Potential sources of conflict in intensive care units - a questionnaire study.

BACKGROUND: Conflicts occur in intensive care units (ICUs), and an international multicentre study conducted in 2008, including 323 ICUs from 24 European countries, confirmed the occurrence of this phenomenon. There are no data in Poland. The aim of the study was to analyse the frequency of the occurrence of conflicts in ICUs in Polish hospitals, and their most frequent sources. METHODS: The study was based on an original questionnaire performed in 12 ICUs in the Pomeranian Voivodship. The respondents were asked questions regarding the frequency, type, and lines of conflicts between employees, as well as potential causes of conflicts. RESULTS: Completed surveys were received from 232 employees, including 79 doctors and 153 nurses. The phenomenon of occurrence of conflicts was confirmed by about 30% of the staff, providing answer that conflicts occur "often". About 43% of staff estimated that conflicts "sometimes" occur and 25% chose the answer "rarely". Analysis of the answers made it possible to identify the most common potential causes of conflict. CONCLUSIONS: The main sources of conflicts in ICUs appear to be external factors such a financial issues and physical overload. The hospital policy and the health policy of the state are also important. The perceived conflicts require careful and constant monitoring. The frequency of hidden conflicts requires thorough assessment of their impact on the quality of work.

Frailty is associated with an increased mortality among patients ≥ 80 years old treated in Polish ICUs

BACKGROUND: The increasing population of very old intensive care patients (VIPs) is a major challenge currently faced by clinicians and policymakers. Reliable indicators of VIPs' prognosis and purposefulness of their admission to the intensive care unit (ICU) are urgently needed. METHODS: This is a report from the Polish sample of the VIP1 multicentre cohort study (NCT03134807). Patients ≥ 80 years of age admitted to the ICU were included in the study. Information on the type and reason for admission, demographics, utilisation of ICU procedures, ICU length of stay, organ dysfunction and the decision to apply end-of-life care was collected. The primary objective was to investigate the impact of frailty syndrome on ICU and 30-day survival of VIPs. Frailty was assessed with the Clinical Frailty Scale (≥ 5 points on a scale of 1-9). RESULTS: We enrolled 272 participants with a median age of 84 (81-87) years. Frailty was diagnosed in 170 (62.5%) patients. The ICU and 30-day survival rates were equal to 54.6% and 47.3% respectively. Three variables were found to significantly increase the odds of death in the ICU in a multiple logistic regression model: SOFA score (OR = 1.16; 95%CI 1.16-1.24), acute mode of admission (OR = 5.1; 95%CI 1.67-15.57) and frailty (OR = 2.25; 95%CI 1.26-4.01). CONCLUSION: Measuring frailty in critically ill older adults can facilitate making more informed clinical decisions and help avoid futile interventions.

Escherichia coli bacteraemias in intensive care unit patients.

BACKGROUND: Although bacterial infections are common in critically ill patients, isolation of bacteria from the sample is not always unambiguous. The authors addressed Escherichia coli bacteraemia in patients treated in the Intensive Care Unit in the Teaching Hospital in Gdansk in 2002-2009. METHODS: Using a computer database, the names of Escherichia coli positive patients and dates of blood sampling were found, followed by a retrospective assessment whether positive blood cultures were accompanied by the clinical features of sepsis or asymptomatic bacteraemia. RESULTS: Positive cultures were found in 40 blood samples (36 patients). Bacteraemia was diagnosed in 11, sepsis in 10, severe sepsis in 6 and septic shock in 13 cases. In the bacteraemia group, the condition originated from the gastrointestinal tract - 4 cases; from the lungs - 1; while in 6 cases, the aetiology was not detected. In patients with an infection, the likely source was the gastrointestinal tract - 12 cases; the lungs - 4; and pyothorax - 2. In 11 cases, the aetiology remained unidentified. In 3 patients in the bacteraemia group, cultures of other microorganisms were found to be positive, while there were 4 cases among the septic patients. In the bacteraemia group, 8 patients died in the intensive care unit, without relation to bacteraemia. Amongst septic patients 17 died, including 12 whose death was probably attributable to Escherichia coli infection. CONCLUSIONS: Escherichia coli bacteraemias and infections have been and will remain an everyday problem in hospital wards. The differentiation of asymptomatic bacteraemia from infection is essential for rational antibiotic therapy, which is particularly important considering the increasing resistance of microorganisms.

The influence of epidural blockade on gut permeability in patients undergoing open surgical repair of abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic clamping during aneurysm repair may cause a decrease in splanchnic blood flow and deterioration of gut barrier integrity. Epidural blocks have beneficial effects on vital organs during abdominal surgery, but sparse data are available on the influence on gut permeability during open aortic surgery. The aim of this study was to verify the hypothesis that epidural blocks may have beneficial effects on intestine permeability changes. METHODS: Seventy individuals undergoing elective open abdominal aortic aneurysm repair were randomly assigned to receive either balanced anaesthesia (continuous epidural and general anaesthesia, group E&G) or only general anaesthesia (group G). For group E&G, an epidural catheter was inserted into the epidural space before the induction of general anaesthesia. Ropivacaine was used for intraoperative and postoperative blocks. For both groups general anaesthesia was maintained with sevoflurane. For group G, analgesia was provided with remifentanil. The assessments of gut function were based on measurements of the absorption and percentages of urinary excretion of four sugars (m 3-O-methyl-D-glucose, D-xylose, L-rhamnose and lactulose) and the lactulose/rhamnose (L/R) ratio. RESULTS: No intergroup differences were observed for sugar recovery or L/R ratio. Significant decreases in 3-O-methyl-D-glucose, D-xylose, and L-rhamnose recoveries were revealed in both examined groups when comparing the results obtained at 12 and 24 hours following the administration of anaesthesia. The rate of blood pressure decrease was significantly higher in group E&G. CONCLUSIONS: Aortic clamping during open abdominal aortic repair led to unfavorable changes in intestinal permeability. Epidural block did not attenuate this deterioration.

Multifactorial analysis of fatigue scale among nurses in Poland.

Significant progress in the field of nursing has contributed to the widening of range of functions and professional duties of nurses. More frequent lack of nursing personnel has an impact on negative reception of work, it decreases sense of professional satisfaction and increases the level of burden and fatigue. METHODS: The study applied the non-experimental method - a descriptive comparative study without a control group. The data was collected on the basis of Polish-language version of a Japanese questionnaire. In order to evaluate the level of physical fatigue the pedometer was used. RESULTS: 158 respondents of a group of 160 were included in the statistical analysis. The study group was internally diversified. The research project assessed the usefulness of the multifactorial analysis in evaluating the main components of nursing fatigue. Multifactorial analysis has shown that mental fatigue concentrated with changes in activeness, motivation and physical fatigue are strongly correlated with age, professional experience and education. CONCLUSION: Nursing is a profession of a special character and mission. Regardless of the place of work, nursing staff should be given the possibility of pursuing their profession under conditions ensuring the sense of security and protecting them from harmful effects on health.

Does epidural anaesthesia reduce the incidence of postoperative oxygen desaturation episodes in patients undergoing open abdominal aortic aneurysm repair?

BACKGROUND: Postoperative desaturation can lead to severe hypoxaemia and even tissue hypoxia, followed by cardiological and neurological complications. Opioid usage is the one of the most important risk factors of postoperative desaturation and hypoxemia. Epidural anaesthesia is recommended for vascular surgery for many reasons; the reduction or elimination of opioid doses is one reason. The aims of the study were to evaluate the incidence of desaturation episodes in patients after surgical procedures with abdominal aortic clamping, to determine whether the episodes in question lead to clinical symptoms of hypoxia and to determine whether epidural anaesthesia decreases the incidence of desaturation episodes. METHODS: After abdominal aortic repair, 58 patients who did not have any respiratory disease, were classified as ASA II-III, and were aged from 46 to 80 years were observed in the ICU during spontaneous breathing with oxygen supplementation. Non-invasive O2 saturation measurements were taken continuously, and all desaturation incidents (defined as O2 saturation ≤ 93% for 4 min) were noted. Patients were divided into two equal groups: A - epidural blockade used after the operation for pain relief and B - intravenous opioids administered during the postoperative period. We evaluated and compared the desaturation frequency during the postoperative period. RESULTS: Desaturation was observed among 26 (89%) patients in group A and 27 (93%) patients in group B. There were no statistical differences among the groups (P = 1.0). Severe hypoxemia (O2 saturation ≤ 84%) was observed among 7 (24.1%) patients in group A and 10 patients in group B (34.5%) (P = 0.38). Clinical symptoms of hypoxia were similar in both groups (P = 1.0). CONCLUSIONS: Epidural anaesthesia did not protect against postoperative desaturation. Though oxygen therapy was used, desaturation was observed in approximately 90% of patients.

Conflicts in the intensive care unit.

Conflicts in intensive care units (ICUs) are common and concern all professional groups, patients and their families. Both intra- and inter-team conflicts occur. The most common conflicts occur between nurses and physicians, followed by those within nursing teams and between ICU personnel and family members. The main causes of conflicts are considered to be unsatisfactory quality of the information provided, inappropriate ways of communication and improper approach towards treatment of patients. ICU conflicts can have serious consequences not only for families but also for patients, physicians, nurses and wider society. Lack of communication among ICU teams is likely to impair cooperation and ICU team-family contacts. From the point of view of patients and their families, communication skills, as one of the factors affecting the satisfaction of families with treatment, are essential to ensure high quality of ICU treatment. While conflicts are generally unfavourable, they can also have positive implications for the parties involved, depending on their prevalence and management, as well as the community they concern.

The influence of intravenous ondansetron on maternal blood haemodynamics after spinal anaesthesia for caesarean section: a double-blind, placebo-controlled study.

OBJECTIVE: verification of a hypothesis assuming that 5-HT3 receptor blockade by intravenous administration of ondansetron reduces the incidence of hypotension and bradycardia in patients undergoing spinal anaesthesia for Caesarean section. MATERIAL AND METHODS: The study design was approved by the Bioethics Committee and included 72 patients undergoing elective Caesarean section, randomly assigned to ondansetron group (group 0) or placebo group (group P). Finally group 0 encompassed 35 patients administered ondansetron 8 mg i.v. dissolved in 10 ml 0.9% NaCl whereas group P consisted of 34 patients receiving 0.9% NaCl 10 mg. Systolic and diastolic pressures were measured every 2 minutes since the onset of anaesthesia. Heart rate (HR) was monitored continuously The criterion of hypotension requiring ephedrine was a decrease in systolic pressure by 20% compared to its baseline value or a decrease in systolic pressure below 90 mm Hg. The criterion of bradycardia was a decrease in HR below 60/min. RESULTS: Hypotension was observed in 14 group 0 patients (39%) and in 15 group P patients (44%); the difference was not statistically significant. Bradycardia was noted in 1 group 0 patient (3%) and in 2 group P patients (6%); the difference was not statistically significant. CONCLUSION: A hypothesis assuming a reduction in pressure following subarachnoid anaesthesia for Caesarean section after the administration of 8 mg of ondansetron was not confirmed.

Assessment of the depth of anaesthesia during inhalational and intravenous induction of general anaesthesia.

BACKGROUND: Tracheal intubation is one of the strongest stimuli during general anaesthesia and may result in an insufficient depth of anaesthesia. The aim of the study was to compare the clinical evaluation of the depth of anaesthesia with an evaluation using entropy during inhalational and intravenous induction of general anaesthesia. METHODS: This study involved 60 patients undergoing elective surgery under general anaesthesia. Patients were divided into two groups, group E (etomidate induction) and group S (sevoflurane induction). The systolic arterial pressure (SAP), heart rate (HR), response entropy (RE), and state entropy (SE) were determined at the following seven measurement points: before anaesthesia induction, at the loss of consciousness (LOC) point, before tracheal intubation, immediately after intubation, and 2 min., 4 min. and 6 min. after tracheal intubation. An increase in HR and/or SAP of more than 20% and/or the occurrence of lacrimation and/or perspiration in response to tracheal intubation was considered a marker of inadequate anaesthesia in the clinical evaluation. The depth of anaesthesia was considered insufficient according to entropy monitoring if the RE and SE were above 60. RESULTS: In clinical evaluation, insufficient anaesthesia in response to tracheal intubation was observed in all the patients in group E and in more than half of the patients in group S. At the same time, the majority of patients in both groups had entropy values that did not exceed the recommended value as an appropriate level of anaesthesia. CONCLUSIONS: We found a discrepancy in the evaluation of the depth of anaesthesia based on clinical criteria compared with evaluations based on entropy values during both intravenous and inhalational induction of general anaesthesia.

The effectiveness of the APACHE II, SAPS II and SOFA prognostic scoring systems in patients with haematological malignancies in the intensive care unit.

BACKGROUND: Cancer-related mortality remains the second most common cause of death in Poland. In many cases, the occurrence of treatment-related complications requires admission to the intensive care unit (ICU). The aim of this study was to assess the clinical application of the APACHE II, SAPS II and SOFA scales to evaluate the risk of death in patients with haematological malignancies treated in the ICU. METHODS: This study's analysis included 99 patients, who were each assigned to one of the following two groups: surviving patients who were discharged from the ICU (n = 24); and patients who died in the ICU (n = 75). Analysis was performed using demographic, clinical and laboratory data obtained during the patient's admission to the ICU and also during the first 24 hours of intensive therapy. Patient assessment was performed using the APACHE II, SAPS II and SOFA scoring systems as well as other clinical variables. RESULTS: Univariate logistic regression identified the following risk factors of death in patients with haematological malignancies: systolic (P = 0.006), diastolic (P = 0.01) and mean arterial pressure values (P = 0.009); occurrence of acute kidney injury; neutrophil (P = 0.009) and platelet count in the peripheral blood (P = 0.001); and the SAPS II (P = 0.00005), SOFA (P = 0.00009) and APACHE II (P = 0.0007) scores. SAPS II score was the only independent risk factor of patient death in multivariate analysis (P = 0.0004; unitary OR 1.052 [95% CI: 1.022-1.082]). CONCLUSION: Of all the applied patient assessment scales, only the SAPS II score was found to be useful in subjects with haematological malignancies hospitalised in the ICU.

The influence of epidural anesthesia on the electrical activity of heart atria.

INTRODUCTION: High thoracic epidural anesthesia (TEA) causes blockade of sympathetic fibers involved in innervation of the heart (segments T1-T4), which results in changes of cardiac electrophysiology. The anti-arrhythmic effects of TEA on supraventricular arrhythmias, mainly atrial fibrillation, are controversial. THE AIM OF THE STUDY: The aim of the study was to assess the influence of epidural anesthesia on the electrical function of heart atria, including proven markers of increased risk of perioperative atrial fibrillation, such as P wave dispersion and P wave maximum duration. MATERIAL AND METHODS: The study involved 50 male patients, without a history of previous heart diseases, scheduled for elective surgical procedures. Patients received thoracic epidural anesthesia (group T, n = 25) or lumbar epidural anesthesia (group L, n = 25). The measurements were obtained from a continuous recording of ECG before epidural anesthesia and after the detection of blockade (T1 or T8 segment sensory block in groups T and L, respectively). RESULTS: The statistical analysis of electrocardiographic parameters, including the maximum, minimum and mean P wave duration; P wave dispersion; the maximum, minimum and mean PR interval duration; and PR interval dispersion, did not show any inter- or intragroup differences at selected time points. CONCLUSIONS: Regardless of its location, epidural anesthesia and sympathetic blockade associated with this procedure do not significantly affect the electrical functions of the cardiac atria reflected in superficial ECG, including the electrocardiographic parameters that are considered to be markers of increased risk of perioperative atrial fibrillation, such as P wave dispersion and its maximum duration.

The impact of colloid infusion prior to spinal anaesthesia for caesarean section on the condition of a newborn--a comparison of balanced and unbalanced hydroxyethyl starch 130/0.4.

BACKGROUND: Fluid therapy is the most commonly used treatment to prevent hypotension associated with spinal anaesthesia. The aim of this study was to test the hypothesis that a balanced solution of 6% hydroxyethyl starch will have a more beneficial impact on the condition of newborns at birth than an unbalanced 6% solution of HES. METHODS: The study participants included 51 healthy parturients undergoing elective caesarean section with spinal anaesthesia. Patients received a transfusion of 500 mL of unbalanced 6% HES (Voluven) or balanced 6% HES (Tetraspan) prior to anaesthesia. The condition of the newborn was assessed using the Apgar score, and the acid-base balances of venous and arterial umbilical cord blood were also measured. RESULTS: The incidence of hypotension after spinal anaesthesia was 80% in Group A and 76.9% in Group B (P = 1.0). There were no differences between the two groups in the total doses of ephedrine and no differences between treatment groups in Apgar scores. Also, no differences in acid-base balance parameters (pH, H(+), pCO(2), pO(2), HCO(3)(-), BE) were found. CONCLUSION: A balanced 6% solution of hydroxyethyl starch (HES 130/0.42) did not significantly influence the condition of the newborns at birth or the acid-base and electrolyte concentration of newborns compared to an unbalanced solution of 6% hydroxyethyl starch (HES 130/0.4).

Use of dexmedetomidine in the adult intensive care unit.

Sedation and analgesia, which are universally used in intensive care units (ICUs), provide patients with comfort and safety. The current trends aim at light sedation; the objective is to ensure the minimal sedation level for improving patients' autonomy and enabling the professional staff to assess the patients' neurological status and cognitive functions. Reports in the literature have indicated that a sedative or an entire sedation procedure can affect cognitive processes, the duration of mechanical ventilation and treatment outcomes in critically ill patients. At present, special attention is given to post-sedation delirium. Although sedatives differ in their uptake points, which can influence the quality of sedation, their common characteristic is substantial impairment of cognitive functions, memory and respiration. Alpha 2-adrenergic receptor agonists, which comprise a novel group of agents, are used frequently for sedation. One of these medications is dexmedetomidine, which is designed to sedate adult ICU patients who exhibit a score ≥ -3 according to the Richmond Agitation-Sedation Scale. Recent studies comparing the use of dexmedetomidine and the other sedative agents that are most commonly administered in ICUs demonstrated that the former largely fulfils the expectations of intensivists.

The influence of low flow anaesthesia on renal function in cancer patients previously treated with nephrotoxic chemotherapeutic agents.

BACKGROUND: The aim of this study was to assess renal morbidity, associated with the use of low flow anaesthesia (LFA), in cancer patients previously treated with nephrotoxic chemotherapeutic agents. METHODS: Seventy-five patients, aged 30-70 years, scheduled for elective surgery, were randomly allocated to three groups: Group A included those patients who had received nephrotoxic chemotherapeutic agents (cisplatin, carboplatin, methotrexate or cyclophosphamide) within 90 days before surgery, and who were anaesthetised with low flow (0.8(-1) L min(-1)) air-oxygen-sevoflurane (1-3 MAC) anaesthesia; Group B included similar patients who received high flow (6 L min-1) anaesthesia. Non-cancer patients receiving low flow anaesthesia served as controls. Blood was sampled for serum creatinine, BUN, cistatin C, and electrolytes (Na(+), K(+), Cl(-), Ca(2+), P(3+), Mg(2+)) before anaesthesia, and one, three and five days after. RESULTS: There were no statistically significant differences between the groups. CONCLUSIONS: The use of low flow sevoflurane anaesthesia is not associated with an increased risk of nephrotoxicity in those previously exposed to nephrotoxic chemotherapeutic agents.

Fluid use in adult intensive care.

Methods for the restoration of circulating blood volume, including the use of intravenous fluids, have been widely discussed over many years. There are no clear guidelines regarding the type of solutions, the total volume that should be transfused, or time schedules. Colloid solutions, usually hydroxyethyl starch compositions, are probably the most commonly used volume expanders in resuscitation, despite the lack of convincing trials and possible nephrotoxicity.In 2012, a task force of ESICM published a consensus statement on colloid use in critically ill adult patients. They stressed that infusion of an inappropriate volume may worsen the outcome of critically ill patients. Static parameters of cardiac filling volume, such as CVP or PCWP, commonly used in clinical practice, were found to be useless in the prediction of fluid responsiveness; volumetric or dynamic parameters, like global end diastolic volume (GEDV) or stroke volume variations (SVV), obtained by PICCO meters, seemed be much more appropriate. The dynamic fluid challenge test, which is transfusion of approx. 200 cc (or 3 mL kg-1) of any fluid over 5-10 min resulting in an increase of stroke volume, has also been recommended for the identification of those patients who may benefit from fluid resuscitation. The old passive leg raising test can also be used for this purpose.Despite prolonged discussion about fluid therapy in specific groups of critically ill patients, there is no convincing data to indicate the superiority of colloids over crystalloids. The choice of fluids is usually based on personal preference and hospital policy. Among crystalloid solutions, balanced preparations such as acetates, lactates, malates or citrates are recommended to avoid hyperchloraemia, a common side effect of saline infusion. There is no agreement regarding colloid solutions.The fluid transfusion regimen in critically ill patients should therefore be based on clinical assessment and patient responses.

Selected methods of measuring workload among intensive care nursing staff.

Intensive care units and well-qualified medical staff are indispensable for the proper functioning of every hospital facility. Due to demographic changes and technological progress having extended the average life expectancy, the number of patients hospitalized in intensive care units increases every year [9,10]. Global shortages of nursing staff (including changes in their age structure) have triggered a debate on the working environment and workload the nursing staff are exposed to while performing their duties. This paper provides a critical review of selected methods for the measurement of the workload of intensive care nurses and points out their practical uses. The paper reviews Polish and foreign literature on workload and the measurement tools used to evaluate workload indicators.

Laryngeal dystonia in the course of multiple system atrophy: a cause of postoperative respiratory insufficiency.

Multiple system atrophy (MSA) is an adult onset, incurable neurodegenerative disease, characterized by symptoms of nervous system failure. Occurrence of laryngeal dystonia indicates increased risk of sudden death caused by airway occlusion. We present the case report of 63-year-old patient with history of orthostatic hypotension, parkinsonism, progressive adynamia, and stridor. The patient was admitted to the hospital for diagnosis of orthostatic hypotension. A diagnosis of possible MSA was made. Because of patient's complaints, an X-ray of the hip joint was taken. It revealed femoral neck fracture. Endoprosthesis insertion under general anesthesia was performed. Two days later the patient presented progressive adynamy and respiratory insufficiency. Endotracheal intubation and respiratory support were required followed by extubation and one more intubation. After second extubation, stridor and acute respiratory insufficiency occurred. Urgent tracheostomy was performed. After 13 days in ICU, the patient was discharged to the rehabilitation center.

Analysis of intraoperative transfusions of red blood cell concentrates in adults.

BACKGROUND: Transfusion of red blood cell (RBC) concentrates is the most common allogeneic transplantation. The aim of the study was to analyse the indications for RBC transfusions, compared to the estimated intraoperative blood loss and the actual requirements for blood transfusion. METHODS: We retrospectively analysed the files of 250 adult patients who were transfused over the year 2006, during various general, oncologic, trauma, vascular, plastic and thoracic surgical procedures. Preoperative screening was done in a hospital laboratory, whereas postoperative haemoglobin concentration and haematocrit were assessed at the bedside using a co-oximeter. RESULTS: The majority of RBC transfusions were started at relatively high haemoglobin concentrations (mean 5.6 mmol L⁻¹), contrary to the current guidelines. A high correlation coefficient (r=0.82) was found between the estimated blood loss and the volume of RBCs transfused; therefore we concluded that the observed blood loss was the main factor in transfusion decisions. CONCLUSIONS: Despite enormous progress in transfusion science, the current practice in our institution is still far from ideal; RBCs are frequently transfused too early and without a real indication.