David M. Nierman

Self-reported symptom experience of critically ill cancer patients receiving intensive care.

ObjectiveTo characterize the symptom experience of a cohort of intensive care unit (ICU) patients at high risk for hospital death. DesignProspective analysis of patients with a present or past diagnosis of cancer who were consecutively admitted to a medical ICU during an 8-month period. SettingAcademic, university-affiliated, tertiary-care, urban medical center. PatientsOne hundred cancer patients treated in a medical ICU. InterventionAssessment of symptoms. MeasurementsPatients’ self-reports of symptoms using the Edmonton Symptom Assessment Scale (ESAS), and ratings of pain or discomfort associated with ICU diagnostic/therapeutic procedures and of stress associated with conditions in the ICU. Main Results Hospital mortality for the group was 56%. Fifty patients had the capacity to respond to the ESAS, among whom 100% provided symptom reports. Between 55% and 75% of ESAS responders reported experiencing pain, discomfort, anxiety, sleep disturbance, or unsatisfied hunger or thirst that they rated as moderate or severe, whereas depression and dyspnea at these levels were reported by approximately 40% and 33% of responders, respectively. Significant pain, discomfort, or both were associated with common ICU procedures, but most procedure-related symptoms were controlled adequately for a majority of patients. Inability to communicate, sleep disruption, and limitations on visiting were particularly stressful among ICU conditions studied. ConclusionsAmong critically ill cancer patients, multiple distressing symptoms were common in the ICU, often at significant levels of severity. Symptom assessment may suggest more effective strategies for symptom control and may direct decisions about appropriate use of ICU therapies.

Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America

Objective:To update the practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit, for the purpose of guiding clinical practice. Participants:A task force of 11 experts in the disciplines related to critical care medicine and infectious diseases was convened from the membership of the Society of Critical Care Medicine and the Infectious Diseases Society of America. Specialties represented included critical care medicine, surgery, internal medicine, infectious diseases, neurology, and laboratory medicine/microbiology. Evidence:The task force members provided personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus was obtained. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. Consensus Process:The task force met twice in person, several times by teleconference, and held multiple e-mail discussions during a 2-yr period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the strength of the recommendation. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. Conclusions:The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the intensive care unit should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made.

High Cost of Stage IV Pressure Ulcers

BACKGROUND The aim of this study was to calculate and analyze the cost of treatment for stage IV pressure ulcers. METHODS A retrospective chart analysis of patients with stage IV pressure ulcers was conducted. Hospital records and treatment outcomes of these patients were followed up for a maximum of 29 months and analyzed. Costs directly related to the treatment of pressure ulcers and their associated complications were calculated. RESULTS Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts were reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was

Core temperature measurement in the intensive care unit

129,248 for hospital-acquired ulcers during 1 admission, and

Outcome prediction model for very elderly critically ill patients.

124,327 for community-acquired ulcers over an average of 4 admissions. CONCLUSIONS The costs incurred from stage IV pressure ulcers are much greater than previously estimated. Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce health care expenditures by millions of dollars.

Improving medical student intensive care unit communication skills : A novel educational initiative using standardized family members

ObjectiveTo compare three devices that measure core body temperature at the bedside in ICU patients. DesignProspective, consecutive sample. SettingVoluntary community teaching hospital. PatientsFifteen patients, 78 ± 6 (SD) yrs of age, admitted to the medical ICU over a 5-month period who had pulmonary artery catheters inserted as part of their routine care were studied. Thirteen patients were studied once, one patient twice, and one patient six times for a total of 21 sets of measurements. InterventionsAll patients had urinary bladder thermistor catheters inserted just before pulmonary artery catheterization. Simultaneous core temperatures were measured for the duration of pulmonary artery catheterization every 4 hrs by the pulmonary artery thermistor catheter, the bladder thermistor catheter, and by a tympanic membrane infrared probe set on its core temperature setting. The three devices were then compared with each other in vitro using a specialized constant water bath setup. Finally, two of the tympanic membrane infrared probes were compared with each other in 20 ambulatory emergency department patients. Measurements and Main ResultsOver 32 hrs of pulmonary artery catheterization, the pulmonary artery thermistor catheters and bladder thermistor catheters showed excellent agreement, with a bias of only −0.04°C between the two. However, the bias comparing the tympanic membrane infrared probe with the pulmonary artery thermistor catheter was −0.38°C, and the bias was −0.34°C comparing the tympanic membrane infrared probe with the bladder thermistor catheter. The tympanic membrane infrared probe readings remained significantly higher than the pulmonary artery thermistor catheter or bladder thermistor catheter readings over the entire 32-hr period. The two tympanic membrane infrared probes compared with each other in emergency room patients showed excellent agreement (p < .001). In the in vivo water bath setup, the tympanic membrane infrared probe on most of its settings again registered significantly (p < .01) higher than both the pulmonary artery thermistor catheter and the bladder thermistor catheter. ConclusionsPulmonary artery thermistor catheters and bladder thermistor catheters appear to give consistent, highly reliable bedside measurements of core body temperature in ICU patients. The currently available device that measures core body temperature from the tympanic membrane appears to give erroneously high readings, and should be used with caution.

Hypotestosteronemia in chronically critically ill men.

ContextVery elderly critically ill patients have three possible hospital outcomes: discharge to home, discharge to a skilled nursing or rehabilitation facility, or death. The factors associated with these outcomes are unknown. ObjectiveTo develop a three-outcome prediction model for very elderly critically ill patients. DesignRetrospective chart abstraction with ordered logistic regression analysis. SettingAcademic medical center. PatientsFour hundred and fifty-five patients 85 yrs or older admitted to intensive care units (ICU) during 1996 and 1997. Measurements and Main Results A fitted ordinal logistic regression predictive model was developed using data from 243 patients hospitalized in 1996, and validated on data from 212 patients hospitalized in 1997. Model variables include age, gender, baseline support level, type of ICU, heart rate at ICU admission, use of mechanical ventilation, vasopressors or a pulmonary artery catheter during the ICU stay, and the development of respiratory, neurologic or hematologic failure or sepsis while in the ICU. When tested on the 1997 data, the model was well calibrated and had a high discriminant index. ConclusionsThis mathematical model can be used to predict the risks of these three hospital outcomes for this population of patients. These predictions can provide a context when discussing goals and expectations with patients, families, and other healthcare providers and to aid in hospital discharge planning.

A structure of care for the chronically critically ill.

Objective:To determine whether intensive care unit (ICU) communication skills of fourth-year medical students could be improved by an educational intervention using a standardized family member. Design:Prospective study conducted from August 2003 to May 2004. Setting:Tertiary care university teaching hospital. Participants:All fourth-year students were eligible to participate during their mandatory four-week critical care medicine clerkship. Interventions:The educational intervention focused on the initial meeting with the family member of an ICU patient and included formal teaching of a communication framework followed by a practice session with an actor playing the role of a standardized family member of a fictional patient. At the beginning of the critical care medicine rotation, the intervention group received the educational session, whereas students in the control group did not. Measurements and Main Results:At the end of each critical care medicine rotation, all students interacted with a different standardized family member portraying a different fictional scenario. Sessions were videotaped and were scored by an investigator blinded to treatment assignment using a standardized grading tool across four domains: a) introduction; b) gathering information; c) imparting information; and d) setting goals and expectations. A total of 106 (97% of eligible) medical students agreed to participate in the study. The total mean score as well as the scores for the gathering information, imparting information, setting goals, and expectations domains for the intervention group were significantly higher than for the control group (p < .01). Conclusions:The communication skills of fourth-year medical students can be improved by teaching and then practicing a framework for an initial ICU communication episode with a standardized family member.

Critical illness neuromuscular abnormalities

OBJECTIVE To determine the prevalence of hypotestosteronemia in chronically critically ill (CCI) men. DESIGN Prevalence survey. SETTING Step-down respiratory care unit (RCU) at a tertiary care teaching hospital. PATIENTS Thirty ventilator-dependent CCI men transferred from intensive care units (ICUs) within the same institution. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Total testosterone and bioavailable testosterone (bioT) concentrations were measured within 48 hrs of RCU admission. Patients were hospitalized a median of 40 days (range, 9-185 days) before RCU admission, with a median ICU length of stay of 25 days (range, 9-177 days). At RCU admission, total testosterone concentrations averaged 104+/-96 ng/dL, with average bioT concentrations of 19+/-20 ng/dL (16+/-9% of total testosterone). Twenty-nine of the 30 patients (96%) had bioT concentrations well below the lower limit of normal for their age range. bioT concentrations, expressed as a percentage of the normal mean for each patients age range, were positively correlated with the number of days that the patient was in the ICU before transfer to the RCU (n = 30, r2 = .17, p = .025). However, if the single patient who remained in the ICU for 177 days was excluded, this correlation disappeared (n = 29, r2 = .07, p = .09). No other relationship was found between bioT concentrations and any other variable, including type of patient, ICU length of stay, reason for either initial admission to the ICU or prolonged mechanical ventilation, type of nutritional support, or use of dopamine. CONCLUSIONS CCI men have a very high prevalence of hypotestosteronemia, which may impede their recuperation and rehabilitation. Further studies are needed to determine whether additional pharmacologic treatment with testosterone can improve the recovery of these patients.

Pressure ulcers in the chronically critically ill patient

The chronically critically ill (CCI) are complicated, labor-intensive, and costly patients to care for. A defined structure of care with different focuses at the beginning, middle, and end of a care episode may improve their outcomes and resource utilization. This article reviews the prediction of CCI, outlines some unifying processes of care during an episode of chronic critical illness, and explores some of the difficulties in defining consistent goals of care for this patient population.