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

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

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

Playing with the future: social irrealism and the politics of aesthetics

In this paper we wish to explore the political possibilities of video games. Numerous scholars now take seriously the place of popular culture in the remaking of our geographies, but video games still lag behind. For us, this tendency reflects a general response to them as imaginary spaces that are separate from everyday life and 'real' politics. It is this disconnect between abstraction and lived experience that we complicate by defining play as an event of what Brian Massumi calls lived abstraction. We wish to short-circuit the barriers that prevent the aesthetic resonating with the political and argue that through their enactment, video games can animate fantastical futures that require the player to make, and reflect upon, profound ethical decisions that can be antagonistic to prevailing political imaginations. We refer to this as social irrealism to demonstrate that reality can be understood through the impossible and the imagined