RESUMO
Health care delivery systems are challenged to support the increasing demands for improving patient safety, satisfaction, and outcomes. Limited resources and staffing are common barriers for making significant and sustained improvements. At Oregon Health & Science University, the medical intensive care unit (MICU) leadership team faced internal capacity limitations for conducting continuous quality improvement, specifically for the implementation and evaluation of the mobility portion of an evidence-based care bundle. The MICU team successfully addressed this capacity challenge using the person power of prehealth volunteers. In the first year of the project, 52 trained volunteers executed an evidence-based mobility intervention for 305 critically ill patients, conducting more than 200 000 exercise repetitions. The volunteers contributed to real-time evaluation of the project, with the collection of approximately 26 950 process measure data points. Prehealth volunteers are an untapped resource for effectively expanding internal continuous quality improvement capacity in the MICU and beyond.
Assuntos
Fortalecimento Institucional/organização & administração , Unidades de Terapia Intensiva/organização & administração , Pacotes de Assistência ao Paciente/normas , Gestão da Qualidade Total/organização & administração , Voluntários , Fortalecimento Institucional/normas , Comunicação , Estado Terminal , Medicina Baseada em Evidências/organização & administração , Feedback Formativo , Humanos , Capacitação em Serviço , Unidades de Terapia Intensiva/normas , Liderança , Avaliação de Programas e Projetos de Saúde , Gestão da Qualidade Total/normasRESUMO
INTRODUCTION: Massive intentional verapamil overdose is a toxic ingestion which can cause multiorgan system failure and has no currently known antidote. CASE PRESENTATION: The patient is a 41-year-old Caucasian woman who ingested 19.2 g of sustained release verapamil in a suicide attempt. Our patient became hypotensive requiring three high-dose vasopressors to maintain arterial pressure. She also developed acute respiratory failure, bradycardic ventricular rhythm necessitating continuous transvenous pacing, and anuric renal failure. Our patient was treated with intravenous calcium, bicarbonate, hyperinsulinemic euglycemic therapy and continuous venovenous hemodialysis without success. On the fourth day after hospital admission continuous intravenous lipid therapy was initiated. Within three hours of beginning lipid therapy, our patient's vasopressor requirement decreased by half. Within 24 hours, she was on minimal vasopressor support and regained an underlying junctional rhythm. After three days of lipid infusion, she no longer required inotropic agents to maintain blood pressure or pacing to maintain stable hemodynamics. CONCLUSIONS: Intravenous fat emulsion therapy may be an effective antidote for massive verapamil toxicity.
RESUMO
INTRODUCTION: Pulmonary oedema and impairment of oxygenation are reported as common consequences of haemorrhagic shock and resuscitation (HSR). Surprisingly, there is little information in the literature examining differences in crystalloid type during the early phase of HSR regarding the development of pulmonary oedema, the impact on oxygenation and the haemodynamic response. These experiments were designed to determine if differences exist because of crystalloid fluid type in the development of oedema, the impact on oxygenation and the haemodynamic response to fluid administration in early HSR. METHODS: Twenty anaesthetised swine underwent a grade V liver injury and bled without resuscitation for 30 minutes. The animals were randomised to receive, in a blinded fashion, either normal saline (NS; n = 10) or lactated Ringer's solution (LR; n = 10). They were then resuscitated with study fluid to, and maintained at, the preinjury mean arterial pressure (MAP) for 90 minutes. RESULTS: Extravascular lung water index (EVLWI) began to increase immediately with resuscitation with both fluid types, increasing earlier and to a greater degree with NS. A 1 ml/kg increase in EVLWI from baseline occurred after administartion of (mean +/- standard error of the mean) 68.6 +/- 5.2 ml/kg of normal saline and 81.3 +/- 8.7 ml/kg of LR (P = 0.027). After 150 ml/kg of fluid, EVLWI increased from 9.5 +/- 0.3 ml/kg to 11.4 +/- 0.3 ml/kg NS and from 9.3 +/- 0.2 ml/kg to 10.8 +/- 0.3 ml/kg LR (P = 0.035). Despite this, oxygenation was not significantly impacted (Delta partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) Assuntos
Água Extravascular Pulmonar/efeitos dos fármacos
, Hemodinâmica/efeitos dos fármacos
, Soluções Isotônicas/uso terapêutico
, Consumo de Oxigênio/efeitos dos fármacos
, Ressuscitação/métodos
, Choque Hemorrágico/tratamento farmacológico
, Cloreto de Sódio/uso terapêutico
, Animais
, Soluções Isotônicas/farmacologia
, Lactato de Ringer
, Choque Hemorrágico/fisiopatologia
, Cloreto de Sódio/farmacologia
, Suínos
RESUMO
INTRODUCTION: Benzodiazepine treatment of life-threatening gamma-hydroxybutyrate (GHB) withdrawal is frequently unsatisfactory. Animal studies suggest strongly that treatment with GABA(B) agonists, such as baclofen, will be a more effective strategy. METHODS: A case report from the medical intensive care unit (ICU) of the university tertiary care hospital. RESULTS: A 61-year-old woman was admitted to the medical ICU for severe withdrawal symptoms from chronic GHB use. This manifested as delirium, tremor, and seizures despite only small decreases in GHB dose and treatment with benzodiazepines. The addition of baclofen allowed the rapid sequential decreases in the GHB dose without seizure or delirium and resulted in long-term improvement of her tremor. CONCLUSIONS: Baclofen, a GABA(B) agonist, may be a useful agent in the treatment of severe GHB withdrawal.