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.

[Latin organ donation programme (LODP): an effective initiative to increase organ donation in Switzerland]. / Programme latin de don d'organes (PLDO): une initiative efficace pour augmenter les dons d'organes en Suisse.

The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality and efficiency in the procedures for organ and tissue donation for transplantation. The Latin organ donation programme (LODP) created in 2008 aims to develop organ donation in 17 public hospitals in 7 Latin cantons, covering 2.2 million people; 29% of the Swiss population. The implementation of various effective measures by the LODP enabled the increase in the number of donors by 70% between 2008 and 2010, with four organs procured per donor; greatly exceeding the European average of three. The results show that LODP has successfully professionalised the system and we can only hope that similar organisations will be put into place throughout Switzerland.

The abdominal compartment syndrome. Clinical relevance.

Increased intra-abdominal pressure (IAP) may occur in a number of different situations encountered by intensivists, such as tense ascites, abdominal hemorrhage, use of military antishock trousers, abdominal obstruction, during laparoscopy, large abdominal tumors and peritoneal dialysis.1-3 Both clinical and experimental evidence indicate that increased IAP may adversely affect cardiac, renal, respiratory and metabolic functions.1-5 Despite this, increased IAP is rarely recognized and treated in Intensive Care Unit (ICU) settings. There appears to be two reasons for this: the physiologic consequences of increased IAP are not well know, to most physicians and, more importantly, the capability of easily measuring IAP has not been well documented. In this chapter, we will discuss: 1) the different methods proposed to evaluate IAP in ICU; 2) the physiopathological consequences of increased IAP; 3) the existing clinical data about IAP in critically ill patients. Considering overall our data, we can conclude that: 1) different techniques are available at the bedside to estimate the IAP; 2) the IAP ranges between 10 and 20 cmH2O, substantially increased compared to normal subjects. Most of the patients have IAH, while few of them (<5%) present clinical characteristics of ACS; 3) the IAP is different among different categories of patients and its increase is not limited to surgical patients only; 4) the increase in IAP appears to influence respiratory function, homodynamic, kidney, gut and brain physiology; 5) the IAP seems to be correlated with severity scores but its relation to mortality is controversial; 6) the routine measurements of IAP by means of bladder pressure are not associated with an increased rate of urinary tract infections.

Effect of prone positioning on the survival of patients with acute respiratory failure.

BACKGROUND: Although placing patients with acute respiratory failure in a prone (face down) position improves their oxygenation 60 to 70 percent of the time, the effect on survival is not known. METHODS: In a multicenter, randomized trial, we compared conventional treatment (in the supine position) of patients with acute lung injury or the acute respiratory distress syndrome with a predefined strategy of placing patients in a prone position for six or more hours daily for 10 days. We enrolled 304 patients, 152 in each group. RESULTS: The mortality rate was 23.0 percent during the 10-day study period, 49.3 percent at the time of discharge from the intensive care unit, and 60.5 percent at 6 months. The relative risk of death in the prone group as compared with the supine group was 0.84 at the end of the study period (95 percent confidence interval, 0.56 to 1.27), 1.05 at the time of discharge from the intensive care unit (95 percent confidence interval, 0.84 to 1.32), and 1.06 at six months (95 percent confidence interval, 0.88 to 1.28). During the study period the mean (+/-SD) increase in the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen, measured each morning while patients were supine, was greater in the prone than the supine group (63.0+/-66.8 vs. 44.6+/-68.2, P=0.02). The incidence of complications related to positioning (such as pressure sores and accidental extubation) was similar in the two groups. CONCLUSIONS: Although placing patients with acute respiratory failure in a prone position improves their oxygenation, it does not improve survival.

Attitudes and behavior of young European adults towards the donation of organs--a call for better information.

Public perception of organ donation critically affects the availability of organ transplantation in the Western world. To assess the attitude of young adults towards the donation of organs and to investigate potential factors influencing their knowledge and actual behavior regarding organ transplantation, we evaluated a handout questionnaire survey of all Swiss-Italian recruits during six of the years 1989-98 (n = 7272). The attitude of recruits towards organ donation did not change significantly within the 10-year survey period: 61% of young men would personally donate their organs in the case of brain death, 13% would refuse, and 26% had not made up their mind. If they had to decide for close relatives, 50% would consent; 60% of recruits neither knew their next of kin's attitude nor had informed them about their own opinion; 80% felt they were insufficiently informed about organ transplantation. A significantly more positive attitude towards organ donation was found among men who felt they were sufficiently informed, who had close next of kin who were aware of their personal attitude (p < 0.0001), who had contacts with transplanted persons (p < 0.015), or who believed in an existence after death (p < 0.001; chi2-test). Our results suggest that there is potentially large support towards organ donation in this population. To minimize the high rate of indecisiveness, young adults need more appropriate information on the subject and they ask for it.

Long-term safety of an early ACE-inhibitor treatment of patients with acute myocardial infarction: results of the 3 year follow-up period on 696 Swiss patients randomized to the ISIS-4 trial. ISIS-Switzerland Study Group.

Several large scale clinical trials showed that early ACE inhibitor treatment in patients with acute myocardial infarction reduced 30-day mortality. While the short-term evidence of benefit and risks appears to be consistent among trials, scarce data are available with respect to the long-term effects of short-term treatments. This study shows that the early reduction in mortality rate observed among patients treated with captopril persists for up to 3 years. This suggests that the benefit achieved in the acute phase in not lost even after a long period of time.

[Anxiety and stress in the nursing staff. A comparative study between intensive care and general wards]. / Ansia e stress del personale infermieristico. Analisi comparata tra Terapia Intensiva e reparti di base.

We studied a population of 463 nurses working in intensive care units--ICUs--(distributed in 51 italian hospitals), and 216 nurses working in general medicine units (distributed in 17 italian hospitals). They we asked to fill in a form including: 1) general data and his/her work environment, and 2) some standardized scales (HAD A and D, STAI Y-1 and Y-2, MBI) for estimation of anxiety, depression and "burnout" syndrome. We used also the "P questions", evaluating the different situations of work environment causing anxiety. The aims of the study were to evaluate the effectiveness of different scales and the influence of general medicine and intensive care environment on psychological features. Among different scales estimating anxiety, the STAI Y-2, valuing a chronic anxiety status, results to be efficient, beside the already tested HAD A. The intensive care environment did not seem to be more stressful for nurses staff rather than general medicine units. Furthermore, nurses operating in general medicine units have a major tendency to depression; their work environment seems to favour the development of anxiety. Finally, it results that general medicine units cause a more severe "burnout" syndrome in their nurses staff rather than ICUs.

[Therapy of acute myocardial infarct (1994-1996) at non-university hospitals in Switzerland (CHAMI Study)]. / Die Therapie des akuten Herzinfarkts (1994-1996) an nicht-universitären Spitälern in der Schweiz (CHAMI-Studie).

The CHAMI study (Confederatio Helvetica Acute Myocardial Infarction) recorded the therapies administered for acute myocardial infarction in 520 consecutive patients between October 1994 and February 1996 at 10 non-academic hospitals in Switzerland. The patients in this group consisted of 363 men and 157 women with an average age of 63.2 years. The prescribed medications administered from the day of hospital admission until the day of discharge were recorded. In the acute phase, the patients were given the following therapy: thrombolytic agents 40%, i.v. nitrates 65%, i.v. beta-blockers 22%, aspirin 95%, oral beta-blockers 36%, ACE inhibitors 14%. Impressive was the lower distribution of thrombolytic agents and beta-blockers among the older patients (age > 70) (thrombolytic agents 52.1% vs 28.4%; oral beta-blockers 44.0% vs 29.1%) and in particular among women (thrombolytic agents 26.8% vs 46%; oral beta-blockers 29.3% vs 39.7%) in men. Therapy at hospital discharge consisted, inter alia, of aspirin (73%), beta-blockers (54%), ACE inhibitors (3%), and lipid lowering agents (10%). The hospital mortality was 12.6%. The CHAMI study provided the participating hospitals with a quality control comparison with other participating centers and impressively demonstrated with the example of the lipid lowering agents, that the significance of secondary prophylaxis is assigned too little importance in contrast to acute therapy.

Determination of cardiac output during mechanical ventilation by electrical bioimpedance or thermodilution in patients with acute lung injury: effects of positive end-expiratory pressure.

OBJECTIVE: To evaluate the usefulness of transthoracic electrical bioimpedance in sedated and paralyzed patients with acute lung injury during mechanical ventilation with and without early application of positive end-expiratory pressure (PEEP). DESIGN: Prospective, repeated-measures study. SETTING: University-affiliated intensive care center. PATIENTS: Ten patients with acute lung injury. INTERVENTIONS: Simultaneous, three-paired cardiac output (CO) measurements by transthoracic electrical bioimpedance (TEB) and thermodilution (TD) were made at 0 and 15 cm H2O of PEEP. MEASUREMENTS AND MAIN RESULTS: The average of the TD-CO measurements was 7.22 +/- 2.12 (SD) L/min during 0 cm H2O of positive end-expiratory pressure (ZEEP), and 6.91 +/- 1.72 L/min during PEEP (NS). The average of the TEB-CO measurements was 4.48 +/- 1.37 L/min during ZEEP, and 6.03 +/- 2.03 L/min during PEEP (p < .05). For each level of PEEP, bias and precision between methods were calculated. Bias calculations between TD-CO and TEB-CO ranged from -1.54 +/- 7.02 L/min at ZEEP to -2.52 +/- 4.28 L/ min at PEEP, and -2.47 +/- 6.09 L/min for mixed data at ZEEP and PEEP. There was no significant correlation between the percent change with PEEP in TEB-CO and TD-CO (r2 =.05, NS). CONCLUSIONS: In patients with acute lung injury: a) the agreement between TEB-CO and TD-CO measurements is poor; b) agreement is not clinically improved by application of PEEP; and c) TEB cannot monitor trends in CO.

Reasons for dissatisfaction: a survey of relatives of intensive care patients who died.

OBJECTIVE: To describe the reasons for eventual dissatisfaction among the families of patients who died in the intensive care unit (ICU), regarding both the assistance offered during the patient's stay in the hospital and the information received from the medical staff. DESIGN: Cross-sectional descriptive study, which was conducted after a survey using a questionnaire. SETTING: Interdisciplinary ICU (n = 8 beds) at San Giovanni Hospital in Bellinzona (CH). SUBJECTS: Three-hundred ninety families of patients who died in the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A postal questionnaire (n = 43 questions) was sent to the families of 390 patients who died in the ICU during 8 yrs (1981 to 1989). The results referred to 123 replies: a) 82.6% of the respondents expressed no criticism of the patient's hospital stay; b) 90% considered the patient's treatment was adequate; c) 17% felt that the information received concerning diagnosis was insufficient or unclear; and d) 30% (particularly close relatives and those relatives who were informed of the death by telephone and not in person) expressed dissatisfaction regarding the information received on the cause of death. CONCLUSIONS: Our survey found that the relatives of patients who died were most dissatisfied with the care received according to: a) the type of death (e.g., sudden death vs. death preceded by a gradual deterioration in the patient's condition); and b) the manner in which the relatives were notified of the death (in person vs. by telephone). The personal characteristics of the people interviewed, such as gender and the closeness of their relationship to the deceased, also seem to have some bearing on the opinions expressed. A high percentage of respondents were satisfied with the treatment received by their dying relative and the information conveyed by caregivers. Nevertheless, the dissatisfaction expressed by some respondents indicates a need for improvement, especially in communicating information to the relatives of these patients.

Administration of thrombolytic therapy to 17,944 patients with acute myocardial infarction: the GISSI-3 database.

BACKGROUND: There is growing interest in assessing therapy for acute myocardial infarction. Because thrombolysis was not a study therapy in the GISSI-3 trial, the decision about thrombolysis was left to the responsible physicians. We evaluated the data on thrombolytic therapy among patients with acute myocardial infarction enrolled in the GISSI-3 trial to study the relation between rate of prescription and the characteristics of patients and participating coronary care units. METHODS: Complete clinical data were available for 17,944 patients randomized between June 1991 and July 1993 from 200 coronary care units in Italy. Demographic and clinical information were obtained for each patient, and each coronary care unit was classified according to patient volume, level of technology, and wide geographic area in which it was located. A multivariate logistic regression was performed with administration of thrombolytic therapy as the dependent variable and previously defined clinical and structural variables as independent variables. RESULTS: The most important factor in administration of thrombolytic therapy was that less than 6 hours elapse from symptom onset to hospital admission (odds ratio [OR] 14.05; 95% confidence interval [CI] 12.3 to 16.0). Next were location of coronary care unit in southern Italy (OR 1.81; 95% CI 1.62 to 2.01), presence of ST elevation at entrance electrocardiogram ECG (OR 1.47; 95% CI 1.35 to 1.61), absence of previous myocardial infarction (OR 1.35; 95% CI 1.22 to 1.49), and presence of catheterization laboratory or cardiac surgery program or both in the same hospital (OR 1.24; 95% CI 1.14 to 1.35). Coronary care units with high or low patient volume did not show different rates of administration of thrombolytic agents. CONCLUSIONS: The GISSI-3 experience confirmed a high rate of prescription of thrombolytic therapy to patients admitted within 6 hours of symptom onset and those with ST-segment elevation on entrance electrocardiogram. It demonstrated that patients admitted to coronary care units with catheterization laboratories or cardiac programs or both have higher chances of receiving thrombolytic treatment than those admitted to hospitals without these capabilities.

A comparison of the early outcome of acute myocardial infarction in women and men. The Third International Study of Infarct Survival Collaborative Group.

BACKGROUND: In previous studies, unadjusted comparisons of mortality and major morbidity after acute myocardial infarction have generally indicated that women have a poorer outcome than men. Much larger studies are needed, with more complete adjustment for coexisting conditions, to determine whether this difference is explained by the older age of the women studied or by the presence of other unfavorable prognostic factors, or both. METHODS: As part of the Third International Study of Infarct Survival (ISIS-3), information was collected on deaths during days 0 to 35 and on major clinical events during hospitalization up to day 35 for 9600 women and 26,480 men with suspected acute myocardial infarction who were considered to have a clear indication for fibrinolytic therapy. We compared the outcome among women and men, first without adjustment, then with adjustment for age, and finally with adjustment for other recorded baseline characteristics by means of multiple logistic regression. RESULTS: The unadjusted odds ratio for death among women as compared with men was 1.73 (95 percent confidence interval, 1.61 to 1.86). The women were significantly older than the men, and after adjustment for age the odds ratio was reduced markedly to 1.20 (95 percent confidence interval, 1.11 to 1.29). Adjustment for other differences in base-line clinical features further reduced the odds ratio to 1.14 (95 percent confidence interval, 1.05 to 1.23). Excesses in other major clinical events among women were generally reduced to a similar extent by adjustment. CONCLUSIONS: It seems likely that there is at most only a small independent association between female sex and early mortality and morbidity after suspected acute myocardial infarction.

[Medicine and humanism: clinical ethics and the community dimension of geriatrics]. / Médecine et humanisme: l'éthique clinique et la gériatrie à dimension communautaire.

Clinical ethics is generally related to the clinical bedside activity. Clinical ethics constitutes one aspect of bioethics. In particular, its aim consists in facilitating the solving of conflicts of values in practical care. By encouraging effective communication and discussion within the interdisciplinary team, geriatricians will be able to make adequate diagnostic and therapeutic interventions, in accordance with the fundamental desire of the patient and her or his family.

Epidemiologic variables and outcome of 1972 young patients with acute myocardial infarction. Data from the GISSI-2 database. Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2).

BACKGROUND: Acute myocardial infarction in younger patients is uncommon, occurring mainly in men. The recent introduction of thrombolysis improved survival, left ventricular function, and infarct size. OBJECTIVE: To evaluate characteristics and clinical outcome of the patients younger than 50 years randomized in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico study. All patients received a thrombolytic treatment. METHODS: The 11483 patients were divided into 3 age subgroups: younger than 50 years (17.2%), between 50 and 70 years (60.2%), and older than 70 years (22.6%). All relations between variables were first determined by an unadjusted analysis. An adjusted analysis was performed by multiple logistic regression models for in-hospital and 6-month mortality. RESULTS: While older patients had a significantly higher rate of a history of hypercholesterolemia, diabetes, and hypertension, smoking and a positive family history were significantly more frequent in younger patients. Total in-hospital and 6-month mortality were significantly lower in patients younger than 50 years (2.7% and 1.2%, respectively) than in patients between 50 and 70 years old (6.9% and 2.7%) and those older than 70 years (21.1% and 8.4%). After multivariate analysis, the predictive value of age was confirmed. CONCLUSIONS: Our findings, based on a large group of patients who received thrombolytic treatment, suggest that younger age is a significant independent indicator of a favorable prognosis after acute myocardial infarction.

[Attitude of Swiss Army recruits from Tessin to pain and euthanasia (1992 and 1995)]. / Les attitudes des candidats tessinois au recrutement face à la douleur et à l'euthanasie (1992 et 1995).

Nineteen-year-old Swiss Army conscripts were questioned in 1992 (n = 1361) and 1995 (n = 1050) about their opinions regarding pain and euthanasia. In 1995, 85% (1992: 71%) considered pain as a fundamental part of life, 73% (1992: 77%) thought that the patient himself should decide how to control pain, and 50% (1992: 51%) would accept the idea of euthanasia at the request of a family member with an incurable disease and in pain. Significant differences were found only in correlation to the degree of religious belief.

[Contraindications of thrombolytic therapy in acute myocardial infarct]. / Kontraindikationen der thrombolytischen Therapie beim akuten Myokardinfarkt.

In 43 Swiss hospitals, 824 patients have been included in the ISIS-3 trial with suspected or proven myocardial infarction. Another 504 patients with proven myocardial infarction have been excluded for various reasons and have been registered in the study log-book (total 1328 patients). The usual clinical contraindications for thrombolysis are listed and discussed in this paper. 1/3 of those patients excluded from the trial had not received thrombolysis without clear contraindications (age, diabetes, anticoagulation, candidates for a pace-maker) and another 27% have had only relative contraindications (resuscitation, puncture, ulcer pain, hypertension). The new guidelines for thrombolytic therapy allowed more patients to benefit from this therapy.

[Time loss in the therapy of acute heart infarct]. / Zeitverlust in der Therapie des akuten Herzinfarkts.

As part of the ISIS study, the prehospitalization phase in 570 patients with acute myocardial infarction was evaluated and protocolled in 34 Swiss hospitals. The aim was to assess whether the time lapse between onset of pain symptoms and start of treatment could be shortened. It was felt that, particularly in the case of lethal cardiac arrhythmias, rapid intervention could secure reversal or controlled relief of symptoms and/or conduction disorders. The study protocol recorded the specific time lapses between onset of symptoms and notification of the physician, notification of the physician and hospital admission, and between hospital admission and therapeutic action. The longest time lapse observed was the patient's delay (57%). Delay by the patient was shortened when pain symptoms (a) occurred during daytime, (b) were preceded by symptoms in the week before the infarction, (c) occurred at work, and (d) occurred during exercise, particularly in the company of unknown persons. The longest time lapse observed in hospital was associated with the night shift. The time lost through delay in contacting a doctor, the main factor in delaying therapeutic action in acute myocardial infarction, is very difficult to influence since the target group for a public information campaign is hard to identify. On the other hand, the "door to needle" time lapse observed in hospital can be reduced by the introduction of clear-cut guidelines.

[ACE-inhibitors in acute heart infarct]. / ACE-Hemmer beim akuten Herzinfarkt.

The use of ACE-inhibitors in heart failure has been established over the past years. Their use is of uncertain value in the early phases of myocardial infarction, where they are supposed to prevent left ventricular dilatation. More recent studies (ISIS-4, GISSI-3) have tested early treatment by ACE-inhibitors in the acute phase of myocardial infarction. On one hand, it was possible to disprove reservations about risks (hypotension)n in a large cohort; on the other hand, a further reduction of mortality in hospitalized patients by 7% has been shown, corresponding to five patient lives saved for 1000 treated patients. Thus, after institution of the customary therapy of myocardial infarction (inhibitor of platelet aggregation, thrombolysis, beta-blocker) and after exclusion of specific contraindications (hypotension < 100 mmHg, renal failure) ACE-inhibitors could be administered in the acute phase of myocardial infarction. An analysis of the results from these large trials will show whether ACE-inhibitors may benefit groups of patients at particular risks (Killip > 1, age > 70 years, preceding renal failure) noticeably. ACE-inhibitors remain the treatment of choice in patients with developing left ventricular failure.