Intraosseous vascular access in critically ill adults-a review of the literature

Aim & objectives. This literature review aim is to present a detailed investigation critiquing contemporary practices of intraosseous vascular access in adult patients. Specific objectives identified led to the exploration of clinical contexts, IO device/s and anatomical sites; education and training requirements; implications and recommendations for emergency healthcare practice and any requirements for further research. Background. The intraosseous route is an established method of obtaining vascular access in children in acute and emergency situations and is now increasingly being used in adults as an alternative to intravenous access, yet a paucity of evidence exists regarding its use, effectiveness and implementation. Search strategies. An exploratory literature review was undertaken in acknowledgement of the broad and complex nature of the project aim. Five electronic search engines were examined iteratively from June 2013 to February 2014. The search terms were ‘intraosseous’ AND ‘adult’ which were purposely limited due to the exploratory nature of the review. Studies that met the inclusion criteria of primary research articles with adult focus, paediatric lead research were excluded. Primary research international also included. Secondary research, reviews, case reports, editorials and opinion papers were excluded. Conclusion. Intraosseous vascular access is considered an alternative vascular access route although debate considering the preferred anatomical site is ongoing. Documented practices are only established in pre-hospital and specialist Emergency Department settings, however variety exists in policy and actual practice. Achieving insertion competence is relatively uncomplicated following minimal preparation although ongoing skill maintenance is less clear. Intraosseous vascular access is associated with minimal complications although pain is a significant issue for the conscious patient especially during fluid administration. Relevance to clinical practice. The intraosseous route is clearly a valuable alternative to problematic intravascular access. However further research, including cost effectiveness reviews, is required to gain clarity of whole acute care approaches

The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

Purpose: This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting.<p></p> Methods: This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed.<p></p> Results: Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86).<p></p> Conclusions: This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores

Maternal perceptions of supervision in preschool-aged children: a qualitative approach to understanding differences between families living in affluent and disadvantaged areas

Aim: To explore maternal perceptions of supervision and childhood unintentional injury in order to develop understanding and explanation for differences in unintentional injury rates between an advantaged and disadvantaged area. Background: Unintentional injury is the second cause of mortality and a significant cause of morbidity in the zero to four year age group. Children living in socio economic disadvantage are at a greater risk of unintentional injury than their more affluent counter-parts. Methods: Qualitative study using semi-structured interviews; content data analysis was undertaken. Participants included 37 mothers with a child aged less than five years; 16 living in an area of disadvantage (and high rate of childhood unintentional injury) and 21= living in an advantaged area (and low rate of childhood unintentional injury). Findings: Parents in both areas described the importance of parental supervision in reducing child unintentional injury risks. Parents in both areas used listening as a supervision strategy. Parents in both areas described how ‘when the child goes quiet’ that is a cue for them to make a visual check on the child. Listening was used more for boys than girls in both areas, but parents in the advantaged area used listening as a supervision strategy more frequently than those in the disadvantaged area. Parents described supervision strategies as being shaped by child character and age rather than child gender. Parents in both areas described similar strategies for managing distractions. An important difference was found with regard to older siblings; parents living in the advantaged area described older siblings as an injury risk to younger children. Parents in the disadvantaged area described older siblings as providing some supervision for younger children. Parents living in disadvantaged circumstances may face greater challenges with regard to supervision than parents living in advantaged circumstances and this may partly explain differences in injury risk

Small-scale spatial and temporal variability in growth and mortality of fish larvae in the subtropical northcentral Gulf of Mexico: implications for assessing recruitment success

Extensive plankton collections were taken during seven September cruises (1990–93) along the inner continental shelf of the northcentral Gulf of Mexico (GOM). Despite the high productivity and availability of food during these cruises, significant small-scale spatial variability was found in larval growth rates for both Atlantic bumper (Chloroscombrus chrysurus, Carangidae) and vermilion snapper (Rhomboplites aurorubens, Lutjanidae). The observed variability in larval growth rates was not correlated with changes in water temperature or associated with conspicuous hydrographic features and suggested the existence of less-recognizable regions where conditions for growth vary. Cruise estimates of mortality coefficients (Z) for larval Atlantic bumper (n=32,241 larvae from six cruises) and vermilion snapper (n= 2581 larvae from four cruises) ranged from 0.20 to 0.37 and 0.19 to 0.29, respectively. Even in a subtropical climate like the GOM, where larval-stage durations may be as short as two weeks, observed variability in growth rates, particularly when combined with small changes in mortality rates, can cause order-of-magnitude differences in cumulative larval survival. To what extent the observed differences in growth rates at small spatial scales are fine-scale “noise” that ultimately is smoothed by larger-scale processes is not known. Future research is needed to further characterize the small-scale variability in growth rates of larvae, particularly with regard to microzooplankton patchiness and the temporal and spatial pattern of potential predators. Small-scale spatial variability in larval growth rates may in fact be the norm, and understanding the implications of this subtle mosaic may help us to better evaluate our ability to partition the causes of recruitment variability

Adaptive resource use in a re-introduced black rhinoceros population

Ph. D, Faculty of Science, University of Witwatersrand, 2011The aim of biological management for black rhinoceros (Diceros bicornis) conservation is to maximise meta-population growth rates to aid species recovery. This research investigated how adaptive resource use in response to seasonal variation in resource availability could affect maximum productive habitat capacity for this critically endangered species. Analysis was based on a population of rhinos which had shown excellent annual growth rates and low inter-calving intervals since re-introduction to Tswalu Kalahari Reserve in the Northern Cape of South Africa in 1995. Acacia haematoxylon, a semi-evergreen species, was identified as the key resource forming the majority of diet contents during the late dry season. Use of this species resulted in a low level of seasonal variation in dietary contents of energy and protein. During the data collection period, energy and protein gains of individual female rhinos were estimated to exceed maximum requirements for reproduction throughout the seasonal cycle. An experiment designed to test the compensatory growth response of A. haematoxylon found that clipping trees in a way that simulated rhino browsing stimulated an increased growth response in the following wet season. This response indicated potential for a facilitatory relationship in the short term. A large proportion of the available area at Tswalu was not used by black rhinos. Home range location and habitat type selection within home ranges during the dry season were positively associated with two shrubveld habitat types containing greater A. haematoxylon biomass than other habitat types. Results from all aspects of field data analysis emphasized the importance of A. haematoxylon as the key dry season resource for black rhino at Tswalu. Field data were used to develop a conceptual model of how seasonally adaptive resource use by black rhinos could determine maximum productive habitat capacity. The crux of the model was to estimate the highest population density at which female rhinos could attain maximum energetic gains for reproduction throughout the entire seasonal cycle. The most limiting period was the nutritional bottleneck during the late dry season. The rationale behind this approach was to enable females to maintain body condition and be capable of meeting nutritional requirements for reproduction throughout the year, thus minimizing inter-calving intervals and maximising population growth rates. Model projections indicated that female rhinos could not attain energy gains for reproduction throughout the dry season in certain habitat types due to low availability of A. haematoxylon. However, model outputs indicated potential for an increase in rhino density by approximately one third in the two favoured shrubveld habitat types, assuming that habitat conditions remained unchanged. Availability of semi-evergreen A. haematoxylon was identified as the key vegetation component determining maximum productive habitat capacity for black rhino at Tswalu. Monitoring available biomass of this species at the end of the dry season could provide a simple plant-based indicator of how close the population is to maximum productive habitat capacity. Managing rhino densities in fenced reserves elsewhere around spatial and temporal availability of key resources may assist in achieving black rhino conservation goals of maximising metapopulation growth rates. Joanne Aileen Sha

Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process

Purpose: People with cancer and their families experience high levels of psychological morbidity. However many cancer services do not routinely screen patients for anxiety and depression and there are no standardized clinical referral pathways. This study aimed to establish consensus on elements of a draft clinical pathway tailored to the Australian context. Methods: A two-round Delphi study was conducted to gain consensus among Australian oncology and psycho-oncology clinicians about the validity of 39 items that form the basis of a clinical pathway that includes screening, assessment, referral and stepped-care management of anxiety and depression in the context of cancer. The expert panel comprised 87 multidisciplinary clinician members of the Australian Psycho-oncology Cooperative Research Group (PoCoG). Respondents rated their level of agreement with each statement on a 5-point likert scale. Consensus was defined as >80% of respondents scoring within 2 points on the likert scale. Results: Consensus was reached for 21 of 39 items, and a further 15 items approached consensus except for specific contextual factors, after 2 Delphi rounds. Formal screening for anxiety and depression, a stepped care model of management and recommendations for inclusion of length of treatment and time to review were endorsed. Consensus was not reached on items related to roles and responsibilities, particularly those not applicable across cancer settings. Conclusions: This study identified a core set of evidence- and consensus-based principles considered essential to a stepped care model of care incorporating identification, referral and management of anxiety and depression in adult cancer patients.This study was funded by Sydney Catalyst Translational Cancer Research Centr

Safety of extubating mechanically ventilated patients on vasoactive infusions: a retrospective cohort study

No abstract available

Do alcohol use disorders impact on long term outcomes from intensive care?

Introduction: There is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge.<p></p> Method: This was an 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency.<p></p> Results: 34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001).<p></p> Conclusion: Alcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care.<p></p&gt

Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines.

Purpose A clinical pathway for anxiety and depression in adult cancer patients was developed to guide best practice in Australia. Methods The pathway was based on a rapid review of existing guidelines, systematic reviews and meta-analyses, stakeholder interviews, a Delphi process with 87 multi-disciplinary stakeholders and input from a multidisciplinary advisory panel. Results The pathway recommends formalised routine screening for anxiety and depression in patients with cancer at key points in the patient’s journey. The Edmonton Symptom Assessment System (ESAS) or Distress Thermometer (DT) with problem checklist are recommended as brief screening tools, combined with a more detailed tool, such as the Hospital Anxiety and Depression Scale (HADS), to identify possible cases. A structured clinical interview will be required to confirm diagnosis. When anxiety or depression is identified it is recommended one person in a treating team takes responsibility for co-ordinating appropriate assessment, referral and follow-up (not necessarily carrying these out themselves). A stepped care model of intervention is proposed, beginning with the least intensive available that is still likely to provide significant health gain. The exact intervention, treatment length and follow up timelines as well as professionals involved, are provided as a guide only. Each service should identify their own referral network based on local resources and current service structure, as well as patient preference. Discussion This clinical pathway will assist cancer services to design their own systems to detect and manage anxiety and depression in their patients, to improve the quality of care