Physical restraint in the ICU: does it prevent device removal?

BACKGROUND: Physical restraint is frequently used in the intensive care setting but little is known regarding its clinical scenario and effectiveness in preventing adverse events (AEs), defined as device removal. METHODS: We carried out a prospective observational study in three Intensive Care Units on 120 adult high-risk patients. The effectiveness of physical restraint was evaluated using the propensity score methodology in order to obtain comparable groups. RESULTS: Physical restraint was applied in 1371 of 3256 (43%) nurse shifts accounting for 120 patients. Substantial agitation, the nurse's judgement of insufficient sedation and sedative drug reduction were positively associated with physical restraint, whereas the presence of analgesics at admission, increased disease gravity and the treating hospital as the most substantial variable showed a negative association. Eighty-six AEs were observed in 44 patients. Quiet (SAS=1-4), unrestrained patients accounted for 40 cases, and agitated (SAS≥5) but physically restrained patients for 17 cases. The presence of any type of physical restraint had a protective effect against any type of AE (OR=0.28; CI 0.16-0.51). The observed AEs showed a limited impact on the patients' course of illness. No physical harm related to physical restraint was reported. CONCLUSION: Physical restraint efficiently averts AEs. Its application is mainly driven by local habits. Typically, the almost recovered, apparently calm and hence unrestrained patient is at greatest risk for undesirable device removal. The control/interpretation of the patient's analgo-sedation might be inappropriate.

Feasibility and initial efficacy of a cognitive-behavioural group programme for managing anger and aggressiveness after traumatic brain injury.

This study assesses the feasibility of a cognitive-behavioural group programme for treating anger and aggressiveness after a traumatic brain injury (TBI). Five feasibility criteria were considered: demand, implementation, practicality, acceptability and initial efficacy. A self-report questionnaire of aggressiveness (AQ-12) was administered before the intervention (T1), one week following the intervention (T2) and at a four months follow-up (T3). Ten patients with moderate to severe chronic TBI completed the programme through eight once-a-week sessions. The analysis of the feasibility outcomes suggests that: (1) The recruitment, the process of grouping participants and the characterisation of anger and aggressiveness at baseline need to be re-evaluated and improved for future designs. (2) The use of specific strategies for bypassing cognitive and other behavioural dysfunctions related to TBI is crucial for the success of this intervention and merits special attention. (3) The high retention rate, the convenient meeting schedule, cost advantages and the good acceptability by participants are positive arguments for the implementation of a larger trial. (4) The significant reduction of AQ-12 scores at T3 and the high effect size constitute a change in the expected direction and support the initial efficacy of the programme.

VEGF-A, VEGFR-1, VEGFR-2 and Tie2 levels in plasma of premature infants: relationship to retinopathy of prematurity.

AIM: To study prospectively the plasma levels of vascular endothelial growth factor (VEGF-A), its soluble receptors sVEGFR-1, sVEGFR-2 and soluble Tie2 in premature infants. To identify their changes related to the onset of retinopathy of prematurity (ROP). METHODS: Blood samples of 63 preterm infants born at a postmenstrual age (PMA) of 23-32 weeks were obtained between 5 days and 15 weeks after birth. 42 infants had no ROP, two had stage 1, nine stage 2 and 10 stage 3. Of these, four infants were treated with retinal photocoagulation. VEGF-A, sVEGFR-1, sVEGFR-2, and sTie2 were measured in the plasma with a sandwich enzyme immunoassay using factor-specific monoclonal mouse antibodies. The time course of concentrations plotted by kernel smoothing in infants with and without ROP were compared and a paired subgroup with analysis of variance was analysed. RESULTS: ROP patients had raised plasma levels of sVEGFR-2 and sTie2 compared with premature infants without ROP. VEGF-A and sVEGFR-1 levels were similar in both groups. Analysis of a subgroup with pairs of measurements, one before 32 weeks and one after 36 weeks, showed a significant increase in sTie2 after 36 weeks of PMA independent of ROP (p = 0.03). CONCLUSION: This is the first study to measure plasma levels of angiogenic factors in ROP. Similar VEGF-A plasma levels in infants with and without ROP suggest that pathogenic retinal angiogenesis in ROP is mainly driven by local VEGF-A synthesis. Elevated plasma levels in active ROP were observed for sVEGFR-2 and sTie2. These increases have yet to be confirmed as predictive values for ROP.

Rate of abnormalities in lambs from in vitro produced embryos transferred on Day 2 compared with Day 6 postfertilization.

The effect of transferring ovine IVP embryos on Day 2 versus Day 6 postinsemination was investigated. Oocytes were collected from 35 cull ewes and cultured separately for each donor. Embryos were exposed to serum in the maturation and fertilization media, and then cultured in a serum-free SOF system under serum-conditioned silicone oil. Cleaved Day 2 postfertilization embryos were randomly allocated for immediate transfer versus Day 6 transfer. Parturition was induced (with 15 mg dexamethasone) between Days 141 and 143 of pregnancy; those failing to initiate parturition by Day 146 had a Caesarean section. Stillborn lambs and those dying within several days of birth were necropsied. Lambs were weighed at birth; lambs (n = 132) derived from the same flock (from natural breeding or AI) were used as a control. An estimate of the 99th percentile of the normal population was used as the point above which lambs from three litter-size categories were classified as abnormally large (analysis was repeated for 95% confidence and median estimates of this value). Thirty-eight lambs were born from early transfer, 45 from late transfer and 12 from unobserved lambings (parentage could not be determined). Lambs from early transfer were heavier at birth (P = 6.0 x 10 (-11)). The early treatment group had fewer lambs produced per embryo transferred (P = 0.0002), fewer live lambs per embryo transferred (P = 0.00009) and fewer normal lambs per embryo transferred (P= 0.0002). There was an effect of donor on the number of dead lambs per embryo transferred (P = 0.017). The number of dystocias per transfer was not significantly different for early versus late transfer groups. However, the probabilities of survival for cleaved embryos were 27.3% and 13.1% in the early and late transfer treatment, respectively. There were more lambs produced per cleaved embryo with early transfer (P = 0.004) and there was an effect of donor within ram and replicate (P = 0.04) on the number of lambs produced. The odds ratio for early/late treatment was 2.449 with a confidence interval of 1.368-4.382. Day 2 transfer of cleaved embryos did not prevent the production of oversized or abnormal offspring; however, there was an increased chance of a cleaved embryo producing a lamb when transferred on Day 2 rather than Day 6 postfertilization.

Further development of a transcervical technique for artificial insemination in sheep using previously frozen semen.

A transcervical technique (the Guelph System for transcervical AI) was used to inseminate 2060 ewes on 65 farms (average 31 ewes, range 5 to 107) in Ontario, Canada, from October 1990 to September 1992, using previously frozen semen. Estrus was synchronized using progestagen pessaries and PMSG with median inseminations done at 54 h from pessary removal. Maiden ewes were not included. Only ewes in which the cervix could be penetrated were inseminated with 150 million spermatozoa per insemination. A total of 1809 were penetrated and inseminated (penetration rate 87.8%). Success of penetration increased from 76.3% in the first 500 ewes to 97.9% in the last 500 (P=0.01). Cervical penetration was more successful in ewes in the accelerated lambing program (92.3%, average 3.1 mo since the previous lambing) than those in the annual lambing program (82.4%, average 7.0 mo since the previous lambing; P=0.06). The lambing rate for ewes bred during the combined traditional breeding seasons (Fall of 1990, 1991, 1992) was 50.7% compared to 24.4% for ewes bred at other periods (P=0.00001). The average time required for handling and insemination decreased from 8.62 min in the first 500 ewes to 3.62 min in the last 500 ewes. The Guelph System for Transcervical AI was found to be successful for cervical penetration in most ewes. Penetration success was affected by period since the last lambing and by inseminator experience. The lambing rate was higher for ewes bred during the traditional Fall breeding seasons than during other times of the year.

Transcervical artificial insemination of Australian Merino ewes with frozen-thawed semen.

We compared conventional methods for laparoscopic and cervical artificial insemination (AI) to a transcervical AI procedure (Guelph System for Transcervical AI; GST-AI) for use with frozen semen in Merino ewes. The GST-AI procedure was performed by an experienced operator in Experiment 1 (771 ewes) and by 2 inexperienced operators in Experiment 2 (555 ewes). In Experiment 1, intrauterine insemination by GST-AI was achieved in 76% of the ewes. The pregnancy rate at Day 70 for ewes inseminated by laparoscopy (48%, 120 251 ) was higher (P<0.01) than for ewes inseminated by either intrauterine GST-AI (32%, 64 201 ) or cervical AI (9%, 24 256 ). The overall (intrauterine and intracervical) pregnancy rate for GST-AI was 26% (68 264 ) and was unaffected by depth of insemination within the cervix. Pregnancy rates were unaffected by ram or day of insemination. In Experiment 2, the operators achieved intrauterine inseminations by GST-AI in 43% (78 182 ) of the ewes, with a significant operator effect (P<0.01) on depth of cervical penetration. The pregnancy rate to intrauterine GST-AI (40%, 31 78 ) did not differ from that to laparoscopic insemination. The total pregnancy rate for GST-AI in Experiment 2 (19%, 34 182 ) was lower (P<0.05) than that for laparoscopic AI (39%, 72 187 ) but superior (P<0.05) to that for cervical AI (1%, 1 186 ). The GST-AI pregnancy rates were affected by depth of AI (P<0.01) and by operator (P<0.05). It is concluded that GST-AI is superior to cervical AI, and may have application in Merinos if cervical penetration rates can be improved.