.1016/j.jaip.2020.09.04
Nawijn, M. C., & Timens, W. (2020). Can ACE2 expression explain SARS-CoV-2 infection of the respiratory epithelia in COVID-19?. Molecular systems biology, 16(7), e9841. https://doi.org/10.15252/msb.20209841
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I agree with your statement. I still would not like to find out personally as i am an asthmatic.
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best method to control Mucor mycosis at a ICU set up especially is cases of COVID19 patients?
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Depends on how early the disease can be been picked up. Mucor in COVID 19 patients develop due to multiple reasons- sudden rise in blood sugar and development of diabetic ketoacidosis , deranged iron metabolism, high dose of steroids comprosing the immune system.
Few studies have shown that mucor are present in improperly cleaned bed linen and has been responsible for mucor outbreaks in the past.
Prophylactically the use of steroids and monitoring of blood sugars must be done very carefully. Few guidelines have also been formulated for keeping in check the surge of blood.
Many believe that contaminated oxygen masks and humidifiers also act as a source of mucor. Making it a communicable disease amongst immunocompromised patients. In developing countries the use of tap water as humidifying agent may be another source of mucorales. Few have advocated methylene blue dye in the humidifier to stop fungus.
Ideally all high risk patients- diabetic, those with fluctuating blood sugars, chronic debilitated, history of transplant and receiving O2 therapy should be screened for early signs of Mucor on a regular basis.
Once the disease sets in and reaches the orbit its very difficult to manage even with Amphotericin B or posaconazole and most require surgical debridement with or without exenteration.
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A comparison between Thoracic epidural, Intercostal nerve block and Paravertebral nerve block in terms of their limitation, efficacy, side effects etc.
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Thoracic epidural is superior among all..
Erector spinae plane block is more safer than Paravertibral block ...
SAP block serratus anterior plane block also a safer option...
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ICU patients who are receiving invasive mechanical ventilation and noninvasive ventilation often require sedation and analgesia. COVID-19 pneumonia / ARDS induced acute respiratory failure patients are not indifferent in this aspect. Sometimes, it also feels that these patients need more sedation, even on NIV. I shall be delighted to know the sedation practices, drugs, single or combinations you are using in your set-up.
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Dead high: Until I contracted Covid-19 myself, I have been in command of a Covid Care Unit (vaccinating, treating patients with it at all levels and, of course, sedating myself -both to intubate , as in sedation in Palliative Care -PC- including deep and irreversible sedation, if necessary, and with all the legal and bioethical guidelines required).
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What is your practice/research reading about Early Vs. Late Intubation in COVID-19 Patients? how you define early vs. late? Is there any evidence to intubate early to save lives in COVID-19 patients?
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Depending on the patient's condition, their oxygenation levels, etc. There cannot be a single and standard answer without analyzing each patient ... but, even if this patient needs help in his breathing, it is not the same "glasses" for oxygen -introduced through the endonasal route-, than intubation and oxygen cylinder : THERE ARE SICK, NO ILLNESS!
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Hello. The circadian-clock mechanisms must still be working in some way in the intensive care unit (ICU) or critical care unit (CCU) for patients with Covid-19.
What can be recommended in relation to the management of light/darkness in these patients to improve their recovery (e.g. covering the eyes periodically, circadian stimulation/non-stimulation)?
Thank you for your kind opinion or advice.
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I think inside the brain peace are necessary. Cells at night clean our CNS, do it by astrocytes, and eliminate toxics sustances and excessive activation of neurons. So, controlling the clycle and rhythmicity will be very necessary. Remember that neurons, astrocytes and oligodendroglia develpmed from ectodermic embryon and, such as skin do, they can respond more or less to light. So much light will be bad, but necessary and so much night too. In our evolution, light and dark, was implanted in our genes and, as a monkey, we are awake in the morning with light and sleep at night. We need it.
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We are planning to begin using nitric oxide on our cardiac surgery CABG patients. I would like to know if there is risk to pregnant ICU nurses caring for the the patient if she inhales any of the nitric oxide.
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Although low concentrations of inhaled nitric oxide may be therapeutic, both nitric oxide and its oxidation product nitrogen dioxide are potentially toxic. The threshold limits for time-weighted average concentrations of nitric oxide and nitrogen dioxide issued by the American Conference of Governmental Industrial Hygienists are 25 and 3 ppm, respectively. The attention of these gases in the breathing space of hospital personnel during the administration of nitric oxide to adult patients has not been reported.
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Multi-modal monitoring for malignant cerebral edema, increased ICP, and other conditions is rapidly gaining favor amongst our Neurological ICU and Neurosurgery community. Thus far, no standard of care has been established. And the data collected from intracranial device monitors such as the Licox and depth electrode EEGs have variable clinical significance. Regardless, the trend will likely continue.
A host of new devices now promise use of infrared and other technology for noninvasive multi-modal monitoring. If proven with accuracy, this would not only be superior to intracranial monitors due to lack of infections and other concerns, but could also being this possibility to a host of patients who have contraindications to or do not want neurological surgery.
I am curious what devices you are using at your institutions and how has your experience been so far? Specifically, do you feel the noninvasive device is as accurate as the current intracranial devices and do you have data correlating the two to affirm this?
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Transcranial Doppler. I and my colleagues are carrying out multi-institutional Phase III Clinical Trial on determining the efficacy of TCD among patients with subarachnoid hemorrhage and traumatic brain injury. Hopefully it can better answer this highly important question.
We also carried out a related meta-analysis:
Fatima N, Shuaib A, Chughtai TS, Ayyad A, Saqqur M. The Role of Transcranial Doppler in Traumatic Brain Injury: A Systemic Review and Meta-Analysis. Asian J Neurosurg. 2019;14(3):626-633. doi:10.4103/ajns.AJNS_42_19
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A large majority of intracerebral hemorrhages, especially in younger patients, are due to hypertensive emergency. Often, these patients will get started on a titratable continuous IV drip medication like Nicardipine in the emergency room. However, there was a recent paper in Neurocritical Care journal that suggests that starting oral antihypertensives in conjunction during this very acute stage can lower morbidity, costs, and hospital/ICU stays. The rebuttal is of course that blood pressures on oral antihypertensives are subject to peaks and troughs with medication administration until steady state is reached. During this time, overshooting the target and causing hypotension can cause significant ischemia to surrounding cellular tissue that may be amenable to rehab, and hence worsening long-term outcomes [though this has not yet been systematically analyzed]. What is your opinion on this?
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ESSENTIAL!!
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Participating in an ICU based study looking at intubated and ventilated COVID patients first out of bed rehabilitation session with Physiotherapists and trying to determine if it is safe by using group analysis to analyse physiological parameters such as systolic and diastolic blood pressure, heart rate and oxygenation. Currently very little data on what the MCID to determine how much of a change in these parameters would be clinically important that may determine if rehabilitation is safe for this patient group.
Any help would be greatly appreciated.
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The clinical significance of the selected parameters is related to the initial condition of the patient and the disease. Any sustained positive dynamics should be considered clinically significant.
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Participating in an ICU based study looking at intubated and ventilated COVID patients first out of bed rehabilitation session with Physiotherapists and trying to determine if it is safe by using group analysis to analyse physiological parameters such as systolic and diastolic blood pressure, heart rate and oxygenation. Currently very little data on what the MCID to determine how much of a change in these parameters would be clinically important that may determine if rehabilitation is safe for this patient group.
Any help would be greatly appreciated.
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In hereditary neuropathy, "uniform conduction block" was once thought to be a characteristic in contrast to "non-uniform conduction block". Uniform conduction block is characterized by conduction block without any temporal dispersion. Now this is only seen CMT 1A hereditary neuropathy. Non-uniform conduction block is seen in other hereditary neuropathies and acquired demyelinating neuropathy. In the recent years, uniform conduction block is also observed in "axonal form of GBS" (AMAN and AMSAN), Some called this "axonal conduction block". This is misnomer. This is discussed in my recent paper in Muscle Nerve in 2021 Feb issue.
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What are the major differences in ICU admissions during the first and second COVID_19 wave?
ICU addmissions ,COVID_19 Waves ,Differences.
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There is obvious decrease in thrombotic events during the second wave as early use of glucocorticoids and thromboprophylaxis
you may read more on following link
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The coronavirus pandemic has been hard on the whole world. However, some countries and places have been affected by way more than others. COVID-19 has always been reported to have a high risk of contraction and complications among the elderly. However, in the second wave of COVID, ICU admissions among the young have increased in many countries.
Your viewpoints :)
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Quite likely: YES!
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This question refers to the issues that nurses face when they are caring for patients with COVID-19 on isolation protocols ,and which triaging methods you use in your medical facility?
I am looking forward your replies,
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In children, any case with respiratory symptoms are considered suspects of COVID-19; preventive isolation is performed until the test results are obtained. However, a problem becomes relevant in this case and consists of the limitation of companions in specialized units, in some cases promoting the dehumanization of services and reducing the provision of services that could improve their immune response.
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Tools to assess this problem
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Review the paper by Greenleaf et al 1992 35,2,119-128,Hypnotizability,and Recovery from coronary bypass surgery in the ICU also ,Wickramasekera 1995,1998,2003 for clinically relevant psychometric measures of therapy efficacy and prognosis in the ICU and in recovery eg hospitalization days,medication for blood pressure stabilization ,Meds reduction,etc.
Ian Wickramasekera PhD
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I will try to summarized most important points regarding thromboembolic events in COVID-19 patients:
* 1/3 of patients with covid-19 in ICU have reported venous thrombo-embolism (despite prophylactic anticoagulation)
* 3/4 of patients were male.
* Most of venous thrombo-embolism events were pulmonary embolisms.
* Common in COVID-19-associated acute respiratory distress syndrome (ARDS) to a matched cohort of 145 patients with non-COVID-19-ARDS (12 versus 2 percent).
* Some experts suggest more aggressive thrombo-prophylactic dosing of anticoagulants or even empiric therapeutic dose anticoagulation for VTE prevention .
* Data are more limited regarding the rate of VTE in inpatients who are not in the ICU.
* Venous thrombo-embolism events in COVID-19 patients have been observed in outpatient and non-ICU inpatients but it is less than ICU patients and data regarding this issue are more limited.
* Arterial thrombosis are also reported e.g. acute ischemic stroke (patients were under 50 years of age), myocardial infarction and peripheral arterial thromboembolism.
* Microvascular thrombosis are also reported in autopsy studies of the lungs and mechanism is unclear (may involve hypercoagulability, direct endothelial injury, complement activation, or other processes). So, testing for thrombotic microangiopathies (eg, ADAMTS13 activity, complement studies) or specialized therapies (eg, plasma exchange, anti-complement therapy) are not recommended without a research study.
* Bleeding is less common than clotting in patients with COVID-19 and usually seen in the setting of anticoagulation).
I hope this could help you to provide better care for your patients.
Regards,
Abdul Hadi Al-Qahtani, MD/MHA
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SARS-CoV-2 enter host cells via ACE2 receptors, which are situated in blood vessels too, so this results in inflammation, which damages the endothelial lining of blood vessels that in turn trigger the coagulation cascade, causing coagulation.
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I have an ICU patient who is known to have ESBL-producing E. coli colonisation detected on numerous rectal swabs in prior admissions. Now, he has E. coli bacteremia with isolates not ESBL-producing. How is this possible? What could be the likely source of his bacteremia? He has no wounds. Thank you in advance for sharing your knowledge.
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plz share with us the outcome of your patient
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Two weeks since cardiac arrest with 30 min CPR and ECMO. Unresponsive with clinical coma. Blinking spontaneously. Do you see the missing AP gradient. What would be your assessment from now.
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ICU patients, after a severe COVID-19 disease, always incur long-term damages?Which are the most frequent ones?
Thanks for the support.
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lung involvement
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The challenge is to create a model that uses data from the first 24 hours of intensive care to predict patient survival . My dataset has more than 130,000 hospital Intensive Care Unit (ICU) visits from patients, spanning a one-year timeframe.
Please point me to sites where I can find relevant research papers.
Thanks
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pubmed
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Does anyone have a clue about the significant differences in mortality rates in COVID infected people between Germany and other countries (Spain, Italy, France…)?
Germany is a densely populated country (86 000 000 inhabitants in just 360 000 square kilometers), with several very populated cities. Nevertheless it is not being hit by COVID as hard as other countries. Are German doctors treating patients in a different way?
I know that probably the explanation is complex:
1. Germans as Oriental people, may be more disciplined than Mediterranean people, and that could justify a slower spread of infection. There may be genetic differences.
2. Probably there are differences in the definition of infected cases and COVID mortality. We know that they have made more PCR tests so their definition of case is wider, and that could explain lower relative figures (number of deaths per each infected people). But absolute figures are also lower. On the March 22th they had only registered 68 COVID deaths.
3. The number of ICU beds could explain some differences (with 28,000 ICU beds, Germany is the first in the ranking of ICU beds (6 ICU beds per 1,000 inhabitants), while Italy has 2.6 ICU per 1,000 inhabitants and Spain only 2,4). (https://www.euronews.com/2020/03/19/covid-19-how-many-intensive-care-beds-do-member-states-have)
4. They could be in an earlier phase of the epidemic. So the figures could worsen in the next days.
In any case they seem to have less severe cases. There may be biological differences between different populations. Still the differences in the absolute figures are really striking.
I would like to open a debate about the standard treatment in Germany vs the standard treatment of COVID infection in other countries.
Are they doing something different?
Is there something we should learn from them?
Best regards from sad Spain.
Julio.
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 I am interested in drug resistant strains.
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Please also go through the following RG link.
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Chiumello et al (2006) suggested that thorax and pelvic supports should not be used in prone patients lying on air mattress beds in the ICU. The supports did not significantly affect intra-abdominal pressure and increased the likelihood of pressure sores.
Do you support the chest and pelvis at all when your patients are prone on air mattresses in ICU? And if you do, what do you use - and why?
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in our place we do not support the chest or pelvis in manual pronation of intubated patients. I think pillows under the chest and pelvis.
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Hi all,
I'm currently preparing RBC aliquots (100μl) from ICU blood samples and I'm looking for a method to determine the qualitative amount of RBCs in every sample to decrease the pipetting error.
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Hi, you can use hemocytometer for quantifying the RBCs manually or even blood analyzers will help you.
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As the title mentioned, we had been preparing the worst scenarios , should we shutdown some regular ICU beds to free mechanical ventilators or should we keep the same numbers and setting patients in isolations with Transport Ventilator( IMPACT EMV+) continuously .
Wards/Beds are available, but equipment arrangement have to be prioritised. Safety is crucial as well. Report from vendor is that once there's continued power inlet, transport vent can be used 24/7 for adult usual ventilation but not defined the settings eg.ARDS high PEEP with difficult ventilation patients cohort.
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This may be the ventilator that you want and need to make.
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I currently have the WHO, the Chinese, and the German guideline for SARS induced by corona virus. I mean management in the ICU.
Can anybody contribute a respective Italian or Spanish guideline?
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This the most promising guideline
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With the new COVID-19 outbreaks and shortages of N95 masks: what are the alternatives for the healthcare workers (doctors, dentists, nurses, RTs) who may be in close contact with potential COVID-19 patients?
Would you recommend putting a regular surgical mask and face shield on top of it?
Suggestions with scientific rationale are welcome...
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First, there is no indication for using respirators for preventing the transmission of corona virus except in situations where there is risk of aerosolization of droplets, e.g., sprays, splashes, coughs, sneezes etc. Therefore, the misuse should stop. Education and training on when, and how to use it could help reduce the demands.
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Here is a question for everyone that I am currently stumped on:
Is there some standardized metrics or quality targets for in-hospital cardiac arrests rates?
Its related to the work I am doing to implement CCOT at SPH. The CCOT literature uses a variety of measures and it gets a little confusing:
· Code blue (all types) per 1000 admissions or per 1000 discharges
· Cardiac Arrest (only code blue with CPR) per 1000 admissions or per 1000 discharges
· Code blue or Cardiac arrest excluding critical care areas (i.e., ED, ICU, CCU, CSICU, OR/PACU) per 1000 admissions or discharges
I looked through CIHI and it does not look like they have any stats on in-hospital cardiac arrest rates that I could find. We keep track of code blue data, but I don’t think it is reported to any external organizations. The UK and Australia have done rapid response systems for far longer, but I haven’t come across any official standardized metrics or definitions of what is considered good, bad or ugly in the way of targets.
Thoughts?
Thanks in advance for any assistance you can offer.
Vini
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I agree with Nikola Bradic
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Hi all,
I want to perform a study in ICU/Oncology with my fellow Clinical Pharmacists. I am very happy to hear from you regarding the research topics which I can go for
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S. Sabishruthi Thanks for the suggestion. I will look into it
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I have two datasets:
One dataset is on patients' daily Blood Pressure measurement (there may be missing data depending on consent each day) and patients unique ID
And other dataset is with patient's unique ID and Date admitted to ICU (only some of the patients are admitted to ICU).
Using this unique identifier (Variable unique ID - common in both datasets), I need to link these two datasets to identify: Among those admitted to ICU (i.e. only those IDs with date admitted to ICU)
How many days in the 2 weeks before, and the 4 weeks after the index date (date admitted to ICU) does that that patient have given Blood pressure data.
Any suggestion on how to generate a syntax for finding this information in Stata please?
Thank you.
            
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So, the first step is to merge both datasets doing the following:
  1. Open dataset 1
  2. Then, type: merge 1:1 PatientID using [path to dataset 2]
After that you have to calculate the difference between both dates. If BPrecord and DataAdmittedToICU are datetime variables in Stata, you just have to perform a simple subtraction and generate a new variable based on this subtraction: gen BP_2weeks = DateAdmittedToICU - BPrecord < 14
When you subtract two datetime variables in Stata it calculates the difference in days between the variables. That is why I used 14 in the command above (14 days = 2 weeks)
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Anyone interested in exploring novel ways of monitoring the appropriate position of endotracheal tube (ETT) in mechanically ventilated ICU patients?
Traditionally this is done with repeated Chest X-rays. What about researching new available technologies, like ultrasound or wireless methods, without the potential hazards of repeated radiation?
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Dear Polly Dendy , yes, USG is already being used to detect ETT position in many centers with necessary expertise by the interventionists. Of course, the supportive options like direct visualization, capnography etc may be adopted in exclusively difficult plus suspected scenarios. You may please go through this related paper:
Regards- Rabiul
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how many of you use BIS monitors in ICU ?
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Dear Sharma
Firstly, I would like to inform that we do not use it regularly/routinely.
Secondly, I would like to draw your attention to the fact that the evidence for BIS use in critically ill patients in the ICU is not very strong. Clinical Assessments and validated assessment tools (different scales) has shown an equal role in non-paralyzed mechanically ventilated patients. (
Furthermore, the use of BIS alone cannot also be recommended (
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According to the Centre for Disease Control and Prevention (CDC), additional consideration should be given to patients with Multiple Drug Resistant Organisms (MDROs) in ICUs using measures that include single room isolation and dedicated specific staff to provide the bulk of the patient’s care rather than all staff available.
If single rooms are not available to isolate MDRO positive patients then the use of cohorting is advised, meaning that these patients should be grouped with others who have cultured positive with the same organism(s).
But, Isolation and cohorting is not always feasible to achieve.
So. When MDRO positive ICU patient isolation and cohorting is not feasible, what comes next?
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Despite differences in study design and methodology, and acknowledging the high transmission dynamics in the ICU, the following three papers may give some answers: the ESCMID guidelines on IC measures to reduce MDR-GNB transmission which are presented separately for each type of pathogen ( https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)60007-0/fulltext); a technical report by the ECDC on CRE (see syst.review #2 that supports specific measures as the most effective) ( https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/110913_Risk_assessment_resistant_CPE.pdf); and a recent Dutch study which showed the non-inferiority of contact precautions in multiple-bed rooms compared to single-bed (isolation) rooms for ESBL (https://www.sciencedirect.com/science/article/abs/pii/S1473309919302622).
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While more than half of the ICU patients have either sepsis/infection or are on antimicrobial - How we practice infectious diseases differ significantly between an ICU and other even in the same country (sometimes even different ICUs in the same hospital).
Understanding such practice is fundamental to improve patients' outcome, antibiotic resistance, length of stay, morbidity as well as antimicrobial resistance.
Can you help by answering this survey:
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I have observed in recent years that critically ill patients in the ICU are sometimes maintained on mechanical hyperventilation with propofol sedation. ln my opinion, this is harmful and counterproductive. All hypnotics are inherently toxic, including anesthetic inhalation agents. The toxicity of propofol is notorious. George Washington Crile described how he cured sepsis and peritonitis 100 years ago when primitive needle technology made intravenous access impractical. He used massive doses of intramuscular morphine that caused his patients to become essentially comatose for up to a week, without the help of intravenous fluids or even antibiotics. This cured cases of sepsis and peritonitis. Crile had discovered the nervous component of what was then called "shock". He describes his discoveries and treatment strategies in his famous book called "Anoci-association" that can be accessed free of charge via the Internet. With our modern machines, medications and monitors we can do better. We can safely maintain deliberate high levels of "permissive hypercarbia" that offsets the respiratory depression caused by modern synthetic opioids; the combination works like love and marriage. Hypercarbia optimizes cardiopulmonary performance and enhances the release of oxygen from the hemoglobin molecule, and therefore optimizes tissue oxygenation. This is helpful in all forms of sepsis and especially helpful in stubborn cases of infestation with "facultative anaerobes" that proliferate in poorly perfused and oxygenated tissues where antibiotic "penetration" is limited, such as Lyme Disease, MRSA and so forth. Last, but not least, non-toxic opioid supplementation reduces reliance on toxic hypnotic agents. The best choice for a hypnotic agent is anesthetic inhalation agents, which can be maintained at precise levels, adjusted quickly, and rapidly rid from the body. These principles could revolutionize the care of critically ill patients if they were fully utilized.
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Occasionally we used to have transcutaneous CO2 monitors for selected ICU patients, especially those who are ventilated with HFOV.
However, with its poor correlation with the blood gas analysis and the complications of the electrode site burns, I think it is out of fashion?
Is anyone using similar products with better clinical experience?
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I'm a little confused by the comments about "burn sites" because modern transcutaneous oxygen and carbon dioxide monitors don't burn the skin. When I was an anesthesia resident at UCLA, I had the opportunity to try the earliest version of a transcutaneous oxygen monitor, and with these primitive machines there was some concern about leaving the sensor in the same location for prolonged periods of time due to the possibility of causing tissue damage. They warmed the skin to "arterialize" capillary flow, but the heating element was not regulated by a thermostat. It was impossible to calibrate these original monitors. They provided a numerical "readout" for oxygen concentration that rose with increased tissue oxygenation, but they could not actually measure the partial pressure. There has been considerable improvment in the technology during the 50 years since I was a resident. I have purchased one of the new machines. They now measure transcutaneous CO2 as well as oxygen, and can be calibrated to measure the partial pressures of both. However, they remain far from ideal. They are very "tricky" to use. Their main advantage is that they are non-invasive, and can provide continuous measurement of the partial pressures of oxygen and carbon dioxide. The sensors are not likely to cause tissue damage, because they are now governed by a thermostat that maintains the skin temperature around 45 degrees celsius, so patient injury is no longer a concern.
I am now working with the Plexus software company to enable automatic incorporation of TcO2 and TcCO2 data into my anesthetic records, and capture readings every five minutes.
Carbon dioxide chemistry and pathophysiology is very tricky stuff. I once had an engineer who helped design modern capnographs tell me that it was necessary to install a fan in the measurement chamber of the machines to constant stir the gas mixture, because carbon dioxide has a vexing tendency to "settle" and thereby frustrate accurate measurement. Transcutaneous CO2 measurement is similarly vexed by variables. The sensor is mounted in a small plastic cup that is pasted to the skin. About five drops of saline solution must be installed in the cup before the sensor is attached. The skin must be carefully "prepped" to prevent the water from leaking out of the plastic cup "chamber" where the measurement takes place. The temperature must rise to 45 degrees before the machine begins to operate. Too much or too little water in the chamber will disrupt measurement. The sensor must be calibated each time it is applied, and if you are using it in an ICU setting it's probably a good idea to re-calibrate the sensor every hour or so. I use the machine only during short dental surgeries, and must re-calibrate between each case. It's essential to have a clear understanding of the role of carbon dioxide in the pathophysiology of oxygen transport and delivery, and CO2 data alone is meaningless in the absence of O2 data.
Exactly what are you trying to accomplish in the ICU setting? Are you performing some sort of study, or are you using the machine to manage critically ill patients?
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As compared to the "traditional" intracoastal chest tube that are inserted at the bed side for ICU patients to drain pneumothorax / pleural effusion. In the last years some ICUs have been using the newer "Seldenger" over the guide wire technique.
Which style do you prefer? Why?
Is your setup Adult / Pedia or Neonatal ICU?
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In our PICU setting , the Seldenger technique is usually preferred : faster and somewhat "less invasive"
However, the team needs to keep their "traditional" technique handy , as on one instance the PICU supply was out, so going back to the original style was literally "life-saving"!
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Post intensive care syndrome (PICS) is very common, primary care doctors have little or no help from us intencivist in taking care of these patients post critical illness recovery and discharge from ICU. Being an intencivist I think our main focus is to save lives and act acutely. But I think there is little or no focus on post critical illness and we should have special clinics for these patients.
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Thank you Dr.Sharma for being such a genuine advocate of patient's health outcome!
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In my clinical practice I have seen many nephrologist ordering renal usg in AKI patients, but current literature does not support it.
What do you practice in your ICU ?
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Empirically, we prefer to go for an USG of KUB to exclude any pathology (parenchyma) other than the specific scenario-based suspected causes of AKI along with other investigations. Although this's not conclusive. Regards- Rabiul.
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For those connected with the ICU settings : Do you routinely send tips of removed central lines for culture?
Is identification of the biofilm from these lines helping?
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As per CDC- Catheter tip cultures have been shown to have higher rates of contamination than blood cultures. Furthermore, not all laboratories are able to perform quantified catheter tip cultures. Catheter tips are a part of other types of non-NHSN surveillance such as catheter-related BSI (CRBSI) which is generally thought of as a clinical definition, used when diagnosing and treating patients.
I agree with you all to send it in immunocompromised patients, as far as I know this is clinical practice -do we have it in any guidelines or any RCT ?
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through out my training I have seen continuous feed in icu critically ill patient. But normally we human beings don't eat all the time and especially at night time. Why don't we just bolus feed or feed in day at higher rate ?
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cont. feeding because it is better tolerated and in accordance with ESPEN and DGEM guidélines.
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We are trying to create an SMR for our ICU network. We calculated the predicted mortality for all the patients for six months and plotted an ROC for the prediction tool used. However from the tool, to generate a predicted mortality, one should have a threshold mortality percentage above which the patient will be counted as dead, right? How do we determine that threshold?
To illustrate with an example, if in an ICU with 5 admissions a month, APACHE predicted mortality for the patients are
10%, 17%, 32%, 6% and 17%
And say the observed mortality is one
What is the expected mortality here? Who do we count as dead here? Strangely none of the literature mentions about this. Could anyone please shed some light in here.
Thank you so much.
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Dear Colleague,
First of all you have to collect at least 200 patients. Otherwise, the result does not make sense. However, to obtain the SMR according to your example, you have to follow the following steps:
1) You have to transform the percentages in numbers.
In your example you will have: 0.1, 0.17, 0.32, 0.06, 0.17
2) You have to sum the numbers: the total is 0.82
This is the number of expected deaths
3) The formula to obtain SMR is: observed hospital deaths/predicted hospital deaths. In you example SMR is 1/0.82= 0.21
See also Rhodes et al Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Med (2012) 38:598–605 DOI 10.1007/s00134-011-2462-3
Best regards
Maurizia Capuzzo
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I am a recently qualified HCPC clinical scientist looking to start publishing papers. I specialise in critical care across paediatrics, neonates and adult ICU. I am looking for suggestions of journals that are related to healthcare science rather than intensive care.
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Thank you very much Ahtisham! There are a couple of the list that were not on my radar.
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Dear,
My name is Noemi Giannetta; I am Italian PhD student at the Tor Vergata, University of Rome. I am writing to ask you if you are interested to partecipate to an international study about medication errors in ICU (intensive Care Unit). It is a study conducted for Tor Vergata University of Rome and Sapienza University of Rome. The aim of this study will be to assess knowledge, attitudes and professional behaviour of Italian and “international” nurses towards preparation and administration of intravenous medications in ICUs. At the moment, Spain, Portugal and Malta are the country involved. I'm very grateful if you can help me to administrate a web survey to your colleagues in ICU (Di Muzio, Tartaglini, De Vito, & La Torre, 2016). I am very happy if you are interested to help us to publicizing of the web survey.
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hello.
yes i am interested, would you like to share the details?
thanks
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There's a new type of antibiotic prophylaxis for severerly burn patients in ICU.
My thesis will be about introducing this new regimen to a Hospital.
There's a recent systematic review providing evidence about how this prophylaxis lowers mortality.
My question is: what is necessary to include in the thesis? Is it necessary to write a new systematic review that shows evidence about its results?
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Miguel
It is a taught masters with a mini dissertation or a research only Masters? In what disciple? Is this basically a Clinical Audit?
The Results of the Systematic review could be a part of you research question i.e. How can the Systematic Review (Ref) be operationalised to improve outcomes by using x treatment of antibiotic prophylaxis for severely burn patients in ICU.
Hope that helps your thinking
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Hello
My name is Luis and I am working in emergency laboratory in Santa Lucia Hospital, in Cartagena (Spain)
We have investigated about PSP in adults ED and in febrile neutropenia (paper is going to be published In Clin Chem Lab Med). Now we are writting a paper about prognostic value of PSP in ICU patients with sepsis. Are you investigating about PSP?
Best regards
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Hello dr. Romualdo.
We did some research of PSP in multiorgan failure and sepsis in children back in 2014 with Michal Fedora and Jiří Žurek . Paper is in the attachment. We used commercially available colorimetric sandwich ELISA from Biovendor Ltd., Czech Republic.
Best regards,
Martin Vavřina
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Graduated nurse, doing ICU course in the Netherlands.
For my final project trying to improve our NPPV protocol.
Not really lucky with finding any evidence on the naso gastric tube in NPPV.
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DOI: 10.1056/NEJMc1508384
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We have used the Inventory of Callous-Unemotional Traits (ICU; Kimonis et al. 2008)
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These data are from young adults attending college/university. The RPQ measures reactive aggression (gotten angry when frustrated) and proactive aggression (vandalized something for fun). The APSD has items like You blame others for your mistakes, your emotions are shallow and fake, and you lie easily and skillfully.The sample with these measures include 599 participants.
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We are using the RASS scale, but that was developed for evaluating delirium and agiation in the ICU population, not a psychiatric population
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Thank you for your reply and recommendations; I will explore those.
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working on a presentation
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Fluid responsiveness in ICU - we usually use leg raising test as first line. Fluid challenge is also practiced and response in terms of BP, HR and their sustainability after loading fluid. But depending on patients condition, we also frequently use both static and dynamic parameters from hemodynamic monitoring (EV1000 from Edward lifesciences), Ultrasound / Echo too. CVP, although limited in many aspects, is also used frequently; especially the trend than the single reading.
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Outbreak alert user friendly application
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I agree with the above statements. Daily rounds, markers, and imaging are vital. Furthermore, close communication with nursing staff can often identify concerns by those providing bedside care. Not only an this type of communication identify potential issues in individual patients under your care but could additionally assist in alerting physicians in recent outbreaks in the ICU or other local hospitals/ICUs staffed by many of the same individuals. Discussions with bedside staff often (1) alerts providers regarding observed issues, (2) provides valuable information, and (3) benefits all individuals involved.
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  • Interaction with humans is never a one-way street. The doctor is in command while interacting with patients, but educated intelligent patients are always evaluating the motives and competence of their doctors, albeit with varying and limited success.
  • The awe of specialist wears off, generally, after the first visit. The patient is hapless and helpless but not witless. Every word and mannerism of the doctor (or the stoic unemotional lack of both) conveys some meaning to the patient. This hyperacute mental state of the patient worsens with polymedicine and polytherapy and peaks in the pre-agonal stage. Woe falls on the doctor who changes medicines at each subsequent appointment or waits indefinitely for the issue to resolve by itself.
  • Desperately ill and dying patients have no option. By the time DNR Wills can be produced, the end-drama plays out, frequently. You may do anything with them, insert all kinds if lines, central or peripheral, order an unending list of investigations, take a series of informed but cosmetic consents, initiate heroic invasive procedures, rush them to the ICU or place them on ventilator just to delay the inevitable without a murmur from the care givers.
  • The treating doctor must realize that the boomerang curve of time could well strike her/him unpredictably but similarly.
  • Is it true that what goes around, comes around?
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I very much agree with Ashley and her response. The relationship between doctor-patient is a very important element in any treatment plan with the absence of trust, there is very little expectation that the patient will get full benefit from the doctor patient treatment plan.
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A 80 year old female patient with normal blood sugar level but a little hyper tension has been undergoing gradual increase in the pCO2 levels. Lives in a healthy environment, but the pCO2 levels hit 100+ 2 times in the past 4 months. Every possible tests including neural conduction test have been done. But the actual cause remains unknown. When given oxygen, fast recovery is seen in the patient. Was rushed to the ICU twice. No loss of memory or speech. Early symptoms include dozing off and gradual loss of interest.
P.S - Under contrast CT, perigastric mass measuring 71X68mm was found and confirmed. Due to lack of fitness, biopsy was not done, suspected leiomyosarcoma, but no symptoms found. Looks like mass is not the cause for the above mentioned problem. Please help... Comment for further data.
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Sorry to hear the serious condition of your grandmother Navneeth.
The amount of carbon dioxide in arterial blood is sensed in the brain and the respiratory center regulates how deep and fast we breathe, although oxygen is what we need to stay alive. If the brain doesn’t react to increasing CO2 or if the breathing muscles doesn’t react to the signals from the brain, the amount of O2 gets too low, CO2 too high and the patient becomes increasingly confused and eventually unconscious.
I agree with Gill in PE not being likely. However, intracranial pathology or a combination of chronic lung disease with brain damage or muscle weakness/disease can result in respiratory failure type 2, which seem to be the case here. Do you have CT scans from the brain stem?
Kind regards, Nils H
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My ICU is located around 1400 metres above sea level. The barometric pressure at this altitude, based upon the altitude-pressure tables, comes around 650mmHg. However, the climate authorities here mention that the measured 'air pressure' is around 1015mb, which is 760mmHg. For the same reason, the A-a gradient that we calculate in our patients is much different than that provided by the ABG machine. Can Patm at this altitude be same as that of sea level? which one do you think is preferable?
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For the purpose of making weather forecast, barometers are often adjusted to compensate for actual altitude, so that “normal” atmospheric pressure for that altitude is shown as 760 mmHg (1 013 hPa). I assume that the barometer of the ABG machine is not altitude compensated which explains the unexpected values of the A-a gradient you calculated using a ‘fake’ barometric pressure in the formula. I think you should use the true atmospheric pressure measured by an uncompensated and accurate barometer. However, I’m afraid that even a correctly calculated gradient at 1 400 meters above the sea level will be difficult to use for judging the state of the lungs. I believe that calculating venous admixture would yield the best result for estimating impairment of the pulmonary oxygenating capacity, if that is what you want. This can be done from arterial ABG if you use a standard value for arteriovenous oxygen content difference in the formula. Doing that, it will also be possible to compare values obtained with different inspired fractions of oxygen (provided you know how many % oxygen inhaled), which is practically impossible if you use the A-a gradient.
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i do a prediction model using data mining classification algorithms (neural networks, SVM, RF, naive bayes, CART ,...) to predict length of stay LOS in Intensive Care unit department ICU. data sets consists of discrete variables as (gender (1,0) for male and female) also 0 value for not having specific chronic illness or complaint and 1 for occurrence. the rest of features are continuous for blood pressure, temperature, PH, Na, and K labs results. the output is three values (1,2 and 3) refers to the duration of stay in icu.
the prediction results accuracy are very low when performing the prediction using the raw data set or even after discrete and normalize (min-max) of all features.
any suggestions please?
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Merhan,
You May want to use factor analysis to reduce your data variables into grouped factors and then use those factors in your prediction algorithm. The reduction of the continuous variables to a percentage change from either the patients‘ baseline or a benchmark value (ie relative hypotension or hypertension vs. Normotention) instead of a numeric value will be more useful than 146/97. The same can be done for acidosis, electrolyte status etc.
Regards,
Christopher
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What is the influence of AI and UX on ICU projects? Someone can instruct me on the current use of AI (architecture of the information) and UX (user experience) in the current software development.
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both AI and UX are major applications of computing, and as such influenced programming style and languages (the interplay of application and software languages, tools, and styles is huge!). AI led to Lisp and Prolog, as major examples of building programming languages for software that is AI reasoning style compatible. Similarly, UX led to GUI manipulation based languages, like Perl and other scripting languages, and so on.
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I want to gather opinions about PACT modules by the European Society of Intensive Care Medicine!
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Thank you Rainer. Looking forward to any feedback!
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Can somebody tell me the most common microorganism isolated from ICU?
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Dear Manar, this article will help you:
Semin Respir Crit Care Med. 2003 Feb;24(1):3-22.
Epidemiology, prevalence, and sites of infections in intensive care units.
Richards M1, Thursky K, Buising K.
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I manage Nîmes' rehabilitative post-ICU unit (RPR - "rééducation post-réanimation" in french)
Can we be part of this database ? Do we need to be linked to Nîmes'ICU units ?
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Sorry, I am not in this field of knowledge.
Hope you found helpful answers from other experts
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Risk factors for CRBSI are well documented but I´m looking for a sort of screening tool in ICU pacientes with CVC.
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