2009 Beta-blockers reduce reinfarction in acute MI, but have no effect on mortality in the short term, and increase cardiogenic shock
Wakai A. Myocardial infarction (ST-elevation). Clin Evid. 2009 Jan 9.
eKG Full Text for HA staff (eKG a/c login required outside HA Intranet)
Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, Katsios N, Papastylianou A, Gkisioti S, et al. Arch Intern Med. 2009 Jan 12;169(1):15-24.
Authors: Thomas ST Li, Gavin M. Joynt, Hing Y. So, Charles D. Gomersall, Florence HY Yap
Critical Care and Shock » May 2008, Volume 11, No. 2
Purpose: Positioning mechanically ventilated patients in an adequate semi-recumbent position is a low cost and apparently easy applied measure to prevent new VAP. We performed an unannounced audit to compare the actual backrest angle with the target backrest angle of 30-45 degrees, assess whether compliance was better in patients whose bed had a built-in bedside protractor, and document diffi culties reported when failing to achieve the target backrest angle.
Authors: Gavin M. Joynt, Charles D. Gomersall, Gordon Choi, Po T. Chui
Critical Care and Shock » August 2008, Volume 11, No. 3
Introduction: Femoral vein catheterization provides an alternative route of access to central veins, is technically easy and relatively safe. There is good evidence of a general agreement between intrathoracic central venous pressure (CVP) and CVP measured in the iliofemoral veins or inferior vena cava in critically ill patients. This agreement is not well documented when intra-abdominal pressure is raised.
2006 Molecular adsorbent recirculating system treatment for patients with liver failure: the Hong Kong experience
Chiu A, Chan LM, Fan ST.
Intensive Care Unit, Queen Mary Hospital, Hong Kong, China.
BACKGROUND: The molecular adsorbent recirculating system (MARS) is an
extracorporeal liver dialysis system that allows selective removal of bilirubin
and other albumin-bound toxins. We reported here our experience with the use of
this technique for management of liver failure at Queen Mary Hospital, Hong Kong.
METHODS: From December 2002 to 2004, a total of 74 MARS sessions were performed
on 22 patients. The cause of liver failure included acute liver failure (n = 2),
acute on chronic liver failure (n = 12), posthepatectomy liver failure (n = 4),
and posttransplantation allograft failure (n = 4). RESULTS: MARS treatment showed
significant reduction in total bilirubin level, serum ammonia level and blood
urea, and nitrogen (P < 0.001 for all three parameters). Five patients (22.7%)
were able to bridge to transplantation and one patient (4.5%) made a spontaneous
recovery. The 30-day mortality rate was 72.7%. CONCLUSIONS: Our results indicated
that MARS can effectively improve serum biochemistry and is suitable for
temporarily supporting patients with liver failure where transplantation is not
immediately available. There is, however, no clear evidence showing that MARS can
increase survival, improve the chance of transplantation or assist liver
regeneration. Future studies in the form of randomized-controlled trials are
crucial to characterize the true potential of this treatment.
Chiu A, Fan ST.
Intensive Care Unit, Queen Mary Hospital, and Department of Surgery, University
of Hong Kong, China.
Molecular Adsorbent Recirculation System (MARS) is a form of extracorporeal
detoxification system used as an artificial liver support system. Numerous
studies have been published on the topic, with the majority of them describing
the capability of MARS in removing albumin-bound toxins and improving systemic
hemodynamics. Whether such improvement could be translated into survival benefit
is still uncertain, given the paucity of randomized controlled trials available.
The outcome of patients receiving MARS treatment is difficult to analyze because
liver failure patients constitute a heterogeneous population and different
subgroups carry different prognoses. An evidence-based recommendation on the
timing of MARS initiation is not available and currently MARS is usually
commenced for hyperbilirubinemia or presence of complications of liver failure.
MARS is in general a safe procedure, but there are still potential complications
that need to be cautioned, along with various operative issues that are worth
attention. The future prospects of MARS would rely on the completion of
adequately powered randomized controlled trials.
2007 An analysis of the stressors and coping strategies of Chinese adults with a partner admitted to an intensive care unit in Hong Kong: an exploratory study
Chan KS, Twinn S.
Intensive Care Unit, United Christian Hospital, Hong Kong, China.
AIMS: The aim of this study was to identify the major stressors affecting Chinese
adults whose partner had been admitted to an intensive care unit and to
understand the major coping strategies employed to manage such stressors.
BACKGROUND: Recently a greater number of patients of higher acuity have been
admitted to intensive care units and survive lengthy illnesses of an
unpredictable course. Such critical illnesses have been identified as a major
life event to family members of these patients. Little is known, however, about
the stressors and coping mechanisms of Chinese adults whose critically ill
partner is admitted to an intensive care unit. METHODS: An exploratory
qualitative design was selected to achieve the aims of the study. A purposive
sample of 10 Chinese adults with a partner in an intensive care unit of a
regional general hospital in Hong Kong participated in tape-recorded
semi-structured interviews. Content analysis was employed to analyse the
translated interviews. FINDINGS: Categories of stressors included uncertainty,
difficulties in communication, changes in roles and responsibilities,
difficulties in decision making, financial strain as well as changes in
relationships. Analysis identified a range of coping strategies which included
seeking information, seeking support, reliance on cultural beliefs and practices,
turning to religious beliefs, maintaining hope and acceptance of illness.
CONCLUSIONS: The findings demonstrate the importance of cultural beliefs and
practices in determining the coping mechanisms employed to manage the stressors
identified by this sample of Chinese adults. Such findings indicate the use of
both internal and external coping strategies in order to maintain equilibrium in
the family. RELEVANCE TO CLINICAL PRACTICE: Implications for nursing practice
highlight the significance of seeking information throughout the critical period
and also culturally appropriate support from healthcare professionals.
Chui WY, Chan SW.
Intensive Care Unit, Queen Elizabeth Hospital, Hong Kong, China.
AIM: The present study aimed to investigate the stress and coping strategies of
Hong Kong Chinese families during a critical illness and to examine the
relationships between stress and coping. BACKGROUND: Admissions to intensive care
unit are usually an unanticipated event, which imposes stress on the family.
Family's wellness is one of the significant factors affecting patient's
well-beings. Much work has been conducted in Western societies. Stress and coping
in Chinese families of critically ill patients have rarely been discussed.
METHOD: Structured face-to-face interviews were conducted, using the Impact of
Events Scale and the Family Crisis Oriented Personal Evaluation Scales. A
convenience sample of 133 participants was recruited from a regional hospital in
Hong Kong. Many were patients' children with age between 30 and 49. A total of
39.1% (n = 52) of the participants were males and 60.9% (n = 81) were females.
RESULTS: The participants experienced high level of stress (mean = 25.1, SD =
8.3). Higher level of stress were experienced by female (t = -4.6; d.f. = 1, 131;
P = 0.00), those with lower educational attainment (F = 3.0; d.f. = 2, 130; P =
0.05) and those whose relatives were admitted to the intensive care unit
unexpectedly (t = -2.2; d.f. = 1; P = 0.03). Patients' length of stay in the unit
was significantly correlated with levels of stress (r = 0.5, P < 0.00). Level of
stress had significant correlation with coping strategies utilization (r = 0.5, P
< 0.00). Reframing strategies were frequently used whereas the passive appraisal
strategies were least used. Family members used positive-coping strategies, which
concurred with the Chinese stress-coping pattern 'fatalistic voluntarism'.
RELEVANCE TO CLINICAL PRACTICE: This study contributes to the understanding of
Hong Kong Chinese families' stress and coping during a critical illness.
Comprehensive assessments of family members' psychosocial needs are important to
plan appropriate interventions to alleviate their stress and strengthen their
coping skills. The findings will serve as guidance for nurses in delivering
culturally sensitive and competent interventions.
2007 Evaluation of the performance of a modified Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system for critically ill patients in emergency departments in Hong Kong
Resuscitation. 2008 Mar;76(3):488.
Man SY, Chan KM, Wong FY, Wong KY, Yim CL, Mak PS, Kam CW, Lau CC, Lau FL, Graham
CA, Rainer TH.
Accident and Emergency Medicine Academic Unit, The Chinese University of Hong
Kong, Hong Kong SAR, China.
INTRODUCTION: Numerous prognostic predictive models have been developed for
critically ill patients, many of which are primarily designed for use in
intensive care units. The objective of this study was to evaluate the accuracy of
a modified Acute Physiology and Chronic Health Evaluation (APACHE II) scoring
system in predicting the mortality for critically ill patients managed in
emergency department (ED) resuscitation rooms in Hong Kong. METHOD: A
multi-centre, prospective study was conducted for patients managed in the
resuscitation rooms of the EDs of four major hospitals, including one university
teaching hospital. The primary outcome measure was 14 day all-cause mortality and
the secondary outcome measure was the length of stay in hospital. RESULTS: Of 867
patients recruited between 4 and 30 April 2004, 106 (12.2%) patients died. The
modified APACHE II score was found to be significantly higher in non-survivors
compared to survivors (mean+/-S.D.: 21.2+/-7.7 versus 14.4+/-7.1, p<0.001). The
area under the curve for modified APACHE II in predicting mortality was 0.743
(95% CI, 0.696-0.790). CONCLUSION: The modified APACHE II score is only a
moderate predictor of mortality for critically ill patients managed in the
resuscitation rooms of EDs in Hong Kong. A more ED specific scoring method is
Cheng CH, Graham CA, Gabbe BJ, Yeung JH, Kossmann T, Judson RT, Rainer TH,
Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong,
Trauma and Emergency Centre, Prince of Wales Hospital, Shatin, New Territories,
BACKGROUND: Despite the high incidence of major trauma, few studies have directly
compared the performance of trauma systems. This study compared the trauma system
performance in Victoria, Australia, (VIC) and Hong Kong, China (HK). METHODS:
Prospectively collected data over 5 years from January 2001 from the 2 trauma
systems were compared using univariate analysis. Variables were then entered into
a multivariate logistic regression to assess differences in outcome between the
systems and adjusted for effects of clinically important factors. RESULTS: Five
thousand five thirty-six cases from VIC and 580 cases from HK were taken for
analysis. The HK group was older, but mechanisms of injury were similar in both
systems. Thoracic and abdominal trauma was more common in VIC, compared with more
head injuries in HK. More patients were admitted to intensive care in VIC and
patients stayed in intensive care 1 day longer on average, despite more
comorbidity in HK patients. Overall mortality was 20.2% for HK and 11.9% for VIC
(X(2)(1) = 32.223, P < 0.001). CONCLUSION: The performance of the HK trauma
system was comparable to international standards, but there was a significant
difference in the probability of survival of major trauma between the 2 systems.
Possible modifiable factors may include criteria for activation of trauma calls
and improved ICU utilization.
2008 Comparing the effectiveness of polyethylene covers (Gladwrap) with lanolin (Duratears) eye ointment to prevent corneal abrasions in critically ill patients: a randomized controlled study
Comparing the effectiveness of polyethylene covers (Gladwrap) with lanolin
So HM, Lee CC, Leung AK, Lim JM, Chan CS, Yan WW.
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man
BACKGROUND: In unconscious ventilated patients, various eye protective measures
have been used to prevent corneal abrasions. Two randomized controlled studies in
Australia had compared the effectiveness of polyethylene films and eye
instillations to prevent corneal abrasions but results were inconsistent. The
local acceptance of polyethylene films as a standard eye protective measure is
still limited. OBJECTIVES: Our study aims to compare the effectiveness of
polyethylene covers (Gladwrap) with lanolin (Duratears) eye ointment in the
prevention of corneal abrasions in critically ill patients. DESIGN: A prospective
randomized controlled study was conducted between April 2004 and December 2005.
SETTING AND PARTICIPANTS: One hundred and twenty ventilated patients admitted to
the intensive care unit (ICU) were randomly assigned to receive either
polyethylene covers or lanolin eye ointment to prevent corneal abrasions.
METHODS: All participants received a standard eye care regime together with the
eye protective interventions. A fluorescein stain test was performed by the eye
care team daily and then weekly to detect any corneal abrasions. RESULTS: Four
participants were not included in the data analysis as they died soon after
commencement of the study. A total of 116 patients were included in the final
analysis. Of the seven patients (6.0%) that had a positive fluorescein test, four
(6.8%) were in the polyethylene covers group (n=59) and three (5.3%) were in the
lanolin eye ointment group (n=57). This was not statistically significant
(p=0.519). One patient in the lanolin eye ointment group had an eye infection.
Upon follow-up of those patients with positive fluorescein test results, two
patients spontaneously converted to stain negative within 24h and two patients
died before the ophthalmologist's assessment. The remaining three patients were
diagnosed to have epithelial cell loss without corneal abrasions. CONCLUSIONS:
With the implementation of a standardized eye care protocol, polyethylene cover
is found to be equally effective in preventing corneal abrasions when compared
with lanolin eye ointment. The additional benefit of polyethylene cover as a
physical barrier to protect patients' eyes needed further evaluation.
Hon KL, Ho JK, Hung EC, Cheung KL, Ng PC.
Department of Pediatrics, The Chinese University of Hong Kong, Prince of Wales
Hospital, Shatin, Hong Kong Special Administrative Region, People's Republic of
INTRODUCTION: Childhood poisonings are common, but usually trivial, and
infrequently necessitate intensive care unit (ICU) admissions. METHODS: A
retrospective record review was conducted to analyze the pattern of severe
poisoning-associated ICU admissions at a teaching hospital between May 2002 and
December 2007. RESULTS: Six cases (4 boys and 2 girls, aged 2 months to 11 years)
of drug poisoning-associated ICU admissions were identified. Methadone was the
culprit in 3 boys and 1 girl, resulting in respiratory failure, depressed
conscious state and pinpoint pupils. As relevant exposure history was not
immediately apparent, diagnosis at the emergency department was only made
correctly in 2 patients. Phenobarbitone overdose occurred in 1 girl with past
history of phenobarbitone overdose as a clue. She was also considered to have
pinpoint pupils that were unresponsive to naloxone. Features consistent with
cholinergic toxidrome, including small pupils, and increased secretion occurred
in an infant fed with milk prepared with an herbal broth suspected to have been
adulterated with a pesticide. Atropine as an antidote was used when the child was
in the pediatric ICU. All children made an uneventful recovery following their
short ICU stay. CONCLUSIONS: Life-threatening poisonings requiring ICU support
can pose diagnostic difficulties and challenges to frontline medical officers at
the emergency department. Children from all age groups can be affected. Prompt
diagnosis is based on relevant history, careful clinical examination and a high
index of suspicion in patients known to be at risk. The pupillary size and its
reaction following treatment serves as an important diagnostic clue.
2008 Investigating the physiological responses of patients listening to music in the intensive care unit
Chan MF, Chung YF, Chung SW, Lee OK.
Alice Lee Centre for Nursing Studies, National University of Singapore,
Aims. To determine whether definable subtypes exist within a cohort of patients
listening to music with regard to their physiological patterns and to compare
whether associated factors vary between subjects in groups with different
profiles. Background. The intensive care unit (ICU) is one of the most stressful
environments for patients among various clinical settings in a hospital. ICU
patients are not only compromised by illness but also faced with a wide range of
stressors. Design. A repeated-measures design was conducted with one music group.
Method. One hundred and one patients were recruited in three intensive care units
in Hong Kong. There were two main outcome variables: demographic characteristics
and physiological outcomes. Results. A cluster analysis yielded two clusters.
Patients in cluster 1 typically experienced relatively low therapeutic effects
from listening to music. There were more males, of a younger age but more
educated and employed than patients in cluster 2, and they represented 41.6% of
the total respondents. Cluster 2 comprised almost 58.4% of this study sample and
they reported high therapeutic effects of music. There were more females in this
group as well as more older people and they mainly used a ventilator in the
intensive care unit. Conclusion. Our study shows that music may have a more
positive effect on groups of patients whose profile is similar to that of the
patients in cluster 2, than for patients such as those in cluster 1. A clear
profile may help health professionals to design appropriate care therapy to
target a specific group of patients to improve their physiological outcomes.
Relevance to clinical practice. The implication of this study is that music
therapy should be provided to patients as a relaxation technique if they are
willing to accept it, and the selection of music should be based on their
preferences. Information should be given to patients so that they can understand
how music therapy works and they should be encouraged to focus their attention on
listening to the music to maximise its benefits.
2008 Use of plasma DNA to predict mortality and need for intensive care in patients with abdominal pain
Rainer TH, Chan AK, Lee LL, Yim VW, Lam NY, Yeung SW, Graham CA, Lo DY.
Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong,
BACKGROUND: We investigated the value of plasma deoxyribonucleic acid concentrations in patients presenting with acute abdominal pain to predict need for intensive care or mortality. METHODS: Plasma deoxyribonucleic acid taken from patients with acute abdominal pain was analyzed for the beta-globin gene using the quantitative polymerase chain reaction. The primary outcome measure was the combined 28-day mortality or admission to the intensive care unit. RESULTS: Of 287 consecutive patients with acute abdominal pain recruited, 12 patients were admitted to the intensive care unit and/or died. Median plasma DNA concentrations were higher in patients with cancer and major organ inflammation. Mean plasma DNA concentrations were three-fold higher in patients with systemic inflammatory
response syndrome, five-fold higher in patients who died within 28 days, and eight-fold higher in patients admitted to the intensive care unit. The area under the receiver operator curve for plasma DNA concentrations and intensive care unit
admission/mortality was 0.804. At a cut-off of 1100 GE/ml, the sensitivity was 67% (95%CI 35-90) and specificity was 89% (95%CI 84-92). At a cut-off of 175 GE/ml, the sensitivity was 100% (95%CI 73-100) and specificity was 30% (95%CI 25-36). Plasma DNA concentration predicted need for intensive care unit admission or death (adjusted odds ratio 1.4; P<0.0001). CONCLUSIONS: Plasma DNA may have a role in patients with acute abdominal pain as a marker for inflammation and cancer, and a predictor of intensive care unit admission/mortality.
Pang PS, Suen LK.
Intensive Care Unit, Queen Mary Hospital, Hong Kong.
AIMS AND OBJECTIVES: The aim of the study was to compare the stressors as perceived by patients in an intensive care unit (ICU) against those of nurses on the basis of their perceptions of patients' stressors. BACKGROUND: Getting
admitted to an ICU is viewed as a stressful event by patients. However, numerous studies have indicated that nurses do not always accurately perceive the stressors of their clients. Therefore, it is important for nurses to know what seems most stressful from the patients' perspective so that appropriate nursing measures can be directed towards minimising such stressors. DESIGN: Survey. METHODS: As a convenience sample, 60 patients and 54 critical care nurses were
recruited. The Intensive Care Unit Stressor Questionnaire (Chinese) (ICU-CSQ) was used to collect the perceptions of stressors by the patients. Nurses were also asked to rate the items in the said questionnaire according to how they believe patients would rate them. RESULTS: In every comparison, nurses evaluated the items to be significantly more stressful than patients did. Overall perceived stress levels of nurses were also significantly higher than those of their
patients (z = -8.78, p < 0.001). CONCLUSIONS: Nurses tended to rate the items as more stressful than did the patients, perhaps over-emphasising the stressful nature of the ICU. The findings also highlight the importance of cultural beliefs
on the perceived stress levels among the Chinese population. RELEVANCE TO CLINICAL PRACTICE: Findings in this study have strong implications in clinical practice, especially in a critical care setting. Nurses must attempt to identify
and endeavour to cope with the situations that patients listed as most stressful. Moreover, attention must be drawn towards measures aimed at relieving the stress of patients by taking into account their cultural values so that culture-specific interventions for reducing their stress can be established.
2008 Use of the molecular adsorbents recirculating system as a treatment for acute decompensated Wilson disease
Chiu A, Tsoi NS, Fan ST.
Intensive Care Unit, Queen Mary Hospital, The University of Hong Kong, Hong Kong,
Acute decompensated Wilson disease presenting as fulminant liver failure is a life-threatening condition for which liver transplantation is the ultimate treatment. It is listed as a status 1 indication according to the United Network for Organ Sharing classification. A massive amount of copper released during the attack induces hemolytic anemia and acute renal failure. Conventional chelating therapy attempting to remove copper from the patient is not satisfactory because
there is inadequate time for these drugs to take action and patients are usually oliguric. The Molecular Adsorbents Recirculating System (MARS) is a form of modified dialysis that removes putative albumin-bound toxins associated with
liver failure. It is believed that extracorporeal albumin dialysate absorbs the circulating copper molecules that are trapped in the patient's circulation. We report 2 patients with acute decompensated Wilson disease treated with MARS. In the first case, the patient was started on MARS once conventional treatment failed. A significant amount of copper was removed from her circulatory system, and her condition stabilized afterwards. The treatment gained her extra time, and she was eventually bridged to liver transplantation. In the second case, the patient was started on MARS treatment early in the course of his illness, and his condition soon stabilized after the treatment. He was able to return to his home
country for liver transplantation. In both cases, MARS was used as a means of preventing deterioration rather than salvaging devastation. In conclusion, MARS may confer benefits to patients with acute decompensated Wilson disease if it is started early in the course of illness. (c) 2008 AASLD.
2008 Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials
BMJ 2008; 337: a1841
Tao Fan, medical student1, Gang Wang, associate professor and respiratory physician1, Bing Mao, associate professor and respiratory physician1, Zeyu Xiong, research associate2, Yu Zhang, critical care physician3, Xuemei Liu, research associate4, Lei Wang, respiratory physician1, Sai Yang, respiratory and critical care physician5
1 Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, China, 2 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA, 3 Department of Intensive Care Medicine, First People’s Hospital of Chengdu City, Chengdu 610041, China, 4 Chinese Cochrane Centre, West China Hospital, Sichuan University, Chengdu, 5 Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, ChengduObjective To determine whether steroids are effective in preventing laryngeal oedema after extubation and reducing the need for subsequent reintubation in critically ill adults.
Data sources PubMed, Cochrane Controlled Trials Register, Web of Science, and Embase with no limitation on language, study year, or publication status.
Selection criteria Randomised placebo controlled trials in which parenteral steroids were compared with placebo for preventing complications after extubation in adults.
Review methods Search, application of inclusion and exclusion criteria, data extraction, and assessment of methodological quality, independently performed in duplicate. Odds ratios with 95% confidence intervals, risk difference, and number needed to treat were calculated and pooled.
Main outcome measures Primary outcome: laryngeal oedema after extubation. Secondary outcome: subsequent reintubation because of laryngeal oedema.
Results Six trials (n=1923) were identified. Compared with placebo, steroids given before planned extubation decreased the odds ratio for laryngeal oedema (0.38, 95% confidence interval 0.17 to 0.85) and subsequent reintubation (0.29, 0.15 to 0.58), corresponding with a risk difference of –0.10 (–0.12 to –0.07; number needed to treat 10) and –0.02 (–0.04 to –0.01; 50), respectively. Subgroup analyses indicated that a multidose regimen of steroids had marked positive effects on the occurrence of laryngeal oedema (0.14; 0.08 to 0.23) and on the rate of subsequent reintubation (0.19; 0.07 to 0.50), with a risk difference of –0.19 (–0.24 to –0.15; 5) and –0.04 (–0.07 to –0.02; 25). In single doses there was only a trend towards benefit, with the confidence interval including 1. Side effects related to steroids were not found.
Conclusion Prophylactic administration of steroids in multidose regimens before planned extubation reduces the incidence of laryngeal oedema after extubation and the consequent reintubation rate in adults, with few adverse events.