Asphyxiated bladder syndrome in a pediatric intensive care unit

Sixteen neonates and infants with asphyxiated bladder syndrome (ABS) were prospectively studied over a two-year period. Their transient urinary bladder distention had developed as a sequel of asphyxial events, and presented as delayed micturition in the absence of obstructive lesion. The incidence was 1.9 percent in this Pediatric Intensive Care Unit. Five cases occurred in the neonatal period. All patients were younger than three years of age (mean: 9.1 months), and the incidence of ABS was 2.8 percent within this age group. For intermittent decompression of the bladder, all responded successfully to the suprapubic bladder expression method (Crede's maneuver). Most (81.3%, 13/16) ABS cases coexisted with intestinal dysfunction as either paralytic ileus (62.5%, 10/16) or as gas-less abdomen (18.8%, 3/16). There was no evidence of association with either systemic or urinary bacterial infection. Normal spontaneous voiding and bowel function were regained in all cases except one, who died early. Mean (SD) duration of bladder dysfunction was 66.9 (40.3) hours. Sonography showed normal kidneys and collecting system in all patients both during and after ABS episodes. Half of the patients (8/16) died ultimately. No urinary tract abnormality was found in post-mortem examinations in five cases.     

Pain management in the pediatric intensive care unit

Control of pain in the pediatric intensive care unit has become increasingly important to intensivists. Improved understanding of the pharmacology of analgesics and the development of new techniques for analgesic administration have greatly enhanced the ability of intensivists to successfully manage patients in pain. The appropriate selection, use, and techniques for administration of analgesics in the treatment of pain in pediatric patients are discussed.     

Complications of care in a pediatric intensive care unit: a prospective study

OBJECTIVES: (a) To examine the frequency, type, and severity of complications occurring in a pediatric intensive care unit; (b) to identify populations at risk; and (c) to study the impact of complications on morbidity and mortality. DESIGN: Prospective survey. SETTING: Pediatric intensive care unit (PICU) of a university-affiliated hospital. PATIENTS: 1035 consecutive admissions over an 18-month period. RESULTS: 115 complications occurred during 83 (8.0%) admissions, for 2.7 complications per 100 PICU-days; 48 (42%) complications were major, 45 (39%) moderate, and 22 (19%) minor. Sixty complications (52%) were ventilator-related, 14 were drug-related, 13 procedure-related, 24 infectious, and 22 involved invasive devices (18 vascular catheters). Human error was involved in 41 (36%) cases, 21 of which were major (18%). Treatments included reintubation < 24 h (28), intravenous antimicrobials (24), and invasive bedside procedures (14). Cardiopulmonary resuscitation was required in 6 patients. Thirteen patients with complications died (15.7%); 2 deaths were directly due to complications. Patients with complications were younger, had longer lengths of stay, and had a higher mortality. Length of stay was a positive risk factor for complication risk (odds ratio = 1.09, 95% confidence interval: 1.05 to 1.13; p = 0.0001); other patient characteristics had no predictive effect. Kaplan-Meier estimates showed that the most severe complications occurred early in the PICU stay. The best indicators of patient mortality were number of complications (odds ratio = 2.96, 95% confidence interval 1.72 to 5.08; p = 0.0001), and mortality risk derived from the Pediatric Risk of Mortality Score (odds ratio = 1.08, 95% confidence interval 1.06 to 1.10; p = 0.0001). Mortality was correlated with increasing severity of complications. CONCLUSION: Complications have a significant impact on patient care. Patients may be at increased risk earlier in their PICU course, when the number of interventions may be greatest. Complications may increase patient mortality and predict patient death better than other patient variables.     

Accuracy and efficacy of chest radiography in the intensive care unit

264 patients with cancer of larynx, 21 female and 234 male, had a testosterone and sex hormone binding globulin (SHBG) before the treatment in serum estimated. Because of dependence of levels of hormones the group of patients was divided into three following groups: "lower than standard", "standard", "higher than standard". The correlation between these groups and sex, age, localization of tumor, organs' advances, stage of morphological malignancy and type of cancer was reported. Anomalous values of testosterone were in male group more frequently reported. Anomalous values of SHBG were similar in male and female groups, but in the female group there was a significant majority of "lower than standard" values reported. The majority of abnormal values of testosterone and SHBG was described in groups of age higher than 50 years. There were no differences in testosterone and SHBG levels in different localization of tumors in larynx. In advanced stage T3 and T4 there were more frequent lower mean values of testosterone levels and higher values of SHBG levels in comparison to T2 stages. In tumors in G1 and G2 stages of histological malignancy higher levels of SHBG and higher mean levels of testosterone. The tumors in stage G3 the hormone levels were lowers were observed. The levels of SHBG in groups of carcinoma planoepitheliale keratodes were in 66% higher than in a group of carcinoma planoepitheliale akeratodes but in both groups the levels of testosterone were nearing the same. In group of patients with larynx cancer the negative correlation between the levels of testosterone and SHBG was not observed. Higher SHBG levels were not always accompanied by lower testosterone levels.     

Mental health consultation in the pediatric intensive care unit.

The need for psychosocial intervention to be integrated with medical care on intensive care units is high, but too often mental health professionals are ill-equipped by traditional training programs for such work. Medical crisis counseling provides a conceptual framework useful in developing the skills needed to effectively intervene in such settings. The pediatric intensive care unit ( PICU ) is arguably one of the most emotionally demanding and high-stress areas where mental health clinicians may be asked to consult. This article describes medical crisis consultation in the PICU setting, suggests survival strategies for the mental health consultant to the PICU, and provides illustrative case examples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study on the behavior of pediatric intensive care unit nurses, concerning the care given to suicidal children

Pediatric intensive care units use sophisticated medical technology and are staffed by deeply committed nurses who are subjected to significant psychological stress. This stress varies with the type of patient and influences the style and quality of care. With this respect, children and adolescents admitted after a suicidal attempt are considered catalysts. However, there have been no systematic studies of how pediatric intensive care nurses respond emotionally to their interactions with these patients. This epidemiological study conducted in five Parisian Teaching Hospital pediatric intensive care units used a specially designed questionnaire to evaluate nurses' responses on the basis of style of care. Children under 16 years of age admitted after attempted suicide were studied comparatively with same age children admitted for status asthmaticus or encephalopathy with seizures. Results highlighted the differences in nurses' psychological responses to these situations and their difficulties in interacting with patients. This study provides strict methodological guidelines for investigating an issue often discussed emotionally or on the basis of anecdotal data.     

Routine portable chest radiographs in the medical intensive care unit: effects and costs

OBJECTIVE: To determine the effects and net costs of routine chest radiographs in a medical intensive care unit (ICU). DESIGN: A prospective, cohort study. A survey of experts in critical care and pulmonary diseases was undertaken to assess the effect of routine radiographs on patient management. SETTING: Medical ICU of a university hospital. PATIENTS: Eighty randomly selected patients admitted to a medical ICU. Two hundred fourteen experts were surveyed; 118 (55%)/214 responded. MEASUREMENTS AND MAIN RESULTS: Daily interviews with medical ICU clinicians were conducted to assess the radiographic findings in the routine radiographs and actions taken based on these findings. Experts evaluated the findings, their importance, the actions taken, and the probability of complications if the actions had not been taken at that time. Experts also predicted increases in length of stay associated with these complications. Presence of radiographic findings, changes in management because of the findings, net costs of routine chest radiographs, cost per finding that prompted an action, and expected changes in length of stay resulting from the actions were also assessed. Seventy-two (33%) of 221 routine radiographs (95% confidence interval: 25% to 39%) had findings, of which 44 (61%) were judged important, and 18 (8%, 95% confidence interval: 5% to 12%) prompted actions. Experts predicted that each action averted, on average, 2.1 +/- 1.7 days (SD) in the medical ICU. Mean savings per routine radiograph was $98. Net savings from routine chest radiographs remained after sensitivity analysis for expected change in length of stay, percentage of patients with routine radiographs, and percentage of routine radiographs that produce changes in management. CONCLUSION: The policy of obtaining routine chest radiographs in the medical ICU is effective and results in net savings.     

Bronchoscopy in the intensive care unit

With the prevalence of bronchopulmonary disease in the intensive care unit, bronchoscopy has become an essential tool for the management of patients. This article describes the variety of situations in which bronchoscopy can be of assistance in establishing diagnosis, managing the difficult airway, and supporting the patient's suffering of trauma, hemoptysis, atelectasis, and pneumonia.     

Decrease in costs for management of lower airway disease in the pediatric intensive care unit

PURPOSE: Hypertensive patients exhibit exaggerated cardiovascular responses to tracheal extubation. This study was undertaken to examine the inhibitory effects of calcium channel blockers, nicardipine and diltiazem, on haemodynamic changes after tracheal extubation. METHODS: Sixty hypertensive patients (ASA physical status II) undergoing elective orthopaedic (upper and lower extremity) surgery received, in a randomized, double-blind manner, 30 micrograms.kg-1 nicardipine, 0.2 mg.kg-1 diltiazem or saline (as a control) (n = 20 of each) i.v. before tracheal extubation. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and after tracheal extubation. RESULTS: The HR, MAP and RPP increased after tracheal extubation in the control group (P < 0.05). The increases in these haemodynamic variables were attenuated with nicardipine or diltiazem. The inhibitory effects of diltiazem on these cardiovascular responses to tracheal extubation were greater than those of nicardipine (HR; 86 +/- 7 vs 101 +/- 10, RPP; 11,437 +/- 1,575 vs 14,675 +/- 2,874, mean +/- SD, P < 0.05). CONCLUSION: Compared with nicardipine, administration of diltiazem produced greater attenuating the circulatory responses to tracheal extubation in hypertensive patients.     

Nosocomial infections in a neurosurgical intensive care unit

The occurrence of nosocomial infections in 1017 consecutive patients seen in a neurosurgical intensive care unit (ICU), over a period of 18 months is reported. The frequency of infections is low, which may possibly be due partly to the short stay in the ICU. Close interdisciplinary cooperation is stressed as an important factor in limiting infections. BACKGROUND. The aim of this study was to analyse the nosocomial infections in a neurosurgical intensive care unit over a period of 18 months, emphasizing localization and cause of infection, in order to adapt treatment and to take preventive measures. From 15% to 27% of patients treated in ICUs acquire nosocomial infections. In Germany this means 500,000-800,000 patients a year, and the annual costs related to nosocomial infections are estimated at 1.7 billion Deutschmarks. PATIENTS AND METHODS. In all, 1017 consecutive patients were evaluated. The patients were divided into two groups, depending on the duration of treatment in the ICU: Patients who remained for less than 48 h (1017 patients) Patients who were treated for a period exceeding 48 h (314 patients) The evaluation was performed retrospectively from the medical documentation. Criteria for registration are those of the Centers for Disease Control (Atlanta 1988). When more than one infection was diagnosed, each was considered as a new infection, regardless of the bacteria involved. Among the 314 patients who were in the ICU for more than 48 h a total of 114 nosocomial infections were recorded. The frequency of infection referred to all patients treated during that time (n = 1017) was 11.2%, while the frequency among those who were treated for longer than 48 h was 36.3%. Most infections (38.6%) affected the respiratory tract, followed by infections of the urinary tract. Of the bacteria determined 56.7% were gram-negative. In this group E. coli was the most frequently found (29.8%). In the group of gram-positive bacteria, S. aureus was diagnosed in 56.3% of cases. Twelve (16%) of the infected patients died and lethality referred to all patients was 8.6%. DISCUSSION. Compared with other studies, this study revealed a low the infection rate, at 11.2%. This can be explained partly by the short stay in this ICU (mean 3.7 days) and partly by the retrospective method of registration and the particular medical characteristics of neurosurgical patients. The well-known general risk factors for infection, such as age, mechanical ventilation, continuous catheterization of the bladder, and long duration of stay, are also found in neurosurgical ICUs. It is quite difficult to determine to what extent nosocomial infections prolong the treatment necessitated by the primary neurosurgical disease. We were not able to extrapolate the influence of immunosuppressant treatment on the appearance of nosocomial infections, as almost all patients in this study were receiving steroids. This study underlines the necessity of interdisciplinary cooperation between neurosurgeons, anaesthesiologists, microbiologists and nurses in neurosurgical ICUs, where most patients staying longer than 48 h are immunosuppressed and ventilated and thereby particularly at risk of nosocomial infections.     

Bedside tracheostomy in the intensive care unit

OBJECTIVE: To prove that tracheostomy performed at the bedside in the intensive care unit is a safe, cost-effective procedure. DESIGN: Retrospective review of all adult patients undergoing elective bedside tracheostomy in the intensive care unit between January 1983 and December 1988. Two hundred four patients were identified. SETTING: A private 1200-bed tertiary care center with a 120-bed critical care facility. MAIN OUTCOME MEASURES: Major and minor perioperative complications, cost savings, and comparison of risk between bedside tracheostomy and that performed in the operating room. RESULTS: There were six major complications (2.9%): one death due to tube obstruction, two bleeding episodes requiring reoperation, one tube entrapment requiring operative removal, one nonfatal respiratory arrest, and one bilateral pneumothorax; and seven minor complications (3.4%): five episodes of minor bleeding, one tube dislodgement in a tracheostomy with a well-developed tract, and one episode of mucus plugging. One late complication (tracheal stenosis) was identified. CONCLUSIONS: Bedside tracheostomy in the intensive care unit can be performed with morbidity and mortality rates comparable to operative tracheostomy. In addition, it provides a significant cost savings for the patient.     

Acute cholecystitis in the intensive care unit

The development of acute cholecystitis in the ICU is now a well-recognized complication of many acute illnesses that precipitate ICU admission and may also result as a complication of the subsequent treatment. The etiology of the disease remains obscure and, unlike acute cholecystitis outside the ICU setting, most cases are acalculous and not associated with gallstones. The disease may often go unrecognized due to the complexity of the patient's medical and surgical problems. Clinical examination is often unhelpful, as many patients are receiving mechanical ventilation and have decreased mental awareness. Biochemical markers are nonspecific and contribute to the delay in diagnosis and treatment. Early diagnosis is essential to avoid the high rates of associated morbidity and mortality. The diagnosis is usually made by radiologic tests, most often by sonographic examination of the gallbladder, which can be performed at the bedside. However, radiologic findings may also be nonspecific. The treatment involves gallbladder drainage by percutaneous cholecystostomy, which is usually curative in acalculous cholecystitis. Interval cholecystectomy is indicated for the remaining patients with gallstone-associated cholecystitis.     

Fungal infection in the intensive care unit

Fungal infection in critically ill patients is an increasingly prevalent problem. Candida spp. cause the majority of these infections in ICU. They occur most commonly in patients with severe underlying illness, multiple courses of antibiotics and intravascular catheters. Clinical diagnosis is difficult due to nonspecific signs and the frequent occurrence of widespread superficial colonization with Candida spp. in ventilated patients. Most patients are diagnosed using inferential evidence of infection, such as persistent pyrexia despite antibiotics, raised serum C-reactive protein and the presence of individual risk factors. Amphotericin B and fluconazole are the most commonly used anti-fungals dependent on the identity of the fungus. Most of these infections are endogenous; however, a proportion may be caused via the hands of healthcare staff or contaminated medical equipment.     

Hematologic emergencies in the intensive care unit

Hematologic emergencies in the oncology population may require an admission to the intensive care unit (ICU). Syndrome of inappropriate antidiuretic hormone, hypercalcemia, tumor lysis syndrome, and disseminated intravascular coagulation are diseases defined in this article. These are common conditions in oncology patients that are reduced or prevented with close monitoring and accurate assessments. The purpose of this article is to introduce intensive care nurses to these disease entities so they will have a better understanding of the care involved with an oncology patient in the ICU unit.     

Candidemia in the neonatal intensive care unit

The hospital records of 18 infants (9 males & 9 females) with one or more positive cultures for Candida species were studied retrospectively in an attempt to define the characteristics, associated factors and treatment for candidemia in the neonatal intensive care unit. The number of patients have increased recently and the mortality rate is 56% (10/18). The Candida species isolated from blood were Candida albicans in 16 cases and Candida parapsilosis in 2 cases. Fever, not-doing-well, and abdominal distention were the most common presentations, prompting us to the initial impression of bacterial sepsis and/or necrotizing enterocolitis. Eleven associated factors for candidemia were relating to the measures and therapy in the neonatal intensive care unit, such as prolonged use of broad-spectrum antibiotics, parenteral hyperalimentation etc. All of these 18 patients were treated with intravenous amphotericin B. Six patients were given adequate total dose (> 25 mg/Kg), while 12 patients underwent inadequate treatment (3.7 +/- 2.9 mg/Kg). The 10 fatal patients belonged to the inadequate treatment group. As there is continual progress in neonatal intensive care units, candidemia is becoming an increasing common problem and which deserves attention.     

Outbreak of influenza in a neonatal intensive care unit

An outbreak of influenza A/Victoria/3/75 (H3N2) involving five infants in a neonatal intensive care unit is described. The clinical signs and symptoms were indistinguishable from those seen in bacterial sepsis. There was no evidence of meningoencephalitis. All infants recovered without any sequelae.