Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature.

BACKGROUND: The use of central venous lines carries a significant risk for serious complications and high economic costs. Lately, the peripherally inserted central venous catheter (PICC) has gained in popularity due to presumed advantages over other central venous lines. The aim of this systematic literature review was to identify scientific evidence justifying the use of PICC. MATERIAL AND METHODS: The literature review was performed according to the principles of Cochrane Collaboration. The electronic literature search included common databases up to March 2011. Only those studies rated as high or moderate quality were used for grading of evidence and conclusions. RESULTS: The search resulted in 827 abstracts, 48 articles were read in full text, and 11 met the inclusion criteria. None of the articles was classified as high quality and two had moderate quality. The results of these two studies indicate that PICC increases the risk for deep venous thrombosis (DVT), but decreases the risk for catheter occlusion. The quality of scientific evidence behind these conclusions, however, was limited. Due to the lack of studies with sufficiently high quality, questions such as early complications, patient satisfaction and costs could not be answered. DISCUSSION: We conclude that although PICCs are frequently used in oncology, scientific evidence supporting any advantage or disadvantage of PICC when comparing PICC with traditional central venous lines is limited, apart from a tendency towards increased risk for DVT and a decreased risk for catheter occlusion with PICC.

The influence of perioperative care and treatment on the 4-month outcome in elderly patients with hip fracture.

The purpose of this descriptive cohort study was to identify perioperative risk factors associated with postoperative outcome up to 4 months after surgery in elderly patients with hip fracture. Data were collected prospectively through the Swedish National Hip Fracture, the local Acute and Emergency, and Anesthesia registers, and retrospectively from medical and nursing records. The 428 patients (aged > or = 65 years) with hip fracture were consecutively included. Multiple logistic regression analyses were used to identify factors predicting each of 4 outcomes. Perioperative risk factors predicting death within 4 months after surgery were fasting time of 12 or more hours and blood transfusion of 1 U or more. Risk factors predicting postoperative confusion were postoperative oxygen saturation less than 90% and fasting time 12 hours or longer. Risk factors predicting in-hospital complications were transfusion of 1 or more units of blood, preoperative oxygen saturation less than 90%, and fasting time 12 hours or more. Risk factor predicting length of stay longer than 10 days was blood transfusion of 1 U or more. To minimize morbidity and mortality, providers should increase efforts to optimize the patients' oxygen saturation and hemoglobin level and reduce fasting time and waiting time for surgery.

Factors at admission associated with 4 months outcome in elderly patients with hip fracture.

The purpose of this descriptive cohort study was to describe patients with hip fracture on the basis of ASA physical status and to identify preoperative risk factors associated with postoperative outcome up to 4 months after surgery. Data were collected prospectively through the Swedish National Hip Fracture and Anesthetic registers and retrospectively from medical and nursing records. The 428 patients (aged > or = 65 years) with hip fracture were consecutively included. Multiple logistic regression analyses were used to identify factors predicting each of 4 outcomes. Risk factors for a poorer 4-month survival after hip fracture were ASA physical status 3 and 4, more extensive fractures, 85 years or older, male sex, and dependency in living. Mortality within 4 months was significantly associated with ASA physical status 3 and 4, age 85 years or older, male sex, dementia diagnosis, fewer than 8 correct answers on the Short Portable Mental Status Questionnaire, 4 or more prescribed drugs, hemoglobin level less than 100 g/L, creatinine level more than 100 micromol/L, dependency in living, inability to walk alone, and fracture other than undisplaced intracapsular. Elderly patients with hip fracture should be identified immediately at admission regarding risk factors leading to a poorer survival and more complications.

Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care.

BACKGROUND: To examine the relationship between delusional memories from the Intensive Care Unit (ICU) stay, health related quality of life (HRQoL), anxiety, and symptoms of depression in patients with physical trauma, 6 months to 18 months after their ICU stay. METHODS: Multicenter study in five combined medical and surgical ICUs (n = 239). A questionnaire comprising the Medical outcome Short Form 36, the Hospital Anxiety and Depression scale, and the Intensive Care Unit Memory tool was sent to the patients with trauma 6 months to 18 months after their discharge from the ICU. Clinical data were drawn from patient records in retrospect. A matched reference sample (n = 159) was randomly drawn from the Swedish Short Form 36 norm database (n = 8,930). RESULTS: Patients with trauma had significantly lower HRQoL than the reference sample. One or more delusional memories such as hallucinations, nightmares, dreams, or sensations of people trying to hurt them in the ICU were experienced by 26%. These patients were significantly younger, had a longer ICU stay, relied more on mechanical ventilation, and had higher Injury Severity Score and Sequential Organ Failure Assessment scores. They also reported a significantly poorer HRQoL and a higher probability of experiencing anxiety (51% vs. 29%) and symptoms of depression (48% vs. 26%) compared with patients without such memories. CONCLUSIONS: Our results highlight the importance of treating the delusional memories experienced by ICU patients with a trauma diagnosis as a postinjury factor with a potential to create anxiety and symptoms of depression and which may affect HRQoL after discharge.

Spinal cord stimulation in severe angina pectoris--a systematic review based on the Swedish Council on Technology assessment in health care report on long-standing pain.

Patients who continue to suffer from lasting and severely disabling angina pectoris despite optimum drug treatment and who are not suitable candidates for invasive procedures, suffer from a condition referred to as "chronic refractory angina pectoris". Based on the available data, spinal cord stimulation, SCS, is considered as the first-line additional treatment for these patients by the European Society of Cardiology. However, no systematic review of randomised controlled studies has yet been published. A systematic literature research, 1966-2003, as part of the Swedish Board of Health and Welfare (SBU) report on long-standing pain, and an additional research covering the years 2003-2007, were carried out. Acute studies, case reports and mechanistic reviews were excluded, and the remaining 43 studies were graded for study quality according to a modified Jadad score. The eight medium- to high-score studies formed the basis for conclusions regarding the scientific evidence (strong, moderately strong or limited) for the efficacy of SCS. There is strong evidence that SCS gives rise to symptomatic benefits (decrease in anginal attacks) and improved quality of life in patients with severe angina pectoris. There is also a strong evidence that SCS can improve the functional status of these patients, as illustrated by the improved exercise time on treadmill or longer walking distance without angina. In addition, SCS does not seem to have any negative effects on mortality in these patients (limited scientific evidence). The complication rate was found to be acceptable.

Stressful experiences in relation to depth of sedation in mechanically ventilated patients.

In mechanically ventilated patients, sedatives and analgesics are commonly used to ensure comfort, but there is no documented knowledge about the impact of depth of sedation on patients' perception of discomfort. The aim of this study was, therefore, to investigate the relationship between stressful experiences and intensive care sedation, including the depth of sedation. During 18 months, 313 intubated mechanically ventilated adults admitted to two general intensive care units (ICU) for more than 24 h were included. Patients (n = 250) were interviewed on the general ward 5 days after ICU discharge using the ICU Stressful Experiences Questionnaire. Patient data including sedation scores as measured by the Motor Activity Assessment Scale (MAAS) were collected from hospital records after the interview. Of the 206 patients with memories of the intensive care, 82% remembered at least one experience as quite a bit or extremely bothersome. Multivariate analyses showed that higher proportion of MAAS score 3 (indicating more periods of wakefulness), longer ICU stay and being admitted emergent were factors associated with remembering stressful experiences of the ICU as more bothersome. The findings indicate that the depth of sedation has an impact on patients' perception of stressful experiences and that light sedation compared with heavy seems to increase the risk of perceiving experiences in the ICU as more bothersome. In reducing discomfort, depth of sedation and patient comfort should be assessed regularly, non-pharmacological interventions taken into account and the use of sedatives and analgesics adapted to the individual requirements of the patient.

Delusional memories from the intensive care unit--experienced by patients with physical trauma.

During and after intensive care unit (ICU) stays some patients report unreal experiences or so called delusional memories, which can be a source of distress. The aims of this study were: to describe trauma patients' memories of their stay in the ICU, factors that may influence delusional memories, problems experienced after discharge from the ICU and the patients' return to work. In this multi-centre study, 239 trauma patients filled in a self-administered questionnaire (ICUM tool) 6-18 months after their ICU stay. Clinical data were obtained from patient records. Fifteen percent of the respondents had no memory whatsoever of the ICU. Factual memories such as visits by family members were recalled by 83%. Delusional memories were reported by 26%, nightmares being the most common. These patients' also had more memories of pain, fear and panic. Significant factors associated with delusional memories were age <50 year, ICU stay >or=3 days, temperature >or=38 degrees C, S-Haemaglobin

Memory in relation to depth of sedation in adult mechanically ventilated intensive care patients.

OBJECTIVE: To investigate the relationship between memory and intensive care sedation. DESIGN AND SETTING: Prospective cohort study over 18[Symbol: see text]months in two general intensive care units (ICUs) in district university hospitals. PATIENTS: 313 intubated mechanically ventilated adults admitted for more than 24 h, 250 of whom completed the study. MEASUREMENTS: Patients (n=250) were interviewed in the ward 5 days after discharge from the ICU using the ICU Memory Tool. Patient characteristics, doses of sedative and analgesic agents, and sedation scores as measured by the Motor Activity Assessment Scale (MAAS) were collected from hospital records after the interview. RESULTS: Patients with no recall (18%) were significantly older, had higher baseline severity of illness, and experienced fewer periods of wakefulness (median proportion of MAAS score 3; 0.37 vs. 0.70) than those who had memories of the ICU (82%). Multivariate analyses showed that increasing proportion of MAAS 0-2 and older age were significantly associated with having no recall. Patients with delusional memories (34%) had significantly longer ICU stay (median 6.6 vs. 2.2 days), higher baseline severity of illness, higher proportions of MAAS scores 4-6, and more administration of midazolam than those with recall of the ICU without delusional memories. CONCLUSIONS: Heavy sedation increases the risk of having no recall, and longer ICU stay increases the risk of delusional memories. The depth of sedation during total ICU stay as recorded with the MAAS may predict the probability of having memories of the ICU.

Cancer-related pain in palliative care: patients' perceptions of pain management.

BACKGROUND: Pain is still a significant problem for many patients with cancer, despite numerous, clear and concise guidelines for the treatment of cancer-related pain. The impact of pain cognition on patients' experiences of cancer-related pain remains relatively unexplored. AIM: The aim of this study was to describe how patients with cancer-related pain in palliative care perceive the management of their pain. METHOD: Thirty patients were strategically selected for interviews with open-ended questions, designed to explore the pain and pain management related to their cancer. The interviews were analysed using a phenomenographic approach. FINDINGS: Patients described 10 different perceptions of pain and pain management summarized in the three categories: communication, planning and trust. In terms of communication, patients expressed a need for an open and honest dialogue with health care professionals about all problems concerning pain. Patients expressed an urgent need for planning of their pain treatment including all caring activities around them. When they felt trust in the health care organization as a whole, and in nurses and physicians in particular, they described improved ability and willingness to participate in pain management. While the findings are limited to patients in palliative care, questions are raised about others with cancer-related pain without access to a palliative care team. CONCLUSION: The opportunity for patients to discuss pain and its treatment seems to have occurred late in the course of disease, mostly not until coming in contact with a palliative care team. They expressed a wish to be pain-free, or attain as much pain relief as possible, with as few side effects as possible.

Intensive care sedation of mechanically ventilated patients: a national Swedish survey.

Sedation in critically ill patients is a complex issue and at the same time an important concept for ensuring patient comfort. The aim of this study was to review the current practice of sedation for patients on mechanical ventilation in Swedish intensive care units (ICUs). Questionnaires were sent by post to head nurses in 89 ICUs with mechanically ventilated patients. By August 2000, 87 (98%) questionnaires had been returned. The results show that mechanically ventilated patients were routinely sedated in 91% of ICUs. Midazolam or propofol in combination with an opioid were the drugs preferred by 76%. Heavy sedation was most usual in 63% of ICUs but, when asked about the sedation level preferred by nurses, 78% chose light sedation (P=0.001). Only 16% used sedation scales. This study indicates that local habits and personal attitudes seem to have a great impact on sedation routines. It therefore appears worthwhile for ICUs to review their practice and, if necessary, to consider implementing sedation scales and sedation guidelines. Research pertaining to potential complications and patient comfort in relation to different sedation levels as well as further validation of the efficacy of sedation scales is needed.

A comparison of pain and health-related quality of life between two groups of cancer patients with differing average levels of pain.

A study was performed to describe and compare pain and Health-Related Quality of Life (HRQOL) in two groups of cancer patients in palliative care as well as to describe the correlation between pain and HRQOL. Forty-seven patients with mild average pain [Visual Analogue Scale (VAS) 3) were included. Medical Outcomes Study Short Form (SF-36) was used to evaluate HRQOL, pain intensity levels were measured with the VAS on Pain-O-Meter. Compared to patients with mild pain, patients with moderate to severe pain had statistically significant, higher pain intensity for the items 'pain at time of interview', 'worst pain in the past 24 hours' and 'pain interrupting sleep.' They also had the lowest scores of the SF-36 dimensions: physical functioning, role-physical, and bodily pain. Patients with moderate to severe pain had statistically significant, fewer months of survival. There were statistically significant positive correlations between pain items and negative correlation between pain and SF-36 dimensions. The conclusion is that pain has a negative impact on HRQOL, especially on physical health and that pain increases towards the final stages of life. Even if patients have to endure symptoms such as fatigue and anxiety during their short survival time, dealing with pain is an unnecessary burden, which can be prevented.

Pain and health-related quality of life among cancer patients in final stage of life: a comparison between two palliative care teams.

A two-centred descriptive study was performed in order to describe and compare pain and health-related quality of life (HRQOL) among cancer patients, in their final stage of life. The patients were cared for by either a nurse-led palliative care team I (PCT I) or a physician-led palliative care team II (PCT II). Forty-six consecutive, stratified patients (PCT I, n = 21 and PCT II, n = 25) participated. The medical outcomes study short form 36 (SF-36) was used for evaluating HRQOL and the Pain-O-Meter for assessing pain. Patients' pain intensity, pain quality and HRQOL showed no significant difference between the two groups PCT I and PCT II. The patients from PCT I had significantly longer survival time (P = 0.017) than those from PCT II. The different composition of the teams being led by nurses or physicians is worth further research; both from the patient's and staff's viewpoint, there may also be cost-benefits worth examining.

The quotient end-tidal/inspired concentration of sevoflurane in a low-flow system.

STUDY OBJECTIVE: To investigate the effect of two different fresh gas flows on inspired and end-tidal sevoflurane concentration for a given vaporizer setting in a low-flow anesthesia system. DESIGN: Prospective clinical study. SETTING: Department of Anesthesiology of a university teaching hospital. PATIENTS: 56 ASA physical status I and II patients without systemic diseases, having elective surgery with an expected anesthesia time of at least 120 minutes. INTERVENTIONS: Patients were randomly assigned to receive either 1.0 or 2.0 L/min fresh gas flow with the vaporizer setting fixed at 2% sevoflurane. The inspired (In), end-tidal (Et), and Et/In ratio sevoflurane concentrations were estimated. MEASUREMENTS AND MAIN RESULTS: After 120 minutes of sevoflurane anesthesia the inspired and end-tidal sevoflurane concentration were 1.45 +/- 0.10% versus 1.28 +/- 0.12% (p < 0.001) in the 1.0 L/min group and 1.64 +/- 0.08% versus 1.46 +/- 0.11% (p < 0.001) in the 2.0 L/min group. The ratio end-tidal and inspired concentrations/vaporizer setting was 0.64 +/- 0.06 and 0.73 +/- 0.05 in the 1.0 L/min group versus 0.73 +/- 0.05 and 0.82 +/- 0.04 in the 2.0 L/min group. For the ratio inspired and end-tidal/vaporizer setting there were significant difference between the groups (p < 0.001). The estimated ratio end-tidal/inspired was 0.88 +/- 0.04 in the 1.0 L/min group versus 0.89 +/- 0.04 in the 2.0 L/min group (ns). CONCLUSION: After 120 minutes of sevoflurane anesthesia at a vaporizer setting of 2% there is a significant difference between fresh gas flow of 1.0 and 2.0 L/min for inspired and end-tidal concentrations, but not for the ratio end-tidal/inspired.