Please click the slide to advance to the next one.
Moral distress is an all too common and frustrating aspect of critical care nursing. Just consider the following case scenarios.
NT-pro B-Type Natriuretic Peptide (NT-pro BNP): Evidence is emerging to suggest that measurement of BNP as a prognostic marker may be a powerful tool. The St Paul’s Hospital Heart Transplant Program uses NT-proBNP (a form of BNP) in conjunction with the measurements outlined in CCS Guidelines to aid in transplant listing or delisting decisions. Currently, a level of 1,500pg/ml has been identified. Levels greater than this has been associated with significantly increased mortality in heart failure patients[2-5]
Interesting site for:
The information provided here is for educational and informational purposes only...
It shouldn't be used in either diagnosis or treatment .
Medicine
LINK
GENERAL INFORMATION:
High Frequency Oscillatory Ventilation (HFO) is a ventilatory strategy that employs very small tidal volumes (often less than anatomic dead space) combined with very fast rates or frequencies (where 1 Hertz or Hz = 60cycles/min).
The Sensormedics 3100B high frequency oscillator consists of a continuous positive airway pressure circuit with an integrated motor-driven piston/diaphragm for generating the oscillations. There is active inspiration as well as active expiration on the oscillator.
Gas transport during HFO is thought to be as a result of several factors: molecular diffusion, direct alveolar ventilation (bulk gas flow to the proximal alveoli), net convective transport caused by asymmetric gas-velocity profiles, improved gas mixing caused by Taylor dispersion in turbulent flow, pendelluft, and cardiogenic mixing.
In HFO, alveolar ventilation (and thus CO2 elimination) is dependent on frequency and tidal volume, but relatively independent of lung volume. Oxygenation is “uncoupled” from ventilation; that is, it is proportional to mean airway pressure and lung volume.
And an interesting article from Stanford:
Drug Monographs
PLEASE BE AWARE THAT THESE ARE PROVIDED EXTERNALLY FROM LONDON HEALTH SCIENCES AS A REFERENCE ONLY.
Interesting information regarding hospital workers and MRSA.
Between October 2001 and February 2002, 324 healthcare workers were screened for methicillin-resistant Staphylococcus aureus (MRSA) by nose and throat swabs. A positive finding led to activation of a standardised control programme for the affected person who was immediately excluded from work.
(1 in 6 Hospital staff are MRSA carriers)
Because of the small number of patients with this disease, the treatment of scleroderma, generally, and of its associated lung disease, specifically, have not been well defined by controlled trials. With the current limited knowledge, a reasonable approach is to treat progressive interstitial lung disease with immunosuppressive drugs such as cyclophosphamide and corticosteroids. Those patients with pulmonary vascular disease have a poor prognosis and therapy is currently limited. However, new treatment strategies are on the horizon, the most promising of which are the recent development of locally administered therapies such as inhaled iloprost†, a prostaglandin analogue.
† In the US, nitric oxide is only available on a compassionate use basis.
Continue reading "Scleroderma Lung Disease: A Common Phenomenon in a Rare Disease" »
Background: A working definition of nosocomial pneumonia (NP) is that of a new pulmonary infiltrate that occurs after one week of hospitalization and that resembles a bacterial pneumonia on the chest radiograph. Although most patients have fever and leukocytosis, these findings are not uniformly present nor are they a requisite for the presumptive diagnosis of NP.
"(Synonyms: GBS, Landry-Guillain-Barré syndrome, Landry's ascending paralysis, acute idiopathic polyneuritis, infectious polyneuritis, acute inflammatory demyelinating polyneuropathy)
While Guillain-Barré syndrome (GBS) is relatively rare, affecting one in 100,000 people, Mayo Clinic has extensive experience in treating the disorder among all ages. Because Guillain-Barré progresses so rapidly and can be life threatening, early medical treatment is critical. While most people recover from even the most severe cases; the length and degree of recovery varies. About 5 to 15 percent have serious, lifelong disabilities.″
By Brian Walsh, BS, RRT-NPS, RPFT
University of Virginia
Children’s Medical Center
Conclusion:
All studies demonstrate that the clinical response to inhaled PGI
2 in terms of selectively decreasing PAP without effecting SAP, and/or improved oxygenation is as good, if not better, than INO. Where continuous inhalation has been used, the rate of PGI 2
administration is comparable to the IV infusion dose, i.e. 1.5 to 50 ng/kg/min. Mikhail et al12 were unable to detect a dose response between 15 to 50 ng/kg/min suggesting that lower doses should be evaluated. In a dog model of hypoxic pulmonary vasoconstriction,
Zwissler et al found a dose of inhaled PGI 2 as low as 0.9 ng/kg/min caused a significant reduction in PAP27. The actual dose reaching the pulmonary vasculature is unknown as only approximately 10% of the initial dose of a nebulized agent reaches the alveolus28. Distal deposition of a nebulized drug is related to particle size; to achieve distal deposition a particle must be less than 5μm. No studies have been able to demonstrate tolerance to sustained treatment with
inhaled PGI 2 and, where repeated nebulized treatments have been given, there has been no evidence of deleterious rebound pulmonary hypertension in-between doses.
Download an Adobe PDF of this entry
Conclusions: IAP is an efficacious SPV, with marked dose-related improvement in oxygenation and with no demonstrable effect on systemic arterial pressures over the dose range 0 to 50 ng/kg/min. Despite significant systemic levels of prostacyclin metabolite, there was no demon- strable platelet function defect.
Download an Adobe PDF of this entry
Infection Prevention and Control now has a video on the PHC Intranet demonstrating how to put on and remove personal protective equipment (e.g. gowns, masks, goggles) when entering and exiting an isolation room. The video is called “Be Barrier Wise” and was produced by the Occupational Health and Safety Agency for Healthcare in British Columbia (OHSAH).
You can download the video from the PHC Intranet website under Programs and Services / Clinical Services - Nursing / Education - Education Materials / Resources / Self-Directed Learning. The video is most easily located by typing in “Be Barrier Wise” in the search box on the top right corner on PHC Connect.
The "normal" CXR
The appearance of the chest radiograph in ICU or in any acutely ill patient is affected by the necessity for AP positioning, supine or sitting position, and the variable degree of inspiration. When the radiograph is taken make sure that ECG cables and other radio-opaque objects are removed from the radiographic field, when reasonable.
The AP view results in the magnification of anterior structures - the clavicle,
Here is a link to an interesting "Intubation Proceedure" video from the "New England Journal of Medicine".
See the video Here
Conclusion
All studies demonstrate that the clinical response to inhaled PGI2 in terms of selectively decreasing PAP without effecting SAP, and/or improved oxygenation is as good, if not better, than INO. Where continuous inhalation has been used, the rate of PGI2 administration is comparable to the IV infusion dose, i.e. 1.5 to 50 ng/kg/min. Mikhail et al12 were unable to detect a dose response between 15 to 50 ng/kg/min suggesting that lower doses should be evaluated. In a dog model of hypoxic pulmonary vasoconstriction, Zwissler et al found a dose of inhaled PGI2 as low as 0.9 ng/kg/min caused a significant reduction in PAP27. The actual dose reaching the pulmonary vasculature is unknown as only approximately 10% of the initial dose of a nebulized agent reaches the alveolus28. Distal deposition of a nebulized drug is related to particle size; to achieve distal deposition a particle must be less than 5μm.
Pulmonary hypertension is high blood pressure in the arteries to your lungs. It is a serious condition for which there are treatments but no cure. If you have it, the blood vessels that carry oxygen-poor blood from your heart to your lungs become hard and narrow. Your heart has to work harder to pump the blood through. Over time, your heart weakens and cannot do its job and you can develop heart failure.
One of the main factors determining oxygen delivery to cells is the oxygen content of the blood. Blood gas tensions are measured by direct blood sampling or transcutaneous diffusion and oxygen saturation of haemoglobin from pulse oximetry. Arterial blood gas analysis is widely available in hospitals and the direct measurements (pH, PaO2, PaCO2) are among the most precise in medicine. The value of such measurements, however, depends on the ability of doctors to interpret the results properly.
Defined as a communication between a bronchus and the pleural cavity; usually caused by necrotizing pneumonia or empyema.
Defined as a communication between a bronchus and the pleural cavity; usually caused by necrotizing pneumonia or empyema.
The U.S. National Library of Medicine's Visible Human Project has
produced high resolution (4096 x 2048 x 24 bits) cryosectional
color images of human anatomy. The Lister Hill National Center
for Biomedical Communications, an R&D division of the NLM,
through its Communications Engineering Branch, has created a
database for this image dataset as well as for 3D rendered
images of anatomic objects created from cryosectional images
(cross-sections or slices).
See the amazing resource database HERE
Transition is a "process or period in which something undergoes a change and passes from one state, stage, form, or activity to another."1 Ideally, healthcare transitions encompass safe and efficient movements of patients between different sectors or levels of care within the healthcare system2 and appear to be fundamental in achieving beneficial outcomes for patients.3 Critically ill patients in the intensive care unit (ICU) often experience multiple transitions as they move through different levels of care. The transfer of ICU patients to intermediate care units and subsequent ongoing provision of care are a daily occurrence in acute care hospitals.
Read the full article
More and more we are seeing the use of endobronchial dual lumen tubes.
These tubes are really nothing new, but here at St. Paul's we have seen
a rise in their use. From lung protection strategies where the
isolation of 1 lung is critical in the outcome of a patient due to
hemorrhage, unilateral consolidation, or other pathology, it is best we
have a clear understanding of their characteristics.
The
following 2 articles provide a good starting point in providing a
refresher to new and experienced R.T.’s alike, as well as the nursing
staff.
Double Lumen Endotracheal Tube refresher
Careful handling of epicardial pacing wires is
paramount to your patient's safety. Here are
the steps you'll need to take.
How is pneumococcal infection transmitted?
These bacteria can spread from the nose and throat of one person to another by close direct contact like kissing, coughing, or sneezing and through saliva when people share food, cups, water bottles, toothbrushes, etc. Currently, there is no evidence of nosocomial spread.
What Infection Control Precautions are required for patients with pneumococcal infection?
Standard Precautions are adequate to prevent the spread of this organism from the patient to patient and from patient to staff.
Standard Precautions:
Hand washing.
Appropriate use of Personal Protective Equipment (PPE) for contact with all blood and body fluids except sweat and tears.
Proper handling of needles and sharps.
When should I wash my hands?
Hands should be washed before and after every patient contact, as well as after touching potentially contaminated items in the environment (e.g., respiratory equipment). Hand washing with an alcohol hand gel (e.g., MicrosanTM) is appropriate for use if hands are not visibly soiled, but remember to let them air dry. Conventional handwashing with antiseptic soap and water is recommended for hands that are grossly soiled.
Standard Precautions: What PPE do I need?
Gloves - for direct to anticipated direct contact with all blood and body fluids (i.e., providing suctioning).
Gown or plastic apron - protection against splashes and sprays (i.e., intubation).
Face Protection - masks, goggles, face shield - during procedures that are likely to cause splashes or sprays of blood, body fluids or secretions (i.e., intubation).
Can pneumococcal infection be prevented?
Vaccination can prevent most serious pneumoccocal infections. The pneumococcal polysaccharide vaccine is recommended for and provided free to people who are at high risk of getting serious infections. This includes:
All those 65 years or older.
Residents of extended care and intermediate care facilities.
All people with:
Asplenia (removed or impaired spleen);
Weakened immune system such as HIV disease, haematopoietic stem cell transplantation; (HSCT), solid organ transplantation, certain cancers (leukemia, lymphoma, Hodgkins's Disease);
Conditions requiring ongoing high dose oral corticosteroid therapy; or
Chronic diseases such as heart disease, lung disease, liver disease, diabetes, alcoholism, cerebral spinal fluid leak, cochlear implant.
The VCH Public Health has also initiated a vaccination campaign in the DTES at a variety of locations, and would like to expand it to include patients in the SPH and VGH Emergency Departments.
Thank you very much for your help!
More information on Standard Precautions other infection control issues is available online on the PHC intranet at HYPERLINK "http://phcmanuals.phcnet.ca/Level2.asp?L1Heading=Standard+Precautions&LibCode=ICON" http://phcmanuals.phcnet.ca/Level2.asp?L1Heading=Standard+Precautions&LibCode=ICON
PHC Infection Prevention and Control (IPAC)
Pneumococcal Infection
Fact Sheet for Health Care Workers, Physicians and House Staff
How is pneumococcal infection transmitted?
These bacteria can spread from the nose and throat of one person to another by close direct contact like kissing, coughing, or sneezing and through saliva when people share food, cups, water bottles, toothbrushes, etc. Currently, there is no evidence of nosocomial spread.
What Infection Control Precautions are required for patients with pneumococcal infection?
Standard Precautions are adequate to prevent the spread of this organism from the patient to patient and from patient to staff.
Standard Precautions:
Hand washing.
Appropriate use of Personal Protective Equipment (PPE) for contact with all blood and body fluids except sweat and tears.
Proper handling of needles and sharps.
When should I wash my hands?
Hands should be washed before and after every patient contact, as well as after touching potentially contaminated items in the environment (e.g., respiratory equipment). Hand washing with an alcohol hand gel (e.g., MicrosanTM) is appropriate for use if hands are not visibly soiled, but remember to let them air dry. Conventional handwashing with antiseptic soap and water is recommended for hands that are grossly soiled.
Standard Precautions: What PPE do I need?
Gloves - for direct to anticipated direct contact with all blood and body fluids (i.e., providing suctioning).
Gown or plastic apron - protection against splashes and sprays (i.e., intubation).
Face Protection - masks, goggles, face shield - during procedures that are likely to cause splashes or sprays of blood, body fluids or secretions (i.e., intubation).
Can pneumococcal infection be prevented?
Vaccination can prevent most serious pneumoccocal infections. The pneumococcal polysaccharide vaccine is recommended for and provided free to people who are at high risk of getting serious infections. This includes:
All those 65 years or older.
Residents of extended care and intermediate care facilities.
All people with:
Asplenia (removed or impaired spleen);
Weakened immune system such as HIV disease, haematopoietic stem cell transplantation; (HSCT), solid organ transplantation, certain cancers (leukemia, lymphoma, Hodgkins's Disease);
Conditions requiring ongoing high dose oral corticosteroid therapy; or
Chronic diseases such as heart disease, lung disease, liver disease, diabetes, alcoholism, cerebral spinal fluid leak, cochlear implant.
The VCH Public Health has also initiated a vaccination campaign in the DTES at a variety of locations, and would like to expand it to include patients in the SPH and VGH Emergency Departments.
Thank you very much for your help!
More information on Standard Precautions other infection control issues is available online on the PHC intranet at HYPERLINK "http://phcmanuals.phcnet.ca/Level2.asp?L1Heading=Standard+Precautions&LibCode=ICON" http://phcmanuals.phcnet.ca/Level2.asp?L1Heading=Standard+Precautions&LibCode=ICON
PHC Infection Prevention and Control (IPAC)
Pneumococcal Infection
Fact Sheet for Health Care Workers, Physicians and House Staff
7 Deadly Sins of Spread!
Author: Roger Resar & Carol Haraden, VP IHI – taken from Teleconference Oct 15th, 2006
The things we’ve learned NOT to do:
1. Start with a Large Pilot area – Go Big or Go Home
Starting with a large pilot area like an entire hospital, makes the job an impossible task.
Sequencing is important – start small using the 1:1:1 principle. When your change
works for one provider, one patient on one day, widen the scope to 3 patients, 3
providers, 3 days and so on to 5 providers, 5 days 5 patients. If the change is successful
at this stage, you are ready for using this principle of spread to 1 unit – 3 units and 5
units.
Continue Reading:
Background:
Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is com- monly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach (CCO). Studies show that an RRS may improve outcome, but questions remain regarding the benefit, design elements, and advisability of implementing a MET system. Methods: In June 2005 an International Conference on Medical Emergency Teams (ICMET) included experts in patient safety, hospital medicine, critical care medicine, and METs. Seven of 25 had no experience with an RRS, and the remainder had experi- ence with one of the three major forms of RRS. After preconfer- ence telephone and e-mail conversations by the panelists in which questions to be discussed were characterized, literature reviewed, and preliminary answers created, the panelists con- vened for 2 days to create a consensus document. Four major content areas were addressed: What is a MET response? Is there a MET syndrome? What are barriers to METS? How should out- come be measured? Panelists considered whether all hospitals should implement an RRS. Results: Patients needing an RRS intervention are suddenly critically ill and have a mismatch of resources to needs. Hospitals should implement an RRS, which consists of four elements: an afferent, “crisis detection” and “response triggering” mecha- nism; an efferent, predetermined rapid response team; a gover- nance/administrative structure to supply and organize resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events. (Crit Care Med 2006; 34:2463–2478) KEY WORDS: medical emergency teams; rapid response teams; cardiac arrest; resuscitation; process improvement; consensuspanel; patient safety; critical care
Have you ever woken up under the operating table or in a crumpled heap in a corner of day surgery or spent most of an amniocentesis with your head between your knees? Jessica Whitworth used to...
Objective: Quality improvement is an important activity for all
members of the interdisciplinary critical care team. Although an
increasing number of resources are available to guide clinicians,
quality improvement activities can be overwhelming. Therefore, the
Society of Critical Care Medicine charged this Outcomes Task Force
with creating a “how-to” guide that focuses on critical care, sum-
marizes key concepts, and outlines a practical approach to the
development, implementation, evaluation, and maintenance of an
interdisciplinary quality improvement program in the intensive care
unit.
THE PURSUIT OF EVIDENCE-BASED MEDICINE IS NOW AT Punitive cultures..Before the 1990s, health- care providers ofte attempted to manage risk and errors by making frequent exhortation to work carefully and by retraining, counseling, or disciplinin workers involved in errors, particularly those closest to the event
. Th prevailing thought at the time was that individual workers were fully, an sometimes solely, accountable for the outcomes of patients under their care even if the underlying processes for achieving those outcomes were not unde their direct control. example, when a medication error
occurred—with little direction about how to achieve the goals or how to make safer behavioral choices. Punitive cultures..Before the 1990s, health- care providers ofte attempted to manage risk and errors by making frequent exhortation to work carefully and by retraining, counseling, or disciplinin workers involved in errors, particularly those closest to the event. Th prevailing thought at the time was that individual workers were fully, an sometimes solely, accountable for the outcomes of patients under their care even if the underlying processes for achieving those outcomes were not unde their direct control. example, when a medication error
occurred—with little direction about how to achieve the goals or how to make safer behavioral choices.
