Jaap E. Tulleken

Efficacy of Magnesium-Amiodarone Step-Up Scheme in Critically Ill Patients With New-Onset Atrial Fibrillation: A Prospective Observational Study

Amiodarone is considered a first-choice antiarrhythmic drug in critically ill patients with new-onset atrial fibrillation (AF). However, evidence supporting the use of this potentially toxic drug in critically ill patients is scarce. Magnesium sulphate (MgSO 4) has shown to be effective for both rate and rhythm control, to act synergistically with antiarrhythmic drugs, and to prevent proarrhythmia. Treatment with MgSO4 may reduce the need for antiarrhythmic drugs such as amiodarone in critically ill patients with new-onset atrial fibrillation. The efficacy of a new institutional protocol was evaluated. Patients were treated with a new institutional protocol for new-onset atrial fibrillation in critically ill patients. An MgSO4 bolus (0.037 g/kg body weight in 15 minutes) was followed by continuous infusion (0.025 g/kg body weight/h). Intravenous amiodarone (loading dose 300 mg, followed by continuous infusion of 1200 mg/24 h) was given to those not responding to MgSO4 within 1 hour. Clinical response was defined as conversion to sinus rhythm or decrease in heart rate <110 beats/min. Sixteen of the 29 patients responded to MgSO4 monotherapy, whereas the addition of amiodarone was needed in 13 patients. Median (range) time until conversion to sinus rhythm after MgSO4 was 2 (1-45) hours. Median (range) conversion time in patients requiring amiodarone was 4 (2-78) hours, and median (range) conversion time in all patients was 3 (1-78) hours. The 24-hour conversion rate was 90%. Relapse atrial fibrillation was seen in 7 patients. The magnesium-amiodarone step-up scheme reduces the need for amiodarone, effectively converts new-onset atrial fibrillation into a sinus rhythm within 24 hours, and seems to be safe in critically ill patients.

A good death

We describe the cases of two patients discharged home directly from the ICU. Both patients had the strong wish to die at home after being told that there were no therapeutic options. Sometimes discharge is feasible and can mean very much for patients and their family. Taking measures to ensure axa0“good deathbed” is an obligation for doctors and nursing staff. However, due to the focus on cure this palliative goal is not always pursued.

Quality improvement of interdisciplinary rounds by leadership training based on essential quality indicators of the Interdisciplinary Rounds Assessment Scale

PurposeThe implementation of interdisciplinary teams in the intensive care unit (ICU) has focused attention on leadership behavior. Daily interdisciplinary rounds (IDRs) in ICUs integrate leadership behavior and interdisciplinary teamwork. The purpose of this intervention study was to measure the effect of leadership training on the quality of IDRs in the ICU.MethodsA nonrandomized intervention study was conducted in four ICUs for adults. The intervention was a 1-day training session in a simulation environment and workplace-based feedback sessions. Measurement included 28 videotaped IDRs (total, 297 patient presentations) that were assessed with 10 essential quality indicators of the validated IDR Assessment Scale. Participants were 19 intensivists who previously had no formal training in leading IDRs. They were subdivided by cluster sampling into a control group (ten experienced intensivists) and intervention group (nine intensive care fellows). Mann–Whitney U test was used to compare results between control and intervention groups.ResultsBaseline measurements of control and intervention groups revealed two indicators that differed significantly. The frequency of yes ratings for the intervention group significantly increased for seven of the ten indicators from before to after intervention. The frequency of yes ratings after training was significantly greater in the intervention than control groups for eight of the ten essential quality indicators.ConclusionsThe leadership training improved the quality of the IDRs performed in the ICUs. This may improve quality and safety of patient care.

The effect of chronotype on sleepiness, fatigue, and psychomotor vigilance of ICU nurses during the night shift.

PurposeIn general, sleeping and activity patterns vary between individuals. This attribute, known as chronotype, may affect night shift performance. In the intensive care unit (ICR), night shift performance may impact patient safety. We have investigated the effect of chronotype and social demographics on sleepiness, fatigue, and night shift on the performance of nurses.MethodsThis was a prospective observational cohort study which assessed the performance of 96 ICU night shift nurses during the day and night shifts in a mixed medical–surgical ICU in the Netherlands. We determined chronotype and assessed sleeping behaviour for each nurse prior to starting shift work and before free days. The level of sleepiness and fatigue of nurses during the day and night shifts was determined, as was the effect of these conditions on psychomotor vigilance and mathematical problem-solving.ResultsThe majority of ICU nurses had a preference for early activity (morning chronotype). Compared to their counterparts (i.e. evening chronotypes), they were more likely to nap before commencing night shifts and more likely to have young children living at home. Despite increased sleepiness and fatigue during night shifts, no effect on psychomotor vigilance was observed during night shifts. Problem-solving accuracy remained high during night shifts, at the cost of productivity.ConclusionsMost of the ICU night shift nurses assessed here appeared to have adapted well to night shift work, despite the high percentage of morning chronotypes, possibly due to their 8-h shift duration. Parental responsibilities may, however, influence shift work tolerance.

Pharmacokinetics of cefpirome in critically ill patients with renal failure treated by continuous veno-venous hemofiltration

Objective: To study the cefpirome pharmacokinetics of patients with sepsis and multiple organ failure treated with CVVH. Design: Measurements of serum and ultrafiltrate (UF) concentrations and in vitro sensitivity testing of isolated micro-organisms. Setting: University hospital-based, single ICU. Patients: Six critically ill CVVH- dependent patients with sepsis and multiple organ dysfunction syndrome in need of antimicrobial therapy. Age range: 60–75 years; APACHE II score for severity of illness on admission: 19–30. One patient survived. Interventions: Cefpirome i. v. was started at 2 g in 30 min, then continued 1 g i. v. b. i. d. Measurements: The UF rate was 27 ± 7 ml/min on day 1 and 34 ± 2 ml/min on day 2. Serum and ultrafiltrate samples were measured by a validated high performance liquid chromatography assay. Volume of distribution: 23 · 5(SD ± 4 · 6) l. Total cefpirome clearance was 32 ± 6 · 3 ml/min; cefpirome CVVH clearance (ClCVVH): 17 ± 4.2 ml/min; mean serum half-life (t1/2): 8.8 ± 2.3 h; mass transfer on day 1: 660 ± 123 mg/12 h (33 ± 6 % of administered dose)and day 2: 642 ± 66 mg/12 h (64 ± 7 %). Estimated sieving coefficient (ClCVVH/UF rate): 64 ± 11 %. In vitro sensitivity of isolated microbes was excellent except for two non-sensitive enterococci and Candida spp. Conclusions: The sieving coefficient (64 %) indicates that a substantial fraction of the drug is not filtered; clearance by pathways other than CVVH mounted to 50 % of the total clearance and increased on day 2, indicating that the dosing schedule used is appropriate for this setting. Cefpirome appeared to be safe in these patients and effective for most of the nosocomial microbial isolates. During more than 90 % of the time, serum levels were maintained above killing concentrations for susceptible micro-organisms.

Prone position in a spontaneously breathing near-drowning patient

Sir: In 1977 Douglas et al. [1] first observed improvement in arterial oxygen tension (PaO2) by prone positioning that prevented the need for mechanical ventilation in a patient with acute lung injury. Now, we describe a second case with moderate respiratory insufficiency where managing the spontaneously breathing patient in the prone position avoided the need for endotracheal intubation and mechanical ventilation. A 16-year-old boy with a history of epilepsy was admitted to hospital with acute, moderate respiratory insufficiency resulting from near drowning after a generalized seizure. On examination his temperature was 37.5 C and blood pressure 130/ 80 mmHg. He was slightly confused, there were spontaneous movements of the extremities and idiomuscular reflexes were present. Cardiac and abdominal examination revealed no specific abnormalities. He presented with tachypnea and mild cough and produced frothy blood-tinged sputum. His respiration rate varied between 30 and 40 breaths/min. Oxygen was applied through a face mask [approximate fractional inspired oxygen (FIO2) of 0.40]. On auscultation, crackles were noted over the left lung. Moderate respiratory insufficiency was based on the clinical symptoms and the PaO2/FIO2 was 31 kPa (233 mmHg). In order to improve gas exchange and reduce the work of breathing in our patient, we considered continuous positive airway pressure by face mask, but we first tried the prone position. The positional change was well tolerated and resulted in a remarkable clinical recovery with improved oxygenation: PaO2 rose from 12.5 to 22 kPa, arterial carbondioxide tension from 5.7 to 6.0 kPa, and the alveolar-arterial oxygen difference changed from 17.8 kPa (134 mmHg) to 4.1 kPa (33.2 mmHg) within 2 h. As a result, the high fractional inspired oxygen was tapered down. Chest radiograph in the supine position showed left unilateral consolidations (Fig.1a). On the chest radiographs (taken in the supine position) after 3 and 20 h of prone position, the pulmonary abnormalities had resolved (Figs.1b and 1c). The patient made an uneventful recovery, mechanical ventilation was redundant and he was discharged from hospital on day 4. While there seems to be little doubt of the beneficial effects of prone position on oxygenation in mechanically ventilated patients with the acute respiratory distress syndrome (ARDS) [2,3], it remains unclear whether the same holds true in moderate respiratory insufficiency. In our patient, prone positioning rapidly reversed hypoxemia and prevented the necessity of orotracheal intubation and mechanical ventilation. Prone position alters the transpulmonary pressure in the atelectatic dorsal lung regions with a reduction in VA/Q mismatch and shunt [4]. The observed improvement in the alveolar-arterial oxygen difference coincided with favorable changes in radiographic appearance when the patient was turned from the supine to the prone position. Whether the changes in transpulmonary pressure due to maneuvering the body position of our patient are of an order of magnitude sufficient to open consolidated pulmonary units has often been suggested but is still questioned [5]. Perhaps the overall improvement in aeration observed in our patient is an additive Intensive Care Med (1999) 25: 1469±1478 Ó Springer-Verlag 1999 CORRESPONDENCE

Non-conventional mechanical ventilation in severe ARDS, illustrated by a complicated case

When conventional respiratory strategies fail to maintain adequate oxygenation treatment of severe ARDS is largely empirical. Modern techniques such as inverse ratio ventilation, permissive hypercapnia, NO inhalation and lowering tidal volumes/pressures are advocated. We report on a patient with severe ARDS who showed all the complications of the disease. The risks and benefits of (non)conventional ventilatory strategies are discussed and illustrated.

& Pain Well-performed interdisciplinary rounds as a strategy to increase quality of care in the intensive care unit

Abstract Introduction An interdisciplinary round is a patient-focused communication system aimed to agree to, understand and execute the appropriate plan of care for the patient by specialists from different disciplines. In the intensive care unit, interdisciplinary rounds are increasingly recommended because ineffective interdisciplinary communication among medical teams is a leading cause of preventable patient harm and a source of xadseverexadconflicts.xad In recent years, intensive care unit management and staff have conducted these interdisciplinary rounds by bringing different disciplines in the same meeting to discuss diagnosis and disease management of the intensive care unit patient. Nevertheless,xad itxadprovesxaddifficultxadtoxadadequatelyxad perform these meetings, because each profession within the intensivexadcarexadunitxadhasxadaxaduniquexadperspective and professional culture. Previous studies about interdisciplinary rounds were in particular survey studies, which described the differences between doctors and nurses regarding status/authority, gender, training and patient care responsibilities. We therefore developed performance improvements, based on 60 videotaped interdisciplinary rounds, literature reviews and Delphi Rounds, aimed at supporting and xadincreasingxadthexadqualityxadofxadxadperformancexad in IDRs. We discuss here the applications of these performance improvements with reference to processes within interdisciplinary rounds as a strategy for improving ICU care. Conclusion This review discusses the observation and intervention applications of performance improvements for interdisciplinary rounds. Depending on the characteristics of the intensivexad carexad unit,xad suchxad asxad staffingxad levelxad and open versus closed unit type, work rounds being interdisciplinary rounds in crowded hallways, or teaching obligations, the intensive care unit staff have some options to choose for which instrument(s) to apply.

Leitung der interdisziplinären Visite – Training lohnt sich

Auf vielen Intensivstationen sind multidisziplinare Visiten etabliert. Arzte, Pflegepersonal sowie Vertreter weiterer therapeutischer Disziplinen sind daran beteiligt. Wie sich ein spezielles Training auf die Leitung dieser Visiten auswirkt, testete ein niederlandisches Autorenteam.