The effect of tracheostomy on outcome in intensive care unit patients.

BACKGROUND: Percutaneous dilatation tracheostomy (PDT) is increasingly being used in the intensive care unit (ICU), and has probably increased the number of procedures performed. The primary aim of this study was to document the short- and long-term outcome of patients with a tracheostomy performed during an ICU stay. METHODS: Patients in our ICU who underwent an unplanned tracheostomy between 1997 and 2003 were included in this analysis. The type of tracheostomy (PDT or surgical tracheostomy) and time of the procedure were registered prospectively in our ICU database. Survival was followed using the People's Registry of Norway and morbidity data from the individual hospital record. These patients were also compared with a group of ICU patients ventilated for more than 24 h, but managed without a tracheostomy. We also compared patients who had early tracheostomy (less than median time to procedure) with those who had late tracheostomy. RESULTS: Of the 2844 admissions (2581 patients), unplanned tracheostomy was performed during 461 admissions (16.2%) on 454 patients (17.6%). The median time to tracheostomy was 6 days. The ICU, hospital and 1-year mortality rates were 10.8, 27.1 and 37.2%, respectively, significantly less than those of the group ventilated without tracheostomy. The median time to decannulation was 14 days. Patients who had early tracheostomy had a more favourable long-term survival than those who had late tracheostomy. No procedure-related mortality was registered. CONCLUSIONS: In our ICU, having a tracheostomy performed was associated with a favourable long-term outcome with regard to survival, and early tracheostomy improved survival in addition to consuming less ICU resources.

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit.

PROBLEM: Need for improved sedation strategy for adults receiving ventilator support. DESIGN: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative. BACKGROUND AND SETTING: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. KEY MEASURES FOR IMPROVEMENT: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. STRATEGIES FOR CHANGE: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. EFFECTS OF CHANGE: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. LESSONS LEARNT: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

Anti-cardiolipin autoantibodies and pulmonary embolism. A case for a common cause.

A patient with primary Sjögren's syndrome developed pulmonary embolism following infection with influenza A virus. IgM anti-cardiolipin autoantibodies (aCL) evolved two weeks after hospitalisation, synchronously with antibodies against influenza A. IgG aCL developed three weeks after hospitalization, peaked during the recovery period, and gradually declined to undetectable levels 12 months after admission. Antibodies against beta2 glycoprotein I were not detected. Our results assign a high likelihood to the hypothesis that influenza A virus caused the patient's thromboembolic disease as well as development of aCL. aCL may have contributed to tissue pathology by forming immune-complexes with cardiolipin and rheumatoid factor.

Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication.

UNLABELLED: This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis. CASE HISTORY: A 46-year-old woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal herniation.

Surgery during inhalation with nitric oxide in a patient with severe adult respiratory distress syndrome (ARDS).

Nitric oxide (NO) is increasingly used in intensive care units (ICU) in order to treat serious hypoxaemia secondary to ARDS. Since interrupting NO delivery in such patients for more than a few minutes could lead to serious adverse events, moving the patient outside the ICU has been very difficult. Recently developed equipment (Noresc 1503) enabled us to deliver 10 or 20 ppm NO from a ventilatory bag with reservoir. This is used for ventilation under transport from the ICU to the operating theatre (OT) or radiology department. We present a patient with severe ARDS undergoing major surgery while being treated with NO. The patient could be moved to the OT and operated on during five hours without significant changes in vital functions.

[Use of growth hormone during catabolic state in a patient in postoperative intensive care]. / Bruk av veksthormon ved katabol tilstand hos en kirurgisk intensivpasient.

Patients in the intensive care unit often enter a catabolic state with significant protein loss, which may increase postoperative complications. Nutritional support alone usually does not reverse a catabolic state and thereby induce a positive protein balance. Recent studies suggest that recombinant human growth hormone (rhGH) stimulates protein synthesis and improves protein balance in critically ill patients. An increase in the level of growth hormone often fails to occur in critical illness and injury. We describe the case of a man aged 45 years who underwent laparoscopic fundoplasty for hiatus hernia repair. Because of complications, including perforation of the oesophagus, he entered a sustained catabolic state with negative protein balance and a weight loss approaching 20%. Therefore, on the 29th day after operation we started treatment with rhGH, Norditropin 24 IE/day im. The protein balance became positive three days later. This parameter maintained positive, also after the growth hormone therapy was discontinued 12 days later. The further course was uneventful and the patient was transferred to his local hospital 51 days after the fundoplasty. His condition was improving steadily.