177 research outputs found
Management Of Patients With Stroke In Critical Care Units, Considering Osmotic Therapy And Hypothermia
No full textCytotoxic brain edema is an early complication of stroke which increases the possibility of secondary ischemia. Hypertonic solutions, mannitol and recently hypertonic saline (HS) has been considered for treatment of increased ICP. HS could decrease ICP especially in hypotensive patients with different mechanisms, direct effect on edema, decreasing inflammation which is mediated by attenuation of TNFa and IL-1b stimulation on Na-K-Cl cotransporter 1 and improvement of microcirculation. Improvement of microcirculation is so important for hypertonic solutions to be effective in ischemia especially focal ischemia. Based on the literature, hypertonic saline is more effective in decreasing cerebral edema than the equal volume of mannitol. The optimal dose and duration of therapy needs more trials. Caution should be performed with patients with moderate size hemispheric infarcts on presentation, race and genetic factors regarding osmotic therapy.Hypothermia has been rated as one of the most active modes of neuroprotection based on the results of different trials. Hypothermia in both ways, surface and intravascular, decreases cerebral metabolic rate of O2 and glucose and reduces brain oxygen consumption, inflammation and oxidative stress. Recent data continue to support consideration of therapeutic hypothermia for cerebral ischemia in larger clinical trials of acute ischemic stroke. By increasing the time window to therapy initiation and decreasing the treatment duration, selective intracarotid cold saline administration brings increased feasibility, potentially better outcomes and perhaps fewer complications compared with the whole body cooling. Hypothermia is now recommended as a targeted temperature management with defined protocol which should be started early; it may be performed pharmacologically in combination with other therapies. Applying hypothermia should be considered regarding its cost, using in awaked patients, re-warming protocol, incorporation of thrombolysis and its complications. </jats:p
Dysglycemia in Critically Ill Patients: Common Problems and Future Direction
No full textThe management of blood glucose (BG) in the critically ill became a topic of great interest following the publication of the landmark single-center surgical ICU study targeting euglycemia (80 to 110 mg/dL) in Leuven, Belgium, in 2001 (1). This study resulted in thousands of protocols and guidelines promoting 'tight' BG control . The failure to show the same results and high incidence of hypoglycemia in following trials have resulted in controversy in blood glucose management in critically ill patients. Analysis of dysglycemia in critically ill patients should include markers of three domains: hyperglycemia, hypoglycemia, and glycemic variability (2,3). Thus, hyperglycemia, hypoglycemia, and blood glucose variability should all be regarded as independent predictors of adverse outcomes in critically ill patients. Agus et al., in their multicenter study (4), showed that critically ill children with hyperglycemia did not benefit from strict glycemic control to a target glucose of 80-110 mg/dL compared to 150-180 mg/dL and patients in lower treatment target showed an insignificant 90-day mortally rate compared to other group. There are so many reasons to describe these controversies: In LEUVEN III study (5), despite a 25% hypoglycemia incidence, tight glycemic control had a significant treatment effect; nevertheless, in Agus et al. study, despite a lower incidence of hypoglycemia, treatment effect was not significant. The reasons can be explained with the fact that first trials were single centered open label studies which were terminated at early stages of the study because of observed benefits which may have exaggerated the treatment effect. Also, the observed difference was found in subgroup analysis which could have been due to chance factor. Findings from RCTs conducted on critically ill adults and children strongly suggest that the largest benefit for blood glucose control can be expected if the difference in blood glucose concentrations between the study groups is large and if the study is done in a single-centre setting where the blood glucose management is tailored to the local treatment habits. Consequently, we could not compare those single centered trials which are not externally validated with high level of adherence to protocols, lower time to target range, higher time in target range with multi centered trials with a low level of adherence to protocol higher time to target range, lower time in target range and a totally different method of energy supplementation. Finally, the era of 'one size fits all' in regard to glycemic targets in the critically ill seems to be over. We should also consider the correct and earlier diagnosis of patients, their glycemic status and preadmission glycemic control individually (6). Future trials should consider the discrepancies accounting for controversial points like nutritional status of patients, glucose monitoring methods (7) and insulin titration method. </jats:p
A Simple Strategy for the Sterile Use of Reusable Laryngoscope Blades in Resource Limited Countries
No full textThe laryngoscope blade has a potential role for crossinfection due to its contamination with bacteria, blood,and microorganisms. Cleaning the laryngoscope bladehas various methods in different countries. Most operatingrooms have no guidelines for laryngoscope disinfectionafter each usage (1). Some use tap water for cleaningwhich is an inadequate method while others add disinfectantto tap water which is more effective for the controlof infection, but this may result in the emergence ofresistant bacteria. There are so many disinfectants likealdehyde-free biguanide and Chlorine dioxide or chlorhexidinewithout any international guideline for commonpractice. Cleaning with most of these disinfectants istime consuming and needs at least 10 minutes for disinfection(2). In some centers, anesthesiologists use disposableblade laryngoscopes which brings, sometimes, difficultyin airway management especially in the emergencysituations compared to standard laryngoscopes, becauseof the shape of the blade or light carrying capacity. Most ofthe single-use laryngoscopes tested were significantly inferiorto the standard Macintosh blade. This raises concernover their use in clinical practice, particularly if intubationis difficult (3). The cost of disposable blades for laryngoscopesis almost 5 to 10 dollars
Evaluation of clinical pharmacy services in the intensive care unit of a Tertiary University Hospital in the Northwest of Iran
No full textObjective: Current literature indicates that the presence of clinical pharmacists in hospitals results in improved patient care, rational drug therapy, and treatment costs. This study assessed the clinical pharmacy services in the intensive care unit (ICU) of a tertiary hospital at Tabriz University of Medical Sciences, Iran. Methods: During a 9-month cross-sectional study (2014–2015), the clinical pharmacy interventions in 27 sessions and educational activities for patients and health-care professionals were randomly assessed based on the Australian guideline and standard of practice for clinical pharmacy. The interventions of clinical pharmacist were evaluated in terms of their clinical importance. Findings: In this study, a total of 832 interventions on 242 patients were performed by the clinical pharmacist, and approximately 93.6% of the interventions were approved by the attending physician. Most interventions concerned adding a new medication to a drug regimen or switching to a needed new medication. Each patient received an average of three interventions. The clinical pharmacist provided drug information to employees and medical staff in 108 of the total 832 interventions (13%). Medical residents who were surveyed indicated that the quality of education, research, and patient care was improved by the attendance of a clinical pharmacist. Conclusion: The results of this study show that the collaboration of a clinical pharmacist with the medical staff of an ICU can improve pharmacotherapy approach and increase the quality of education
Optimizing Energy Supply by Parenteral Nutrition in the Critically-Ill: Muscle Weakness and its Monitoring
No full textSensitivity of palm print, modified mallampati score and 3-3-2 rule in prediction of difficult intubation
No full textBackground: This study evaluated the performance of modified Mallampati score, 3-3-2 rule and palm print in prediction of difficult intubation.
Methods: In a prospective descriptive study, data from 500 patients scheduled for elective surgery under general anesthesia were collected. An anesthesiologist evaluated the airway using mentioned tests and another anesthesiologist evaluated difficult intubation. Laryngoscopic views were determined by Cormack and Lehane score. Grades 3 and 4 were defined as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were determined for all tests.
Results: Difficult intubation was reported in 8.9% of the patients. There was a significant correlation between body mass index and difficult intubation (P : 0.004); however, other demographic characteristics didn′t have a significant correlation with difficult intubation. Among three tests, palm print was of highest specificity (96.46%) and modified Mallampati of highest sensitivity (98.40%). In a combination of the tests, the highest specificity, sensitivity and Youden index were observed when using all three tests together.
Conclusions: Palm print has a high specificity for prediction of difficult intubation, but the best way for prediction of difficult intubation is using all three tests together
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