Critical Care

Ventilator hyperinflation: a survey of current physiotherapy practice in Australia and New Zealand

by Daniel Seller

Kate Hayes, Daniel Seller, Melissa Webb, Carol L Hodgson, Anne E Holland

Hyperinflation of the lungs is a technique commonly employed by physiotherapists in the intensive care setting. Whilst... more Hyperinflation of the lungs is a technique commonly employed by physiotherapists in the intensive care setting. Whilst there is extensive evidence to support the use of manual hyperinflation, there is limited evidence regarding the efficacy of ventilator hyperinflation. The aim of this study was to investigate the current physiotherapy practice of ventilator hyperinflation throughout Australia and New Zealand. A purpose-designed postal survey was distributed to senior physiotherapists in all intensive care units throughout Australia and New Zealand (n=189). A response rate of 87% was obtained (n=165). A minority of respondents (21%, n=35/165) performed ventilator hyperinflation. A lack of training in ventilator hyperinflation was cited as the main barrier to use (44%, n=46/105). Ventilator hyperinflation was most commonly performed by a senior physiotherapist in a tertiary intensive care unit. When performed, ventilator hyperinflation was used as an alternative to manual hyperinflation, to allow improved monitoring and control of ventilator parameters (74%, n=25/34) and maintain positive end expiratory pressure (59%, n=20/34). Ventilator hyperinflation is not commonly used by physiotherapists in intensive care units throughout Australia and New Zealand and considerable variability was found in its application between respondents. Further studies are required to define optimal parameters for ventilator hyperinflation and promote standardised delivery of this technique.

Predicting health care associated infections (HAI) in a high incidence low cost intensive care unit

by Gautam George

International Journal of Infectious Diseases, Volume 14, Supplement 1, March 2010, Pages e259
http://www.ijidonline.com/article/S1201-9712(10)02103-X/abstract

Precision and Accuracy: Comparison of Point-of-Care and Laboratory Glucose Concentrations in Cardiothoracic Surgery Patients

by Teresa Goodell

ser centred critical care discharge information to support early critical illness rehabilitation; development and evaluation using the Medical Research Council’s complex interventions framework Intensive and Critical Care Nursing

by Peter Griffiths

PBench, S., Day, T., & Griffiths, P. (2012). User centred critical care discharge information to support early critical illness rehabilitation; development and evaluation using the Medical Research Council’s complex interventions framework Intensive and Critical Care Nursing, online early(http://dx.doi.org/10.1016/j.iccn.2012.02.002). doi: http://dx.doi.org/10.1016/j.iccn.2012.02.002
ublished as:

Objectives
This paper reports on an intervention designed during an ongoing two phase project aimed at improving... more Objectives
This paper reports on an intervention designed during an ongoing two phase project aimed at improving early critical illness rehabilitation. It focuses specifically on the justification for a newly developed critical care discharge information pack: ‘User Centred Critical Care Discharge Information Pack’ (UCCDIP). The intervention is described in detail and the chosen research methods are discussed.

Background
Discharge from critical care to a ward is a difficult time for patients and relatives. Research suggests that effective information has the potential to reduce relocation stress and optimise recovery.

Methods
Using the Medical Research Council framework for the development and evaluation of complex interventions, a phase I focus group study and collaboration with service users/carers informed the development of a new critical care discharge information pack, currently being evaluated in a phase II Randomised Controlled Trial.

Conclusion
UCCDIP acknowledges the patients’ need to understand what they have been through and the progress they have made. It provides for the different information needs of patients and relatives, recognising their physical and psychological vulnerability. Through its use of reflection and participation, UCCDIP has the potential to optimise support of adult patients and their families during early critical illness rehabilitation.

Keywords
Critical care; Patient discharge; Patient education handout; Rehabilitation; Relocation stress

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Involving Users in the Development of Effective Critical Care Discharge Information: A Focus Group Study

by Peter Griffiths

Bench, S.D., T. Day, and P. Griffiths, Involving Users in the Development of Effective Critical Care Discharge Information: A Focus Group Study. American Journal of Critical Care, 2011. 20(6): p. 443-452.

Background Discharge from critical care to a general care unit is a difficult period, and more effective information... more Background Discharge from critical care to a general care unit is a difficult period, and more effective information is needed to support patients and their families at this time.Objectives This study sought the views of patients, relatives and health care staff on (1) the most effective methods of delivering critical care discharge information, (2) the required information content of any proposed strategies, (3) the benefits and limitations of any existing strategies, and (4) potential resource implications.Methods In this qualitative focus group study, 11 adult patients, 8 family members, and 23 health care staff in Eng-land took part in 8 focus group interviews at 2 hospitals. The computer software program NVIVO7 was used for thematic analysis of the data.Results Three key themes were identified from the data: (1) considerations related to effective discharge information, (2) goals of critical care discharge information, and (3) resource implications.Conclusions This focus group study provides unique user insight into what influences successful and unsuccessful information giving. Based on real experiences, it adds to the limited international body of current evidence. Findings will be of value in designing future critical care discharge information and identifying the related resource implications.

Staphylococcal Toxic Shock Syndrome: Mechanisms and Management

by Andrew Ferguson

Silversides J, Lappin E, Ferguson AJ. Staphylococcal Toxic Shock Syndrome. Curr Infect Dis Rep 2010;12:392-400.

Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in which bacterial... more Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in which bacterial toxins act as superantigens, activating very large numbers of T cells and generating an overwhelming immune-mediated cytokine avalanche that manifests clinically as fever, rash, shock, and rapidly progressive multiple organ failure, often in young, previously healthy patients. The syndrome can occur with any site of S. aureus infection, and so clinicians of all medical specialties should have a firm grasp of the presentation and management. In this article, we review the literature on the pathophysiology, clinical features, and treatment of this serious condition with emphasis on recent insights into pathophysiology and on information of relevance to the practicing clinician.

Gram-positive Toxic Shock Syndromes: A Pathophysiological Review

by Andrew Ferguson

The Lancet Infectious Diseases,  Volume 9, Issue 5, Pages 281 - 290, May 2009 . doi:10.1016/S1473-3099(09)70066-0. Co-authored with Dr. E. Lappin

Toxic shock syndrome (TSS) is an acute, multi-system, toxin-mediated illness, often resulting in multi-organ failure.... more Toxic shock syndrome (TSS) is an acute, multi-system, toxin-mediated illness, often resulting in multi-organ failure. It represents the most fulminant expression of a spectrum of diseases caused by toxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes (group A streptococcus). The importance of Gram-positive organisms as pathogens is increasing, and TSS is likely to be underdiagnosed in patients with staphylococcal or group A streptococcal infection who present with shock. TSS results from the ability of bacterial toxins to act as superantigens, stimulating immune-cell expansion and rampant cytokine expression in a manner that bypasses normal MHC-restricted antigen processing. A repetitive cycle of cell stimulation and cytokine release results in a cytokine avalanche that causes tissue damage, disseminated intravascular coagulation, and organ dysfunction. Specific therapy focuses on early identification of the illness, source control, and administration on antimicrobial agents including drugs capable of suppressing toxin production (eg, clindamycin, linezolid). Intravenous immunoglobulin has the potential to neutralise superantigen and to mitigate subsequent tissue damage.

Changes in serum procalcitonin and C-reactive protein following antimicrobial therapy as a guide to antibiotic duration in the critically ill: a prospective evaluation

by Gillian Ray-Barruel

Venkatesh B, Kennedy P, Kruger PS, Looke D, Jones M, Hall J, Barruel GR. Anaesth Intensive Care. 2009 Jan;37(1):20-6.

Nursing considerations to complement the Surviving Sepsis Campaign guidelines

by Gillian Ray-Barruel

Critical Care Medicine:
July 2011 - Volume 39 - Issue 7 - pp 1800-1818


Aitken LM, Williams G, Harvey M, Blot S, Kleinpell R, Labeau S, Marshall A, Ray-Barruel G, et al.

Objectives: To provide a series of recommendations based on the best available evidence to guide clinicians providing... more Objectives: To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis.

Design: Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus.

Methods: We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding.

Results: Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points.

Conclusion: Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.