Background: Patients who require positive pressure ventilation through a tracheostomy are unable ... more Background: Patients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation. Methods: A prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients' EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use. Results: Use of in-line SVs resulted in significant increase of EELI. This effect grew and was maintained for at least 15 minutes after removal of the SV (p < 0.001). EtCO 2 showed a significant drop during SV use (p = 0.01) whilst SpO 2 remained unchanged. Respiratory rate (RR (breaths per minute)) decreased whilst the SV was in situ (p <0.001), and heart rate (HR (beats per minute)) was unchanged. All results were similar regardless of the patients' respiratory requirements at time of recruitment. Conclusions: In this cohort of critically ill ventilated patients, SVs did not cause derecruitment of the lungs when used in the ventilator weaning period. Deflating the tracheostomy cuff and restoring the airflow via the upper airway with a one-way valve may facilitate lung recruitment during and after SV use, as indicated by increased EELI.
Introduction: Critically ill children are at an increased risk of malnutrition. Variability in fe... more Introduction: Critically ill children are at an increased risk of malnutrition. Variability in feeding practices has been highlighted as a barrier to optimising nutrition during Paediatric Intensive Care Unit (PICU) admission. Introduction of a feeding algorithmhas been shown to improve nutritional outcomes in this population. Studyobjective: To develop and implement a feeding algorithm for patients in a tertiary 22 bed PICU. Methods: The study was performed in three phases: Phase 1: A survey of nursing attitudes and perceived practices to enteral feeding. Phase 2: A three week prospective nutrition audit to evaluate the adequacy of energy and protein intake compared to estimated requirements. Phase 3: A multidisciplinary working group formed to devise, pilot and implement a feeding algorithm. Results: Phase 1: Demonstrated considerable variability and specific barriers to feeding. These included delayed medical approval to initiate feeds and multiple fasting for procedures and possible extubations. Phase 2: The mean time to feed initiation was 22h (range 0–92h). Within 72h of admission, patients achieved 66% of estimated energy requirements (EER); and 36% of estimated protein requirements (EPR), with only 4 (15%) reaching their EER; none reached EPR. Phase 3: A multidisciplinary team (dietetics, medical and nursing) reviewed the results of phases 1 and 2 and developed a single page algorithm. This was piloted in April 2014 and the final algorithm initiated in May 2014. Conclusion:Barriers to nutrition in a tertiary children’s hospital PICUwere identified by survey and audit tools. A feeding algorithm was developed by a multidisciplinary team utilising these results. A one page feeding algorithm was initiated in May 2014.
Patients who require positive pressure ventilation through a tracheostomy are unable to phonate d... more Patients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation. A prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients' EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use. Use of in-line SVs resulted in significant increase of EELI. This effect grew ...
Timely discharge of patients from ICU when deemed suitable releases beds for admissions and impro... more Timely discharge of patients from ICU when deemed suitable releases beds for admissions and improves patient flow. This study aimed to determine the effect of hospital occupancy on patient transfers from ICU. Patients admitted to ICU 1/05/2010 to 30/04/2012 were included. Hospital bed occupancy data, including ICU, were collected prospectively from existing databases hourly. Time-series modelling was performed. Of 3300 ICU admissions, 341 patients died in ICU. 58% ICU discharges were delayed 4+ hours (range 0-8 days) for bed unavailability (82%), medical complication (4%) and equipment issues (5%). 249 patients were denied ICU admission because of bed unavailability (30%), no necessity (36%) and end-stage disease (33%). Refusal increased when the hospital was on bypass diversion (p = 0.001). ICU discharges were not associated with patient arrival at ED within 1 h or longer (p = 0.69). Reduced ICU discharges were associated with arrivals to and departures from medical wards and there was an interaction between the two (p = 0.013, 0.007 and 0.013, respectively). ICU discharge was associated with discharge from surgical wards (p = 0.001). Arrivals and departures from the ED are both significantly associated with departures from the surgical wards but not from the ICU or medical wards (p = 0.047 and 0.041, respectively). In conclusion, relationship dynamics for patient movement between the 'compartments' of a large hospital are complex and clearly affect patient movement to and from ICU. Further investigation may elucidate these relationships and indicate areas where anticipatory action can reduce ICU occupancy pressure.
Patients who require positive pressure ventilation through a tracheostomy are unable to phonate d... more Patients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation. A prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients&amp;amp;amp;amp;amp;amp;#39; EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use. Use of in-line SVs resulted in significant increase of EELI. This effect grew and was maintained for at least 15 minutes after removal of the SV (p &amp;amp;amp;amp;amp;amp;lt; 0.001). EtCO2 showed a significant drop during SV use (p = 0.01) whilst SpO2 remained unchanged. Respiratory rate (RR (breaths per minute)) decreased whilst the SV was in situ (p &amp;amp;amp;amp;amp;amp;lt;0.001), and heart rate (HR (beats per minute)) was unchanged. All results were similar regardless of the patients&amp;amp;amp;amp;amp;amp;#39; respiratory requirements at time of recruitment. In this cohort of critically ill ventilated patients, SVs did not cause derecruitment of the lungs when used in the ventilator weaning period. Deflating the tracheostomy cuff and restoring the airflow via the upper airway with a one-way valve may facilitate lung recruitment during and after SV use, as indicated by increased EELI. Anna-Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12615000589583. 4/6/2015.
Electrical impedance tomography is a novel technology capable of quantifying ventilation distribu... more Electrical impedance tomography is a novel technology capable of quantifying ventilation distribution in the lung in real time during various therapeutic manoeuvres. The technique requires changes to the patient's position to place the electrical impedance tomography electrodes circumferentially around the thorax. The impact of these position changes on the time taken to stabilise the regional distribution of ventilation determined by electrical impedance tomography is unknown. This study aimed to determine the time taken for the regional distribution of ventilation determined by electrical impedance tomography to stabilise after changing position. Eight healthy, male volunteers were connected to electrical impedance tomography and a pneumotachometer. After 30 minutes stabilisation supine, participants were moved into 60 degrees Fowler's position and then returned to supine. Thirty minutes was spent in each position. Concurrent readings of ventilation distribution and tidal ...
43 2011;20:35-67 Abstracts with 'high' dose therapy. Patients in each dose category did not demon... more 43 2011;20:35-67 Abstracts with 'high' dose therapy. Patients in each dose category did not demonstrate clinically meaningful differences on measures of acuity, transfusion requirements or prior medications. Results demonstrated no significant differences in the rate of thromboembolic adverse events, response to bleeding or 28-day mortality . Discussion: These findings raise the important question of whether lower doses of rFVIIa may be as effective and efficacious as higher doses in the treatment of severe bleeding in cardiac surgery patients.
Electrical impedance tomography (EIT) can guide lung recruitment using the redistribution of regi... more Electrical impedance tomography (EIT) can guide lung recruitment using the redistribution of regional ventilation (RV). A previous study has demonstrated that the RV may not be reproducible in spontaneous breathing, with the result that regional filling constants (RFC) or the timing of onset of regional filling have been used as an alternative to guide recruitment. The aim of this study was to determine the reproducibility of RV and RFC using EIT. Ten males were recruited to this observational study. Two minute recordings, twice a day were made in supine lying after allowing 15 min to reach a steady state. The skin was marked to ensure accurate replacement of electrodes. Bland and Altman plots determined the reproducibility of tidal variation (TVar), RV, and RFC. To account for the biological variability of ventilation TVar and RV were averaged over a minute. Two subjects were excluded due to nonreproducible TVar. The RV was not reproducible with clustering above or below the zero line for all regions (anterior-posterior-left-right). The RFC for all regions spanned the zero line and were deemed reproducible. This study shows that the RFC is reproducible and may be useful in determining if the benefits of certain manoeuvres (e.g. recruitment) remain when electrodes are removed and replaced. Changes in RV may not be reproducible hours later, and may therefore not be as useful as RFC in guiding ventilation.
Background: Patients who require positive pressure ventilation through a tracheostomy are unable ... more Background: Patients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation. Methods: A prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients' EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use. Results: Use of in-line SVs resulted in significant increase of EELI. This effect grew and was maintained for at least 15 minutes after removal of the SV (p < 0.001). EtCO 2 showed a significant drop during SV use (p = 0.01) whilst SpO 2 remained unchanged. Respiratory rate (RR (breaths per minute)) decreased whilst the SV was in situ (p <0.001), and heart rate (HR (beats per minute)) was unchanged. All results were similar regardless of the patients' respiratory requirements at time of recruitment. Conclusions: In this cohort of critically ill ventilated patients, SVs did not cause derecruitment of the lungs when used in the ventilator weaning period. Deflating the tracheostomy cuff and restoring the airflow via the upper airway with a one-way valve may facilitate lung recruitment during and after SV use, as indicated by increased EELI.
Introduction: Critically ill children are at an increased risk of malnutrition. Variability in fe... more Introduction: Critically ill children are at an increased risk of malnutrition. Variability in feeding practices has been highlighted as a barrier to optimising nutrition during Paediatric Intensive Care Unit (PICU) admission. Introduction of a feeding algorithmhas been shown to improve nutritional outcomes in this population. Studyobjective: To develop and implement a feeding algorithm for patients in a tertiary 22 bed PICU. Methods: The study was performed in three phases: Phase 1: A survey of nursing attitudes and perceived practices to enteral feeding. Phase 2: A three week prospective nutrition audit to evaluate the adequacy of energy and protein intake compared to estimated requirements. Phase 3: A multidisciplinary working group formed to devise, pilot and implement a feeding algorithm. Results: Phase 1: Demonstrated considerable variability and specific barriers to feeding. These included delayed medical approval to initiate feeds and multiple fasting for procedures and possible extubations. Phase 2: The mean time to feed initiation was 22h (range 0–92h). Within 72h of admission, patients achieved 66% of estimated energy requirements (EER); and 36% of estimated protein requirements (EPR), with only 4 (15%) reaching their EER; none reached EPR. Phase 3: A multidisciplinary team (dietetics, medical and nursing) reviewed the results of phases 1 and 2 and developed a single page algorithm. This was piloted in April 2014 and the final algorithm initiated in May 2014. Conclusion:Barriers to nutrition in a tertiary children’s hospital PICUwere identified by survey and audit tools. A feeding algorithm was developed by a multidisciplinary team utilising these results. A one page feeding algorithm was initiated in May 2014.
Patients who require positive pressure ventilation through a tracheostomy are unable to phonate d... more Patients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation. A prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients' EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use. Use of in-line SVs resulted in significant increase of EELI. This effect grew ...
Timely discharge of patients from ICU when deemed suitable releases beds for admissions and impro... more Timely discharge of patients from ICU when deemed suitable releases beds for admissions and improves patient flow. This study aimed to determine the effect of hospital occupancy on patient transfers from ICU. Patients admitted to ICU 1/05/2010 to 30/04/2012 were included. Hospital bed occupancy data, including ICU, were collected prospectively from existing databases hourly. Time-series modelling was performed. Of 3300 ICU admissions, 341 patients died in ICU. 58% ICU discharges were delayed 4+ hours (range 0-8 days) for bed unavailability (82%), medical complication (4%) and equipment issues (5%). 249 patients were denied ICU admission because of bed unavailability (30%), no necessity (36%) and end-stage disease (33%). Refusal increased when the hospital was on bypass diversion (p = 0.001). ICU discharges were not associated with patient arrival at ED within 1 h or longer (p = 0.69). Reduced ICU discharges were associated with arrivals to and departures from medical wards and there was an interaction between the two (p = 0.013, 0.007 and 0.013, respectively). ICU discharge was associated with discharge from surgical wards (p = 0.001). Arrivals and departures from the ED are both significantly associated with departures from the surgical wards but not from the ICU or medical wards (p = 0.047 and 0.041, respectively). In conclusion, relationship dynamics for patient movement between the 'compartments' of a large hospital are complex and clearly affect patient movement to and from ICU. Further investigation may elucidate these relationships and indicate areas where anticipatory action can reduce ICU occupancy pressure.
Patients who require positive pressure ventilation through a tracheostomy are unable to phonate d... more Patients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation. A prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients&amp;amp;amp;amp;amp;amp;#39; EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use. Use of in-line SVs resulted in significant increase of EELI. This effect grew and was maintained for at least 15 minutes after removal of the SV (p &amp;amp;amp;amp;amp;amp;lt; 0.001). EtCO2 showed a significant drop during SV use (p = 0.01) whilst SpO2 remained unchanged. Respiratory rate (RR (breaths per minute)) decreased whilst the SV was in situ (p &amp;amp;amp;amp;amp;amp;lt;0.001), and heart rate (HR (beats per minute)) was unchanged. All results were similar regardless of the patients&amp;amp;amp;amp;amp;amp;#39; respiratory requirements at time of recruitment. In this cohort of critically ill ventilated patients, SVs did not cause derecruitment of the lungs when used in the ventilator weaning period. Deflating the tracheostomy cuff and restoring the airflow via the upper airway with a one-way valve may facilitate lung recruitment during and after SV use, as indicated by increased EELI. Anna-Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12615000589583. 4/6/2015.
Electrical impedance tomography is a novel technology capable of quantifying ventilation distribu... more Electrical impedance tomography is a novel technology capable of quantifying ventilation distribution in the lung in real time during various therapeutic manoeuvres. The technique requires changes to the patient's position to place the electrical impedance tomography electrodes circumferentially around the thorax. The impact of these position changes on the time taken to stabilise the regional distribution of ventilation determined by electrical impedance tomography is unknown. This study aimed to determine the time taken for the regional distribution of ventilation determined by electrical impedance tomography to stabilise after changing position. Eight healthy, male volunteers were connected to electrical impedance tomography and a pneumotachometer. After 30 minutes stabilisation supine, participants were moved into 60 degrees Fowler's position and then returned to supine. Thirty minutes was spent in each position. Concurrent readings of ventilation distribution and tidal ...
43 2011;20:35-67 Abstracts with 'high' dose therapy. Patients in each dose category did not demon... more 43 2011;20:35-67 Abstracts with 'high' dose therapy. Patients in each dose category did not demonstrate clinically meaningful differences on measures of acuity, transfusion requirements or prior medications. Results demonstrated no significant differences in the rate of thromboembolic adverse events, response to bleeding or 28-day mortality . Discussion: These findings raise the important question of whether lower doses of rFVIIa may be as effective and efficacious as higher doses in the treatment of severe bleeding in cardiac surgery patients.
Electrical impedance tomography (EIT) can guide lung recruitment using the redistribution of regi... more Electrical impedance tomography (EIT) can guide lung recruitment using the redistribution of regional ventilation (RV). A previous study has demonstrated that the RV may not be reproducible in spontaneous breathing, with the result that regional filling constants (RFC) or the timing of onset of regional filling have been used as an alternative to guide recruitment. The aim of this study was to determine the reproducibility of RV and RFC using EIT. Ten males were recruited to this observational study. Two minute recordings, twice a day were made in supine lying after allowing 15 min to reach a steady state. The skin was marked to ensure accurate replacement of electrodes. Bland and Altman plots determined the reproducibility of tidal variation (TVar), RV, and RFC. To account for the biological variability of ventilation TVar and RV were averaged over a minute. Two subjects were excluded due to nonreproducible TVar. The RV was not reproducible with clustering above or below the zero line for all regions (anterior-posterior-left-right). The RFC for all regions spanned the zero line and were deemed reproducible. This study shows that the RFC is reproducible and may be useful in determining if the benefits of certain manoeuvres (e.g. recruitment) remain when electrodes are removed and replaced. Changes in RV may not be reproducible hours later, and may therefore not be as useful as RFC in guiding ventilation.
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