https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60658-9.pdf

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.

Background Continuous infusions of sedative drugs in the intensive care unit may prolong the duration of mechanical ventilation, prolong the length of stay in the intensive care unit and the hospital, impede efforts to perform daily neurologic examinations, and increase the need for tests to assess alterations in mental status. Whether regular interruption of such infusions might accelerate recovery is not known. Methods We conducted a randomized, controlled trial involving 128 adult patients who were receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. In the intervention group, the sedative infusions were interrupted until the patients were awake, on a daily basis; in the control group, the infusions were interrupted only at the discretion of the clinicians in the intensive care unit. Results The median duration of mechanical ventilation was 4.9 days in the intervention group, as compared with 7.3 days in the control group (P=0.004), and the media...

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD; Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD; Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD; William M. Coplin, MD; David W. Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN; Paul E. Marik, MDBCh, FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM; William T. Peruzzi, MD, FCCM; Philip D. Lumb, MB, BS, FCCM. Developed through the Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), in collaboration with the American Society of Health-System Pharmacists (ASHP), and in alliance with the American College of Chest Physicians; and approved by the Board of Regents of ACCM and the Council of SCCM and the ASHP Board of Directors

/pdf/clinical-practice-guidelines-for-the-sustained-use-of-550x8gqibj.pdf

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.

The Circumplex Model focuses on the three central dimensions of marital and family systems: cohesion, flexibility and communication. The major hypothesis of the Circumplex Model is that balanced couple and family systems tend to be more functional compared to unbalanced systems. In over 250 studies using the Family Adaptability and Cohesion Scales (FACES), a linear self-report measure, strong support has been found for this hypothesis. In several studies using the Clinical Rating Scale (CRS), a curvilinear observational measure, the hypothesis was also supported. These two assessment tools, the FACES and the CRS, are designed for research, clinical assessment and treatment planning with couples and families.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/1467-6427.00144

Circumplex Model of Marital and Family Systems

ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography

Hyperthermic critically ill patients are commonly cooled to reduce their oxygen consumption (VO2). However, no previous studies in febrile humans have measured VO2 during cooling. We cooled 12 febrile, critically ill, mechanically ventilated patients while measuring VO2 and CO2 production (VCO2) by analysis of inspired and expired gases. All patients were mechanically ventilated for hypoxemic, hypercapneic, or shock-related respiratory failure and had a mean APACHE II score of 22.4 +/- 7.7. As temperature was reduced from 39.4 +/- 0.8 to 37.0 +/- 0.5 degrees C, VO2 decreased from 359.0 +/- 65.0 to 295.1 +/- 57.3 ml/min (p < 0.01) and VCO2 decreased from 303.6 +/- 43.6 to 243.5 +/- 37.3 ml/min (p < 0.01). The respiratory quotient (RQ) did not change significantly, and calculated energy expenditure decreased from 2,481 +/- 426 to 1,990 +/- 33 kcal/day (p < 0.01). In 7 patients with right heart catheters, cardiac output decreased from 8.4 +/- 3.2 to 6.5 +/- 1.8 L/min (p < 0.01) as the oxygen extraction fraction also tended to decrease from a mean of 28.2 +/- 6.8 to 23.4 +/- 4.7% (p = 0.12) during cooling. Accordingly, cooling the febrile patient unloads the cardiorespiratory system and, in situations of limited oxygen delivery or hypoxemic respiratory failure, may thus facilitate resuscitation and minimize the potential for hypoxic tissue injury.

Effect of cooling on oxygen consumption in febrile critically ill patients.

We present the effects of abrupt discontinuation of inhaled nitric oxide (NO) in four patients with severe hypoxemic respiratory failure These patients ranged from 9 mo to 65 yr of age In each patient, after the initiation of inhaled NO, a marginal, but immediate, beneficial effect on gas exchange and, when measured, a reduction in pulmonary artery pressures was noted However, during attempts to discontinue inhaled NO, not only did these patients develop worsening oxygenation and recrudescence of pulmonary hypertension but, unexpectedly, these parameters were worse than the baseline values, leading to life-threatening hemodynamic instability These effects reversed immediately after reinstitution of inhaled NO The mechanism of this severe ?rebound? in pulmonary hypertension after abrupt withdrawal of NO is unclear, but its existence emphasizes the need to avoid a substantial risk to these patients Moreover, we believe that both unintentional and intentional termination of inhaled NO therapy may lead to life-threatening deterioration in gas exchange and circulatory hemodynamics that exceeds the initial therapeutic benefit

Life-threatening effects of discontinuing inhaled nitric oxide in severe respiratory failure.

Tissue hypoxia resulting from regional blood flow abnormalities and oxygen extraction defects may underlie the pathogenesis of multiple system organ failure (MSOF) in sepsis. Low-dose dopamine (LDD) is widely employed to enhance splanchnic perfusion although data to support this approach are lacking. We assessed the effect of LDD on surrogate markers of renal and gastric perfusion. Sixteen nonoliguric mechanically ventilated patients with sepsis syndrome received LDD (3 micrograms/kg/min) or placebo in a double-blind crossover design experiment. Hemodynamics, gastric intramucosal pH (pHi) urine volumes, urinary sodium excretion, and cimetidine-corrected creatinine clearance were compared. Mortality for the group was 63%. LDD caused a significant increase in urine volume (88 +/- 58 to 115 +/- 70 ml/h, p = 0.02, 95% confidence interval for change 4.7 to 49 ml/h), but no significant change in any other parameter. We conclude that use of LDD results in diuresis but does not improve other markers of renal or g...

Administration of low-dose dopamine to nonoliguric patients with sepsis syndrome does not raise intramucosal gastric pH nor improve creatinine clearance.

Utility of the Circumplex Model with severely dysfunctional family systems.

Sexually Addicted Families: Clinical Use of the Circumplex Model

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