The role of intensive care unit diaries in the grieving process: A monocentric qualitative study.

BACKGROUND: The growing importance of psychological recovery for patients and their families following intensive care unit (ICU) experiences in recent years cannot be overemphasized. The ICU diary is used to aid patients in reducing the prevalence of post-traumatic stress disorder, anxiety, and depression. The usefulness of maintaining a diary during the grieving process has not yet been thoroughly investigated. AIM: To investigate the role of ICU diaries in the grief process experienced by family members of a person who died in the intensive care unit. STUDY DESIGN: Nine family members of seven deceased ICU patients with an ICU diary were contacted and interviewed by phone using a semi-structured interview. A qualitative data analysis was performed using thematic synthesis. SETTING: Italian general intensive care unit. FINDINGS: Interviewed family members felt that the diary helped them during the grieving process. The return of diaries was desired by family members for support and to remember one's loved one. The diary helped them process their losses in various ways, including signs of evidence of care, emotional involvement, consideration, and coping with grief. Four main themes emerged from the analysis: writing the diary, reading the diary, talking about the diary, and the diary during the grieving process. CONCLUSIONS: The overall perception of the ICU diary was positive. The diary mostly helped relatives to "give back something of what we lost". This study also affirms the positive link between ICU diaries and bereavement in Italian ICU. Further studies are required to confirm the usefulness of this tool in the grieving process. RELEVANCE TO CLINICAL PRACTICE: The ICU diary can help patients' family members understand what happened to their loved one and play an important role in the grieving process. The diary served as a valuable source of information that aided in providing bereavement support to the family by helping them to gain a rational and emotional understanding of the patient's death.

Current trends in polytrauma management. Diagnostic and therapeutic algorithms operational in the Trauma Center of Cesena, Italy.

INTRODUCTION: The purpose of this paper is to present the most recent revision of diagnostic therapeutic protocols regarding polytrauma that are operational in the Trauma Center of Cesena, and to check what impact the progressive implementation and review of these algorithms has had on predefined indicators of results and utilization of diagnostic and therapeutic resources. Finally for the purpose of comparing the results obtained in a subgroup of patients treated in the Trauma Center of Cesena, with those obtained in a group homogeneous for ISS and year of hospitalization stored in the RRGT (Registro Regionale Grandi Traumi - Regional Major Trauma Registry). MATERIALS AND METHODS: Through a retrospective study we analyzed a population of 21,704 patients hospitalized for trauma in our Trauma Center from 2001 to November 2009, 40.1% females and 59.9% males, aged between 0 and 105 years, who were treated with the protocols developed in the Trauma Service. Indicators of results and of diagnostic and therapeutic resource utilization were analyzed. All patients enrolled in the study were divided by year of admission to assess the performance of these indicators over the years. An ISS homogeneous subgroup including only patients hospitalized in the year 2007 was also created for comparison with the report of RRGT (Regional Major Trauma Registry). Emergency Department code yellow or red patients were divided into 3 groups based on the hemodynamic response after primary assessment. Group A included patients that were hemodynamically stable (ATLS criteria); Group B included patients that were hemodynamically stabilized; Group C included patients that were hemodynamically unstable. Each group of patients was treated according to precise diagnostic and therapeutic protocols. RESULTS: The overall hospital mortality was 2.4%. Mortality at discharge from intensive care was 11.6% while at discharge from the Emergency Surgery was 0.2%. The total average hospital stay was 10.1 days. ICU stay was 7.8 days, while in Emergency Surgery was 12.4 days. 79.4% of the patients were discharged home. Overall, the percentage of patients undergoing surgery was 64.3%. Patients undergoing diagnostic level II with multislice CT were 19.3%; those undergoing CT of the chest and / or abdomen were 5%. A total 0.8% of patients underwent angiography, and 0.2% underwent embolization. The overall percentage of patients transfused with packed red blood cell was 3.9%. CONCLUSIONS: The hemodynamic response of patients after primary assessment determines the subsequent diagnostic and therapeutic procedures. The protocols that we utilized had a positive impact on the mortality of patients hospitalized in the intensive care and on the average intensive care stay, and were also associated with an increase in the number of angiography and arterial embolizations performed in sicker patients and those with relevant surgical lesions. The decrease in mortality is also observed in comparison with the RRGT data. We believe therefore that these protocols can provide a valuable and effective aid for those involved in the care of trauma victims, allowing them to always be able to quickly decide what to do, when to do, how to do, and where to do what needs to be done.

The Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) A retrospective review of 379 patients undergoing laparoscopic splenectomy.

In December 2000, the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was formally launched under the auspices of the Italian Society for Endoscopic Surgery and New Technologies (SICE). The aim of this multicentre study was to analyse various aspects of the treatment that are still under discussion, such as the extension of the laparoscopic indications in cases of malignancy, independently of the associated splenomegaly, patient selection and operative techniques. A retrospective review of 379 patients undergoing laparoscopic splenectomy for haematological diseases from February 1, 1993, to September 15, 2005, was conducted. Data were collected from the 18 italian centres participating in the IRLSS. The mean length of surgery was 140 minutes (range: 25-420). Conversion was necessary in 25 cases (6.6%), and at least one accessory spleen was found in 30 patients (8%). The mean spleen weight was 1200 g (range: 85-4500). Perioperative death occurred in two cases (0.5%). There were no complications in 312 patients (82.3%), with a mean hospital stay of 5.5 days (range: 2-30). Morbidity occurred in 67 patients (17.8%), mainly consisting in transient fever (n = 22), pleural effusions (n = 16), and actual or suspected haemorrhage (n = 14), requiring re-intervention in 7 patients. This first study carried out on the IRLSS data shows that laparoscopic splenectomy may constitute the gold standard for haematological diseases with a normal-sized spleen. The low morbidity and mortality rates suggest that laparoscopic splenectomy can be successfully proposed also for splenomegaly in haematological malignancies.

Clinical strategies for the management of intestinal obstruction and pseudo-obstruction. A Delphi Consensus study of SICUT (Società Italiana di Chirurgia d'Urgenza e del Trauma).

BACKGROUND: Intestinal obstructions/pseudo-obstruction of the small/large bowel are frequent conditions but their management could be challenging. Moreover, a general agreement in this field is currently lacking, thus SICUT Society designed a consensus study aimed to define their optimal workout. METHODS: The Delphi methodology was used to reach consensus among 47 Italian surgical experts in two study rounds. Consensus was defined as an agreement of 75.0% or greater. Four main topic areas included nosology, diagnosis, management and treatment. RESULTS: A bowel obstruction was defined as an obstacle to the progression of intestinal contents and fluids generally beginning with a sudden onset. The panel identified four major criteria of diagnosis including absence of flatus, presence of >3.5 cm ileal levels or >6 cm colon dilatation and abdominal distension. Panel also recommended a surgical admission, a multidisciplinary approach, and a gastrografin swallow for patients presenting occlusions. Criteria for immediate surgery included: presence of strangulated hernia, a >10 cm cecal dilatation, signs of vascular pedicles obstructions and persistence of metabolic acidosis. Moreover, rules for non-operative management (to be conducted for maximum 72 hours) included a naso-gastric drainage placement and clinical and laboratory controls each 12 hours. Non-operative treatment should be suspended if any suspects of intra-abdominal complications, high level of lactates, leukocytosis (>18.000/mm3 or Neutrophils >85%) or a doubling of creatinine level comparing admission. Conversely, consensus was not reached regarding the exact timing of CT scan and the appropriateness of colonic stenting. CONCLUSIONS: This consensus is in line with current international strategies and guidelines, and it could be a useful tool in the safe basic daily management of these common and peculiar diseases. KEY WORDS: Delphi study, Intestinal obstruction, Large bowel obstruction, Pseudo-obstruction, Small bowel.

Outcomes in polytrauma: comparison between the results achieved in the Cesena Trauma Centre and in the Regional Registry of a (RRGT) of Emilia Romagna, Italy.

AIM: The aim of this retrospective study is to compare the outcomes achieved in the Trauma Centre of Cesena to those of the Regional Registry of Major Trauma (RRGT) of Emilia-Romagna, where a coordinated trauma care network has been implemented since 2001, based on the hub & spoke model. MATERIAL OF STUDY: A group of 747 patients were compared to 3.803 cases of the RRGT. The most serious patients, who arrived to the emergency room with a red or yellow emergency code, were sorted into 3 groups according to their haemodynamic response after the primary survey. Each group of patients was treated following a determined diagnostic and therapeutic protocol. Outcome indicators as well as diagnostic and therapeutic resources were examined. RESULTS: Mortality at discharge from Intensive Care was 10.6%. A drop of 2.2% mortality in ICU was recorded as well as reductions in the ICU average stay (13.6%) and in the use of CT (3.9%). On the other hand, surgeries increased by 17% in the Trauma Centre of Cesena as well as the use of angiographies (3.8%) compared to the RRGT regional register. DISCUSSION: The most important data is a sensible reduction in mortality among the group of patients who were hospitalized in ICU. These results can be compared to those which have recently been published by Scalea [1] concerning a retrospective analysis studying a 12-year period. CONCLUSIONS: A significant improvement of some indicators, with respect to the RRGT, was registered within the last three years among the group of the analyzed major traumas. It is therefore arguable that these protocols may represent a viable and clear reference point for all trauma care providers.

Development of a low cost laparostomy technique. Two years experience in the Trauma Center of Cesena, Italy.

BACKGROUND: In the last few years laparostomy has become an even more useful option for the surgeon due to the development of the experience in the critical abdominal trauma and in the severe surgical urgencies as PANE and peritonitis with the introduction of Damage Control as surgical strategy to prevent the abdominal compartimental syndrom (ACS). After a laparostomy the surgeon needs to provide a delayed fascial closure to achieve the best outcome for the patient. The aim of this paper is to illustrate the experience and the results after the introduction of a modified laparostomy technique in our surgical activity. METHODS: Protection of intestinal content, aspiration under sub-athmospheric pressure, control in quality and quantity of the drainage and skin temporary closure, rappresent the four principles of the PACS tecnique. In order to evaluate the rate of delayed fascial closure and the rate of ACS onset, we have retrospectively studied 31 patients over a period of 2 years treated with open abdomen with an amount of 36 PACS performed. Routinely IAP measurament was also performed. RESULTS: ACS was developed in no patients. IAP was measured on average at 19. DFC was achieved in 33 PACS of 36 (91.7%) after 5 days on average (20 hours as minimum; 20 days as maximum). Aspected mortality (SAPSII) in ICU for these patient was 76.5% on average. On 31 patients, 20 (64.5%) died and 11 (35.5%) survived. CONCLUSION: PACS seems to be an effective, easy and low cost technique for the management of open abdomen.