Martin Boyle

Pressure sores in intensive care: defining their incidence and associated factors and assessing the utility of two pressure sore risk assessment tools

Patients in intensive care units (ICU) are at high risk of developing pressure sores and the use of pressure sore risk tools has been advocated as a means of identifying patients at risk. A prospective multi-site observational study was conducted to define the incidence of pressure sores, assess two pressure sore risk scales and to define risk factors relevant to intensive care. Patients (n = 534) were assessed for the presence of pressure sores. The Waterlow and Jackson/Cubbin risk scales were completed each day for 314 and 188 of these patients respectively. A total of 75 pressure sores were recorded. Of these, 34 were present on admission. Of the remaining 41, 16 were classified as Grade 1 and 24 as Grade 2 sores. The pressure sore (PS) incidence was 5.2 per cent. Expressed as PS/1000 patient days there were 18.48 pressure sores per 1000 patient days. The ability of the risk scores to predict pressure sores was tested using a Receiver Operating Characteristic (ROC) analysis. The association of risk score with pressure sores was analysed using a survival function (Kaplan Meier) and variables compared using a logrank test (Mantel-Cox). Factors associated with pressure sore occurrence were developed and tested using a survival regression model. Both risk scales were poor predictors of pressure sores (ROC curve area approximately 70 per cent for both). The factors, coma/unresponsiveness/paralysed & sedated and cardiovascular instability were significantly associated with pressure sores with relative risks of 4.2 and 2.5 respectively. Risk increased as a function of time such that the cumulative risk was 50 per cent at 20 days.

The effect of chronic pain on health related quality of life amongst intensive care survivors

Intensive care unit (ICU) survivors report reductions in health-related quality of life (HR-QOL), whilst chronic pain is common in the general population. However, it is unknown whether there are associations between the experience of ICU and the incidence of chronic pain. A questionnaire--Pain Scale, Pain Self-Efficacy Questionnaire (PSEQ), Centre of Epidemiology Study Depression Scale (CES-D Scale) and the Short Form Health Survey (SF-36)--was sent to 99 consenting patients who had been in the ICU for >48 hours. Sixty-six and 52 questionnaires were returned at 1 and 6 months respectively. There was a general limitation in activities of daily living; younger ages (36-65 years) experienced a decease in work performance and other physical activities. Bodily pain increased, general health diminished, and engagements in social activities were severely affected. There was a decline in mental health for those 36-65 years of age. HR-QOL improved over time; 28% experienced chronic pain and had longer hospital length of stay (LOS), tended to have longer ICU LOS and were ventilated for longer. Those with chronic pain had significant reductions in physical function, bodily pain, general health and vitality. Ventilator hours and hospital LOS were associated with risk of chronic pain (OR 1.09, p=0.033 and OR 1.27, p=0.046). HR-QOL in ICU survivors declined, although there was a general improvement from 1-6 months. This decline in HR-QOL affected younger people (less than 65 years) more than older people. Chronic pain is a significant issue post ICU and is associated with poorer HR-QOL.

Eyecare in the critically ill: Clinical practice guideline

OBJECTIVE The Intensive Care Collaborative project was established with the specific aim of developing recommendations for clinical practice that are underpinned by the best available evidence to support the objective of improving the standard of care delivered in NSW Intensive Care Units. The eyecare clinical practice guideline for intensive care patients were developed as a result of this initiative. METHODS Search: The bibliographic databases (PubMed; The Cummulative Index of Nursing and Allied Health Literature (CINAHL); Medline and The Cochrane Library) were searched. The search terms used alone and in combination were: intensive care; prevention; eye; eyecare; and guidelines. In addition, reference lists of relevant papers were assessed to identify additional studies and Google Scholar was searched using the keywords eyecare and intensive care. The search strategy was limited to the English language but was not limited by year of publication. Study selection criteria: All relevant observational and interventional studies were included, regardless of study design. Review process: Each paper was reviewed by at least two Guideline Development Network (GDN) members independently using a data extraction tool. Papers were assessed against the National Health and Medical Research Council (NHMRC) levels of evidence. Recommendations were assigned using a modified Delphi process to ensure consensus. SUMMARY OF RECOMMENDATIONS We recommend that each patient is assessed for the risk factors of iatrogenic ophthalmologic complications; the ability to maintain eyelid closure; for iatrogenic ophthalmologic complications. It is also recommended that; the rates of iatrogenic ophthalmologic complications are monitored; referral is made in a timely manner for any suspected iatrogenic ophthalmologic complications; eyelid closure is maintained if eyelid closure cannot be maintained passively; all patients who cannot achieve eyelid closure independently should receive eye care every 2h. CONCLUSIONS The recommendations from this clinical practice guideline were peer-reviewed and examined by ophthalmology experts. Despite the heavy reliance on only a small number of studies and low level of evidence, the recommendations have the potential to positively affect patient outcomes by encouraging clinicians to assess and monitor for ophthalmological complications and to provide appropriate preventative interventions if implemented extensively.

Paracetamol induced skin blood flow and blood pressure changes in febrile intensive care patients: An observational study

OBJECTIVE To determine the relationship between paracetamol administration and skin blood flow (skBF) and blood pressure (BP) in critically ill patients treated for fever. DESIGN Prospective, observational study. SETTING Intensive care units of university teaching hospital. PATIENTS 29 adults (17 males and 12 females), aged 58±15 years treated with enteral or intravenous paracetamol for fever. APACHE II score was 17.2±8.3 and admission classifications were 41% medical (n=12), 31% surgical (n=9), and 28% neurological intervention (n=8). Thirty healthy afebrile volunteers were also studied after ingesting 1g paracetamol. MEASUREMENTS AND MAIN RESULTS Temperature, BP and skBF (laser Doppler flowmetry perfusion units) were recorded 15 min prior to administration of paracetamol, at administration (T0) and then for every 15 min for 60 min. Cutaneous vascular conductance (CVC=skBF/mean arterial pressure) was calculated. Thirty data sets were recorded from 29 patients. Temperature at T0 was 38.7±0.6°C. BP decreased over the study period whilst skBF and CVC increased (repeated measured ANOVA, p<.05). Systolic BP decreased significantly (p<.01) at all post-administration times and was 90±13% of T0 at 60 min. CVC was 128±48% of T0 at 60 min. Systolic BP fell by a clinically significant amount (≥15%) in 17 patients (59%) and hypotension was treated during 33% (n=10) of the observation periods. BP and skBF did not change significantly in afebrile volunteers. CONCLUSIONS Paracetamol induced increases in skBF consistent with its antipyretic action and may be associated with significant falls in BP in the critically ill.

Equipment review: the molecular adsorbents recirculating system (MARS).

The molecular adsorbents recirculating system (MARS®) is a form of artificial liver support that has the potential to remove substantial quantities of albumin-bound toxins that have been postulated to contribute to the pathogenesis of liver cell damage, haemodynamic instability and multi-organ failure in patients with acute liver failure (ALF) and acute-on-chronic liver failure (AoCLF). These toxins include fatty acids, bile acids, tryptophan, bilirubin, aromatic amino acids and nitric oxide. Data from controlled clinical trials are limited so far. One of two studies performed on small numbers of patients with AoCLF suggest a survival benefit, but no controlled data are available in the ALF setting. Our preliminary experience with MARS therapy, instituted late in the clinical course of five patients with severely impaired liver function, including three with AoCLF precipitated by sepsis and two with liver dysfunction due to sepsis in the absence of pre-existing chronic liver disease, indicates some clinical efficacy. However, the overall survival rate (1 of 5; 20%) remained poor. More data obtained from larger cohorts of patients enrolled in randomised controlled studies will be required in both the AoCLF and ALF settings to identify categories of liver failure patients who might benefit most from MARS treatment, to ascertain the most appropriate timing of intervention and to determine the overall impact on outcome, including cost-effectiveness.

Introduction to an alternate view of acid/base balance: The strong ion difference or stewart approach

Abstract The carbonic acid/bicarbonate system, as defined by the Henderson-Hasselbach (H-H) equation1, has traditionally formed the centrepiece of the presentation of acid/base physiology in nursing education. However, an alternative approach to describe acid/base physiology was proposed by Peter Stewart in 19832. Stewart determined, using the physiochemical principles of dissociation equilibrium, electroneutrality and conservation of mass, that hydrogen ion concentration [H+] was dependent upon the difference between the concentrations of strong cations and strong anions in a solution (the strong ion difference or SID), concentration of weak acid anions, and the partial pressure of carbon dioxide in plasma. Therefore, a change in pH (the [H+] expressed as its negative log) indicates that there must be a change in one of these independent variables, and not simply explained by movement of hydrogen ions or bicarbonate into or out of the body fluids. An analysis of the complex acid/base derangements commonly seen in the critically ill can be achieved using this approach. The acid/base consequences of vomiting, gastric aspiration, diarrhoea, diuretic therapy, the infusion of large volumes of normal saline, the contribution of lactate, and the effects of methanol and ethylene glycol poisoning can all be more readily understood considering Stewarts explanation of acid/base balance. This paper outlines this alternative approach and provides some examples for the intensive care setting.

The Development of the Australian Basic Intensive Care Knowledge Test

The Basic knowledge Assessment Tool (BKAT), a test developed in the United States, has been presented as a valid and reliable test of basic knowledge for critical care nursing. However, it was necessary to determine the BKATs validity and reliability in the Australian intensive care (IC) context. The Delphi technique, utilising a panel of eleven experts, was used to determine the content validity of the BKAT. The Delphi process resulted in the development of a test with 105 questions. These questions consist of 49 original BKAT questions, 25 original BKAT questions slightly modified, 3 original BKAT questions with major modifications and 28 new questions. A criterion group design was used to establish the modified tests reliability and decision validity. Item analysis was undertaken using item difficulty and item discrimination indexes. The modified test was completed by 14 registered nurses with no IC experience, 18 registered nurses with intermediate IC experience and 25 registered nurses qualified as intensive care specialists. The mean score (and standard deviation) for the test for each of the respective groups was 41(9), 69(9) and 86(7). These results were significantly different (p < 0001). The reliability was established with a Cronbach Alpha coefficient of .96. The modified test is a reliable and valid measure of IC basic knowledge and can be used as a valuable adjunct in the assessment of IC orientation programs.

Study to validate the outcome goal, competencies and educational objectives for use in intensive care orientation programs

Intensive care orientation programs have become an accepted component of intensive care education. To date, however, there have been no Australian-based standards defining the appropriate level of competence to be attained upon completion of orientation. The aim of this study was to validate a set of aims, competencies and educational objectives that could form the basis of intensive care orientation and which would ensure an outcome standard of safe and effective practice. An initial document containing a statement of the desired outcome goal, six competency statements and 182 educational objectives was developed through a review of the orientation programs developed by the investigators. The Delphi technique was used to gain consensus among 13 nurses recognised for their expertise in intensive care education. The expert group rated the acceptability of each of the study items and provided suggestions for objectives to be included. An approval rating of 80 per cent was required to retain each of the study items, with the document refined through three Delphi rounds. The final document contains a validated statement of outcome goal, competencies and educational objectives for intensive care orientation programs.

THIS ARTICLE HAS BEEN RETRACTED: An Australian Experience With the Molecular Adsorbents Recirculating System (MARS)

Abstract:  The molecular adsorbents recirculating system (MARS) is a form of artificial extracorporeal liver support which has the potential to remove substantial quantities of albumin‐bound toxins postulated to contribute to the pathogenesis of liver cell damage, hemodynamic instability and multi‐organ failure in patients with acute liver failure and acute‐on‐chronic liver failure (AoCLF). We assessed the efficacy of MARS therapy in a cohort of patients with severe liver damage unresponsive to intensive medical therapy. MARS therapy was instituted late in the clinical course of six patients with severely impaired liver function refractory to intensive medical therapy, including four with AoCLF precipitated by sepsis and two with liver dysfunction due to sepsis in the absence of pre‐existing chronic liver disease. Outcome measures included markers of hemodynamic stability, renal function, serum bilirubin and bile acid levels, arterial ammonia levels, the arterial ketone body (acetoacetate/β‐hydroxybutyrate) ratio, hepatic encephalopathy grade and the plasma disappearance rate of indocyanine green. The rates of discharge from the intensive care unit and in‐hospital mortality were determined. Our findings suggest that MARS treatment might be associated with some clinical efficacy even in patients with advanced multi‐organ dysfunction occurring in the setting of severe liver damage and in whom treatment is instituted late in the clinical course. However, the overall survival rate (1/6; 17%) was poor. More data obtained from larger cohorts of patients enrolled in randomized controlled studies will be required in order to identify categories of liver failure patients who might benefit most from MARS treatment and to ascertain the most appropriate timing of intervention.

An Australian experience with the molecular adsorbents recirculating system (Mars).

Abstract:  The molecular adsorbents recirculating system (MARS) is a form of artificial extracorporeal liver support which has the potential to remove substantial quantities of albumin‐bound toxins postulated to contribute to the pathogenesis of liver cell damage, hemodynamic instability and multi‐organ failure in patients with acute liver failure and acute‐on‐chronic liver failure (AoCLF). We assessed the efficacy of MARS therapy in a cohort of patients with severe liver damage unresponsive to intensive medical therapy. MARS therapy was instituted late in the clinical course of six patients with severely impaired liver function refractory to intensive medical therapy, including four with AoCLF precipitated by sepsis and two with liver dysfunction due to sepsis in the absence of pre‐existing chronic liver disease. Outcome measures included markers of hemodynamic stability, renal function, serum bilirubin and bile acid levels, arterial ammonia levels, the arterial ketone body (acetoacetate/β‐hydroxybutyrate) ratio, hepatic encephalopathy grade and the plasma disappearance rate of indocyanine green. The rates of discharge from the intensive care unit and in‐hospital mortality were determined. Our findings suggest that MARS treatment might be associated with some clinical efficacy even in patients with advanced multi‐organ dysfunction occurring in the setting of severe liver damage and in whom treatment is instituted late in the clinical course. However, the overall survival rate (1/6; 17%) was poor. More data obtained from larger cohorts of patients enrolled in randomized controlled studies will be required in order to identify categories of liver failure patients who might benefit most from MARS treatment and to ascertain the most appropriate timing of intervention.