Anaesthesia and intensive care
-
Anaesth Intensive Care · Oct 2007
Atrial fibrillation in a tertiary care multidisciplinary intensive care unit--incidence and risk factors.
Atrial fibrillation is a common arrhythmia in an intensive care unit. We performed a prospective observational study over a period of three months, to study the incidence, risk factors and outcome of patients who develop atrial fibrillation in a multidisciplinary intensive care unit. All patients above the age of 50 years were eligible. ⋯ Patients who developed atrial fibrillation required a longer period of mechanical ventilation and inotropic support. Multivariate logistic regression analysis showed age >75 years, APACHE II score >20 and sepsis at admission were independent predictors for development of atrial fibrillation in critically ill patients. Although atrial fibrillation by itself is unlikely to be the cause of higher mortality, it is likely to be a marker for increased mortality and resource utilisation in the intensive care unit.
-
Anaesth Intensive Care · Oct 2007
ReviewA clinician's guide to predicting fluid responsiveness in critical illness: applied physiology and research methodology.
Intravenous fluid administration is often used in critical care with the goal of improving haemodynamics and consequently tissue perfusion and oxygen delivery. While inotropic and vasoactive drugs are often necessary to correct haemodynamic instability, resuscitation usually begins with fluid therapy. As fluid challenge can result in clinical deterioration, the ability to predict haemodynamic response is desirable. ⋯ Furthermore, an improved understanding of these principles should assist the clinician in appraising published data, which has been characterised by significant methodological differences. This review aims to assist the clinician by detailing the physiological principles that underlie the prediction of fluid responsiveness in the critically ill. In addition, the potential importance of methodological differences in the cutrent literature will be considered.
-
Anaesth Intensive Care · Oct 2007
Comparative StudyA comparison of tape-tying versus a tube-holding device for securing endotracheal tubes in adults.
During the transfer of intubated patients, endotracheal tube security is paramount. This study aims to compare two methods of securing an endotracheal tube in adults: tying with a cloth tape versus the Thomas Endotracheal Tube Holder (Laerdal). A manikin-based study was performed using paramedics and critical care doctors (consultants and senior trainees) as participants. ⋯ The degree of tube movement was significantly higher when the tube was secured with a tie compared with when the tube holder was used (median movement 22 mm vs. 4 mm, P < 0.0001). We have demonstrated that the tube holder device minimised tube movement in a manikin model when compared with conventional tape tying. The use of this device when transporting intubated patients may reduce the risk of tube displacement though further clinical studies are warranted.
-
Anaesth Intensive Care · Oct 2007
Case ReportsDifficult decisions in the intensive care unit: an illustrative case.
Difficult clinical decision-making is a common experience in intensive care units. There is often considerable pressure on time and decisions may have to be made in a stressful environment. Patients in the intensive care unit not infrequently present with extreme or rare manifestations of a disease process. ⋯ We review the clinical evidence for our decisions at each stage and explain the rationale for our choices, highlighting the many situations for which high quality evidence was lacking. Examples of cognitive bias are identified and techniques of metacognition (thinking about thinking) that can be useful in limiting the effects of bias on complex decision-making are reviewed. The intensivist's evaluation of management alternatives has an important role in steering medical management towards optimal patient outcomes.