Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS: Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.     

Changes of carbohydrate-deficient transferrin in chronic alcoholism

Compared with other well established liver enzyme parameters, carbohydrate-deficient transferrin (CDT) offers a new method for the identification of chronic alcoholism. The dependence of CDT and alcoholism/abstinence was studied in 29 controls and 64 alcoholics (both groups comprising men and women). In contrast to the currently used parameters GOT, GPT, gammaGT, LDH and MCV, CDT measures chronic alcoholism exclusively. CDT is dependent on sex but not age. In chronic alcoholism its rate increases significantly, but drops quickly after a short time of abstinence. CDT variations may be a specific and sensitive indicator of alcoholism or abstinence and possibly the duration.     

Usefulness of carbohydrate-deficient transferrin in alcohol-elated problems

BACKGROUND: Carbohydrate-Deficient Transferrin (CDT) is a new marker for excessive alcohol drinking. It appears to be useful to detect alcoholism, harmful consumption and relapse. It have been introduced in our country recently. METHOD: Recent studies about utility of CDT have been reviewed. RESULTS: Sensitivity and specificity of CDT level as a marker of alcoholism were 72-97% and 31-81% respectively. As a marker of harmful consumption its sensitivity was 15-69% and its sensitivity was higher than 82%. CDT was demonstrated to be a effective maker for evaluating alcoholic abstinence in alcoholic patients. CONCLUSIONS: CDT determinations have a high specificity for screening heavy drinking in different settings. Problems related to its sensitivity are discussed.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Work redesign in the intensive care unit setting

One of the most challenging things that health care providers can be asked to do is change the way that they practice. This article describes such a scenario. The staff of one particular surgical intensive care unit, caring primarily for open-heart surgery patients, has been challenged to increase its nurse:patient ratio without compromising the quality care that staff has been accustomed to providing. This article reviews the process of data gathering, the evaluation of data, and the implementation of the nurse:patient ratio changes. It also describes the outcome criteria used to evaluate the practice changes.     

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.     

Nosocomial infections in an oncology intensive care unit

INTRODUCTION: Treatment of cancer has contributed to a growing number of immunocompromised patients with life-threatening nosocomial infections (NI). High mortality with considerable cost is observed when they are admitted to the intensive care unit (ICU). Few studies on infection control and surveillance have been undertaken in this population group. METHODS: All patients treated at a six-bed medical-surgical oncology ICU for > 48 hours were prospectively observed for the development of an NI and the influence of device utilization on infection rates. The analysis used the standard definitions of the National Nosocomial Infection Surveillance System Intensive Care Unit surveillance component. RESULTS: From September 1993 through November 1995, 370 infections occurred in 623 patients during 4034 patient-days, for an overall rate of 50.0 per 100 patients or 91.7 per 1000 patient-days. Pneumonia (28.9%), urinary tract infections (25.6%), and bloodstream infections (24.1%) were the main types of infection. The most common microorganisms isolated were Enterobacteriaceae (29.7%), fungi (22.2%), and Pseudomonas aeruginosa (13.2%). The median device utilization ratios were 0.63, 0.83, and 0.86 for ventilator, indwelling urinary catheter, and central venous catheter, respectively. The highest median device-specific associated infection rate was 41.7 for ventilator. The median for the average length of stay was 8.8 days, and the average severity of illness score was 4.0. There was a strong positive correlation between the overall NI patient rate and device utilization (r = 0.56, p < 0.01), average severity of illness score (r = 0.54, p < 0.01), and average length of stay (r = 0.67, p < 0.01). No correlations were statistically significant when patient-days were used in the denominator. Among the devices only the number of central venous catheter days was significantly correlated with infections (r = 0.51, p = 0.01). The NI patient-day rates were progressively higher the longer the patients stayed in the ICU. CONCLUSIONS: The high rates reported in this study may reflect a combination of several factors related to the underlying illness, neutrophil count, and exposure to invasive procedures. The adjusted infection rates described here provide specific surveillance data for further interhospital comparisons and also to assess the influence of invasive medical interventions, allowing the implementation of preventable measures to control infections.     

Ethics of allocating intensive care unit resources

ICU clinicians commonly make decisions that allocate resources. Because of the high cost of ICU care, these practitioners can expect to be involved in the growing dilemma of trying to meet increasing demand for healthcare services within financial constraints. In order to participate meaningfully in a societal discussion over fairness in allocating scare and expensive resources, ICU practitioners should have more than a superficial knowledge of the principles of distributive justice. Distributive justice refers to fairness in the distribution of limited resources and benefits. Fairness refers to giving equal treatment to all those who are the same with regard to certain morally significant characteristics and treating in a different manner those who are not the same. Although theoretical issues remain unresolved as to which characteristics should be most significant, the United States has a strong cultural value that regards individuals as inherently valuable and having equal social worth. From this, it is likely that only an egalitarian approach to allocation of lifesaving healthcare resources will be acceptable. Studies of how ICU resources have been allocated during times of scarcity indicates that, in general, when beds are scarce, the average severity of illness of those admitted to the ICU increases. However, in some hospitals, political and economic factors appear to play important roles in determining who has access to scarce ICU beds. Of great concern is documentation of a widespread pattern in which fewer hospital resources, including ICU resources, are provided to seriously ill patients of minority status or with low levels of insurance reimbursement. How society's values get translated into allocation decisions is another unresolved issue. One recent example of how this occurred is the Oregon Medicaid Plan. This plan extended Medicaid coverage to additional people in poverty, despite the same amount of state and federal funds. This was accomplished by not reimbursing what were regarded as marginally beneficial services on the basis of medical and community input. Portents of how society might be involved in the future of health care are illustrated by the argument that society should limit access to all therapies except palliative care solely on the basis of advanced age. Until an open consensus develops in U.S. society about how to allocate scarce healthcare resources, the delivery of ICU care will continue to be at risk of covert, de facto rationing based on ability to pay, race, or other nonmedical personal characteristics.