Publiciteit rondom het artikel:

http://www.usatoday.com/news/health/2008-06-24-hospital-devices_N.htm?loc=interstitialskip
http://www.time.com/time/business/article/0,8599,1817667,00.html
http://news.bbc.co.uk/2/hi/health/7471008.stm
http://www.reutershealth.com/archive/2008/06/24/professional/links/20080624clin015.html
http://www.sciencedaily.com/releases/2008/06/080624174854.htm
http://blogs.wsj.com/health/2008/06/24/study-rfid-tags-can-mess-up-medical-devices/
http://www.telegraph.co.uk/news/uknews/2186852/'Smart'-cards-can-interfere-with-medical-equipment,-study-shows.html
http://abcnews.go.com/Health/HeartDiseaseNews/story?id=5237036&page=1
http://www.forbes.com/forbeslife/health/feeds/hscout/2008/06/24/hscout616833.html
http://www.newscientist.com/article/dn14198-radio-id-tags-can-play-havoc-with-hospital-devices.html?DCMP=ILC-hmts&nsref=news1_head_dn14198
http://ap.google.com/article/ALeqM5iL3yfyTOolPr3RLr7uTTyeyMkUDQD91GL6C81
http://www.upi.com/Science_News/2008/06/25/RFIDs_may_pose_hospital_risk/UPI-10851214451676/

http://science.slashdot.org/article.pl?sid=08/06/24/2152212&from=rss
http://www.theregister.co.uk/2008/06/25/rfid_interference/
http://www.indystar.com/apps/pbcs.dll/article?AID=/20080625/BUSINESS06/806250382/1003/RSS03
http://www.topnews.in/usa/radio-frequency-tags-can-be-dangerous-patients-2600
http://www.medicalnewstoday.com/articles/112877.php
http://www.rfidjournal.com/article/articleview/4166/1/1/
http://www.news-medical.net/?id=39459
http://www.spectrum.ieee.org/jun08/6405
http://www.rfidnews.org/news/2008/06/25/rfid-may-cause-interference-with-medical-equipment/
http://technologyexpert.blogspot.com/2008/06/hospital-rfid-tags-interfere-with.html
http://www.efluxmedia.com/news_Wireless_Chips_May_Interfere_with_Medical_Devices_Posing_Risks_19478.html
http://chinese.eurekalert.org/en/pub_releases/2008-06/jaaj-eif061908.php
http://www.rfidupdate.com/news/06252008.html
http://healthcare.zdnet.com/?p=1093

http://www.volkskrant.nl/binnenland/article1034812.ece/Chips_pasjes_verstoren_medische_apparatuur
http://www.nrc.nl/binnenland/article1143500.ece/Chip_in_pasje_gevaar_voor_apparaten_ziekenhuis
http://www.nrcnext.nl/nieuws/nederland/article1143644.ece
http://www.nu.nl/news/1627935/151/RFID-chips_storen_bij_medische_apparatuur.html
http://www.blikop112.nl/bericht/1720/rfid-technologie_stoort_medische_apparatuur.html
http://www.zdnet.nl/news.cfm?id=87294
http://webwereld.nl/ref/newsletter/51635

COLONIC IRRIGATION - COLONICS - COLONIC CLEANSING - COLON CLEANSER COLONOSCOPIES - COLONIC POLYPS - WEIGHT COLONICS - COLONIC THERAPY - COLONOSCOPY - COLON IRRIGATION - COLONIC HYDROTHERAPY  

SEVERE CONSTIPATION IN A 46-YEAR OLD MAN

Constipation in a 46-year-old man with a history of cerebral palsy presented with difficulty in breathing, which had gradually increased during the previous 2 weeks.

He was admitted to the intensive care unit with a diagnosis of sepsis, for which he received intravenous fluids, antibiotics, and mechanical ventilation. Computed tomography of the abdomen showed a severely distended colon with fecal stasis compressing the abdominal organs and elevating the diaphragm. There were no signs of colonic perforation. After initial conservative measures were unsuccessful in evacuating the impaction, multiple enemas with the use of sodium phosphate and soapsuds finally dislodged the blockage after 2 weeks. The patient's recovery was unremarkable.

SOURCE:

http://content.nejm.org/cgi/content/full/358/22/e26

Gotcha #5 - "My local hospital was in the network when I first enrolled so I'm sure it's still on the PPO list"

Don't bother going back and digging up your PPO (Preferred Provider Organization) directory.  That list was actually outdated the day it was printed!  Being out-of-network is similar to handing the hospital administrator your checkbook and allowing him to bill you whatever he wants.  We have seen 80% or more of the original charges be discounted because the facility was in the PPO network.  There are constant fluctuations with physicians and hospitals moving in and out of PPO networks.  Today the only way to get real-time PPO participation is to look up the network online.  Most insurance cards will show the provider network name or website.  When I travel out of town, I print a PPO network for the city I am traveling just to be safe. 

Gotcha #4 - "I've had the same insurance company for my auto, home, and life.  They have always paid well so their health insurance should be fine also."

We all know the jack-of-all-trades story line.  Just because their auto insurance paid for your fender bender doesn't mean their health insurance will cover a $940 per week prescription drug to fight cancer.  You should search for an independent health insurance agent that represents many different insurance companies and is familiar with the pre-existing condition limitations and underwriting criteria.  It is difficult for an insurance agent that offers many different lines of insurance to remain up-to-date with the changing health insurance landscape.

Gotcha #3 - "A guy I work with recommended this company.  He's had them for years."

Ask your friend if he has had any claims, and if so, how big were they.  There are many inferior health insurance plans being renewed year after year simply because the insured has never had any real large claim experience.  If they are limited benefit plans they have internal limitations that can have severe consequences.  Some common health insurance policy limitations are annual maximums for prescription drugs or outpatient treatment (some "saver" plans exclude these altogether!) and daily maximums for chemotherapy, hospital room charges & intensive care.  I recommend comprehensive major medical plans that include inpatient, outpatient, physician visits, and outpatient prescription drug coverage.  These should all count together towards a large lifetime maximum of at least $2 million (I personally own a $5 million plan).

Gotcha #2 - "My employer group plan has got to be better and less expensive than an individual health insurance policy."

Not so fast!  That depends on how much your employer contributes.  Since group health insurance plans require the employer to pay at least half of the employee's health insurance cost, it is very rare for an employee to be able to purchase an individual plan on their own for less.  The additional family members are a different story.  Most employers pay little or none of the additional family monthly premium.  We often see healthy families paying $500 to $900 per month to get a spouse and/or children covered on the group plan.  With HSA qualified plans (Wow!  This is the first time I mentioned Health Savings Accounts this whole post!), we can sometimes cut this cost in half leaving the other half to deposit in the HSA.  This premium savings can be enough to fully fund the family out-of-pocket maximum within 12 to 24 months! 

Gotcha #1 - "The plan with the lowest deductible and lowest co-pays is the best plan!"

If your family had to choose between 2 plans from the same insurance company using the same PPO network, the first plan has a $0 deductible 80/20 co-insurance plan with co-pays for physician visits and prescription drugs at monthly cost of $900, the second plan is an HSA qualified plan with a family calendar year deductible of $5000 and 100% co-insurance that includes all physician visits, prescription drugs, inpatient and outpatient hospital charges at a monthly cost of $450 per month, which would you choose? 

Let's do the math:  $900 - $450 = $450 per month premium savings x 12 months = $5400 in premium savings to offset a true "out-of-pocket maximum" of $5000 for the HSA qualified plan.  Tough decision here... With the $900 per month plan, you still have to come up with additional money out of your pocket to pay the co-pays and co-insurance.  With the HSA plan, you would have the entire deductible available in your HSA within the first year.   You should still allocate $900 per month for your health care, but give $450 per month to the insurance company and put the other $450 into your HSA account.   You get a tax deduction for every dollar you deposit.  It pays you interest tax free.  Withdrawals can be made at any time tax free for eligible medical expenses.  There is no other savings vehicle that is tax free at both ends.

The beauty of an HSA is that if you don't spend your HSA dollars, YOU KEEP IT!  Unspent balances roll over year to year (not like an FSA or section 125 which are use-it-or-lose-it). 

Just how much money could you be saving with an HSA qualified plan?  Now you can find out!  We utilize unique technology that allows real-time highly competitive HSA qualified health insurance quoting and enrolling online.
  
The ultimate "Gotcha" is paying too much for health insurance.

Do the math...

Get an HSA!

"É uma situação de gravidade, mas os médicos não consideram que o bebê corra risco de vida", disse a mesma fonte, acrescentando que o menino está "respirando espontaneamente" e que está "consciente".

O bebê de 18 meses estava na varanda de um segundo andar de um prédio na rua Álvaro Gomes, na cidade de Armação de Pêra no Distrito de Faro em Algarve (Portugal) e depois da queda deu entrada na Unidade de Terapia Intensiva (Cuidados Intensivos) do Serviço de Pediatria do Hospital Central de Faro, onde o bebê encontra-se atualmente.

_______________________________________
Mas por que tantos pais e mães desnaturadas deixam cair tantas crianças de prédios ?

Hoje em dia o melhor mesmo é viver em uma casa residêncial.

The culture shock is particularly profound the Neuro ICU. For one thing, it is a prime site for so many spectacularly horrific things. While children with neurlogic problems can be heartbreaking, somehow I manage to deal with it. There is something about dealing with severe traumatic brain injury, brain tumors, stroke and brain hemorrhage all day that is particularly soul killing. The place is just saturated with death and loss. It was here I came to understand the phenomenon in medicine that is gallows humor.

My first day in an adult ICU involved more death than I had seen in three years with pediatrics. Talking about withdrawing support was a daily occurence in the Neuro ICU. The Nurses and Doctors actually grew resentful if the family hesitated in these cases, sometimes even when I thought it was too early to take that kind of a step. Hope can become a time and money wasting enemy. No one wants to feel they are working their tails off for a completely futile effort, yet this is what these nurses go through day in and day out. What can one do in the face of such a depressing environment?

It turns out the answer for doctors, is to laugh. During rounds we laugh at things that would absolutely horrify the outside observer. We laugh about near misses when a mistake was almost made or TPA, a clot busting medication that either breaks up your stroke or causes your brain to bleed, was given to someone who should not have had it, and they survived okay. We laugh at frustration in trying to get appropriate help from ancillary caregivers in the midst of an emergency, as their brain is swelling and they have literally minutes to live. We laugh at patient's who simultaneously have these problems and the manpower simply is insufficient to manage both sufficiently. We laugh at the absurdity of dealing with insurance beauracracy. We laugh at inability to get the resources our patient's need to live at home or to manage their disease. It is a mirthless, cynical laugh. I think many of things that we laugh at in life are born out of pain. We find uncomfortable truths funny. We need the natural opioids released to function and move on. In Neurocritical care I learned just how far this can go. The thing is the laughter is not because we don't take these things seriously or that we don't care.  It's quite the opposite.  Sometimes situations in life are so painful, so horrible, so senseless and tragic, that all one can do is sit back and laugh.

I felt extremely guilty the first time this happened to me.  I have since learned to be more forgiving and to see this impulse for what it is, a coping mechanism. I have seen some tireless and wonderful physicians partake in this communal pain and laughter. I have also learned much about how they came to be at peace with the phenomenon. This is some of the most critical teaching I have recieved in residency.

How do we succumb to this kind of laughter and not lose our souls? The more exposure we have to these circumstances, the more our compassion deadens. It is simply too painful. I think much of the frustration with families that "prolong the inevitable" comes from the fact that caregivers suffer as the patients suffer. There is just no way to get around the fact that, for better or worse, we are profoundly changed by exposure to the pain and suffering of others. Trying to wall ourselves off from feeling is a survival mechanism. It is even glorified by some as maintaining objectivity.

To be a doctor in general and a neurologist in particular is to see people at their worst. We witness fury, anguish, anger, weeping, self pity, hopelessness all the time. Our patients are people who are sick, who are tired, people in pain, people who may be addicted or depressed, people who act out, people who often seem like an eternal pit of need. To doctor is to deal with misery. I suppose the spirituality and high minded philosophy I deal with in this blog is something of my coping mechanism. Wearing yourself out at a hospital can make you forget the good things in life. Art, music, literature, prayer, service, nature, ideas are forgotten as time is swallowed up by an punishing profession. Blogging is one way I connect with the best of humanity to remember the good and not get swallowed up by the worst. So is my spirituality escapist?

I am afraid I can't answer that. I am too entangled in the situation to see clearly and objectively. But I do know this. Kids can deal with misery, unfairness, severe disability with a resilience that we adults can scarcely imagine. It wears off on the caregivers. Pediatric nurses and physicians gather strength from their patients. We become, as I said in the beginning, annoyingly chipper. We can't help it. It is an instinct born within us for survival of the species.

Children have the ability to draw out a measure of hope and selflessness in us. I can't look upon this as a trick of nature. I can only see this as what it means to be human. I think this is what childlike faith is about. Kids live in the present. Their past is too small and their future too vague and undefined. They are used to feeling powerless. These added difficulties can't take as much away. It doesn't stop them from seeing what there is to enjoy and revel in around them. They have an optimism untempered by failures. What I learn from children is all about potential.

My faith teaches me that I am a Child of God. That I have a spark of the divine within me. It teaches me about the potential of all mankind. It teaches me about a pipe dread called Zion, a people united in love and service. I am afraid I can't see hope as escapist. I see it as contagious. Some may call it mass hysteria, I call it mass healing. Where others see self deception, I see self care for all that is good within myself. I cling to hope, because I cannot cling to anything worthwhile without it.

Off the ice: Sean Avery is still in the hospital, but was moved out of the ICU this morning.  That's good news for Avery.  Get well soon!

Evgeni Malkin's dirty plays (he slew-footed Mara twice!) towards the end of the game seem to be a non-issue for the Rangers and for the league. NHL Director of Hockey Operations Colin Campbell told John Dellapina of the Daily News that the league does not plan to investigate further and Malkin is not at risk for suspension. I call shenanigans. This is a dirty play [fast forward to 1:35].

For their part, the Rangers contacted the league regarding a different play Malkin was involved with: the breakaway that led to the penaty shot. While Dan Girardi did push Malkin from behind, and while most parties agree it should be a penalty, the Rangers would like some clarification on the rule because it was not a penalty as per the NHL rulebook.

Avery update: His doctors reported they were able to stop the internal bleeding on Thursday, but Avery remained in intensive care as of yesterday.

He's reportedly walking! Read for yourself here.

You can continue to leave well wishes on our website. Just click here.

More than three weeks after the accident that left Emilio in a coma, some really good news came out today. His wife says he's out of danger!

I haven't watched thisstory yet, but just reading this part gave me goosebumps: "I have been able to read his lips and see in his eyes all the love," Maria Navaira said.

Emilio will soon leave intensive care for a room where his family can spend more time with him. Dr. Alex Valadka says Emilio has written his name, has stood up, is eating and talking. That's remarkable progress for someone who was given a slim chance of waking up from a coma in the days after the accident.

Thisarticle has a little more information on one of Emilio's complications. It says, "Navaira's lung condition turned out to be a 3.5-centimeter aneurysm on the lower left portion of his right lung, said Dr. Alan Cohen, chief of vascular interventional imaging at UT Health Sciences Center. The condition is so rare that it was only the fifth such occurrence known in the world and the first known to have been treated without removing the lung, Cohen said."

It seems all those prayers you all have expressed on this web site and others have been answered. Emilio has beaten some incredible odds, though he still has a long way to go. We're following his progress on our website, so check back often!

A LISTENING FOR THE 13TH DAY

The thirteenth day.

The witching day of April.

So, no reading today. Just listening.

I wonder how long it will take for The Human Kind to know what we're up to, My Black Cat.

PREVENTION OF ANTIBIOTIC RESISTANCE IN THE ICU

Registration with Medscape needed for access.

Those of The Humankind who are so inclined can get CME points for this.

We witches don't care a toss.

PLEASE READ DISCLAIMER

When my dad died about three years ago, as I was sittng next to his bed in the intensive care unit of the hospital some three hundred kilometres from my home, all alone and scared beyond words, I already knew that forces far beyond my control were working to change my life forever.

My father had at that stage of his crazy and adventurous life been married to the worst woman to be created in all of mankind. She was his third wife, although I would often see her flinch at the mere mention of this fact. Which would of course make me mention it to more and more people in her presence.

But back to the hospital and my dad's deathbed, which I was now attending alone. My mother had been dead for two years by that time, my husband was in England trying to keep our heads above stormy financial waters and my stepmother had decided to ignore the fact completely that my father had been connected to a machine to keep him alive for the past three weeks.

Upon asking her why she had decided not to travel the 300km from our hometown in the Free State to the city to at least say goodbye to him, she briskly and dramatically informed me that she had 'already said goodbye to him in her heart' and that 'she was expecting a visit from the department of education to check on her year's progress'. Yes, this woman was in charge of children at an educational instistute, better known as a local high school in our small South African town.

I often wondered if my dad knew that she had forsaken him in his last weeks of life. If he knew how difficult she made it for me to just try and function normally under a barrage of lies, misinformation and drama between her and his doctors, with me trying to impart the truth while he lay there with his eyes taped shut and arms swelling to the size of balloons.

I often wondered if he knew then that she had only married him for his money. And I also knew that she would do everything in her power to take al that money for herself the day he drew his last breath.

And so it was. In her renlentless struggle to take away everything my dad had worked for his whole life, our family farm here in Africa, on which my grandfather and his grandfather before him had toiled, shed blood, fought the English army, died and laughed, cried and lived for the past 170 years, she also almost destroyed my family, my marriage, my pregnancy with twin boys and my life.

It is now three years later, and still a lot remains to be told about what happened. I will do so in the weeks and months to come. It needs to be said. It needs to be outed, to be opened and to be healed.

I still have my marriage, my twins and my life, but our family farm is gone. Some say I should forgive, that God will take care of it.

I say you make your own laws of attraction in life. And now I choose to attract happiness, life and liberty. Freedom from loss, from anger, from heartache and tears. It will not be easy, but it can be done.

More tomorrow.

On any given day in the United States, some ninety thousand people are in intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an I.C.U. from the inside. Wide swaths of medicine now depend on the lifesupport systems that I.C.U.s provide: care for premature infants; victims of trauma, strokes, and heart attacks; patients who have had surgery on their brain, heart, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, I.C.U.s barely existed. Today, in my hospital, a hundred and fifty-five of our almost seven hundred patients are, as I write this, in intensive care. The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six per cent. Going into an I.C.U., being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.

The piece, called The Checklist (and written in the usual Gawande-ian style, which I like a lot) is just what the title says, namely, the role of checklists in intensive care units:

In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

A must-read piece. Take a look!

PS: Vaughan at Mind Hacks recommends the piece too (though, he forgets to mention that the piece is by Gawande).

If you answered yes, then it's time you considered a move for career growth! For immediate consideration, forward your cover letter, resume, and salary history to us.

Keywords: RN, Registered Nurse, ER, Emergency Room, Intensive Care

October 3rd :
Winslow at Skratch Brossard

October 6th:
Explode and Rebuild at Metric
Intensive Care and Odyssey at Reggies

October 7th:
Sign of One and Plight at Club Saphir

Enjoy the shows!

This video demonstrates how to perform orotracheal intubation. Specific indications are discussed, along with contraindications, troubleshooting, and complications.

Specific topics covered in the video include:

• Overview
• Indications
• Contraindications
• Equipment
• Procedure
• Complications

The video can be viewed and downloaded at the NEJM. The video also has a PDF summary to accompany it.

Some previous Videos in Clinical Medicine include endotracheal intubation, arterial line insertion, nasogastric tube insertion, lumbar puncture and thoracentesis.

These are great learning/teaching tools and I definitely recommend checking them out.

A total of 980 patients from 37 hospitals in eight countries who had been mechanically ventilated for >48 hours were included in the study. Every day patients were assessed for the following readiness-to-wean criteria:

• • improvement in the underlying condition that led to respiratory failure
  • alert and able to communicate
  • core temperature not > 38°C
  • no vasoactive drugs (excluding dopamine < 5 µg/kg/min)
  • adequate gas exchange, as indicated by a PO2 of at least 60 mm-Hg with an FiO2 of ≤ 0.40 and a PEEP not > 5 cmH2O

Patients that met the criteria for readiness-to-wean were then weaned using one of the following techniques:

• • daily trial of spontaneous breathing (SBT) for up to 120 mins using a T-piece, CPAP, flow-by, or pressure support of < 8 cmH2O
  • multiple daily SBTs
  • gradual reduction of pressure support until a level of ≤ 7 cmH2O

All patients passed a SBT and were extubated. After extubation patients were followed up for the presence of post-extubation respiratory distress. Patients were re-intubated if they met at least one of the following criteria:

• • lack of improvement and/or worsening in arterial pH or PCO2
  • decreased mental status
  • SaO2 decrease to < 85%, despite high FiO2
  • lack of improvement in signs of respiratory muscle fatigue
  • hypotension, BPsys < 90 mm Hg for 30 mins despite volume loading and vasopressors
  • copious secretions that the patient could not clear

Extubation failure occured in 13.4% of patients. Reasons for reintubation were:

• • lack of improvement in work of breathing (45%)
  • hypoxemia (22%)
  • respiratory acidosis (11%)
  • retained secretions (10%)
  • decreased level of consciousness (6%)
  • hypotension (6%)

From all the gather data collected they found that a rapid shallow breathing index (RSBI=f/VT) > 57 breaths/min/L, a positive fluid balance 24 hours prior to extubation, and pneumonia as the cause of mechanical ventilation was associated with reintubation within 72 hours. The RSBI was an independent predictor of extubation failure and a RSBI of > 57 increase the risk of reintubation from 11% to 18%.

Patients in the study that had a positive fluid balance 24 hours before extubation had a higher incidence of reintubation. The study did not collect data on hemodynamic or echocardiograhic measurements so it cannot be said whether the positive fluid balance correlated with ventricular dysfunction. The other variable that was found to be related toreintubation was pneumonia as the need for mechanical ventilation.

The nice thing about this study is its very large sample size and careful analysis. The study also had a reintubation rate that is consistent with many other reports. One possible flaw in the study is that the decision to extubate was not protocolized, the physician in charge made the final decision. So specifically, we don't know if some of these patients may have had a delay before beingextubated and we do not know why this is. Also, of the patients that required reintubation , very few of them were related to airway protection issues. This may be due to assessments of the patients ability to protect their airway but this was not recorded so we don't know.

This study does add to our knowledge and understanding of the process of weaning and liberation from mechanical ventilation. Especially in understanding why patients failextubation and how our current tools for assessing the readiness for extubation are not perfect. There is still more room for work to be done in this area but Frutos-Vivar et al have begun to give us a clearer understanding of why patients may fail extubation after a successful spontaneous breathing trial.

__________

(1) MacIntyre NR, Cook DJ, Ely EW, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support. Chest 2001; 120:375S-395S.

(2) Frutos-Vivar F, Ferguson N, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006; 130:1664-1671.

Some weaning protocols measure the ratio of frequency to tidal volume (f/VT) during 1 min of spontaneous breathing as a final step before beginning a prolonged spontaneous breathing trial (SBT). The f/VT ratio is used to predict the success of weaning for that day and if a patient has a poor f/VT they may be spared having to perform a SBT. These patients are spared performing a SBT because of the possible risks associated with a failed SBT such as excessive anxiety, hemodynamic instability and it may require greater than 24 hours for muscle strength to recover.

In this month's Critical Care Medicine (Oct 2006), Tanios, Nevin, Hendra et al. (1) looked at the impact weaning predictors (f/TV) had in weaning protocols to assess a patient's readiness to advance to a SBT. They looked at 304 patients that had been ventilated for greater than 24 hrs, every patient under went a weaning screen daily at 7 am, half had the f/TV measured but not included in the weaning readiness assessment while the rest had the f/TV measured and included in the weaning assessment.

The criteria to pass the daily screening:

• PaO2/FiO2 ratio ≥ 150 or SaO2 > 90% at FiO2 ≤ 40%
• PEEP ≤ 5 cm H2O
• mean arterial pressure ≥ 60 mmHg without vasopressors (low-dose dobutamine or dopamine allowed)
• awake or easily arousable
• adequate cough and not requiring suctioning more than every 2 hours
• for patients randomized to the f/VT group, the f/VT could not exceed 105 breaths/min/L

If any of these are not met the patient would not go on to a SBT and would be continued to be screened daily. The SBT consisted of a 2 hour trial on a continuous positive airway pressure (CPAP) of 5 cmH2O and a pressure support (PS) of up to 7 cmH2O after which, if successful, the patient was extubated.

The average weaning time for the group that had f/VT included in the weaning protocol was 3 days, for the group that had f/VT omitted the weaning time was 2 days. The patients that had weaning decisions made without f/VT did not have a higher reintubation or mortality rate.

While the purpose of weaning protocols is to assess when patients are ready for a SBT and to avoid premature SBTs that lead to failure, they may actually lead to a longer weaning period. Failed SBTs may cause respiratory muscle fatigue that can take >24 hours to recover but there is no definitive evidence that a failed SBT adversely affects weaning outcome.

The role of the weaning predictors such as f/VT may need to be moved further along down the weaning process. At our institution we typically now use the f/VT ratio at the end of a SBT to help with deciding whether to extubate, instead of using it as a tool to see if the patient is ready to progress to a SBT. We may need to begin to reevaluate the use of weaning predictors such as f/VT and the role they play in the weaning process.

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(1) Tanios MA, Nevins ML, Hendra P et al. A randomized, controlled trial of the role of weaning predictors in clinical decision making. Crit Care Med. 2006 Oct;34(10):2530-35.

There are two types of cuff leak tests that can be performed, the auscultation cuff leak test and the cuff leak volume test. The auscultation cuff leak test classifies the leak into three categories:

• no leak, where no sound of leak was heard by using stethoscope detection

• mild leak, where a leak is heard using a stethoscope

• significant leak, where the sound of a leak was heard without using a stethoscope

In the cuff leak volume (CLV) test the actual tidal volume at expiration during six consecutive breaths in the Assist Control mode is measured before and after deflation of the ETT cuff, the difference in the tidal volume before and after cuff deflation is the cuff leak volume. This can be shown as an absolute volume or as percentage of tidal volume. When cuff leak volume is less than 140 ml or less than 10-20% the risk for post-extubation stridor is significantly elevated.

Dr. Cheng and colleagues(1) recently looked at IV methylprednisolone to reduce the incidence of post-extubation stridor and they also looked for agreement between qualitative (auscultation) and quantitative (CLV) measurement of cuff leak. They found that 18% of CLV was the optimal predictor for stridor and there was excellent agreement between the auscultation and CLV tests. There does appear to be a lot of false positives (cuff leak predicts stridor but it does not always occur), in 128 patients with a CLV of less than 24%, 70% of patients did not develop stridor and 81% did not require reintubation.

There seems to be a nice correlation between auscultation and CLV tests in assessing for the possibilty of post-extubation stridor. I tend to use the auscultation cuff leak test solely and so do alot of my colleagues. Although it is somewhat subjective it is nice to know that it correlates well with the CLV test.

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(1) Cheng KC, Hou CC, Huang HC, Lin SC, Zhang H. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Crit Care Med. 2006 May;34(5):1345-50.

Ik zal kort samenvatten wat er is gebeurt.

Oscar heeft zweetaanvallen waarvan niet duidelijk is waardoor ze komen en of het door de pijn komt.

Hij is teruggeplaatst naar Intensive Care om hem beter te kunnen monitoren.

Omdat het reeel geacht wordt dat de zweetaanvallen door de druk in zijn hersennen komen en de foto's vochtophopingen laten zien zijn er een aantal operaties geweest die de draines, die het teveel aan vocht uit zijn hersennen kunnen afvoeren, op hun plek hebben moeten zetten. Er wordt gezocht naar de juiste balans van de hersennen en de juiste hersendruk.

Tot nu toe heeft dat er niet voor gezorgd dat de zweetaanvallen ophouden.

Oscar zijn ouders en zus zijn momenteel dag en nacht in de buurt van het AMC.

Het lijkt er op dat het AMC Oscar zijn 'zaak' heel erg serieus neemt. Sinds hij terug is op de IC wordt er echt werk gemaakt van zijn herstel en proberen ze met man en macht een oplossing te zoeken, hoewel dat niet lijkt mee te vallen.

Bezoek is nog steeds niet welkom. Helaas.